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Bruce MK, Islam R, Anstadt EE, Kenkre TS, Pfaff MJ, Canavan T, Goldstein JA. Mandibular Measurements at the 20-Week Anatomy Ultrasound as a Prenatal Diagnostic Predictor of Pierre Robin Sequence. Cleft Palate Craniofac J 2023; 60:352-358. [PMID: 34860601 DOI: 10.1177/10556656211064771] [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] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, and upper airway obstruction. Early recognition and appropriate perinatal management is crucial for optimizing outcomes. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific mandibular measurements could predict PRS diagnosis and disease severity. METHODS A retrospective case-control study of 48 patients with PRS and gender-matched controls was performed. Medical records were reviewed for respiratory and surgical interventions. Three parameters to assess micrognathia were measured on mid-sagittal profile ultrasound images: frontal nasal-mental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. Student's t-test and univariate logistic regression was performed. P ≤ 0.05 was considered statistically significant. RESULTS Patients with PRS demonstrated a significantly smaller mean FNMA compared to the control group, 129.3 ± 8.6° and 137.4 ± 3.2°, respectively (p < 0.0001), as well as significantly smaller mean FMA, 63.2 ± 9.2° and 74.8 ± 6.1°, respectively (p < 0.0001). The PRS group also demonstrated significantly larger mean alveolar overjet compared to the control group, 3.9 ± 1.4 mm and 2.1 ± 0.9 mm, respectively (p < 0.0001). The odds of respiratory intervention increased among cases when FMA was <68°. Additionally, there was a significant difference in median overjet between patients with PRS who did and did not require respiratory intervention. CONCLUSIONS Mandibular features on the 20-week ultrasound can be measured to predict diagnosis and severity of PRS. This is an important first step to prepare for potential respiratory intervention at delivery to minimize perinatal hypoxia. Alveolar overjet, previously not described in prenatal ultrasound literature, is measurable and has utility in prenatal screening for PRS, as do FMA and FNMA.
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Affiliation(s)
| | - Raeesa Islam
- 12317University of Pittsburgh School of Medicine
| | | | - Tanya S Kenkre
- Epidemiology Data Center, 171673University of Pittsburgh Graduate School of Public Health
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Teng CY, Myers S, Kenkre TS, Doney L, Tsang WL, Subramaniam K, Esper SA, Holder-Murray J. Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol. J Gastrointest Surg 2021; 25:2065-2075. [PMID: 33205308 PMCID: PMC8126638 DOI: 10.1007/s11605-020-04876-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets. METHODS We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression. RESULTS Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05). DISCUSSION Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.
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Affiliation(s)
- Cindy Y. Teng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sara Myers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tanya S. Kenkre
- University of Pittsburgh Epidemiology Data Center Graduate School of Public Health, Pittsburgh, PA
| | - Luke Doney
- Department of Anesthesiology and Pain Management, Cleveland Clinic, Cleveland, OH
| | - Wai Lok Tsang
- Department of Anesthesiology, Cleveland Clinic Florida, Weston, FL
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh PA
| | - Stephen A. Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh PA
| | - Jennifer Holder-Murray
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh PA
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Ward WT, Crasto JA, Kenkre TS, Dede O, Bosch PP, Roach JW. Intermediate-term annualized curve progression of adolescent idiopathic scoliosis curves measuring 40° or greater. Spine Deform 2020; 8:629-636. [PMID: 32096130 DOI: 10.1007/s43390-020-00088-3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/29/2019] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES The objective of this study was to examine intermediate-term progression for a large series of patients with adolescent idiopathic scoliosis (AIS) with curves 40° or greater. BACKGROUND Curve progression in AIS has been well documented for smaller