Adolescent knowledge and attitudes related to clinical trials.

PubMed

Brown, Devin L; Cowdery, Joan E; Jones, Toni Stokes; Langford, Aisha; Gammage, Catherine; Jacobs, Teresa L

2015-06-01

Poor enrollment plagues most clinical trials. Furthermore, despite mandates to improve minority representation in clinical trial participation, little progress has been made. We investigated the knowledge and attitudes of adolescents related to clinical trials and made race/ethnicity comparisons in an attempt to identify a possible educational intervention target. Students aged 13-18 years in southeast Michigan were offered participation through a class at one high school or two academic summer enrichment programs that drew from multiple high schools (73% response). Questionnaires previously validated in adults were administered. Non-Hispanic whites were compared with minorities using Wilcoxon rank-sum tests. Of the 82 respondents, the median age was 16 years (interquartile range: 15-17 years); 22 (28%) were white, 41 (51%) were African American, 11 (14%) were multiracial, 2 (2%) were American Indian or Alaska Native, 1 (1%) was Asian, 3 (4%) were Native Hawaiian or other Pacific Islander, and 2 respondents did not report a race (but did report Hispanic ethnicity). Nine (12%) were Hispanic. Only 27 (33%) had ever heard of a clinical trial. On a scale from 1 (most receptive) to 5 (least receptive) for learning more about a clinical trial for a relevant medical condition, the median score was 2 (interquartile range: 1-3) and for participating in a clinical trial for a relevant medical condition was 2 (interquartile range: 2-3). Overall knowledge was poor, with a median of 46% (interquartile range: 23%-62%) of knowledge answers correct. Knowledge was reduced (p = 0.0006) and attitudes were more negative (p = 0.05) in minorities than non-Hispanic whites, while minorities also endorsed more substantial barriers to trial participation (p = 0.0002). Distrust was similar between minority students and non-Hispanic whites (p = 0.15), and self-efficacy was greater in non-Hispanic whites (p = 0.05). Educational interventions directed toward adolescents that address knowledge, attitudes, and distrust in order to improve clinical trial awareness and receptivity overall are needed and may represent a tool to address disparities in minority enrollment in clinical trials. © The Author(s) 2015.

A multicenter study of plasma use in the United States.

PubMed

Triulzi, Darrell; Gottschall, Jerome; Murphy, Edward; Wu, Yanyun; Ness, Paul; Kor, Daryl; Roubinian, Nareg; Fleischmann, Debra; Chowdhury, Dhuly; Brambilla, Donald

2015-06-01

Detailed information regarding plasma use in the United States is needed to identify opportunities for practice improvement and design of clinical trials of plasma therapy. Ten US hospitals collected detailed medical information from the electronic health records for 1 year (2010-2011) for all adult patients transfused with plasma. A total of 72,167 units of plasma were transfused in 19,596 doses to 9269 patients. The median dose of plasma was 2 units (interquartile range, 2-4; range 1-72); 15% of doses were 1 unit, and 45% were 2 units. When adjusted by patient body weight (kg), the median dose was 7.3 mL/kg (interquartile range, 5.5-12.0). The median pretransfusion international normalized ratio (INR) was 1.9 (25%-75% interquartile range, 1.6-2.6). A total of 22.5% of plasma transfusions were given to patients with an INR of less than 1.6 and 48.5% for an INR of 2.0 or more. The median posttransfusion INR was 1.6 (interquartile range, 1.4-2.0). Only 42% of plasma transfusions resulted in a posttransfusion INR of less than 1.6. Correction of INR increased as the plasma dose increased from 1 to 4 units (p < 0.001). There was no difference in the INR response to different types of plasma. The most common issue locations were general ward (38%) and intensive care unit (ICU; 42%). This large database describing plasma utilization in the United States provides evidence for both inadequate dosing and unnecessary transfusion. Measures to improve plasma transfusion practice and clinical trials should be directed at patients on medical and surgical wards and in the ICU where plasma is most commonly used. © 2014 AABB.

A multicenter study of plasma use in the United States

PubMed Central

Triulzi, Darrell; Gottschall, Jerome; Murphy, Edward; Wu, Yanyun; Ness, Paul; Kor, Daryl; Roubinian, Nareg; Fleischmann, Debra; Chowdhury, Dhuly; Brambilla, Donald

2016-01-01

Background Detailed information regarding plasma use in the United States is needed to identify opportunities for practice improvement and design of clinical trials of plasma therapy. Study Design and Methods Ten US hospitals collected detailed medical information from the electronic health records for 1 year (2010-2011) for all adult patients transfused with plasma. Results A total of 72,167 units of plasma were transfused in 19,596 doses to 9269 patients. The median dose of plasma was 2 units (interquartile range, 2-4; range 1-72); 15% of doses were 1 unit, and 45% were 2 units. When adjusted by patient body weight (kg), the median dose was 7.3 mL/kg (interquartile range, 5.5-12.0). The median pretransfusion international normalized ratio (INR) was 1.9 (25%-75% interquartile range, 1.6-2.6). A total of 22.5% of plasma transfusions were given to patients with an INR of less than 1.6 and 48.5% for an INR of 2.0 or more. The median posttransfusion INR was 1.6 (interquartile range, 1.4-2.0). Only 42% of plasma transfusions resulted in a posttransfusion INR of less than 1.6. Correction of INR increased as the plasma dose increased from 1 to 4 units (p < 0.001). There was no difference in the INR response to different types of plasma. The most common issue locations were general ward (38%) and intensive care unit (ICU; 42%). Conclusion This large database describing plasma utilization in the United States provides evidence for both inadequate dosing and unnecessary transfusion. Measures to improve plasma transfusion practice and clinical trials should be directed at patients on medical and surgical wards and in the ICU where plasma is most commonly used. PMID:25522888

Transcatheter aortic valve implantation: durability of clinical and hemodynamic outcomes beyond 3 years in a large patient cohort.

PubMed

Gurvitch, R; Wood, D A; Tay, E L; Leipsic, J; Ye, J; Lichtenstein, S V; Thompson, C R; Carere, R G; Wijesinghe, N; Nietlispach, F; Boone, R H; Lauck, S; Cheung, A; Webb, J G

2010-09-28

Although short- and medium-term outcomes after transcatheter aortic valve implantation are encouraging, long-term data on valve function and clinical outcomes are limited. Consecutive high-risk patients who had been declined as surgical candidates because of comorbidities but who underwent successful transcatheter aortic valve implantation with a balloon-expandable valve between January 2005 and December 2006 and survived past 30 days were assessed. Clinical, echocardiographic, and computed tomographic follow-up examinations were performed. Seventy patients who underwent successful procedures and survived longer than 30 days were evaluated at a minimum follow-up of 3 years. At a median follow-up of 3.7 years (interquartile range 3.4 to 4.3 years), survival was 57%. Survival at 1, 2, and 3 years was 81%, 74%, and 61%, respectively. Freedom from reoperation was 98.5% (1 patient with endocarditis). During this early procedural experience, 11 patients died within 30 days, and 8 procedures were unsuccessful. When these patients were included, overall survival was 51%. Transaortic pressure gradients increased from 10.0 mm Hg (interquartile range 8.0 to 12.0 mm Hg) immediately after the procedure to 12.1 mm Hg (interquartile range 8.6 to 16.0 mm Hg) after 3 years (P=0.03). Bioprosthetic valve area decreased from a mean of 1.7±0.4 cm(2) after the procedure to 1.4±0.3 cm(2) after 3 years (P<0.01). Aortic incompetence after implantation was trivial or mild in 84% of cases and remained unchanged or improved over time. There were no cases of structural valvular deterioration, stent fracture, deformation, or valve migration. Transcatheter aortic valve implantation demonstrates good medium- to long-term durability and preserved hemodynamic function, with no evidence of structural failure. The procedure appears to offer an adequate and lasting resolution of aortic stenosis in selected patients.

The effects of flipped learning for bystander cardiopulmonary resuscitation on undergraduate medical students.

PubMed

Nakanishi, Taizo; Goto, Tadahiro; Kobuchi, Taketsune; Kimura, Tetsuya; Hayashi, Hiroyuki; Tokuda, Yasuharu

2017-12-22

To compare bystander cardiopulmonary resuscitation skills retention between conventional learning and flipped learning for first-year medical students. A post-test only control group design. A total of 108 participants were randomly assigned to either the conventional learning or flipped learning. The primary outcome measures of time to the first chest compression and the number of total chest compressions during a 2-minute test period 6 month after the training were assessed with the Mann-Whitney U test. Fifty participants (92.6%) in the conventional learning group and 45 participants (83.3%) in the flipped learning group completed the study. There were no statistically significant differences 6 months after the training in the time to the first chest compression of 33.0 seconds (interquartile range, 24.0-42.0) for the conventional learning group and 31.0 seconds (interquartile range, 25.0-41.0) for the flipped learning group (U=1171.0, p=0.73) or in the number of total chest compressions of 101.5 (interquartile range, 90.8-124.0) for the conventional learning group and 104.0 (interquartile range, 91.0-121.0) for the flipped learning group (U=1083.0, p=0.75). The 95% confidence interval of the difference between means of the number of total chest compressions 6 months after the training did not exceed a clinically important difference defined a priori. There were no significant differences between the conventional learning group and the flipped learning group in our main outcomes. Flipped learning might be comparable to conventional learning, and seems a promising approach which requires fewer resources and enables student-centered learning without compromising the acquisition of CPR skills.

Clinical presentation of patients with Ebola virus disease in Conakry, Guinea.

PubMed

Bah, Elhadj Ibrahima; Lamah, Marie-Claire; Fletcher, Tom; Jacob, Shevin T; Brett-Major, David M; Sall, Amadou Alpha; Shindo, Nahoko; Fischer, William A; Lamontagne, Francois; Saliou, Sow Mamadou; Bausch, Daniel G; Moumié, Barry; Jagatic, Tim; Sprecher, Armand; Lawler, James V; Mayet, Thierry; Jacquerioz, Frederique A; Méndez Baggi, María F; Vallenas, Constanza; Clement, Christophe; Mardel, Simon; Faye, Ousmane; Faye, Oumar; Soropogui, Baré; Magassouba, Nfaly; Koivogui, Lamine; Pinto, Ruxandra; Fowler, Robert A

2015-01-01

In March 2014, the World Health Organization was notified of an outbreak of Zaire ebolavirus in a remote area of Guinea. The outbreak then spread to the capital, Conakry, and to neighboring countries and has subsequently become the largest epidemic of Ebola virus disease (EVD) to date. From March 25 to April 26, 2014, we performed a study of all patients with laboratory-confirmed EVD in Conakry. Mortality was the primary outcome. Secondary outcomes included patient characteristics, complications, treatments, and comparisons between survivors and nonsurvivors. Of 80 patients who presented with symptoms, 37 had laboratory-confirmed EVD. Among confirmed cases, the median age was 38 years (interquartile range, 28 to 46), 24 patients (65%) were men, and 14 (38%) were health care workers; among the health care workers, nosocomial transmission was implicated in 12 patients (32%). Patients with confirmed EVD presented to the hospital a median of 5 days (interquartile range, 3 to 7) after the onset of symptoms, most commonly with fever (in 84% of the patients; mean temperature, 38.6°C), fatigue (in 65%), diarrhea (in 62%), and tachycardia (mean heart rate, >93 beats per minute). Of these patients, 28 (76%) were treated with intravenous fluids and 37 (100%) with antibiotics. Sixteen patients (43%) died, with a median time from symptom onset to death of 8 days (interquartile range, 7 to 11). Patients who were 40 years of age or older, as compared with those under the age of 40 years, had a relative risk of death of 3.49 (95% confidence interval, 1.42 to 8.59; P=0.007). Patients with EVD presented with evidence of dehydration associated with vomiting and severe diarrhea. Despite attempts at volume repletion, antimicrobial therapy, and limited laboratory services, the rate of death was 43%.

Left ventricular hypertrophy with strain and aortic stenosis.

PubMed

Shah, Anoop S V; Chin, Calvin W L; Vassiliou, Vassilis; Cowell, S Joanna; Doris, Mhairi; Kwok, T'ng Choong; Semple, Scott; Zamvar, Vipin; White, Audrey C; McKillop, Graham; Boon, Nicholas A; Prasad, Sanjay K; Mills, Nicholas L; Newby, David E; Dweck, Marc R

2014-10-28

ECG left ventricular hypertrophy with strain is associated with an adverse prognosis in aortic stenosis. We investigated the mechanisms and outcomes associated with ECG strain. One hundred and two patients (age, 70 years [range, 63-75 years]; male, 66%; aortic valve area, 0.9 cm(2) [range, 0.7-1.2 cm(2)]) underwent ECG, echocardiography, and cardiovascular magnetic resonance. They made up the mechanism cohort. Myocardial fibrosis was determined with late gadolinium enhancement (replacement fibrosis) and T1 mapping (diffuse fibrosis). The relationship between ECG strain and cardiovascular magnetic resonance was then assessed in an external validation cohort (n=64). The outcome cohort was made up of 140 patients from the Scottish Aortic Stenosis and Lipid Lowering Trial Impact on Regression (SALTIRE) study and was followed up for 10.6 years (1254 patient-years). Compared with those without left ventricular hypertrophy (n=51) and left ventricular hypertrophy without ECG strain (n=30), patients with ECG strain (n=21) had more severe aortic stenosis, increased left ventricular mass index, more myocardial injury (high-sensitivity plasma cardiac troponin I concentration, 4.3 ng/L [interquartile range, 2.5-7.3 ng/L] versus 7.3 ng/L [interquartile range, 3.2-20.8 ng/L] versus 18.6 ng/L [interquartile range, 9.0-45.2 ng/L], respectively; P<0.001) and increased diffuse fibrosis (extracellular volume fraction, 27.4±2.2% versus 27.2±2.9% versus 30.9±1.9%, respectively; P<0.001). All patients with ECG strain had midwall late gadolinium enhancement (positive and negative predictive values of 100% and 86%, respectively). Indeed, late gadolinium enhancement was independently associated with ECG strain (odds ratio, 1.73; 95% confidence interval, 1.08-2.77; P=0.02), a finding confirmed in the validation cohort. In the outcome cohort, ECG strain was an independent predictor of aortic valve replacement or cardiovascular death (hazard ratio, 2.67; 95% confidence interval, 1.35-5.27; P<0.01). ECG strain is a specific marker of midwall myocardial fibrosis and predicts adverse clinical outcomes in aortic stenosis. © 2014 American Heart Association, Inc.

Mycophenolate Mofetil in Combination with Steroids for Treatment of C3 Glomerulopathy: A Case Series.

PubMed

Avasare, Rupali S; Canetta, Pietro A; Bomback, Andrew S; Marasa, Maddalena; Caliskan, Yasar; Ozluk, Yasemin; Li, Yifu; Gharavi, Ali G; Appel, Gerald B

2018-03-07

C3 glomerulopathy is a form of complement-mediated GN. Immunosuppressive therapy may be beneficial in the treatment of C3 glomerulopathy. Mycophenolate mofetil is an attractive treatment option given its role in the treatment of other complement-mediated diseases and the results of the Spanish Group for the Study of Glomerular Diseases C3 Study. Here, we study the outcomes of patients with C3 glomerulopathy treated with steroids and mycophenolate mofetil. We conducted a retrospective chart review of patients in the C3 glomerulopathy registry at Columbia University and identified patients treated with mycophenolate mofetil for at least 3 months and follow-up for at least 1 year. We studied clinical, histologic, and genetic data for the whole group and compared data for those who achieved complete or partial remission (responders) with those who did not achieve remission (nonresponders). We compared remission with mycophenolate mofetil with remission with other immunosuppressive regimens. We identified 30 patients who met inclusion criteria. Median age was 25 years old (interquartile range, 18-36), median creatinine was 1.07 mg/dl (interquartile range, 0.79-1.69), and median proteinuria was 3200 mg/g creatinine (interquartile range, 1720-6759). The median follow-up time was 32 months (interquartile range, 21-68). Twenty (67%) patients were classified as responders. There were no significant differences in baseline characteristics between responders and nonresponders, although initial proteinuria was lower (median 2468 mg/g creatinine) in responders compared with nonresponders (median 5000 mg/g creatinine) and soluble membrane attack complex levels were higher in responders compared with nonresponders. For those tapered off mycophenolate mofetil, relapse rate was 50%. Genome-wide analysis on complement genes was done, and in 12 patients, we found 18 variants predicted to be damaging. None of these variants were previously reported to be pathogenic. Mycophenolate mofetil with steroids outperformed other immunosuppressive regimens. Among patients who tolerated mycophenolate mofetil, combination therapy with steroids induced remission in 67% of this cohort. Heavier proteinuria at the start of therapy and lower soluble membrane attack complex levels were associated with treatment resistance. Copyright © 2018 by the American Society of Nephrology.

Prevalence of Anal High-Risk Human Papillomavirus Infections Among HIV-Positive and HIV-Negative Men Who Have Sex With Men in Nigeria.

PubMed

Nowak, Rebecca G; Gravitt, Patti E; He, Xin; Ketende, Sosthenes; Dauda, Wuese; Omuh, Helen; Blattner, William A; Charurat, Manhattan E

2016-04-01

Prevalence estimates of anal high-risk human papillomavirus (HR-HPV) are needed in sub-Saharan Africa where HIV is endemic. This study evaluated anal HR-HPV in Nigeria among HIV-positive and HIV-negative men who have sex with men (MSM) for future immunization recommendations. We conducted a cross-sectional study to compare the prevalence of anal HR-HPV infections between 64 HIV-negative and 90 HIV-positive MSM. Multivariate Poisson regression analyses were used to examine demographic and behavioral risk factors associated with any HR-HPV infections. The median age of the 154 participants was 25 years (interquartile range, 22-28 years; range, 16-38 years), and the median age at initiation of anal sex with another man was 16 years (interquartile range, 13-18 years; range, 7-29 years). The prevalence of anal HR-HPV was higher among HIV-positive than HIV-negative MSM (91.1% vs. 40.6%, P < 0.001). In the multivariate analysis, HIV infection (adjusted prevalence ratio [aPR], 2.02; 95% confidence interval [CI], 1.49-2.72), 10 years or more since anal sexual debut (aPR, 1.26; 95% CI, 1.07-1.49), and concurrent relationships with men (aPR, 1.32; 95% CI, 1.04-1.67) were associated with increased anal HR-HPV prevalence. Anal HR-HPV infection is high for young Nigerian MSM, and rates are amplified in those coinfected with HIV. Providing universal coverage as well as catch-up immunization for young MSM may be an effective anal cancer prevention strategy in Nigeria.

Neurogranin as a Cerebrospinal Fluid Biomarker for Synaptic Loss in Symptomatic Alzheimer Disease

PubMed Central

Kester, Maartje I.; Teunissen, Charlotte E.; Crimmins, Daniel L.; Herries, Elizabeth M.; Ladenson, Jack. H.; Scheltens, Philip; van der Flier, Wiesje M.; Morris, John C.; Holtzman, David M.; Fagan, Anne M.

2015-01-01

IMPORTANCE Neurogranin (NGRN) seems to be a promising novel cerebrospinal fluid (CSF) biomarker for synaptic loss; however, clinical, and especially longitudinal, data are sparse. OBJECTIVE To examine the utility of NGRN, with repeated CSF sampling, for diagnosis, prognosis, and monitoring of Alzheimer disease (AD). DESIGN, SETTING, AND PARTICIPANTS Longitudinal study of consecutive patients who underwent 2 lumbar punctures between the beginning of 1995 and the end of 2010 within the memory clinic–based Amsterdam Dementia Cohort. The study included 163 patients: 37 cognitively normal participants (mean [SE] age, 64 [2] years; 38% female; and mean [SE] Mini-Mental State Examination [MMSE] score, 28 [0.3]), 61 patients with mild cognitive impairment (MCI) (mean [SE] age, 68 [1] years; 38% female; and mean [SE] MMSE score, 27 [0.3]), and 65 patients with AD (mean [SE] age, 65 [1] years; 45% female; and mean [SE] MMSE score, 22 [0.7]). The mean (SE) interval between lumbar punctures was 2.0 (0.1) years, and the mean (SE) duration of cognitive follow-up was 3.8 (0.2) years. Measurements of CSF NGRN levels were obtained in January and February 2014. MAIN OUTCOME AND MEASURE Levels of NGRN in CSF samples. RESULTS Baseline CSF levels of NGRN in patients with AD (median level, 2381 pg/mL [interquartile range, 1651-3416 pg/mL]) were higher than in cognitively normal participants (median level, 1712 pg/mL [interquartile range, 1206-2724 pg/mL]) (P = .04). Baseline NGRN levels were highly correlated with total tau and tau phosphorylated at threonine 181 in all patient groups (all P < .001), but not with Aβ42. Baseline CSF levels of NGRN were also higher in patients with MCI who progressed to AD (median level, 2842 pg/mL [interquartile range, 1882-3950 pg/mL]) compared with those with stable MCI (median level, 1752 pg/mL [interquartile range, 1024-2438 pg/mL]) (P = .004), and they were predictive of progression from MCI to AD (hazard ratio, 1.8 [95% CI, 1.1-2.9]; stratified by tertiles). Linear mixed-model analyses demonstrated that within-person levels of NGRN increased over time in cognitively normal participants (mean [SE] level, 90 [45] pg/mL per year; P < .05) but not in patients with MCI or AD. CONCLUSIONS AND RELEVANCE Neurogranin is a promising biomarker for AD because levels were elevated in patients with AD compared with cognitively normal participants and predicted progression from MCI to AD. Within-person levels of NGRN increased in cognitively normal participants but not in patients with later stage MCI or AD, which suggests that NGRN may reflect presymptomatic synaptic dysfunction or loss. PMID:26366630

Paediatric minor oral surgical procedures under inhalation sedation and general anaesthetic: a comparison of variety and duration of treatment.

PubMed

Foley, J

2008-03-01

To develop baseline data in relation to paediatric minor oral surgical procedures undertaken with both general anaesthesia and nitrous oxide inhalation sedation within a Hospital Dental Service. Data were collected prospectively over a three-year period from May 2003 to June 2006 for patients attending the Departments of Paediatric Dentistry, Dundee Dental Hospital and Ninewells Hospital, NHS Tayside, Great Britain, for all surgical procedures undertaken with either inhalation sedation or general anaesthetic. Both operator status and the procedure being undertaken were noted. In addition, the operating time was recorded. Data for 166 patients (F: 102; M: 64) with a median age of 12.50 (inter-quartile range 10.00, 14.20) years showed that 195 surgical procedures were undertaken. Of these 160 and 35 were with general anaesthetic and sedation respectively. The surgical removal of impacted, carious and supernumerary unit(s) accounted for 53.8% of all procedures, whilst the exposure of impacted teeth and soft tissue surgery represented 34.9% and 11.3% of procedures respectively. The median surgical time for techniques undertaken with sedation was 30.00 (inter-quartile range 25.00, 43.50) minutes whilst that for general anaesthetic was similar at 30.00 (inter-quartile range 15.25, 40.00) minutes (not statistically significant, (Mann Whitney U, W = 3081.5, P = 0.331). The majority of paediatric minor oral surgical procedures entail surgical exposure or removal of impacted teeth. The median treatment time for most procedures undertaken with either general anaesthetic or nitrous oxide sedation was 30 minutes.

High-Target Versus Low-Target Blood Pressure Management During Cardiopulmonary Bypass to Prevent Cerebral Injury in Cardiac Surgery Patients: A Randomized Controlled Trial.

PubMed

Vedel, Anne G; Holmgaard, Frederik; Rasmussen, Lars S; Langkilde, Annika; Paulson, Olaf B; Lange, Theis; Thomsen, Carsten; Olsen, Peter Skov; Ravn, Hanne Berg; Nilsson, Jens C

2018-04-24

Cerebral injury is an important complication after cardiac surgery with the use of cardiopulmonary bypass. The rate of overt stroke after cardiac surgery is 1% to 2%, whereas silent strokes, detected by diffusion-weighted magnetic resonance imaging, are found in up to 50% of patients. It is unclear whether a higher versus a lower blood pressure during cardiopulmonary bypass reduces cerebral infarction in these patients. In a patient- and assessor-blinded randomized trial, we allocated patients to a higher (70-80 mm Hg) or lower (40-50 mm Hg) target for mean arterial pressure by the titration of norepinephrine during cardiopulmonary bypass. Pump flow was fixed at 2.4 L·min -1 ·m -2 . The primary outcome was the total volume of new ischemic cerebral lesions (summed in millimeters cubed), expressed as the difference between diffusion-weighted imaging conducted preoperatively and again postoperatively between days 3 and 6. Secondary outcomes included diffusion-weighted imaging-evaluated total number of new ischemic lesions. Among the 197 enrolled patients, mean (SD) age was 65.0 (10.7) years in the low-target group (n=99) and 69.4 (8.9) years in the high-target group (n=98). Procedural risk scores were comparable between groups. Overall, diffusion-weighted imaging revealed new cerebral lesions in 52.8% of patients in the low-target group versus 55.7% in the high-target group ( P =0.76). The primary outcome of volume of new cerebral lesions was comparable between groups, 25 mm 3 (interquartile range, 0-118 mm 3 ; range, 0-25 261 mm 3 ) in the low-target group versus 29 mm 3 (interquartile range, 0-143 mm 3 ; range, 0-22 116 mm 3 ) in the high-target group (median difference estimate, 0; 95% confidence interval, -25 to 0.028; P =0.99), as was the secondary outcome of number of new lesions (1 [interquartile range, 0-2; range, 0-24] versus 1 [interquartile range, 0-2; range, 0-29] respectively; median difference estimate, 0; 95% confidence interval, 0-0; P =0.71). No significant difference was observed in frequency of severe adverse events. Among patients undergoing on-pump cardiac surgery, targeting a higher versus a lower mean arterial pressure during cardiopulmonary bypass did not seem to affect the volume or number of new cerebral infarcts. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02185885. © 2018 American Heart Association, Inc.

Long-term Outcomes Following Artificial Urinary Sphincter Placement: An Analysis of 1082 Cases at Mayo Clinic.

PubMed

Linder, Brian J; Rivera, Marcelino E; Ziegelmann, Matthew J; Elliott, Daniel S

2015-09-01

To evaluate long-term device outcomes following primary artificial urinary sphincter (AUS) implantation. We identified 1802 male patients with stress urinary incontinence that underwent AUS placement from 1983 to 2011. Of these, 1082 (60%) were involving primary implantations and comprise the study cohort. Multiple clinical and surgical variables were evaluated for potential association with treatment failure, defined as any secondary surgery. Patient follow-up was obtained through office examination, operative report, and written or telephone correspondence. Patients undergoing AUS implantation had a median age of 71 years (interquartile range 66-76) and median follow-up of 4.1 years (interquartile range 0.8-7.7). Overall, 338 of 1082 patients (31.2%) underwent secondary surgery, including 89 for device infection and/or erosion, 131 for device malfunction, 89 for urethral atrophy, and 29 for pump malposition or tubing complications. No patient-related risk factors were independently associated with an increased risk of secondary surgery on multivariable analysis. Secondary surgery-free survival was 90% at 1 year, 74% at 5 years, 57% at 10 years, and 41% at 15 years. Primary AUS implantation is associated with acceptable long-term outcomes. Recognition of long-term success is important for preoperative patient counseling. Copyright © 2015 Elsevier Inc. All rights reserved.

Feasibility and utility of an integrated medical imaging and informatics smartphone system for management of acute stroke.

PubMed

Shkirkova, Kristina; Akam, Eftitan Y; Huang, Josephine; Sheth, Sunil A; Nour, May; Liang, Conrad W; McManus, Michael; Trinh, Van; Duckwiler, Gary; Tarpley, Jason; Vinuela, Fernando; Saver, Jeffrey L

2017-12-01

Background Rapid dissemination and coordination of clinical and imaging data among multidisciplinary team members are essential for optimal acute stroke care. Aim To characterize the feasibility and utility of the Synapse Emergency Room mobile (Synapse ERm) informatics system. Methods We implemented the Synapse ERm system for integration of clinical data, computerized tomography, magnetic resonance, and catheter angiographic imaging, and real-time stroke team communications, in consecutive acute neurovascular patients at a Comprehensive Stroke Center. Results From May 2014 to October 2014, the Synapse ERm application was used by 33 stroke team members in 84 Code Stroke alerts. Patient age was 69.6 (±17.1), with 41.5% female. Final diagnosis was: ischemic stroke 64.6%, transient ischemic attack 7.3%, intracerebral hemorrhage 6.1%, and cerebrovascular-mimic 22.0%. Each patient Synapse ERm record was viewed by a median of 10 (interquartile range 6-18) times by a median of 3 (interquartile range 2-4) team members. The most used feature was computerized tomography, magnetic resonance, and catheter angiography image display. In-app tweet team, communications were sent by median 1 (interquartile range 0-1, range 0-13) users per case and viewed by median 1 (interquartile range 0-3, range 0-44) team members. Use of the system was associated with rapid treatment times, faster than national guidelines, including median door-to-needle 51.0 min (interquartile range 40.5-69.5) and median door-to-groin 94.5 min (interquartile range 85.5-121.3). In user surveys, the mobile information platform was judged easy to employ in 91% (95% confidence interval 65%-99%) of uses and of added help in stroke management in 50% (95% confidence interval 22%-78%). Conclusion The Synapse ERm mobile platform for stroke team distribution and integration of clinical and imaging data was feasible to implement, showed high ease of use, and moderate perceived added utility in therapeutic management.

Student performance and course evaluations before and after use of the Classroom Performance System ™ in a third-year veterinary radiology course.

PubMed

Hecht, Silke; Adams, W H; Cunningham, M A; Lane, I F; Howell, N E

2013-01-01

Effective teaching of veterinary radiology can be challenging in a traditional classroom environment. Audience response systems, colloquially known as "clickers," provide a means of encouraging student interaction. The purpose of this study was to compare student performance and course evaluations before and after using the Classroom Performance System™ in the third-year (fifth semester) didactic radiology course at the University of Tennessee College of Veterinary Medicine. Overall student performance was assessed by comparing median numeric final course grades (%) between years without and with use of the Classroom Performance System™. Grades of students were determined for individual instructors' sections. Student evaluations of the radiology course were compared for the years available (2007-2010). Student interactions were also evaluated subjectively by instructors who used the Classroom Performance System™. There was a significant difference (p = 0.009) between the median student grade before (2005 - 2008, median 82.2%; interquartile range 77.6-85.7%; range 61.9-95.5%) and after use of the classroom performance system (2009-2010, median 83.6%; interquartile range 79.9-87.9%; range 68.2-93.2%). There was no statistically significant difference in median student grades for individual instructors over the study period. The radiology course student evaluation scores were significantly higher in years where the Classroom Performance System™ was used in comparison to previous years (P = 0.019). Subjectively, students appeared more involved when using clickers. Findings indicated that the Classroom Performance System™ may be a useful tool for enhancing veterinary radiology education. © 2012 Veterinary Radiology & Ultrasound.

Increased Heat Generation in Postcardiac Arrest Patients During Targeted Temperature Management Is Associated With Better Outcomes.

PubMed

Uber, Amy J; Perman, Sarah M; Cocchi, Michael N; Patel, Parth V; Ganley, Sarah E; Portmann, Jocelyn M; Donnino, Michael W; Grossestreuer, Anne V

2018-04-03

Assess if amount of heat generated by postcardiac arrest patients to reach target temperature (Ttarget) during targeted temperature management is associated with outcomes by serving as a proxy for thermoregulatory ability, and whether it modifies the relationship between time to Ttarget and outcomes. Retrospective cohort study. Urban tertiary-care hospital. Successfully resuscitated targeted temperature management-treated adult postarrest patients between 2008 and 2015 with serial temperature data and Ttarget less than or equal to 34°C. None. Time to Ttarget was defined as time from targeted temperature management initiation to first recorded patient temperature less than or equal to 34°C. Patient heat generation ("heat units") was calculated as inverse of average water temperature × hours between initiation and Ttarget × 100. Primary outcome was neurologic status measured by Cerebral Performance Category score; secondary outcome was survival, both at hospital discharge. Univariate analyses were performed using Wilcoxon rank-sum tests; multivariate analyses used logistic regression. Of 203 patients included, those with Cerebral Performance Category score 3-5 generated less heat before reaching Ttarget (median, 8.1 heat units [interquartile range, 3.6-21.6 heat units] vs median, 20.0 heat units [interquartile range, 9.0-33.5 heat units]; p = 0.001) and reached Ttarget quicker (median, 2.3 hr [interquartile range, 1.5-4.0 hr] vs median, 3.6 hr [interquartile range, 2.0-5.0 hr]; p = 0.01) than patients with Cerebral Performance Category score 1-2. Nonsurvivors generated less heat than survivors (median, 8.1 heat units [interquartile range, 3.6-20.8 heat units] vs median, 19.0 heat units [interquartile range, 6.5-33.5 heat units]; p = 0.001) and reached Ttarget quicker (median, 2.2 hr [interquartile range, 1.5-3.8 hr] vs median, 3.6 hr [interquartile range, 2.0-5.0 hr]; p = 0.01). Controlling for average water temperature between initiation and Ttarget, the relationship between outcomes and time to Ttarget was no longer significant. Controlling for location, witnessed arrest, age, initial rhythm, and neuromuscular blockade use, increased heat generation was associated with better neurologic (adjusted odds ratio, 1.01 [95% CI, 1.00-1.03]; p = 0.039) and survival (adjusted odds ratio, 1.01 [95% CI, 1.00-1.03]; p = 0.045) outcomes. Increased heat generation during targeted temperature management initiation is associated with better outcomes at hospital discharge and may affect the relationship between time to Ttarget and outcomes.

Intakes and sources of isoflavones, lignans, enterolignans, coumestrol and soya-containing foods in the Norfolk arm of the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk), from 7 d food diaries, using a newly updated database.

PubMed

Mulligan, Angela A; Kuhnle, Gunter G C; Lentjes, Marleen A H; van Scheltinga, Veronica; Powell, Natasha A; McTaggart, Alison; Bhaniani, Amit; Khaw, Kay-Tee

2013-08-01

A diet rich in phyto-oestrogens has been suggested to protect against a variety of common diseases but UK intake data on phyto-oestrogens or their food sources are sparse. The present study estimates the average intakes of isoflavones, lignans, enterolignans and coumestrol from 7 d food diaries and provides data on total isoflavone, lignan and phyto-oestrogen consumption by food group. Development of a food composition database for twelve phyto-oestrogens and analysis of soya food and phyto-oestrogen consumption in a populationbased study. Men and women, aged 40–79 years, from the general population participating in the Norfolk arm of the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk) between 1993 and 1997, with nutrient and food data from 7 d food diaries. A subset of 20 437 participants. The median daily phyto-oestrogen intake for all men was 1199 mg (interquartile range 934–1537mg; mean 1504mg, SD 1502mg) and 888mg for all women (interquartile range 710–1135 mg; mean 1205 mg, SD 1701mg). In soya consumers, median daily intakes were higher: 2861 mg in men (interquartile range 1304–7269mg; mean 5051mg, SD 5031mg) and 3142 mg in women (interquartile range 1089–7327mg; mean 5396 mg, SD 6092 mg). In both men and women, bread made the greatest contribution to phyto-oestrogen intake – 40?8% and 35?6%, respectively. In soya consumers, vegetable dishes and soya/goat’s/sheep’s milks were the main contributors – 45?7% and 21?3% in men and 38?4% and 33?7% in women, respectively. The ability to estimate phyto-oestrogen intake in Western populations more accurately will aid investigations into their suggested effects on health.

Scientific Production of Research Fellows at the Zagreb University School of Medicine, Croatia

PubMed Central

Polašek, Ozren; Kolčić, Ivana; Buneta, Zoran; Čikeš, Nada; Pećina, Marko

2006-01-01

Aim To evaluate scientific production among research fellows employed at the Zagreb University School of Medicine and identify factors associated with their scientific output. Method We conducted a survey among research fellows and their mentors during June 2005. The main outcome measure was publication success, defined for each fellow as publishing at least 0.5 articles per employment year in journals indexed in the Current Contents bibliographic database. Bivariate methods and binary logistic regression were used in data analysis. Results A total of 117 fellows (response rate 95%) and 83 mentors (100%) were surveyed. The highest scientific production was recorded among research fellows employed in public health departments (median 3.0 articles, interquartile range 4.0), compared with those from pre-clinical (median 0.0, interquartile range 2.0) and clinical departments (median 1.0, interquartile range 2.0) (Kruskal-Wallis, P = 0.003). A total of 36 (29%) research fellows published at least 0.5 articles per employment year and were considered successful. Three variables were associated with fellows’ publication success: mentor’s scientific production (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.31-7.53), positive mentor’s assessment (OR, 3.15; 95% CI, 1.10-9.05), and fellows’ undergraduate publication in journals indexed in the Current Contents bibliographic database (OR, 4.05; 95% CI, 1.07-15.34). Conclusion Undergraduate publication could be used as one of the main criteria in selecting research fellows. One of the crucial factors in a fellow’s scientific production and career advancement is mentor’s input, which is why research fellows would benefit most from working with scientifically productive mentors. PMID:17042070

Intestinal cytokines in children with pervasive developmental disorders.

PubMed

DeFelice, Magee L; Ruchelli, Eduardo D; Markowitz, Jonathan E; Strogatz, Melissa; Reddy, Krishna P; Kadivar, Khadijeh; Mulberg, Andrew E; Brown, Kurt A

2003-08-01

A relationship between autism and gastrointestinal (GI) immune dysregulation has been postulated based on incidence of GI complaints as well as macroscopically observed lymphonodular hyperplasia and microscopically determined enterocolitis in pediatric patients with autism. To evaluate GI immunity, we quantitatively assessed levels of proinflammatory cytokines, interleukin (IL)-6, IL-8, and IL-1beta, produced by intestinal biopsies of children with pervasive developmental disorders. Fifteen patients, six with pervasive developmental disorders and nine age-matched controls, presenting for diagnostic colonoscopy were enrolled. Endoscopic biopsies were organ cultured, supernatants were harvested, and IL-6, IL-8, and IL-1beta levels were quantified by ELISA. Tissue histology was evaluated by blinded pathologists. Concentrations of IL-6 from intestinal organ culture supernatants of patients with pervasive developmental disorders (median 318.5 pg/ml, interquartile range 282.0-393.0 pg/ml) when compared with controls (median 436.9 pg/ml, interquartile range 312.6-602.5 pg/ml) were not significantly different (p = 0.0987). Concentrations of IL-8 (median 84,000 pg/ml, interquartile range 16,000-143,000 pg/ml) when compared with controls (median 177,000 pg/ml, interquartile range 114,000-244,000 pg/ml) were not significantly different (p = 0.0707). Concentrations of IL-1beta (median 0.0 pg/ml, interquartile range 0.0-94.7 pg/ml) when compared with controls (median 0.0 pg/ml, interquartile range 0.0-60.2 pg/ml) were not significantly different (p = 0.8826). Tissue histology was nonpathological for all patients. We have demonstrated no significant difference in production of IL-6, IL-8, and IL-1beta between patients with pervasive developmental disorders and age-matched controls. In general, intestinal levels of IL-6 and IL-8 were lower in patients with pervasive developmental disorders than in age-matched controls. These data fail to support an association between autism and GI inflammation.

Evaluation of an artificial intelligence program for estimating occupational exposures.

PubMed

Johnston, Karen L; Phillips, Margaret L; Esmen, Nurtan A; Hall, Thomas A

2005-03-01

Estimation and Assessment of Substance Exposure (EASE) is an artificial intelligence program developed by UK's Health and Safety Executive to assess exposure. EASE computes estimated airborne concentrations based on a substance's vapor pressure and the types of controls in the work area. Though EASE is intended only to make broad predictions of exposure from occupational environments, some occupational hygienists might attempt to use EASE for individual exposure characterizations. This study investigated whether EASE would accurately predict actual sampling results from a chemical manufacturing process. Personal breathing zone time-weighted average (TWA) monitoring data for two volatile organic chemicals--a common solvent (toluene) and a specialty monomer (chloroprene)--present in this manufacturing process were compared to EASE-generated estimates. EASE-estimated concentrations for specific tasks were weighted by task durations reported in the monitoring record to yield TWA estimates from EASE that could be directly compared to the measured TWA data. Two hundred and six chloroprene and toluene full-shift personal samples were selected from eight areas of this manufacturing process. The Spearman correlation between EASE TWA estimates and measured TWA values was 0.55 for chloroprene and 0.44 for toluene, indicating moderate predictive values for both compounds. For toluene, the interquartile range of EASE estimates at least partially overlapped the interquartile range of the measured data distributions in all process areas. The interquartile range of EASE estimates for chloroprene fell above the interquartile range of the measured data distributions in one process area, partially overlapped the third quartile of the measured data in five process areas and fell within the interquartile range in two process areas. EASE is not a substitute for actual exposure monitoring. However, EASE can be used in conditions that cannot otherwise be sampled and in preliminary exposure assessment if it is recognized that the actual interquartile range could be much wider and/or offset by a factor of 10 or more.

