Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage

BACKGROUND

Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists.

METHODS

We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model.

RESULTS

A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant.

CONCLUSIONS

The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Starting Young: Trends in Opioid Therapy Among US Adolescents and Young Adults With Inflammatory Bowel Disease in the Truven MarketScan Database Between 2007 and 2015

Background

Opioids are commonly prescribed for relief in inflammatory bowel disease (IBD). Emerging evidence suggests that adolescents and young adults are a vulnerable population at particular risk of becoming chronic opioid users and experiencing adverse effects.

Objectives

This study evaluates trends in the prevalence and persistence of chronic opioid therapy in adolescents and young adults with IBD in the United States.

Method

A longitudinal retrospective cohort analysis was conducted with the Truven MarketScan Database from 2007 to 2015. Study subjects were 15-29 years old with ≥2 IBD diagnoses (Crohn's: 555/K50; ulcerative colitis: 556/K51). Opioid therapy was identified with prescription claims within the Truven therapeutic class 60: opioid agonists. Persistence of opioid use was evaluated by survival analysis for patients who remained in the database for at least 3 years following index chronic opioid therapy use.

Results

In a cohort containing 93,668 patients, 18.2% received chronic opioid therapy. The annual prevalence of chronic opioid therapy increased from 9.3% in 2007 to 10.8% in 2015 (P < 0.01), peaking at 12.2% in 2011. Opioid prescriptions per patient per year were stable (approximately 5). Post hoc Poisson regression analyses demonstrated that the number of opioid pills dispensed per year increased with age and was higher among males. Among the 2503 patients receiving chronic opioid therapy and followed longitudinally, 30.5% were maintained on chronic opioid therapy for 2 years, and 5.3% for all 4 years.

Conclusion

Sustained chronic opioid use in adolescents and young adults with IBD is increasingly common, underscoring the need for screening and intervention for this vulnerable population.

Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014

BACKGROUND & AIMS

Epidemiologic analyses of acute pancreatitis (AP) and chronic pancreatitis (CP) provide insight into causes and strategies for prevention and affect allocation of resources to its study and treatment. We sought to determine current and accurate incidences of AP and CP, along with the prevalence of CP, in children and adults in the United States.

METHODS

We collected data from the Truven MarketScan Research Databases of commercial inpatient and outpatient insurance claims in the United States from 2007 through 2014 (patients 0-64 years old). We calculated the incidences of AP and CP and prevalence of CP based on International Classification of Diseases, 9th Revision diagnosis codes. Children were defined as 18 years or younger and adults as 19 to 64 years old.

RESULTS

The incidence of pediatric AP was stable from 2007 through 2014, remaining at 12.3/100,000 persons in 2014. Meanwhile, the incidence for adult AP decreased from 123.7/100,000 persons in 2007 to 111.2/100,000 persons in 2014. The incidence of CP decreased over time in children (2.2/100,000 persons in 2007 to 1.9/100,000 persons in 2014) and adults (31.7/100,000 persons in 2007 to 24.7/100,000 persons in 2014). The prevalences of pediatric and adult CP were 5.8/100,000 persons and 91.9/100,000 persons, respectively, in 2014. Incidences of AP and CP increased with age. We found little change in incidence during the first decade of life but linear increases starting in the second decade.

CONCLUSIONS

We performed a comprehensive epidemiologic analysis of privately insured, non-elderly adults and children with AP and CP in the United States. Changes in gallstone formation, smoking, and alcohol consumption, along with advances in pancreatitis management, may be responsible for the stabilization and even decrease in the incidences of AP and CP.

Non-stationary Myoelectric Signals and Muscle Fatigue

A mathematical derivation for the mean frequency of a myoelectric signal (MES) is provided based on an amplitude modulation model for non-stationary MES. With this derivation, it is shown that mean frequency estimates of stationary and non-stationary myoelectric signals theoretically are not significantly different in a physiologically practical context. While this prediction is confirmed via a computer simulation, it is refuted with empirical evidence. Regardless, it is shown in a final study that mean frequency is capable of tracking a downward shift in the power spectrum with fatigue even in non-stationary myoelectric signals.

Market share and costs of biologic therapies for inflammatory bowel disease in the USA

BACKGROUND

Real-world data quantifying the costs of increasing use of biologics in inflammatory bowel disease (IBD) are unknown.

AIM

To determine the outpatient IBD drug utilization trends, relative market share, and costs in the USA during a 9-year period.

METHODS

The Truven MarketScan^® Database was analysed for patients with Crohn's disease (CD) and ulcerative colitis (UC) during 2007-2015. National drug codes were used to identify prescription drugs; Healthcare Common Procedure Coding System J-codes were used to capture biologic out-patient infusions. Proportion of drug usage, relative market share and per-member per-year (PMPY) costs were analysed for biologics, immunomodulators, 5-ASAs and corticosteroids.