curves in adolescence up to skeletal maturity; however, the data on curve progression past 40° or into adulthood are limited. With many surgeons recommending surgical correction when patients reach this threshold, it is important to understand the radiographic progression of curves into adulthood. METHODS A database of all patients seen by a single surgeon from 1984 through 2018 with AIS curves progressing to at least 40° entered prospectively was utilized for this study. This included a total of 738 patients. Curve progression was analyzed overall and stratified by length of follow-up, curve location, and Risser stage at the time of presentation among other variables. Curve magnitude and Risser stage designations in this study were validated by performing a separate inter- and intrarater agreement study using four independent reviewers reading 50 patients' Cobb angle and Risser stage blinded in triplicate to examine the reliability of the study measurements. RESULTS Annualized curve progression (ACP) averaged 6.3 ± 10.4°. ACP varied with length of follow-up: patients with up to 1 year of follow-up had an average ACP of 11.5 ± 17.0°, while those with 1-2 years had 8.2 ± 8.8°, and 2-5 years had 3.7 ± 4.1°, tapering off further from there. Risser stage 0 or 1 was associated with the highest ACP as compared to Risser stage 2-3 or 4-5. Intraclass correlation (ICC) values for Cobb angle measurement and Risser stage designations from four raters measuring 50 patients' measures, blinded and in triplicate, were all > 0.80, signifying a high degree of reliability within and between readers. CONCLUSIONS Annualized curve progression for 40° and greater curves was not linear over time; it was greatest immediately after a curve reaches 40° and tapered off over the next decade. Immature Risser stage at presentation was strongly associated with increasing ACP at all time frames. LEVEL OF EVIDENCE Prognostic Level I.
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Affiliation(s)
- W Timothy Ward
- Pediatric Orthopaedic Division, Children's Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Jared A Crasto
- Pediatric Orthopaedic Division, Children's Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Tanya S Kenkre
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ozgur Dede
- Pediatric Orthopaedic Division, Children's Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Patrick P Bosch
- Pediatric Orthopaedic Division, Children's Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - James W Roach
- Pediatric Orthopaedic Division, Children's Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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Abstract
OBJECTIVES The aim of this study was to determine if implementation of our evidence-based medicine (EBM) curriculum had an effect on pediatric emergency medicine fellows' scores on the relevant section of the in-training examination (ITE). METHODS We obtained deidentified subscores for 22 fellows over 6 academic years for the Core Knowledge in Scholarly Activities (SA) and, as a balance measure, Emergencies Treated Medically sections. We divided the subscores into the following 3 instruction periods: "baseline" for academic years before our current EBM curriculum, "transition" for academic years with use of a research method curriculum with some overlapping EBM content, and "EBM" for academic years with our current EBM curriculum. We analyzed data using the Kruskal-Wallis test, the Mann-Whitney U test, and multivariate mixed-effects linear models. RESULTS The SA subscore median was higher during the EBM period in comparison with the baseline and transition periods. In contrast, the Emergencies Treated Medically subscore median was similar across instruction periods. Multivariate modeling demonstrated that our EBM curriculum had the following independent effects on the fellows' SA subscore: (1) in comparison with the transition period, the fellows' SA subscore was 21 percentage points higher (P = 0.005); and (2) in comparison to the baseline period, the fellows' SA subscore was 28 percentage points higher during the EBM curriculum instruction period (P < 0.001). CONCLUSIONS Our EBM curriculum was associated with significantly higher scores on the SA section of the ITE. Pediatric emergency medicine educators could consider using fellows' scores on this section of the ITE to assess the effect of their EBM curricula.