Age at Virologic Control Influences Peripheral Blood HIV Reservoir Size and Serostatus in Perinatally-Infected Adolescents

PubMed Central

Persaud, Deborah; Patel, Kunjal; Karalius, Brad; Rainwater-Lovett, Kaitlin; Ziemniak, Carrie; Ellis, Angela; Chen, Ya Hui; Richman, Douglas; Siberry, George K.; Van Dyke, Russell B.; Burchett, Sandra; Seage, George R.; Luzuriaga, Katherine

2014-01-01

Importance Combination antiretroviral therapy (cART) initiated within several weeks of HIV infection in adults limits proviral reservoirs that preclude HIV cure. Biomarkers of restricted proviral reservoirs may aid in the monitoring of HIV remission or cure. Objectives To quantify peripheral blood proviral reservoir size in perinatally HIV-infected adolescents and to identify correlates of limited proviral reservoirs. Design, Setting, and Participants A cross-sectional study including 144 perinatally HIV-infected (PHIV+) youth (median age: 14.3 years), enrolled in the US-based Pediatric HIV/AIDS Cohort Study, on durable (median: 10.2 years) cART, stratified by age at virologic control. Main Outcome and Measures The primary endpoint was peripheral blood mononuclear cell (PBMC) proviral load following virologic control at different ages. Correlations between proviral load and markers of active HIV production (HIV-specific antibodies, 2-long terminal repeat (2-LTR) circles), and markers of immune activation and inflammation were also assessed. Results Proviral reservoir size was markedly reduced in the PHIV+ youth who achieved virologic control by age 1 year (4.2 [interquartile range, 2.6-8 6] copies per 1 million PBMCs) compared to those who achieved virologic control between 1-5 years of age (19.4 [interquartile range, 5.5-99.8] copies per 1 million PBMCs) or after age 5 years (−(70.7 [interquartile range, 23.2-209.4] copies per 1 million PBMCs; P < .00l). A proviral burden <10 copies/million PBMCs was measured in 11 (79%), 20 (40%), and 13 (18%) participants with virologic control at ages <1 year, 1-5 years, and >5 years, respectively (p<0.001). Lower proviral load was associated with undetectable 2-LTR circles (p<0.001) and HIV negative or indeterminate serostatus (p<0.001), but not with concentrations of soluble immune activation markers CD14 and CD163. Conclusions and Relevance Early effective cART along with prolonged virologic suppression after perinatal HIV infection leads to negligible peripheral blood proviral reservoirs in adolescence and is associated with negative or indeterminate HIV serostatus. These findings highlight the long-term effect of early effective control of HIV replication on biomarkers of HIV persistence in perinatal infection and the utility of HIV serostatus as a biomarker for small proviral reservoir size, though not necessarily of cure. PMID:25286283

Single-Incision Laparoscopic Sterilization of the Cheetah (Acinonyx jubatus).

PubMed

Hartman, Marthinus J; Monnet, Eric; Kirberger, Robert M; Schmidt-Küntzel, Anne; Schulman, Martin L; Stander, Jana A; Stegmann, George F; Schoeman, Johan P

2015-07-01

To describe laparoscopic ovariectomy and salpingectomy in the cheetah (Acinonyx jubatus) using single-incision laparoscopic surgery (SILS). Prospective cohort. Female cheetahs (Acinonyx jubatus) (n = 21). Cheetahs were randomly divided to receive either ovariectomy (n = 11) or salpingectomy (n = 10). The use and complications of a SILS port was evaluated in all of cheetahs. Surgery duration and insufflation volumes of carbon dioxide (CO2 ) were recorded and compared across procedures. Laparoscopic ovariectomy and salpingectomy were performed without complications using a SILS port. The poorly-developed mesosalpinx and ovarian bursa facilitated access to the uterine tube for salpingectomy in the cheetah. The median surgery duration for ovariectomy was 24 minutes (interquartile range 3) and for salpingectomy was 19.5 minutes (interquartile range 3) (P = .005). The median volume of CO2 used for ovariectomy was 11.25 L (interquartile range 3.08) and for salpingectomy was 4.90 L (interquartile range 2.52), (P = .001) CONCLUSIONS: Laparoscopic ovariectomy and salpingectomy can be performed in the cheetah using SILS without perioperative complications. Salpingectomy is faster than ovariectomy and requires less total CO2 for insufflation. © Copyright 2015 by The American College of Veterinary Surgeons.

Central obesity, leptin and cognitive decline: the Sacramento Area Latino Study on Aging.

PubMed

Zeki Al Hazzouri, Adina; Haan, Mary N; Whitmer, Rachel A; Yaffe, Kristine; Neuhaus, John

2012-01-01

Central obesity is a risk factor for cognitive decline. Leptin is secreted by adipose tissue and has been associated with better cognitive function. Aging Mexican Americans have higher levels of obesity than non-Hispanic Whites, but no investigations examined the relationship between leptin and cognitive decline among them or the role of central obesity in this association. We analyzed 1,480 dementia-free older Mexican Americans who were followed over 10 years. Cognitive function was assessed every 12-15 months with the Modified Mini Mental State Exam (3MSE) and the Spanish and English Verbal Learning Test (SEVLT). For females with a small waist circumference (≤35 inches), an interquartile range difference in leptin was associated with 35% less 3MSE errors and 22% less decline in the SEVLT score over 10 years. For males with a small waist circumference (≤40 inches), an interquartile range difference in leptin was associated with 44% less 3MSE errors and 30% less decline in the SEVLT score over 10 years. There was no association between leptin and cognitive decline among females or males with a large waist circumference. Leptin interacts with central obesity in shaping cognitive decline. Our findings provide valuable information about the effects of metabolic risk factors on cognitive function. Copyright © 2012 S. Karger AG, Basel.

Evidence for activation of nuclear factor kappaB in obstructive sleep apnea.

PubMed

Yamauchi, Motoo; Tamaki, Shinji; Tomoda, Koichi; Yoshikawa, Masanori; Fukuoka, Atsuhiko; Makinodan, Kiyoshi; Koyama, Noriko; Suzuki, Takahiro; Kimura, Hiroshi

2006-12-01

Obstructive sleep apnea (OSA) is a risk factor for atherosclerosis, and atherosclerosis evolves from activation of the inflammatory cascade. We propose that activation of the nuclear factor kappaB (NF-kappaB), a key transcription factor in the inflammatory cascade, occurs in OSA. Nine age-matched, nonsmoking, and non-hypertensive men with OSA symptoms and seven similar healthy subjects were recruited for standard polysomnography followed by the collection of blood samples for monocyte nuclear p65 concentrations (OSA and healthy groups). In the OSA group, p65 and of monocyte production of tumor necrosis factor alpha (TNF-alpha) were measured at the same time and after the next night of continuous positive airway pressure (CPAP). p65 Concentrations in the OSA group were significantly higher than in the control group [median, 0.037 ng/microl (interquartile range, 0.034 to 0.051) vs 0.019 ng/microl (interquartile range, 0.013 to 0.032); p = 0.008], and in the OSA group were significantly correlated with apnea-hypopnea index and time spent below an oxygen saturation of 90% (r = 0.77 and 0.88, respectively) after adjustment for age and BMI. One night of CPAP resulted in a reduction in p65 [to 0.020 ng/mul (interquartile range, 0.010 to 0.036), p = 0.04] and levels of TNF-alpha production in cultured monocytes [16.26 (interquartile range, 7.75 to 24.85) to 7.59 ng/ml (interquartile range, 5.19 to 12.95), p = 0.01]. NF-kappaB activation occurs with sleep-disordered breathing. Such activation of NF-kappaB may contribute to the pathogenesis of atherosclerosis in OSA patients.

Gamma-knife radiosurgery in acromegaly: a 4-year follow-up study.

PubMed

Attanasio, Roberto; Epaminonda, Paolo; Motti, Enrico; Giugni, Enrico; Ventrella, Laura; Cozzi, Renato; Farabola, Mario; Loli, Paola; Beck-Peccoz, Paolo; Arosio, Maura

2003-07-01

Stereotactic radiosurgery by gamma-knife (GK) is an attractive therapeutic option after failure of microsurgical removal in patients with pituitary adenoma. In these tumors or remnants of them, it aims to obtain the arrest of cell proliferation and hormone hypersecretion using a single precise high dose of ionizing radiation, sparing surrounding structures. The long-term efficacy and toxicity of GK in acromegaly are only partially known. Thirty acromegalic patients (14 women and 16 men) entered a prospective study of GK treatment. Most were surgical failures, whereas in 3 GK was the primary treatment. Imaging of the adenoma and target coordinates identification were obtained by high resolution magnetic resonance imaging. All patients were treated with multiple isocenters (mean, 8; range, 3-11). The 50% isodose was used in 27 patients (90%). The mean margin dose was 20 Gy (range, 15-35), and the dose to the visual pathways was always less than 8 Gy. After a median follow-up of 46 months (range, 9-96), IGF-I fell from 805 micro g/liter (median; interquartile range, 640-994) to 460 micro g/liter (interquartile range, 217-654; P = 0.0002), and normal age-matched IGF-I levels were reached in 7 patients (23%). Mean GH levels decreased from 10 micro g/liter (interquartile range, 6.4-15) to 2.9 micro g/liter (interquartile range, 2-5.3; P < 0.0001), reaching levels below 2.5 micro g/liter in 11 (37%). The rate of persistently pathological hormonal levels was still 70% at 5 yr by Kaplan-Meier analysis. The median volume was 1.43 ml (range, 0.20-3.7). Tumor shrinkage (at least 25% of basal volume) occurred after 24 months (range, 12-36) in 11 of 19 patients (58% of assessable patients). The rate of shrinkage was 79% at 4 yr. In no case was further growth observed. Only 1 patient complained of side-effects (severe headache and nausea immediately after the procedure, with full recovery in a few days with steroid therapy). Anterior pituitary failures were observed in 2 patients, who already had partial hypopituitarism, after 2 and 6 yr, respectively. No patient developed visual deficits. GK is a valid adjunctive tool in the management of acromegaly that controls GH/IGF-I hypersecretion and tumor growth, with shrinkage of adenoma and no recurrence of the disease in the considered observation period and with low acute and chronic toxicity.

Comparative Definitions for Moderate-Severe Ischemia in Stress Nuclear, Echocardiography, and Magnetic Resonance Imaging

PubMed Central

Shaw, Leslee J.; Berman, Daniel S.; Picard, Michael H.; Friedrich, Matthias G.; Kwong, Raymond Y.; Stone, Gregg W.; Senior, Roxy; Min, James K.; Hachamovitch, Rory; Scherrer-Crosbie, Marielle; Mieres, Jennifer H.; Marwick, Thomas H.; Phillips, Lawrence M.; Chaudhry, Farooq A.; Pellikka, Patricia A.; Slomka, Piotr; Arai, Andrew E.; Iskandrian, Ami E.; Bateman, Timothy M.; Heller, Gary V.; Miller, Todd D.; Nagel, Eike; Goyal, Abhinav; Borges-Neto, Salvador; Boden, William E.; Reynolds, Harmony R.; Hochman, Judith S.; Maron, David J.; Douglas, Pamela S.

2014-01-01

The lack of standardized reporting of the magnitude of ischemia on noninvasive imaging contributes to variability in translating the severity of ischemia across stress imaging modalities. We identified the risk of coronary artery disease (CAD) death or myocardial infarction (MI) associated with ≥10% ischemic myocardium on stress nuclear imaging as the risk threshold for stress echocardiography and cardiac magnetic resonance. A narrative review revealed that ≥10% ischemic myocardium on stress nuclear imaging was associated with a median rate of CAD death or MI of 4.9%/year (interquartile range: 3.75% to 5.3%). For stress echocardiography, ≥3 newly dysfunctional segments portend a median rate of CAD death or MI of 4.5%/year (interquartile range: 3.8% to 5.9%). Although imprecisely delineated, moderate-severe ischemia on cardiac magnetic resonance may be indicated by ≥4 of 32 stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments. Risk-based thresholds can define equivalent amounts of ischemia across the stress imaging modalities, which will help to translate a common understanding of patient risk on which to guide subsequent management decisions. PMID:24925328

Out-of-pocket costs for childhood stroke: the impact of chronic illness on parents' pocketbooks.

PubMed

Plumb, Patricia; Seiber, Eric; Dowling, Michael M; Lee, JoEllen; Bernard, Timothy J; deVeber, Gabrielle; Ichord, Rebecca N; Bastian, Rachel; Lo, Warren D

2015-01-01

Direct costs for children who had stroke are similar to those for adults. There is no information regarding the out-of-pocket costs families encounter. We described the out-of-pocket costs families encountered in the first year after a child's ischemic stroke. Twenty-two subjects were prospectively recruited at four centers in the United States and Canada in 2008 and 2009 as part of the "Validation of the Pediatric NIH Stroke Scale" study; families' indirect costs were tracked for 1 year. Every 3 months, parents reported hours they did not work, nonreimbursed costs for medical visits or other health care, and mileage. They provided estimates of annual income. We calculated total out-of-pocket costs in US dollars and reported costs as a proportion of annual income. Total median out-of-pocket cost for the year after an ischemic stroke was $4354 (range, $0-$28,666; interquartile range, $1008-$8245). Out-of-pocket costs were greatest in the first 3 months after the incident stroke, with the largest proportion because of lost wages, followed by transportation, and nonreimbursed health care. For the entire year, median costs represented 6.8% (range, 0%-81.9%; interquartile range, 2.7%-17.2%) of annual income. Out-of-pocket expenses are significant after a child's ischemic stroke. The median costs are noteworthy provided that the median American household had cash savings of $3650 at the time of the study. These results with previous reports of direct costs provide a more complete view of the overall costs to families and society. Childhood stroke creates an under-recognized cost to society because of decreased parental productivity. Copyright © 2015 Elsevier Inc. All rights reserved.

Vitamin D and parathyroid hormone status in a representative population living in Macau, China.

PubMed

Ke, L; Mason, R S; Mpofu, E; Dibley, M; Li, Y; Brock, K E

2015-04-01

Associations between documented sun-exposure, exercise patterns and fish and supplement intake and 25-hydroxyvitamin D (25OHD) and parathyroid hormone (PTH) were investigated in a random household survey of Macau residents (aged 18-93). Blood samples (566) taken in summer were analyzed for 25OHD and PTH. In this Chinese population, 55% were deficient (25OHD <50nmol/L: median (interquartile range)=47.7 (24.2) nmol/L). Vitamin D deficiency was greatest in those aged <50 years: median (interquartile range)=43.3 (18.2) nmol/L, females: median (interquartile range)=45.5 (19.4) nmol/L and those with higher educational qualifications: median (interquartile range)=43.1 (18.7) nmol/L. In the total Macau population, statistically significant (p<0.01) modifiable associations with lower 25OHD levels were sunlight exposure (β=0.06), physical activity (PA) (measured as hours(hrs)/day: β=0.08), sitting (measured as hrs/day β=-0.20), intake of fish (β=0.08) and calcium (Ca) supplement intake (β=0.06) [linear regression analysis adjusting for demographic risk factors]. On similar analysis, and after adjustment for 25OHD, the only significant modifiable associations in the total population with PTH were sitting (β=-0.17), Body Mass Index (β=0.07) and Ca supplement intake (β=-0.06). In this Macau population less documented sun exposure, fish and Ca supplement intake and exercise were associated with lower 25OHD levels, especially in the younger population, along with the interesting finding that more sitting was associated with both lower 25OHD and high PTH blood levels. In conclusion, unlike findings from Caucasian populations, younger participants were significantly more vitamin D deficient, in particular highly educated single females. This may indicate the desire of young females to be pale and avoid the sun. There are also big differences in lifestyle between the older generation and the younger, in particular with respect to sun exposure and PA. This article is part of a Special Issue entitled '17th Vitamin D Workshop'. Copyright © 2015 Elsevier Ltd. All rights reserved.

A Pilot Study of the Immunologic, Virologic, and Pathologic Consequences of Intra-anal 5% Imiquimod in HIV-1-Infected Men With High-Grade Squamous Intraepithelial Lesions.

PubMed

Cranston, Ross D; Baker, Jonathan R; Siegel, Aaron; Brand, Rhonda M; Janocko, Laura; McGowan, Ian

2018-03-01

Imiquimod can be used to treat internal anal high-grade squamous intraepithelial lesions. In HIV-1-infected individuals there is a theoretical concern for increased HIV replication in anorectal tissue secondary to imiquimod-induced mucosal inflammation. The purpose of this study was to assess local virologic, immunologic, and pathologic effects of imiquimod treatment in HIV-infected individuals. This was a pilot study at a single academic center. The study was conducted at the University of Pittsburgh Anal Dysplasia Clinic. HIV-1-infected individuals with biopsy-confirmed internal anal high-grade squamous intraepithelial lesions were included. Imiquimod cream was prescribed for intra-anal use 3 times per week for 9 weeks. Anal human papillomavirus typing, anal and rectal tissue HIV-1 RNA and DNA quantification, cytokine gene expression, and anal histology were measured. Nine evaluable participants (1 participant was lost to follow-up) were all white men with a median age of 46 years (interquartile range = 12 y) and a median CD4 T-cell count of 480 cells per cubic millimeter (interquartile range = 835). All were taking antiretroviral therapy, and 7 of 9 had HIV-1 RNA <50 copies per milliliter. The median dose of imiquimod used was 27.0 (interquartile range = 3.5), and there was a median of 11 days (interquartile range = 10 d) from last dose to assessment. There was no progression to cancer, no significant change in the number of human papillomavirus types detected, and no significant change in quantifiable cytokines/HIV-1 RNA or DNA levels in anal or rectal tissue. Seven (35%) of 20 high-grade lesions resolved to low-grade squamous intraepithelial lesions. The study was limited by the small number of participants and variable time to final assessment. Intra-anal imiquimod showed no evidence of immune activation or increase in HIV-1 viral replication in anal and rectal tissue and confirmed efficacy for intra-anal high-grade squamous intraepithelial lesion treatment morbidity. See Video Abstract at http://links.lww.com/DCR/A498.

Long-term results of percutaneous balloon valvuloplasty in pulmonary valve stenosis in the pediatric population.

PubMed

Merino-Ingelmo, Raquel; Santos-de Soto, José; Coserria-Sánchez, Félix; Descalzo-Señoran, Alfonso; Valverde-Pérez, Israel

2014-05-01

Percutaneous pulmonary valvuloplasty is the preferred interventional procedure for pulmonary valve stenosis. The aim of this study was to evaluate the effectiveness of this technique, assess the factors leading to its success, and determine the long-term results in the pediatric population. The study included 53 patients with pulmonary valve stenosis undergoing percutaneous balloon valvuloplasty between December 1985 and December 2000. Right ventricular size and functional echocardiographic parameters, such as pulmonary regurgitation and residual transvalvular gradient, were assessed during long-term follow-up. Peak-to-peak transvalvular gradient decreased from 74 mmHg [interquartile range, 65-100 mmHg] to 20 mmHg [interquartile range, 14-34 mmHg]. The procedure was unsuccessful in 2 patients (3.77%). The immediate success rate was 73.58%. Follow-up ranged from 10 years to 24 years (median, 15 years). During follow-up, all patients developed late pulmonary regurgitation which was assessed as grade II in 58.4% and grade III in 31.2%. There was only 1 case of long-term restenosis (2.1%). Severe right ventricular dilatation was observed in 27.1% of the patients. None of the patients developed significant right ventricular dysfunction. Pulmonary valve replacement was not required in any of the patients. Percutaneous balloon valvuloplasty is an effective technique in the treatment of pulmonary valve stenosis with good long-term results. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

Speed of Adoption of Immune Checkpoint Inhibitors of Programmed Cell Death 1 Protein and Comparison of Patient Ages in Clinical Practice vs Pivotal Clinical Trials.

PubMed

O'Connor, Jeremy M; Fessele, Kristen L; Steiner, Jean; Seidl-Rathkopf, Kathi; Carson, Kenneth R; Nussbaum, Nathan C; Yin, Emily S; Adelson, Kerin B; Presley, Carolyn J; Chiang, Anne C; Ross, Joseph S; Abernethy, Amy P; Gross, Cary P

2018-05-10

The US Food and Drug Administration (FDA) is increasing its pace of approvals for novel cancer therapeutics, including for immune checkpoint inhibitors of programmed cell death 1 protein (anti-PD-1 agents). However, little is known about how quickly anti-PD-1 agents reach eligible patients in practice or whether such patients differ from those studied in clinical trials that lead to FDA approval (pivotal clinical trials). To assess the speed with which anti-PD-1 agents reached eligible patients in practice and to compare the ages of patients treated in clinical practice with the ages of those treated in pivotal clinical trials. This retrospective cohort study, performed from January 1, 2011, through August 31, 2016, included patients from the Flatiron Health Network who were eligible for anti-PD-1 treatment of selected cancer types, which included melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). Cumulative proportions of eligible patients receiving anti-PD-1 treatment and their age distributions. The study identified 3089 patients who were eligible for anti-PD-1 treatment (median age, 66 [interquartile range, 56-75] years for patients with melanoma, 66 [interquartile range, 58-72] years for patients with RCC, and 67 [interquartile range, 59-74] years for patients with NSCLC; 1742 male [56.4%] and 1347 [43.6%] female; 2066 [66.9%] white). Of these patients, 2123 (68.7%) received anti-PD-1 treatment, including 439 eligible patients with melanoma (79.1%), 1417 eligible patients with NSCLC (65.6%), and 267 eligible patients with RCC (71.2%). Within 4 months after FDA approval, greater than 60% of eligible patients in each cohort had received anti-PD-1 treatment. Overall, similar proportions of older and younger patients received anti-PD-1 treatment during the first 9 months after FDA approval. However, there were significant differences in age between clinical trial participants and patients receiving anti-PD-1 treatment in clinical practice, with more patients being older than 65 years in clinical practice (range, 327 of 1365 [60.6%] to 46 of 72 [63.9%]) than in pivotal clinical trials (range, 38 of 120 [31.7%] to 223 of 544 [41.0%]; all P < .001). Anti-PD-1 agents rapidly reached patients in clinical practice, and patients treated in clinical practice differed significantly from patients treated in pivotal clinical trials. Future actions are needed to ensure that rapid adoption occurs on the basis of representative trial evidence.

Recipient Age and Mortality Risk after Liver Transplantation: A Population-Based Cohort Study.

PubMed

Chen, Hsiu-Pin; Tsai, Yung-Fong; Lin, Jr-Rung; Liu, Fu-Chao; Yu, Huang-Ping

2016-01-01

The aim of the present large population-based cohort study is to explore the risk factors of age-related mortality in liver transplant recipients in Taiwan. Basic information and data on medical comorbidities for 2938 patients who received liver transplants between July 1, 1998, and December 31, 2012, were extracted from the National Health Insurance Research Database on the basis of ICD-9-codes. Mortality risks were analyzed after adjusting for preoperative comorbidities and compared among age cohorts. All patients were followed up until the study endpoint or death. This study finally included 2588 adults and 350 children [2068 (70.4%) male and 870 (29.6%) female patients]. The median age at transplantation was 52 (interquartile range, 43-58) years. Recipients were categorized into the following age cohorts: <20 (n = 350, 11.9%), 20-39 (n = 254, 8.6%), 40-59 (n = 1860, 63.3%), and ≥60 (n = 474, 16.1%) years. In the total population, 428 deaths occurred after liver transplantation, and the median follow-up period was 2.85 years (interquartile range, 1.2-5.5 years). Dialysis patients showed the highest risk of mortality irrespective of age. Further, the risk of death increased with an increase in the age at transplantation. Older liver transplant recipients (≥60 years), especially dialysis patients, have a higher mortality rate, possibly because they have more medical comorbidities. Our findings should make clinicians aware of the need for better risk stratification among elderly liver transplantation candidates.

Diagnostic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS).

PubMed

Tobin, W Oliver; Guo, Yong; Krecke, Karl N; Parisi, Joseph E; Lucchinetti, Claudia F; Pittock, Sean J; Mandrekar, Jay; Dubey, Divyanshu; Debruyne, Jan; Keegan, B Mark

2017-09-01

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a central nervous system inflammatory syndrome predominantly affecting the brainstem, cerebellum, and spinal cord. Following its initial description, the salient features of CLIPPERS have been confirmed and expanded upon, but the lack of formalized diagnostic criteria has led to reports of patients with dissimilar features purported to have CLIPPERS. We evaluated clinical, radiological and pathological features of patients referred for suspected CLIPPERS and propose diagnostic criteria to discriminate CLIPPERS from non-CLIPPERS aetiologies. Thirty-five patients were evaluated for suspected CLIPPERS. Clinical and neuroimaging data were reviewed by three neurologists to confirm CLIPPERS by consensus agreement. Neuroimaging and neuropathology were reviewed by experienced neuroradiologists and neuropathologists, respectively, both of whom were blinded to the clinical data. CLIPPERS was diagnosed in 23 patients (18 male and five female) and 12 patients had a non-CLIPPERS diagnosis. CLIPPERS patients' median age of onset was 58 years (interquartile range, 24-72) and were followed a median of 44 months (interquartile range 38-63). Non-CLIPPERS patients' median age of onset was 52 years (interquartile range, 39-59) and were followed a median of 27 months (interquartile range, 14-47). Clinical symptoms of gait ataxia, diplopia, cognitive impairment, and facial paraesthesia did not discriminate CLIPPERS from non-CLIPPERS. Marked clinical and radiological corticosteroid responsiveness was observed in CLIPPERS (23/23), and clinical worsening occurred in all 12 CLIPPERS cases when corticosteroids were discontinued. Corticosteroid responsiveness was common but not universal in non-CLIPPERS [clinical improvement (8/12); radiological improvement (2/12); clinical worsening on discontinuation (3/8)]. CLIPPERS patients had brainstem predominant perivascular gadolinium enhancing lesions on magnetic resonance imaging that were discriminated from non-CLIPPERS by: homogenous gadolinium enhancing nodules <3 mm in diameter without ring-enhancement or mass effect, and homogenous T2 signal abnormality not significantly exceeding the T1 enhancement. Brain neuropathology on 14 CLIPPERS cases demonstrated marked CD3-positive T-lymphocyte, mild B-lymphocyte and moderate macrophage infiltrates, with perivascular predominance as well as diffuse parenchymal infiltration (14/14), present in meninges, white and grey matter, associated with variable tissue destruction, astrogliosis and secondary myelin loss. Clinical, radiological and pathological feature define CLIPPERS syndrome and are differentiated from non-CLIPPERS aetiologies by neuroradiological and neuropathological findings. © The Author (2017). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Videogame playing as distraction technique in course of venipuncture.

PubMed

Minute, M; Badina, L; Cont, G; Montico, M; Ronfani, L; Barbi, E; Ventura, A

2012-01-01

Needle-related procedures (venipuncture, intravenous cannulation) are the most common source of pain and distress for children. Reducing needle related pain and anxiety could be important in order to prevent further distress, especially for children needing multiple hospital admissions. The aim of the present open randomized controlled trial was to investigate the efficacy of adding an active distraction strategy (videogame) to EMLA premedication in needle-related pain in children. One-hundred and nine children (4 -10 years of age) were prospectively recruited to enter in the study. Ninety-seven were randomized in two groups: CC group (conventional care: EMLA only) as control group and AD group (active distraction: EMLA plus videogame) as intervention group. Outcome measures were: self-reported pain by mean of FPS-R scale (main study outcome), observer-reported pain by FLACC scale, number of attempts for successful procedure. In both groups FPS-R median rate was 0 (interquartile range: 0-2), with significant pain (FPS-R > 4) reported by 9% of subjects. FLACC median rate was 1 in both groups (interquartile range 0-3 in CC group; 0-2 in AD group). The percentage of children with major pain (FLACC > 4) was 18% in CC group and 9% in AD group (p = 0.2). The median of necessary attempts to succeed in the procedures was 1 (interquartile range 1-2) in both groups.. Active distraction doesn't improve EMLA analgesia for iv cannulation and venipuncture. Even though, it resulted in an easily applicable strategy appreciated by children. This technique could be usefully investigated in other painful procedures.

Closed-loop insulin delivery during pregnancy complicated by type 1 diabetes.

PubMed

Murphy, Helen R; Elleri, Daniela; Allen, Janet M; Harris, Julie; Simmons, David; Rayman, Gerry; Temple, Rosemary; Dunger, David B; Haidar, Ahmad; Nodale, Marianna; Wilinska, Malgorzata E; Hovorka, Roman

2011-02-01

This study evaluated closed-loop insulin delivery with a model predictive control (MPC) algorithm during early (12-16 weeks) and late gestation (28-32 weeks) in pregnant women with type 1 diabetes. Ten women with type 1 diabetes (age 31 years, diabetes duration 19 years, BMI 24.1 kg/m(2), booking A1C 6.9%) were studied over 24 h during early (14.8 weeks) and late pregnancy (28.0 weeks). A nurse adjusted the basal insulin infusion rate from continuous glucose measurements (CGM), fed into the MPC algorithm every 15 min. Mean glucose and time spent in target (63-140 mg/dL), hyperglycemic (>140 to ≥ 180 mg/dL), and hypoglycemic (<63 to ≤ 50 mg/dL) were calculated using plasma and sensor glucose measurements. Linear mixed-effects models were used to compare glucose control during early and late gestation. During closed-loop insulin delivery, median (interquartile range) plasma glucose levels were 117 (100.8-154.8) mg/dL in early and 126 (109.8-140.4) mg/dL in late gestation (P = 0.72). The overnight mean (interquartile range) plasma glucose time in target was 84% (50-100%) in early and 100% (94-100%) in late pregnancy (P = 0.09). Overnight mean (interquartile range) time spent hyperglycemic (>140 mg/dL) was 7% (0-40%) in early and 0% (0-6%) in late pregnancy (P = 0.25) and hypoglycemic (<63 mg/dL) was 0% (0-3%) and 0% (0-0%), respectively (P = 0.18). Postprandial glucose control, glucose variability, insulin infusion rates, and CGM sensor accuracy were no different in early or late pregnancy. MPC algorithm performance was maintained throughout pregnancy, suggesting that overnight closed-loop insulin delivery could be used safely during pregnancy. More work is needed to achieve optimal postprandial glucose control.

Closed-Loop Insulin Delivery During Pregnancy Complicated by Type 1 Diabetes

PubMed Central

Murphy, Helen R.; Elleri, Daniela; Allen, Janet M.; Harris, Julie; Simmons, David; Rayman, Gerry; Temple, Rosemary; Dunger, David B.; Haidar, Ahmad; Nodale, Marianna; Wilinska, Malgorzata E.; Hovorka, Roman

2011-01-01

OBJECTIVE This study evaluated closed-loop insulin delivery with a model predictive control (MPC) algorithm during early (12–16 weeks) and late gestation (28–32 weeks) in pregnant women with type 1 diabetes. RESEARCH DESIGN AND METHODS Ten women with type 1 diabetes (age 31 years, diabetes duration 19 years, BMI 24.1 kg/m2, booking A1C 6.9%) were studied over 24 h during early (14.8 weeks) and late pregnancy (28.0 weeks). A nurse adjusted the basal insulin infusion rate from continuous glucose measurements (CGM), fed into the MPC algorithm every 15 min. Mean glucose and time spent in target (63–140 mg/dL), hyperglycemic (>140 to ≥180 mg/dL), and hypoglycemic (<63 to ≤50 mg/dL) were calculated using plasma and sensor glucose measurements. Linear mixed-effects models were used to compare glucose control during early and late gestation. RESULTS During closed-loop insulin delivery, median (interquartile range) plasma glucose levels were 117 (100.8–154.8) mg/dL in early and 126 (109.8–140.4) mg/dL in late gestation (P = 0.72). The overnight mean (interquartile range) plasma glucose time in target was 84% (50–100%) in early and 100% (94–100%) in late pregnancy (P = 0.09). Overnight mean (interquartile range) time spent hyperglycemic (>140 mg/dL) was 7% (0–40%) in early and 0% (0–6%) in late pregnancy (P = 0.25) and hypoglycemic (<63 mg/dL) was 0% (0–3%) and 0% (0–0%), respectively (P = 0.18). Postprandial glucose control, glucose variability, insulin infusion rates, and CGM sensor accuracy were no different in early or late pregnancy. CONCLUSIONS MPC algorithm performance was maintained throughout pregnancy, suggesting that overnight closed-loop insulin delivery could be used safely during pregnancy. More work is needed to achieve optimal postprandial glucose control. PMID:21216859

The Society of Thoracic Surgeons Composite Measure of Individual Surgeon Performance for Adult Cardiac Surgery: A Report of The Society of Thoracic Surgeons Quality Measurement Task Force.

PubMed

Shahian, David M; He, Xia; Jacobs, Jeffrey P; Kurlansky, Paul A; Badhwar, Vinay; Cleveland, Joseph C; Fazzalari, Frank L; Filardo, Giovanni; Normand, Sharon-Lise T; Furnary, Anthony P; Magee, Mitchell J; Rankin, J Scott; Welke, Karl F; Han, Jane; O'Brien, Sean M

2015-10-01

Previous composite performance measures of The Society of Thoracic Surgeons (STS) were estimated at the STS participant level, typically a hospital or group practice. The STS Quality Measurement Task Force has now developed a multiprocedural, multidimensional composite measure suitable for estimating the performance of individual surgeons. The development sample from the STS National Database included 621,489 isolated coronary artery bypass grafting procedures, isolated aortic valve replacement, aortic valve replacement plus coronary artery bypass grafting, mitral, or mitral plus coronary artery bypass grafting procedures performed by 2,286 surgeons between July 1, 2011, and June 30, 2014. Each surgeon's composite score combined their aggregate risk-adjusted mortality and major morbidity rates (each weighted inversely by their standard deviations) and reflected the proportion of case types they performed. Model parameters were estimated in a Bayesian framework. Composite star ratings were examined using 90%, 95%, or 98% Bayesian credible intervals. Measure reliability was estimated using various 3-year case thresholds. The final composite measure was defined as 0.81 × (1 minus risk-standardized mortality rate) + 0.19 × (1 minus risk-standardized complication rate). Risk-adjusted mortality (median, 2.3%; interquartile range, 1.7% to 3.0%), morbidity (median, 13.7%; interquartile range, 10.8% to 17.1%), and composite scores (median, 95.4%; interquartile range, 94.4% to 96.3%) varied substantially across surgeons. Using 98% Bayesian credible intervals, there were 207 1-star (lower performance) surgeons (9.1%), 1,701 2-star (as-expected performance) surgeons (74.4%), and 378 3-star (higher performance) surgeons (16.5%). With an eligibility threshold of 100 cases over 3 years, measure reliability was 0.81. The STS has developed a multiprocedural composite measure suitable for evaluating performance at the individual surgeon level. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Considerable decrease of antibody titers against measles, mumps, and rubella in preschool children from an e-waste recycling area.

PubMed

Lin, Yucong; Xu, Xijin; Dai, Yifeng; Zhang, Yuling; Li, Weiqiu; Huo, Xia

2016-12-15

Data on vaccination effects in children chronically exposed to heavy metals are extremely scarce. This study aims to investigate the immune responsiveness to measles, mumps, and rubella (MMR) vaccination in children from an e-waste recycling area. 378 healthy children from Guiyu (exposed group) and Haojiang (reference group) were surveyed. Blood lead (Pb) levels were measured by graphite furnace atomic absorption. Titers of antibodies against MMR were quantified by ELISA. Blood Pb levels of children from the exposed group were significantly higher than those from the reference group (5.61μg/dL vs. 3.57μg/dL, p<0.001). In contrast, the antibody titers against MMR of the children from the exposed group were significantly lower than those from the reference group. The median titer of the anti-measles antibody of the exposed group was 669.64mIU/mL, with an interquartile range of 372.88-1068.42mIU/mL; this was decreased by nearly 40% compared to that of the reference group (median 1046.79mIU/mL, interquartile range 603.29-1733.10mIU/mL). For antibody titers against mumps, there was an about 45% decrease in the exposed group (median 272.24U/mL, interquartile range 95.19-590.16U/mL), compared to the reference group (median 491.78U/mL, interquartile range 183.38-945.96U/mL). In the case of rubella, the median titer of the antibody was also significantly lower in the exposed group (median 37.08IU/mL, interquartile range 17.67-66.66IU/mL) compared to the reference group (median 66.50IU/mL, interquartile range 25.32-105.59IU/mL); the decrease in this case was nearly 44%. The proportion of children whose antibody titers against MMR were below protective level in the exposed group was higher than it was in the reference group. The present study demonstrates that the immune responsiveness to routine vaccination was suppressed in children chronically exposed to lead. Thus, the vaccination strategies for these children living in an e-waste recycling area should be modified. Copyright © 2016. Published by Elsevier B.V.

Transmission of molecularly undetectable circulating parasite clones leads to high infection complexity in mosquitoes post feeding.

PubMed

Grignard, Lynn; Gonçalves, Bronner P; Early, Angela M; Daniels, Rachel F; Tiono, Alfred B; Guelbéogo, Wamdaogo M; Ouédraogo, Alphonse; van Veen, Elke M; Lanke, Kjerstin; Diarra, Amidou; Nebie, Issa; Sirima, Sodiomon B; Targett, Geoff A; Volkman, Sarah K; Neafsey, Daniel E; Wirth, Dyann F; Bousema, Teun; Drakeley, Chris

2018-05-05

Plasmodium falciparum malaria infections often comprise multiple distinct parasite clones. Few datasets have directly assessed infection complexity in humans and mosquitoes they infect. Examining parasites using molecular tools may provide insights into the selective transmissibility of isolates. Using capillary electrophoresis genotyping and next generation amplicon sequencing, we analysed complexity of parasite infections in human blood and in the midguts of mosquitoes that became infected in membrane feeding experiments using the same blood material in two West African settings. Median numbers of clones in humans and mosquitoes were higher in samples from Burkina Faso (4.5, interquartile range 2-8 for humans; and 2, interquartile range 1-3 for mosquitoes) than in The Gambia (2, interquartile range 1-3 and 1, interquartile range 1-3, for humans and mosquitoes, respectively). Whilst the median number of clones was commonly higher in human blood samples, not all transmitted alleles were detectable in the human peripheral blood. In both study sample sets, additional parasite alleles were identified in mosquitoes compared with the matched human samples (10-88.9% of all clones/feeding assay, n = 73 feeding assays). The results are likely due to preferential amplification of the most abundant clones in peripheral blood but confirm the presence of low density clones that produce transmissible sexual stage parasites. Copyright © 2018. Published by Elsevier Ltd.

Serum Fatty Acid Binding Protein 4 (FABP4) Predicts Pre-eclampsia in Women With Type 1 Diabetes.

PubMed

Wotherspoon, Amy C; Young, Ian S; McCance, David R; Patterson, Chris C; Maresh, Michael J A; Pearson, Donald W M; Walker, James D; Holmes, Valerie A

2016-10-01

To examine the association between fatty acid binding protein 4 (FABP4) and pre-eclampsia risk in women with type 1 diabetes. Serum FABP4 was measured in 710 women from the Diabetes and Pre-eclampsia Intervention Trial (DAPIT) in early pregnancy and in the second trimester (median 14 and 26 weeks' gestation, respectively). FABP4 was significantly elevated in early pregnancy (geometric mean 15.8 ng/mL [interquartile range 11.6-21.4] vs. 12.7 ng/mL [interquartile range 9.6-17]; P < 0.001) and the second trimester (18.8 ng/mL [interquartile range 13.6-25.8] vs. 14.6 ng/mL [interquartile range 10.8-19.7]; P < 0.001) in women in whom pre-eclampsia later developed. Elevated second-trimester FABP4 level was independently associated with pre-eclampsia (odds ratio 2.87 [95% CI 1.24-6.68], P = 0.03). The addition of FABP4 to established risk factors significantly improved net reclassification improvement at both time points and integrated discrimination improvement in the second trimester. Increased second-trimester FABP4 independently predicted pre-eclampsia and significantly improved reclassification and discrimination. FABP4 shows potential as a novel biomarker for pre-eclampsia prediction in women with type 1 diabetes. © 2016 by the American Diabetes Association.

Maximal exercise testing variables and 10-year survival: fitness risk score derivation from the FIT Project.

PubMed

Ahmed, Haitham M; Al-Mallah, Mouaz H; McEvoy, John W; Nasir, Khurram; Blumenthal, Roger S; Jones, Steven R; Brawner, Clinton A; Keteyian, Steven J; Blaha, Michael J

2015-03-01

To determine which routinely collected exercise test variables most strongly correlate with survival and to derive a fitness risk score that can be used to predict 10-year survival. This was a retrospective cohort study of 58,020 adults aged 18 to 96 years who were free of established heart disease and were referred for an exercise stress test from January 1, 1991, through May 31, 2009. Demographic, clinical, exercise, and mortality data were collected on all patients as part of the Henry Ford ExercIse Testing (FIT) Project. Cox proportional hazards models were used to identify exercise test variables most predictive of survival. A "FIT Treadmill Score" was then derived from the β coefficients of the model with the highest survival discrimination. The median age of the 58,020 participants was 53 years (interquartile range, 45-62 years), and 28,201 (49%) were female. Over a median of 10 years (interquartile range, 8-14 years), 6456 patients (11%) died. After age and sex, peak metabolic equivalents of task and percentage of maximum predicted heart rate achieved were most highly predictive of survival (P<.001). Subsequent addition of baseline blood pressure and heart rate, change in vital signs, double product, and risk factor data did not further improve survival discrimination. The FIT Treadmill Score, calculated as [percentage of maximum predicted heart rate + 12(metabolic equivalents of task) - 4(age) + 43 if female], ranged from -200 to 200 across the cohort, was near normally distributed, and was found to be highly predictive of 10-year survival (Harrell C statistic, 0.811). The FIT Treadmill Score is easily attainable from any standard exercise test and translates basic treadmill performance measures into a fitness-related mortality risk score. The FIT Treadmill Score should be validated in external populations. Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Adverse events and dropouts in Alzheimer's disease studies: what can we learn?

