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Vandenberg AE, Hwang U, Das S, Genes N, Nyamu S, Richardson L, Ezenkwele U, Legome E, Richardson C, Belachew A, Leong T, Kegler M, Vaughan CP. Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models. J Am Geriatr Soc 2024. [PMID: 38259070 DOI: 10.1111/jgs.18746] [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] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/09/2023] [Accepted: 12/09/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.
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Affiliation(s)
- Ann E Vandenberg
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ula Hwang
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA
- James J. Peters VA Medical Center GRECC, Bronx, New York, USA
| | - Shamie Das
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas Genes
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Sylviah Nyamu
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ugo Ezenkwele
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric Legome
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Belachew
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michelle Kegler
- Department of Behavioural, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Birmingham/Atlanta VA GRECC, Atlanta, Georgia, USA
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Lin X, Geng R, Menke K, Edelson M, Yan F, Leong T, Rust GS, Waller LA, Johnson EL, Cheng Immergluck L. Machine learning to predict risk for community-onset Staphylococcus aureus infections in children living in southeastern United States. PLoS One 2023; 18:e0290375. [PMID: 37656705 PMCID: PMC10473480 DOI: 10.1371/journal.pone.0290375] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 08/07/2023] [Indexed: 09/03/2023] Open
Abstract
Staphylococcus aureus (S. aureus) is known to cause human infections and since the late 1990s, community-onset antibiotic resistant infections (methicillin resistant S. aureus (MRSA)) continue to cause significant infections in the United States. Skin and soft tissue infections (SSTIs) still account for the majority of these in the outpatient setting. Machine learning can predict the location-based risks for community-level S. aureus infections. Multi-year (2002-2016) electronic health records of children <19 years old with S. aureus infections were queried for patient level data for demographic, clinical, and laboratory information. Area level data (Block group) was abstracted from U.S. Census data. A machine learning ecological niche model, maximum entropy (MaxEnt), was applied to assess model performance of specific place-based factors (determined a priori) associated with S. aureus infections; analyses were structured to compare methicillin resistant (MRSA) against methicillin sensitive S. aureus (MSSA) infections. Differences in rates of MRSA and MSSA infections were determined by comparing those which occurred in the early phase (2002-2005) and those in the later phase (2006-2016). Multi-level modeling was applied to identify risks factors for S. aureus infections. Among 16,124 unique patients with community-onset MRSA and MSSA, majority occurred in the most densely populated neighborhoods of Atlanta's metropolitan area. MaxEnt model performance showed the training AUC ranged from 0.771 to 0.824, while the testing AUC ranged from 0.769 to 0.839. Population density was the area variable which contributed the most in predicting S. aureus disease (stratified by CO-MRSA and CO-MSSA) across early and late periods. Race contributed more to CO-MRSA prediction models during the early and late periods than for CO-MSSA. Machine learning accurately predicts which densely populated areas are at highest and lowest risk for community-onset S. aureus infections over a 14-year time span.
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Affiliation(s)
- Xiting Lin
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Atlanta, Georgia, United States of America
| | - Ruijin Geng
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Atlanta, Georgia, United States of America
| | | | - Mike Edelson
- InterDev, Roswell, Georgia, United States of America
| | - Fengxia Yan
- Morehouse School of Medicine, Department of Community Health and Preventive Medicine, Atlanta, Georgia, United States of America
| | - Traci Leong
- Emory University, Rollins School of Public Health, Department of Biostatistics & Bioinformatics, Atlanta, Georgia, United States of America
| | - George S. Rust
- College of Medicine, and Center for Medicine and Public Health, Florida State University, Tallahassee, Florida, United States of America
| | - Lance A. Waller
- Emory University, Rollins School of Public Health, Department of Biostatistics & Bioinformatics, Atlanta, Georgia, United States of America
| | - Erica L. Johnson
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Atlanta, Georgia, United States of America
| | - Lilly Cheng Immergluck
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Atlanta, Georgia, United States of America
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Lin X, Ali F, Leong T, Edelson M, Hampton S, Zuo Z, Li C, Rice C, Yan F, Baltrus PT, Randolph S, Immergluck LC. Influence of Mask Wearing during COVID-19 Surge and Non-Surge Time Periods in Two K-12 Public School Districts in Georgia, USA. IJERPH 2023; 20:5715. [PMID: 37174233 PMCID: PMC10177845 DOI: 10.3390/ijerph20095715] [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] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/16/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Into the third year of the COVID-19 pandemic and the second year of in-person learning for many K-12 schools in the United States, the benefits of mitigation strategies in this setting are still unclear. We compare COVID-19 cases in school-aged children and adolescents between a school district with a mandatory mask-wearing policy to one with an optional mask-wearing policy, during and after the peak period of the Delta variant wave of infection. METHODS COVID-19 cases during the Delta variant wave (August 2021) and post the wave (October 2021) were obtained from public health records. Cases of K-12 students, stratified by grade level (elementary, middle, and high school) and school districts across two counties, were included in the statistical and spatial analyses. COVID-19 case rates were determined and spatially mapped. Regression was performed adjusting for specific covariates. RESULTS Mask-wearing was associated with lower COVID-19 cases during the peak Delta variant period; overall, regardless of the Delta variant period, higher COVID-19 rates were seen in older aged students. CONCLUSION This study highlights the need for more layered prevention strategies and policies that take into consideration local community transmission levels, age of students, and vaccination coverage to ensure that students remain safe at school while optimizing their learning environment.
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Affiliation(s)
- Xiting Lin
- Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | - Fatima Ali
- Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | - Traci Leong
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | | | | | - Zoey Zuo
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Chaohua Li
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | | | - Fengxia Yan
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | - Peter T Baltrus
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | - Sonya Randolph
- Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA
| | - Lilly Cheng Immergluck
- Department of Microbiology/Biochemistry/Immunology and Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA
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Arlen AM, Leong T, Kirsch AJ, Cooper CS. Spontaneous vesicoureteral reflux resolution curves based on ureteral diameter ratio. J Pediatr Urol 2023:S1477-5131(23)00157-2. [PMID: 37188603 DOI: 10.1016/j.jpurol.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Various factors influence the clinical course of vesicoureteral reflux (VUR) in the pediatric population. Distal ureteral diameter ratio (UDR) is an objective measure reflective of ureterovesical junction anatomy that has been shown to independently predict both spontaneous resolution and breakthrough febrile urinary tract infection (UTI) in children with primary reflux. UDR resolution curves were created, hypothesizing that a UDR value existed at which spontaneous resolution was unlikely to occur. MATERIALS AND METHODS UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1-L3 vertebral bodies. Recursive partitioning with 10-fold cross validation methodology for time to event data, utilizing martingale residuals was used to create high and low risk groups based on UDR, and stratified by age at diagnosis and laterality. RESULTS Three hundred and four patients (226 female, 78 male) were analyzed with a mean age at diagnosis of 1.55 ± 1.98 years. Unilateral reflux (p = 0.02), VUR grades 1-3 (p < 0.001), and lower UDR (p < 0.001) were associated with spontaneous resolution on univariate analysis. UDR values were categorized into risk groups based on recursive partitioning. Low risk patients (those with UDR <0.30) achieved VUR resolution faster and with a continuing rate compared to the high-risk group (≥0.30), which had persistent reflux after 3 years [Summary Figure]. When the 0.30 cutoff was applied randomly to patients in test group, the cutoff significantly discriminated between low and high-risk patients (log rank test p = 0.02). DISCUSSION Primary VUR is often a self-limiting diagnosis, with conservative management favored in low-risk children, UDR may be used to help distinguish those children who may benefit from intervention. Unlike traditional VUR grading where children with any grade of reflux may spontaneously resolve, there appears to be a consistent UDR cutoff whereby patients are very unlikely to spontaneously resolve, regardless of length of follow-up. Therefore, parents of children with a UDR above the 0.3 cutoff, regardless of VUR grade, may be counselled that VUR is very unlikely to resolve over time - thereby reducing the number of VCUGs and length of time these patients are on prophylactic antibiotic prior to surgical intervention. CONCLUSIONS Children with primary VUR and a UDR of greater than 0.30 are significantly less likely to spontaneously resolve regardless of length of follow-up, and resolution after 3 years was rare. UDR provides objective prognostic information facilitating individualized patient management.
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Affiliation(s)
- Angela M Arlen
- From the Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Traci Leong
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew J Kirsch
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Christopher S Cooper
- Departments of Urology and Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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Immergluck LC, Geng R, Li C, Edelson M, Lin X, Waller LA, Rust G, Xu J, Leong T, Baltrus P. Space-Time Trends of Community Onset Staphylococcus aureus Infections in Children: A Group Based Trajectory Modeling Approach. Ann Epidemiol 2023:S1047-2797(23)00045-5. [PMID: 36905976 DOI: 10.1016/j.annepidem.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/04/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Staphylococcus aureus (S. aureus) remains a serious cause of infections in the U.S. and worldwide. In the U.S., methicillin resistant S. aureus (MRSA) is the leading cause of skin and soft tissue infections. This study identifies 'best' to 'worst' infection trends from 2002 to 2016, using group-based trajectory modelling approach. METHODS Electronic health records of children living in the southeastern U.S. with S. aureus infections from 2002-2016 were retrospectively studied, by applying a group-based trajectory model to estimate infection trends (low, high, very high), and then assess spatial significance of these trends at the census tract level; we focused on community onset (CO) infections and not those considered healthcare acquired. RESULTS Three methicillin sensitive (MSSA) infection trends (low, high, very high) and three MRSA trends (low, high, very high) were identified from 2002-2016. Among census tracts with community onset (CO) S. aureus cases, 29% of tracts belonged to the best trend (low infection) for both MRSA and MSSA; higher proportions occurring in the less densely populated areas. Race disparities were seen with the worst MRSA infection trends and were more often in urban areas. CONCLUSIONS Group based trajectory modeling identified unique trends of S. aureus infection rates over time and space, giving insight into the associated population characteristics which reflect these trends of community onset infection.
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Affiliation(s)
- Lilly Cheng Immergluck
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology; Clinical Research Center -Pediatric Clinical & Translational Research Unit,720 Westview Dr., Atlanta, Georgia 30310, USA.
| | - Ruijin Geng
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology; Clinical Research Center -Pediatric Clinical & Translational Research Unit,720 Westview Dr., Atlanta, Georgia 30310, USA
| | - Chaohua Li
- Morehouse School of Medicine, National Center for Primary Care, 720 Westview Dr., Atlanta, Georgia 30310, USA.
| | - Mike Edelson
- Interdev, 900 Holcomb Woods Parkway, Roswell, Georgia 30076 USA.
| | - Xiting Lin
- Morehouse School of Medicine, Department of Microbiology/Biochemistry/Immunology; Clinical Research Center -Pediatric Clinical & Translational Research Unit,720 Westview Dr., Atlanta, Georgia 30310, USA.
| | - Lance A Waller
- Emory University, Rollins School of Public Health, Department of Biostatistics & Bioinformatics, 201 Dowman Drive, Atlanta Georgia 30322, USA.
| | - George Rust
- Florida State University, Center for Medicine & Public Health, 1115 West Call Street, Tallahassee, Florida 32306, USA.
| | - Junjun Xu
- Ningbo Consulting, Inc, 1813 Cromwell Walk, Atlanta, Georgia 30338, USA.
| | - Traci Leong
- Emory University, Rollins School of Public Health, Department of Biostatistics & Bioinformatics, 201 Dowman Drive, Atlanta Georgia 30322, USA.
| | - Peter Baltrus
- Morehouse School of Medicine, National Center for Primary Care, 720 Westview Dr., Atlanta, Georgia 30310, USA.