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Affiliation(s)
- Melissa M. Tavarez
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Tanya S. Kenkre
- University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA
| | - Noel Zuckerbraun
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
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Bosch P, Kenkre TS, Soliman D, Londino JA, Novak NE. Comparison of the Coagulation Profile of Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion With and Without Tranexamic Acid. Spine Deform 2019; 7:910-916. [PMID: 31732001 DOI: 10.1016/j.jspd.2019.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 01/28/2019] [Revised: 04/03/2019] [Accepted: 04/16/2019] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Prospective, observational cohort study. OBJECTIVE To improve the understanding of coagulation and bleeding mechanisms during spinal deformity surgery. SUMMARY OF BACKGROUND DATA Fibrinolysis is the mechanism of bleeding for adolescent idiopathic scoliosis undergoing posterior spinal fusion. Antifibrinolytics have become popular; however, literature to support their use remains mixed. The mechanism of action has not been demonstrated. METHODS The coagulation profile of 88 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion was analyzed. Standard coagulation laboratory investigations and thromboelastograms were drawn hourly through the case. Fifty-eight patients received no antifibrinolytic, whereas 30 patients received tranexamic acid by standardized protocol. The coagulation parameters, estimated blood loss, and transfusion requirements were compared in the two groups. RESULTS The two cohorts had no differences in demographic or surgical characteristics. Mean age was 13.6 years, 83% were female, a mean of 11.1 levels were fused, and the mean duration of surgery was 209 minutes. The tranexamic acid cohort did not demonstrate a decrease in blood loss. The transfusion rate, however, dropped from 47% in the non-tranexamic acid cohort to 23% in the tranexamic acid cohort (p = .03). Standard coagulation parameters did not differ between the groups. Fibrinolysis was diminished in the tranexamic acid cohort as measured by a Fibrinolysis score (mean maximum value 2.0 without tranexamic acid vs. 0.7 with tranexamic acid, p < .0001) and the lysis percent at 30 minutes by thromboelastogram (elevated to 3.9% without tranexamic acid vs. 1.2% with tranexamic acid at the 3-hour mark, p = .05). CONCLUSIONS This study provides confirmation of antifibrinolytic activity during posterior spinal fusion for adolescent idiopathic scoliosis. The presented data of fibrinolysis are proposed as standard measurements for future work on controlling blood loss during scoliosis surgery. LEVEL OF EVIDENCE Level 2, prospective comparative study.
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Affiliation(s)
- Patrick Bosch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA.
| | - Tanya S Kenkre
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Public Health Building, 130 De Soto St, Pittsburgh, PA 15261, USA
| | - Doreen Soliman
- Department of Anesthesia, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
| | - Joanne A Londino
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
| | - Natalie E Novak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
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Kenkre TS, Malhotra P, Johnson BD, Handberg EM, Thompson DV, Marroquin OC, Rogers WJ, Pepine CJ, Bairey Merz CN, Kelsey SF. Ten-Year Mortality in the WISE Study (Women's Ischemia Syndrome Evaluation). Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.116.003863. [PMID: 29217675 DOI: 10.1161/circoutcomes.116.003863] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [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: 04/21/2017] [Accepted: 09/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The WISE study (Women's Ischemia Syndrome Evaluation) was a prospective cohort study of 936 clinically stable symptomatic women who underwent coronary angiography to evaluate symptoms and signs of ischemia. Long-term mortality data for such women are limited. METHODS AND RESULTS Obstructive coronary artery disease (CAD) was defined as ≥50% stenosis on angiography by core laboratory. We conducted a National Death Index search to assess the mortality of women who were alive at their final WISE contact date. Death certificates were obtained. All deaths were adjudicated as cardiovascular or noncardiovascular by a panel of WISE cardiologists masked to angiographic data. Multivariate Cox proportional hazards regression was used to identify significant independent predictors of mortality. At baseline, mean age was 58±12 years; 176 (19%) were non-white, primarily black; 25% had a history of diabetes mellitus, 59% hypertension, 55% dyslipidemia, and 59% had a body mass index ≥30. During a median follow-up of 9.5 years (range, 0.2-11.5 years), a total of 184 (20%) died. Of these, 115 (62%) were cardiovascular deaths; 31% of all cardiovascular deaths occurred in women without obstructive CAD (<50% stenosis). Independent predictors of mortality were obstructive CAD, age, baseline systolic blood pressure, history of diabetes mellitus, history of smoking, elevated triglycerides, and estimated glomerular filtration rate. CONCLUSIONS Among women referred for coronary angiography for signs and symptoms of ischemia, 1 in 5 died from predominantly cardiac pathogeneses within 9 years of angiographic evaluation. A majority of the factors contributing to the risk of death seem to be modifiable by existing therapies. Of note, 1 in 3 of the deaths in this cohort occurred in women without obstructive CAD, a condition often considered benign and without guideline-recommended treatments. Clinical trials are needed to provide treatment guidance for the group without obstructive CAD.