PubMed

Henley, David B; Sundell, Karen L; Sethuraman, Gopalan; Schneider, Lon S

2015-01-01

Interpreting Alzheimer's disease (AD) clinical trial (CT) outcomes is complicated by treatment dropouts and adverse events (AEs). In elderly participants, AE rates, dropouts, and deaths are important considerations as they may undermine the validity of clinical trials. Published discontinuation and safety data are limited. Safety data from 1054 placebo-treated participants in IDENTITY and IDENTITY-2, 76-week, Phase 3 AD studies conducted in 31 countries, were pooled, annualized, and summarized overall, by country and age group. Median age was 74.2 (interquartile range 67.9-79.5) years; 57.4% were female; and median observation time was 63.2 (interquartile range 41.6-77.4) weeks when study drug dosing was halted. Overall annualized rates for discontinuations, discontinuations due to AEs, serious adverse events (SAEs), and deaths were 21.6% (range 19.6%-24.0%), 8.2% (range 8.1%-8.3%), 12.0%, and 1.7%, respectively. AE and discontinuation rates varied by country and age groups. Fall, pneumonia, and atrial fibrillation AEs were more frequent in the oldest age group. These annualized placebo safety data provide insight into the course of enrolled patients with mild-to-moderate AD, and are useful in planning longer term trials and in monitoring safety. Copyright © 2015 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.

Spectrum and clinical significance of systolic function and myocardial fibrosis assessed by cardiovascular magnetic resonance in hypertrophic cardiomyopathy.

PubMed

Olivotto, Iacopo; Maron, Barry J; Appelbaum, Evan; Harrigan, Caitlin J; Salton, Carol; Gibson, C Michael; Udelson, James E; O'Donnell, Christopher; Lesser, John R; Manning, Warren J; Maron, Martin S

2010-07-15

In hypertrophic cardiomyopathy (HCM), the clinical significance attributable to the broad range of left ventricular (LV) systolic function, assessed as the ejection fraction (EF), is incompletely resolved. We evaluated the EF using cardiovascular magnetic resonance (CMR) imaging in a large cohort of patients with HCM with respect to the clinical status and evidence of left ventricular remodeling with late gadolinium enhancement (LGE). CMR imaging was performed in 310 consecutive patients, aged 42 +/- 17 years. The EF in patients with HCM was 71 +/- 10% (range 28% to 89%), exceeding that of 606 healthy controls without cardiovascular disease (66 +/- 5%, p <0.001). LGE reflecting LV remodeling showed an independent, inverse relation to the EF (B-0.69, 95% confidence interval -0.86 to -0.52; p <0.001) and was greatest in patients with an EF <50%, in whom it constituted a median value of 29% of the LV volume (interquartile range 16% to 40%). However, the substantial subgroup with low-normal EF values of 50% to 65% (n = 45; 15% of the whole cohort), who were mostly asymptomatic or mildly symptomatic (37 or 82% with New York Heart Association functional class I to II), showed substantial LGE (median 5% of LV volume, interquartile range 2% to 10%). This overlapped with the subgroup with systolic dysfunction and significantly exceeded that of patients with an EF of 66% to 75% and >75% (median 2% of the LV volume, interquartile range 1.5% to 4%; p <0.01). In conclusion, in a large cohort of patients with HCM, a subset of patients with low-normal EF values (50% to 65%) was identified by contrast-enhanced CMR imaging as having substantial degrees of LGE, suggesting a transition phase, potentially heralding advanced LV remodeling and systolic dysfunction, with implications for clinical surveillance and management. Copyright (c) 2010. Published by Elsevier Inc.

A Comparison of Environmental Contamination by Patients Infected or Colonized with Methicillin-Resistant Staphylococcus aureus or Vancomycin-Resistant Enterococci: A Multicenter Study

PubMed Central

Knelson, Lauren P.; Williams, David A.; Gergen, Maria F.; Rutala, William A.; Weber, David J.; Sexton, Daniel J.; Anderson, Deverick J.

2014-01-01

A total of 1,023 environmental surfaces were sampled from 45 rooms with patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) before terminal room cleaning. Colonized patients had higher median total target colony-forming units (CFU) of MRSA or VRE than did infected patients (median, 25 CFU [interquartile range, 0–106 CFU] vs 0 CFU [interquartile range, 0–29 CFU]; P = .033). PMID:24915217

RECAST (Remote Ischemic Conditioning After Stroke Trial): A Pilot Randomized Placebo Controlled Phase II Trial in Acute Ischemic Stroke.

PubMed

England, Timothy J; Hedstrom, Amanda; O'Sullivan, Saoirse; Donnelly, Richard; Barrett, David A; Sarmad, Sarir; Sprigg, Nikola; Bath, Philip M

2017-05-01

Repeated episodes of limb ischemia and reperfusion (remote ischemic conditioning [RIC]) may improve outcome after acute stroke. We performed a pilot blinded placebo-controlled trial in patients with acute ischemic stroke, randomized 1:1 to receive 4 cycles of RIC within 24 hours of ictus. The primary outcome was tolerability and feasibility. Secondary outcomes included safety, clinical efficacy (day 90), putative biomarkers (pre- and post-intervention, day 4), and exploratory hemodynamic measures. Twenty-six patients (13 RIC and 13 sham) were recruited 15.8 hours (SD 6.2) post-onset, age 76.2 years (SD 10.5), blood pressure 159/83 mm Hg (SD 25/11), and National Institutes of Health Stroke Scale (NIHSS) score 5 (interquartile range, 3.75-9.25). RIC was well tolerated with 49 out of 52 cycles completed in full. Three patients experienced vascular events in the sham group: 2 ischemic strokes and 2 myocardial infarcts versus none in the RIC group ( P =0.076, log-rank test). Compared with sham, there was a significant decrease in day 90 NIHSS score in the RIC group, median NIHSS score 1 (interquartile range, 0.5-5) versus 3 (interquartile range, 2-9.5; P =0.04); RIC augmented plasma HSP27 (heat shock protein 27; P <0.05, repeated 2-way ANOVA) and phosphorylated HSP27 ( P <0.001) but not plasma S100-β, matrix metalloproteinase-9, endocannabinoids, or arterial compliance. RIC after acute stroke is well tolerated and appears safe and feasible. RIC may improve neurological outcome, and protective mechanisms may be mediated through HSP27. A larger trial is warranted. URL: http://www.isrctn.com. Unique identifier: ISRCTN86672015. © 2017 American Heart Association, Inc.

Double balloon catheter for induction of labour in Chinese women with previous caesarean section: one-year experience and literature review.

PubMed

Cheuk, Queenie K Y; Lo, T K; Lee, C P; Yeung, Anita P C

2015-06-01

To evaluate the efficacy and safety of double balloon catheter for induction of labour in Chinese women with one previous caesarean section and unfavourable cervix at term. Retrospective cohort study. A regional hospital in Hong Kong. Women with previous caesarean delivery requiring induction of labour at term and with an unfavourable cervix from May 2013 to April 2014. Primary outcome was to assess rate of successful vaginal delivery (spontaneous or instrument-assisted) using double balloon catheter. Secondary outcomes were double balloon catheter induction-to-delivery and removal-to-delivery interval; cervical score improvement; oxytocin augmentation; maternal or fetal complications during cervical ripening, intrapartum and postpartum period; and risk factors associated with unsuccessful induction. All 24 Chinese women tolerated double balloon catheter well. After double balloon catheter expulsion or removal, the cervix successfully ripened in 18 (75%) cases. The improvement in Bishop score 3 (interquartile range, 2-4) was statistically significant (P<0.001). Overall, 18 (75%) cases were delivered vaginally. The median insertion-to-delivery and removal-to-delivery intervals were 19 (interquartile range, 13.4-23.0) hours and 6.9 (interquartile range, 4.1-10.8) hours, respectively. Compared with cases without, the interval to delivery was statistically significantly shorter in those with spontaneous balloon expulsion or spontaneous membrane rupture during ripening (7.8 vs 3.0 hours; P=0.025). There were no major maternal or neonatal complications. The only factor significantly associated with failed vaginal birth after caesarean was previous caesarean section for failure to progress (P<0.001). This is the first study using double balloon catheter for induction of labour in Asian Chinese women with previous caesarean section. Using double balloon catheter, we achieved a vaginal birth after caesarean rate of 75% without major complications.

Contemporary outcomes of complete atrioventricular septal defect repair: analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database.

PubMed

St Louis, James D; Jodhka, Upinder; Jacobs, Jeffrey P; He, Xia; Hill, Kevin D; Pasquali, Sara K; Jacobs, Marshall L

2014-12-01

Contemporary outcomes data for complete atrioventricular septal defect (CAVSD) repair are limited. We sought to describe early outcomes of CAVSD repair across a large multicenter cohort, and explore potential associations with patient characteristics, including age, weight, and genetic syndromes. Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having repair of CAVSD (2008-2011) were included. Preoperative, operative, and outcomes data were described. Univariate associations between patient factors and outcomes were described. Of 2399 patients (101 centers), 78.4% had Down syndrome. Median age at surgery was 4.6 months (interquartile range, 3.5-6.1 months), with 11.8% (n = 284) aged ≤ 2.5 months. Median weight at surgery was 5.0 kg (interquartile range, 4.3-5.8 kg) with 6.3% (n = 151) < 3.5 kg. Pulmonary artery band removal at CAVSD repair was performed in 122 patients (4.6%). Major complications occurred in 9.8%, including permanent pacemaker implantation in 2.7%. Median postoperative length of stay (PLOS) was 8 days (interquartile range, 5-14 days). Overall hospital mortality was 3.0%. Weight < 3.5 kg and age ≤ 2.5 months were associated with higher mortality, longer PLOS, and increased frequency of major complications. Patients with Down syndrome had lower rates of mortality and morbidities than other patients; PLOS was similar. In a contemporary multicenter cohort, most patients with CAVSD have repair early in the first year of life. Prior pulmonary artery band is rare. Hospital mortality is generally low, although patients at extremes of low weight and younger age have worse outcomes. Mortality and major complication rates are lower in patients with Down syndrome. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Incidence and Characteristics of Autoimmune Hepatitis.

PubMed

Jiménez-Rivera, Carolina; Ling, Simon C; Ahmed, Najma; Yap, Jason; Aglipay, Mary; Barrowman, Nick; Graitson, Samantha; Critch, Jeff; Rashid, Mohsin; Ng, Vicky L; Roberts, Eve A; Brill, Herbert; Dowhaniuk, Jenna K; Bruce, Garth; Bax, Kevin; Deneau, Mark; Guttman, Orlee R; Schreiber, Richard A; Martin, Steven; Alvarez, Fernando

2015-11-01

Autoimmune hepatitis (AIH) is a progressive inflammatory liver disease of unknown etiology, with limited population-based estimates of pediatric incidence. We reported the incidence of pediatric AIH in Canada and described its clinical characteristics. We conducted a retrospective cohort study of patients aged <18 years diagnosed with AIH between 2000-2009 at all pediatric centers in Canada. A total of 159 children with AIH (60.3% female, 13.2% type 2 AIH) were identified. Annual incidence was 0.23 per 100000 children. Median age at presentation for type 1 was 12 years (interquartile range: 11-14) versus 10 years for type 2 (interquartile range: 4.5-13) (P = .03). Fatigue (58%), jaundice (54%), and abdominal pain (49%) were the most common presenting symptoms. Serum albumin (33 vs 38 g/L; P = .03) and platelet count (187 000 vs 249 000; P <.001) were significantly lower and the international normalized ratio (1.4 vs 1.2; P <.001) was higher in cirrhotic versus noncirrhotic patients. Initial treatment included corticosteroids (80%), azathioprine (32%), and/or cyclosporine (13%). Response to treatment at 1 year was complete in 90%, and partial in 3%. 3% of patients had no response, and 3% responded and later relapsed. Nine patients underwent liver transplantation, and 4 patients died at a mean follow-up of 4 years. AIH is uncommon in children and adolescents in Canada. Type 1 AIH was diagnosed 5.5 times more frequently than type 2 AIH. Most patients respond well to conventional therapy, diminishing the need for liver transplantation. Copyright © 2015 by the American Academy of Pediatrics.

Necrotizing fasciitis: eight-year experience and literature review.

PubMed

Wang, Jinn-Ming; Lim, Hwee-Kheng

2014-01-01

To describe clinical, laboratory, microbiological features, and outcomes of necrotizing fasciitis. From January 1, 2004 to December 31, 2011, 115 patients (79 males, 36 females) diagnosed with necrotizing fasciitis were admitted to Mackay Memorial Hospital in Taitung. Demographic data, clinical features, location of infection, type of comorbidities, microbiology and laboratory results, and outcomes of patients were retrospectively analyzed. Among 115 cases, 91 survived (79.1%) and 24 died (20.9%). There were 67 males (73.6%) and 24 females (26.4%) with a median age of 54 years (inter-quartile ranges, 44.0-68.0 years) in the survival group; and 12 males (50%) and 12 females (50%) with a median age of 61 years (inter-quartile ranges, 55.5-71.5 years) in the non-surviving group. The most common symptoms were local swelling/erythema, fever, pain/tenderness in 92 (80%), 87 (76%) and 84 (73%) patients, respectively. The most common comorbidies were liver cirrhosis in 54 patients (47%) and diabetes mellitus in 45 patients (39%). A single organism was identified in 70 patients (61%), multiple pathogens were isolated in 20 patients (17%), and no microorganism was identified in 30 patients (26%). The significant risk factors were gender, hospital length of stay, and albumin level. Necrotizing fasciitis, although not common, can cause notable rates of morbidity and mortality. It is important to have a high index of suspicion and increase awareness in view of the paucity of specific cutaneous findings early in the course of the disease. Prompt diagnosis and early operative debridement with adequate antibiotics are vital. Copyright © 2013 Elsevier Editora Ltda. All rights reserved.

Biological accidents in last-year medical students from three hospitals in Lima Peru.

PubMed

Charca-Benavente, Lilyan Consuelo; Huanca-Ruelas, Grozny Howell; Moreno-Loaiza, Oscar

2016-08-11

To determine the frequency and characteristics of biological accidents in last-year medical students from three hospitals in Lima. Cross-sectional study performed at three Public Health Insurance hospitals in Lima, in December 2014. The study population comprised last-year medical interns. Biological accidents were recorded with a questionnaire of exposure to blood and body fluids based on the formats used by the Exposure Prevention Information Network system and the Centers for Disease Control and Prevention. We inquired about occurrence and number of biological accidents as well as the characteristics of the last accident. Categorical data are presented as absolute and percentage frequencies and numeric data, as median and interquartile ranges. We collected 100 respondents; 85% of them had had a biological accident during the last year, with a median of 2 and interquartile range of 3. The most frequent type of exposure was percutaneous (71.8%) and the most common device was the hollow needle (54.1%). The most frequent place of occurrence and activities at the moment of exposure were at the delivery room (44.7%), while supervising a vaginal delivery (24.7%), and during suturing (24.7%). Three accidents involved high-risk patients, but only one student received antiviral prophylaxis; 49.4% attributed the cause of the accident to fatigue, and 75.3% of accidents are not reported. Gloves are the most used protective barrier (95%). The frequency of biological accidents among last-year medical students is high. Underreporting and inappropriate use of protective barriers increase the risk of medical students for biological accidents.

Osteogenesis imperfecta in childhood: effects of spondylodesis on functional ability, ambulation and perceived competence.

PubMed

Tolboom, N; Cats, E A; Helders, P J M; Pruijs, J E H; Engelbert, R H H

2004-03-01

We studied the effects of spondylodesis on spinal curvature, functional outcome, level of ambulation and perceived competence in 11 children with osteogenesis imperfecta (OI). Mean age at surgical intervention was 13.1 years (SD 2.5 years) and follow-up amounted to 3.4 years (SD 2.3 years). Spinal curvature was measured according to Cobb. The level of ambulation was scored according to the modified criteria of Bleck. Functional abilities and the amount of parental assistance were scored using the Dutch version of the Pediatric Evaluation of Disability Inventory (PEDI). Perceived competence was measured using the Harter Self-Perception Profile for Children. The amount of fatigue, spinal pain and presence of subjective dyspnea were scored with a visual analog scale. The median progression per year before spondylodesis was 6.1 degrees (interquartile range 2.9 degrees -12.9 degrees ) and after the spondylodesis it was 5.0 degrees (interquartile range 1.6 degrees -11.0 degrees ). No significant progression or regression in the level of ambulation was found. Perceived competence improved slightly. In the total score of the perceived competence, a borderline significant increase was found ( P-value 0.068). We concluded that spinal fusion in children with OI does not materially influence functional ability and level of ambulation. Self-perceived competence seemed to improve after surgery. The amount of pain, fatigue and subjective dyspnea seemed to diminish after spinal surgery. Progression of scoliosis proceeded, as did development of spinal curvature at the junction of the spondylodesis. Therefore, oral or intravenous bisphosphonates before and after spinal surgery should be considered.

Intraprocedure contrast enhanced ultrasound: the value in assessing the effect of ultrasound-guided high intensity focused ultrasound ablation for uterine fibroids.

PubMed

Peng, Song; Hu, Liang; Chen, Wenzhi; Chen, Jinyun; Yang, Caiyong; Wang, Xi; Zhang, Rong; Wang, Zhibiao; Zhang, Lian

2015-04-01

To investigate the value of microbubble contrast-enhanced ultrasound (CEUS) in evaluating the treatment response of uterine fibroids to HIFU ablation. Sixty-eight patients with a solitary uterine fibroid from the First Affiliated Hospital of Chongqing Medical University were included and analyzed. All patients underwent pre- and post-treatment magnetic resonance imaging (MRI) with a standardized protocol, as well as pre-evaluation, intraprocedure, and immediate post-treatment CEUS. CEUS and MRI were compared by different radiologists. In comparison with MRI, CEUS showed that the size of fibroids, volume of fibroids, size of non-perfused regions, non-perfused volume (NPV) or fractional ablation (NPV ratio) was similar to that of MRI. In terms of CEUS examination results, the median volume of fibroids was 75.2 (interquartile range, 34.2-127.3) cm(3), the median non-perfused volume was 54.9 (interquartile range, 28.0-98.1) cm(3), the mean fractional ablation was 83.7±13.6 (range, 30.0-100.0)%. In terms of MRI examination results, the median volume of fibroids was 74.1 (interquartile range, 33.4-116.2) cm(3). On the basis of contrast-enhanced T1-weighted images immediately after HIFU treatment, the median non-perfused volume was 58.5 (interquartile range, 27.7-100.0) cm(3), the average fractional ablation was 84.2±14.2 (range, 40.0-100.0)%. CEUS clearly showed the size of fibroids and the non-perfused areas of the fibroid. Results from CEUS correlated well with results obtained from MRI. Copyright © 2015 Elsevier B.V. All rights reserved.

Cell-Free circulating DNA: a new biomarker for the acute coronary syndrome.

PubMed

Cui, Ming; Fan, Mengkang; Jing, Rongrong; Wang, Huimin; Qin, Jingfeng; Sheng, Hongzhuan; Wang, Yueguo; Wu, Xinhua; Zhang, Lurong; Zhu, Jianhua; Ju, Shaoqing

2013-01-01

In recent studies, concentrations of cell-free circulating DNA (cf-DNA) have been correlated with clinical characteristics and prognosis in several diseases. The relationship between cf-DNA concentrations and the acute coronary syndrome (ACS) remains unknown. Moreover, no data are available for the detection cf-DNA in ACS by a branched DNA (bDNA)-based Alu assay. The aim of the present study was to investigate cf-DNA concentrations in ACS and their relationship with clinical features. Plasma cf-DNA concentrations of 137 ACS patients at diagnosis, of 60 healthy individuals and of 13 patients with stable angina (SA) were determined using a bDNA-based Alu assay. ACS patients (median 2,285.0, interquartile range 916.4-4,857.3 ng/ml), especially in ST-segment elevation myocardial infarction patients (median 5,745.4, interquartile range 4,013.5-8,643.9 ng/ml), showed a significant increase in plasma cf-DNA concentrations compared with controls (healthy controls: median 118.3, interquartile range 81.1-221.1 ng/ml; SA patients: median 202.3, interquartile range 112.7-256.1 ng/ml) using a bDNA-based Alu assay. Moreover, we found positive correlations between cf-DNA and Gensini scoring and GRACE (Global Registry of Acute Coronary Events) scoring in ACS. cf-DNA may be a valuable marker for diagnosing and predicting the severity of coronary artery lesions and risk stratification in ACS. Copyright © 2013 S. Karger AG, Basel.

Effort of breathing in children receiving high-flow nasal cannula.

PubMed

Rubin, Sarah; Ghuman, Anoopindar; Deakers, Timothy; Khemani, Robinder; Ross, Patrick; Newth, Christopher J

2014-01-01

High-flow humidified nasal cannula is often used to provide noninvasive respiratory support in children. The effect of high-flow humidified nasal cannula on effort of breathing in children has not been objectively studied, and the mechanism by which respiratory support is provided remains unclear. This study uses an objective measure of effort of breathing (Pressure. Rate Product) to evaluate high-flow humidified nasal cannula in critically ill children. Prospective cohort study. Quaternary care free-standing academic children's hospital. ICU patients younger than 18 years receiving high-flow humidified nasal cannula or whom the medical team planned to extubate to high-flow humidified nasal cannula within 72 hours of enrollment. An esophageal pressure monitoring catheter was placed to measure pleural pressures via a Bicore CP-100 pulmonary mechanics monitor. Change in pleural pressure (ΔPes) and respiratory rate were measured on high-flow humidified nasal cannula at 2, 5, and 8 L/min. ΔPes and respiratory rate were multiplied to generate the Pressure.Rate Product, a well-established objective measure of effort of breathing. Baseline Pes, defined as pleural pressure at end exhalation during tidal breathing, reflected the positive pressure generated on each level of respiratory support. Twenty-five patients had measurements on high-flow humidified nasal cannula. Median age was 6.5 months (interquartile range, 1.3-15.5 mo). Median Pressure,Rate Product was lower on high-flow humidified nasal cannula 8 L/min (median, 329 cm H2O·min; interquartile range, 195-402) compared with high-flow humidified nasal cannula 5 L/min (median, 341; interquartile range, 232-475; p = 0.007) or high-flow humidified nasal cannula 2 L/min (median, 421; interquartile range, 233-621; p < 0.0001) and was lower on high-flow humidified nasal cannula 5 L/min compared with high-flow humidified nasal cannula 2 L/min (p = 0.01). Baseline Pes was higher on high-flow humidified nasal cannula 8 L/min than on high-flow humidified nasal cannula 2 L/min (p = 0.03). Increasing flow rates of high-flow humidified nasal cannula decreased effort of breathing in children, with the most significant impact seen from high-flow humidified nasal cannula 2 to 8 L/min. There are likely multiple mechanisms for this clinical effect, including generation of positive pressure and washout of airway dead space.

Effect of Age and Sex on the QTc Interval in Children and Adolescents With Type 1 and 2 Long-QT Syndrome.

PubMed

Vink, Arja S; Clur, Sally-Ann B; Geskus, Ronald B; Blank, Andreas C; De Kezel, Charlotte C A; Yoshinaga, Masao; Hofman, Nynke; Wilde, Arthur A M; Blom, Nico A

2017-04-01

In congenital long-QT syndrome, age, sex, and genotype have been associated with cardiac events, but their effect on the trend in QTc interval has never been established. We, therefore, aimed to assess the effect of age and sex on the QTc interval in children and adolescents with type 1 (LQT1) and type 2 (LQT2) long-QT syndrome. QTc intervals of 12-lead resting electrocardiograms were determined, and trends over time were analyzed using a linear mixed-effects model. The study included 278 patients with a median follow-up of 4 years (interquartile range, 1-9) and a median number of 6 (interquartile range, 2-10) electrocardiograms per patient. Both LQT1 and LQT2 male patients showed QTc interval shortening after the onset of puberty. In LQT2 male patients, this was preceded by a progressive QTc interval prolongation. In LQT1, after the age of 12 years, male patients had a significantly shorter QTc interval than female patients. In LQT2, during the first years of life and from 14 to 26 years, male patients had a significantly shorter QTc interval than female patients. On the contrary, between 5 and 14 years, LQT2 male patients had significantly longer QTc interval than LQT2 female patients. There is a significant effect of age and sex on the QTc interval in long-QT syndrome, with a unique pattern per genotype. The age of 12 to 14 years is an important transitional period. In the risk stratification and management of long-QT syndrome patients, clinicians should be aware of these age-, sex-, and genotype-related trends in QTc interval and especially the important role of the onset of puberty. © 2017 American Heart Association, Inc.

Quality control in QuantiFERON-TB gold in-tube for screening latent tuberculosis infection in health care workers.

PubMed

Igari, Hidetoshi; Watanabe, Akira; Ichimura, Yasunori; Sakurai, Takayuki; Taniguchi, Toshibumi; Ishiwada, Naruhiko

2017-04-01

QuantiFERON-TB gold in-tube has been used for screening latent tuberculosis infection in newly employed health care workers in Japan. There have been a few studies concerning quality control. We retrospectively analysed QuantiFERON-TB gold in-tube results in a hospital in Japan. Interferon-γ values in three blood collection tubes for QuantiFERON-TB gold in-tube were analysed in association with the positivity rate. The data set consisted of health care workers aged 20-29 years during the 7 years between 2010 and 2016. The yearly QuantiFERON-TB gold in-tube positivity rate was 0.9%, 16.4%, 3.0%, 39.3%, 2.8%, 0.9% and 1.5%, and was extremely high in 2011 and 2013. The interferon-γ values in the tuberculosis antigen tube were elevated in these two years, as indicated by higher median and wider interquartile range. The interferon-γ value in the negative control tube was also higher in 2011. The higher interferon-γ values in collection tubes (tuberculosis antigen tube and/or negative control tube) resulted in higher QuantiFERON-TB gold in-tube positivity rate. The distribution of interferon-γ in tuberculosis antigen tube and negative control tube, as evaluated by median and interquartile range, proved to be an effective index for the quality control of QuantiFERON-TB gold in-tube. Copyright © 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

An Initial Evaluation of the Impact of Pokémon GO on Physical Activity.

PubMed

Xian, Ying; Xu, Hanzhang; Xu, Haolin; Liang, Li; Hernandez, Adrian F; Wang, Tracy Y; Peterson, Eric D

2017-05-16

Pokémon GO is a location-based augmented reality game. Using GPS and the camera on a smartphone, the game requires players to travel in real world to capture animated creatures, called Pokémon. We examined the impact of Pokémon GO on physical activity (PA). A pre-post observational study of 167 Pokémon GO players who were self-enrolled through recruitment flyers or online social media was performed. Participants were instructed to provide screenshots of their step counts recorded by the iPhone Health app between June 15 and July 31, 2016, which was 3 weeks before and 3 weeks after the Pokémon GO release date. Of 167 participants, the median age was 25 years (interquartile range, 21-29 years). The daily average steps of participants at baseline was 5678 (SD, 2833; median, 5718 [interquartile range, 3675-7279]). After initiation of Pokémon GO, daily activity rose to 7654 steps (SD, 3616; median, 7232 [interquartile range, 5041-9744], pre-post change: 1976; 95% CI, 1494-2458, or a 34.8% relative increase [ P <0.001]). On average, 10 000 "XP" points (a measure of game progression) was associated with 2134 additional steps per day (95% CI, 1673-2595), suggesting a potential dose-response relationship. The number of participants achieving a goal of 10 000+ steps per day increased from 15.3% before to 27.5% after (odds ratio, 2.06; 95% CI, 1.70-2.50). Increased PA was also observed in subgroups, with the largest increases seen in participants who spent more time playing Pokémon GO, those who were overweight/obese, or those with a lower baseline PA level. Pokémon GO participation was associated with a significant increase in PA among young adults. Incorporating PA into gameplay may provide an alternative way to promote PA in persons who are attracted to the game. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02888314. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

A Predictive Model to Identify Patients With Fecal Incontinence Based on High-Definition Anorectal Manometry.

PubMed

Zifan, Ali; Ledgerwood-Lee, Melissa; Mittal, Ravinder K

2016-12-01

Three-dimensional high-definition anorectal manometry (3D-HDAM) is used to assess anal sphincter function; it determines profiles of regional pressure distribution along the length and circumference of the anal canal. There is no consensus, however, on the best way to analyze data from 3D-HDAM to distinguish healthy individuals from persons with sphincter dysfunction. We developed a computer analysis system to analyze 3D-HDAM data and to aid in the diagnosis and assessment of patients with fecal incontinence (FI). In a prospective study, we performed 3D-HDAM analysis of 24 asymptomatic healthy subjects (control subjects; all women; mean age, 39 ± 10 years) and 24 patients with symptoms of FI (all women; mean age, 58 ± 13 years). Patients completed a standardized questionnaire (FI severity index) to score the severity of FI symptoms. We developed and evaluated a robust prediction model to distinguish patients with FI from control subjects using linear discriminant, quadratic discriminant, and logistic regression analyses. In addition to collecting pressure information from the HDAM data, we assessed regional features based on shape characteristics and the anal sphincter pressure symmetry index. The combination of pressure values, anal sphincter area, and reflective symmetry values was identified in patients with FI versus control subjects with an area under the curve value of 1.0. In logistic regression analyses using different predictors, the model identified patients with FI with an area under the curve value of 0.96 (interquartile range, 0.22). In discriminant analysis, results were classified with a minimum error of 0.02, calculated using 10-fold cross-validation; different combinations of predictors produced median classification errors of 0.16 in linear discriminant analysis (interquartile range, 0.25) and 0.08 in quadratic discriminant analysis (interquartile range, 0.25). We developed and validated a novel prediction model to analyze 3D-HDAM data. This system can accurately distinguish patients with FI from control subjects. Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.

Biomarkers and electrocardiographic evidence of myocardial ischemia in patients with human immunodeficiency virus infection.

PubMed

Gupta, Mihir; Miller, Christopher J; Baker, Jason V; Lazar, Jason; Bogner, Johannes R; Calmy, Alexandra; Soliman, Elsayed Z; Neaton, James D

2013-03-01

We assessed the relation of inflammatory and coagulation biomarkers with electrocardiographic (ECG) evidence of myocardial ischemia. High-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and D-dimer levels were measured at study entry for 3,085 human immunodeficiency virus-infected participants (mean age 44 years; 26.4% women; 24.6% black) in the Strategies for Management of Antiretroviral Therapy trial. Logistic regression models were used to examine the associations of these biomarkers with prevalent and incident myocardial ischemia. The latter analyses were performed for 1,411 participants who were randomly assigned to receive continuous antiretroviral therapy during follow-up to suppress the human immunodeficiency virus viral load and had ≥1 ECG reading during the follow-up period. The median hsCRP, IL-6, and D-dimer level was 1.65 μg/ml (interquartile range 0.69 to 4.11), 1.60 pg/ml (interquartile range 1.00 to 2.75), and 0.18 μg/ml (interquartile range 0.11 to 0.32), respectively. At baseline, the prevalence of major or minor Q-QS or ST-T ECG abnormalities was 18.6%. The biomarker levels were associated with prevalent major or minor ischemic abnormalities on the univariate analyses; however, adjustment for traditional risk factors attenuated these associations. The adjusted odds ratio for major or minor ischemic abnormalities and 95% confidence intervals for the greatest versus lowest quartiles was 1.3 (95% confidence interval 0.9 to 1.7) for hsCRP, 1.0 (95% confidence interval 0.7 to 1.3) for IL-6, and 1.1 (95% confidence interval 0.9 to 1.5) for D-dimer. During a median follow-up of 2.3 years, new definite or probable ischemic ECG abnormalities developed in 11.7% of participants receiving continuous antiretroviral therapy. Biomarker levels were not associated with incident abnormalities on unadjusted or adjusted analyses. In conclusion, higher levels of hsCRP, IL-6, and D-dimer were not associated with ischemic ECG abnormalities. Elevated biomarker levels and ECG abnormalities indicating myocardial ischemia might reflect different risk pathways for cardiovascular disease. Copyright © 2013 Elsevier Inc. All rights reserved.

Depression during pregnancy and the postpartum among HIV-infected women on antiretroviral therapy in Uganda.

PubMed

Kaida, Angela; Matthews, Lynn T; Ashaba, Scholastic; Tsai, Alexander C; Kanters, Steve; Robak, Magdalena; Psaros, Christina; Kabakyenga, Jerome; Boum, Yap; Haberer, Jessica E; Martin, Jeffrey N; Hunt, Peter W; Bangsberg, David R

2014-12-01

Among HIV-infected women, perinatal depression compromises clinical, maternal, and child health outcomes. Antiretroviral therapy (ART) is associated with lower depression symptom severity but the uniformity of effect through pregnancy and postpartum periods is unknown. We analyzed prospective data from 447 HIV-infected women (18-49 years) initiating ART in rural Uganda (2005-2012). Participants completed blood work and comprehensive questionnaires quarterly. Pregnancy status was assessed by self-report. Analysis time periods were defined as currently pregnant, postpartum (0-12 months post-pregnancy outcome), or non-pregnancy-related. Depression symptom severity was measured using a modified Hopkins Symptom Checklist 15, with scores ranging from 1 to 4. Probable depression was defined as >1.75. Linear regression with generalized estimating equations was used to compare mean depression scores over the 3 periods. At enrollment, median age was 32 years (interquartile range: 27-37), median CD4 count was 160 cells per cubic millimeter (interquartile range: 95-245), and mean depression score was 1.75 (s = 0.58) (39% with probable depression). Over 4.1 median years of follow-up, 104 women experienced 151 pregnancies. Mean depression scores did not differ across the time periods (P = 0.75). Multivariable models yielded similar findings. Increasing time on ART, viral suppression, better physical health, and "never married" were independently associated with lower mean depression scores. Findings were consistent when assessing probable depression. Although the lack of association between depression and perinatal periods is reassuring, high depression prevalence at treatment initiation and continued incidence across pregnancy and non-pregnancy-related periods of follow-up highlight the critical need for mental health services for HIV-infected women to optimize both maternal and perinatal health.

Radiographic Local Tumor Control and Pain Palliation of Sarcoma Metastases within the Musculoskeletal System with Percutaneous Thermal Ablation.

PubMed

Vaswani, Devin; Wallace, Adam N; Eiswirth, Preston S; Madaelil, Thomas P; Chang, Randy O; Tomasian, Anderanik; Jennings, Jack W

2018-03-14

To evaluate the effectiveness of percutaneous image-guided thermal ablation in achieving local tumor control and pain palliation of sarcoma metastases within the musculoskeletal system. Retrospective review of 64 sarcoma metastases within the musculoskeletal system in 26 women and 15 men (total = 41) treated with ablation between December 2011 and August 2016 was performed. Mean age of the cohort was 42.9 years ± 16.0 years. Two subgroups were treated: oligometastatic disease (n = 13) and widely metastatic disease (n = 51). A variety of sarcoma histologies were treated with average tumor volume of 42.5 cm 3 (range 0.1-484.7 cm 3 ). Pain scores were recorded before and 4 weeks after therapy for 59% (38/64) of treated lesions. Follow-up imaging was evaluated for local control and to monitor sites of untreated disease as an internal control. Fifty-eight percent (37/64) were lost to imaging follow-up at varying time points over a year. Complication rate was 5% (3/64; one minor and two major events). One-year local tumor control rates were 70% (19/27) in all patients, 67% (12/18) in the setting of progression of untreated metastases, and 100% (10/10) in the setting of oligometastatic disease. Median pain scores decreased from 8 (interquartile range 5.0-9.0) to 3 (interquartile range 0.1-4.0) 1 month after the procedure (P < 0.001). Image-guided percutaneous ablation is an effective option for local tumor control and pain palliation of metastatic sarcomas within the musculoskeletal system. Treatment in the setting of oligometastatic disease offers potential for remission. Level 4, Retrospective Review.

Utilization and Outcomes of Sentinel Lymph Node Biopsy for Vulvar Cancer.

PubMed

Cham, Stephanie; Chen, Ling; Burke, William M; Hou, June Y; Tergas, Ana I; Hu, Jim C; Ananth, Cande V; Neugut, Alfred I; Hershman, Dawn L; Wright, Jason D

2016-10-01

To examine the use and predictors of sentinel node biopsy in women with vulvar cancer. The Perspective database, an all-payer database that collects data from more than 500 hospitals, was used to perform a retrospective cohort study of women with vulvar cancer who underwent vulvectomy and lymph node assessment from 2006 to 2015. Multivariable models were used to determine factors associated with sentinel node biopsy. Length of stay and cost were compared between women who underwent sentinel node biopsy and lymphadenectomy. Among 2,273 women, sentinel node biopsy was utilized in 618 (27.2%) and 1,655 (72.8%) underwent inguinofemoral lymphadenectomy. Performance of sentinel node biopsy increased from 17.0% (95% confidence interval [CI] 12.0-22.0%) in 2006 to 39.1% (95% CI 27.1-51.0%) in 2015. In a multivariable model, women treated more recently were more likely to have undergone sentinel node biopsy, whereas women with more comorbidities and those treated at rural hospitals were less likely to have undergone the procedure. The median length of stay was shorter for those undergoing sentinel node biopsy (median 2 days, interquartile range 1-3) compared with women who underwent inguinofemoral lymphadenectomy (median 3 days, interquartile range 2-4). The cost of sentinel node biopsy was $7,599 (interquartile range $5,739-9,922) compared with $8,095 (interquartile range $5,917-11,281) for lymphadenectomy. The use of sentinel node biopsy for vulvar cancer has more than doubled since 2006. Sentinel lymph node biopsy is associated with a shorter hospital stay and decreased cost compared with inguinofemoral lymphadenectomy.

Cardiorespiratory Fitness Change and Mortality Risk Among Black and White Patients: Henry Ford Exercise Testing (FIT) Project.

PubMed

Ehrman, Jonathan K; Brawner, Clinton A; Al-Mallah, Mouaz H; Qureshi, Waqas T; Blaha, Michael J; Keteyian, Steven J

2017-10-01

Little is known about the relationship of change in cardiorespiratory fitness and mortality risk in Black patients. This study assessed change in cardiorespiratory fitness and its association with all-cause mortality risk in Black and White patients. This is a retrospective, longitudinal, observational cohort study of 13,345 patients (age = 55 ± 11 years; 39% women; 26% black) who completed 2 exercise tests, at least 12 months apart at Henry Ford Hospital, Detroit, Mich. All-cause mortality was identified through April 2013. Data were analyzed in 2015-2016 using Cox regression to calculate hazard ratios (HR) for risk of mortality associated with change in sex-specific cardiorespiratory fitness. Mean time between the tests was 3.4 years (interquartile range 1.9-5.6 years). During 9.1 years (interquartile range 6.3-11.6 years) of follow-up, there were 1931 (14%) deaths (16.5% black, 13.7% white). For both races, change in fitness from Low to the Intermediate/High category resulted in a significant reduction of death risk (HR 0.65 [95% confidence interval (CI), 0.49-0.87] for Black; HR 0.41 [95% CI, 0.34-0.51] for White). Each 1-metabolic-equivalent-of-task increase was associated with a reduced mortality risk in black (HR 0.84 [95% CI, 0.81-0.89]) and white (HR 0.87 [95% CI, 0.82-0.86]) patients. There was no interaction by race. Among black and white patients, change in cardiorespiratory fitness from Low to Intermediate/High fitness was associated with a 35% and 59% lower risk of all-cause mortality, respectively. Copyright © 2017 Elsevier Inc. All rights reserved.

The New MIRUS System for Short-Term Sedation in Postsurgical ICU Patients.

PubMed

Romagnoli, Stefano; Chelazzi, Cosimo; Villa, Gianluca; Zagli, Giovanni; Benvenuti, Francesco; Mancinelli, Paola; Arcangeli, Giulio; Dugheri, Stefano; Bonari, Alessandro; Tofani, Lorenzo; Belardinelli, Andrea; De Gaudio, A Raffaele

2017-09-01

To evaluate the feasibility and safety of the MIRUS system (Pall International, Sarl, Fribourg, Switzerland) for sedation with sevoflurane for postsurgical ICU patients and to evaluate atmospheric pollution during sedation. Prospective interventional study. Surgical ICU. February 2016 to December 2016. Postsurgical patients requiring ICU admission, mechanical ventilation, and sedation. Sevoflurane was administered with the MIRUS system targeted to a Richmond Agitation Sedation Scale from -3 to -5 by adaptation of minimum alveolar concentration. Data collected included Richmond Agitation Sedation Scale, minimum alveolar concentration, inspired and expired sevoflurane fraction, wake-up times, duration of sedation, sevoflurane consumption, respiratory and hemodynamic data, Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment, and laboratory data and biomarkers of organ injury. Atmospheric pollution was monitored at different sites: before sevoflurane delivery (baseline) and during sedation with the probe 15 cm up to the MIRUS system (S1) and 15 cm from the filter-Reflector group (S2). Sixty-two patients were enrolled in the study. No technical failure occurred. Median Richmond Agitation Sedation Scale was -4.5 (interquartile range, -5 to -3.6) with sevoflurane delivered at a median minimum alveolar concentration of 0.45% (interquartile range, 0.4-0.53) yielding a mean inspiratory and expiratory concentrations of 0.79% (SD, 0.24) and 0.76% (SD, 0.18), respectively. Median awakening time was 4 minutes (2.2-5 min). Median duration of sevoflurane administration was 3.33 hours (2.33-5.75 hr), range 1-19 hours with a mean consumption of 7.89 mL/hr (SD, 2.99). Hemodynamics remained stable over the study period, and no laboratory data indicated liver or kidney injury or dysfunction. Median sevoflurane room air concentration was 0.10 parts per million (interquartile range, 0.07-0.15), 0.17 parts per million (interquartile range, 0.14-0.27), and 0.15 parts per million (interquartile range, 0.07-0.19) at baseline, S1, and S2, respectively. The MIRUS system is a promising and safe alternative for short-term sedation with sevoflurane of ICU patients. Atmospheric pollution is largely below the recommended thresholds (< 5 parts per million). Studies extended to more heterogeneous population of patients undergoing longer duration of sedation are needed to confirm these observations.