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Li H, Herms L, Leong T, Conkling PR, Franco S, Singhal P, Mamtani R, Bupathi M. US real-world first-line (1L) treatment patterns and outcomes for patients with metastatic urothelial carcinoma (mUC) following maintenance avelumab approval. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
483 Background: The introduction of the immune checkpoint inhibitors (ICI) pembrolizumab and atezolizumab has dramatically changed the 1L mUC treatment paradigm. These agents are currently recommended by the National Comprehensive Cancer Network for platinum-ineligible patients (irrespective of programmed death-ligand 1 (PD-L1) status) and, in the case of atezolizumab, for cisplatin-ineligible patients whose tumors express PD-L1. More recently, avelumab, received approval as the first ICI for the maintenance treatment of patients who have not progressed on 1L platinum-containing chemotherapy. In this study, we described real-world 1L treatment patterns and outcomes for mUC patients following avelumab maintenance approval. Methods: We used electronic medical record data from The US Oncology Network, which includes 1,400 affiliated physicians operating in over 500 sites of care across states and treats approximately 1.2 million cancer patients annually. mUC patients diagnosed between 30 April 2020 (i.e., ~3 months before avelumab maintenance approval) and 30 June 2021 were included, with follow-up until 31 December 2021, last patient record or death, whichever occurred first. Chart review was conducted to verify mUC diagnosis, baseline characteristics, treatment patterns, and clinical outcomes. Avelumab maintenance was defined as receiving avelumab after 1L platinum-containing chemotherapy, with no documented progressive disease prior to avelumab start or as maintenance therapy indicated by physician notes. Results: A total of 249 eligible mUC patients initiated 1L treatment. Of these, 132 (53%) received ICI monotherapy, 99 (40%) received platinum-containing chemotherapy, and 18 (7%) received other treatments. Almost one-third (n=32) of those who received 1L platinum-containing chemotherapy received avelumab maintenance therapy. ICI monotherapy use increased with age, ranging from 36% among <65-year-olds to 67% among ≥75-year-olds. During a median follow-up of 14.5 months, 68 (27%) patients received second-line treatment. Median (95% confidence interval) overall survival (OS) for 1L ICI monotherapy and 1L platinum-containing chemotherapy was 10.9 (7.2, 13.0) and 16.8 (13.5, not reached) months, respectively. Conclusions: During the 18-month period following maintenance avelumab approval, in this US community oncology setting, ICI monotherapy was the most utilized 1L treatment for mUC patients, especially among older patients. The uptake of maintenance avelumab was modest. Longer follow-up is needed to further characterize OS, especially for those who received platinum therapy followed by avelumab maintenance.
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Affiliation(s)
| | | | | | | | | | | | - Ronac Mamtani
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Lin X, Ali F, Edelson MR, Jerris RC, Leong T, Baltrus PT, Immergluck L. 568. Using Machine Learning to Predict Place-Based Risks for Staphylococcus aureus Infections in Children. Open Forum Infect Dis 2022. [PMCID: PMC9751907 DOI: 10.1093/ofid/ofac492.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Community-onset Staphylococcus aureus (CO-S. aureus) pediatric infections, methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) continue to contribute to the burden of infections seen in the ambulatory setting in the US. Individual risk factors have been identified, but place-based factors and specific geographic locality have not been well-studied. The purpose of this study is to predict place-based factors that contribute to the spread of CO-S. aureus in a major urban area using maximum entropy (MaxEnt), a machine learning technique. Methods Electronic medical records from two pediatric hospitals (2002 to 2016) were retrospectively reviewed. Inclusion criteria: a confirmed S. aureus infection within 48 hours of hospital admission (CO-S. aureus), < 19 years old, and a geo-referenced address within Atlanta’s metropolitan statistical area (MSA). Fourteen place-based factors, at the US Census block group level, were included in the MaxEnt models: < 18 years old, Caucasian, African American, ethnicity, poverty, education attainment, crowding, daycare, kindergarten enrollment, distance to K-12 school, distance to a children’s hospital, distance to a daycare center, and population density. A total of four models (CO-MRSA early, CO-MSSA early, CO-MRSA later, and CO-MSSA later) were run using the MaxEnt software. For each model, 75% and 25% of data was randomly assigned to training and testing groups, respectively. Models were assessed by jack-knife tests. Results 16,124 records met eligibility criteria for MaxEnt models. The training Area Under the Curve (AUC) ranged from 0.771 to 0.837 and the test AUC ranged from 0.769 to 0.804. Population density had the highest contribution in predicting CO-MRSA and CO-MSSA locations, which was confirmed by jack-knife tests. Conclusion By applying MaxEnt to pediatric CO-S. aureus infections in the Atlanta MSA, it was found that higher risks of CO-S. aureus infections may exist in more densely populated areas. MaxEnt can be utilized to identify potential future areas of CO-MRSA and CO-MSSA infections based on estimated or predicted changes to the place-based factors used to build these models. Disclosures Lilly Immergluck, MD, MS, GSK: Clinical Trial- PI|Merck: Vaccine Trial Site- serve as PI|Moderna: Board Member|Novavax: Part of CoVID-19 Phase 3 Trial through US Covid Prevention Network.
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Affiliation(s)
- Xiting Lin
- Morehouse School of Medicine, Atlanta, Georgia
| | - Fatima Ali
- Morehouse School of Medicine, Atlanta, Georgia
| | | | - Robert C Jerris
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, Georgia
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Patidar V, Park JM, Khasnavis T, Baker D, Leong T, Crichlow V, Hunt DP, O’Donnell C. Evaluation of a Multifaceted Protocol in Reducing Unnecessary Telemetry Monitoring across a Large Healthcare System. South Med J 2022; 115:930-935. [DOI: 10.14423/smj.0000000000001485] [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: 03/29/2023]
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O'Boyle H, Kirpalani A, Weiss L, Hames N, Li R, Leong T, Gonzalez M, Shane AL, Charvat C. Management and Outcomes of Salmonella Gastroenteritis in the Era of Rapid Molecular Testing. Hosp Pediatr 2022; 12:1011-1019. [PMID: 36263712 DOI: 10.1542/hpeds.2021-006450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Molecular diagnostics provide a rapid and sensitive diagnosis of gastroenteritis compared with a stool culture. In this study, we seek to describe the changes in medical management and outcomes of children with Salmonella gastroenteritis as our hospital system adopted molecular diagnostics. METHODS This study is a retrospective chart review of children <18 years of age diagnosed with nontyphoidal Salmonella gastroenteritis between 2008 and 2018 at a large pediatric health care system in the southeastern United States. Those with immunocompromising conditions and hemoglobinopathies were excluded. Patients diagnosed via molecular testing were compared with those diagnosed solely by stool culture for aspects of management including admission rates, blood culture obtainment, and antibiotic administration. RESULTS Of 965 eligible patients with Salmonella gastroenteritis, 264 (27%) had a stool molecular test and 701 (73%) only had a stool culture performed. Groups were similar in age and presentation. Those diagnosed by molecular methods had higher hospitalization rates (69% vs 50%, P <.001), more blood cultures obtained (54% vs 44%, P <.01), and received more antibiotics (49% vs 34%, P <.001) despite statistically similar rates of bacteremia (11% vs 19%, P = .05). CONCLUSIONS The rapid diagnosis of Salmonella gastroenteritis by molecular methods was associated with increased hospital admission rates, blood culture obtainment, and antibiotic use. This suggests possible overmedicalization of uncomplicated Salmonella gastroenteritis, and clinicians should remain cognizant of the possibility of providing low-value care for uncomplicated disease.
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Affiliation(s)
- Hillary O'Boyle
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Affiliation has changed since this research was conducted
| | - Anjali Kirpalani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lindsay Weiss
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nicole Hames
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ruoxing Li
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | | | - Andi L Shane
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Courtney Charvat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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Obermannová R, Alsina M, Cervantes A, Leong T, Lordick F, Nilsson M, van Grieken NCT, Vogel A, Smyth EC. Oesophageal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2022; 33:992-1004. [PMID: 35914638 DOI: 10.1016/j.annonc.2022.07.003] [Citation(s) in RCA: 121] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- R Obermannová
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - M Alsina
- Department of Medical Oncology, Hospital Universitario de Navarra (HUN), Pamplona; Gastrointestinal Tumours Group, Vall d'Hebron Institute of Oncology, Barcelona
| | - A Cervantes
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia; CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - T Leong
- The Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - F Lordick
- Department of Medicine II (Oncology, Gastroenterology, Hepatology, Pulmonology and Infectious Diseases), University Cancer Center Leipzig (UCCL), Leipzig University Medical Center, Leipzig, Germany
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - N C T van Grieken
- Department of Pathology, Amsterdam University Medical Centers, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
| | - A Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - E C Smyth
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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11
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Li DC, Dighe NM, Barbee BR, Pitts EG, Kochoian B, Blumenthal SA, Figueroa J, Leong T, Gourley SL. A molecularly integrated amygdalo-fronto-striatal network coordinates flexible learning and memory. Nat Neurosci 2022; 25:1213-1224. [PMID: 36042313 PMCID: PMC10614133 DOI: 10.1038/s41593-022-01148-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/18/2022] [Indexed: 01/28/2023]
Abstract
Behavioral flexibility-that is, the ability to deviate from established behavioral sequences-is critical for navigating dynamic environments and requires the durable encoding and retrieval of new memories to guide future choice. The orbitofrontal cortex (OFC) supports outcome-guided behaviors. However, the coordinated neural circuitry and cellular mechanisms by which OFC connections sustain flexible learning and memory remain elusive. Here we demonstrate in mice that basolateral amygdala (BLA)→OFC projections bidirectionally control memory formation when familiar behaviors are unexpectedly not rewarded, whereas OFC→dorsomedial striatum (DMS) projections facilitate memory retrieval. OFC neuronal ensembles store a memory trace for newly learned information, which appears to be facilitated by circuit-specific dendritic spine plasticity and neurotrophin signaling within defined BLA-OFC-DMS connections and obstructed by cocaine. Thus, we describe the directional transmission of information within an integrated amygdalo-fronto-striatal circuit across time, whereby novel memories are encoded by BLA→OFC inputs, represented within OFC ensembles and retrieved via OFC→DMS outputs during future choice.
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Affiliation(s)
- Dan C Li
- Medical Scientist Training Program, Emory University School of Medicine, Atlanta, GA, USA
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Niharika M Dighe
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Britton R Barbee
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Elizabeth G Pitts
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Brik Kochoian
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Sarah A Blumenthal
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Janet Figueroa
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Traci Leong
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Shannon L Gourley
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
- Emory National Primate Research Center, Emory University, Atlanta, GA, USA.
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12
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Hussen SA, Doraivelu K, Camp DM, Moore SJ, Kalokhe AS, Wade R, Leong T, Ali MK, Farber EW. Burden and Correlates of Mental Health Symptoms Among Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Engaged in HIV Care in Atlanta. AIDS Behav 2022; 26:2844-2854. [PMID: 35199249 DOI: 10.1007/s10461-022-03629-1] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 11/01/2022]
Abstract
Mental health comorbidities are prevalent among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) living with HIV and can adversely impact HIV-related outcomes. We conducted a cross-sectional survey study with 100 YB-GBMSM recruited from two HIV care centers in Atlanta, and constructed multivariable logistic and linear regression models to examine correlates of depression, anxiety, trauma symptoms, and general well-being. In adjusted models, full-time employment was associated with fewer depressive symptoms, while HIV stigma and substance use were associated with higher levels of depressive symptoms. Younger age and full-time employment were negatively associated with severe anxiety, while HIV stigma was positively associated with severe anxiety and trauma symptoms. Trust in physicians, lower HIV stigma, full-time employment, and lack of substance use were associated with higher average general well-being scores. In conclusion, we found high frequency of depressive, anxiety, and trauma-related symptoms among this sample of YB-GBMSM living with HIV. Unemployment, substance use, and HIV stigma emerged as particularly salient correlates of psychological morbidity, suggesting a need for structural and community-level interventions to address mental health in this population.
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Affiliation(s)
- Sophia A Hussen
- Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Mailstop 1518-002-7BB, Atlanta, GA, 30322, USA.