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Affiliation(s)
- Tanya S Kenkre
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.).
| | - Pankaj Malhotra
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - B Delia Johnson
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Eileen M Handberg
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Diane V Thompson
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Oscar C Marroquin
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - William J Rogers
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Carl J Pepine
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - C Noel Bairey Merz
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Sheryl F Kelsey
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
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Mehta PK, Johnson BD, Kenkre TS, Eteiba W, Sharaf B, Pepine CJ, Reis SE, Rogers WJ, Kelsey SF, Thompson DV, Bittner V, Sopko G, Shaw LJ, Bairey Merz CN. Sudden Cardiac Death in Women With Suspected Ischemic Heart Disease, Preserved Ejection Fraction, and No Obstructive Coronary Artery Disease: A Report From the Women's Ischemia Syndrome Evaluation Study. J Am Heart Assoc 2017; 6:JAHA.117.005501. [PMID: 28862961 PMCID: PMC5586417 DOI: 10.1161/jaha.117.005501] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Sudden cardiac death (SCD) is often the first presentation of ischemic heart disease; however, there is limited information on SCD among women with and without obstructive coronary artery disease (CAD). We evaluated SCD incidence in the WISE (Women's Ischemia Syndrome Evaluation) study. Methods and Results Overall, 904 women with suspected ischemic heart disease with preserved ejection fraction and core laboratory coronary angiography were followed for outcomes. In case of death, a death certificate and/or a physician or family narrative of the circumstances of death was obtained. A clinical events committee rated all deaths as cardiovascular or noncardiovascular and as SCD or non‐SCD. In total, 96 women (11%) died over a median of 6 years (maximum: 8 years). Among 65 cardiovascular deaths, 42% were SCD. Mortality per 1000 person‐hours increased linearly with CAD severity (no CAD: 5.8; minimal: 15.9; obstructive: 38.6; P<0.0001). However, the proportion of SCD was similar across CAD severity: 40%, 58%, and 38% for no, minimal, and obstructive CAD subgroups, respectively (P value not significant). In addition to traditional risk factors (age, diabetes mellitus, smoking), a history of depression (P=0.018) and longer corrected QT interval (P=0.023) were independent SCD predictors in the entire cohort. Corrected QT interval was an independent predictor of SCD in women without obstructive CAD (P=0.033). Conclusions SCD contributes substantially to mortality in women with and without obstructive CAD. Corrected QT interval is the single independent SCD risk factor in women without obstructive CAD. In addition to management of traditional risk factors, these data indicate that further investigation should address mechanistic understanding and interventions targeting depression and corrected QT interval in women.
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Affiliation(s)
- Puja K Mehta
- Emory University School of Medicine, Atlanta, GA
| | - B Delia Johnson
- Graduate School of Public Health, University of Pittsburgh, PA
| | - Tanya S Kenkre
- Graduate School of Public Health, University of Pittsburgh, PA
| | - Wafia Eteiba
- Graduate School of Public Health, University of Pittsburgh, PA
| | | | | | - Steven E Reis
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Sheryl F Kelsey
- Graduate School of Public Health, University of Pittsburgh, PA
| | - Diane V Thompson
- Allegheny General Hospital, Pittsburgh, PA.,National Institutes of Health, Bethesda, MD
| | | | - George Sopko
- Allegheny General Hospital, Pittsburgh, PA.,National Institutes of Health, Bethesda, MD
| | | | - C Noel Bairey Merz
- Emory University School of Medicine, Atlanta, GA.,Cedars Sinai Heart Institute, Los Angeles, CA
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Bosch P, Kenkre TS, Londino JA, Cassara A, Yang C, Waters JH. Coagulation Profile of Patients with Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion. J Bone Joint Surg Am 2016; 98:e88. [PMID: 27869629 DOI: 10.2106/jbjs.16.00114] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 02/01/2023]
Abstract