Chlamydia pneumoniae antibody titers and cardiac calcifications: a cross-sectional serological-echocardiographic correlative study.

PubMed

Atar, Shaul; Tolstrup, Kirsten; Cercek, Bojan; Siegel, Robert J

2007-07-01

Chlamydia pneumoniae has previously been associated with higher prevalence of valvular and cardiac calcifications. To investigate a possible association of seropositivity for C. pneumoniae and the presence of cardiac calcifications (mitral annular or aortic root calcification, and aortic valve sclerosis). We retrospectively analyzed serological data (immunoglobulin G TWAR antibodies) from the AZACS trial (Azithromycin in Acute Coronary Syndromes), and correlated the serological findings according to titer levels with the presence of cardiac calcifications as detected by transthoracic echocardiography. In 271 patients, age 69 +/- 13 years, who underwent both serological and echocardiographic evaluation, we found no significant association between the "calcification sum score" (on a scale of 0-3) in seropositive compared to seronegative patients (1.56 +/- 1.15 vs.1.35 +/- 1.15, respectively, P = 0.26). The median calcification sum score was 1 (interquartile range 0-3) for the seronegative group, and 2 (interquartile range 0-3) for the seropositive group (P = 0.2757). In addition, we did not find a significant correlation of any of the individual sites of cardiac calcification and C. pneumoniae seropositivity. Our findings suggest that past C. pneumoniae infection may not be associated with the pathogenesis of valvular and cardiac calcifications.

Differences in sleep architecture between left and right temporal lobe epilepsy.

PubMed

Nakamura, Miki; Jin, Kazutaka; Kato, Kazuhiro; Itabashi, Hisashi; Iwasaki, Masaki; Kakisaka, Yosuke; Nakasato, Nobukazu

2017-01-01

To investigate whether seizure lateralization affects sleep macrostructure in patients with left and right temporal lobe epilepsy (TLE), as rapid eye movement (REM) sleep is shorter in patients with right hemispheric cerebral infarction than with left. We retrospectively analyzed data from 16 patients with TLE (6 men and 10 women aged 34.9 ± 11.4 years) who underwent polysomnography as well as long-term video electroencephalography. Ten patients were diagnosed with left TLE and six patients with right TLE. Sleep stages and respiratory events were scored based on the American Academy of Sleep Medicine criteria. Sleep and respiratory parameters were compared between the patient groups. Percentage of REM stage sleep was significantly (p < 0.05) lower in patients with left TLE (median 8.8 %, interquartile range 5.5-13.8 %) than in patients with right TLE (median 17.0 %, interquartile range 14.1-18.3 %). The other parameters showed no significant differences. Shorter REM sleep in patients with left TLE sharply contrasts with the previous report of shorter REM sleep in patients with right cerebral infarction. Laterality of the irritative epileptic focus versus destructive lesion may have different effects on the sleep macrostructures.

The effectiveness of a near-infrared vascular imaging device to support intravenous cannulation in children with dark skin color: a cluster randomized clinical trial.

PubMed

van der Woude, Olga C P; Cuper, Natascha J; Getrouw, Chavalleh; Kalkman, Cor J; de Graaff, Jurgen C

2013-06-01

Poor vein visibility can make IV cannulation challenging in children with dark skin color. In the operating room, we studied the effectiveness of a near-infrared vascular imaging device (VascuLuminator) to facilitate IV cannulation in children with dark skin color. In the operating room of a general hospital in Curacao, all consecutive children (0-15 years of age) requiring IV cannulation were included in a pragmatic cluster randomized clinical trial. The VascuLuminator was made available to anesthesiologists at the operating complex in randomized clusters of 1 week. Success at first attempt was 63% (27/43, 95% confidence interval [CI], 47%-77%) in the VascuLuminator group vs 51% (23 of 45 patients, 95% CI, 36%-66%) in the control group (P = 0.27). Median time to successful cannulation was 53 seconds (interquartile range: 34-154) in the VascuLuminator group and 68 seconds (interquartile range: 40-159) in the control group (P = 0.54), and hazard ratio was 1.12 (95% CI, 0.73-1.71). The VascuLuminator has limited value in improving success at first attempt of facilitating IV cannulation in children with dark skin color.

Comparison of Antivenom Dosing Strategies for Rattlesnake Envenomation.

PubMed

Spyres, Meghan B; Skolnik, Aaron B; Moore, Elizabeth C; Gerkin, Richard D; Padilla-Jones, Angela; Ruha, Anne-Michelle

2018-06-01

This study compares maintenance with clinical- and laboratory-triggered (as-needed [PRN]) antivenom dosing strategies with regard to patient-centered outcomes after rattlesnake envenomation. This is a retrospective cohort study of adult rattlesnake envenomations treated at a regional toxicology center. Data on demographics, envenomation details, antivenom administration, length of stay, and laboratory and clinical outcomes were compared between the PRN and maintenance groups. Primary outcomes were hospital length of stay and total antivenom used, with a hypothesis of no difference between the two dosing strategies. A single regional toxicology center PATIENTS:: Three-hundred ten adult patients envenomated by rattlesnakes between 2007 and 2014 were included. Patients were excluded if no antivenom was administered or for receiving an antivenom other than Crofab (BTG International, West Conshohocken, PA). This is a retrospective study of rattlesnake envenomations treated with and without maintenance antivenom dosing. One-hundred forty-eight in the maintenance group and 162 in the PRN group were included. There was no difference in demographics or baseline envenomation severity or hemotoxicity (32.7% vs 40.5%; respectively; p = 0.158) between the two groups. Comparing the PRN with the maintenance group, less antivenom was used (8 [interquartile range, 6-12] vs 16 [interquartile range, 12-18] vials, respectively; p < 0.001), and hospital length of stay was shorter (27 hr [interquartile range, 20-44 hr] vs 34 hr [interquartile range, 24-43 hr], respectively; p = 0.014). There were no differences in follow-up outcomes of readmission, retreatment, or bleeding and surgical complications. Hospital length of stay was shorter, and less antivenom was used in patients receiving a PRN antivenom dosing strategy after rattlesnake envenomation.

Paracervical Block for Laminaria Insertion Before Second-Trimester Abortion: A Randomized Controlled Trial.

PubMed

Soon, Reni; Tschann, Mary; Salcedo, Jennifer; Stevens, Katelyn; Ahn, Hyeong Jun; Kaneshiro, Bliss

2017-08-01

To evaluate the efficacy of a paracervical block to decrease pain during osmotic dilator insertion before second-trimester abortion. In this double-blind, randomized trial, 41 women undergoing Laminaria insertion before a second-trimester abortion received either a paracervical block with 18 mL 1% lidocaine and 2 mL sodium bicarbonate or a sham block. Women were between 14 and 23 6/7 weeks of gestation. The primary outcome was pain immediately after insertion of Laminaria. Women assessed their pain on a 100-mm visual analog scale. Secondary outcomes included assessment of pain at other times during the insertion procedure and overall satisfaction with pain control. To detect a 25-mm difference in pain immediately after Laminaria insertion, at an α of 0.05 and 80% power, we aimed to enroll 20 patients in each arm. From May 2015 to December 2015, 20 women received a paracervical block and 21 received a sham block. Groups were similar in demographics, including parity, history of surgical abortion, and number of Laminaria placed. The paracervical block reduced pain after Laminaria insertion (median scores 13 mm [interquartile range 2-39] compared with 54 mm [interquartile range 27-61], P=.01, 95% CI -47.0 to -4.0). Women who received a paracervical block also reported higher satisfaction with overall pain control throughout the entire Laminaria insertion procedure (median scores 95 mm [interquartile range 78-100] compared with 70 mm [interquartile range 44-90], P=.05, 95% CI 0.0-37.0). Paracervical block is effective at reducing the pain of Laminaria insertion. Additionally, a paracervical block increases overall patient satisfaction with pain control during Laminaria placement. ClinicalTrials.gov, NCT02454296.

Effect of a Perioperative Intra-Aortic Balloon Pump in High-Risk Cardiac Surgery Patients: A Randomized Clinical Trial.

PubMed

Rocha Ferreira, Graziela Santos; de Almeida, Juliano Pinheiro; Landoni, Giovanni; Vincent, Jean Louis; Fominskiy, Evgeny; Gomes Galas, Filomena Regina Barbosa; Gaiotto, Fabio A; Dallan, Luís Oliveira; Franco, Rafael Alves; Lisboa, Luiz Augusto; Palma Dallan, Luis Roberto; Fukushima, Julia Tizue; Rizk, Stephanie Itala; Park, Clarice Lee; Strabelli, Tânia Mara; Gelas Lage, Silvia Helena; Camara, Ligia; Zeferino, Suely; Jardim, Jaquelline; Calvo Arita, Elisandra Cristina Trevisan; Caldas Ribeiro, Juliana; Ayub-Ferreira, Silvia Moreira; Costa Auler, Jose Otavio; Filho, Roberto Kalil; Jatene, Fabio Biscegli; Hajjar, Ludhmila Abrahao

2018-04-30

The aim of this study was to evaluate the efficacy of perioperative intra-aortic balloon pump use in high-risk cardiac surgery patients. A single-center randomized controlled trial and a meta-analysis of randomized controlled trials. Heart Institute of São Paulo University. High-risk patients undergoing elective coronary artery bypass surgery. Patients were randomized to receive preskin incision intra-aortic balloon pump insertion after anesthesia induction versus no intra-aortic balloon pump use. The primary outcome was a composite endpoint of 30-day mortality and major morbidity (cardiogenic shock, stroke, acute renal failure, mediastinitis, prolonged mechanical ventilation, and a need for reoperation). A total of 181 patients (mean [SD] age 65.4 [9.4] yr; 32% female) were randomized. The primary outcome was observed in 43 patients (47.8%) in the intra-aortic balloon pump group and 42 patients (46.2%) in the control group (p = 0.46). The median duration of inotrope use (51 hr [interquartile range, 32-94 hr] vs 39 hr [interquartile range, 25-66 hr]; p = 0.007) and the ICU length of stay (5 d [interquartile range, 3-8 d] vs 4 d [interquartile range, 3-6 d]; p = 0.035) were longer in the intra-aortic balloon pump group than in the control group. A meta-analysis of 11 randomized controlled trials confirmed a lack of survival improvement in high-risk cardiac surgery patients with perioperative intra-aortic balloon pump use. In high-risk patients undergoing cardiac surgery, the perioperative use of an intra-aortic balloon pump did not reduce the occurrence of a composite outcome of 30-day mortality and major complications compared with usual care alone.

THE FUNDUS PHENOTYPE ASSOCIATED WITH THE p.Ala243Val BEST1 MUTATION.

PubMed

Khan, Kamron N; Islam, Farrah; Moore, Anthony T; Michaelides, Michel

2018-03-01

To describe a highly recognizable and reproducible retinal phenotype associated with a specific BEST1 mutation-p.Ala243Val. Retrospective review of consecutive cases where genetic testing has identified p.Ala243Val BEST1 as the cause of disease. Electronic patient records were used to extract demographic, as well as functional and anatomical data. These data were compared with those observed with the most common BEST1 genotype, p.Arg218Cys. Eight individuals (six families) were identified with the p.Ala243Val BEST1 mutation and seven patients with the pathologic variant p.Arg218Cys. No patients with mutation of codon 243 knowingly had a family history of retinal disease, whereas all patients with the p.Arg218Cys variant did. The maculopathy was bilateral in all cases. The p.Ala243Val mutation was associated with a pattern dystrophy-type appearance, most visible with near-infrared reflectance and fundus autofluorescence imaging. This phenotype was never observed with any other genotype. This mutation was associated with an older median age of symptom onset (median = 42, interquartile range = 22) compared with those harboring the p.Arg218Cys mutation (median = 18, interquartile range = 12; Mann-Whitney U test; P < 0.05). Despite their older age, the final recorded acuity seemed to be better in the p.Ala243Val group (median = 0.55, interquartile range = 0.6475; median = 0.33, interquartile range = 0.358), although this did not reach statistical significance (Mann-Whitney U test; P > 0.05). The mutation p.Ala243Val is associated with highly recognizable and reproducible pattern dystrophy-like phenotype. Patients develop symptoms at a later age and tend to have better preservation of electrooculogram amplitudes.

Syphilis in Drug Users in Low and Middle Income Countries

PubMed Central

Coffin, Lara S.; Newberry, Ashley; Hagan, Holly; Cleland, Charles M.; Des Jarlais, Don C.; Perlman, David C.

2009-01-01

Background Genital ulcer disease (GUD), including syphilis, is an important cause of morbidity in low and middle income (LMI) countries and syphilis transmission is associated with HIV transmission. Methods We conducted a literature review to evaluate syphilis infection among drug users in LMI countries for the period 1995–2007. Countries were categorized using the World Bank Atlas method (The World Bank, 2007) according to 2006 gross national income per capita. Results Thirty-two studies were included (N=13,848 subjects), mostly from Southeast Asia with some from Latin America, Eastern Europe, Central and East Asia, North Africa and the Middle East but none from regions such as Sub-Saharan Africa. The median prevalence of overall lifetime syphilis (N=32 studies) was 11.1% (interquartile range: 6.3% to 15.3%) and of HIV (N=31 studies) was 1.1% (interquartile range: 0.22% to 5.50%). There was a modest relation (r=0.27) between HIV and syphilis prevalence. Median syphilis prevalence by gender was 4.0% (interquartile range: 3.4% to 6.6%) among males (N=11 studies) and 19.9% (interquartile range: 11.4% to 36.0%) among females (N=6 studies). There was a strong relation (r= 0.68) between syphilis prevalence and female gender that may be related to female sex work. Conclusion Drug users in LMI countries have a high prevalence of syphilis but data are limited and, in some regions, entirely lacking. Further data are needed, including studies targeting the risks of women. Interventions to promote safer sex, testing, counseling and education, as well as health care worker awareness, should be integrated in harm reduction programs and health care settings to prevent new syphilis infections and reduce HIV transmission among drug users and their partners in LMI countries. PMID:19361976

Is VEGF under-expressed in Indian children with Perthes disease?

PubMed

Tiwari, V; Poudel, R R; Khan, S A; Mehra, S; Chauhan, S S; Raje, A

2018-04-01

The role of vascular endothelial growth factor (VEGF) after ischaemic necrosis of the femoral head in Legg-Calve-Perthes disease (LCPD) has not been adequately studied in humans, especially in Indian population. Therefore, we aimed to evaluate the serum levels of VEGF-A in Indian children with various stages of LCPD and compare them with those of an age- and sex-matched control group of healthy children. In this case-control study, we enrolled 42 children (below 14 years age) suffering from LCPD and 21 age- and sex-matched healthy controls. Patients were classified radiographically according to Waldenstrom's classification. Serum VEGF-A was estimated by sandwich enzyme-linked immunosorbent assay technique. The serum values were compared between the patient group and the control group, as well as between the Waldenstrom subgroups. Results were expressed as means with ranges or median with interquartile range. The mean age in the patient as well as the control group was 9 years (range 4-13 years). The median value (interquartile range) of serum VEGF-A was 162.5 pg/ml (673.75 pg/ml) in the patient group and 652 pg/ml (190.5 pg/ml) in the control group (p = 0.013). When compared between lower Waldenstrom stages (initial stage + stage of fragmentation) and higher Waldenstrom stages (re-ossification stage + stage of healing), the mean values of serum VEGF-A were 464.7 pg/ml (range 0-2211 pg/ml) and 301.1 pg/ml (range 0-1910 pg/ml), respectively (p = 0.305). VEGF is under-expressed in Indian children suffering from LCPD. As VEGF acts as a key regulator of endochondral ossification, our finding may open new therapeutic approaches to the disease. Also, serum VEGF may act as a valuable marker for the follow-up of the disease. Our study also provides baseline data about serum VEGF-A levels in Indian cohort of LCPD patients. Future multi-centre studies are warranted with a larger sample size to fully appreciate the patho-physiological changes in VEGF occurring in LCPD.

Age of diagnosis in Rett syndrome: patterns of recognition among diagnosticians and risk factors for late diagnosis

PubMed Central

Tarquinio, Daniel C.; Hou, Wei; Neul, Jeffrey L.; Lane, Jane B.; Barnes, Katherine V.; O’Leary, Heather M.; Bruck, Natalie M.; Kaufmann, Walter E.; Motil, Kathleen J.; Glaze, Daniel G.; Skinner, Steven A.; Annese, Fran; Baggett, Lauren; Barrish, Judy O.; Geerts, Suzanne P.; Percy, Alan K.

2015-01-01

Purpose Diagnosis of Rett syndrome (RTT) is often delayed. We sought to determine type of physician who typically makes the diagnosis of RTT and to identify risk factors for delayed diagnosis. Methods One-thousand eighty-five participants from the multicenter longitudinal RTT natural history study with classic and atypical RTT were recruited from 2006 to 2014. Age of diagnosis, diagnostician, diagnostic criteria, clinical and developmental data were collected. Results Among 919 classic and 166 atypical RTT participants, median diagnosis age was 2.7 years (interquartile range 2.0–4.1) in classic and 3.8 years (interquartile range 2.3–6.9) in atypical RTT. Pediatricians made the diagnosis of classic RTT rarely (5.2%); however, proportion diagnosed by pediatricians increased since 2006. Since the first diagnostic criteria, the age of diagnosis decreased among subspecialists but not pediatricians. Odds of a pediatrician making the diagnosis of classic RTT were higher if a child stopped responding to parental interaction, and lower if they possessed gastro-esophageal reflux, specific stereotypies, lost babbling or the ability to follow commands. Delayed acquisition of basic gross motor skills or finger feeding were associated with younger diagnosis; delayed acquisition of higher level fine motor skills, later onset of supportive features, and normal head circumference were associated with late diagnosis. 33% with microcephaly before 2.5 years were diagnosed after the median age of 2.7 years. Conclusions Age of RTT diagnosis has improved among subspecialists, and pediatricians have made the diagnosis of classic RTT more frequently since 2006. Strategies for educating diagnosticians should incorporate specific risk factors for delayed diagnosis. PMID:25801175

Association between implementation of a code stroke system and poststroke epilepsy.

PubMed

Chen, Ziyi; Churilov, Leonid; Chen, Ziyuan; Naylor, Jillian; Koome, Miriam; Yan, Bernard; Kwan, Patrick

2018-03-27

We aimed to investigate the effect of a code stroke system on the development of poststroke epilepsy. We retrospectively analyzed consecutive patients treated with IV thrombolysis under or outside the code stroke system between 2003 and 2012. Patients were followed up for at least 2 years or until death. Factors with p < 0.1 in univariate comparisons were selected for multivariable logistic and Cox regression. A total of 409 patients met the eligibility criteria. Their median age at stroke onset was 75 years (interquartile range 64-83 years); 220 (53.8%) were male. The median follow-up duration was 1,074 days (interquartile range 119-1,671 days). Thirty-two patients (7.8%) had poststroke seizures during follow-up, comprising 7 (1.7%) with acute symptomatic seizures and 25 (6.1%) with late-onset seizures. Twenty-six patients (6.4%) fulfilled the definition of poststroke epilepsy. Three hundred eighteen patients (77.8%) were treated with the code stroke system while 91 (22.2%) were not. After adjustment for age and stroke etiology, use of the code stroke system was associated with decreased odds of poststroke epilepsy (odds ratio = 0.36, 95% confidence interval 0.14-0.87, p = 0.024). Cox regression showed lower adjusted hazard rates for poststroke epilepsy within 5 years for patients managed under the code stroke system (hazard ratio = 0.60, 95% confidence interval 0.47-0.79, p < 0.001). The code stroke system was associated with reduced odds and instantaneous risk of poststroke epilepsy. Further studies are required to identify the contribution of the individual components and mechanisms against epileptogenesis after stroke. This study provides Class III evidence that for people with acute ischemic stroke, implementation of a code stroke system reduces the risk of poststroke epilepsy. © 2018 American Academy of Neurology.

Possible risk for cancer among children born following assisted reproductive technology in Israel.

PubMed

Lerner-Geva, Liat; Boyko, Valentina; Ehrlich, Shelley; Mashiach, Shlomo; Hourvitz, Ariel; Haas, Jigal; Margalioth, Ehud; Levran, David; Calderon, Ilan; Orvieto, Raoul; Ellenbogen, Adrian; Meyerovitch, Joseph; Ron-El, Raphael; Farhi, Adel

2017-04-01

Among children conceived by assisted reproductive technology (ART), increased risk of adverse birth outcomes has been observed, including multiple births, preterm births, and congenital malformations. Regarding cancer among ART-conceived children, findings are discrepant. This is a historical cohort of 9,042 ART-conceived children and 211,763 spontaneously conceived (SC) children born from 1997 through 2004. The median duration of follow-up was 10.6 years (interquartile range 9.0-12.3) in the ART group and 9.3 years (interquartile range 8.0-10.6) in the SC group. The cohort database was linked with the Israel National Cancer Registry updated until December 31, 2011 using each child's personal identification number. Twenty-one cases of cancer were identified in the ART group (2.2 per 10,000 person-years), as compared to 361 cancer cases in the SC group (1.8 per 10,000 person-years). The relative risk (RR) for overall cancer in the ART group compared to the SC group adjusted for maternal characteristics was 1.18 (95% confidence interval [CI] 0.80-1.75). ART children had a significantly increased risk for specific cancers, although based on small number of cases, including two cases of retinoblastoma (RR 6.18, 95% CI 1.22-31.2), as well as four cases of renal tumors (RR 3.25, 95% CI 1.67-6.32). A statistically significant increased risk for two pediatric cancers was found. However, for overall types of cancer the risk estimate was elevated but not statistically significant. Further studies with larger sample size and longer follow-up time are warranted in order to either confirm or refute these findings. © 2016 Wiley Periodicals, Inc.

COPD characteristics and socioeconomic burden in Hellenic correctional institutions.

PubMed

Bania, Eleni G; Daniil, Zoe; Hatzoglou, Chrysa; Alexopoulos, Evangelos C; Mitsiki, Eirini; Gourgoulianis, Konstantinos I

2016-01-01

The high prevalence of smoking (80%) in Greek correctional institutions is anticipated to result in high prevalence of COPD in such settings. The aim of the Greek obstructive luNg disease epidemiOlogy and health economics Study In corrective institutionS (GNOSIS) is to determine the prevalence of smoking and COPD among inmates and to assess the health-related quality of life. GNOSIS, a cross-sectional epidemiological study, was conducted between March 2011 and December 2011 in seven correctional institutions in Greece. A total of 552 participants, 91.3% male, median age of 43.0 years (interquartile range: 35-53), were enrolled. COPD prevalence was 6.0% and was found to increase with age (18.6% among those ≥60 years), length of prison stay, and length of sentence. Of the participants diagnosed with COPD, 36.4% were diagnosed with Global initiative for chronic Obstructive Lung Disease (GOLD) stage I and 51.5% were diagnosed with stage II. Dyspnea severity was assessed as grades 0-1 on the medical research council dyspnea scale for 88.3%, while 31% reported ≥2 COPD exacerbations in the past year. Seventy-nine percent of the total number of the participants were smokers, with a median smoking of 20.0 cigarettes per day, while 42.9% were assessed as having a strong addiction to nicotine. The median EuroQol visual analog scale score was 70.0 (interquartile range: 60.0-90.0). Problems in the dimension of anxiety/depression were reported by 82.8%. The results of the study support the notion that the prevalence of COPD among inmates of Greek correctional institutions may increase in the following years. The findings underscore the importance of taking actions to limit COPD prevalence and its risk factors in the Greek correctional system.

Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms.

PubMed

Vyles, David; Adams, Juan; Chiu, Asriani; Simpson, Pippa; Nimmer, Mark; Brousseau, David C

2017-08-01

Penicillin allergy is commonly reported in the pediatric emergency department (ED). True penicillin allergy is rare, yet the diagnosis results from the denial of first-line antibiotics. We hypothesize that all children presenting to the pediatric ED with symptoms deemed to be low-risk for immunoglobulin E-mediated hypersensitivity will return negative results for true penicillin allergy. Parents of children aged 4 to 18 years old presenting to the pediatric ED with a history of parent-reported penicillin allergy completed an allergy questionnaire. A prespecified 100 children categorized as low-risk on the basis of reported symptoms completed penicillin allergy testing by using a standard 3-tier testing process. The percent of children with negative allergy testing results was calculated with a 95% confidence interval. Five hundred ninety-seven parents completed the questionnaire describing their child's reported allergy symptoms. Three hundred two (51%) children had low-risk symptoms and were eligible for testing. Of those, 100 children were tested for penicillin allergy. The median (interquartile range) age at testing was 9 years (5-12). The median (interquartile range) age at allergy diagnosis was 1 year (9 months-3 years). Rash (97 [97%]) and itching (63 [63%]) were the most commonly reported allergy symptoms. Overall, 100 children (100%; 95% confidence interval 96.4%-100%) were found to have negative results for penicillin allergy and had their labeled penicillin allergy removed from their medical record. All children categorized as low-risk by our penicillin allergy questionnaire were found to have negative results for true penicillin allergy. The utilization of this questionnaire in the pediatric ED may facilitate increased use of first-line penicillin antibiotics. Copyright © 2017 by the American Academy of Pediatrics.

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity.

PubMed

Kim, Joon-Tae; Chung, Pil-Wook; Starkman, Sidney; Sanossian, Nerses; Stratton, Samuel J; Eckstein, Marc; Pratt, Frank D; Conwit, Robin; Liebeskind, David S; Sharma, Latisha; Restrepo, Lucas; Tenser, May-Kim; Valdes-Sueiras, Miguel; Gornbein, Jeffrey; Hamilton, Scott; Saver, Jeffrey L

2017-02-01

The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region. We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals. Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20-50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119-180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120-180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were r=0.49 for the prehospital LAMS and r=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale, r=-0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74-0.78); EPA LAMS, 0.85 (95% confidence interval 0.83-0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85-0.88). In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field. © 2017 American Heart Association, Inc.

Geographic Variance of Cost Associated With Hysterectomy.

PubMed

Sheyn, David; Mahajan, Sangeeta; Billow, Megan; Fleary, Alexandra; Hayashi, Emi; El-Nashar, Sherif A

2017-05-01

To estimate whether the cost of hysterectomy varies by geographic region. This was a cross-sectional, population-based study using the 2013 Healthcare Cost and Utilization Project National Inpatient Sample of women older than 18 years undergoing inpatient hysterectomy for benign conditions. Hospital charges obtained from the National Inpatient Sample database were converted to actual costs using cost-to-charge ratios provided by the Healthcare Cost and Utilization Project. Multivariate regression was used to assess the effects that demographic factors, concomitant procedures, diagnoses, and geographic region have on hysterectomy cost above the median. Women who underwent hysterectomy for benign conditions were identified (N=38,414). The median cost of hysterectomy was $13,981 (interquartile range $9,075-29,770). The mid-Atlantic region had the lowest median cost of $9,661 (interquartile range $6,243-15,335) and the Pacific region had the highest median cost, $22,534 (interquartile range $15,380-33,797). Compared with the mid-Atlantic region, the Pacific (adjusted odds ratio [OR] 10.43, 95% confidence interval [CI] 9.44-11.45), South Atlantic (adjusted OR 5.39, 95% CI 4.95-5.86), and South Central (adjusted OR 2.40, 95% CI 2.21-2.62) regions were associated with the highest probability of costs above the median. All concomitant procedures were associated with an increased cost with the exception of bilateral salpingectomy (adjusted OR 1.03, 95% CI 0.95-1.12). Compared with vaginal hysterectomy, laparoscopic and robotic modes of hysterectomy were associated with higher probabilities of increased costs (adjusted OR 2.86, 95% CI 2.61-3.15 and adjusted OR 5.66, 95% CI 5.11-6.26, respectively). Abdominal hysterectomy was not associated with a statistically significant increase in cost compared with vaginal hysterectomy (adjusted OR 1.01, 95% CI 0.91-1.09). The cost of hysterectomy varies significantly with geographic region after adjusting for confounders.

Rapid Increase in Reports of Syphilis Associated With Men Who Have Sex With Women and Women Who Have Sex With Men, Japan, 2012 to 2016

PubMed Central

Takahashi, Takuri; Arima, Yuzo; Yamagishi, Takuya; Nishiki, Shingo; Kanai, Mizue; Ishikane, Masahiro; Matsui, Tamano; Sunagawa, Tomimasa; Ohnishi, Makoto; Oishi, Kazunori

2018-01-01

Background In Japan, syphilis reports have recently increased rapidly. However, unlike other developed countries where men who have sex with men (MSM) were associated with the rise, the increase in Japan has been attributed more to men who have sex with women (MSW) and women who have sex with men (WSM). We report on this increase based on surveillance data. Methods Syphilis is a notifiable disease requiring all laboratory-confirmed cases to be reported; stage and sex of the sex partner(s) suspected as the infection source are also reported. Focusing on primary and secondary (P&S) cases, we describe the temporal, demographic, and geographic distributions of reported cases in 2012 through 2016. Results A total of 7040 (64.0%) of 10,997 cases were P&S; the annual rate of increase was greatest for P&S and the proportion of P&S increased over time. Among P&S cases (1609 MSM, 2768 MSW, and 1323 WSM), MSW and WSM each surpassed MSM cases in 2016. Men were older with a wider age distribution (median, 37 years; interquartile range, 28–46 years) relative to women (median, 26 years; interquartile range, 21–34 years). Among women, 20- to 24-year-olds consistently had the highest reporting rate, reaching 9.0 per 100,000 in 2016. Congenital syphilis reports increased from 0.4 in 2012 to 1.4 per 100,000 live births in 2016. Although Tokyo prefecture had the highest reporting rate (3.98 per 100,000 person-years), the proportionate contribution from Tokyo decreased in 2016. Conclusions Reports on P&S syphilis increased yearly among MSW and WSM. Young women seem to be at particular risk, and with increased reports of congenital syphilis, syphilis prevention and control is currently a public health priority in Japan. PMID:29420439

Influence of paternal age on perinatal outcomes.

PubMed

Hurley, Emily G; DeFranco, Emily A

2017-11-01

There is an increasing trend to delay childbearing to advanced parental age. Increased risks of advanced maternal age and assisted reproductive technologies are widely accepted. There are limited data regarding advanced paternal age. To adequately counsel patients on risk, more research regarding advanced paternal age is necessary. We sought to determine the influence of paternal age on perinatal outcomes, and to assess whether this influence differs between pregnancies achieved spontaneously and those achieved with assisted reproductive technology. A population-based retrospective cohort study of all live births in Ohio from 2006 through 2012 was completed. Data were evaluated to determine if advanced paternal age is associated with an increased risk of adverse outcomes in pregnancies. The analysis was stratified by status of utilization of assisted reproductive technology. Generalized linear regression models assessed the association of paternal age on pregnancy complications in assisted reproductive technology and spontaneously conceived pregnancies, after adjusting for maternal age, race, multifetal gestation, and Medicaid status, using Stata software (Stata, Release 12; StataCorp, College Station, TX). Paternal age was documented in 82.2% of 1,034,552 live births in Ohio during the 7-year study period. Paternal age ranged from 12-87 years, with a median of 30 (interquartile range, 26-35) years. Maternal age ranged from 11-62 years, with a median of 27 (interquartile range, 22-31) years. The use of assisted reproductive technology in live births increased as paternal age increased: 0.1% <30 years vs 2.5% >60 years, P < .001. After accounting for maternal age and other confounding risk factors, increased paternal age was not associated with a significant increase in the rate of preeclampsia, preterm birth, fetal growth restriction, congenital anomaly, genetic disorder, or neonatal intensive care unit admission. The influence of paternal age on pregnancy outcomes was similar in pregnancies achieved with and without assisted reproductive technology. Older paternal age does not appear to pose an independent risk of adverse perinatal outcomes, in pregnancies achieved either with or without assisted reproductive technology. However, small effect sizes such as very small risk increases or decreases may not be detectable despite the large sample size in this study of >830,000 births. Copyright © 2017 Elsevier Inc. All rights reserved.

Retrospective analysis of obstetric and anesthetic management of patients with placenta accreta spectrum disorders.

PubMed

Riveros-Perez, Efrain; Wood, Cristina

2018-03-01

To assess the management and maternal outcomes of placenta accreta spectrum (PAS) disorders. A retrospective chart review was conducted of patients diagnosed with PAS disorders (placenta creta, increta, or percreta) who were treated at a US tertiary care center between February 1, 2011, and January 31, 2016. Obstetric management, anesthetic management, and maternal outcomes were analyzed. A total of 43 cases were identified; placenta previa was diagnosed among 33 (77%). Median age was 33 years (range 23-42). Median blood loss was 1500 mL (interquartile range 1000-2500); blood loss was greatest among the 10 patients with placenta percreta (3250 mL, interquartile range 2200-6000). Transfusion of blood products was necessary among 14 (33%) patients, with no difference in frequency according to the degree of placental invasion (P=0.107). Surgical complications occurred among 10 (23%) patients. Overall, 30 (70%) patients received combined spinal-epidural plus general anesthesia, 4 (9%) received only general anesthesia, and 9 (21%) underwent surgery with combined spinal-epidural anesthesia. One patient experienced difficult airway and another experienced accidental dural puncture. Placenta previa and accreta coexist in many patients, leading to substantial bleeding related to the degree of myometrial invasion. An interdisciplinary team approach plus the use of combined spinal-epidural anesthesia, transitioning to general anesthesia, were advisable and safe. © 2017 International Federation of Gynecology and Obstetrics.

The cervical mucus plug inhibits, but does not block, the passage of ascending bacteria from the vagina during pregnancy.

PubMed

Hansen, Lea K; Becher, Naja; Bastholm, Sara; Glavind, Julie; Ramsing, Mette; Kim, Chong J; Romero, Roberto; Jensen, Jørgen S; Uldbjerg, Niels

2014-01-01

To evaluate the microbial load and the inflammatory response in the distal and proximal parts of the cervical mucus plug. Experimental research. Twenty women with a normal, singleton pregnancy. Vaginal swabs and specimens from the distal and proximal parts of the cervical mucus plug. Immunohistochemistry, enzyme-linked immunosorbent assay, quantitative polymerase chain reaction and histology. The total bacterial load (16S rDNA) was significantly lower in the cervical mucus plug compared with the vagina (p = 0.001). Among women harboring Ureaplasma parvum, the median genome equivalents/g were 1574 (interquartile range 2526) in the proximal part, 657 (interquartile range 1620) in the distal part and 60,240 (interquartile range 96,386) in the vagina. Histological examinations and quantitative polymerase chain reaction revealed considerable amounts of lactobacilli and inflammatory cells in both parts of the cervical mucus plug. The matrix metalloproteinase-8 concentration was decreased in the proximal part of the plug compared with the distal part (p = 0.08). The cervical mucus plug inhibits, but does not block, the passage of Ureaplasma parvum during its ascending route from the vagina through the cervical canal. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review.

PubMed

Mekonnen, Alemayehu B; Alhawassi, Tariq M; McLachlan, Andrew J; Brien, Jo-Anne E

2018-03-01

Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload. Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors.

New treatment for IgA nephropathy: enteric budesonide targeted to the ileocecal region ameliorates proteinuria.

PubMed

Smerud, Hilde Kloster; Bárány, Peter; Lindström, Karin; Fernström, Anders; Sandell, Anna; Påhlsson, Peter; Fellström, Bengt

2011-10-01

Systemic corticosteroid treatment has been shown to exert some protection against renal deterioration in IgA nephropathy (IgAN) but is not commonly recommended for long-term use due to the well-known systemic side effects. In this study, we investigated the efficacy and safety of a new enteric formulation of the locally acting glucocorticoid budesonide (Nefecon®), designed to release the active compound in the ileocecal region. The primary objective was to evaluate the efficacy of targeted release budesonide on albuminuria. Budesonide 8 mg/day was given to 16 patients with IgAN for 6 months, followed by a 3-month follow-up period. The efficacy was measured as change in 24-h urine albumin excretion, serum creatinine and estimated glomerular filtration rate (eGFR). The median relative reduction in urinary albumin excretion was 23% during the treatment period (interquartile range: -0.36 to -0.04, P = 0.04) with pretreatment values ranging from 0.3 to 6 g/24 h (median: 1.5 g/24 h). The median reduction in urine albumin peaked at 40% (interquartile range: -0.58 to -0.15) 2 months after treatment discontinuation. Serum creatinine was reduced by 6% (interquartile range: -0.12 to -0.02; P = 0.003), and eGFR [Modification of Diet in Renal Disease (MDRD)] increased ∼8% (interquartile range: 0.02-0.16, P = 0.003) during treatment. No major corticosteroid-related side effects were observed. In the present pilot study, enteric budesonide targeted to the ileocecal region had a significant effect on urine albumin excretion, accompanied by a minor reduction of serum creatinine and a modest increase of eGFR calculated by the MDRD equation, while eGFR calculated from Cockcroft-Gault equation and cystatin C was not changed. Enteric budesonide may represent a new treatment of IgAN warranting further investigation.

Interdisciplinary simulation-based training to improve delivery room communication.

PubMed

Dadiz, Rita; Weinschreider, Joanne; Schriefer, Jan; Arnold, Christine; Greves, Cole D; Crosby, Erin C; Wang, Hongyue; Pressman, Eva K; Guillet, Ronnie

2013-10-01

Poor communication among obstetric and pediatric professionals is associated with adverse perinatal events leading to severe disability and neonatal mortality. This study evaluated the effectiveness of an interdisciplinary simulation-based training (SBT) program to improve delivery room communication between obstetric and pediatric teams. Obstetric and pediatric teams participated in an SBT annually during 3 academic years, 2008-2011 (Y1-Y3), in a prospective, observational study. Eligible participants (n = 228) included attendings, fellows, house staff, midlevel providers, and nurses involved in delivery room care. Simulations were videotaped and evaluated using a validated 20-item checklist of best communication practices. Checklist scores were compared across years with the Kruskal-Wallis test. Providers were also surveyed annually regarding communication during actual deliveries using a standardized questionnaire. Ratings were analyzed using two-way analysis of covariance. At least 60% of eligible providers participated in 1 or more SBT sessions and completed surveys annually. Checklist scores on communication during SBT improved from Y1 (median, 6; interquartile range, 4) to Y3 (median, 11; interquartile range, 6) (P < 0.001). Survey results showed the perception of improvement over time in interteam communication during actual deliveries by obstetric (P < 0.005) and pediatric (P < 0.0001) providers. The obstetric team also perceived improved provider communication with the family (P < 0.05). Communication during SBT as well as the perception of communication during actual deliveries improved across the study period. The potential of a checklist to standardize delivery room communication and improve patient outcomes merits further investigation.

Randomized cross-over trial of polyethylene glycol electrolyte solution and water for colostomy irrigation.

PubMed

O'Bichere, Austin; Green, Colin; Phillips, Robin K S

2004-09-01

Water for colostomy irrigation is largely absorbed by the colon, which may result in less efficient expulsion of stool. This study compared the outcome of colonic cleansing with water and polyethylene glycol solution. In a cross-over study, 41 colostomy irrigators were randomly assigned to water or polyethylene glycol solution irrigation first and then the other regimen, each for one week. Patients recorded fluid inflow time, total washout time, cramps, leakage episodes, number of stoma pouches used, and satisfaction scores (Visual Analog Scale, 1-10: 1 = poor, and 10 = excellent). The median and interquartile range for each variable was calculated, and the two treatments were compared (Wilcoxon's test). Eight patients failed to complete the study. Thirty-three patients (20 females; mean age, 55 (range, 39-73) years) provided 352 irrigation sessions: water (n = 176), and polyethylene glycol solution (n = 176). Irrigation was performed every 24, 48, and 72 hours by 17, 9, and 7 patients respectively, using 500 ml (n = 1), 750 ml (n = 2), 1,000 ml (n = 16), 1,500 ml (n = 11), 2,000 ml (n = 2), and 3,500 ml (n = 1) of fluid. The median and interquartile range for water vs. polyethylene glycol solution were: fluid inflow time (6 (range, 4.4-10.8) vs. 6.3 (range, 4.1-11) minutes; P = 0.48), total washout time (53 (range, 33-69) vs. 38 (range, 28-55) minutes; P = 0.01), leakage episodes (2.3 (range, 1.7-3.8) vs. 0.7 (range, 0.2-1); P < 0.001), satisfaction score (5.8 (range, 4-7.5) vs. 8.8 (range, 8.3-10); P < 0.001), and stoma pouch usage per week (75 (range, 45-80) vs. 43 (range, 0-80); P = 0.008). No difference was demonstrated for frequency of cramps ( P = 0.24). Polyethylene glycol solution performed significantly better than water and may be a superior alternative fluid regimen for colostomy irrigation.

Association of Lithium in Drinking Water With the Incidence of Dementia.