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Kamini Doraivelu
- Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Mailstop 1518-002-7BB, Atlanta, GA, 30322, USA
| | - Daniel M Camp
- Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Mailstop 1518-002-7BB, Atlanta, GA, 30322, USA
| | - Shamia J Moore
- Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Mailstop 1518-002-7BB, Atlanta, GA, 30322, USA
| | - Ameeta S Kalokhe
- Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Mailstop 1518-002-7BB, Atlanta, GA, 30322, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ryan Wade
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Traci Leong
- Department of Biostatistics, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Mohammed K Ali
- Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Mailstop 1518-002-7BB, Atlanta, GA, 30322, USA
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Eugene W Farber
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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13
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Stirling R, Smith S, Brand M, Harden S, Briggs L, Leigh L, Brims F, Brooke M, Brunelli V, Chia C, Dawkins P, Lawrenson R, Duffy M, Evans S, Leong T, Marshall H, Patel D, Pavlakis N, Philip J, Rankin N, Singhal N, Stone E, Tay R, Vinod S, Windsor M, Wright G, Leong D, Zalcberg J. EP04.01-023 Development of an Australia and New Zealand Lung Cancer Clinical Quality Registry (ANZLCR). J Thorac Oncol 2022. [DOI: 10.1016/j.jtho.2022.07.435] [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: 10/14/2022]
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14
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Stevens JP, Xiang Y, Leong T, Naik K, Gupta NA. Portal vein complications and outcomes following pediatric liver transplantation: Data from the Society of Pediatric Liver Transplantation. Liver Transpl 2022; 28:1196-1206. [PMID: 35092344 DOI: 10.1002/lt.26412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 09/22/2021] [Revised: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 12/29/2022]
Abstract
Children who undergo liver transplantation are at risk for portal vein complications (PVCs) including thrombosis (PVT) and stenosis (PVS). Using multicenter data from the Society of Pediatric Liver Transplantation, we analyzed the prevalence, timing, and risk factors for PVC following a first liver transplantation, and assessed the potential impact of PVC on patient outcomes. Our cohort included 4278 patients, of whom 327 (7.6%) developed PVC. Multivariate analysis discovered several factors independently associated with PVC: younger recipient age, lower weight at time of transplantation, diagnosis of biliary atresia (BA), receiving a technical variant graft (TVG), warm ischemia time over 3 h, PVT in the recipient's pretransplantation native liver, and concurrent hepatic artery thrombosis (all p < 0.05). Subgroup analysis of those with BA found higher prevalence in patients transplanted at less than 2 years of age and those with TVGs. There was no difference in PVC prevalence among patients with BA with vs. without prior Kasai portoenterostomy. Most PVT (77.7%) presented within 90 days after transplantation. Patients with PVC had a higher risk of graft failure (23.9% vs. 8.3%; adjusted hazard ratio [HR], 3.08; p < 0.001) and a higher risk of death (16.4% vs. 8.9%; adjusted HR, 1.96; p = 0.01). Recurrence after retransplantation was similar to the overall prevalence in the cohort (8.2%). Our results recognize the common occurrence of PVC following pediatric liver transplantation, describe independently associated risk factors, and determine that patients with PVC have worse outcomes. Further studies are needed to improve PVC prevention, detection, and management strategies.
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Affiliation(s)
- James P Stevens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Yijin Xiang
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Traci Leong
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kushal Naik
- Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nitika Arora Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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15
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Glover B, Charvat C, Weiss L, Kirpalani A, Shane AL, Li R, Leong T, Hames N. Intravenous Antibiotic Duration for Nontyphoidal Salmonella Bacteremia in Children. Hosp Pediatr 2022; 12:e225-e229. [PMID: 35726559 DOI: 10.1542/hpeds.2021-006387] [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] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVE The optimal duration of intravenous (IV) antibiotic therapy for children with nontyphoidal Salmonella bacteremia (NTSB) is unknown. The objective of the authors of this study is to evaluate differences in outcomes among children with NTSB who received a short (≤3 days; short-duration group [SDG]) versus long (>3 days; long-duration group [LDG]) course of IV antibiotics. METHODS This is a retrospective study of children 3 months to 18 years old with NTSB admitted to a tertiary pediatric health care system in the southeastern United States between 2008 and 2018. RESULTS Among 57 patients with NTSB without focal infection, 24 (42%) were in the SDG and received IV antibiotics for a median of 3.0 days and 33 (58%) were in the LDG and received IV antibiotics for a median of 5.0 days. Demographic and clinical characteristics were similar between the SDG and LDG. The median total duration of antibiotics was 11.5 days in the SDG and 13.0 in the LDG (P = .068). The median length of stay was 3.0 days in the SDG and 4.0 in the LDG (P ≤ .001). Two children in the SDG (8%) and 1 child in the LDG (3%) returned to the emergency department for care unrelated to the duration of their IV antibiotic therapy (P = .567). None of the children were readmitted for sequelae related to salmonellosis. CONCLUSIONS The duration of IV antibiotics varied for NTSB, but the outcomes were excellent regardless of the initial IV antibiotic duration. Earlier transitions to oral antibiotics can be considered for NTSB.
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Affiliation(s)
- Brianna Glover
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Lindsay Weiss
- Division of Hospital Medicine, Department of Pediatrics, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | | | - Andi L Shane
- Division of Infectious Diseases, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ruoxing Li
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
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16
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Alholm Z, He D, Ting J, Zhang YJ, Sudharshan L, Leong T, Coleman RL, Monk BJ. Real-world treatment drop-off among recurrent or metastatic cervical cancer patients: A US community oncology-based analysis. Gynecol Oncol 2022; 166:567-575. [DOI: 10.1016/j.ygyno.2022.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/12/2022] [Accepted: 07/21/2022] [Indexed: 12/18/2022]
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17
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Arlen AM, Amin J, Leong T. Voiding cystourethrogram: Who gets a cyclic study and does it matter? J Pediatr Urol 2022; 18:378-382. [PMID: 35241383 DOI: 10.1016/j.jpurol.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/06/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Voiding cystourethrogram (VCUG) images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when vesicoureteral reflux (VUR) is present. Given the variation in VCUG technique and reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016, which included the recommendation of at least 2 voiding cycles to identify intermittent VUR and/or ureteral ectopia. STUDY DESIGN VCUG were assessed for adherence to performance of cyclic study. Children who underwent cyclic evaluation were compared to those who underwent a single cycle VCUG. Radiation dosage was also analyzed. Studies performed on patients >18 years of age and those obtained as part of a trauma evaluation were excluded from study. RESULTS Two hundred and eighty-four VCUGs were analyzed, 97 (34.2%) were positive for VUR on the initial cycle. Of the remaining 187 studies, 116 (62%) had multiple filling-voiding cycles while in 71 (38%) only a single cycle was performed. One hundred and sixty-one (86.1%) were negative for vesicoureteral reflux. Twenty-six (13.9%) children were diagnosed with VUR after the initial filling-voiding cycle: 6 were diagnosed with grade I, 2 grade II, 11 grade III, 2 grade IV and 5 grade V. Of the 123 total children found to have VUR, 26 (21.2%) were diagnosed after an initial negative cycle. Younger children were significantly more likely to have a cyclic study performed; mean age of patients undergoing a cyclic study was 1.09 ± 2.16 years versus 3.86 ± 4.5 years (p ≤ 0.0001). Categorically, 74.1% of children less than 1 year of age underwent a cyclic study compared to 6.9% of children older than 5 years of age (p ≤ 0.0001). There was no difference based on sex with 49.1% of males and 50.9% of females (p = 0.667) undergoing cyclic evaluation. Children undergoing a cyclic study had lower median radiation dose 2.15 microGy m2 (range 0.09-111) compared to 4.41 (range 1.3-104) [p = 0.01]. DISCUSSION Vesicoureteral reflux may occur intermittently and cyclic VCUG is thought to enhance the ability to detect reflux. In our cohort, 26 children (9.2%) were only diagnosed after an additional cycle - ie 21.1% of reflux would have been missed had a cyclic study not been performed. The majority of these patients (69.2%, 18 of 26) were found to have dilating, and thus perhaps more clinically significant, reflux. Our study highlights the importance of obtaining as much information as possible and adhering to the standardized VCUG protocol. CONCLUSION Younger children are more likely to undergo cyclic VCUG. While most reflux is detected with the initial filling-voiding cycle, 26 (21.2%) patients were diagnosed after an initial negative cycle with the majority being dilating VUR.
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Affiliation(s)
- Angela M Arlen
- Department of Urology, Yale School of Medicine, New Haven, CT, USA.
| | - Jay Amin
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Traci Leong
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
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18
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Marinelli B, Goldman D, Sharma H, Leong T, Bishay V, Garcia-Reyes K, Shilo D, Kim E, Nowakowski S, Fischman A, Lookstein R, Patel R. Abstract No. 187 Safety and feasibility of “gun-sight technique” for complex transjugular intrahepatic portosystemic shunt (TIPS) creation: single-center retrospective study of 98 interventions. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Vos MB, Gonzalez MD, Stone C, Cleeton R, Figueroa J, Jerris R, Park SI, Heilman S, Nayee R, Chahroudi A, Schoof N, Mavigner M, Morris CR, Leong T, Grindle A, Westbrook A, Lam W, Rogers BB. Comparison of Mid-turbinate Nasal Swabs, Saliva and Nasopharyngeal Swabs for SARSCoV-2 Reverse Transcription Polymerase Chain Reaction Testing in Pediatric Outpatients. Arch Pathol Lab Med 2022; 146:1056-1061. [PMID: 35576234 DOI: 10.5858/arpa.2021-0625-sa] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.– Diagnostic testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in symptomatic and asymptomatic children remains integral to care, particularly for supporting return to and attendance in schools. The concordance of SARS-CoV-2 detection in children using various specimen types has not been widely studied. OBJECTIVE.– To compare three sample types for SARS-CoV-2 PCR testing in children collected and tested at a single facility. DESIGN.– We prospectively recruited 142 symptomatic and asymptomatic children into a sample comparison study performed in a single healthcare system. Each child provided self-collected saliva, and a trained healthcare provider collected a mid-turbinate nasal swab and nasopharyngeal (NP) swab. Specimens were assayed within 24 hours of collection using reverse transcriptase-polymerase chain reaction (RT-PCR) to detect SARS-CoV-2 on a single testing platform. RESULTS.– Concurrently collected saliva and mid-turbinate swabs had >95% positive agreement with NP swabs when obtained within 10 days of symptom onset. Positive agreement of saliva and mid-turbinate samples collected from children with symptom onset >10 days prior, or without symptoms, was 82% compared to NP swab samples. Cycle threshold (Ct) values for mid-turbinate nasal samples more closely correlated with Ct values from NP samples than saliva sample Ct values. CONCLUSIONS.– These findings suggest that all three sample types from children are useful for SARS-CoV-2 diagnostic testing by RT-PCR, and that concordance is greatest when the child has symptoms of coronavirus disease 2019 (COVID-19) within the past 10 days. This study provides scientific justification for utilizing sample types other than the NP swab for SARS-CoV-2 testing in pediatric populations.
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Affiliation(s)
- Miriam B Vos
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Mark D Gonzalez
- Department of Pathology (Gonzalez, Jerris, Park, Rogers), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Cheryl Stone
- Department of Research Administration (Stone), Children's Healthcare of Atlanta, Atlanta, GA
| | - Rebecca Cleeton
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Janet Figueroa
- Department of Pediatrics (Figueroa, Nayee, Schoof, Mavigner, Westbrook), Emory University School of Medicine, Atlanta, GA
| | - Robert Jerris
- Department of Pathology (Gonzalez, Jerris, Park, Rogers), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Sunita I Park
- Department of Pathology (Gonzalez, Jerris, Park, Rogers), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Stacy Heilman
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Risha Nayee
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA.,Department of Pediatrics (Figueroa, Nayee, Schoof, Mavigner, Westbrook), Emory University School of Medicine, Atlanta, GA
| | - Ann Chahroudi
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Nils Schoof
- Department of Pediatrics (Figueroa, Nayee, Schoof, Mavigner, Westbrook), Emory University School of Medicine, Atlanta, GA
| | - Maud Mavigner
- Department of Pediatrics (Figueroa, Nayee, Schoof, Mavigner, Westbrook), Emory University School of Medicine, Atlanta, GA
| | - Claudia R Morris
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, GA (Leong)
| | - Amanda Grindle
- Special Care Unit (Grindle), Children's Healthcare of Atlanta, Atlanta, GA
| | - Adrianna Westbrook
- Department of Pediatrics (Figueroa, Nayee, Schoof, Mavigner, Westbrook), Emory University School of Medicine, Atlanta, GA
| | - Wilbur Lam
- Department of Pediatrics (Vos, Cleeton, Heilman, Nayee, Chahroudi, Morris, Lam), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Georgia Institute of Technology (Lam)
| | - Beverly B Rogers
- Department of Pathology (Gonzalez, Jerris, Park, Rogers), Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
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20
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Nadeem S, Tangpricha V, Ziegler TR, Rhodes JE, Leong T, Xiang Y, Greenbaum LA. Randomized trial of two maintenance doses of vitamin D in children with chronic kidney disease. Pediatr Nephrol 2022; 37:415-422. [PMID: 34392411 DOI: 10.1007/s00467-021-05228-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Correction of nutritional vitamin deficiency is recommended in children with chronic kidney disease (CKD). The optimal daily dose of vitamin D to achieve or maintain vitamin D sufficiency is unknown. METHODS We conducted a phase III, double-blind, randomized trial of two doses of vitamin D3 in children ≥ 9 years of age with CKD stages 3-5 or kidney transplant recipients. Patients were randomized to 1000 IU or 4000 IU of daily vitamin D3 orally. We measured 25-hydroxvitamin D (25(OH)D) levels at baseline, 3 months and 6 months. The primary efficacy outcome was the percentage of patients who were vitamin D replete (25(OH)D ≥ 30 ng/mL) at 6 months. RESULTS Ninety-eight patients were enrolled: 49 randomized into each group. Eighty (81.6%) patients completed the study and were analyzed. Baseline plasma 25(OH)D levels were ≥ 30 ng/mL in 12 (35.3%) and 12 (27.3%) patients in the 1000 IU and 4000 IU treatment groups, respectively. At 6 months, plasma 25(OH)D levels were ≥ 30 ng/mL in 33.3% (95% CI: 18.0-51.8%) and 74.4% (95% CI: 58.8-86.5%) in the 1000 IU and 4000 IU treatment groups, respectively (p = 0.0008). None of the patients developed vitamin D toxicity or hypercalcemia. CONCLUSIONS In children with CKD, 1000 IU of daily vitamin D3 is unlikely to achieve or maintain a plasma 25(OH)D ≥ 30 ng/mL. In children with CKD stages 3-5, a dose of vitamin D3 4000 IU daily was effective in achieving or maintaining vitamin D sufficiency. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01909115.