BACKGROUND Blood loss and transfusion requirements during posterior spinal fusion for adolescent idiopathic scoliosis remain a concern. The mechanism of bleeding in these patients is poorly characterized. Thromboelastography is a comprehensive test of a patient's coagulation system commonly used in cardiac surgical procedures. It has not been well studied for use in patients with adolescent idiopathic scoliosis. METHODS A prospective, observational study of the coagulation profile of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion is presented. Healthy patients with adolescent idiopathic scoliosis without a bleeding abnormality were analyzed during posterior spinal fusion. Standard coagulation laboratory and thromboelastogram measures were obtained at the time of the incision and at 1-hour intervals during the surgical procedure. Laboratory values were analyzed in relation to outcomes such as bleeding, transfusion, and a fibrinolysis score. RESULTS Fifty-eight patients were observed. Eighty-one percent of patients were female, the mean age was 13.5 years, a mean of 11.1 levels were fused, the median estimated blood loss was 645 mL, and 47% of patients received blood products. Overall, laboratory values remained stable throughout the surgical procedure. Mild increases in prothrombin time and partial thromboplastin time were observed, and platelets remained stable. From thromboelastogram analysis, an acceleration of clot formation (decreased reaction time) and a slight increase in clot lysis (increased lysis percentage at 30 minutes) were observed. A fibrinolysis score compiled from the presence of fibrin degradation products, the presence of D-dimers, and increased prothrombin time rose steadily over surgical time. The fibrinolysis score was predictive of both transfusion and greater estimated blood loss per level. CONCLUSIONS The stress of posterior spinal fusion induces a hypercoagulable state in patients with adolescent idiopathic scoliosis. Over the first 2 hours of a surgical procedure, varying degrees of fibrinolysis develop. Platelets and coagulation factors are not depleted. Our data support the use of antifibrinolytic therapy for patients with adolescent idiopathic scoliosis.
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Affiliation(s)
- Patrick Bosch
- Departments of Orthopaedic Surgery (P.B. and J.A.L.) and Anesthesia (A.C. and C.Y.), Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tanya S Kenkre
- Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Joanne A Londino
- Departments of Orthopaedic Surgery (P.B. and J.A.L.) and Anesthesia (A.C. and C.Y.), Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Antonio Cassara
- Departments of Orthopaedic Surgery (P.B. and J.A.L.) and Anesthesia (A.C. and C.Y.), Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charles Yang
- Departments of Orthopaedic Surgery (P.B. and J.A.L.) and Anesthesia (A.C. and C.Y.), Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan H Waters
- Department of Anesthesia, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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9
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Rutledge T, Kenkre TS, Thompson DV, Bittner VA, Whittaker K, Eastwood JA, Eteiba W, Cornell CE, Krantz DS, Pepine CJ, Johnson BD, Handberg EM, Bairey Merz CN. Psychosocial predictors of long-term mortality among women with suspected myocardial ischemia: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation. J Behav Med 2016; 39:687-93. [PMID: 27017335 DOI: 10.1007/s10865-016-9737-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 10/05/2015] [Accepted: 03/21/2016] [Indexed: 11/26/2022]
Abstract
This paper evaluated long-term associations between psychosocial factors and premature mortality among women with suspected coronary artery disease (CAD). We tracked total mortality events over a median 9.3 years in a cohort of 517 women [baseline mean age = 58.3 (11.4) years]. Baseline evaluations included coronary angiography, psychosocial testing, and CAD risk factors. Measures included the Spielberger Trait Anxiety Scale, Beck Depression Inventory, self-rated health, and Social Network Index. Cox regression analysis was used to assess relationships. Covariates included age, CAD risk factors, and CAD severity. BDI scores (HR 1.09, 95 % CI 1.02-1.15), STAI scores (HR .86, 95 % CI .78-.93), and very good self-rated health (relative to the poor self-rated health group; HR .33, 95 % CI .12-.96) each independently predicted time to mortality outcomes in the combined model. SNI scores (HR .91, 95 % CI .81-1.06) and other self-rated health categories (i.e., fair, good, and excellent categories) were not significant mortality predictors after adjusting for other psychosocial factors. These results reinforce and extend prior psychosocial research in CAD populations.