PubMed

Kessing, Lars Vedel; Gerds, Thomas Alexander; Knudsen, Nikoline Nygård; Jørgensen, Lisbeth Flindt; Kristiansen, Søren Munch; Voutchkova, Denitza; Ernstsen, Vibeke; Schullehner, Jörg; Hansen, Birgitte; Andersen, Per Kragh; Ersbøll, Annette Kjær

2017-10-01

Results from animal and human studies suggest that lithium in therapeutic doses may improve learning and memory and modify the risk of developing dementia. Additional preliminary studies suggest that subtherapeutic levels, including microlevels of lithium, may influence human cognition. To investigate whether the incidence of dementia in the general population covaries with long-term exposure to microlevels of lithium in drinking water. This Danish nationwide, population-based, nested case-control study examined longitudinal, individual geographic data on municipality of residence and data from drinking water measurements combined with time-specific data from all patients aged 50 to 90 years with a hospital contact with a diagnosis of dementia from January 1, 1970, through December 31, 2013, and 10 age- and sex-matched control individuals from the Danish population. The mean lithium exposure in drinking water since 1986 was estimated for all study individuals. Data analysis was performed from January 1, 1995, through December 31, 2013. A diagnosis of dementia in a hospital inpatient or outpatient contact. Diagnoses of Alzheimer disease and vascular dementia were secondary outcome measures. In primary analyses, distribution of lithium exposure was compared between patients with dementia and controls. A total of 73 731 patients with dementia and 733 653 controls (median age, 80.3 years; interquartile range, 74.9-84.6 years; 44 760 female [60.7%] and 28 971 male [39.3%]) were included in the study. Lithium exposure was statistically significantly different between patients with a diagnosis of dementia (median, 11.5 µg/L; interquartile range, 6.5-14.9 µg/L) and controls (median, 12.2 µg/L; interquartile range, 7.3-16.0 µg/L; P < .001). A nonlinear association was observed. Compared with individuals exposed to 2.0 to 5.0 µg/L, the incidence rate ratio (IRR) of dementia was decreased in those exposed to more than 15.0 µg/L (IRR, 0.83; 95% CI, 0.81-0.85; P < .001) and 10.1 to 15.0 µg/L (IRR, 0.98; 95% CI, 0.96-1.01; P = .17) and increased with 5.1 to 10.0 µg/L (IRR, 1.22; 95% CI, 1.19-1.25; P < .001). Similar patterns were found with Alzheimer disease and vascular dementia as outcomes. Long-term increased lithium exposure in drinking water may be associated with a lower incidence of dementia in a nonlinear way; however, confounding from other factors associated with municipality of residence cannot be excluded.

Three-Year Outcomes of Transcatheter Aortic Valve Implantation in Patients With Varying Levels of Surgical Risk (from the CoreValve ADVANCE Study).

PubMed

Barbanti, Marco; Schiltgen, Molly; Verdoliva, Sarah; Bosmans, Johan; Bleiziffer, Sabine; Gerckens, Ulrich; Wenaweser, Peter; Brecker, Stephen; Gulino, Simona; Tamburino, Corrado; Linke, Axel

2016-03-01

This study compared 3-year clinical outcomes of patients who underwent transcatheter aortic valve implantation with the Society of Thoracic Surgeons (STS) score ≤7% to those of patients with a score >7%. Data were drawn from the ADVANCE study, a multinational post-market clinical trial that enrolled real-world patients with severe aortic stenosis treated with the CoreValve bioprosthesis. Events were independently adjudicated using Valve Academic Research Consortium-1 definitions. A total of 996 patients were implanted: STS ≤7% (n = 697, median STS 4.3%, interquartile range 3.1% to 5.4%) and STS >7% (n = 298, median STS 9.7%, interquartile range 8.0% to 12.4%). At 3 years, the STS ≤7% group had lower rates of all-cause mortality (28.6 vs 45.9, p <0.01) and cardiovascular mortality (19.0 vs 30.2, p <0.01) than the STS >7% group. No differences were observed in cerebrovascular accidents, vascular complications, bleeding, or myocardial infarction. In patients with STS ≤7%, mortality at 3 years was higher in those with moderate or severe aortic regurgitation (AR) at discharge than in those with mild or less AR (39.9% vs 22.9%; hazard ratio 1.98; 95% confidence interval 1.37 to 2.86; p <0.01). Conversely, the severity of AR at discharge did not affect 3-year mortality in patients with STS >7% (42.9% vs 44.6%, moderate/severe vs mild/less; hazard ratio 1.04; 95% confidence interval, 0.62 to 1.75; p = 0.861; p for interaction = 0.047). In conclusion, patients with STS ≤7% had lower rates of all-cause and cardiovascular mortality at 3 years after transcatheter aortic valve implantation. Complication rates were low and stable in both groups, demonstrating the safety of this procedure for patients at various levels of surgical risk. Copyright © 2016 Elsevier Inc. All rights reserved.

Time dependency of the prediction skill for the North Atlantic subpolar gyre in initialized decadal hindcasts

NASA Astrophysics Data System (ADS)

Brune, Sebastian; Düsterhus, André; Pohlmann, Holger; Müller, Wolfgang A.; Baehr, Johanna

2017-11-01

We analyze the time dependency of decadal hindcast skill in the North Atlantic subpolar gyre within the time period 1961-2013. We compare anomaly correlation coefficients and temporal interquartile ranges of total upper ocean heat content and sea surface temperature for three differently initialized sets of hindcast simulations with the global coupled model MPI-ESM. All initializations use weakly coupled assimilation with the same full value nudging in the atmospheric component and different assimilation techniques for oceanic temperature and salinity: (1) ensemble Kalman filter assimilating EN4 observations and HadISST data, (2) nudging of anomalies to ORAS4 reanalysis, (3) nudging of full values to ORAS4 reanalysis. We find that hindcast skill depends strongly on the evaluation time period, with higher hindcast skill during strong multiyear trends, especially during the warming in the 1990s and lower hindcast skill in the absence of such trends. Differences between the prediction systems are more pronounced when investigating any 20-year subperiod within the entire hindcast period. In the ensemble Kalman filter initialized hindcasts, we find significant correlation skill for up to 5-8 lead years, albeit along with an overestimation of the temporal interquartile range. In the hindcasts initialized by anomaly nudging, significant correlation skill for lead years greater than two is only found in the 1980s and 1990s. In the hindcasts initialized by full value nudging, correlation skill is consistently lower than in the hindcasts initialized by anomaly nudging in the first lead years with re-emerging skill thereafter. The Atlantic meridional overturning circulation reacts on the density changes introduced by oceanic nudging, this limits the predictability in the subpolar gyre in the first lead years. Overall, we find that a model-consistent assimilation technique can improve hindcast skill. Further, the evaluation of 20 year subperiods within the full hindcast period provides essential insights to judge the success of both the assimilation and the subsequent hindcast quality.

Joint estimation of CD4+ cell progression and survival in untreated individuals with HIV-1 infection.

PubMed

Mangal, Tara D

2017-05-15

We compiled the largest dataset of seroconverter cohorts to date from 25 countries across Africa, North America, Europe, and Southeast/East (SE/E) Asia to simultaneously estimate transition rates between CD4 cell stages and death, in antiretroviral therapy (ART)-naive HIV-1-infected individuals. A hidden Markov model incorporating a misclassification matrix was used to represent natural short-term fluctuations and measurement errors in CD4 cell counts. Covariates were included to estimate the transition rates and survival probabilities for each subgroup. The median follow-up time for 16 373 eligible individuals was 4.1 years (interquartile range 1.7-7.1), and the mean age at seroconversion was 31.1 years (SD 8.8). A total of 14 525 individuals had recorded CD4 cell counts pre-ART, 1885 died, and 6947 initiated ART. Median (interquartile range) survival for men aged 20 years at seroconversion was 13.0 (12.4-13.4), 11.6 (10.9-12.3), and 8.3 years (7.9-8.9) in Europe/North America, Africa, and SE/E Asia, respectively. Mortality rates increase with age (hazard ratio 2.22, 95% confidence interval 1.84-2.67 for >45 years compared with <25 years) and vary by region (hazard ratio 2.68, 1.75-4.12 for Africa and 1.88, 1.50-2.35 for Asia compared with Europe/North America). CD4 cell decline was significantly faster in Asian cohorts compared with Europe/North America (hazard ratio 1.45, 1.36-1.54). Mortality and CD4 cell progression rates exhibited regional and age-specific differences, with decreased survival in African and SE/E Asian cohorts compared with Europe/North America and in older age groups. This extensive dataset reveals heterogeneities between regions and ages, which should be incorporated into future HIV models.

Borderline Changes on Dysfunctional Renal Allograft Biopsies: Clinical Relevance in a Living Related Renal Transplant Setting.

PubMed

Mubarak, Muhammed; Shakeel, Shaheera; Abbas, Khawar; Aziz, Tahir; Zafar, Mirza Naqi; Naqvi, Syed Anwer; Rizvi, Syed Adibul Hasan

2017-02-01

Our aim was to determine the clinical significance of borderline lymphocytic infiltrates on indicated renal allograft biopsies in a living related renal transplant setting. The study was conducted at the histopathology department of Sindh Institute of Urology and Transplantation. A retrospective review of 421 renal transplant patients was conducted from October 2007 to September 2008 to identify patients in whom a histologic diagnosis of borderline changes was made on dysfunctional renal allograft biopsies. Demographic, clinical, and laboratory data; biopsy findings; treatments given; and responses to treatment were collected and analyzed. Standard biopsy indications determined the need for graft biopsies. Biopsies were reported according to Banff criteria. Mean age was 26.92 ± 9.14 years (range, 10-45) for recipients and 38.46 ± 9.16 years (range, 19-50) for donors. Males were predominant among recipients (84.6% vs 15.4%), and females were predominant among donors (57.7% vs 42.3%). The best serum creatinine levels were 1.79 ± 1.15 mg/dL (range, 0.83-6.12). These were achieved after a median of 3 days (interquartile range, 2-7.25). Dysfunctional biopsies exhibiting borderline infiltrates were performed at a median duration of 5.5 days (interquartile range, 3-14.25). Mean serum creatinine at the time of biopsy was 2.34 ± 1.43 mg/dL (range, 1.25-8.25). The biopsies showed borderline cellular infiltrates (interstitial inflammation 1 [i1] and tubulitis 1 and [t1] lesions). All recipients except one received antirejection treatment (antithymocyte globulin, n = 5; escalation of mycophenolate mofetil dosage, n = 1; pulse steroids, n = 19); all recipients responded with a decline in serum creatinine toward baseline, with a mean serum creatinine of 1.31 ± 0.42 mg/dL (range, 0.40-2.71). This response was achieved at a median duration of 9.73 ± 5.32 days (range, 1-23) after starting treatment. The borderline cellular infiltrates on dysfunctional renal allograft biopsies signify evolving phases of acute cellular rejection. These infiltrates responded favorably to antirejection treatment in our setting.

Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens.

PubMed

Shea, Kevin G; Milewski, Matthew D; Cannamela, Peter C; Ganley, Theodore J; Fabricant, Peter D; Terhune, Elizabeth B; Styhl, Alexandra C; Anderson, Allen F; Polousky, John D

2017-06-01

Anterior cruciate ligament (ACL) reconstruction failure rates are highest in youth athletes. The role of the anterolateral ligament in rotational knee stability is of increasing interest, and several centers are exploring combined ACL and anterolateral ligament reconstruction for these young patients. Literature on the anterolateral ligament of the knee is sparse in regard to the pediatric population. A single study on specimens younger than age 5 years demonstrated the presence of the anterolateral ligament in only one of eight specimens; therefore, much about the prevalence and anatomy of the anterolateral ligament in pediatric specimens remains unknown. We sought to (1) investigate the presence or absence of the anterolateral ligament in prepubescent anatomic specimens; (2) describe the anatomic relationship of the anterolateral ligament to the lateral collateral ligament; and (3) describe the anatomic relationship between the anterolateral ligament and the physis. Fourteen skeletally immature knee specimens (median age, 8 years; range, 7-11 years) were dissected (12 male, two female specimens). The posterolateral structures were identified in all specimens, including the lateral collateral ligament and popliteus tendon. The presence or absence of the anterolateral ligament was documented in each specimen, along with origin, insertion, and dimensions, when applicable. The relationship of the anterolateral ligament origin to the lateral collateral ligament origin was recorded. The anterolateral ligament was identified in nine of 14 specimens. The tibial attachment point was consistently located in the same region on the proximal tibia, between the fibular head and Gerdy's tubercle; however, the femoral origin of the anterolateral ligament showed considerable variation with respect to the lateral collateral ligament origin. The median femoral origin of the anterolateral ligament was 10 mm (first interquartile 6 mm, third interquartile 13) distal to the distal femoral physis, whereas its median insertion was 9 mm (first interquartile 5 mm, third interquartile 11 mm) proximal to the proximal tibial physis. The frequency of the anterolateral ligament in pediatric specimens we observed was much lower than other studies on adult specimens; future studies might further investigate the prevalence, development, and functional role of the anterolateral ligament of the knee. This study expands our understanding of the anterolateral ligament and provides important anatomic information to surgeons considering anterolateral ligament reconstruction concomitantly with primary or revision ACL reconstruction in pediatric athletes.

Air Pollution and Ischemic Stroke Among Young Adults.

PubMed

Yitshak Sade, Maayan; Novack, Victor; Ifergane, Gal; Horev, Anat; Kloog, Itai

2015-12-01

Studies have demonstrated consistent associations between cardiovascular illness and particulate matter (PM) <10 and <2.5 μm in diameter, but stroke received less attention. We hypothesized that air pollution, an inflammation progenitor, can be associated with stroke incidence in young patients in whom the usual risk factors for stroke are less prevalent. We aimed to evaluate the association between stroke incidence and exposure to PM <10 and <2.5 μm, in a desert area characterized by a wide range of PM. We included all members of the largest health maintenance organization in Israel, who were admitted to a local hospital with stroke between 2005 and 2012. Exposure assessment was based on a hybrid model incorporating daily satellite remote sensing data at 1-km spatial resolution. We performed case-crossover analysis, stratified by personal characteristics and distance from main roads. We identified 4837 stroke cases (89.4% ischemic stroke). Interquartile range of PM <10 and <2.5 μm was 36.3 to 54.7 and 16.7 to 23.3 μg/m(3), respectively. The subjects' average age was 70 years; 53.4% were males. Associations between ischemic stroke and increases of interquartile range average concentrations of particulate matter <10 or <2.5 μm at the day of the event were observed among subjects <55 years (odds ratio [95% confidence interval], 1.11 [1.02-1.20] and 1.10 [1.00-1.21]). Stronger associations were observed in subjects living within 75 m from a main road (1.22 [1.03-1.43] and 1.26 [1.04-1.51]). We observed higher risk for ischemic stroke associated with PM among young adults. This finding can be explained by the inflammatory mechanism, linking air pollution and stroke. © 2015 American Heart Association, Inc.

The operative outcomes of displaced medial-end clavicle fractures.

PubMed

Sidhu, Verinder S; Hermans, Deborah; Duckworth, David G

2015-11-01

Nonoperative treatment of displaced medial clavicle fractures often leads to poor functional outcomes and painful nonunions. This study investigates the functional outcomes of patients undergoing operative fixation of these fractures. We investigated 27 patients undergoing operative fixation of a medial clavicle fracture; 24 had an acute, displaced fracture and 3 had fixation for nonunions. Preoperative radiographs or computed tomography scans were obtained, and data collected included age, sex, mechanism of injury, and fixation method. Follow-up included physical examination and radiographs for assessment of union; Disabilities of the Arm, Shoulder, and Hand scores at 12 months; and the recording of complications. The median age was 37 years (interquartile range, 17-47 years). There were 26 male patients and one female patient included, with 7 physeal injuries and 20 adult injuries. The most common mechanism of fracture was vehicular accident (n = 15). Three patients had operations for nonunions and 2 for a periprosthetic fracture medial to an existing plate. The fracture was fixed with plate and screws in 19 cases and with transosseous sutures in 8 cases. The median Disabilities of the Arm, Shoulder, and Hand score at 12 months was 0.4 (interquartile range, 0-5.0), with a union rate of 100% at 12 months. All patients had full shoulder range of motion at final follow-up and were able to return to preinjury occupational activities. There were no significant complications. Operative fixation of displaced medial clavicle fractures results in anatomic reconstruction and excellent functional outcomes, even in the setting of fixation performed for symptomatic nonunion. Early intervention can minimize the risk of painful nonunion. Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.

Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.

PubMed

Larochelle, Marc R; Bernson, Dana; Land, Thomas; Stopka, Thomas J; Wang, Na; Xuan, Ziming; Bagley, Sarah M; Liebschutz, Jane M; Walley, Alexander Y

2018-06-19

Opioid overdose survivors have an increased risk for death. Whether use of medications for opioid use disorder (MOUD) after overdose is associated with mortality is not known. To identify MOUD use after opioid overdose and its association with all-cause and opioid-related mortality. Retrospective cohort study. 7 individually linked data sets from Massachusetts government agencies. 17 568 Massachusetts adults without cancer who survived an opioid overdose between 2012 and 2014. Three types of MOUD were examined: methadone maintenance treatment (MMT), buprenorphine, and naltrexone. Exposure to MOUD was identified at monthly intervals, and persons were considered exposed through the month after last receipt. A multivariable Cox proportional hazards model was used to examine MOUD as a monthly time-varying exposure variable to predict time to all-cause and opioid-related mortality. In the 12 months after a nonfatal overdose, 2040 persons (11%) enrolled in MMT for a median of 5 months (interquartile range, 2 to 9 months), 3022 persons (17%) received buprenorphine for a median of 4 months (interquartile range, 2 to 8 months), and 1099 persons (6%) received naltrexone for a median of 1 month (interquartile range, 1 to 2 months). Among the entire cohort, all-cause mortality was 4.7 deaths (95% CI, 4.4 to 5.0 deaths) per 100 person-years and opioid-related mortality was 2.1 deaths (CI, 1.9 to 2.4 deaths) per 100 person-years. Compared with no MOUD, MMT was associated with decreased all-cause mortality (adjusted hazard ratio [AHR], 0.47 [CI, 0.32 to 0.71]) and opioid-related mortality (AHR, 0.41 [CI, 0.24 to 0.70]). Buprenorphine was associated with decreased all-cause mortality (AHR, 0.63 [CI, 0.46 to 0.87]) and opioid-related mortality (AHR, 0.62 [CI, 0.41 to 0.92]). No associations between naltrexone and all-cause mortality (AHR, 1.44 [CI, 0.84 to 2.46]) or opioid-related mortality (AHR, 1.42 [CI, 0.73 to 2.79]) were identified. Few events among naltrexone recipients preclude confident conclusions. A minority of opioid overdose survivors received MOUD. Buprenorphine and MMT were associated with reduced all-cause and opioid-related mortality. National Center for Advancing Translational Sciences of the National Institutes of Health.

Kidney function and plasma copeptin levels in healthy kidney donors and autosomal dominant polycystic kidney disease patients.

PubMed

Zittema, Debbie; van den Berg, Else; Meijer, Esther; Boertien, Wendy E; Muller Kobold, Anneke C; Franssen, Casper F M; de Jong, Paul E; Bakker, Stephan J L; Navis, Gerjan; Gansevoort, Ron T

2014-09-05

Plasma copeptin, a marker of arginine vasopressin, is elevated in patients with autosomal dominant polycystic kidney disease and predicts disease progression. It is unknown whether elevated copeptin levels result from decreased kidney clearance or as compensation for impaired concentrating capacity. Data from patients with autosomal dominant polycystic kidney disease and healthy kidney donors before and after donation were used, because after donation, overall GFR decreases with a functionally normal kidney. Data were obtained between October of 2008 and January of 2012 from healthy kidney donors who visited the institution for routine measurements predonation and postdonation and patients with autosomal dominant polycystic kidney disease who visited the institution for kidney function measurement. Plasma copeptin levels were measured using a sandwich immunoassay, GFR was measured as (125)I-iothalamate clearance, and urine concentrating capacity was measured as urine-to-plasma ratio of urea. In patients with autosomal dominant polycystic kidney disease, total kidney volume was measured with magnetic resonance imaging. Patients with autosomal dominant polycystic kidney disease (n=122, age=40 years, men=56%) had significantly higher copeptin levels (median=6.8 pmol/L; interquartile range=3.4-15.7 pmol/L) compared with donors (n=134, age=52 years, men=49%) both predonation and postdonation (median=3.8 pmol/L; interquartile range=2.8-6.3 pmol/L; P<0.001; median=4.4 pmol/L; interquartile range=3.6-6.1 pmol/L; P<0.001). In donors, copeptin levels did not change after donation, despite a significant fall in GFR (from 105 ± 17 to 66 ± 10; P<0.001). Copeptin and GFR were significantly associated in patients with autosomal dominant polycystic kidney disease (β=-0.45, P<0.001) but not in donors. In patients with autosomal dominant polycystic kidney disease, GFR and total kidney volume were both associated significantly with urine-to-plasma ratio of urea (β=0.84, P<0.001; β=-0.51, P<0.001, respectively). On the basis of the finding in donors that kidney clearance is not a main determinant of plasma copeptin levels, it was hypothesized that, in patients with autosomal dominant polycystic kidney disease, kidney damage and associated impaired urine concentration capacity determine copeptin levels. Copyright © 2014 by the American Society of Nephrology.

Potential Reporting Bias in Neuroimaging Studies of Sex Differences.

PubMed

David, Sean P; Naudet, Florian; Laude, Jennifer; Radua, Joaquim; Fusar-Poli, Paolo; Chu, Isabella; Stefanick, Marcia L; Ioannidis, John P A

2018-04-17

Numerous functional magnetic resonance imaging (fMRI) studies have reported sex differences. To empirically evaluate for evidence of excessive significance bias in this literature, we searched for published fMRI studies of human brain to evaluate sex differences, regardless of the topic investigated, in Medline and Scopus over 10 years. We analyzed the prevalence of conclusions in favor of sex differences and the correlation between study sample sizes and number of significant foci identified. In the absence of bias, larger studies (better powered) should identify a larger number of significant foci. Across 179 papers, median sample size was n = 32 (interquartile range 23-47.5). A median of 5 foci related to sex differences were reported (interquartile range, 2-9.5). Few articles (n = 2) had titles focused on no differences or on similarities (n = 3) between sexes. Overall, 158 papers (88%) reached "positive" conclusions in their abstract and presented some foci related to sex differences. There was no statistically significant relationship between sample size and the number of foci (-0.048% increase for every 10 participants, p = 0.63). The extremely high prevalence of "positive" results and the lack of the expected relationship between sample size and the number of discovered foci reflect probable reporting bias and excess significance bias in this literature.

Outcome in obscure gastrointestinal bleeding after capsule endoscopy.

PubMed

Cañas-Ventura, Alex; Márquez, Lucia; Bessa, Xavier; Dedeu, Josep Maria; Puigvehí, Marc; Delgado-Aros, Sílvia; Ibáñez, Ines Ana; Seoane, Agustin; Barranco, Luis; Bory, Felipe; Andreu, Montserrat; González-Suárez, Begoña

2013-11-16

To investigate the clinical impact of capsule endoscopy (CE) after an obscure gastrointestinal bleeding (OGIB) episode, focusing on diagnostic work-up, follow-up and predictive factors of rebleeding. Patients who were referred to Hospital del Mar (Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid anti-inflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings (significant or non-significant), work-up and patient outcomes were analyzed from electronic charts. Variables were compared by χ (2) analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model. There were 105 patients [45.7% women, median age of 72 years old (interquartile range 56-79)] and a median follow-up of 326 d (interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1% (55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients (69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios (HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above (HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE (HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding. One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.

Outcomes With Transcatheter Mitral Valve Repair in the United States: An STS/ACC TVT Registry Report.

PubMed

Sorajja, Paul; Vemulapalli, Sreekanth; Feldman, Ted; Mack, Michael; Holmes, David R; Stebbins, Amanda; Kar, Saibal; Thourani, Vinod; Ailawadi, Gorav

2017-11-07

Post-market surveillance is needed to evaluate the real-world clinical effectiveness and safety of U.S. Food and Drug Administration-approved devices. The authors examined the commercial experience with transcatheter mitral valve repair for the treatment of mitral regurgitation. Data from the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry on patients commercially treated with transcatheter mitral valve repair were analyzed. The study population consisted of 2,952 patients treated at 145 hospitals between November 2013 and September 2015. In 1,867 patients, data were linked to patient-specific Centers for Medicare and Medicaid Services administrative claims for analyses. The median age was 82 years (55.8% men), with a median Society of Thoracic Surgery predicted risk of mortality of 6.1% (interquartile range: 3.7% to 9.9%) and 9.2% (interquartile range: 6.0% to 14.1%) for mitral repair and replacement, respectively. Overall, in-hospital mortality was 2.7%. Acute procedure success occurred in 91.8%. Among the patients with Centers for Medicare and Medicaid Services linkage data, the mortality at 30 days and at 1 year was 5.2% and 25.8%, respectively, and repeat hospitalization for heart failure at 1 year occurred in 20.2%. Variables associated with mortality or rehospitalization for heart failure after multivariate adjustment were increasing age, lower baseline left ventricular ejection fraction, worse post-procedural mitral regurgitation, moderate or severe lung disease, dialysis, and severe tricuspid regurgitation. Our findings demonstrate that commercial transcatheter mitral valve repair is being performed in the United States with acute effectiveness and safety. Our findings may help determine which patients have favorable long-term outcomes with this therapy. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Angiotensin-converting enzyme inhibition and novel cardiovascular risk biomarkers: results from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study.

PubMed

Cesari, Matteo; Kritchevsky, Stephen B; Atkinson, Hal H; Penninx, Brenda W; Di Bari, Mauro; Tracy, Russell P; Pahor, Marco

2009-02-01

Beneficial effects of angiotensin-converting enzyme (ACE) inhibitors seem to be mediated by mechanisms that are partly independent of blood pressure lowering. The present study evaluates effects of an ACE inhibitor (ie, fosinopril) intervention on novel cardiovascular risk factors. Data are from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study, a double-blind, crossover, randomized, placebo-controlled trial enrolling subjects > or =55 years old with high cardiovascular disease risk profile. Biomarkers of hemostasis (ie, plasminogen activator inhibitor 1, D-dimer), inflammation (ie, C-reactive protein, interleukin-6), and endothelial function (ie, endothelin 1, vascular cell adhesion molecule 1) were measured at the baseline, at the midterm, and at end of follow-up (after 1 year) clinic visits. Paired t test analyses (after Sidak's adjustment, P < .009) were performed to compare biomarkers modifications after fosinopril/placebo interventions. Mean age of the sample (n = 290, women 43.4%) was 66.0 years old. No significant differences were reported for C-reactive protein, interleukin 6, plasminogen activator inhibitor 1, vascular cell adhesion molecule 1, and endothelin 1 levels in the comparisons between fosinopril and placebo interventions. D-dimer was the only biomarker showing a significant difference between fosinopril intervention (median 0.32 microg/mL, interquartile range 0.22-0.52 microg/mL) and placebo (median 0.29 microg/mL, interquartile range 0.20-0.47 microg/mL, P = .007) when analyses were restricted to participants with higher compliance to treatment and receiving the maximum ACE inhibitor dosage. Angiotensin-converting enzyme inhibition does not significantly modify major biomarkers of inflammation, hemostasis, and endothelial function. Further studies should confirm the possible effect of ACE inhibitors on the fibrinolysis pathway.

Urinary potassium excretion and risk of developing hypertension: the prevention of renal and vascular end-stage disease study.

PubMed

Kieneker, Lyanne M; Gansevoort, Ron T; Mukamal, Kenneth J; de Boer, Rudolf A; Navis, Gerjan; Bakker, Stephan J L; Joosten, Michel M

2014-10-01

Previous prospective cohort studies on the association between potassium intake and risk of hypertension have almost exclusively relied on self-reported dietary data, whereas repeated 24-hour urine excretions, as estimate of dietary uptake, may provide a more objective and quantitative estimate of this association. Risk of hypertension (defined as blood pressure ≥140/90 mm Hg or initiation of blood pressure-lowering drugs) was prospectively studied in 5511 normotensive subjects aged 28 to 75 years not using blood pressure-lowering drugs at baseline of the Prevention of Renal and Vascular End-Stage Disease (PREVEND) study. Potassium excretion was measured in two 24-hour urine specimens at baseline (1997-1998) and midway during follow-up (2001-2003). Baseline median potassium excretion was 70 mmol/24 h (interquartile range, 57-85 mmol/24 h), which corresponds to a dietary potassium intake of ≈91 mmol/24 h. During a median follow-up of 7.6 years (interquartile range, 5.0-9.3 years), 1172 subjects developed hypertension. The lowest sex-specific tertile of potassium excretion (men: <68 mmol/24 h; women: <58 mmol/24 h) had an increased risk of hypertension after multivariable adjustment (hazard ratio, 1.20; 95% confidence interval, 1.05-1.37), compared with the upper 2 tertiles (Pnonlinearity=0.008). The proportion of hypertension attributable to low potassium excretion was 6.2% (95% confidence interval, 1.7%-10.9%). No association was found between the sodium to potassium excretion ratio and risk of hypertension after multivariable adjustment. Low urinary potassium excretion was associated with an increased risk of developing hypertension. Dietary strategies to increase potassium intake to the recommended level of 90 mmol/d may have the potential to reduce the incidence of hypertension. © 2014 American Heart Association, Inc.

Long-Term Effect of Pravastatin on Carotid Intima–Media Complex Thickness

PubMed Central

Toyoda, Kazunori; Minematsu, Kazuo; Yasaka, Masahiro; Nagai, Yoji; Aoki, Shiro; Nezu, Tomohisa; Hosomi, Naohisa; Kagimura, Tatsuo; Origasa, Hideki; Kamiyama, Kenji; Suzuki, Rieko; Ohtsuki, Toshiho; Maruyama, Hirofumi; Kitagawa, Kazuo; Uchiyama, Shinichiro; Matsumoto, Masayasu

2018-01-01

Background and Purpose— The effect of statins on progression of carotid intima–media complex thickness (IMT) has been shown exclusively in nonstroke Western patients. This study aimed to determine the effect of low-dose pravastatin on carotid IMT in Japanese patients with noncardioembolic ischemic stroke. Methods— This is a substudy of the J-STARS trial (Japan Statin Treatment Against Recurrent Stroke), a multicenter, randomized, open-label, parallel-group trial to examine whether pravastatin reduces stroke recurrence. Patients were randomized to receive pravastatin (10 mg daily, usual dose in Japan; pravastatin group) or not to receive any statins (control group). The primary outcome was IMT change of the common carotid artery for a 5-year observation period. IMT change was compared using mixed-effects models for repeated measures. Results— Of 864 patients registered in this substudy, 71 without baseline ultrasonography were excluded, and 388 were randomly assigned to the pravastatin group and 405 to the control group. Baseline characteristics were not significantly different, except National Institutes of Health Stroke Scale scores (median, 0 [interquartile range, 0–2] versus 1 [interquartile range, 0–2]; P=0.019) between the 2 groups. Baseline IMT (mean±SD) was 0.887±0.155 mm in the pravastatin group and 0.887±0.152 mm in the control group (P=0.99). The annual change in the IMT at 5-year visit was significantly reduced in the pravastatin group as compared with that in the control group (0.021±0.116 versus 0.040±0.118 mm; P=0.010). Conclusions— The usual Japanese dose of pravastatin significantly reduced the progression of carotid IMT at 5 years in patients with noncardioembolic stroke. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00361530. PMID:29191850

The impact of endovascular aneurysm repair on mortality for elective abdominal aortic aneurysm repair in England and the United States.

PubMed

Karthikesalingam, Alan; Holt, Peter J; Vidal-Diez, Alberto; Bahia, Sandeep S; Patterson, Benjamin O; Hinchliffe, Robert J; Thompson, Matthew M

2016-08-01

Procedural mortality is of paramount importance for patients undergoing elective abdominal aortic aneurysm (AAA) repair. Previous comparative studies have demonstrated international differences in the care of ruptured AAA. This study compared the use of endovascular aneurysm repair (EVAR) and in-hospital mortality for elective AAA repair in England and the United States. The English Hospital Episode Statistics and the U.S. Nationwide Inpatient Sample (NIS) were interrogated for elective AAA repair from 2005 to 2010. In-hospital mortality and the use of EVAR were analyzed separately for each health care system, after within-country risk adjustment for age, gender, year, and an accepted national comorbidity index. The study included 21,272 patients with AAA in England, of whom 86.61% were male, with median (interquartile range) age of 74 (69-79) years. There were 196,113 AAA patients in the United States, of whom 76.14% were male, with median (interquartile range) age of 73 (67-78) years. In-hospital mortality was greater in England (4.09% vs 1.96 %; P < .01) and EVAR less common (37.33% vs 64.36%; P < .01). These observations persisted in age- and gender-matched comparison. In both countries, lower mortality and greater use of EVAR were seen in centers performing greater numbers of AAA repairs per annum. In England, lower mortality and greater use of EVAR were seen in teaching hospitals with larger bed capacity. In-hospital survival and the uptake of EVAR are lower in England than in the United States. In both countries, mortality was lowest in high-caseload centers performing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients requiring elective AAA repair. Copyright © 2016. Published by Elsevier Inc.

Risk of First and Recurrent Stroke in Childhood Cancer Survivors Treated With Cranial and Cervical Radiation Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mueller, Sabine, E-mail: muellers@neuropeds.ucsf.edu; Department of Pediatrics, University of California, San Francisco, California; Department of Neurosurgery, University of California, San Francisco, California

Purpose: To assess, in a retrospective cohort study, rates and predictors of first and recurrent stroke in patients treated with cranial irradiation (CRT) and/or cervical irradiation at ≤18 years of age. Methods and Materials: We performed chart abstraction (n=383) and phone interviews (n=104) to measure first and recurrent stroke in 383 patients who received CRT and/or cervical radiation at a single institution between 1980 and 2009. Stroke was defined as a physician diagnosis and symptoms consistent with stroke. Incidence of first stroke was number of first strokes per person-years of observation after radiation. We used survival analysis techniques to determinemore » cumulative incidence of first and recurrent stroke. Results: Among 325 subjects with sufficient follow-up data, we identified 19 first strokes (13 ischemic, 4 hemorrhagic, 2 unknown subtype) occurring at a median age of 24 years (interquartile range 17-33 years) in patients treated with CRT. Imaging was reviewed when available (n=13), and the stroke was confirmed in 12. Overall rate of first stroke was 625 (95% confidence interval [CI] 378-977) per 100,000 person-years. The cumulative incidence of first stroke was 2% (95% CI 0.01%-5.3%) at 5 years and 4% (95% CI 2.0%-8.4%) at 10 years after irradiation. With each 100-cGy increase in the radiation dose, the stroke hazard increased by 5% (hazard ratio 1.05; 95% CI 1.01-1.09; P=.02). We identified 6 recurrent strokes; 5 had available imaging that confirmed the stroke. Median time to recurrence was 15 months (interquartile range 6 months-3.2 years) after first stroke. The cumulative incidence of recurrent stroke was 38% (95% CI 17%-69%) at 5 years and 59% (95% CI 27%-92%) at 10 years after first stroke. Conclusion: Cranial irradiation puts childhood cancer survivors at high risk of both first and recurrent stroke. Stroke prevention strategies for these survivors are needed.« less

Incidence of Second Malignancies Among Patients Treated With Proton Versus Photon Radiation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chung, Christine S., E-mail: chungc1@sutterhealth.org; Yock, Torunn I.; Nelson, Kerrie

2013-09-01

Purpose: Proton radiation, when compared with photon radiation, allows delivery of increased radiation dose to the tumor while decreasing dose to adjacent critical structures. Given the recent expansion of proton facilities in the United States, the long-term sequelae of proton therapy should be carefully assessed. The objective of this study was to compare the incidence of second cancers in patients treated with proton radiation with a population-based cohort of matched patients treated with photon radiation. Methods and Materials: We performed a retrospective cohort study of 558 patients treated with proton radiation from 1973 to 2001 at the Harvard Cyclotron inmore » Cambridge, MA and 558 matched patients treated with photon therapy in the Surveillance, Epidemiology, and End Results (SEER) Program cancer registry. Patients were matched by age at radiation treatment, sex, year of treatment, cancer histology, and site. The main outcome measure was the incidence of second malignancies after radiation. Results: We matched 558 proton patients with 558 photon patients from the Surveillance, Epidemiology, and End Results registry. The median duration of follow-up was 6.7 years (interquartile range, 7.4) and 6.0 years (interquartile range, 9.3) in the proton and photon cohorts, respectively. The median age at treatment was 59 years in each cohort. Second malignancies occurred in 29 proton patients (5.2%) and 42 photon patients (7.5%). After we adjusted for sex, age at treatment, primary site, and year of diagnosis, proton therapy was not associated with an increased risk of second malignancy (adjusted hazard ratio, 0.52 [95% confidence interval, 0.32-0.85]; P=.009). Conclusions: The use of proton radiation therapy was not associated with a significantly increased risk of secondary malignancies compared with photon therapy. Longer follow-up of these patients is needed to determine if there is a significant decrease in second malignancies. Given the limitations of the study, these results should be viewed as hypothesis generating.« less

Third molars and periodontal pathology in American adolescents and young adults: a prevalence study.

PubMed

Blakey, George H; Gelesko, Savannah; Marciani, Robert D; Haug, Richard H; Offenbacher, Steven; Phillips, Ceib; White, Raymond P

2010-02-01

To assess the association between visible third molars and the prevalence of periodontal inflammatory disease of non-third molars. Subjects aged 14 to 45 years with 4 asymptomatic third molars were enrolled in an institutional review board-approved study. Subjects were classified based on whether at least 1 third molar was visible or all third molars were not visible. Full-mouth periodontal probing depth (PD) data, with 6 sites per tooth, were obtained as a measure of a subject's periodontal status. At least 1 non-third molar PD of 4 mm or greater was indicative of periodontal inflammatory disease. Outcomes for the respective groups were compared by use of Cochran-Mantel-Haenszel row mean score statistics. The level of significance for differences was set at .05. The 342 subjects in the visible group were significantly older, with a median age of 26 years (interquartile range, 22.4-32.2 years), as compared with the 69 subjects in the not visible group, with a median age of 21 years (interquartile range, 18.8-24.9 years) (P < .01). The proportion of males and females was not statistically different between groups (P > .05). Most subjects were white. Significantly more subjects with at least a college education were in the visible group than in the not visible group (P < .01). The rate of tobacco use was low and did not differ between groups. Subjects in the visible group were significantly more likely to have at least 1 PD of 4 mm or greater on non-third molars than those in the not visible group: 59% versus 35%. In both groups, first/second molars were more affected than nonmolars when we controlled for differences in age between groups. The visible presence of third molars in adolescents and young adults was significantly associated with periodontal inflammatory disease of non-third molars. Copyright 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Risk Factors for De Novo Malignancies in Women After Kidney Transplantation: A Multicenter Transversal Study.

PubMed

Helmy, Samir; Marschalek, Julian; Bader, Yvonne; Koch, Marianne; Schmidt, Alice; Kanzler, Marina; Gyoeri, Georg; Polterauer, Stephan; Reinthaller, Alexander; Grimm, Christoph

2016-06-01

Transplantation results in a 5-time elevated risk for a variety of malignancies (Kaposi sarcoma, skin, liver, lung, gastrointestinal cancer). A patient's risk for malignancies could be of particular interest for the follow-up programs of patients and risk adaption after kidney transplantation. The aim of this study was to identify independent risk factors for de novo malignancies in women after renal transplantation. This is a multicenter transversal study, conducted at the Medical University of Vienna and Hospital Rudolfstiftung, Vienna, Austria. We included female kidney graft recipients who were transplanted between 1980 and 2012 and followed-up at our institutions (N = 280). Clinical data of patients were extracted from hospital charts and electronic patient files. Patients were interviewed using a standardized questionnaire regarding their medical history, history of transplantation, and malignant diseases. Detailed information about present and past immunosuppressive regimens, rejection episodes and therapies, renal graft function, and information about primary disease was obtained. Diagnostic work-up and/or surgical exploration was performed if any presence of malignancy was suspected during routine follow-up. Histological specimens were obtained from all patients. the presence of de novo malignancy after kidney transplantation. Two hundred sixty-two women were included for statistical analysis. Median (interquartile range) follow-up period after transplantation was 101.1 (27.3-190.7) months. Thirty-two patients (12.2%) developed a malignancy: dermatologic malignancies (5.7%), breast cancer (3.4%), cervical cancer (0.8%), lung cancer (0.4%), gastrointestinal malignancies (1.5%), vulvar cancer (0.4%), and unclassified malignancies (1.9%). Median (interquartile range) time to malignancy after transplantation was 185.9 (92.0-257.6) months. Cumulative cancer rates were 4.9% (1 year), 14.4% (3 years), 16.4% (5 years), and 21.8% (10 years). Second transplantations were identified as independent risk factor for development of malignancy after transplantation. Long-term risk of developing a malignancy after kidney transplantation is high, which might justify a follow-up of more than 10 years.

Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions.

PubMed

Unaka, Ndidi I; Statile, Angela; Haney, Julianne; Beck, Andrew F; Brady, Patrick W; Jerardi, Karen E

2017-02-01

The average American adult reads at an 8th-grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross-sectional study at a large urban academic children's hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th-grade reading level (interquartile range, 8-12; range, 1-13). Median PEMAT score was 73% (interquartile range, 64%-82%; range, 45%-100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home. Journal of Hospital Medicine 2017;12:98-101. © 2017 Society of Hospital Medicine.

Retrospective Consent to Hemicraniectomy after Malignant Stroke among the Elderly, Despite Impaired Functional Outcome.