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Affiliation(s)
- Shahid Nadeem
- Department of Pediatrics, University of Texas Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, USA.
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - James E Rhodes
- Investigational Drug Service Pharmacy, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Traci Leong
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
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21
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Immergluck L, geng R, Li C, Edelson M, Waller L, Rust G, Xu J, Ali F, Baltrus P, Leong T. 2. Space Time Trends of Community Onset Staphylococcus aureus Infections in Children Living in Southeastern United States: 2002-2016. Open Forum Infect Dis 2021. [PMCID: PMC8644380 DOI: 10.1093/ofid/ofab466.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Staphylococcus aureus (S. aureus) remains a serious cause of infections in the United States and worldwide. Methicillin susceptible S. aureus (MSSA) is the cause of half of all health care–associated staphylococcal infections, and Methicillin Resistant S. aureus (MRSA) is the leading cause of community onset skin and soft tissue infections in the US. This study looks at a 15-year trend of community onset (CO)-MRSA and MSSA infections and determines ‘best’ to ‘worst’ infection trends. We identified distinct groups of CO-MRSA and MSSA infection rate trajectories by grouping census tracts of the 20 county Atlanta Metropolitan Statistical Area (MSA) between 2002 to 2016 with similar temporal trajectories. Methods This is a retrospective study from 2002-2016, using electronic health records of children living in Atlanta, Georgia with S. aureus infections and relevant US census data (at the census tract level). A group based trajectory model was applied to generate community onset S. aureus trajectory infection groups (low, high, very high) by census tract and were mapped using ArcGIS. ![]()
Results Three CO-MSSA infection groups (low, high, very high) and two CO-MRSA infection groups (low, high) were detected among 909 census tracts in the 20 counties. We found ~74% of all the census tracts with S.aureus occurrence during this time period belonged to low infection rate groups for both MRSA and MSSA, with a higher proportion occurring in the less densely populated counties. Census tracts in DeKalb County, one of Atlanta’s most densely populated areas, had the highest proportion of the worst infection trend patterns (CO-MRSA high or very high, CO-MSSA high or very high). Trends of Community-Onset MRSA and MSSA Infection Rates Based on Group-based Trajectory Models ![]()
Spatial patterns for CO-MRSA and CO-MSSA Trajectory Trends in the Atlanta Metropolitan Area Between 2002 to 2016 ![]()
Conclusion Trends of S. aureus infection patterns, stratified by antibiotic resistance over geographic areas and time, identify communities with higher risks for MRSA infection compared to MSSA infection. Further investigation of the determinants of the trajectory groupings and the geographic outliers identified by this study may be a way to target prevention strategies aimed to prevent S. aureus infections. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | - Ruijin geng
- Morehouse School of Medicine, Atlanta, GA 30310, Georgia
| | - Chaohua Li
- Morehouse School of Medicine, Atlanta, GA 30310, Georgia
| | | | | | | | - Junjun Xu
- Ningbo Consulting Inc, Dunwoody, Georgia
| | - Fatima Ali
- Morehouse School of Medicine, Atlanta, GA 30310, Georgia
| | - Peter Baltrus
- Morehouse School of Medicine, Atlanta, GA 30310, Georgia
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22
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Vaughan CP, Hwang U, Vandenberg AE, Leong T, Wu D, Stevens MB, Clevenger C, Eucker S, Genes N, Huang W, Ikpe-Ekpo E, Nassisi D, Previl L, Rodriguez S, Sanon M, Schlientz D, Vigliotti D, Hastings SN. Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme. BMJ Open Qual 2021; 10:bmjoq-2021-001369. [PMID: 34750188 PMCID: PMC8576471 DOI: 10.1136/bmjoq-2021-001369] [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: 01/25/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022] Open
Abstract
Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. We describe prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme. EQUIPPED was adapted from a model developed in the Veterans Health Administration (VA) and sequentially implemented in one academic health system per year over a 3-year period. The monthly proportion of PIMs, as defined by the 2015 American Geriatrics Beers Criteria, of all medications prescribed to adults aged 65 years and older at discharge was assessed for 6 months preimplementation until 12 months postimplementation using a generalised linear time series model with a Poisson distribution. The EQUIPPED programme was translated from the VA health system and its electronic medical record into three health systems each using a version of the Epic electronic medical record. Adaptation occurred through local modification of order sets and in the generation and delivery of provider prescribing reports by local champions. Baseline monthly PIM proportions 6 months prior to implementation at the three sites were 5.6% (95% CI 5.0% to 6.3%), 5.8% (95% CI 5.0% to 6.6%) and 7.3% (95% CI 6.4% to 9.2%), respectively. Evaluation of monthly prescribing including the twelve months post-EQUIPPED implementation demonstrated significant reduction in PIMs at one of the three sites. In exploratory analyses, the proportion of benzodiazepine prescriptions decreased across all sites from approximately 17% of PIMs at baseline to 9.5%–12% postimplementation, although not all reached statistical significance. EQUIPPED is feasible to implement outside the VA system. While the impact of the EQUIPPED model may vary across different health systems, results from this initial translation suggest significant reduction in specific high-risk drug classes may be an appropriate target for improvement at sites with relatively low baseline PIM prescribing rates.
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Affiliation(s)
- Camille P Vaughan
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA .,Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Ula Hwang
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Geriatric Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Ann E Vandenberg
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Traci Leong
- Biostatistics and Bioinformatics, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Daniel Wu
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Melissa B Stevens
- Medicine (CPV, AEV, MBS) & Emergency Medicine (DW), Emory University School of Medicine, Atlanta, Georgia, USA.,Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia, USA
| | | | - Stephanie Eucker
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Nick Genes
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wennie Huang
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Edidiong Ikpe-Ekpo
- Emergency Medicine, The Southeast Permanente Medical Group, Atlanta, Georgia, USA
| | - Denise Nassisi
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Previl
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | - Sandra Rodriguez
- Columbia University School of Social Work, New York, New York, USA
| | - Martine Sanon
- Emergency Medicine (NG, DN) and Medicine (MS), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Schlientz
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA
| | | | - S Nicole Hastings
- Medicine (LP, DS, SNH) & Emergency Medicine (SE, WH), Duke University School of Medicine, Durham, NC, USA.,Centre of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
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Lukovic J, Moore A, Lee M, Willis D, Ahmed S, Akra M, Hortobagyi E, Joon D, Kron T, Liu Z, Ryan J, Thomas M, Wall K, Ward I, Wiltshire K, O'Callaghan C, Wong R, Ringash J, Haustermans K, Leong T. The Feasibility of Quality Assurance in the TOPGEAR International Phase III Clinical Trial of Neoadjuvant Chemoradiotherapy for Gastric Cancer (An Intergroup Trial of the AGITG/TROG/EORTC/CCTG). Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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24
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Al-Wahaibi K, Khan I, McAdam B, Leong T. The association between novel ST2, BNP, atrial fibrillation and heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background/Introduction
ST2, a novel marker of fibrosis has been proposed as a novel biomarker for heart failure. There is paucity of data suggesting its association with Atrial Fibrillation (AF), in particular, with regards to the its independent effect after adjustment for clinical factors and traditional biomarkers such as BNP. There is increasing evidence that inflammation and fibrosis are important players in the pathogenesis of AF, the most common arrhythmia that is associated with considerable morbidity.
Purpose
We sought to examine the association of ST2 with AF and its possible incremental value in combination with traditional biomarkers already used in routine clinical practice such as BNP.
Methods
Unselected patients presenting to a Cardiology service who had BNP for clinical reasons, concomitantly had ST2 sent. These patients included those with heart failure, acute coronary syndromes and AF, as well as patients attending cardioversion and cardiac catheterisation. The association between ST2, BNP and clinical factors was examined. ST2 was examined in tertiles as its distribution was highly skewed. Raised BNP was defined as usual (≥100 pg/ml).
Results
Of the 619 patients, the mean age was 69 years and 66% were male. The prevalence of co-morbidities were: Coronary heart disease - CHD (41%), Atrial Fibrillation – AF (30%), Heart Failure - HF (20%), Chronic Kidney Disease – CKD (23%). The mean eGFR was 68 ml/h and the mean LV ejection fraction was 55%. Both ST2 and BNP levels were significantly higher in patients with heart failure, CKD and AF. Mean levels of ST2 were (in ng/ml): HF vs no HF (65 vs. 38, p=0.0001) and in CKD vs. no CKD (49 vs. 41, p=0.001), CAD vs no CAD (43 vs. 42, p=0.3). Mean levels of BNP were (in pg/ml): HF vs no HF (579 vs. 131, p=0.0001), CKD vs. no CKD (379 vs. 173, p=0.0001), CAD vs. no CAD (239 vs. 206, p=0.5).
In patients with AF, levels of both ST2 and BNP were higher, as were their mean ages and prevalence of co-morbidities (see Table 1). Both ST2 and BNP correlated with AF (Pearson r=0.2, p<0.0001 for ST2 and r=0.5, p<0.0001 for BNP). There was also a graded association of ST2 with AF (15%, 33% and 40% across tertiles of ST2, p=0.0001).
Both ST2 and raised BNP were significant associated with AF in both univariable and multi-variable regression models, and remained independent predictors when adjusted for HF, CHD, LV EF and eGFR (Table 2, Model 2 – Relative risk ratio of AF with ST2 across tertiles 1.5, p0.005, and Odds ratio of AF with raised BNP 7.4, p<0.001). However, ST2 loses significance when BNP is added to the model in combination (Table 2 – Model 3).
Conclusions
Both ST2 and BNP are independent predictors of AF even after adjustment for heart failure and other clinical factors. When ST2 is used in combination with BNP, raised BNP appears to be a stronger predictor of AF than ST2.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- K Al-Wahaibi
- Hermitage Medical Clinic, Cardiology, Dublin, Ireland
| | - I Khan
- Hermitage Medical Clinic, Cardiology, Dublin, Ireland
| | - B McAdam
- Hermitage Medical Clinic, Cardiology, Dublin, Ireland
| | - T Leong
- Hermitage Medical Clinic, Cardiology, Dublin, Ireland
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Abstract
BACKGROUND The management of acute pancreatitis (AP) in children was historically derived from adult practice recommendations. Pediatric-specific recommendations for treatment of AP were recently developed by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, but their impact on clinical outcomes has yet to be evaluated. We developed an AP order set on the basis of these recommendations to assess impact on clinical outcomes. METHODS Patients admitted to a single center with 3 children's hospitals in 2017 and 2018 for isolated AP were included in a retrospective review. Patient demographic data, order set use, treatment variables (eg, fluid type, rate, type and timing of diet initiation, and narcotic use), and outcome variables (eg, length of stay [LOS], PICU admission, and 30-day readmission) were collected. Mixed-effects modeling was used to estimate the impact of order set use on clinical outcomes. RESULTS There were 159 pancreatitis encounters and 137 unique patients who met inclusion criteria. In 2018, when using the log transform of LOS in a linear mixed-effects model for clustering by hospital, there was a 10% decrease in mean LOS, but this failed to reach statistical significance (P = .30). Among the 107 encounters who received at least 1 dose of narcotic, there were significantly fewer doses prescribed after implementation of the order set: mean (SD) of5.22 (2.86) vs 3.59 (2.47) (P < .001). Thirty-day readmission (P = .25) and PICU admission rates (P = .31) were not different between years. CONCLUSIONS The implementation of a pancreatitis order set is associated with a significant decrease in narcotic use in pediatric patients with AP without increasing readmission rates or PICU admissions.