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Affiliation(s)
- Thomas Rutledge
- VA San Diego Healthcare System, Psychology Service 116B, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA.
- University of California, San Diego, CA, USA.
| | | | | | - Vera A Bittner
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kerry Whittaker
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | - Carol E Cornell
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David S Krantz
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | | | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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Hager E, Steinmetz A, Washington CB, Wu T, Singh MJ, Kenkre TS, Dillavou E. Factors That Influence Immediate Perforator Vein Closure Rates With Radiofrequency Ablation, Laser Ablation, or Foam Sclerotherapy. J Vasc Surg Venous Lymphat Disord 2014; 3:125. [PMID: 26993713 DOI: 10.1016/j.jvsv.2014.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- E Hager
- University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - A Steinmetz
- University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - T Wu
- University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - M J Singh
- University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - T S Kenkre
- University of Pittsburgh, Pittsburgh, Pa
| | - E Dillavou
- University of Pittsburgh Medical Center, Pittsburgh, Pa
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11
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Rutledge T, Kenkre TS, Thompson DV, Bittner VA, Whittaker K, Eastwood JA, Eteiba W, Cornell CE, Krantz DS, Pepine CJ, Johnson BD, Handberg EM, Bairey Merz CN. Depression, dietary habits, and cardiovascular events among women with suspected myocardial ischemia. Am J Med 2014; 127:840-7. [PMID: 24769297 PMCID: PMC4161621 DOI: 10.1016/j.amjmed.2014.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Dietary habits and depression are associated with cardiovascular disease risk. Patients with depression often report poor eating habits, and dietary factors may help explain commonly observed associations between depression and cardiovascular disease. METHODS From 1996 to 2000, 936 women were enrolled in the Women's Ischemia Syndrome Evaluation at 4 US academic medical centers at the time of clinically indicated coronary angiography and then assessed (median follow-up, 5.9 years) for adverse outcomes (cardiovascular disease death, heart failure, myocardial infarction, stroke). Participants completed a protocol including coronary angiography (coronary artery disease severity) and depression assessments (Beck Depression Inventory scores, antidepressant use, and depression treatment history). A subset of 201 women (mean age, 58.5 years; standard deviation, 11.4) further completed the Food Frequency Questionnaire for Adults (1998 Block). We extracted daily fiber intake and daily servings of fruit and vegetables as measures of dietary habits. RESULTS In separate Cox regression models adjusted for age, smoking, and coronary artery disease severity, Beck Depression Inventory scores (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.01-1.10), antidepressant use (HR, 2.4; 95% CI, 1.01-5.9), and a history of treatment for depression (HR, 2.4; 95% CI, 1.1-5.3) were adversely associated with time to cardiovascular disease outcomes. Fiber intake (HR, 0.87; 95% CI, 0.78-0.97) and fruit and vegetable consumption (HR, 0.36; 95% CI, 0.19-0.70) were associated with a decreased time to cardiovascular disease event risk. In models including dietary habits and depression, fiber intake and fruit and vegetable consumption remained associated with time to cardiovascular disease outcomes, whereas depression relationships were reduced by 10% to 20% and nonsignificant. CONCLUSIONS Among women with suspected myocardial ischemia, we observed consistent relationships among depression, dietary habits, and time to cardiovascular disease events. Dietary habits partly explained these relationships. These results suggest that dietary habits should be included in future efforts to identify mechanisms linking depression to cardiovascular disease.