PubMed

Ragoschke-Schumm, Andreas; Junk, Christina; Lesmeister, Martin; Walter, Silke; Behnke, Stefanie; Schumm, Julia; Fassbender, Klaus

2015-01-01

Decompressive hemicraniectomy (DHC) after space-occupying strokes among patients older than 60 years has been shown to reduce mortality rates but at the cost of severe disability. There is an ongoing debate about what could be considered an acceptable outcome for these patients. Data about retrospective consent to the procedure after lengthy time periods are lacking. This study included 79 consecutive patients who underwent DHC during a 7.75-year period. Surviving patients were assessed for functional and psychological outcome, quality of life (QoL) and retrospective consent for the procedure. Patients younger than 60 years were compared with older patients. Of our 79 patients, 44 were younger than 60 years (median 50 years, interquartile range (IQR) 19-59 years) and 35 were older (median 68 years, interquartile range 60-87 years). The 30-day mortality rate was higher for the older group, but the difference was not statistically significant. Functional outcome was significantly better in the younger group: 31% of the patients in this group vs. 10% in the older group had a modified Rankin Scale score of 0-3 (p = 0.046). The mean National Institutes of Health Stroke Scale score was 17 ± 14 for the younger group and 29 ± 15 for the older group (p = 0.002). On the 36-Item Short Form Health Survey, with the exception of the item 'General health', the older group reported higher values for all items, with statistically significant differences between the 2 groups on the items 'Role limitation emotional' (p = 0.0007) and 'Vitality' (p = 0.02). In the younger group, 29% of patients retrospectively declined consent for DHC opposed to 0% of patients in the older group (p = 0.07). Despite impaired functional outcome after DHC, indicators of QoL and retrospective consent are higher for patients older than 60 years over the long term. This finding should be taken into account by those who counsel patients and caregivers with regard to this serious procedure. © 2015 S. Karger AG, Basel.

Biomechanical and Hemodynamic Measures of Right Ventricular Diastolic Function: Translating Tissue Biomechanics to Clinical Relevance.

PubMed

Jang, Sae; Vanderpool, Rebecca R; Avazmohammadi, Reza; Lapshin, Eugene; Bachman, Timothy N; Sacks, Michael; Simon, Marc A

2017-09-12

Right ventricular (RV) diastolic function has been associated with outcomes for patients with pulmonary hypertension; however, the relationship between biomechanics and hemodynamics in the right ventricle has not been studied. Rat models of RV pressure overload were obtained via pulmonary artery banding (PAB; control, n=7; PAB, n=5). At 3 weeks after banding, RV hemodynamics were measured using a conductance catheter. Biaxial mechanical properties of the RV free wall myocardium were obtained to extrapolate longitudinal and circumferential elastic modulus in low and high strain regions (E 1 and E 2 , respectively). Hemodynamic analysis revealed significantly increased end-diastolic elastance (E ed ) in PAB (control: 55.1 mm Hg/mL [interquartile range: 44.7-85.4 mm Hg/mL]; PAB: 146.6 mm Hg/mL [interquartile range: 105.8-155.0 mm Hg/mL]; P =0.010). Longitudinal E 1 was increased in PAB (control: 7.2 kPa [interquartile range: 6.7-18.1 kPa]; PAB: 34.2 kPa [interquartile range: 18.1-44.6 kPa]; P =0.018), whereas there were no significant changes in longitudinal E 2 or circumferential E 1 and E 2 . Last, wall stress was calculated from hemodynamic data by modeling the right ventricle as a sphere: stress=Pressure×radius2×thickness. RV pressure overload in PAB rats resulted in an increase in diastolic myocardial stiffness reflected both hemodynamically, by an increase in E ed , and biomechanically, by an increase in longitudinal E 1 . Modest increases in tissue biomechanical stiffness are associated with large increases in E ed . Hemodynamic measurements of RV diastolic function can be used to predict biomechanical changes in the myocardium. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Measured degree of dehydration in children and adolescents with type 1 diabetic ketoacidosis.

PubMed

Ugale, Judith; Mata, Angela; Meert, Kathleen L; Sarnaik, Ashok P

2012-03-01

Successful management of diabetic ketoacidosis depends on adequate rehydration while avoiding cerebral edema. Our objectives are to 1) measure the degree of dehydration in children with type 1 diabetes mellitus and diabetic ketoacidosis based on change in body weight; and 2) investigate the relationships between measured degree of dehydration and clinically assessed degree of dehydration, severity of diabetic ketoacidosis, and routine serum laboratory values. Prospective observational study. University-affiliated tertiary care children's hospital. Sixty-six patients <18 yrs of age with type 1 diabetic ketoacidosis. Patients were weighed using a portable scale at admission; 8, 16, and 24 hrs; and daily until discharge. Measured degree of dehydration was based on the difference between admission and plateau weights. Clinical degree of dehydration was assessed by physical examination and severity of diabetic ketoacidosis was assessed by blood gas values as defined by international guidelines. Laboratory values obtained on admission included serum glucose, urea nitrogen, sodium, and osmolality. Median measured degree of dehydration was 5.2% (interquartile range, 3.1% to 7.8%). Fourteen (21%) patients were clinically assessed as mild dehydration, 49 (74%) as moderate, and three (5%) as severe. Patients clinically assessed as moderately dehydrated had a greater measured degree of dehydration (5.8%; interquartile range, 3.6% to 9.6%) than those assessed as mildly dehydrated (3.7%; interquartile range, 2.3% to 6.4%) or severely dehydrated (2.5%; interquartile range, 2.3% to 2.6%). Nine (14%) patients were assessed as mild diabetic ketoacidosis, 18 (27%) as moderate, and 39 (59%) as severe. Diabetic ketoacidosis severity groups did not differ in measured degree of dehydration. Variables independently associated with measured degree of dehydration included serum urea nitrogen and sodium concentration on admission. Hydration status in children with diabetic ketoacidosis cannot be accurately assessed by physical examination or blood gas values. Fluid therapy based on maintenance plus 6% deficit replacement is reasonable for most patients.

Cognitive-behavioral therapy for sleep disturbance in patients undergoing peritoneal dialysis: a pilot randomized controlled trial.

PubMed

Chen, Hung-Yuan; Chiang, Chih-Kang; Wang, Hsi-Hao; Hung, Kuan-Yu; Lee, Yue-Joe; Peng, Yu-Sen; Wu, Kwan-Dun; Tsai, Tun-Jun

2008-08-01

Greater than 50% of dialysis patients experience sleep disturbances. Cognitive-behavioral therapy (CBT) is effective for treating chronic insomnia, but its effectiveness has never been reported in peritoneal dialysis (PD) patients and its association with cytokines is unknown. We investigated the effectiveness of CBT in PD patients by assessing changes in sleep quality and inflammatory cytokines. Randomized control study with parallel-group design. 24 PD patients with insomnia in a tertiary medical center without active medical and psychiatric illness were enrolled. The intervention group (N = 13) received CBT from a psychiatrist for 4 weeks and sleep hygiene education, whereas the control group (N = 11) received only sleep hygiene education. Primary outcomes were changes in the Pittsburgh Sleep Quality Index and Fatigue Severity Scale scores, and secondary outcomes were changes in serum interleukin 6 (IL-6), IL-1beta, IL-18, and tumor necrosis factor alpha levels during the 4-week trial. Median percentages of change in global Pittsburgh Sleep Quality Index scores were -14.3 (interquartile range, -35.7 to - 6.3) and -1.7 (interquartile range, -7.6 to 7.8) in the intervention and control groups, respectively (P = 0.3). Median percentages of change in global Fatigue Severity Scale scores were -12.1 (interquartile range, -59.8 to -1.5) and -10.5 (interquartile range, -14.3 to 30.4) in the intervention and control groups, respectively (P = 0.04). Serum IL-1beta level decreased in the intervention group, but increased in the control group (P = 0.04). There were no significant differences in changes in other cytokines. This study had a small number of participants and short observation period, and some participants concurrently used hypnotics. CBT may be effective for improving the quality of sleep and decreasing fatigue and inflammatory cytokine levels. CBT can be an effective nonpharmacological therapy for PD patients with sleep disturbances.

Index to Estimate the Efficiency of an Ophthalmic Practice.

PubMed

Chen, Andrew; Kim, Eun Ah; Aigner, Dennis J; Afifi, Abdelmonem; Caprioli, Joseph

2015-08-01

A metric of efficiency, a function of the ratio of quality to cost per patient, will allow the health care system to better measure the impact of specific reforms and compare the effectiveness of each. To develop and evaluate an efficiency index that estimates the performance of an ophthalmologist's practice as a function of cost, number of patients receiving care, and quality of care. Retrospective review of 36 ophthalmology subspecialty practices from October 2011 to September 2012 at a university-based eye institute. The efficiency index (E) was defined as a function of adjusted number of patients (N(a)), total practice adjusted costs (C(a)), and a preliminary measure of quality (Q). Constant b limits E between 0 and 1. Constant y modifies the influence of Q on E. Relative value units and geographic cost indices determined by the Centers for Medicare and Medicaid for 2012 were used to calculate adjusted costs. The efficiency index is expressed as the following: E = b(N(a)/C(a))Q(y). Independent, masked auditors reviewed 20 random patient medical records for each practice and filled out 3 questionnaires to obtain a process-based quality measure. The adjusted number of patients, adjusted costs, quality, and efficiency index were calculated for 36 ophthalmology subspecialties. The median adjusted number of patients was 5516 (interquartile range, 3450-11,863), the median adjusted cost was 1.34 (interquartile range, 0.99-1.96), the median quality was 0.89 (interquartile range, 0.79-0.91), and the median value of the efficiency index was 0.26 (interquartile range, 0.08-0.42). The described efficiency index is a metric that provides a broad overview of performance for a variety of ophthalmology specialties as estimated by resources used and a preliminary measure of quality of care provided. The results of the efficiency index could be used in future investigations to determine its sensitivity to detect the impact of interventions on a practice such as training modules or practice restructuring.

Measurement precision in a series of visual fields acquired by the standard and fast versions of the Swedish interactive thresholding algorithm: analysis of large-scale data from clinics.

PubMed

Saunders, Luke J; Russell, Richard A; Crabb, David P

2015-01-01

Swedish Interactive Thresholding Algorithm (SITA) testing strategies for the Humphrey Field Analyzer have become a clinical standard. Measurements from SITA Fast are thought to be more variable than SITA Standard, yet some clinics routinely use SITA Fast because it is quicker. To examine the measurement precision of the 2 SITA strategies across a range of sensitivities using a large number of visual field (VF) series from 4 glaucoma clinics in England. Retrospective cohort study at Moorfields Eye Hospital in London, England; Gloucestershire Eye Unit at Cheltenham General Hospital; Queen Alexandra Hospital in Portsmouth, England; and the Calderdale and Huddersfield National Health Service Foundation Trust that included 66,974 Humphrey 24-2 SITA Standard VFs (10,124 eyes) and 19,819 Humphrey 24-2 SITA Fast VFs (3654 eyes) recorded between May 20, 1997, and September 20, 2012. Pointwise ordinary least squares linear regression of measured sensitivity over time was conducted using VF series of 1 random eye from each patient. Residuals from the regression were pooled according to fitted sensitivities. For each sensitivity (decibel) level, the standard deviation of the residuals was used to estimate measurement precision and were compared for SITA Standard and SITA Fast. Simulations of progression from different VF baselines were used to evaluate how different levels of precision would affect time to detect VF progression. Median years required to detect progression. Median (interquartile range) patient age, follow-up, and series lengths for SITA Standard were 64 (53-72) years, 6.0 (4.0-8.5) years, and 6 (4-8) VFs, respectively; for SITA Fast, medians (interquartile range) were 70 (61-78) years, 5.1 (3.2-7.3) years, and 5 (4-6) VFs. Measurement precision worsened as sensitivity decreased for both test strategies. In the 20 to 5 dB range, SITA Fast was less precise than SITA Standard; this difference was largest between 15 to 10 dB, where variability in both methods peaked. Translated to median time to detection, differences in measurement precision were negligible, suggesting minimal effects on time to detect progression. Although SITA Standard is a more precise testing algorithm than SITA Fast at lower VF sensitivities, it is unlikely to make a sizeable difference to improving the time to detect VF progression.

Changing paradigms in the management of 2184 patients with traumatic brain injury.

PubMed

Joseph, Bellal; Haider, Ansab A; Pandit, Viraj; Tang, Andrew; Kulvatunyou, Narong; OʼKeeffe, Terence; Rhee, Peter

2015-09-01

The aim of this study was to assess the change in trends in the management of traumatic brain injury (TBI) at a level I trauma center and the utilization of resources as a result of this change in management. The management of TBI has been evolving with trends toward management of minimally injured patients with intracranial hemorrhage exclusively by trauma surgeons. A 5-year (2009-2014) prospective database on all patients with TBI (skull fracture/intracranial hemorrhage on head computed tomography) presenting to a level I trauma center was analyzed for patient demographics, injuries, admission physiology, computed tomographic scan results, and hospital outcomes. These records were matched to the institutional registry and hospital financial database. A total of 2184 patients were included with median (interquartile range) Glasgow Coma Scale score of 15 (12-15), and median (interquartile range) head-abbreviated injury scale score of 3 (2-4). The distribution of types and size of intracranial bleeds remained unchanged throughout the study period. The proportion of TBI managed exclusively by trauma surgeons increased significantly over the years from 6.8% to 40.1% (P < 0.001). Proportion of patients who received neurosurgical consultations (P < 0.001) and repeat head computed tomographic scans (P < 0.001), hospital length of stay (P = 0.028), and costs (P < 0.001) decreased significantly over time. The overall mortality rate (18.5%) and rate of intervention (14.1%) remained unchanged. TBI patients can be selectively managed without initially involving neurosurgeons safely in a cost-effective manner, resulting in more effective use of precious resources.

Acute care costs of patients admitted for management of chronic obstructive pulmonary disease exacerbations: contribution of disease severity, infection and chronic heart failure.

PubMed

Hutchinson, A; Brand, C; Irving, L; Roberts, C; Thompson, P; Campbell, D

2010-05-01

In 2003, chronic obstructive pulmonary disease (COPD) accounted for 46% of the burden of chronic respiratory disease in the Australian community. In the 65-74-year-old age group, COPD was the sixth leading cause of disability for men and the seventh for women. To measure the influence of disease severity, COPD phenotype and comorbidities on acute health service utilization and direct acute care costs in patients admitted with COPD. Prospective cohort study of 80 patients admitted to the Royal Melbourne Hospital in 2001-2002 for an exacerbation of COPD. Patients were followed for 12 months and data were collected on acute care utilization. Direct hospital costs were derived using Transition II, an activity-based costing system. Individual patient costs were then modelled to ascertain which patient factors influenced total direct hospital costs. Direct costs were calculated for 225 episodes of care, the median cost per admission was AU$3124 (interquartile range $1393 to $5045). The median direct cost of acute care management per patient per year was AU$7273 (interquartile range $3957 to $14 448). In a multivariate analysis using linear regression modelling, factors predictive of higher annual costs were increasing age (P= 0.041), use of domiciliary oxygen (P= 0.008) and the presence of chronic heart failure (P= 0.006). This model has identified a number of patient factors that predict higher acute care costs and awareness of these can be used for service planning to meet the needs of patients admitted with COPD.

Maternal Folate Intake during Pregnancy and Childhood Asthma in a Population-based Cohort.

PubMed

Parr, Christine L; Magnus, Maria C; Karlstad, Øystein; Haugen, Margaretha; Refsum, Helga; Ueland, Per M; McCann, Adrian; Nafstad, Per; Håberg, Siri E; Nystad, Wenche; London, Stephanie J

2017-01-15

A potential adverse effect of high folate intake during pregnancy on children's asthma development remains controversial. To prospectively investigate folate intake from both food and supplements during pregnancy and asthma at age 7 years when the diagnosis is more reliable than at preschool age. This study included eligible children born 2002-2006 from the Norwegian Mother and Child Cohort Study, a population-based pregnancy cohort, linked to the Norwegian Prescription Database. Current asthma at age 7 was defined by asthma medications dispensed at least twice in the year (1,901 cases; n = 39,846) or by maternal questionnaire report (1,624 cases; n = 28,872). Maternal folate intake was assessed with a food frequency questionnaire validated against plasma folate. We used log-binomial and multinomial regression to calculate adjusted relative risks with 95% confidence intervals. Risk of asthma was increased in the highest versus lowest quintile of total folate intake with an adjusted relative risk of 1.23 (95% confidence interval, 1.06-1.44) that was similar for maternally reported asthma. Mothers in the highest quintile had a relatively high intake of food folate (median, 308; interquartile range, 241-366 μg/d) and nearly all took at least 400 μg/d of supplemental folic acid (median, 500; interquartile range, 400-600 μg/d). In this large prospective population-based cohort with essentially complete follow-up, pregnant women taking supplemental folic acid at or above the recommended dose, combined with a diet rich in folate, reach a total folate intake level associated with a slightly increased risk of asthma in children.

A comparison of image interpretation times in full field digital mammography and digital breast tomosynthesis

NASA Astrophysics Data System (ADS)

Astley, Susan; Connor, Sophie; Lim, Yit; Tate, Catriona; Entwistle, Helen; Morris, Julie; Whiteside, Sigrid; Sergeant, Jamie; Wilson, Mary; Beetles, Ursula; Boggis, Caroline; Gilbert, Fiona

2013-03-01

Digital Breast Tomosynthesis (DBT) provides three-dimensional images of the breast that enable radiologists to discern whether densities are due to overlapping structures or lesions. To aid assessment of the cost-effectiveness of DBT for screening, we have compared the time taken to interpret DBT images and the corresponding two-dimensional Full Field Digital Mammography (FFDM) images. Four Consultant Radiologists experienced in reading FFDM images (4 years 8 months to 8 years) with training in DBT interpretation but more limited experience (137-407 cases in the past 6 months) were timed reading between 24 and 32 two view FFDM and DBT cases. The images were of women recalled from screening for further assessment and women under surveillance because of a family history of breast cancer. FFDM images were read before DBT, according to local practice. The median time for readers to interpret FFDM images was 17.0 seconds, with an interquartile range of 12.3-23.6 seconds. For DBT, the median time was 66.0 seconds, and the interquartile range was 51.1-80.5 seconds. The difference was statistically significant (p<0.001). Reading times were significantly longer in family history clinics (p<0.01). Although it took approximately four times as long to interpret DBT than FFDM images, the cases were more complex than would be expected for routine screening, and with higher mammographic density. The readers were relatively inexperienced in DBT interpretation and may increase their speed over time. The difference in times between clinics may be due to increased throughput at assessment, or decreased density.

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis.

PubMed

Li, Debbie; Baxter, Nancy N; McLeod, Robin S; Moineddin, Rahim; Wilton, Andrew S; Nathens, Avery B

2014-12-01

There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis. The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes. This is a population-based retrospective cohort study using administrative discharge data. This study was conducted in Ontario, Canada. All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012). Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics. There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001). There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data. There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

COPD characteristics and socioeconomic burden in Hellenic correctional institutions

PubMed Central

Bania, Eleni G; Daniil, Zoe; Hatzoglou, Chrysa; Alexopoulos, Evangelos C; Mitsiki, Eirini; Gourgoulianis, Konstantinos I

2016-01-01

Background The high prevalence of smoking (80%) in Greek correctional institutions is anticipated to result in high prevalence of COPD in such settings. Aim The aim of the Greek obstructive luNg disease epidemiOlogy and health economics Study In corrective institutionS (GNOSIS) is to determine the prevalence of smoking and COPD among inmates and to assess the health-related quality of life. Methods GNOSIS, a cross-sectional epidemiological study, was conducted between March 2011 and December 2011 in seven correctional institutions in Greece. Results A total of 552 participants, 91.3% male, median age of 43.0 years (interquartile range: 35–53), were enrolled. COPD prevalence was 6.0% and was found to increase with age (18.6% among those ≥60 years), length of prison stay, and length of sentence. Of the participants diagnosed with COPD, 36.4% were diagnosed with Global initiative for chronic Obstructive Lung Disease (GOLD) stage I and 51.5% were diagnosed with stage II. Dyspnea severity was assessed as grades 0–1 on the medical research council dyspnea scale for 88.3%, while 31% reported ≥2 COPD exacerbations in the past year. Seventy-nine percent of the total number of the participants were smokers, with a median smoking of 20.0 cigarettes per day, while 42.9% were assessed as having a strong addiction to nicotine. The median EuroQol visual analog scale score was 70.0 (interquartile range: 60.0–90.0). Problems in the dimension of anxiety/depression were reported by 82.8%. Conclusion The results of the study support the notion that the prevalence of COPD among inmates of Greek correctional institutions may increase in the following years. The findings underscore the importance of taking actions to limit COPD prevalence and its risk factors in the Greek correctional system. PMID:26929618

Pulmonary rehabilitation in lymphangioleiomyomatosis: a controlled clinical trial.

PubMed

Araujo, Mariana S; Baldi, Bruno G; Freitas, Carolina S G; Albuquerque, André L P; Marques da Silva, Cibele C B; Kairalla, Ronaldo A; Carvalho, Celso R F; Carvalho, Carlos R R

2016-05-01

Lymphangioleiomyomatosis (LAM) is a cystic lung disease frequently associated with reduced exercise capacity. The aim of this study was to assess safety and efficacy of pulmonary rehabilitation in LAM.This controlled clinical trial included 40 patients with LAM and a low physical activity level. The pulmonary rehabilitation programme comprised 24 aerobic and muscle strength training sessions and education. The primary outcome was exercise capacity (endurance time during a constant work rate exercise test). Secondary outcomes included health-related quality of life (St George's Respiratory Questionnaire (SGRQ)), 6-min walking distance (6MWD), dyspnoea, peak oxygen consumption (V'O2 ), daily physical activity (pedometer), symptoms of anxiety and depression, lung function and peripheral muscle strength (one-repetition maximum).The baseline characteristics were well balanced between the groups. The pulmonary rehabilitation group exhibited improvements in the following outcomes versus controls: endurance time (median (interquartile range) 169 (2-303) s versus -33 (-129-39) s; p=0.001), SGRQ (median (interquartile range) -8 (-16-2) versus 2 (-4-5); p=0.002) and 6MWD (median (interquartile range) 59 (13-81) m versus 20 (-12-30) m; p=0.002). Dyspnoea, peak V'O2 , daily physical activity and muscle strength also improved significantly. No serious adverse events were observed.Pulmonary rehabilitation is a safe intervention and improves exercise capacity, dyspnoea, daily physical activity, quality of life and muscle strength in LAM. Copyright ©ERS 2016.

Location and size of flux ropes in Titan's ionosphere

NASA Astrophysics Data System (ADS)

Martin, C.; Arridge, C. S.; Badman, S. V.; Dieval, C.

2017-12-01

Cassini magnetometer data was surveyed during Titan flybys to find 73 instances of flux rope signatures. A force free flux rope model was utilised to obtain the radii, maximum magnetic field and flux content of flux ropes that adhere to the force-free assumptions. We find that flux ropes at Titan are similar in size in km and flux content to the giant flux ropes identified at Venus, with a median radii of 280 km and an inter-quartile range of 270 km, a median maximum magnetic field of 8 nT with an inter-quartile range of 7 nT and a median flux content of 76 Wb with a large inter-quartile range of 250 Wb. We additionally investigate the occurrence of flux ropes with respect to the Sun-lit facing hemisphere (zenith angle) and the ram-side of Titan within Saturn's corotating magnetosphere (angle of attack of the incoming plasma flow). We find that flux ropes are more commonly detected in Sun-lit areas of Titan's ionosphere, as well as the ram-side of Titan. We see a statistically-significant absence of flux ropes in all SLT sectors in the night side of Titan and the anti-ram side of Titan. We also comment on the physical mechanisms associated with the production of these flux ropes, with particular attention on the variability of Titan's environment in Saturn's magnetosphere.

Factors Associated With Mortality in Low-Risk Pediatric Critical Care Patients in The Netherlands.

PubMed

Verlaat, Carin W; Visser, Idse H; Wubben, Nina; Hazelzet, Jan A; Lemson, Joris; van Waardenburg, Dick; van der Heide, Douwe; van Dam, Nicolette A; Jansen, Nicolaas J; van Heerde, Mark; van der Starre, Cynthia; van Asperen, Roelie; Kneyber, Martin; van Woensel, Job B; van den Boogaard, Mark; van der Hoeven, Johannes

2017-04-01

To determine differences between survivors and nonsurvivors and factors associated with mortality in pediatric intensive care patients with low risk of mortality. Retrospective cohort study. Patients were selected from a national database including all admissions to the PICUs in The Netherlands between 2006 and 2012. Patients less than 18 years old admitted to the PICU with a predicted mortality risk lower than 1% according to either the recalibrated Pediatric Risk of Mortality or the Pediatric Index of Mortality 2 were included. None. In total, 16,874 low-risk admissions were included of which 86 patients (0.5%) died. Nonsurvivors had more unplanned admissions (74.4% vs 38.5%; p < 0.001), had more complex chronic conditions (76.7% vs 58.8%; p = 0.001), were more often mechanically ventilated (88.1% vs 34.9%; p < 0.001), and had a longer length of stay (median, 11 [interquartile range, 5-32] d vs median, 3 [interquartile range, 2-5] d; p < 0.001) when compared with survivors. Factors significantly associated with mortality were complex chronic conditions (odds ratio, 3.29; 95% CI, 1.97-5.50), unplanned admissions (odds ratio, 5.78; 95% CI, 3.40-9.81), and admissions in spring/summer (odds ratio, 1.67; 95% CI, 1.08-2.58). Nonsurvivors in the PICU with a low predicted mortality risk have recognizable risk factors including complex chronic condition and unplanned admissions.

A comparison of GlideScope(®) videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children.

PubMed

Kim, Hyun-Jung; Kim, Jin-Tae; Kim, Hee-Soo; Kim, Chong-Sung; Kim, Seong-Deok

2011-04-01

The relative effectiveness of GlideScope(®) videolaryngoscopy (GV) for nasotracheal intubation in pediatric patients is unclear. The purpose of this study is to evaluate the usefulness of GV for nasotracheal intubation compared with direct laryngoscopy (DL) in pediatric patients. Our patient cohort consisted of 80 children <10 years of age who required nasotracheal intubation for elective dental or facial surgery. The patients were randomly allocated to GV (n = 40) or DL (n = 40) group. The time to intubation (TTI), glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation were evaluated. The median TTI was similar between the groups. The TTI of the former 20 patients was faster in the DL group (53.3 s, interquartile range: 42.0-64.3) than GV group (65.9 s, interquartile range: 56.0-93.9) (P = 0.007), whereas the TTI of the latter 20 patients was comparable between the groups. There were no significant differences in glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation between the two groups. GV can provide similar intubation performance characteristics compared with DL when used for nasotracheal intubation in pediatric patients. However, experience is needed to be skillful in the GV to acquire comparable TTI with DL. © 2011 Blackwell Publishing Ltd.

The use of theatre time for paediatric dentistry under general anaesthesia.

PubMed

Foley, Jennifer; Soldani, Francesca

2007-01-01

The aim of this paper was to determine the use of theatre time for all procedures performed under general anaesthetic on a paediatric dental list. A prospective study of paediatric dental general anaesthetic procedures was undertaken at Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK. Data were collected prospectively for 71 operating lists over a 3-year period from April 2003 to March 2006. Both operator status and the procedure being undertaken were recorded. In addition, pre-anaesthetic, anaesthetic, operating and disconnection times were recorded. Of the 71 lists examined, 61 either finished early or on time, with a median unused time of 32.50 min (interquartile range = 19.50, 50.00 min), whilst 10 lists finished late with a median overrun time of 30.50 min (interquartile range = 9.25, 45.50 min). Comparing lists which finished late with those which were completed within time, the median pre-anaesthetic time was significantly longer (Mann-Whitney U-test, W = 20.05, P = 0.048). Overall, the theatre was in use for 78.22% of time combining pre-anaesthetic, anaesthetic, operating and disconnection times; hence, there was poor time utilization of theatre for 21.78% of the total theatre time. Overall, 85.9% of theatre sessions for dental procedures under general anaesthetic in children finished early or on time. Where lists finished late, the duration of the pre-anaesthetic time appeared to be the significant factor.

Perceived doctor-patient relationship and satisfaction with general practitioner care in older persons in residential homes.

PubMed

de Waard, Claudia S; Poot, Antonius J; den Elzen, Wendy P J; Wind, Annet W; Caljouw, Monique A A; Gussekloo, Jacobijn

2018-06-01

Understanding patient satisfaction from the perspective of older adults is important to improve quality of their care. Since patient and care variables which can be influenced are of specific interest, this study examines the relation between patient satisfaction and the perceived doctor-patient relationship in older persons and their general practitioners (GPs). Cross-sectional survey. Older persons (n = 653, median age 87 years; 69.4% female) living in 41 residential homes. Patient satisfaction (report mark) and perceived doctor-patient relationship (Leiden Perioperative care Patient Satisfaction questionnaire); relationships were examined by comparing medians and use of regression models. The median satisfaction score was 8 (interquartile range 7.5-9; range 0-10) and doctor-patient relationship 65 (interquartile range 63-65; range 13-65). Higher satisfaction scores were related to higher scores on doctor-patient relationship (Jonckheere Terpstra test, p for trend <.001) independent of gender, age, duration of stay in the residential home, functional and clinical characteristics. Adjusted for these characteristics, per additional point for doctor-patient relationship, satisfaction increased with 0.103 points (β = 0.103, 95% CI 0.092-0.114; p < .001). In those with a 'low' doctor-patient relationship rating, the percentage awarding 'sufficient or good' to their GP for 'understanding about the personal situation' was 12%, 'receiving attention as an individual' 22%, treating the patient kindly 78%, and being polite 94%. In older persons, perceived doctor-patient relationship and patient satisfaction are related, irrespective of patient characteristics. GPs may improve patient satisfaction by focusing more on the affective aspects of the doctor-patient relationship. Key Points Examination of the perceived doctor-patient relationship as a variable might better accommodate patients' expectations and improve satisfaction with the provided primary care.

Nutritional Status of Breast Cancer Survivors 1 Year after Diagnosis: A Preliminary Analysis from the Malaysian Breast Cancer Survivorship Cohort Study.

PubMed

Majid, Hazreen Abd; Keow, Low Phei; Islam, Tania; Su, Tin Tin; Cantwell, Marie; Taib, Nur Aishah

2018-04-01

Lifestyle factors, such as diet, body weight, and physical activity, are linked to better survival after breast cancer (BC) diagnosis. A high percentage of the Malaysian population is overweight or obese. In addition, studies have shown a disparity in survival among Malaysian women compared with other higher-income countries. The Malaysian Breast Cancer Survivorship Cohort (MyBCC) study aims to study lifestyle factors that affect survival in BC survivors. These are the preliminary findings on the nutritional status of Malaysian BC survivors. Our aim was to evaluate the nutritional status of BC survivors at 1 year after diagnosis. This was a cross-sectional study of 194 participants from the MyBCC study, recruited within 1 year of their diagnosis. Participants completed a 3-day food diary. Malaysian women (aged 18 years and older) who were newly diagnosed with primary BC, managed at the University Malaya Medical Center, and able to converse either in Malay, English, or Mandarin were included. Dietary intake and prevalence of overweight or obesity among participants 1 year after diagnosis were measured. Student's t test and analysis of variance or its equivalent nonparametric test were used for association in continuous variables. About 66% (n=129) of participants were overweight or obese and >45% (n=86) had high body fat percentage 1 year after diagnosis. The participants' diets were low in fiber (median=8.7 g/day; interquartile range=7.2 g/day) and calcium (median=458 mg/day; interquartile range=252 mg/day). Ethnicity and educational attainment contributed to the differences in dietary intake among participants. Higher saturated fat and lower fiber intake were observed among Malay participants compared with other ethnic groups. Overweight and obesity were highly prevalent among BC survivors and suboptimal dietary intake was observed. Provision of an individualized medical nutrition therapy by a qualified dietitian is crucial as part of comprehensive BC survivorship care. Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.

Risk of contralateral avascular necrosis (AVN) after total hip arthroplasty (THA) for non-traumatic AVN.

PubMed

Goker, Berna; Block, Joel A

2006-01-01

The risk of developing bilateral disease progressing to total hip arthroplasty (THA) among patients who undergo unilateral THA for non-traumatic avascular necrosis (AVN) remains poorly understood. An analysis of the time-course to contralateral THA, as well as the effects of underlying AVN risk factors, is presented. Forty-seven consecutive patients who underwent THA for AVN were evaluated. Peri-operative and annual post-operative antero-posterior pelvis radiographs were examined for evidence of contralateral involvement. Patient age, weight, height, underlying AVN risk factor(s), date of onset of contralateral hip pain if occurred, and date of contralateral THA if performed, were recorded. Bone scan, computerized tomography and magnetic resonance imaging data were utilized when available. Twenty-one patients (46.6%) underwent contralateral THA for AVN within a median of 9 months after the initial THA (range 0-93, interquartile range 28.5 months). The median follow-up for patients without contralateral THA was 75 months (range 3-109, interquartile range 69 months). Thirty-four patients had radiographic findings of contralateral AVN at study entry; 25 were symptomatic bilaterally at entry and 7 developed contralateral symptoms within a mean time of 12 months (median 10 months, interquartile range 12 months). None of the 13 patients who were free of radiographic evidence of contralateral AVN at study entry developed evidence of AVN during the follow-up. AVN associated with glucocorticoid use was more likely to manifest as bilateral disease than either idiopathic AVN or ethanol-associated AVN (P=0.02 and P=0.03 respectively). Radiographically-evident AVN in the contralateral hip at THA is unlikely to remain asymptomatic for a prolonged period of time. Conversely, asymptomatic contralateral hips without radiographic evidence of AVN are unlikely to develop clinically significant AVN.

Financial Ties Between Emergency Physicians and Industry: Insights From Open Payments Data.

PubMed

Fleischman, William; Ross, Joseph S; Melnick, Edward R; Newman, David H; Venkatesh, Arjun K

2016-08-01

The Open Payments program requires reporting of payments by medical product companies to teaching hospitals and licensed physicians. We seek to describe nonresearch, nonroyalty payments made to emergency physicians in the United States. We performed a descriptive analysis of the most recent Open Payments data released to the public by the Centers for Medicare & Medicaid Services covering the 2014 calendar year. We calculated the median payment, the total pay per physician, the types of payments, and the drugs and devices associated with payments to emergency physicians. For context, we also calculated total pay per physician and the percentage of active physicians receiving payments for all specialties. There were 46,405 payments totaling $10,693,310 to 12,883 emergency physicians, representing 30% of active emergency physicians in 2013. The percentage of active physicians within a specialty who received a payment ranged from 14.6% in preventive medicine to 91% in orthopedic surgery. The median payment and median total pay to emergency physicians were $16 (interquartile range $12 to $68) and $44 (interquartile range $16 to $123), respectively. The majority of payments (83%) were less than $100. Food and beverage (86%) was the most frequent type of payment. The most common products associated with payments to emergency physicians were rivaroxaban, apixaban, ticagrelor, ceftaroline, canagliflozin, dabigatran, and alteplase. Nearly a third of emergency physicians received nonresearch, nonroyalty payments from industry in 2014. Most payments were of small monetary value and for activities related to the marketing of antithrombotic drugs. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Air Pollution and Hospitalization for Acute Myocardial Infarction in China.

PubMed

Liu, Hui; Tian, Yaohua; Xiang, Xiao; Sun, Kexin; Juan, Juan; Song, Jing; Cao, Yaying; Xu, Beibei; Hu, Yonghua

2017-09-01

There is growing interest in the association between ambient air pollution and acute myocardial infarction (AMI). The objective of this study was to explore the association in 14 Chinese cities using a time-stratified case-crossover design. We identified 80,787 hospital admissions for AMI between January 1, 2014 and December 31, 2015 from electronic hospitalization summary reports. Conditional logistic regression was used to estimate the percent changes with 95% confidence intervals (CIs) in AMI admissions in relation to an interquartile range increase in ambient air pollutant concentrations. All analyzed air pollutants, with the exception of ozone, were positively associated with daily AMI admissions on lag2 and lag3 days. An interquartile range increase in particulate matter <10 µm in aerodynamic diameter, sulfur dioxide, nitrogen dioxide, and carbon monoxide concentrations on lag2 day was significantly associated with a 0.8% (95% CI 0.1%, 1.6%), 2.0% (95% CI 1.2%, 2.9%), 2.2% (95% CI 1.4%, 3.1%), and 1.1% (95% CI 0.4%, 1.8%) increase in AMI admissions, respectively. We also observed a significant association in relation to ozone on lag4 day (percent change: 1.3%; 95% CI 0.2%, 2.4%). Subgroup analyses indicated no effect modification of risk by age (≥65 years and <65 years) or gender. In conclusion, this is the first multicity study in China, or even in other developing countries, to report the short-term effects of air pollution on AMI morbidity. Our findings contribute to the limited scientific data on the effects of ambient air pollution on AMI in developing countries. Copyright © 2017 Elsevier Inc. All rights reserved.

Prevalence of depressive disorders in the elderly.

PubMed

Barua, Ankur; Ghosh, Mihir Kumar; Kar, Nilamadhab; Basilio, Mary Anne

2011-01-01

Community-based mental health studies have revealed that the point prevalence of depressive disorders in the elderly population of the world varies between 10% and 20%, depending on cultural situations. A retrospective study based on analysis of various study reports was conducted, to determine the median prevalence rates of depressive disorders in the elderly population of India and various other countries in the world. All the studies that constituted the sample were conducted between 1955 and 2005. Included are only community-based, cross-sectional surveys and some prospective studies that had not excluded depression at baseline. These studies were conducted on a homogenous community of the elderly population in the world, who were selected by a simple random sampling technique. After applying the inclusion and exclusion criteria on published and indexed articles, 74 original research studies that surveyed a total of 487,275 elderly individuals, in the age group of 60 years and above, residing in various parts of the world, were included for the final analysis. The median prevalence rate and its corresponding interquartile range were calculated. The chi-square test and chi-square for linear trend were applied. A P value of <.05 was considered as statistically significant. The median prevalence rate of depressive disorders in the world for the elderly population was determined to be 10.3% (interquartile range [IQR], 4.7%-16.0%). The median prevalence rate of depression among the elderly Indian population was determined to be 21.9% (IQR, 11.6%-31.1%). Although there was a significant decrease in the trend of world prevalence of geriatric depression, it was significantly higher among Indians, in recent years, than the rest of the world.

Human milk IgA concentrations during the first year of lactation

PubMed Central

Weaver, L.; Arthur, H.; Bunn, J.; Thomas, J.

1998-01-01

AIMS—To measure the concentrations of total IgA in the milk secreted by both breasts, throughout the first year of lactation, in a cohort of Gambian mothers of infants at high risk of infection.
SUBJECTS AND METHODS—Sixty five women and their infants were studied monthly from the 4th to 52nd postpartum week. Samples of milk were obtained from each breast by manual expression immediately before the infant was suckled. Milk intakes were measured by test weighing the infants before and after feeds over 12 hour periods; IgA concentrations were determined by enzyme linked immunosorbent assay.
RESULTS—A total of 1590 milk samples was measured. The median (interquartile range) concentration of IgA for all samples was 0.708(0.422-1.105) g/l; that in milk obtained from the left breast was 0.785 (0.458-1.247) g/l, and that in milk obtained from the right breast was 0.645 (0.388-1.011) g/l (p < 0.0001). There was no significant change in milk or IgA intakes with advancing infant age, but there was a close concordance of IgA concentrations between the two breasts, with "tracking" of the output of the left and right breasts. There was a significant (p < 0.01) negative correlation between maternal age and parity, and weight of milk ingested by infants. During the dry season (December to May) the median (interquartile range) IgA concentration was significantly higher at 0.853 (0.571-1.254) g/l than during the rainy season (June to November), when it was 0.518 (0.311-0.909) g/l (p < 0.0001).
CONCLUSIONS—Sustained IgA secretion is likely to protect suckling infants from microbial infection.

 PMID:9613353

No Racial Difference in Rehabilitation Therapy Across All Post-Acute Care Settings in the Year Following a Stroke.

PubMed

Skolarus, Lesli E; Feng, Chunyang; Burke, James F

2017-12-01

Black stroke survivors experience greater poststroke disability than whites. Differences in post-acute rehabilitation may contribute to this disparity. Therefore, we estimated racial differences in rehabilitation therapy utilization, intensity, and the number of post-acute care settings in the first year after a stroke. We used national Medicare data to study 186 168 elderly black and white patients hospitalized with a primary diagnosis of stroke in 2011. We tabulated the proportion of stroke survivors receiving physical, occupational, and speech and language therapy in each post-acute care setting (inpatient rehabilitation facility, skilled nursing facility, and home health agency), minutes of therapy, and number of transitions between settings. We then used generalized linear models to determine whether racial differences in minutes of physical therapy were influenced by demographics, comorbidities, thrombolysis, and markers of stroke severity. Black stroke patients were more likely to receive each type of therapy than white stroke patients. Compared with white stroke patients, black stroke patients received more minutes of physical therapy (897.8 versus 743.4; P <0.01), occupational therapy (752.7 versus 648.9; P <0.01), and speech and language therapy (865.7 versus 658.1; P <0.01). There were no clinically significant differences in physical therapy minutes after adjustment. Blacks had more transitions (median, 3; interquartile range, 1-5) than whites (median, 2; interquartile range, 1-5; P <0.01). There are no clinically significant racial differences in rehabilitation therapy utilization or intensity after accounting for patient characteristics. It is unlikely that differences in rehabilitation utilization or intensity are important contributors to racial disparities in poststroke disability. © 2017 American Heart Association, Inc.

Impact of an endothelial progenitor cell capturing stent on coronary microvascular function: comparison with drug-eluting stents.