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Affiliation(s)
- Meera Shah
- Department of Pediatrics, School of Medicine
| | - Traci Leong
- Division of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - A Jay Freeman
- Children's Healthcare of Atlanta and Division of Gastroenterology, Hepatology and Nutrition
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26
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Ireland-Jenkin K, Fuller P, Alexiadis M, Pendlebury A, Hyde S, Grant P, Lamont J, Leong T, Newman M. Utility of FOXL2 mutation testing in differential diagnosis of adult granulosa cell tumour. Pathology 2021. [DOI: 10.1016/j.pathol.2021.05.085] [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: 10/21/2022]
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27
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Nehl E, Heilman S, Ku D, Gottfried D, Farmer S, Mannino R, Tyburski E, Sullivan J, Suessmith A, Bassit L, Figueroa J, Wood A, Leong T, Rao A, Rogers B, Jerris R, Park S, Gonzalez M, Frediani J, Morris C, Levy J, Schoof N, Mavigner M, Roback J, Herzegh K, Saakadze N, Ingersoll J, Cheedarla N, Neish A, Hanberry B, Porter C, Esper A, Kempker R, Rebolledo P, McGuinness P, Balagadde F, Gore R, Koren A, Pollock N, Rogers E, Simin K, Hafer N, Picard MA, Ghezzi C, McManus D, Buchholz B, Rostad C, Claveria V, Ramachandra T, Wang YF, Washington C, Stone C, Griffiths M, Schinazi R, Chahroudi A, Vos M, Brand O, Martin G, Lam W. The RADx Tech Test Verification Core and the ACME POCT in the Evaluation of COVID-19 Testing Devices: A Model for Progress and Change. IEEE Open J Eng Med Biol 2021; 2:142-151. [PMID: 34192286 PMCID: PMC8118690 DOI: 10.1109/ojemb.2021.3070825] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 12/23/2022] Open
Abstract
Faced with the COVID-19 pandemic, the US system for developing and testing technologies was challenged in unparalleled ways. This article describes the multi-institutional, transdisciplinary team of the “RADxSM Tech Test Verification Core” and its role in expediting evaluations of COVID-19 testing devices. Expertise related to aspects of diagnostic testing was coordinated to evaluate testing devices with the goal of significantly expanding the ability to mass screen Americans to preserve lives and facilitate the safe return to work and school. Focal points included: laboratory and clinical device evaluation of the limit of viral detection, sensitivity, and specificity of devices in controlled and community settings; regulatory expertise to provide focused attention to barriers to device approval and distribution; usability testing from the perspective of patients and those using the tests to identify and overcome device limitations, and engineering assessment to evaluate robustness of design including human factors, manufacturability, and scalability.
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28
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O'Donnell C, Molitch-Hou E, James K, Leong T, Perry M, Wood D, Masud T, Thomas B, Ross MA, Franks N. Fast track dialysis: Improving emergency department and hospital throughput for patients requiring hemodialysis. Am J Emerg Med 2021; 45:92-99. [PMID: 33677266 DOI: 10.1016/j.ajem.2021.02.035] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To describe the impact of a novel communication and triage pathway called fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting to the emergency department (ED). METHODS Prospective and retrospective cohorts of ESRD patients meeting requirements of routine or urgent hemodialysis at a tertiary academic hospital from September 25th, 2016 to September 25th, 2018 in 1 year cohorts. Two sample t-tests were used to compare most outcomes of the cohorts with a Mann-Whitney U test used for skewed data. Nephrology group outcomes were analyzed by two-way ANOVA and Kruskal-Wallis and chi-square tests. RESULTS There were 98 encounters in the historical cohort and 143 encounters in the fast track dialysis cohort. FTD had significantly lowered median ED LOS (4.05 h, vs 5.3 h, p < 0.001), median hospital LOS (12.8 h vs 27 h, p < 0.001), time to hemodialysis (4.78 h vs 7.29 h, p < 0.001), and median hospital charges ($26,040 vs $30,747, p < 0.016). The FTD cohort had increased 30 day ED return for each encounter compared to the historical cohort (1.85 visits vs 0.73 visits, p < 0.001), however no significant increase in 1 year ED visits (6.52 visits vs 5.80, p = 0.4589) or 1 year readmissions (5.89 readmissions vs 4.81 readmissions, p = 0.3584). Most nephrology groups had significantly lower time to hemodialysis order placement and time to start hemodialysis. CONCLUSION A multidisciplinary approach with key stakeholders using a standard pathway can lead to improved efficiency in throughput, reduced charges, and hospital resource utilization for patients needing urgent or routine hemodialysis. A study with a dedicated geographic observation unit for protocolized short stay patients including conditions ranging from low risk chest pain to transient ischemic events that incorporates FTD patients under this protocol should be considered.
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Affiliation(s)
- Christopher O'Donnell
- Division of Hospital Medicine, Department of Medicine, Emory University, 550 Peachtree St, Atlanta, GA 30319, United States of America.
| | - Ethan Molitch-Hou
- Division of Hospital Medicine, Department of Medicine, Emory University, 550 Peachtree St, Atlanta, GA 30319, United States of America; Section of Hospital Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Ave., MC 5000, Chicago, IL 60637, United States of America
| | - Kyle James
- Division of Hospital Medicine, Department of Medicine, Emory University, 550 Peachtree St, Atlanta, GA 30319, United States of America
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA 30322, United States of America
| | - Michael Perry
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
| | - Daniel Wood
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
| | - Tahsin Masud
- Division of Nephrology, Department of Medicine, Emory University, 1639 Pierce Dr. NE # 338, Atlanta, GA 30322, United States of America
| | - Brittany Thomas
- Southwest Atlanta Nephrology, 3620 Martin Luther King Jr Dr. S., Atlanta, GA 30331, United States of America
| | - Michael A Ross
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
| | - Nicole Franks
- Department of Emergency Medicine, Emory University, 100 Woodruff Circle, Atlanta, GA 30322, United States of America
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Best S, Hess J, Souza-Fonseca Guimaraes F, Cursons J, Kersbergen A, You Y, Ng J, Davis M, Leong T, Irving L, Ritchie M, Steinfort D, Huntington N, Sutherland K. FP10.02 Investigating the Immunophenotype of Small Cell Lung Cancer to Improve Immunotherapeutic Targeting. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.01.124] [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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30
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George PE, Stokes CL, Bassit LC, Chahroudi A, Figueroa J, Griffiths MA, Heilman S, Ku DN, Nehl EJ, Leong T, Levy JM, Kempker RR, Mannino RG, Mavigner M, Park SI, Rao A, Rebolledo PA, Roback JD, Rogers BB, Schinazi RF, Suessmith AB, Sullivan J, Tyburski EA, Vos MB, Waggoner JJ, Wang YF(W, Madsen J, Wechsler DS, Joiner CH, Martin GS, Lam WA. Covid-19 will not "magically disappear": Why access to widespread testing is paramount. Am J Hematol 2021; 96:174-178. [PMID: 33576528 PMCID: PMC7753266 DOI: 10.1002/ajh.26059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Paul E. George
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics Atlanta Georgia USA
| | - Claire L. Stokes
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics Atlanta Georgia USA
| | - Leda C. Bassit
- Laboratory of Biochemical Pharmacology, Department of Pediatrics Children's Healthcare of Atlanta, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Ann Chahroudi
- Center for Childhood Infections and Vaccines of Children's Healthcare of Atlanta and Emory University The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Janet Figueroa
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Mark A. Griffiths
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta Georgia USA
| | - Stacy Heilman
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - David N. Ku
- GWW School of Mechanical Engineering The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Georgia Institute of Technology Atlanta Georgia USA
| | - Eric J. Nehl
- Emory University Rollins School of Public Health, Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Atlanta Georgia USA
| | - Traci Leong
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University Rollins School of Public Health Atlanta Georgia USA
| | - Joshua M. Levy
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Russell R. Kempker
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Robert G. Mannino
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Atlanta Georgia USA
| | - Maud Mavigner
- Center for Childhood Infections and Vaccines of Children's Healthcare of Atlanta and Emory University The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Sunita I. Park
- Children's Healthcare of Atlanta The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Anuradha Rao
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Paulina A. Rebolledo
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine, Emory University Rollins School of Public Health Atlanta Georgia USA
| | - John D. Roback
- Center for Transfusion and Cellular Therapies Emory University School of Medicine, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Atlanta Georgia USA
| | - Beverly B. Rogers
- Children's Healthcare of Atlanta The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Raymond F. Schinazi
- Laboratory of Biochemical Pharmacology, Department of Pediatrics Children's Healthcare of Atlanta, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Allie B. Suessmith
- Emory University Laney Graduate School, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Julie Sullivan
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Erika A. Tyburski
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Atlanta Georgia USA
| | - Miriam B. Vos
- Emory University Laney Graduate School, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies, Emory University School of Medicine Atlanta Georgia USA
| | - Jesse J. Waggoner
- Emory University School of Medicine, Division of Infectious Diseases Atlanta Georgia
| | - Yun F. (Wayne) Wang
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Jen Madsen
- The MITRE Corporation McLean Virginia USA
| | - Daniel S. Wechsler
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics Atlanta Georgia USA
| | - Clinton H. Joiner
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics Atlanta Georgia USA
| | - Greg S. Martin
- The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Emory University School of Medicine Atlanta Georgia USA
| | - Wilbur A. Lam
- Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta Emory University School of Medicine, Department of Pediatrics, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, The Atlanta Center for Microsystems‐Engineered Point‐of‐Care Technologies Atlanta Georgia USA
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Lordick F, Nilsson M, Leong T. Adjuvant radiotherapy for gastric cancer-end of the road? Ann Oncol 2020; 32:287-289. [PMID: 33321194 DOI: 10.1016/j.annonc.2020.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- F Lordick
- Department of Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases, University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany.
| | - M Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Leong
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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32
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Savitz S, Leong T, Sung S, Lee K, Rana J, Tabada G, Go A. Novel Data Domains and Machine Learning Modestly Improved Performance of Risk Calculators for Heart Failure Readmission. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- S. Savitz
- Kaiser Permanente Division of Research Oakland CA USA
| | - T. Leong
- Kaiser Permanente Division of Research Oakland CA USA
| | - S.H. Sung
- Kaiser Permanente Division of Research Oakland CA USA
| | - K. Lee
- The Permanente Medical Group Oakland CA USA
| | - J. Rana
- The Permanente Medical Group Oakland CA USA
| | - G. Tabada
- Kaiser Permanente Division of Research Oakland CA USA
| | - A. Go
- Kaiser Permanente Division of Research Oakland CA USA
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Kihira S, Koo C, Mahmoudi K, Leong T, Mei X, Rigney B, Aggarwal A, Doshi AH. Combination of Imaging Features and Clinical Biomarkers Predicts Positive Pathology and Microbiology Findings Suggestive of Spondylodiscitis in Patients Undergoing Image-Guided Percutaneous Biopsy. AJNR Am J Neuroradiol 2020; 41:1316-1322. [PMID: 32554421 DOI: 10.3174/ajnr.a6623] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/23/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Pathology and microbiology results for suspected spondylodiscitis on MR imaging are often negative in up to 70% of cases. We aimed to predict whether MR imaging features will add diagnostic value when combined with clinical biomarkers to predict positive findings of spondylodiscitis on pathology and/or microbiology from percutaneous biopsy. MATERIALS AND METHODS In this retrospective single-center institutional review board-approved study, patients with radiologically suspected spondylodiscitis and having undergone percutaneous biopsies were assessed. Demographic characteristics, laboratory values, and tissue and blood cultures were collected. Pathology and microbiology results were used as end points. Three independent observers provided MR imaging-based scoring for typical MR imaging features for spondylodiscitis. Multivariate logistic regression and receiver operating characteristic analysis were performed to determine an optimal combination of imaging and clinical biomarkers in predicting positive findings on pathology and/or microbiology from percutaneous biopsy suggestive of spondylodiscitis. RESULTS Our patient cohort consisted of 72 patients, of whom 33.3% (24/72) had spondylodiscitis. The mean age was 63 ± 16 years with a male/female ratio of 41:31. Logistic regression revealed a combination with an area under the curve of 0.72 for pathology and 0.68 for pathology and/or microbiology. Epidural enhancement on MR imaging improved predictive performance to 0.87 for pathology and 0.78 for pathology and/or microbiology. CONCLUSIONS Our findings demonstrate that epidural enhancement on MR imaging added diagnostic value when combined with clinical biomarkers to help predict which patients undergoing percutaneous biopsy will have positive findings for spondylodiscitis on pathology and/or microbiology.