RESULTS

In 415 405 patients (188 842 CD; 195 183 UC; 31 380 indeterminate colitis; 54.67% female), utilization trends show a consistent rise in the market share of biologics during the 9-year study period. The proportion of patients using biologics increased from 21.8% to 43.8% for CD and 5.1%-16.2% for UC. This contrasts a small decrease in immunomodulator and 5-ASA use for CD and relative constancy of other classes including corticosteroids-only use as primary IBD medication from 2007 to 2015. The average biologic-taking patient accounted for $25 275 PMPY in 2007 and $36 051 PMPY in 2015. The average paediatric biologic-taking patient accounted for $23 616 PMPY in 2007 and $41 109 PMPY in 2015. In all patients, the share of costs for biologics increased from 72.9% in 2007 to 85.7% in 2015 (81.7% in 2007 to 94.9% in 2015 in paediatrics).

CONCLUSION

The vast majority of costs allocated to out-patient IBD medications in the USA is attributed to increasing use of biologic therapies despite the relative minority of biologic-taking patients.

CleanEMG--power line interference estimation in sEMG using an adaptive least squares algorithm

This paper presents an adaptive least squares algorithm for estimating the power line interference in surface electromyography (sEMG) signals. The algorithm estimates the power line interference, without the need for a reference input. Power line interference can be removed by subtracting the estimate from the original sEMG signal. The algorithm is evaluated with simulated sEMG based on its ability to accurately estimate power line interference at different frequencies and at various signal-to-noise ratios. Power line estimates produced by the algorithm are accurate for signal-to-noise ratios below 15 dB (SNR estimation error at 15 dB is 14.7995 dB + 1.6547 dB).

Trends in charges and payments for nonhospitalized emergency department pediatric visits, 1996-2003

OBJECTIVES

To compare charges and payments for outpatient pediatric emergency visits across payer groups to provide information on reimbursement trends.

METHODS

Total charges and payments for emergency department (ED) visits Medicaid/State Children's Health Insurance Program (SCHIP), privately insured, and uninsured pediatric patients from 1996 to 2003 using data from the Medical Expenditure Panel Survey. Average charges per visit and average payments per visit were also tracked, using regression analysis to adjust for changes in patient characteristics.

RESULTS

While charges for pediatric ED visits rose over time, payments did not keep pace. This led to a decrease in reimbursement rates from 63% in 1996 to 48% in 2003. For all years, Medicaid/SCHIP visits had the lowest reimbursement rates, reaching 35% in 2003. The proportion of visits from children insured by Medicaid/SCHIP also increased over the period examined. In 2003, after adjustment, charges were $792 per visit from children covered by Medicaid/SCHIP, $913 for visits from uninsured children, and $952 for visits from privately insured children.

CONCLUSIONS

Reimbursements for outpatient ED visits in the pediatric population have decreased from the period of 1996 to 2003 in all payer groups: public (Medicaid/SCHIP), private, and the uninsured. Medicaid/SCHIP has consistently paid less per visit than the privately insured and the uninsured. Further research on the effects of these declining reimbursements on the financial viability of ED services for children is warranted.

Decreasing reimbursements for outpatient emergency department visits across payer groups from 1996 to 2004

STUDY OBJECTIVE

There is increasing concern that decreasing reimbursements to emergency departments (EDs) will negatively affect their functioning, but little evidence has been published identifying trends in reimbursement rates. We seek to examine and document the trends in reimbursement for outpatient ED visits throughout the past decade.

METHODS

We use Medical Expenditure Panel Survey data covering a 9-year span from 1996 to 2004, using outpatient ED visits as the unit of analysis. Our primary outcome variables were total and per-visit charges and payments across insurance. Using regression analyses with a generalized linear models approach, we also derived the adjusted mean payment and mean charge for each ED visit, as well as the average payment ratio.

RESULTS

Overall, adjusted mean charges for an outpatient ED visit increased from $713 (95% confidence interval [CI] $665 to $771) in 1996 to $1,390 (95% CI $1,317 to $1,462) in 2004. The adjusted mean payment also increased from $410 (95% CI $366 to $453) in 1996 to $592 (95% CI $551 to $634) in 2004. Because payments increased at a slower rate in all payer groups compared with charges, the overall share of charges that were paid decreased over time from 57% in 1996 (n=3,433) to 42% in 2004 (n=5,763; P<.001). The proportion of total charges paid in 2004 was highest for privately insured visits (56%; n=2,005) and lowest for Medicaid visits (33%; n=1,618). For visits by uninsured patients (n=996), 35% of charges were paid in 2004.

CONCLUSION

The proportion of charges paid for outpatient ED visits from Medicaid, Medicare, and privately insured and uninsured patients persistently decreased from 1996 to 2004. These concerning decreases may threaten the survival of EDs and their ability to continue to provide care as safety nets in the US health care system.

Physician practice size and variations in treatments and outcomes: evidence from Medicare patients with AMI

Little is known about the relationships between physician practice size and patient treatments or outcomes. We examined whether the practice size of attending physicians was related to within-hospital differences in care for Medicare patients with acute myocardial infarction (AMI). We found that patients treated by solo physicians were less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics were taken into account. These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty.