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Affiliation(s)
- Thomas Rutledge
- VA San Diego Healthcare System, San Diego, Calif; University of California, San Diego.
| | | | | | | | - Kerry Whittaker
- Uniformed Services University of the Health Sciences, Bethesda, Md
| | | | | | | | - David S Krantz
- Uniformed Services University of the Health Sciences, Bethesda, Md
| | | | | | | | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, Calif
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Petersen JW, Mehta PK, Kenkre TS, Anderson RD, Johnson BD, Shufelt C, Samuels B, Kar S, Azarbal B, Handberg E, Kothawade K, Pepine CJ, Merz CNB. Comparison of low and high dose intracoronary adenosine and acetylcholine in women undergoing coronary reactivity testing: results from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE). Int J Cardiol 2014; 172:e114-5. [PMID: 24461979 DOI: 10.1016/j.ijcard.2013.12.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 12/22/2013] [Indexed: 10/25/2022]
Affiliation(s)
- John W Petersen
- Division of Cardiology, University of Florida, Gainesville, FL, United States.
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | - R David Anderson
- Division of Cardiology, University of Florida, Gainesville, FL, United States
| | | | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Bruce Samuels
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Saibal Kar
- Division of Cardiology, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Babak Azarbal
- Division of Cardiology, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Eileen Handberg
- Division of Cardiology, University of Florida, Gainesville, FL, United States
| | - Kamlesh Kothawade
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville, FL, United States
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Rutledge T, Kenkre TS, Bittner V, Krantz DS, Thompson DV, Linke SE, Eastwood JA, Eteiba W, Cornell CE, Vaccarino V, Pepine CJ, Johnson BD, Bairey Merz CN. Anxiety associations with cardiac symptoms, angiographic disease severity, and healthcare utilization: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation. Int J Cardiol 2013; 168:2335-40. [PMID: 23410495 DOI: 10.1016/j.ijcard.2013.01.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/21/2012] [Accepted: 01/18/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anxiety is common among patients presenting with suspected coronary artery disease (CAD). In a sample of women with signs and symptoms of ischemia, we examined three anxiety markers as predictors of CAD endpoints including: 1) cardiac symptom indicators; 2) angiographic CAD severity; and 3) healthcare utilization (cardiac hospitalizations and 5-year cardiovascular [CVD] healthcare costs). METHODS Participants completed a baseline protocol including coronary angiogram, cardiac symptoms, psychosocial measures and a median 5.9-year follow-up to track hospitalizations. We calculated CVD costs based on cardiac hospitalizations, treatment visits, and CVD medications. Anxiety measures included anxiolytic medication use, Spielberger Trait Anxiety Inventory (STAI) scores, and anxiety disorder treatment history. RESULTS The sample numbered 514 women with anxiety measure data and covariates (mean age=57.5 [11.1]). One in five (20.4%) women reported using anxiolytic agents. Anxiety correlated with cardiac symptom indicators (anxiolytic use with nighttime angina and nitroglycerine use; STAI scores and anxiety disorder treatment history with nighttime angina, shortness of breath, and angina frequency). Anxiety disorder treatment history (but not STAI scores or anxiolytics) predicted less severe CAD. Anxiolytic use (but not STAI scores or anxiety disorder treatment history) predicted hospitalizations for chest pain and coronary catheterization (HRs=2.0, 95% CIs=1.1-4.7). Anxiety measures predicted higher 5-year CVD costs (+9.0-42.7%) irrespective of CAD severity. CONCLUSIONS Among women with signs and symptoms of myocardial ischemia, anxiety measures predict cardiac endpoints ranging from cardiac symptom severity to healthcare utilization. Based on these findings, anxiety may warrant greater consideration among women with suspected CAD.
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Affiliation(s)
- Thomas Rutledge
- VA San Diego Healthcare System, San Diego, CA, United States; University of California, San Diego, CA, United States.
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Abstract
This study examines various dimensions of satisfaction with obstetricians among mainland Puerto Ricans using data from a survey administered to a representative sample of 1,219 Puerto Rican mothers. The results indicate that the majority of Puerto Rican women are satisfied with their obstetricians, but they are not typically "extremely" satisfied. Moreover, satisfaction is influenced by the structure of care, the process of care, and the outcome of care. Two aspects of process that are especially important are the continuity and content of care. Although satisfaction is not generally associated with the ethnicity or the gender of physicians, some evidence suggests that patients who utilize public facilities or lack continuity of care tend to be more satisfied if they have a female physician.
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