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Affiliation(s)
- S Kihira
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - C Koo
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - K Mahmoudi
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - T Leong
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - X Mei
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - B Rigney
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - A Aggarwal
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - A H Doshi
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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Leong T, Roome K, Miller T, Gorbatkin O, Singleton L, Agarwal M, Lazarus SG. Expansion of a multi-pronged safe sleep quality improvement initiative to three children's hospital campuses. Inj Epidemiol 2020; 7:32. [PMID: 32532333 PMCID: PMC7291418 DOI: 10.1186/s40621-020-00256-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their Back, and in a clear Crib to combat relatively stagnant rates of sudden unexpected infant death (SUID). These are referred to as the ABCs of safe sleep. Studies have shown these recommendations are not consistently followed in the hospital setting, but further investigation would determine how to improve the rate of adherence. The objective of this study was to evaluate the impact of an expanded safe sleep initiative at three Georgia free-standing children’s hospital campuses before and after a multipronged safe sleep initiative. Methods A quality improvement program with a pre/post analysis was performed using a convenience method of sampling. Infants < 12 months old in three inpatient pediatric campuses were analyzed pre- and post- interventions. The intervention included: 1) nursing education, 2) identification of nurse “safe sleep” champions, 3) crib cards, 4) crib audits, and 5) weekly reporting of data showing nursing unit ABC compliance via tracking boards. The goal was ABC compliance of ≥25% for the post-intervention period. A standardized crib audit tool evaluated sleep position/location, sleep environment, and ABC compliance (both safe position/location and environment). Chi square analysis, Fisher’s exact test, and logistic regression were used to compare safe sleep behaviors before and after the interventions. Results There were 204 cribs included pre-intervention and 274 cribs post-intervention. Overall, there was not a significant change in sleep position/location (78.4 to 76.6%, p = 0.64). There was a significant increase in the percent of infants sleeping in a safe sleep environment following the intervention (5.9 to 39.8%, p < 0.01). Overall ABC compliance, including both sleep position/location and environment, improved from 4.4% pre-intervention to 32.5% post-intervention (p < 0.01). There was no significant variability between the hospitals (p = 0.71, p = 1.00). Conclusions The AAP’s safe sleep recommendations are currently not upheld in children’s hospitals, but safer sleep was achieved across three children’s campuses in this study. Significant improvements were made in sleep environment and overall safe sleep compliance with this multi-pronged initiative.
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Affiliation(s)
- Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, 30322, USA
| | - Kerryn Roome
- Emory University School of Medicine, Atlanta, 30322, USA
| | - Terri Miller
- Georgia Department of Public Health, Atlanta, 30303, USA
| | | | - Lori Singleton
- Children's Healthcare of Atlanta, Atlanta, 30322, USA.,Morehouse School of Medicine, Atlanta, 30310, USA
| | - Maneesha Agarwal
- Emory University School of Medicine, Atlanta, 30322, USA.,Children's Healthcare of Atlanta, Atlanta, 30322, USA
| | - Sarah Gard Lazarus
- Children's Healthcare of Atlanta, Atlanta, 30322, USA. .,Pediatric Emergency Medicine Associates, Atlanta, 30342, USA.
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Anderson CR, Haydek J, Golub L, Leong T, Smith DT, Liebzeit J, Dressler DD. Practical Evidence-Based Medicine at the Student-to-Physician Transition: Effectiveness of an Undergraduate Medical Education Capstone Course. Med Sci Educ 2020; 30:885-890. [PMID: 34457746 PMCID: PMC8368742 DOI: 10.1007/s40670-020-00970-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Medical information is expanding at exponential rates. Practicing physicians must acquire skills to efficiently navigate large bodies of evidence to answer clinical questions daily. How best to prepare medical students to meet this challenge remains unknown. The authors sought to design, implement, and assess a pragmatic evidence-based medicine (EBM) course engaging students at the transition from undergraduate to graduate medical education. MATERIALS AND METHODS An elective course was offered during the required 1-month Capstone medical school curriculum. Participants included one hundred sixty-eight graduating fourth-year medical students at Emory University School of Medicine who completed the course from 2012 to 2018. Through interactive didactics, small groups, and independent work, students actively employed various electronic tools to navigate medical literature and engaged in structured critical appraisal of guidelines and meta-analyses to answer clinical questions. RESULTS Assessment data was available for 161 of the 168 participants (95.8%). Pre- and post-assessments demonstrated students' significant improvement in perceived and demonstrated EBM knowledge and skills (p < 0.001), consistent across gender and specialty subgroups. DISCUSSION The Capstone EBM course empowered graduating medical students to comfortably navigate electronic medical resources and accurately appraise summary literature. The objective improvement in knowledge, the perceived improvement in skill, and the subjective comments support this curricular approach to effectively prepare graduating students for pragmatic practice-based learning as resident physicians.
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Affiliation(s)
- Caitlin R. Anderson
- Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303 USA
| | - John Haydek
- Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303 USA
| | | | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Dustin T. Smith
- Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303 USA
| | - Jason Liebzeit
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Daniel D. Dressler
- Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303 USA
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Clark J, Lokan J, Fellowes A, Xu H, Smith K, Gan H, Cher L, Desai J, Leong T, Fox S. 51. Adult brainstem anaplastic astrocytoma with an unusual molecular profile. Pathology 2020. [DOI: 10.1016/j.pathol.2020.01.051] [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: 10/25/2022]
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Krishnamurti L, Ross D, Sinha C, Leong T, Bakshi N, Mittal N, Veludhandi D, Pham AP, Taneja A, Gupta K, Nwanze J, Matthews AM, Joshi S, Vazquez Olivieri V, Arjunan S, Okonkwo I, Lukombo I, Lane P, Bakshi N, Loewenstein G. Comparative Effectiveness of a Web-Based Patient Decision Aid for Therapeutic Options for Sickle Cell Disease: Randomized Controlled Trial. J Med Internet Res 2019; 21:e14462. [PMID: 31799940 PMCID: PMC6934048 DOI: 10.2196/14462] [Citation(s) in RCA: 12] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/18/2019] [Accepted: 09/04/2019] [Indexed: 01/30/2023] Open
Abstract
Background Hydroxyurea, chronic blood transfusions, and bone marrow transplantation are efficacious, disease-modifying therapies for sickle cell disease but involve complex risk-benefit trade-offs and decisional dilemma compounded by the lack of comparative studies. A patient decision aid can inform patients about their treatment options, the associated risks and benefits, help them clarify their values, and allow them to participate in medical decision making. Objective The objective of this study was to develop a literacy-sensitive Web-based patient decision aid based on the Ottawa decision support framework, and through a randomized clinical trial estimate the effectiveness of the patient decision aid in improving patient knowledge and their involvement in decision making. Methods We conducted population decisional needs assessments in a nationwide sample of patients, caregivers, community advocates, policy makers, and health care providers using qualitative interviews to identify decisional conflict, knowledge and expectations, values, support and resources, decision types, timing, stages and learning, and personal clinical characteristics. Interview transcripts were coded using QSR NVivo 10. Alpha testing of the patient decision aid prototype was done to establish usability and the accuracy of the information it conveyed, and then was followed by iterative cycles of beta testing. We conducted a randomized clinical trial of adults and of caregivers of pediatric patients to evaluate the efficacy of the patient decision aid. Results In a decisional needs assessment, 223 stakeholders described their preferences, helping to guide the development of the patient decision aid, which then underwent alpha testing by 30 patients and 38 health care providers and iterative cycles of beta testing by 87 stakeholders. In a randomized clinical trial, 120 participants were assigned to either the patient decision aid or standard care (SC) arm. Qualitative interviews revealed high levels of usability, acceptability, and utility of the patient decision aid in education, values clarification, and preparation for decision making. On the acceptability survey, 72% (86/120) of participants rated the patient decision aid as good or excellent. Participants on the patient decision aid arm compared to the SC arm demonstrated a statistically significant improvement in decisional self-efficacy (P=.05) and a reduction in the informed sub-score of decisional conflict (P=.003) at 3 months, with an improvement in preparation for decision making (P<.001) at 6 months. However, there was no improvement in terms of the change in knowledge, the total or other domain scores of decisional conflicts, or decisional self-efficacies at 6 months. The large amount of missing data from survey completion limited our ability to draw conclusions about the effectiveness of the patient decision aid. The patient decision aid met 61 of 62 benchmarks of the international patient decision aid collaboration standards for content, development process, and efficacy. Conclusions We have developed a patient decision aid for sickle cell disease with extensive input from stakeholders and in a randomized clinical trial demonstrated its acceptability and utility in education and decision making. We were unable to demonstrate its effectiveness in improving patient knowledge and involvement in decision making. Trial Registration ClinicalTrials.gov NCT03224429; https://clinicaltrials.gov/ct2/show/NCT03224429 and ClinicalTrials.gov NCT02326597; https://clinicaltrials.gov/ct2/show/NCT02326597
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Affiliation(s)
- Lakshmanan Krishnamurti
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Diana Ross
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Cynthia Sinha
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Namita Bakshi
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Nonita Mittal
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Divya Veludhandi
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Anh-Phuong Pham
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Alankrita Taneja
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Kamesh Gupta
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Julum Nwanze
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Andrea Marie Matthews
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Saumya Joshi
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Veronica Vazquez Olivieri
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Santhi Arjunan
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Ifechi Okonkwo
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Ines Lukombo
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Peter Lane
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Nitya Bakshi
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - George Loewenstein
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States.,Center for Behavioral Decision Research, Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
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Koh T, Ong W, Leong T, Lapuz C, Lim A. P1.17-17 Outcomes Following Stereotactic Body Radiotherapy (SBRT) for Biopsy-Confirmed vs. Radiologically-Diagnosed Primary Lung Cancer. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.1291] [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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Leong T, Billaud M, Agarwal M, Miller T, McFadden T, Johnson J, Lazarus SG. As easy as ABC: evaluation of safe sleep initiative on safe sleep compliance in a freestanding pediatric hospital. Inj Epidemiol 2019; 6:26. [PMID: 31333992 PMCID: PMC6616382 DOI: 10.1186/s40621-019-0205-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background The American Academy of Pediatrics (AAP) recommends the ABCs of safe infant sleep (alone, back, clear crib) to combat the increasing rates of Sudden Unexplained Infant Death (SUID). It is unclear if these recommendations are followed for infants hospitalized in pediatric facilities after the newborn period. The objectives of this study were to assess baseline infant sleep behaviors at a tertiary care freestanding pediatric hospital and to evaluate the effectiveness of a hospital-based infant safe sleep program in improving adherence to safe sleep recommendations. Methods A quality improvement program with pre- and post- analyses was performed on a convenience sample of infants < 12-months old utilizing a crib audit tool on two general pediatric inpatient units. The crib audit tool was used before and after the safe sleep program intervention. It recorded the infant's sleep position, location during sleep, and sleep environment. Interventions included: 1) nursing education, 2) crib cards with a checklist of the ABC's of safe sleep provided for the cribs of hospitalized infants, and 3) tracking boards to report weekly measured compliance with the ABCs. Chi square analysis was used to compare adherence to recommendations before and after program implementation. Results There were 62 cribs included pre-intervention and 90 cribs post-intervention. Overall, there was no significant change in safe sleep positioning (81% to 82%, p = 0.97). There was a significant increase in adherence to the safe sleep environment recommendation (3% to 38%, p < 0.01). Overall safe sleep, including both position and environment, referred to as ABC compliance, improved from 3% pre-intervention to 34% post-intervention (p < 0.01). Only 18% of cribs audited displayed a crib card, demonstrating poor compliance on placement of the cards. There was no significant difference in compliance with safe sleep recommendations between infants with a crib card compared to those without (25% vs. 37%, p = 0.51). Conclusions Significant improvements were made in sleep environments and overall safe sleep compliance after introduction of crib cards and tracking boards. Most likely the crib auditing process itself and the tracking boards had a larger impact than the crib cards.