Innervation zone shift with changes in joint angle in the brachial biceps

Empirical evidence is presented suggesting that the innervation zone of the brachial biceps shifts relative to recording electrodes with changes in joint angle. Myoelectric signal data were acquired from five subjects using a 16-channel linear electrode array, and analyzed to determine a reversal in signal propagation direction indicating innervation zone location. An analysis of the effect of joint angle changes on innervation zone location yielded statistically significant results (ANOVA, alpha = 0.05, p < 0.001) suggesting that the innervation zone moves between 5 and 30 mm in a direction distal to the shoulder as the arm is extended, statistically independent of force level (ANOVA, alpha = 0.05, p > 0.2).

The short-time Fourier transform and muscle fatigue assessment in dynamic contractions

The mean frequency of the power spectrum of an electromyographic signal is an accepted index for monitoring fatigue in static contractions. There is however, indication that it may be a useful index even in dynamic contractions in which muscle length and/or force may vary. The objective of this investigation was to explore this possibility. An examination of the effects of amplitude modulation on modeled electromyographic signals revealed that changes in variance created in this way do not sufficiently affect characteristic frequency data to obscure a trend with fatigue. This validated the contention that not all non-stationarities in signals necessarily manifest in power spectral parameters. While an investigation of the nature and effects of non-stationarities in real electromyographic signals produced from dynamic contractions indicated that a more complex model is warranted, the results also indicated that averaging associated with estimating spectral parameters with the short-time Fourier transform can control the effects of the more complex non-stationarities. Finally, a fatigue test involving dynamic contractions at a force level under 30% of peak voluntary dynamic range, validated that it was possible to track fatigue in dynamic contractions using a traditional short-time Fourier transform methodology.

Non-stationary myoelectric signals and muscle fatigue

A mathematical derivation for the mean frequency of a myoelectric signal (MES) is provided based on an amplitude modulation model for non-stationary MES. With this derivation, it is shown that mean frequency estimates of stationary and non-stationary myoelectric signals theoretically are not significantly different in a physiologically practical context. While this prediction is confirmed via a computer simulation, it is refuted with empirical evidence. Regardless, it is shown in a final study that mean frequency is capable of tracking a downward shift in the power spectrum with fatigue even in non-stationary myoelectric signals.

Interleukin 6 differentially potentiates the antitumor effects of taxol and vinblastine in U266 human myeloma cells

Newer therapeutic strategies for the treatment of multiple myeloma have focused on antagonizing the growth-promoting functions of interleukin 6 (IL-6). In this study, we examined the antitumor effects of two mechanistically different microtubule poisons, Taxol and vinblastine, in U266 human myeloma cells and determined whether IL-6 altered these effects. Taxol and vinblastine led to a dose-dependent inhibition of [3H]thymidine incorporation and altered the DNA distribution pattern of U266 cells. Both drugs led to an increase in the proportion of cells in the sub-G1 fraction (<2N DNA). However, at the IC50 concentration, vinblastine, but not Taxol, increased the percentage of cells in the G2-M phase of the cell cycle. In the presence of IL-6, the DNA distribution pattern induced by Taxol or vinblastine was altered. Whereas IL-6 augmented the sub-G1 fraction and G2-M phase for Taxol-treated cells, only the G2-M phase was increased for vinblastine-treated cells. Furthermore, IL-6 enhanced the cytotoxicity of both drugs, which became evident only during recovery in cytokine-free and drug-free medium. However, the cytotoxicity of Taxol was augmented to a significantly greater extent than that of vinblastine (P < 0.001). Immunostaining with antibodies to alpha-tubulin and mitogen-activated protein kinase revealed colocalization of these two proteins within microtubule asters. In the presence of IL-6, the number of cells containing microtubule asters increased for Taxol treatment, but not for vinblastine treatment. These data indicate that IL-6 leads to differential modulation of the cytotoxicity of Taxol and vinblastine in U266 cells. Whereas recruitment of cells in the S phase of the cell cycle represents a major mechanism by which IL-6 potentiates the cytotoxicity of vinblastine, augmentation of the cytotoxicity of Taxol involves additional mechanisms. Furthermore, our data suggest that the microtubule-associated form of mitogen-activated protein kinase may play a role in IL-6-mediated enhancement of the cytotoxicity of Taxol. The clinical implications of these findings are discussed.

Managing the implementation of a pharmacy information system

The stages by which a pharmacy information system should be implemented are described. Implementation can be divided into three stages. The first stage is preimplementation, during which the hardware vendor installs and configures the operating system, the software is installed, the site is prepared, files are built, policies and procedures are modified or written, staff members are trained, functions or programs are tested, and supplies are purchased. The second stage is implementation, in which the new system becomes operational and is expanded. There are four basic implementation strategies: abrupt switchover, parallel conversion, conversion of one location at a time, and conversion of functions or modules in stages. The final stage is postimplementation, which consists of testing of the system, acceptance or rejection of the system, and the institution of quality control procedures. The acceptance criteria should be developed before the system is purchased. It is important to involve the pharmacy staff and other hospital departments in the planning for an information system. Careful management before, during, and after the implementation of a new pharmacy information system is essential to a smooth and timely conversion.