PubMed

Choi, Woong Gil; Kim, Soo Hyun; Yoon, Hyung Seok; Lee, Eun Joo; Kim, Dong Woon

2015-01-01

Although drug-eluting stents (DESs) effectively reduce restenosis following percutaneous coronary intervention (PCI), they also delay re-endothelialization and impair microvascular function, resulting in adverse clinical outcomes. Endothelial progenitor cell (EPC) capturing stents, by providing a functional endothelial layer on the stent, have beneficial effects on microvascular function. However, data on coronary microvascular function in patients with EPC stents versus DESs are lacking. Seventy-four patients who previously underwent PCI were enrolled in this study. Microvascular function was evaluated 6 months after PCI based on the index of microvascular resistance (IMR) and the coronary flow reserve (CFR). IMR was calculated as the ratio of the mean distal coronary pressure at maximal hyperemia to the inverse of the hyperemic mean transit time (hTmn). The CFR was calculated by dividing the hTmn by the baseline mean transit time. Twenty-one patients (age, 67.2 ± 9.6 years; male:female, 15:6) with an EPC stent and 53 patients (age, 61.5 ± 14.7 years; male:female, 40:13) with second-generation DESs were included in the study. There were no significant differences in the baseline clinical and angiographic characteristics of the two groups. Angiography performed 6 months postoperatively did not show significant differences in their CFR values. However, patients with the EPC stent had a significantly lower IMR than patients with second-generation DESs (median, 25.5 [interquartile range, 12.85 to 28.18] vs. 29.0 [interquartile range, 15.42 to 39.23]; p = 0.043). Microvascular dysfunction was significantly improved after 6 months in patients with EPC stents compared to those with DESs. The complete re-endothelialization achieved with the EPC stent may provide clinical benefits over DESs, especially in patients with microvascular dysfunction.

Anti-Müllerian hormone levels and antral follicle count in women enrolled in in vitro fertilization cycles: relationship to lifestyle factors, chronological age and reproductive history.

PubMed

Nardo, Luciano G; Christodoulou, Dimitra; Gould, Della; Roberts, Steve A; Fitzgerald, Cheryl T; Laing, Ian

2007-01-01

The aims of this prospective study were to investigate the relationship between anti-Müllerian hormone (AMH) and antral follicle count (AFC), and to determine whether these markers of ovarian reserve correlate with lifestyle factors, ethnicity, chronological age and reproductive history. Participants were 136 normo-ovulatory women undergoing infertility work-up within 3 months of their first ovarian stimulation cycle for in vitro fertilization. On day 3 of a spontaneous menstrual cycle, a blood sample for measurement of plasma AMH levels was taken and a transvaginal ultrasound scan to determine the AFC (follicles measuring 2-5 mm in diameter) was performed. Information about smoking, body mass index, alcohol consumption, ethnic origin, chronological age, age at menarche, years since menarche and gravidity were recorded using a case report form. The main outcome measures were plasma AMH concentrations and total number of small antral follicles (AFC). Median plasma levels of AMH were 2.0 ng/ml (interquartile range 1.1-3.6) and AFC was 10 (interquartile range 7-15). A positive correlation between AMH and AFC (r = 0.54, p < 0.0001) was found. AMH and AFC correlated negatively with age (r = -0.30, p < 0.001 and r = -0.27, p = 0.001 respectively) and number of years since menarche (r = -0.23, p = 0.007 and r = -0.21, p = 0.015 respectively), but not with any of the other measures. Circulating AMH levels and AFC correlated with each other and declined significantly with age. There were only weak, non-significant, correlations with lifestyle factors and reproductive history. These putative markers could be used individually or together to assess the age-related decline of ovarian function in normo-ovulatory candidates for IVF.

Primary Sinonasal Malignant Melanoma: Effect of Clinical and Histopathologic Prognostic Factors on Survival.

PubMed

Göde, Sercan; Turhal, Göksel; Tarhan, Ceyda; Yaman, Banu; Kandiloğlu, Gülşen; Öztürk, Kerem; Kaya, İsa; Midilli, Raşit; Karcı, Bülent

2017-05-05

Mucosal melanoma is a rare malignancy arising from melanocytes of the mucosal surfaces. The pattern and frequency of oncogenic mutations and histopathological biomarkers have a role on distinct tumour behaviour and survival. To assess the rate of C-KIT positivity and its effect on survival of surgically treated sinonasal malignant melanoma patients with other histopathological biomarkers and clinical features. Retrospective cross-sectional study. Seventeen sinonasal malignant melanoma patients with a mean age of 65.41 (39-86) years were included. Overall survival and disease-specific survival rates were calculated. The impact of age, gender, stage and extent of the disease, type of surgery, and adjuvant therapies were also taken into consideration. The effect of mitotic index, pigmentation, S100, HMB-45, Melan-A and C-KIT on survival were evaluated. Median tumour size was 20 mm (interquartile range=27.5 mm). Pigmentation was present in 7 (41.2%) cases. Median number of mitoses per millimetre squared was 11 (interquartile range=13). Melan A was positive in 7 (41.2%) patients, ulceration was present in 6 cases (35.3%), and necrosis was present in (47.1%) 8 cases. Six patients (35.3%) were positive for S100, 14 (82.4%) specimens stained positive for HMB-45 and C-KIT (CD117) was positive in 9 cases (52.9%). Three patients (16.7%) developed distant metastasis. Five year overall and disease free survival rates were 61.4% and 43.8%, respectively. Although C-KIT positive sinonasal malignant melanoma patients (52.9%) can be candidates for targeted tumour therapies, the studied clinical or histopathological features along with C-KIT seem to have no significant effect on survival in a small group of patients with sinonasal malignant melanoma.

Outcomes of Primary Transsphenoidal Surgery in Cushing Disease: Experience of a Tertiary Center.

PubMed

Keskin, Fatma Ela; Ozkaya, Hande Mefkure; Bolayirli, Murat; Erden, Secil; Kadioglu, Pınar; Tanriover, Necmettin; Gazioglu, Nurperi

2017-10-01

To report the initial and long-term remission rates and related factors, secondary treatments, and outcomes of a series of patients with Cushing disease (CD). We included 147 consecutive adult patients with CD who underwent primary transsphenoidal surgery (TSS) between 1998 and 2014 in this study. Eighty-two were followed up in the Cerrahpasa Medical Faculty Endocrinology and Metabolism outpatient clinic. Patients were requested to attend a long-term remission assessment; 55 could be contacted, and data for the remaining 27 patients' last visit to the outpatient clinics were reviewed for early and late remission. Six patients were excluded from the study. Magnetic resonance imaging (MRI) findings and pathologic results including mitosis, Ki-67 levels, and P53 in immunostaining of all patients were evaluated. Data of 82 patients with CD with an average age of 36 years [interquartile range: 29-47] were analyzed with a mean follow-up of 7.5 years [interquartile range: 5-10]. Overall initial remission rates were 72.3% after TSS. Among the 82 patients, 16 patients had Gamma Knife radiosurgery and 7 patients underwent adrenalectomy. After these additional treatments, the long-term remission rate was found as 69.7%. The highest remission rates were with microadenomas. Recurrence was most frequently seen in patients without tumor evidence on MRI. Patients with high Ki-67 levels had higher recurrence rates in long-term follow-up (P = 0.02). Life-long follow-up for patients with CD seems essential. Undetectable tumors on MRI before TSS and high Ki-67 immunopositivity were found as risk factors for tumor recurrence. Copyright © 2017 Elsevier Inc. All rights reserved.

Maternal Folate Intake during Pregnancy and Childhood Asthma in a Population-based Cohort

PubMed Central

Magnus, Maria C.; Karlstad, Øystein; Haugen, Margaretha; Refsum, Helga; Ueland, Per M.; McCann, Adrian; Nafstad, Per; Håberg, Siri E.; Nystad, Wenche; London, Stephanie J.

2017-01-01

Rationale: A potential adverse effect of high folate intake during pregnancy on children’s asthma development remains controversial. Objectives: To prospectively investigate folate intake from both food and supplements during pregnancy and asthma at age 7 years when the diagnosis is more reliable than at preschool age. Methods: This study included eligible children born 2002–2006 from the Norwegian Mother and Child Cohort Study, a population-based pregnancy cohort, linked to the Norwegian Prescription Database. Current asthma at age 7 was defined by asthma medications dispensed at least twice in the year (1,901 cases; n = 39,846) or by maternal questionnaire report (1,624 cases; n = 28,872). Maternal folate intake was assessed with a food frequency questionnaire validated against plasma folate. We used log-binomial and multinomial regression to calculate adjusted relative risks with 95% confidence intervals. Measurements and Main Results: Risk of asthma was increased in the highest versus lowest quintile of total folate intake with an adjusted relative risk of 1.23 (95% confidence interval, 1.06–1.44) that was similar for maternally reported asthma. Mothers in the highest quintile had a relatively high intake of food folate (median, 308; interquartile range, 241–366 μg/d) and nearly all took at least 400 μg/d of supplemental folic acid (median, 500; interquartile range, 400–600 μg/d). Conclusions: In this large prospective population-based cohort with essentially complete follow-up, pregnant women taking supplemental folic acid at or above the recommended dose, combined with a diet rich in folate, reach a total folate intake level associated with a slightly increased risk of asthma in children. PMID:27518161

Circulating proteins as predictors of incident heart failure in the elderly.

PubMed

Stenemo, Markus; Nowak, Christoph; Byberg, Liisa; Sundström, Johan; Giedraitis, Vilmantas; Lind, Lars; Ingelsson, Erik; Fall, Tove; Ärnlöv, Johan

2018-01-01

To identify novel risk markers for incident heart failure using proteomic profiling of 80 proteins previously associated with cardiovascular pathology. Proteomic profiling (proximity extension assay) was performed in two community-based prospective cohorts of elderly individuals without heart failure at baseline: the Prospective Investigation of the Vasculature in Uppsala Seniors [PIVUS, n = 901, median age 70.2 (interquartile range 70.0-70.3) years, 80 events]; and the Uppsala Longitudinal Study of Adult Men [ULSAM, n = 685, median age 77.8 (interquartile range 76.9-78.1) years, 90 events]. Twenty-nine proteins were associated with incident heart failure in the discovery cohort PIVUS after adjustment for age and sex, and correction for multiple testing. Eighteen associations replicated in ULSAM. In pooled analysis of both cohorts, higher levels of nine proteins were associated with incident heart failure after adjustment for established risk factors: growth differentiation factor 15 (GDF-15), T-cell immunoglobulin and mucin domain 1 (TIM-1), tumour necrosis factor-related apoptosis-inducing ligand receptor 2 (TRAIL-R2), spondin-1 (SPON1), matrix metalloproteinase-12 (MMP-12), follistatin (FS), urokinase-type plasminogen activator surface receptor (U-PAR), osteoprotegerin (OPG), and suppression of tumorigenicity 2 (ST2). Of these, GDF-15, U-PAR, MMP-12, TRAIL-R2, SPON1 and FS were associated with worsened echocardiographic left ventricular systolic function at baseline, while only TIM-1 was positively associated with worsened diastolic function (P < 0.02 for all). Proteomic profiling identified several novel associations between proteins involved in apoptosis, inflammation, matrix remodelling, and fibrinolysis with incident heart failure in elderly individuals. Our results encourage additional studies investigating the underlying mechanisms and the clinical utility of our findings. © 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.

Anorectal pathology amongst HIV infected patients attending the Douala General Hospital: a cross-sectional study.

PubMed

Luma, Henry Namme; Eloumou, Servais Albert Fiacre Bagnaka; Fualefeh-Morfaw, Ellis Atemlefeh; Malongue, Agnes; Temfack, Elvis; Lekpa, Fernando Kemta; Donfack-Sontsa, Olivier; Ndip, Lucy; Ditah, Ivo Che

2017-03-01

While gastrointestinal disease is common among HIV infected individuals, the prevalence and distribution of ano-rectal pathology has not been well studied in our setting. The objective of this study therefore was to determine the prevalence and determinants of ano-rectal pathology in HIV infected patients attending the Douala General Hospital HIV treatment centre. A hospital-based cross-sectional study was undertaken. We collected socio-demographic, clinical and laboratory data using a structured questionnaire and patients' files. Each study participant had a full physical and ano-rectal examination. We further studied factors associated with having at least one ano-rectal lesion by logistic regression reporting odds ratios (ORs) and their 95% confidence intervals (CI). We included 390 HIV infected patients. The mean age was 41 (SD: 8) years and 48% were men. Median duration since HIV diagnosis was 3 (interquartile range: 2-5) years and median CD4 cell count was 411 (interquartile range: 234-601) cells/mm 3 . Prevalence of ano-rectal pathology was 22.8% (95% CI: 18.7-27.3). Hemorrhoids and proctitis were most common lesions found; each in 10% of patients. From multivariate logistic regression, factors associated with ano-rectal pathology were CD4 < 350 cells/ml (OR: 2.1, 95% CI: 1.1-4.2), not on highly active antiretroviral therapy (OR: 2.2, 95% CI: 1.1-4.6), inpatient (OR: 2.3, 95% CI: 1.2-4.3), ano-rectal intercourse (OR: 5.0, 95% CI: 1.7-15.1), and more than one sexual partner (OR: 2.4, 95% CI: 1.3-4.2). Ano-rectal pathology is common amongst HIV infected patients. Care givers should actively investigate and treat them as this will improve the quality of life of people living with HIV/AIDS.

Airway Hypersensitivity, Reflux, and Phonation Contribute to Chronic Cough

PubMed Central

Francis, David O.; Slaughter, James C.; Ates, Fehmi; Higginbotham, Tina; Stevens, Kristin L.; Garrett, C. Gaelyn; Vaezi, Michael F.

2015-01-01

Background & Aims Although chronic cough is a common, its etiology is often elusive, making patient management a challenge. Gastroesophageal reflux and airway hypersensitivity can cause chronic cough. We explored the relationship between reflux, phonation, and cough in patients with idiopathic chronic cough. Methods We performed a blinded, cross-sectional study of non-smoking patients with chronic cough (duration > 8 weeks) refractory to reflux treatment referred to the Digestive Disease Center at Vanderbilt University. All underwent 24-hour acoustic recording concurrently and temporally synchronized with ambulatory pH-impedance monitoring. Cough, phonation, and pH-impedance events were recorded. We evaluated the temporal relationship between cough and phonation or reflux events using Poisson and logistic regression. Results Seventeen patients met the inclusion criteria (88% female; 100% Caucasian; median age, 63 years and interquartile age range, 52–66 years; mean body mass index, 30.6 and interquartile range 27.9–34.0); there were 2048 analyzable coughing events. The probability of subsequent coughing increased with higher burdens of preceding cough, reflux, or phonation. Within the first 15 min after a cough event, the cough event itself was the main trigger of subsequent cough events. After this period, de novo coughing occurred with increases of 1.46-fold in association with reflux alone (95% confidence interval, 1.17–1.82; P<.001) and 1.71-fold in association with the combination of phonation and reflux events. Conclusion Antecedent phonation and reflux increased the rate of cough events in patients with idiopathic chronic cough. Reflux events were more strongly associated with increased rate of coughing. Our findings support the concept that airway hypersensitivity is a cause of chronic cough, and that the vocal folds may be an effector in chronic cough. ClinicalTrials.gov number, NCT01263626. PMID:26492842

Hand disinfection in a neonatal intensive care unit: continuous electronic monitoring over a one-year period.

PubMed

Helder, Onno K; van Goudoever, Johannes B; Hop, Wim C J; Brug, Johannes; Kornelisse, René F

2012-10-08

Good hand hygiene compliance is essential to prevent nosocomial infections in healthcare settings. Direct observation of hand hygiene compliance is the gold standard but is time consuming. An electronic dispenser with built-in wireless recording equipment allows continuous monitoring of its usage. The purpose of this study was to monitor the use of alcohol-based hand rub dispensers with a built-in electronic counter in a neonatal intensive care unit (NICU) setting and to determine compliance with hand hygiene protocols by direct observation. A one-year observational study was conducted at a 27 bed level III NICU at a university hospital. All healthcare workers employed at the NICU participated in the study. The use of bedside dispensers was continuously monitored and compliance with hand hygiene was determined by random direct observations. A total of 258,436 hand disinfection events were recorded; i.e. a median (interquartile range) of 697 (559-840) per day. The median (interquartile range) number of hand disinfection events performed per healthcare worker during the day, evening, and night shifts was 13.5 (10.8 - 16.7), 19.8 (16.3 - 24.1), and 16.6 (14.2 - 19.3), respectively. In 65.8% of the 1,168 observations of patient contacts requiring hand hygiene, healthcare workers fully complied with the protocol. We conclude that the electronic devices provide useful information on frequency, time, and location of its use, and also reveal trends in hand disinfection events over time. Direct observations offer essential data on compliance with the hand hygiene protocol. In future research, data generated by the electronic devices can be supplementary used to evaluate the effectiveness of hand hygiene promotion campaigns.

IGF-I generation test in prepubertal children with Noonan syndrome due to mutations in the PTPN11 gene.

PubMed

Bertelloni, Silvano; Baroncelli, Giampiero I; Dati, Eleonora; Ghione, Silvia; Baldinotti, Fulvia; Toschi, Benedetta; Simi, Paolo

2013-01-01

Short stature represents one of the main features of children with Noonan syndrome. The reason for impaired growth remains largely unknown. To assess GH and IGF1 secretion in children with Noonan syndrome. 12 prepubertal children with Noonan syndrome due to mutations in the PTPN11 gene [7 males, 6 females; median age, years: 8.6 (range 5.1-13.4)] were studied; 12 prepubertal children with short stature (SS) [7 males, 5 females; median age, years: 8.1 (range 4.8-13.1)] served as the control group. GH secretion after arginine stimulation test; IGF1 generation test by measurement of IGF1 levels before and after recombinant GH (rGH) administration (0.05 mg/kg/day for 4 days). Baseline and stimulated peak values of GH were not significantly different between the two groups. At +120 minutes, GH levels remained significantly higher (p = 0.0121) in comparison with baseline values in children with Noonan syndrome. Baseline IGFI levels in patients and in SS controls were not significantly different, in contrast to values after the rGH generation test [205 ng/mL (interquartiles 138.2-252.5 ng/mL) and 284.5 ng/mL (interquartiles 172-476 ng/mL), respectively; p = 0.0248]. IGF1 values were significantly related to height (baseline: r = 773, p = 0.0320; peak: r = 0.591, p = 0.0428) in children with Noonan syndrome. Blunted increase of IGF1 after the rGH generation test was present in children with Noonan syndrome due to mutations in the PTPN11 gene in comparison with SS children. This finding may be due to partial GH resistance in the former likely related to altered Ras-MAPK signaling pathway.

Effect of milk thistle on the pharmacokinetics of darunavir-ritonavir in HIV-infected patients.

PubMed

Moltó, José; Valle, Marta; Miranda, Cristina; Cedeño, Samandhy; Negredo, Eugenia; Clotet, Bonaventura

2012-06-01

The aim of this open-label, fixed-sequence study was to investigate the potential of the botanical supplement milk thistle (silymarin) to interact with the boosted protease inhibitor combination darunavir-ritonavir. Fifteen HIV-infected patients receiving antiretroviral therapy with darunavir-ritonavir (600/100 mg twice daily) for at least 4 weeks were included. Silymarin (150 mg every 8 h) was added to the antiretroviral treatment from days 1 to 14. Darunavir concentrations in plasma were determined by high-performance liquid chromatography immediately before and 1, 2, 4, 6, 8, 10, and 12 h after a morning dose of darunavir-ritonavir on day 0 and darunavir-ritonavir plus silymarin on day 14. Individual darunavir pharmacokinetic parameters were calculated by noncompartmental analysis and compared between days 0 and 14 by means of the geometric mean ratio (GMR) and its 90% confidence interval (CI). The median age was 48 years (interquartile range, 44 to 50 years), and the median body weight was 70 kg (interquartile range, 65 to 84 kg). Silymarin was well tolerated, and all participants completed the study. The GMRs for darunavir coadministered with silymarin relative to darunavir alone were 0.86 (90% CI, 0.70 to 1.05) for the area under the concentration-time curve from 0 to 12 h, 0.83 (90% CI, 0.80 to 0.98) for the maximum concentration, and 0.94 (90% CI, 0.73 to 1.19) for the concentration at the end of the dosing interval. In summary, coadministration of silymarin with darunavir-ritonavir seems to be safe in HIV-infected patients; no dose adjustment for darunavir-ritonavir seems to be necessary.

Impact of Graft Selection on Donor and Recipient Outcomes After Living Donor Liver Transplantation.

PubMed

Braun, Hillary J; Dodge, Jennifer L; Roll, Garrett R; Freise, Chris E; Ascher, Nancy L; Roberts, John P

2016-06-01

Balancing donor and recipient risks in living donor liver transplantation remains an issue of debate. This study assessed the impact of graft selection on outcomes and complications for left lobe (LL) versus right lobe (RL) donors and recipients. The medical records of donors and recipients, who underwent living donor liver transplantation at our institution between 2003 and 2015, were reviewed. For donors, we evaluated graft volume, residual liver volume per standard liver volume, length of hospital stay (LOS), complications, and readmissions. For recipients, we looked at graft and patient survival, graft function at postoperative days 7 and 14, graft volume, LOS, biliary complications, Model for End-Stage Liver Disease at transplant, and hepatitis C virus status. At 5 years posttransplant, there were no significant differences in graft survival for LL recipients (86% [95% confidence interval, 74-93]) compared with 82% (95% confidence interval, 69-89) for RL recipients (P = 0.85) or recipient survival (90% vs 84%; P = 0.44). In LL recipients, postoperative days 7 and 14 median international normalized ratio (1.5 and 1.2, respectively) and total bilirubin (4.6 and 2.7) were significantly greater compared with RL recipients (7 and 14 days international normalized ratio [1.2, P < 0.001; 1.1, P = 0.001] and total bilirubin (2.7, P = 0.001; 2.1, P = 0.05)). The LL recipients also had a significantly greater median LOS (14 vs 10, P = 0.008). Median donor LOS was significantly greater for RL donors (7 [interquartile range, 7-8] vs 7 [interquartile range, 6-7] days, P < 0.001). The RL and LL grafts provide comparable long-term outcomes in properly selected donor-recipient pairs and the appropriate use of LL grafts does not impact graft or patient survival at 5 years posttransplant.

Effective weight loss management with endoscopic gastric plication using StomaphyX device: is it achievable?

PubMed

Ong'uti, Sharon K; Ortega, Gezzer; Onwugbufor, Michael T; Ivey, Gabriel D; Fullum, Terrence M; Tran, Daniel D

2013-01-01

Despite the effectiveness of Roux-en-Y gastric bypass (RYGB) in promoting excess weight loss, 40% of the patients regain weight. Endoscopic gastric plication (EGP) using the StomaphyX device can serve as a less-invasive procedure for promoting the loss of regained weight. Our objective was to evaluate the effectiveness of the StomaphyX device in sustaining ongoing weight loss in patients who have regained weight after RYGB at the Division of Minimally Invasive and Bariatric Surgery, Howard University Hospital. We performed a retrospective chart review of patients undergoing EGP using the StomaphyX device from April 2008 to May 2010. The patient demographics and clinical information were assessed. Effective weight loss and the proportion of weight lost after EGP relative to the weight regained after achieving the lowest weight following RYGB was calculated. A total of 27 patients underwent EGP using the StomaphyX device; of these, most were women (n = 25, 93%) and black (n = 14, 52%), followed by white (n = 11, 42%), and Hispanic (n = 1, 4%). The median interval between RYGB and EGP was 6 years, with an interquartile range of 5-8 years. After the EGP procedure, the median effective weight loss was 37% (interquartile range 24-61%). Of the 27 patients, 18 had ≥6 months of follow-up after EGP. Eleven patients had achieved their lowest weight at 1-3 months, 7 at 6 months, and 3 at 12 months. Of the 18 patients, 13 (72%) experienced an increase in weight after achieving their lowest weight after EGP. The use of the StomaphyX device achieved the maximum effective weight loss during the 1-6-month period after EGP. Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Patient and health system delay among patients with pulmonary tuberculosis in Beira city, Mozambique.

PubMed

Saifodine, Abuchahama; Gudo, Paula Samo; Sidat, Mohsin; Black, James

2013-06-07

TB control is based on the rapid identification of cases and their effective treatment. However, many studies have shown that there are important delays in diagnosis and treatment of patients with TB. The purpose of this study was to assess the prevalence of and identify risk factors associated with patient delay and health system delay among newly diagnosed patients with pulmonary TB. A cross sectional study was carried out in Beira city, Mozambique between September 2009 and February 2010. Patients in the first month of treatment were consecutively selected to this study if they had a diagnosis of pulmonary TB, had no history of previous TB treatment, and were 18 years or older and provided informed consent. Data was obtained through a questionnaire administered to the patients and from patients' files. Among the 622 patients included in the study the median age was 32 years (interquartile range, 26-40) and 272 (43.7%) were females. The median total delay, patient delay and health system delay was 150 days (interquartile range, 91-240), 61 days (28-113) and 62 days (37-120), respectively. The contribution of patient delay and health system delay to total delay was similar. Farming, visiting first a traditional healer, low TB knowledge and coexistence of a chronic disease were associated with increased patient delay. More than two visits to a health facility, farming and coexistence of a chronic disease were associated with increased health system delay. This study revealed a long total delay with a similar contribution of patient delay and health system delay. To reduce the total delay in this setting we need a combination of interventions to encourage patients to seek appropriate health care earlier and to expedite TB diagnosis within the health care system.

Early Use of N-acetylcysteine With Nitrate Therapy in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction Reduces Myocardial Infarct Size (the NACIAM Trial [N-acetylcysteine in Acute Myocardial Infarction]).

PubMed

Pasupathy, Sivabaskari; Tavella, Rosanna; Grover, Suchi; Raman, Betty; Procter, Nathan E K; Du, Yang Timothy; Mahadavan, Gnanadevan; Stafford, Irene; Heresztyn, Tamila; Holmes, Andrew; Zeitz, Christopher; Arstall, Margaret; Selvanayagam, Joseph; Horowitz, John D; Beltrame, John F

2017-09-05

Contemporary ST-segment-elevation myocardial infarction management involves primary percutaneous coronary intervention, with ongoing studies focusing on infarct size reduction using ancillary therapies. N-acetylcysteine (NAC) is an antioxidant with reactive oxygen species scavenging properties that also potentiates the effects of nitroglycerin and thus represents a potentially beneficial ancillary therapy in primary percutaneous coronary intervention. The NACIAM trial (N-acetylcysteine in Acute Myocardial Infarction) examined the effects of NAC on infarct size in patients with ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention. This randomized, double-blind, placebo-controlled, multicenter study evaluated the effects of intravenous high-dose NAC (29 g over 2 days) with background low-dose nitroglycerin (7.2 mg over 2 days) on early cardiac magnetic resonance imaging-assessed infarct size. Secondary end points included cardiac magnetic resonance-determined myocardial salvage and creatine kinase kinetics. Of 112 randomized patients with ST-segment-elevation myocardial infarction, 75 (37 in NAC group, 38 in placebo group) underwent early cardiac magnetic resonance imaging. Median duration of ischemia pretreatment was 2.4 hours. With background nitroglycerin infusion administered to all patients, those randomized to NAC exhibited an absolute 5.5% reduction in cardiac magnetic resonance-assessed infarct size relative to placebo (median, 11.0%; [interquartile range 4.1, 16.3] versus 16.5%; [interquartile range 10.7, 24.2]; P =0.02). Myocardial salvage was approximately doubled in the NAC group (60%; interquartile range, 37-79) compared with placebo (27%; interquartile range, 14-42; P <0.01) and median creatine kinase areas under the curve were 22 000 and 38 000 IU·h in the NAC and placebo groups, respectively ( P =0.08). High-dose intravenous NAC administered with low-dose intravenous nitroglycerin is associated with reduced infarct size in patients with ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention. A larger study is required to assess the impact of this therapy on clinical cardiac outcomes. Australian New Zealand Clinical Trials Registry. URL: http://www.anzctr.org.au/. Unique identifier: 12610000280000. © 2017 American Heart Association, Inc.

Acute heart failure: perspectives from a randomized trial and a simultaneous registry.

PubMed

Ezekowitz, Justin A; Hu, Jia; Delgado, Diego; Hernandez, Adrian F; Kaul, Padma; Leader, Rolland; Proulx, Guy; Virani, Sean; White, Michel; Zieroth, Shelley; O'Connor, Christopher; Westerhout, Cynthia M; Armstrong, Paul W

2012-11-01

Randomized controlled trials (RCT) are limited by their generalizability to the broader nontrial population. To provide a context for Acute Study of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial, we designed a complementary registry to characterize clinical characteristics, practice patterns, and in-hospital outcomes of acute heart failure patients. Eligible patients for the registry included those with a principal diagnosis of acute heart failure (ICD-9-CM 402 and 428; ICD-10 I50.x, I11.0, I13.0, I13.2) from 8 sites participating in ASCEND-HF (n=697 patients, 2007-2010). Baseline characteristics, treatments, and hospital outcomes from the registy were compared with ASCEND-HF RCT patients from 31 Canadian sites (n=465, 2007-2010). Patients in the registry were older, more likely to be female, and have chronic respiratory disease, less likely to have diabetes mellitus: they had a similar incidence of ischemic HF, atrial fibrillation, and similar B-type natriuretic peptide levels. Registry patients had higher systolic blood pressure (registry: median 132 mm Hg [interquartile range 115-151 mm Hg]; RCT: median 120 mm Hg [interquartile range 110-135 mm Hg]) and ejection fraction (registry: median 40% [interquartile range 27-58%]; RCT: median 29% [interquartile range 20-40 mm Hg]) than RCT patients. Registry patients presented more often via ambulance and had a similar total length of stay as RCT patients. In-hospital mortality was significantly higher in the registry compared with the RCT patients (9.3% versus 1.3%,P<0.001), and this remained after multivariable adjustment (odds ratio 6.6, 95% CI 2.6-16.8, P<0.001). Patients enrolled in a large RCT of acute heart failure differed significantly based on clinical characteristics, treatments, and inpatient outcomes from contemporaneous patients participating in a registry. These results highlight the need for context of RCTs to evaluate generalizability of results and especially the need to improve clinical outcomes in acute heart failure. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00475852.

The impact of 24-hr, in-hospital pediatric critical care attending physician presence on process of care and patient outcomes*.

PubMed

Nishisaki, Akira; Pines, Jesse M; Lin, Richard; Helfaer, Mark A; Berg, Robert A; Tenhave, Thomas; Nadkarni, Vinay M

2012-07-01

Attending physicians are only required to provide in-hospital coverage during daytime hours in many pediatric intensive care units. An in-hospital 24-hr pediatric intensive care unit attending coverage model has been increasingly popular, but the impact of 24-hr, in-hospital attending coverage on care processes and outcomes has not been reported. We compared processes of care and outcomes before and after the implementation of a 24-hr in-hospital pediatric intensive care unit attending physician model. Retrospective comparison of before and after cohorts. A single large, academic tertiary medical/surgical pediatric intensive care unit. : Pediatric intensive care unit admissions in 2000-2006. Transition to 24-hr from 12-hr in-hospital pediatric critical care attending physician coverage model in January 2004. A total of 18,702 patients were admitted to intensive care unit: 8,520 in 24 hrs; 10,182 in 12 hrs. Duration of mechanical ventilation was lower (median 33 hrs [interquartile range 12-88] vs. 48 hrs [interquartile range 16-133], adjusted reduction of 35% [95% confidence interval 25%-44%], p < .001) and intensive care unit length of stay was shorter (median 2 days [interquartile range 1-4] vs. 2 days [interquartile range 1-5], adjusted p < .001) for 24 hr vs. 12 hr coverage. The reduction in mechanical ventilation hours was similar when noninvasive, mechanical ventilation was included in ventilation hours (median 42 hrs vs. 56 hrs, adjusted reduction in ventilation hours: 33% [95% confidence interval 20-45], p < .001). Intensive care unit mortality was not significantly different (2.2% vs. 2.5%, adjusted p =.23). These associations were consistent across daytime and nighttime admissions, weekend and weekday admissions, and among subgroups with higher Pediatric Risk of Mortality III scores, postsurgical patients, and histories of previous intensive care unit admission. Implementation of 24-hr in-hospital pediatric critical care attending coverage was associated with shorter duration of mechanical ventilation and shorter length of intensive care unit stay. After accounting for potential confounders, this finding was consistent across a broad spectrum of critically ill children.

Long-term functional and echocardiographic assessment after penetrating cardiac injury: 5-year follow-up results.

PubMed

Carr, John Alfred; Buterakos, Roxanne; Bowling, William M; Janson, Lisa; Kralovich, Kurt A; Copeland, Craig; Link, Renee; Roiter, Cecilia; Casey, Gregory; Wagner, James W

2011-03-01

There is almost no data describing the long-term functional outcome of patients after penetrating cardiac injury. A retrospective study at a Level I trauma center from 2000 to 2009. Sixty-three patients had penetrating cardiac injuries from 28 stabbings and 35 gunshots. Men comprised 89% (56) of the patients. Overall, there were 21 survivors (33%) and 42 died in the emergency room or perioperative period. The mean age did not significantly differ between survivors (36 years ± 12 years) compared with those who died (30 years ± 11 years; p=0.07). There was an increased chance of survival after being stabbed compared with being shot (17 patients vs. 4 patients; odds ratio=12; p=0.002). Thirteen (62%) had injuries to the right ventricle only. Three patients died during follow-up: one from lung cancer and two other patients died from myocardial infarctions, one 9 years later at the age of 45 years and the other 8 years later at the age of 55 years. The survivors had functional follow-up evaluations from 2 months to 114 months (median, 71; interquartile range, 34-92 months) and echocardiographic follow-up from 2 months to 107 months (median, 64; interquartile range, 31-84 months) after their injuries. Functionally, all patients were in NYHA class 1 status, except one patient in class II who was 54 years old and had a mild exertional limitation. The previously injured area could only be identified by echocardiogram in one patient who had a patch repair of a ventricular septal defect (VSD). The mean ejection fraction improved over time from a mean of 51% ± 8% in the immediate postoperative period to 60% ± 9% after a mean follow-up of 59 months (p=0.01). After surgery, 43% of patients had a mild to moderate pericardial effusion; however, the long-term follow-up studies showed that all these had resolved. Wall motion abnormalities occurred in 33% of patients in the immediate postoperative period and, again, all these resolved during long-term follow-up. Patients who survive penetrating cardiac injuries, without coronary arterial or valvular disruption, have an excellent long-term functional outcome with minimal subsequent cardiac morbidity related to the injury. Full physiologic recovery and normal cardiac function can be expected if the patient survives. Copyright © 2011 by Lippincott Williams & Wilkins

Splenic Artery Embolization in Blunt Trauma: A Single-Center Retrospective Comparison of the Use of Gelatin Sponge Versus Coils.

PubMed

Rasuli, Pasteur; Moosavi, Bardia; French, Gordon J; Petrcich, William; Hammond, Ian

2017-12-01

The purpose of this study was to compare the efficacy of gelatin sponge with that of coils for splenic artery embolization in the treatment of blunt splenic injury. A single-center retrospective review was performed with the records of 63 patients (45 men, 18 women; mean age, 45.5 years; range, 16-84 years) with blunt splenic injury treated at a tertiary care trauma center by splenic artery embolization with gelatin sponge (n = 30 patients) or metallic coils (n = 33 patients) between 2005 and 2014. The two groups had comparable median American Association for the Surgery of Trauma grades of IV and comparable angiographic appearances regarding active extravasation and pseudoaneurysm formation at preembolization splenic arteriography (p = 0.32). Clinical outcomes and procedure-related outcomes were evaluated. The success rates were similar in the two groups: splenic artery embolization failed in 6.6% (2/30) of patients in the gelatin sponge group and 12.1% (4/33) in the coil embolization group (p = 0.45; 95% CI, -30.1% to 19.2%). Major complications occurred in six patients (20.0%) in the gelatin sponge group and in six patients (18.1%) in the coil group (p = 0.85; 95% CI, -23.0% to 26.6%). Minor complications occurred in three patients (10.0%) in the gelatin sponge group and seven patients (21.2%) in the coil group (p = 0.21; 95% CI, -35.4% to 14.0%). Procedure time was significantly shorter in the gelatin sponge group (median, 32 minutes; interquartile range, 18-48 minutes) than in the coil group (median, 53 minutes; interquartile range, 30-76 minutes) (p = 0.01). Splenic artery embolization with gelatin sponge appears to be as effective and as safe as coil embolization and can be completed in a shorter time.

Agricultural Early Warning Informing Humanitarian Response in East Africa for 2012

NASA Astrophysics Data System (ADS)

Husak, G. J.; Funk, C. C.

2012-12-01

Long rains during the March-April-May (MAM) 2011 growing season were a failure for much of the Greater Horn of Africa. These conditions resulted in severe food shortages, with the Famine Early Warning Systems Network (FEWS NET) estimating that 12.4 million people were in need of food assistance in Kenya, Somalia, Ethiopia and Djibouti. Heading into the 2012 season, La Niña conditions, an exceptionally strong western-to-central Pacific sea surface temperature (SST) gradient, and warm SSTs in the eastern Indian Ocean foretold further dryness, compounding the difficulties faced by the already vulnerable populations of this region. In an effort to assess the potential for greater food insecurity in the region, FEWS NET scientists attempted to quantify the likelihood of a dry event. This work used satellite rainfall estimates with a 13-year rainfall history. Weights were assigned to previous years based on the similarity of existing SST conditions to those of previous years in the rainfall record. Scenarios were created by randomly combining dekadal rainfall from the historical record, in accordance with the weights. This bootstrapping resulted in a suite of simulations which could be used to identify the likelihood of specific rainfall outcomes. Areal averages of each simulation were used in the analysis. Analysis of the Global Precipitation Climatology Centre (GPCC) rainfall record, a gridded rainfall product based on available station data, showed that the mean rainfall value for the time period of the satellite data for this region was only about 80% of the 30-year mean. The bootstrapped scenarios were corrected for this bias during the period of the satellite record. Results were expressed as percent of average rather than in absolute rainfall amounts, to account for biases in the satellite products as well as variability in spatial amounts. The results showed that during a normal year the interquartile range is typically 80-120% of normal. However, using the weighted scenarios based on February SSTs, the interquartile range shifted to 75-105% of normal. As the season progressed, March turned out to be exceptionally dry, with a lack of onset of rains for much of the region. This delayed start to the season allowed for the combination of satellite estimates for the start of March to be combined with scenarios to look ahead to end-of-season values. By the end of March, combining estimated 2012 rains with the scenarios built before the season resulted in the interquartile range for expected outcomes dropping to 60-85% of normal. This information was relayed to FEWS NET food security analysts and used in a special report, highlighting the potential for crisis in the region. In April, this forecasting effort, combined with FEWS NET's extensive monitoring activities, helped motivate allocation of an additional $50M in food aid from the U.S. government. This presentation examines the climate conditions associated with MAM drought in the eastern sector of the Greater Horn, reviews the techniques behind the 2012 forecasts, and analyzes the actual outcome for the region. Methods for improving the work to more accurately reflect the variability and future directions and applications will be discussed.

Rapid Web-Based Platform for Assessment of Orthopedic Surgery Patient Care Milestones: A 2-Year Validation.

PubMed

Gundle, Kenneth R; Mickelson, Dayne T; Cherones, Arien; Black, Jason; Hanel, Doug P

To determine the validity, feasibility, and responsiveness of a new web-based platform for rapid milestone-based evaluations of orthopedic surgery residents. Single academic medical center, including a trauma center and pediatrics tertiary hospital. Forty residents (PG1-5) in an orthopedic residency program and their faculty evaluators. Residents and faculty were trained and supported in the use of a novel trainee-initiated web-based evaluation system. Residents were encouraged to use the system to track progress on patient care subcompetencies. Two years of prospectively collected data were reviewed from residents at an academic program. The primary outcome was Spearman's rank correlation between postgraduate year (PGY) and competency level achieved as a measure of validity. Secondary outcomes assessed feasibility, resident self-evaluation versus faculty evaluation, the distributions among subcompetencies, and responsiveness over time. Between February 2014 and February 2016, 856 orthopedic surgery patient care subcompetency evaluations were completed (1.2 evaluations per day). Residents promptly requested feedback after a procedure (median = 0 days, interquartile range: 0-2), and faculty responded within 2 days in 51% (median = 2 days, interquartile range: 0-13). Primary outcome showed a correlation between PGY and competency level (r = 0.78, p < 0.001), with significant differences in competency among PGYs (p < 0.001 by Kruskal-Wallis rank sum test). Self-evaluations by residents substantially agreed with faculty-assigned competency level (weighted Cohen's κ = 0.72, p < 0.001). Resident classes beginning the study as PGY1, 2, and 3 separately demonstrated gains in competency over time (Spearman's rank correlation 0.39, 0.60, 0.59, respectively, each p < 0.001). There was significant variance in the number of evaluations submitted per subcompetency (median = 43, range: 6-113) and competency level assigned (p < 0.01). Rapid tracking of trainee competency with milestone-based evaluations in a learner-centered mobile platform demonstrated validity, feasibility, and responsiveness. Next Accreditation System-mandated data may be efficiently collected and used for trainee and program self-study. Published by Elsevier Inc.

Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football.