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Affiliation(s)
- Traci Leong
- 1Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Manon Billaud
- 1Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Maneesha Agarwal
- 3Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA.,4Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA USA.,5Children's Healthcare of Atlanta, Atlanta, GA USA
| | - Terri Miller
- 2Georgia Department of Public Health, Atlanta, GA USA
| | - Terri McFadden
- 3Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA.,5Children's Healthcare of Atlanta, Atlanta, GA USA
| | | | - Sarah Gard Lazarus
- 5Children's Healthcare of Atlanta, Atlanta, GA USA.,Pediatric Emergency Medicine Associates, Atlanta, GA USA
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Jacobson D, Jacobson J, Leong T, Lourenco S, Mancl L, Chi DL. Evaluating Child Toothbrushing Behavior Changes Associated with a Mobile Game App: A Single Arm Pre /Post Pilot Study. Pediatr Dent 2019; 41:299-303. [PMID: 31439090 PMCID: PMC6709707] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose: The purpose of this pilot study was to evaluate changes in toothbrushing behaviors associated with a mobile game app. Methods: Thirty-four five- to six-year-olds were taught to use the Brush UpTM game app and played it once per day at home for seven days. The primary outcome was toothbrushing quality measured as duration and distribution. The paired t test was used to assess pre/post changes and Holm's method adjusted for multiple testing (α equals 0.05). Results: The mean age was 73.7±6.6 months; 29.4 percent were female, and 47.1 percent were Caucasian. After seven days, toothbrushing duration increased significantly (P<0.001). Toothbrushing distribution improved with increased brushing of the lingual, maxillary occlusal, and posterior buccal surfaces. For 15 children who played the game for 14 days, even greater improvements in quality and distribution were observed. Improvements in toothbrushing did not persist one year later without further app use but there were noted changes that could be clinically meaningful. Conclusions: Mobile health game apps can potentially improve toothbrushing quality in children. Additional trials are needed to assess mobile toothbrushing game apps.
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Affiliation(s)
- Dov Jacobson
- Mr. D. Jacobson, principals, at GamesThatWork, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Ga
| | - Jesse Jacobson
- Mr. J. Jacobson, principals, at GamesThatWork, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Ga
| | - Traci Leong
- Dr. Leong is an assistant research professor, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Ga
| | - Stella Lourenco
- Dr. Lourenco is an associate professor, Department of Psychology, Emory University, Atlanta, Ga
| | - Lloyd Mancl
- Dr. Mancl is a research associate professor, Department of Oral Health Sciences, UW School of Dentistry, University of Washington School of Dentistry, Seattle, Wash., USA
| | - Donald L Chi
- Dr. Chi is a professor, Department of Oral Health Sciences, UW School of Dentistry, University of Washington School of Dentistry, Seattle, Wash., USA;,
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Immergluck LC, Leong T, Malhotra K, Parker TC, Ali F, Jerris RC, Rust GS. Correction to: Geographic surveillance of community associated MRSA infections in children using electronic health record data. BMC Infect Dis 2019; 19:396. [PMID: 31072308 PMCID: PMC6507021 DOI: 10.1186/s12879-019-3972-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/11/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Lilly Cheng Immergluck
- Department of Microbiology/Biochemistry/Immunology, Department of Pediatrics and Clinical Research Center, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA. .,Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Traci Leong
- Rollins School of Public Health, Emory University, 1518 Clifton Rd., Atlanta, GA, 30322, USA
| | - Khusdeep Malhotra
- National Center for Primary Care, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - Trisha Chan Parker
- Department of Microbiology/Biochemistry/Immunology, Department of Pediatrics and Clinical Research Center, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - Fatima Ali
- Department of Microbiology/Biochemistry/Immunology, Department of Pediatrics and Clinical Research Center, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - Robert C Jerris
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.,Department of Pathology, Emory University, 1364 Clifton Road Northeast, Atlanta, GA, 30322, USA
| | - George S Rust
- Florida State University College of Medicine, 1115 W. Call St, Tallahassee, FL, 32306, USA
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Patel R, Spradley L, Patel M, Dale P, Brock J, Kirkpatrick J, Leong T, Bui D, Robinson M, Solomon T, Ghali J. IS BREAST ARTERIAL CALCIFICATION INDICATIVE OF CORONARY ARTERY DISEASE? J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33777-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Stenger EO, Newton JG, Leong T, Kendrick L, McManus L, Rooke C, Krishnamurti L. Application of Parafilm As a Physical Barrier on CVC Connections Is Feasible and May Reduce Clabsi Among Pediatric HCT Patients. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.416] [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: 10/27/2022]
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Immergluck LC, Leong T, Malhotra K, Parker TC, Ali F, Jerris RC, Rust GS. Geographic surveillance of community associated MRSA infections in children using electronic health record data. BMC Infect Dis 2019; 19:170. [PMID: 30777016 PMCID: PMC6378744 DOI: 10.1186/s12879-019-3682-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 10/22/2018] [Accepted: 01/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community- associated methicillin resistant Staphylococcus aureus (CA-MRSA) cause serious infections and rates continue to rise worldwide. Use of geocoded electronic health record (EHR) data to prevent spread of disease is limited in health service research. We demonstrate how geocoded EHR and spatial analyses can be used to identify risks for CA-MRSA in children, which are tied to place-based determinants and would not be uncovered using traditional EHR data analyses. METHODS An epidemiology study was conducted on children from January 1, 2002 through December 31, 2010 who were treated for Staphylococcus aureus infections. A generalized estimated equations (GEE) model was developed and crude and adjusted odds ratios were based on S. aureus risks. We measured the risk of S. aureus as standardized incidence ratios (SIR) calculated within aggregated US 2010 Census tracts called spatially adaptive filters, and then created maps that differentiate the geographic patterns of antibiotic resistant and non-resistant forms of S. aureus. RESULTS CA-MRSA rates increased at higher rates compared to non-resistant forms, p = 0.01. Children with no or public health insurance had higher odds of CA-MRSA infection. Black children were almost 1.5 times as likely as white children to have CA-MRSA infections (aOR 95% CI 1.44,1.75, p < 0.0001); this finding persisted at the block group level (p < 0.001) along with household crowding (p < 0.001). The youngest category of age (< 4 years) also had increased risk for CA-MRSA (aOR 1.65, 95%CI 1.48, 1.83, p < 0.0001). CA-MRSA encompasses larger areas with higher SIRs compared to non-resistant forms and were found in block groups with higher proportion of blacks (r = 0.517, p < 0.001), younger age (r = 0.137, p < 0.001), and crowding (r = 0.320, p < 0.001). CONCLUSIONS In the Atlanta MSA, the risk for CA-MRSA is associated with neighborhood-level measures of racial composition, household crowding, and age of children. Neighborhoods which have higher proportion of blacks, household crowding, and children < 4 years of age are at greatest risk. Understanding spatial relationship at a community level and how it relates to risks for antibiotic resistant infections is important to combat the growing numbers and spread of such infections like CA-MRSA.
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Affiliation(s)
- Lilly Cheng Immergluck
- Department of Microbiology/Biochemistry/Immunology, Department of Pediatrics and Clinical Research Center, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA. .,Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Traci Leong
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
| | - Khusdeep Malhotra
- National Center for Primary Care, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - Trisha Chan Parker
- Department of Microbiology/Biochemistry/Immunology, Department of Pediatrics and Clinical Research Center, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - Fatima Ali
- Department of Microbiology/Biochemistry/Immunology, Department of Pediatrics and Clinical Research Center, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA, 30310, USA
| | - Robert C Jerris
- Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.,Department of Pathology, Emory University, 1364 Clifton Road Northeast, Atlanta, GA, 30322, USA
| | - George S Rust
- Florida State University College of Medicine, 1115 W. Call St, Tallahassee, FL, 32306, USA
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O'Donnell CM, Stern M, Leong T, Molitch-Hou E, Mitchell B. Incorporating Continuity in a 7-On 7-Off Hospitalist Model and the Correlation With Patient Handoffs and Length of Stay. Am J Med Qual 2018; 34:553-560. [PMID: 30569734 DOI: 10.1177/1062860618818355] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Little research in hospital medicine examines the effects of hospitalist continuity on patient outcomes. This study implemented a novel staffing model with approximately half of rounding teams starting their 7-day workweek on Monday and the others on Friday. Teams admitted their own patients on their first 4 days with additional nighttime admissions handed off to those teams. No admissions were given to teams on their last 3 days. Length of stay was significantly reduced from 6.34 days in 2015 to 5.7 days in 2016 (P < .002) with a significant decrease in handoffs. There was an increase in odds ratio of death (1.37, SE = .128) with each additional hospitalist involved in a patient's care while adjusting for year and number of patient diagnoses (P < .001). There was no statistical difference in charges, 30-day readmissions, or mortality between years.
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Wang CS, Travers C, McCracken C, Leong T, Gbadegesin R, Quiroga A, Benfield MR, Hidalgo G, Srivastava T, Lo M, Yadin O, Mathias R, Araya CE, Khalid M, Orjuela A, Zaritsky J, Al-Akash S, Kamel M, Greenbaum LA. Adrenocorticotropic Hormone for Childhood Nephrotic Syndrome: The ATLANTIS Randomized Trial. Clin J Am Soc Nephrol 2018; 13:1859-1865. [PMID: 30442868 PMCID: PMC6302334 DOI: 10.2215/cjn.06890618] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 06/08/2018] [Accepted: 08/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is renewed interest in adrenocorticotropic hormone (ACTH) for the treatment of nephrotic syndrome. We evaluated the efficacy and safety of ACTH in children with frequently relapsing or steroid-dependent nephrotic syndrome in a randomized trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Participants aged 2-20 years old with frequently relapsing or steroid-dependent nephrotic syndrome were enrolled from 16 sites in the United States and randomized 1:1 to ACTH (repository corticotropin injection) or no relapse-preventing treatment. ACTH treatment regimen was 80 U/1.73 m2 administered twice weekly for 6 months, followed by 40 U/1.73 m2 administered twice weekly for 6 months. The primary outcome was disease relapse during the first 6 months. Participants in the control group were offered crossover to ACTH treatment if they relapsed within 6 months. Secondary outcomes were relapse after ACTH dose reduction and treatment side effects. RESULTS The trial was stopped at a preplanned interim analysis after enrollment of 31 participants because of a lack of discernible treatment efficacy. Fourteen out of 15 (93%) participants in the ACTH arm experienced disease relapse in the first 6 months, with a median time to first relapse of 23 days (interquartile range, 9-32), compared with 15 out of 16 (94%) participants and at a median of 21 days (interquartile range, 14-51) in the control group. There was no difference in the proportion of relapsed patients (odds ratio, 0.93; 95% confidence interval, 0.05 to 16.40; P>0.99) or time to first relapse (hazard ratio, 1.03; 95% confidence interval, 0.50 to 2.15; P=0.93). Thirteen out of 16 participants in the control group crossed over to ACTH treatment. Three out of 28 participants completed 12 months of ACTH treatment; the others exited the trial because of frequent relapses or side effects. There were no disease relapses after ACTH dose reduction among the three participants. Most side effects were mild and similar to side effects of corticosteroids. CONCLUSIONS ACTH at 80 U/1.73 m2 administered twice weekly was ineffective at preventing disease relapses in pediatric nephrotic syndrome.
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Affiliation(s)
- Chia-shi Wang
- Department of Pediatrics, Emory and Children’s Pediatric Institute, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rasheed Gbadegesin
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Alejandro Quiroga
- Department of Pediatrics and Human Development, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | | | - Guillermo Hidalgo
- Department of Pediatrics, East Carolina University, Greenville, North Carolina
| | - Tarak Srivastava
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Megan Lo
- Department of Pediatrics, Medical College of Virginia School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ora Yadin
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles Mattel Children’s Hospital, Los Angeles, California
| | - Robert Mathias
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, Florida
| | - Carlos E. Araya
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, Florida
| | - Myda Khalid
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alvaro Orjuela
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joshua Zaritsky
- Department of Pediatrics, A.I. DuPont Hospital for Children/ Nemours, Wilmington, Delaware; and
| | | | - Margret Kamel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Larry A. Greenbaum
- Department of Pediatrics, Emory and Children’s Pediatric Institute, Atlanta, Georgia
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Guidos PJ, Arlen AM, Leong T, Bonnett MA, Cooper CS. Impact of continuous low-dose antibiotic prophylaxis on growth in children with vesicoureteral reflux. J Pediatr Urol 2018; 14:325.e1-325.e7. [PMID: 30181099 DOI: 10.1016/j.jpurol.2018.07.007] [Citation(s) in RCA: 7] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/12/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Continuous antibiotic prophylaxis (CAP) is a mainstay of treatment for children with vesicoureteral reflux (VUR). There has been an increasing focus on the effect of antibiotics on gut microbiota and subsequent repercussions on growth. Continuous antibiotic prophylaxis is generally considered safe; however, its impact on growth in children with VUR remains unknown. OBJECTIVE This objective of this study was to determine whether CAP altered height, weight, or body mass index (BMI) in children with VUR. STUDY DESIGN Children diagnosed with primary VUR were identified. Demographics including weight and height percentiles, BMI and BMI percentiles, age, gender, antibiotic class, prior antibiotic use, urinary tract infection history, and breakthrough infections were tested in univariate and multivariate analyses. Primary outcome was change in BMI as well as weight, height, and BMI percentiles. RESULTS One hundred eighty patients (146 girls, 34 boys) were prescribed CAP at mean age of 29.2 ± 26.2 months. Mean follow-up on CAP was 4.1 ± 3.3 years, with median follow-up of 3.08 years. Mean increase in weight percentile was 1.49 (2.02 males, 1.37 females; P = 0.46). Mean decrease in height percentile was -4.44 (-2.18 males, -4.95 females; P = 0.51). Age at diagnosis (P = 0.004) and history of prior treatment courses of antibiotics (P = 0.007) were associated with a significant BMI increase (Fig. 1). Body mass index percentile increased from 58.4 to 66.5; however, this increase was only significant in children aged above 1 year (P < 0.0001). Of note, children above 1 year of age were significantly more likely to have a history of prior treatment courses of antibiotics (58% vs 32%; P < 0.0001), and when controlling for prior antibiotic use, the increase in BMI percentile in those over 1 year of age did not reach significance. DISCUSSION The use of antibiotics has been associated with alterations in pediatric growth parameters in both animal models and clinical studies. However, little information exists on the impact of prophylactic-dosed antibiotics on growth. While this study is limited by the retrospective analysis and small sample size, it was found that the use of CAP did impact growth parameters, with a stronger effect seen in children who had received prior treatment courses of antibiotics before the infection leading to the initiation of CAP. CONCLUSION Continuous antibiotic prophylaxis was correlated with significant increase in BMI in children with prior antibiotic usage and a significant increase in BMI percentile in children aged above 1 year. Continuous antibiotic prophylaxis was also associated with decreased height percentiles, particularly in patients aged less than 1 year, though it did not reach statistical significance. Further analysis is needed to investigate whether these effects on weight, height, and BMI are persistent and clinically significant.
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Affiliation(s)
- P J Guidos
- Department of Urology and Pediatrics, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242-1089, USA
| | - A M Arlen
- Department of Urology, Yale University, 789 Howard Avenue, New Haven, CT, 06520-8234, USA
| | - T Leong
- Biostatistics and Bioinformation, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Rd. NE, Atlanta, GA, 30322, USA
| | - M A Bonnett
- Department of Urology and Pediatrics, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242-1089, USA
| | - C S Cooper
- Department of Urology and Pediatrics, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242-1089, USA.
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Yee MEM, Josephson CD, Winkler AM, Webb J, Luban NLC, Leong T, Stowell SR, Roback JD, Fasano RM. Hemoglobin A clearance in children with sickle cell anemia on chronic transfusion therapy. Transfusion 2018; 58:1363-1371. [PMID: 29664198 DOI: 10.1111/trf.14610] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic transfusion therapy for sickle cell anemia reduces disease complications by diluting sickle-erythrocytes with hemoglobin A (HbA)-containing erythrocytes and suppressing erythropoiesis. Minor antigen mismatches may result in alloimmunization, but it is unknown if antigen mismatches or recipient characteristics influence HbA clearance posttransfusion. STUDY DESIGN AND METHODS Children with sickle cell anemia on chronic transfusion therapy were followed prospectively for 12 months. All patients received units serologically matched for C/c, E/e, and K; patients with prior red blood cell (RBC) antibodies had additional matching for Fya , Jkb , and any previous alloantibodies. Patients' RBC antigen genotypes, determined by multiplexed molecular assays (PreciseType Human Erythrocyte Antigen, and RHCE and RHD BeadChip, Immucor) were compared to genotypes of transfused RBC units to assess for antigen mismatches. Decline in hbA (ΔHbA) from posttransfusion to the next transfusion was calculated for each transfusion episode. RESULTS Sixty patients received 789 transfusions, 740 with ΔHbA estimations, and 630 with donor Human Erythrocyte Antigen genotyping. In univariate mixed-model analysis, ΔHbA was higher in patients with past RBC antibodies or splenomegaly and lower in patients with splenectomy. RBC antigen mismatches were not associated with ΔHbA. In multivariate linear mixed-effects modeling, ΔHbA was associated with RBC antibodies (2.70 vs. 2.45 g/dL/28 d, p = 0.0028), splenomegaly (2.87 vs. 2.28 g/dL/28 d, p = 0.019), and negatively associated with splenectomy (2.46 vs. 2.70 g/dL/28 d, p = 0.011). CONCLUSIONS HbA decline was increased among patients with sickle cell anemia with prior immunologic response to RBC antigens and decreased among those with prior splenectomy, demonstrating that recipient immunologic characteristics influenced the clearance of transfused RBCs.
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Affiliation(s)
- Marianne E M Yee
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics and Hematology/Oncology, Emory University School of Medicine and the
| | - Cassandra D Josephson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Department of Pediatrics and Hematology/Oncology, Emory University School of Medicine and the.,Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - Anne M Winkler
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - Jennifer Webb
- Center for Cancer and Blood Disorders, Children's National Medical Center, Departments of Hematology and Laboratory Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Naomi L C Luban
- Center for Cancer and Blood Disorders, Children's National Medical Center, Departments of Hematology and Laboratory Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Emory University, Rollins School of Public Health, Atlanta, Georgia
| | - Sean R Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - John D Roback
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia; the
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Balasubramanian A, Ireland-Jenkin K, McDonald A, Khor R, Yeo B, Leong T. Abstract P2-03-08: A retrospective study to identify the frequency of discordant HER2 results using both immunohistochemistry (IHC) and in-situ hybridization (ISH) assays. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p2-03-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
HER2 targeted therapies have substantially improved survival outcomes for patients with breast cancer and HER2 amplification of their tumour. The recently updated American Society of Clinical Oncology/College of American Pathologists (ASCO CAP) guidelines recommend that HER2 testing to be performed on all invasive breast cancers and that positive HER2 status is defined by either evidence of HER2 protein over-expression measured by immunohistochemistry status (IHC 3+) or by in-situ hybridisation (ISH) amplification. Equivocal results require further testing with the alternative assay.
In Australia, Medicare-funded access to HER2 targeted therapies requires demonstration of HER2 positivity by ISH, regardless of IHC status. Thus, currently most breast units perform IHC and ISH on all breast cancers. Given this discrepancy in practice and significant additional cost of performing ISH, this study evaluated the frequency of discordance and the cost burden in using both assays in a historical series of patients with breast cancer.
Methods
A retrospective audit of HER2 histopathology reports was performed for all breast cancers diagnosed between 2007 and 2016 at a single tertiary hospital in Melbourne, Australia (The Austin Hospital). HER2 IHC results were classified as negative (0 or 1+), equivocal (2+) or positive (3+). An analysis was performed to assess the proportion of concordant (defined as samples with IHC 0/1+ and negative ISH, samples with IHC3+ and positive ISH, and samples with IHC2+ regardless of ISH) and discordant results (defined as IHC 3+ and ISH non-amplified or IHC 0/1+ and ISH amplified). Tumour blocks and slides from discordant cases were reviewed by a breast cancer histopathologist. The cost of additional testing in concordant cases was performed based on the Australian Medicare Benefits Schedule (MBS).
Results
Eight hundred and forty-six histopathology reports were reviewed from 786 patients, all of whom had both IHC and ISH assays. There were 832 (98.8%) concordant cases. There were 10 discordant cases (1.2%) in total, including three cases (0.4%) with a negative IHC (1+) result but positive ISH, and 7 cases (0.8%) with a positive IHC but negative ISH result. A detailed analysis of 10 discordant cases will be presented. HER2 status and subsequent treatment remain unchanged with the addition of ISH testing in 665 (79.0%) cases, which amounted to an additional $209,741 (AUD) being spent on unnecessary ISH testing. Given an estimated incidence of 17,730 new cases of breast cancer per year in Australia, the population cost of performing additional HER2 ISH testing ($315.40 per case) in concordant cases would equate to $4.4 million (AUD) per year.
Conclusion
These results describe an extremely low rate of HER2 IHC/ISH discordance suggesting that routine use of both assays is unnecessary in cases with an unequivocal IHC result. The fiscal burden and potential delays to deciding treatment provide a strong rationale for access to HER2 targeted therapies to be based IHC or ISH, as advised by the ASCO CAP guidelines. Our results will be used to support a national review of IHC and ISH discordance using Australian national registry data.
Citation Format: Balasubramanian A, Ireland-Jenkin K, McDonald A, Khor R, Yeo B, Leong T. A retrospective study to identify the frequency of discordant HER2 results using both immunohistochemistry (IHC) and in-situ hybridization (ISH) assays [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-08.
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Affiliation(s)
- A Balasubramanian
- Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences
| | - K Ireland-Jenkin
- Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences
| | - A McDonald
- Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences
| | - R Khor
- Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences
| | - B Yeo
- Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences
| | - T Leong
- Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences
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Parker TC, Mohammed A, Leong T, Mays S, Jain S, Churchill V, Ali F, Immergluck LC. Rotavirus vaccination rate disparities seen among infants with acute gastroenteritis in Georgia. Ethn Health 2017; 22:585-595. [PMID: 27741577 PMCID: PMC6314174 DOI: 10.1080/13557858.2016.1244744] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Rotavirus (RV) is one of the most common diarrheal diseases affecting children less than 5 years of age. RV vaccines have greatly reduced this burden in the United States. The purpose of this study was to determine possible disparities and socio-economic differences in RV vaccination rates. DESIGN Children with acute gastroenteritis were enrolled. Stool was tested for presence of rotavirus using an enzyme immunoassay kit. Vaccination records were abstracted from the state immunization registry and healthcare providers to examine complete and incomplete vaccination status. Cases were identified as children receiving a complete RV dose series and controls were identified as children with incomplete RV doses. A logistic regression model was used to determine disparities seen amongst children with incomplete vaccination status. RESULTS Racial differences between Black and white infants for RV vaccination rates were not significant when controlling for covariates (OR 1.15, 95% CI 0.74-1.78); however ethnicity (p-value .0230), age at onset of illness (p-value .0004), birth year (p-value < .0001), and DTaP vaccination status (p-value < .0001) were all significant in determining vaccination status for children. CONCLUSIONS Racial disparities and socio-economic differences are not determinants in rotavirus vaccination rates; however, age and ethnicity have an effect on RV vaccine status.
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Affiliation(s)
- Trisha C Parker
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
- f Postgraduate Medical Institute Clinical Trials Unit , Anglia Ruskin University , Chelmsford , UK
| | - Anaam Mohammed
- b Pediatric Emergency Medicine Associates , Atlanta , GA , USA
| | - Traci Leong
- c Department of Biostatistics and Bioinformatics , Rollins School of Public Health, Emory University , Atlanta , GA , USA
| | - Shelley Mays
- e Children's Healthcare of Atlanta , Atlanta , GA , USA
| | - Shabnam Jain
- d Departments of Pediatrics and Medicine , Emory University , Atlanta , GA , USA
- e Children's Healthcare of Atlanta , Atlanta , GA , USA
| | - Victoria Churchill
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
| | - Fatima Ali
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
| | - Lilly C Immergluck
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
- d Departments of Pediatrics and Medicine , Emory University , Atlanta , GA , USA
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