PubMed

Mez, Jesse; Daneshvar, Daniel H; Kiernan, Patrick T; Abdolmohammadi, Bobak; Alvarez, Victor E; Huber, Bertrand R; Alosco, Michael L; Solomon, Todd M; Nowinski, Christopher J; McHale, Lisa; Cormier, Kerry A; Kubilus, Caroline A; Martin, Brett M; Murphy, Lauren; Baugh, Christine M; Montenigro, Phillip H; Chaisson, Christine E; Tripodis, Yorghos; Kowall, Neil W; Weuve, Jennifer; McClean, Michael D; Cantu, Robert C; Goldstein, Lee E; Katz, Douglas I; Stern, Robert A; Stein, Thor D; McKee, Ann C

2017-07-25

Players of American football may be at increased risk of long-term neurological conditions, particularly chronic traumatic encephalopathy (CTE). To determine the neuropathological and clinical features of deceased football players with CTE. Case series of 202 football players whose brains were donated for research. Neuropathological evaluations and retrospective telephone clinical assessments (including head trauma history) with informants were performed blinded. Online questionnaires ascertained athletic and military history. Participation in American football at any level of play. Neuropathological diagnoses of neurodegenerative diseases, including CTE, based on defined diagnostic criteria; CTE neuropathological severity (stages I to IV or dichotomized into mild [stages I and II] and severe [stages III and IV]); informant-reported athletic history and, for players who died in 2014 or later, clinical presentation, including behavior, mood, and cognitive symptoms and dementia. Among 202 deceased former football players (median age at death, 66 years [interquartile range, 47-76 years]), CTE was neuropathologically diagnosed in 177 players (87%; median age at death, 67 years [interquartile range, 52-77 years]; mean years of football participation, 15.1 [SD, 5.2]), including 0 of 2 pre-high school, 3 of 14 high school (21%), 48 of 53 college (91%), 9 of 14 semiprofessional (64%), 7 of 8 Canadian Football League (88%), and 110 of 111 National Football League (99%) players. Neuropathological severity of CTE was distributed across the highest level of play, with all 3 former high school players having mild pathology and the majority of former college (27 [56%]), semiprofessional (5 [56%]), and professional (101 [86%]) players having severe pathology. Among 27 participants with mild CTE pathology, 26 (96%) had behavioral or mood symptoms or both, 23 (85%) had cognitive symptoms, and 9 (33%) had signs of dementia. Among 84 participants with severe CTE pathology, 75 (89%) had behavioral or mood symptoms or both, 80 (95%) had cognitive symptoms, and 71 (85%) had signs of dementia. In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football.

Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study.

PubMed

Teshome, Wondu; Belayneh, Mehretu; Moges, Mathewos; Mekonnen, Emebet; Endrias, Misganu; Ayele, Sinafiksh; Misganaw, Tebeje; Shiferaw, Mekonnen; Tesema, Tigist

2015-01-01

Decentralization and task shifting has significantly improved access to antiretroviral therapy (ART). Many studies conducted to determine the attrition rate in Ethiopia have not compared attrition rates between hospitals and health centers in a relatively recent cohort of patients. This study compared death and loss to follow-up (LTFU) rates among ART patients in hospitals and health centers in south Ethiopia. Data routinely collected from patients aged older than 15 years who started ART between July 2011 and August 2012 in 20 selected health facilities (12 being hospitals) were analyzed. The outcomes of interest were LTFU and death. The data were entered, cleaned, and analyzed using Statistical Package for the Social Sciences version 20.0 and Stata version 12.0. Competing-risk regression models were used. The service years of the facilities were similar (median 8 and 7.5 for hospitals and health centers, respectively). The mean patient age was 33.7±9.6 years. The median baseline CD4 count was 179 (interquartile range 93-263) cells/mm(3). A total of 2,356 person-years of observation were made with a median follow-up duration of 28 (interquartile range 22-31) months; 24.6% were either dead or LTFU, resulting in a retention rate of 75.4%. The death rates were 3.0 and 1.5 and the LTFU rate were 9.0 and 10.9 per 100 person-years of observation in health centers and hospitals, respectively. The competing-risk regression model showed that the gap between testing and initiation of ART, body mass index, World Health Organization clinical stage, isoniazid prophylaxis, age, facility type, and educational status were independently associated with LTFU. Moreover, baseline tuberculous disease, poor functional status, and follow-up at a health center were associated with an elevated probability of death. We observed a higher death rate and a lower LTFU rate in health centers than in hospitals. Most of the associated variables were also previously documented. Higher LTFU was noticed for patients with a smaller gap between testing and initiation of treatment.

Longitudinal change of COPD assessment test (CAT) in a telehealthcare cohort is associated with exacerbation risk.

PubMed

Rassouli, Frank; Baty, Florent; Stolz, Daiana; Albrich, Werner Christian; Tamm, Michael; Widmer, Sandra; Brutsche, Martin Hugo

2017-01-01

There are only scarce data regarding the evolution of the chronic obstructive pulmonary disease (COPD) assessment test (CAT) over time. Our aim was to investigate the evolution of the CAT in a telehealthcare (THC) cohort and to evaluate its potential to predict exacerbations. The CAT was measured weekly over up to 1 year in 40 COPD patients undergoing a THC intervention. The evolution of the CAT was analyzed using linear regression. The association between this evolution and the occurrence of exacerbations was evaluated using the Andersen-Gill formulation of the Cox proportional hazards model for the analysis of recurrent time-to-event data with time-varying predictors. The median CAT at inclusion was 17 (interquartile range 13-22) points. During the study, 25% of patients had a significant negative slope (median -7 points per year [ppy]), 38% were stable (median +0 ppy) and 38% had a significant positive slope (median +6 ppy). The median slope of the CAT in the overall cohort was +1 (interquartile range -3 to +6) ppy. A significant positive association was found between the change in CAT scores and the risk of exacerbations (hazard ratio =1.08, 95% CI: 1.03-1.13; p <0.001). There was an 8% increase of the risk of exacerbation per unit increase in CAT. We detected a significant learning effect in filling out the CAT in 18.4% of patients with a median learning phase of five filled questionnaires. Sixty-three percent of the COPD patients monitored by THC experienced a stable or improved CAT during 1-year follow-up. We found a significant positive association between the evolution of the CAT over time and the risk of exacerbations. In about one-fifth of patients, there was a significant learning effect in filling out the CAT, before reliable results could be obtained. The evolution of the CAT could help to assess the risk for future exacerbations.

Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease.

PubMed

Biswas Roy, Sreeja; Elnahas, Shaimaa; Serrone, Rosemarie; Haworth, Cassandra; Olson, Michael T; Kang, Paul; Smith, Michael A; Bremner, Ross M; Huang, Jasmine L

2018-06-01

Gastroesophageal reflux disease (GERD) is prevalent after lung transplantation. Fundoplication slows lung function decline in patients with GERD, but the optimal timing of fundoplication is unknown. We retrospectively reviewed patients who underwent fundoplication after lung transplantion at our center from April 2007 to July 2014. Patients were divided into 2 groups: early fundoplication (<6 months after lung transplantation) and late fundoplication (≥6 months after lung transplantation). Annual decline in percent predicted forced expiratory volume in 1 second (FEV 1 ) was analyzed. Of the 251 patients who underwent lung transplantation during the study period with available pH data, 86 (34.3%) underwent post-transplantation fundoplication for GERD. Thirty of 86 (34.9%) had early fundoplication and 56 of 86 (65.1%) had late fundoplication. Median time from lung transplantation to fundoplication was 4.6 months (interquartile range, 2.0-5.2) and 13.8 months (interquartile range, 9.0-16.1) for the early and late groups, respectively. The median DeMeester score was comparable between groups. One-, 3-, and 5-year actuarial survival rates in the early group were 90%, 70%, and 70%, respectively; in the late group, these rates were 91%, 66%, and 66% (log rank P = .60). Three- and 5-year percent predicted FEV 1 was lower in the late group by 8.9% (95% confidence interval, -30.2 to 12.38; P = .46) and 40.7% (95% confidence interval, -73.66 to -7.69; P = .019). A linear mixed model showed a 5.7% lower percent predicted FEV 1 over time in the late fundoplication group (P < .001). In this study, patients with early fundoplication had a higher FEV 1 5 years after lung transplantation. Early fundoplication might protect against GERD-induced lung damage in lung transplant recipients with GERD. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Relationship between tongue strength, lip strength, and nutrition-related sarcopenia in older rehabilitation inpatients: a cross-sectional study

PubMed Central

Sakai, Kotomi; Nakayama, Enri; Tohara, Haruka; Kodama, Keiji; Takehisa, Takahiro; Takehisa, Yozo; Ueda, Koichiro

2017-01-01

Objective The objective of this study was to clarify the relationship between tongue strength, lip strength, and nutrition-related sarcopenia (NRS). Patients and methods A total of 201 older inpatients aged ≥65 years (70 men, median age: 84 years, interquartile range: 79–89 years) consecutively admitted for rehabilitation were included in this cross-sectional study. The main factors evaluated were the presence of NRS diagnosed by malnutrition using the Mini-Nutrition Assessment – Short Form, sarcopenia based on the criteria of the Asian Working Group for Sarcopenia, tongue strength, and lip strength. Other factors such as age, sex, comorbidity, physical function, cognitive function, and oral intake level were also assessed. Results In all, 78 (38.8%) patients were allocated to the NRS group, and 123 (61.2%) patients were allocated to the non-NRS group. The median tongue strength and lip strength (interquartile range) were significantly lower in the NRS group (tongue: 22.9 kPa [17.7–27.7 kPa] and lip: 7.2 N [5.6–9.8 N]) compared with the non-NRS group (tongue: 29.7 kPa [24.8–35.1 kPa] and lip: 9.9 N [8.4–12.3 N], P<0.001 for both). Multivariable logistic regression analysis showed that NRS was independently associated with tongue strength (odds ratio [OR] =0.93, 95% confidence interval [CI] 0.87–0.98, P=0.012) and lip strength (OR =0.76, 95% CI 0.66–0.88, P<0.001), even after adjusting for age, sex, comorbidity, physical function, cognitive function, and oral intake level. Conclusion The likelihood of occurrence of NRS decreased when tongue strength or lip strength increased. Tongue strength and lip strength may be important factors for preventing and improving NRS, regardless of the presence of low oral intake level in older rehabilitation inpatients. PMID:28814847

Active and uncontrolled asthma among children exposed to air stack emissions of sulphur dioxide from petroleum refineries in Montreal, Quebec: A cross-sectional study

PubMed Central

Deger, Leylâ; Plante, Céline; Jacques, Louis; Goudreau, Sophie; Perron, Stéphane; Hicks, John; Kosatsky, Tom; Smargiassi, Audrey

2012-01-01

BACKGROUND: Little attention has been devoted to the effects on children’s respiratory health of exposure to sulphur dioxide (SO2) in ambient air from local industrial emissions. Most studies on the effects of SO2 have assessed its impact as part of the regional ambient air pollutant mix. OBJECTIVE: To examine the association between exposure to stack emissions of SO2 from petroleum refineries located in Montreal’s (Quebec) east-end industrial complex and the prevalence of active asthma and poor asthma control among children living nearby. METHODS: The present cross-sectional study used data from a respiratory health survey of Montreal children six months to 12 years of age conducted in 2006. Of 7964 eligible households that completed the survey, 842 children between six months and 12 years of age lived in an area impacted by refinery emissions. Ambient SO2 exposure levels were estimated using dispersion modelling. Log-binomial regression models were used to estimate crude and adjusted prevalence ratios (PRs) and 95% CIs for the association between yearly school and residential SO2 exposure estimates and asthma outcomes. Adjustments were made for child’s age, sex, parental history of atopy and tobacco smoke exposure at home. RESULTS: The adjusted PR for the association between active asthma and SO2 levels was 1.14 (95% CI 0.94 to 1.39) per interquartile range increase in modelled annual SO2. The effect on poor asthma control was greater (PR=1.39 per interquartile range increase in modelled SO2 [95% CI 1.00 to 1.94]). CONCLUSIONS: Results of the present study suggest a relationship between exposure to refinery stack emissions of SO2 and the prevalence of active and poor asthma control in children who live and attend school in proximity to refineries. PMID:22536578

Predictors of Prostate Cancer-Specific Mortality in Elderly Men With Intermediate-Risk Prostate Cancer Treated With Brachytherapy With or Without External Beam Radiation Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nanda, Akash, E-mail: ananda@partners.or; Chen, M.-H.; Moran, Brian J.

2010-05-01

Purpose: To identify clinical factors associated with prostate cancer-specific mortality (PCSM), adjusting for comorbidity, in elderly men with intermediate-risk prostate cancer treated with brachytherapy alone or in conjunction with external beam radiation therapy. Methods and Materials: The study cohort comprised 1,978 men of median age 71 (interquartile range, 66-75) years with intermediate-risk disease (Gleason score 7, prostate-specific antigen (PSA) 20 ng/mL or less, tumor category T2c or less). Fine and Gray's multivariable competing risks regression was used to assess whether prevalent cardiovascular disease (CVD), age, treatment, year of brachytherapy, PSA level, or tumor category was associated with the risk ofmore » PCSM. Results: After a median follow-up of 3.2 (interquartile range, 1.7-5.4) years, the presence of CVD was significantly associated with a decreased risk of PCSM (adjusted hazard ratio, 0.20; 95% CI 0.04-0.99; p = 0.05), whereas an increasing PSA level was significantly associated with an increased risk of PCSM (adjusted hazard ratio 1.14; 95% CI 1.02-1.27; p = 0.02). In the absence of CVD, cumulative incidence estimates of PCSM were higher (p = 0.03) in men with PSA levels above as compared with the median PSA level (7.3 ng/mL) or less; however, in the setting of CVD there was no difference (p = 0.27) in these estimates stratified by the median PSA level (6.9 ng/mL). Conclusions: In elderly men with intermediate-risk prostate cancer, CVD status is a negative predictor of PCSM and affects the prognostic capacity of pretreatment PSA level. These observations support the potential utility of prerandomization stratification by comorbidity to more accurately assess prognostic factors and treatment effects within this population.« less

Post Hoc Analyses of Randomized Clinical Trial for the Effect of Clopidogrel Added to Aspirin on Kidney Function.

PubMed

Ikeme, Jesse C; Pergola, Pablo E; Scherzer, Rebecca; Shlipak, Michael G; Benavente, Oscar R; Peralta, Carmen A

2017-07-07

Despite the high burden of CKD, few specific therapies are available that can halt disease progression. In animal models, clopidogrel has emerged as a potential therapy to preserve kidney function. The effect of clopidogrel on kidney function in humans has not been established. The Secondary Prevention of Small Subcortical Strokes Study randomized participants with prior lacunar stroke to treatment with aspirin or aspirin plus clopidogrel. We compared annual eGFR decline and incidence of rapid eGFR decline (≥30% from baseline) using generalized estimating equations and interval-censored proportional hazards regression, respectively. We also stratified our analyses by baseline eGFR, systolic BP target, and time after randomization. At randomization, median age was 62 (interquartile range, 55-71) years old; 36% had a history of diabetes, 90% had hypertension, and the median eGFR was 81 (interquartile range, 65-94) ml/min per 1 m 2 . Persons receiving aspirin plus clopidogrel had an average annual change in kidney function of -1.39 (95% confidence interval, -1.15 to -1.62) ml/min per 1.73 m 2 per year compared with -1.52 (95% confidence interval, -1.30 to -1.74) ml/min per 1.73 m 2 per year among persons receiving aspirin only ( P =0.42). Rapid kidney function decline occurred in 21% of participants receiving clopidogrel plus aspirin compared with 22% of participants receiving aspirin plus placebo (hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.10; P =0.42). Findings did not vary by baseline eGFR, time after randomization, or systolic BP target (all P values for interaction were >0.3). We found no effect of clopidogrel added to aspirin compared with aspirin alone on kidney function decline among persons with prior lacunar stroke. Copyright © 2017 by the American Society of Nephrology.

Normalization methods in time series of platelet function assays

PubMed Central

Van Poucke, Sven; Zhang, Zhongheng; Roest, Mark; Vukicevic, Milan; Beran, Maud; Lauwereins, Bart; Zheng, Ming-Hua; Henskens, Yvonne; Lancé, Marcus; Marcus, Abraham

2016-01-01

Abstract Platelet function can be quantitatively assessed by specific assays such as light-transmission aggregometry, multiple-electrode aggregometry measuring the response to adenosine diphosphate (ADP), arachidonic acid, collagen, and thrombin-receptor activating peptide and viscoelastic tests such as rotational thromboelastometry (ROTEM). The task of extracting meaningful statistical and clinical information from high-dimensional data spaces in temporal multivariate clinical data represented in multivariate time series is complex. Building insightful visualizations for multivariate time series demands adequate usage of normalization techniques. In this article, various methods for data normalization (z-transformation, range transformation, proportion transformation, and interquartile range) are presented and visualized discussing the most suited approach for platelet function data series. Normalization was calculated per assay (test) for all time points and per time point for all tests. Interquartile range, range transformation, and z-transformation demonstrated the correlation as calculated by the Spearman correlation test, when normalized per assay (test) for all time points. When normalizing per time point for all tests, no correlation could be abstracted from the charts as was the case when using all data as 1 dataset for normalization. PMID:27428217

Effect of pathologist's dedication on lymph node detection rate and postoperative survival in colorectal cancer.

PubMed

Unger, L W; Muckenhuber, M; Riss, S; Argeny, S; Stift, J; Mesteri, I; Stift, A

2018-04-28

As adjuvant chemotherapy in colorectal cancer relies on the identification of lymph node metastases, the pathologist's dedication may have a considerable influence on postoperative survival. The aim of this retrospective study was to assess the impact of the pathologist's dedication on lymph node detection rate and postoperative survival in patients operated on by a single experienced colorectal surgeon within a 5-year period. We assessed 229 patients undergoing total mesorectal excision or complete mesocolic excision by the senior author between 1 January 2009 and 31 December 2013. Pathologists were grouped as 'general pathologist' or 'dedicated pathologist' depending on their dedication/specialization. Dedicated pathologists found statistically significantly more lymph nodes in colorectal specimens than general pathologists [23 (interquartile range 24) vs 14 (interquartile range 11), respectively; P < 0.001]. The detection rate of ≥ 12 lymph nodes per specimen was significantly higher in the dedicated pathologist group [65/74 (87.8%) vs 105/155 (67.7%); P = 0.016]. However, postoperative survival did not differ in the respective subgroups. In the multivariable analysis by Cox proportional hazard model, International Union against Cancer Stage IV was the only factor associated with decreased disease-specific survival (hazard ratio 28.257; 95% CI 3.850-207.386; P = 0.001). In our centre, the pathologist's dedication has an impact on lymph node detection rate but does not influence postoperative disease-specific survival. Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.

Preoperative weight loss with glucagon-like peptide-1 receptor agonist treatment predicts greater weight loss achieved by the combination of medical weight management and bariatric surgery in patients with type 2 diabetes: A longitudinal analysis.

PubMed

Tang, Tien; Abbott, Sally; le Roux, Carel W; Wilson, Violet; Singhal, Rishi; Bellary, Srikanth; Tahrani, Abd A

2018-03-01

We examined the relationship between weight changes after preoperative glucagon-like peptide-1 receptor agonist (GLP-1RA) treatment and weight changes from the start of medical weight management (MWM) until 12 months after bariatric surgery in patients with type 2 diabetes in a retrospective cohort study. A total of 45 patients (64.4% women, median [interquartile range] age 49 [45-60] years) were included. The median (interquartile range) weight loss from start of MWM until 12 months post-surgery was 17.9% (13.0%-29.3%). GLP-1RA treatment during MWM resulted in 5.0% (1.9%-7.7%) weight loss. Weight loss during GLP-1RA treatment predicted weight loss from the start of MWM until 12 months post-surgery, but not postoperative weight loss after adjustment. The proportion of weight loss from start of MWM to 12 months post-surgery attributed to GLP-1RA treatment was negatively associated with that attributed to surgery, after adjustment. In conclusion, weight change after GLP-1RA treatment predicted the weight loss achieved by a combination of MWM and bariatric surgery, but not weight loss induced by surgery only. Failure to lose weight after GLP-1RA treatment should not be considered a barrier to undergoing bariatric surgery. © 2017 John Wiley & Sons Ltd.

The effects of inpatient hybrid closed-loop therapy initiated within 1 week of type 1 diabetes diagnosis.

PubMed

Buckingham, Bruce A; Beck, Roy W; Ruedy, Katrina J; Cheng, Peiyao; Kollman, Craig; Weinzimer, Stuart A; DiMeglio, Linda A; Bremer, Andrew A; Slover, Robert; Cantwell, Martin

2013-05-01

This article describes our experience with inpatient hybrid closed-loop control (HCLC) initiated shortly after the diagnosis of type 1 diabetes in a randomized trial designed to assess the effectiveness of inpatient HCLC followed by outpatient sensor-augmented pump (SAP) therapy on the preservation of β-cell function. Forty-eight individuals with newly diagnosed type 1 diabetes and positive pancreatic autoantibodies (7.8-37.7 years old) received inpatient HCLC therapy for up to 93 h, initiated within 7 days of diagnosis. On initiation of HCLC, mean glucose concentration was 240±100 mg/dL. During the first day of HCLC, median of the participant's mean glucose concentrations fell rapidly to 146 mg/dL, a level of control that was sustained on Days 2 and 3 (138 mg/dL and 139 mg/dL, respectively). By Day 3, the median percentage of glucose values >250 and <60 mg/dL was <1%. During the first 2 weeks of SAP treatment at home, the median participant mean glucose level was 126 mg/dL (interquartile range, 117, 137 mg/dL), and the median percentage of values between 71 and 180 mg/dL was 85% (interquartile range, 80%, 90%). Inpatient HCLC followed by outpatient SAP therapy can provide a safe and effective means to rapidly reverse glucose toxicity and establish near-normal glycemic control in patients with newly diagnosed type 1 diabetes.

Early Life Experiences and Telomere Length in Adult Rhesus Monkeys: An Exploratory Study

PubMed Central

Schneper, Lisa M.; Brooks-Gunn, Jeanne; Notterman, Daniel A.; Suomi, Stephen J.

2016-01-01

Objective Child rearing environments have been associated with morbidity in adult rhesus monkeys. We examine whether such links are also seen with leukocyte telomere length. Methods To determine telomere length in leukocytes, blood was collected from 11 adult females aged seven to ten years who had been exposed to different rearing environments between birth and seven months. Four had been reared with their mothers in typical social groups comprised of other females, their offspring, and 1–2 adult males. The other seven had been reared in either small groups of peers or in individual cages with extensive peer interaction daily. After seven months, all shared a common environment. Results Telomere lengths were longer for those adults who had been reared with their mothers in social groups (median = 16.0 kb, interquartile range = 16.5–15.4) than for those who were reared without their mothers (median = 14.0 kb, interquartile range = 14.3–12.7; 2.2 kb/telomere difference, p<0.027). Conclusions This observation adds to emerging knowledge about early adverse child rearing conditions and their potential for influencing later morbidity. As newborns were randomly assigned to the mother or other rearing conditions, the findings are not confounded by other conditions that co-occur with adverse child rearing environments in humans (e.g., prenatal stress, nutrition and health as well as postnatal nutrition and negative life experiences over and above rearing conditions). PMID:27763985

Response rates and survival times for cats with lymphoma treated with the University of Wisconsin-Madison chemotherapy protocol: 38 cases (1996-2003).

PubMed

Milner, Rowan J; Peyton, Jamie; Cooke, Kirsten; Fox, Leslie E; Gallagher, Alexander; Gordon, Patti; Hester, Juli

2005-10-01

To determine response rates and survival times for cats with lymphoma treated with the University of Wisconsin-Madison chemotherapy protocol. Retrospective study. 38 cats with lymphoma. Medical records were reviewed, and information on age, sex, breed, FeLV and FIV infection status, anatomic form, clinical stage, and survival time was obtained. Immunophenotyping was not performed. Mean +/- SD age of the cats was 10.9 +/- 4.4 years. Overall median survival time was 210 days (interquartile range, 90 to 657 days), and overall duration of first remission was 156 days (interquartile range, 87 to 316 days). Age, sex, anatomic form, and clinical stage were not significantly associated with duration of first remission or survival time. Eighteen of the 38 (47%) cats had complete remission, 14 (37%) had partial remission, and 6 (16%) had no response. Duration of first remission was significantly longer for cats with complete remission (654 days) than for cats with partial remission (114 days). Median survival time for cats with complete remission (654 days) was significantly longer than median survival time for cats with partial remission (122 days) and for cats with no response (11 days). Results suggested that a high percentage of cats with lymphoma will respond to treatment with the University of Wisconsin-Madison chemotherapy protocol. Age, sex, anatomic form, and clinical stage were not significantly associated with duration of first response or survival time, but initial response to treatment was.

Persistence of yellow fever vaccine-induced antibodies after solid organ transplantation.

PubMed

Wyplosz, B; Burdet, C; François, H; Durrbach, A; Duclos-Vallée, J C; Mamzer-Bruneel, M-F; Poujol, P; Launay, O; Samuel, D; Vittecoq, D; Consigny, P H

2013-09-01

Immunization using live attenuated vaccines represents a contra-indication after solid organ transplantation (SOT): consequently, transplant candidates planning to travel in countries where yellow fever is endemic should be vaccinated prior to transplantation. The persistence of yellow fever vaccine-induced antibodies after transplantation has not been studied yet. We measured yellow-fever neutralizing antibodies in 53 SOT recipients vaccinated prior to transplantation (including 29 kidney recipients and 18 liver recipients). All but one (98%) had protective titers of antibodies after a median duration of 3 years (min.: 0.8, max.: 21) after transplantation. The median antibody level was 40 U/L (interquartile range: 40-80). For the 46 patients with a known or estimated date of vaccination, yellow-fever antibodies were still detectable after a median time of 13 years (range: 2-32 years) post-immunization. Our data suggest there is long-term persistence of antibodies to yellow fever in SOT recipients who have been vaccinated prior to transplantation. © Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.

Influence of Antiflatulent Dietary Advice on Intrafraction Motion for Prostate Cancer Radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lips, Irene M., E-mail: I.M.Lips@umcutrecht.nl; Kotte, Alexis N.T.J.; Gils, Carla H. van

Purpose: To evaluate the effect of an antiflatulent dietary advice on the intrafraction prostate motion in patients treated with intensity-modulated radiotherapy (IMRT) for prostate cancer. Methods and Materials: Between February 2002 and December 2009, 977 patients received five-beam IMRT for prostate cancer to a dose of 76 Gy in 35 fractions combined with fiducial markers for position verification. In July 2008, the diet, consisting of dietary guidelines to obtain regular bowel movements and to reduce intestinal gas by avoiding certain foods and air swallowing, was introduced to reduce the prostate motion. The intrafraction prostate movement was determined from the portalmore » images of the first segment of all five beams. Clinically relevant intrafraction motion was defined as {>=}50% of the fractions with an intrafraction motion outside a range of 3 mm. Results: A total of 739 patients were treated without the diet and 105 patients were treated with radiotherapy after introduction of the diet. The median and interquartile range of the average intrafraction motion per patient was 2.53 mm (interquartile range, 2.2-3.0) without the diet and 3.00 mm (interquartile range, 2.4-3.5) with the diet (p < .0001). The percentage of patients with clinically relevant intrafraction motion increased statistically significant from 19.1% without diet to 42.9% with a diet (odds ratio, 3.18; 95% confidence interval, 2.07-4.88; p < .0001). Conclusions: The results of the present study suggest that antiflatulent dietary advice for patients undergoing IMRT for prostate cancer does not reduce the intrafraction movement of the prostate. Therefore, antiflatulent dietary advice is not recommended in clinical practice for this purpose.« less

Oxygen Exposure Resulting in Arterial Oxygen Tensions Above the Protocol Goal Was Associated With Worse Clinical Outcomes in Acute Respiratory Distress Syndrome.

PubMed

Aggarwal, Neil R; Brower, Roy G; Hager, David N; Thompson, B Taylor; Netzer, Giora; Shanholtz, Carl; Lagakos, Adrian; Checkley, William

2018-04-01

High fractions of inspired oxygen may augment lung damage to exacerbate lung injury in patients with acute respiratory distress syndrome. Participants enrolled in Acute Respiratory Distress Syndrome Network trials had a goal partial pressure of oxygen in arterial blood range of 55-80 mm Hg, yet the effect of oxygen exposure above this arterial oxygen tension range on clinical outcomes is unknown. We sought to determine if oxygen exposure that resulted in a partial pressure of oxygen in arterial blood above goal (> 80 mm Hg) was associated with worse outcomes in patients with acute respiratory distress syndrome. Longitudinal analysis of data collected in these trials. Ten clinical trials conducted at Acute Respiratory Distress Syndrome Network hospitals between 1996 and 2013. Critically ill patients with acute respiratory distress syndrome. None. We defined above goal oxygen exposure as the difference between the fraction of inspired oxygen and 0.5 whenever the fraction of inspired oxygen was above 0.5 and when the partial pressure of oxygen in arterial blood was above 80 mm Hg. We then summed above goal oxygen exposures in the first five days to calculate a cumulative above goal oxygen exposure. We determined the effect of a cumulative 5-day above goal oxygen exposure on mortality prior to discharge home at 90 days. Among 2,994 participants (mean age, 51.3 yr; 54% male) with a study-entry partial pressure of oxygen in arterial blood/fraction of inspired oxygen that met acute respiratory distress syndrome criteria, average cumulative above goal oxygen exposure was 0.24 fraction of inspired oxygen-days (interquartile range, 0-0.38). Participants with above goal oxygen exposure were more likely to die (adjusted interquartile range odds ratio, 1.20; 95% CI, 1.11-1.31) and have lower ventilator-free days (adjusted interquartile range mean difference of -0.83; 95% CI, -1.18 to -0.48) and lower hospital-free days (adjusted interquartile range mean difference of -1.38; 95% CI, -2.09 to -0.68). We observed a dose-response relationship between the cumulative above goal oxygen exposure and worsened clinical outcomes for participants with mild, moderate, or severe acute respiratory distress syndrome, suggesting that the observed relationship is not primarily influenced by severity of illness. Oxygen exposure resulting in arterial oxygen tensions above the protocol goal occurred frequently and was associated with worse clinical outcomes at all levels of acute respiratory distress syndrome severity.

Functional Status Change Among Children With Extracorporeal Membrane Oxygenation to Support Cardiopulmonary Resuscitation in a Pediatric Cardiac ICU: A Single Institution Report.

PubMed

Beshish, Asaad G; Baginski, Mathew R; Johnson, Thomas J; Deatrick, Barry K; Barbaro, Ryan P; Owens, Gabe E

2018-04-13

The purpose of this study is to describe the functional status of survivors from extracorporeal cardiopulmonary resuscitation instituted during in-hospital cardiac arrest using the Functional Status Scale. We aimed to determine risk factors leading to the development of new morbidity and unfavorable functional outcomes. This was a single-center retrospective chart review abstracting patient characteristics/demographic data, duration of cardiopulmonary resuscitation, duration of extracorporeal membrane oxygenation support, as well as maximum lactate levels within 2 hours before and after extracorporeal cardiopulmonary resuscitation. Cardiac arrest was defined as the administration of chest compressions for a nonperfusing cardiac rhythm. Extracorporeal cardiopulmonary resuscitation was defined by instituting extracorporeal membrane oxygenation during active chest compressions. Functional Status Scale scores were calculated at admission and on hospital discharge for patients who survived. Patients admitted in the pediatric cardiac ICU at C.S. Mott Children's Hospital from January 1, 2005, to December 31, 2015. Children less than 18 years who underwent extracorporeal cardiopulmonary resuscitation. Not applicable. Of 608 extracorporeal membrane oxygenation events during the study period, 80 were extracorporeal cardiopulmonary resuscitation (14%). There were 40 female patients (50%). Median age was 40 days (interquartile range, 9-342 d). Survival to hospital discharge was 48% (38/80). Median Functional Status Scale score at admission was 6 (interquartile range, 6-6) and at hospital discharge 9 (interquartile range, 8-11). Out of 38 survivors, 19 (50%) had a change of Functional Status Scale score greater than or equal to 3, that is consistent with new morbidity, and 26 (68%) had favorable functional outcomes with a change in Functional Status Scale score of less than 5. This is the first extracorporeal cardiopulmonary resuscitation report to examine changes in Functional Status Scale from admission (baseline) to discharge as a measure of overall functional outcome. Half of surviving patients (19/38) had new morbidity, while 68% (26/38) had favorable outcomes. Lactate levels, duration of cardiopulmonary resuscitation, and duration of extracorporeal membrane oxygenation were not found to be risk factors for the development of new morbidity and poor functional outcomes. Functional Status Scale may be used as a metric to monitor improvement of extracorporeal cardiopulmonary resuscitation outcomes and help guide research initiatives to decrease morbidity in this patient population.

Using Clinically Accessible Tools to Measure Sound Levels and Sleep Disruption in the ICU: A Prospective Multicenter Observational Study.

PubMed

Litton, Edward; Elliott, Rosalind; Thompson, Kelly; Watts, Nicola; Seppelt, Ian; Webb, Steven A R

2017-06-01

To use clinically accessible tools to determine unit-level and individual patient factors associated with sound levels and sleep disruption in a range of representative ICUs. A cross-sectional, observational study. Australian and New Zealand ICUs. All patients 16 years or over occupying an ICU bed on one of two Point Prevalence study days in 2015. Ambient sound was measured for 1 minute using an application downloaded to a personal mobile device. Bedside nurses also recorded the total time and number of awakening for each patient overnight. The study included 539 participants with sound level recorded using an application downloaded to a personal mobile device from 39 ICUs. Maximum and mean sound levels were 78 dB (SD, 9) and 62 dB (SD, 8), respectively. Maximum sound levels were higher in ICUs with a sleep policy or protocol compared with those without maximum sound levels 81 dB (95% CI, 79-83) versus 77 dB (95% CI, 77-78), mean difference 4 dB (95% CI, 0-2), p < 0.001. There was no significant difference in sound levels regardless of single room occupancy, mechanical ventilation status, or illness severity. Clinical nursing staff in all 39 ICUs were able to record sleep assessment in 15-minute intervals. The median time awake and number of prolonged disruptions were 3 hours (interquartile range, 1-4) and three (interquartile range, 2-5), respectively. Across a large number of ICUs, patients were exposed to high sound levels and substantial sleep disruption irrespective of factors including previous implementation of a sleep policy. Sound and sleep measurement using simple and accessible tools can facilitate future studies and could feasibly be implemented into clinical practice.

Prenatal Stress, Methylation in Inflammation-Related Genes, and Adiposity Measures in Early Childhood: the Programming Research in Obesity, Growth Environment and Social Stress Cohort Study.

PubMed

Wu, Shaowei; Gennings, Chris; Wright, Rosalind J; Wilson, Ander; Burris, Heather H; Just, Allan C; Braun, Joseph M; Svensson, Katherine; Zhong, Jia; Brennan, Kasey J M; Dereix, Alexandra; Cantoral, Alejandra; Schnaas, Lourdes; Téllez-Rojo, Martha Maria; Wright, Robert O; Baccarelli, Andrea A

2018-01-01

Maternal stress during pregnancy may influence childhood growth and adiposity, possibly through immune/inflammatory programming. We investigated whether exposure to prenatal stress and methylation in inflammation-related genes were associated with childhood adiposity in 424 mother-child pairs in Mexico City, Mexico. A stress index was created based on four prenatally administered stress-related scales (Exposure to Violence, Crisis in Family Systems, State-Trait Anxiety Inventory, and Edinburgh Postnatal Depression Scale). We measured weight, height, body fat mass (BFM), percentage body fat (PBF), and waist circumference in early childhood (age range, 4-6 years). Body mass index (BMI) z scores were calculated according to World Health Organization standards. DNA methylation in gene promoters of tumor necrosis factor α, interleukin 8, and interleukin 6 (IL6) in umbilical cord blood were determined by pyrosequencing. An interquartile range increase in stress index (27.3) was associated with decreases of 0.14 unit in BMI z score (95% confidence interval [CI] = -0.28 to -0.005), 5.6% in BFM (95% CI = -9.7 to -1.4), 3.5% in PBF (95% CI = -6.3 to -0.5), and 1.2% in waist circumference (95% CI = -2.4 to -0.04) in multivariable-adjusted models. An interquartile range increase in IL6 methylation (3.9%) was associated with increases of 0.23 unit in BMI z score (95% CI = 0.06-0.40), 8.1% (95% CI = 2.3-14.3) in BFM, 5.5% (95% CI = 1.7-9.5) in PBF, and 1.7% (95% CI = 0.2-3.3) in waist circumference. Prenatal stress was associated with decreased childhood adiposity, whereas cord blood IL6 methylation was associated with increased childhood adiposity in Mexican children.

Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients.

PubMed

Gener, G; Canoui-Poitrine, F; Revuz, J E; Faye, O; Poli, F; Gabison, G; Pouget, F; Viallette, C; Wolkenstein, P; Bastuji-Garin, S

2009-01-01

Antibiotics are frequently used to treat hidradenitis suppurativa (HS); however, few data on their efficacy are available. To evaluate the efficacy of a combination of systemic clindamycin (300 mg twice daily) and rifampicin (600 mg daily) in the treatment of patients with severe HS. Patients (n = 116) who received this combination were studied retrospectively. The main outcome measure was the severity of the disease, assessed by the Sartorius score, before and after 10 weeks of treatment. The Sartorius score dramatically improved at the end of treatment (median = 29, interquartile range = 14.5, vs. median = 14.5, interquartile range = 11; p < 0.001), as did other parameters of severity as well as the quality of life score. Eight patients (6.9%) stopped the treatment because of side effects. The combination of clindamycin and rifampicin is effective in the treatment of severe HS. Copyright 2009 S. Karger AG, Basel.

Geographic variability of adherence to occupational injury treatment guidelines.

PubMed

Trujillo, Antonio J; Heins, Sara E; Anderson, Gerard F; Castillo, Renan C

2014-12-01

To determine the geographic variability and relationship between six occupational injury practice guidelines. Guidelines were developed by an expert panel and evaluated using workers' compensation claims data from a large, national insurance company (1999 to 2010). Percentage compliance for each guideline was adjusted for age and sex using linear regression and mapped by hospital referral region. Regions with the lowest compliance were identified, and correlations between guidelines were calculated. Compliance to the unnecessary home care guideline showed the lowest geographic variation (interquartile range: 97.3 to 99.0), and inappropriate shoulder bracing showed the highest variation (interquartile range: 77.7 to 90.8). Correlation between the guidelines was weak and not always positive. Different guidelines showed different degrees of geographic variation. Lack of correlation between guidelines suggests that these indicators were not associated with a single underlying health care quality or patient severity construct.

A Model for Developing and Assessing Community College Students' Conceptions of the Range, Interquartile Range, and Standard Deviation

ERIC Educational Resources Information Center

Turegun, Mikhail

2011-01-01

Traditional curricular materials and pedagogical strategies have not been effective in developing conceptual understanding of statistics topics and statistical reasoning abilities of students. Much of the changes proposed by statistics education research and the reform movement over the past decade have supported efforts to transform teaching…

Association of Sleep Deprivation With Reduction in Insulin Sensitivity as Assessed by the Hyperglycemic Clamp Technique in Adolescents.

PubMed

De Bernardi Rodrigues, Ana Maria; da Silva, Cleliani de Cassia; Vasques, Ana Carolina Junqueira; Camilo, Daniella Fernandes; Barreiro, Francieli; Cassani, Roberta Soares Lara; Zambon, Mariana Porto; Antonio, Maria Ângela Reis de Góes Monteiro; Geloneze, Bruno

2016-05-01

The association between short sleep duration and decreased insulin sensitivity in adolescents has been described. However, to our knowledge, no studies have investigated this association measuring insulin sensitivity by the hyperglycemic clamp technique. To compare the distributions of parameters of insulin resistance in adolescents with sleep deprivation vs adequate sleep, and to investigate the association between sleep deprivation and insulin sensitivity. Cross-sectional multicenter study using data from the Brazilian Metabolic Syndrome Study conducted from June 29, 2011, to December 3, 2014, at an obesity outpatient clinic at the University of Campinas and public schools, with a convenience sample of 615 adolescents aged 10 to 19.9 years with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) for age and sex at the fifth percentile or higher. A subsample of 81 adolescents underwent the hyperglycemic clamp technique. The self-reported sleep duration was used to classify the population into 2 groups: adolescents with sleep deprivation (<8 hours/night) and adolescents with adequate sleep (≥8 hours/night). Insulin sensitivity was assessed using the hyperglycemic clamp technique. Among the 615 adolescents (56.3% female; median age, 15.9 years [interquartile range, 12.9-17.8 years]) included in the sample, the mean (SD) sleep duration was 7.9 (1.7) hours/night. The adolescents with sleep deprivation (n = 257) compared with those with adequate sleep (n = 358) had a higher median (interquartile range) age (17.0 [15.4-18.3] vs 14.1 [11.8-16.9] years), BMI (25.0 [21.2-29.3] vs 23.1 [19.5-27.6]), waist circumference (83.0 [73.5-95.4] vs 79.0 [68.5-91.0] cm), sagittal abdominal diameter (17.9 [15.8-20.8] vs 17.0 [15.0-19.8] cm), neck circumference (35.2 [33.0-38.0] vs 33.0 [30.0-35.5] cm), uric acid level (4.9 [4.0-5.8] vs 4.5 [3.7-5.5] mg/dL), and white blood cell count (7000 [5900-8200] vs 6600 [5600-7800] cells/μL) (all P < .05). Moreover, the adolescents with sleep deprivation had a lower median (interquartile range) insulin sensitivity index compared with those with adequate sleep (0.10 [0.05-0.21] vs 0.21 [0.09-0.33] mg · kgfat-free mass-1 · min-1 · mU/L × 100, respectively; difference, -0.01; 95% CI, -0.01 to -0.00; P = .02). After controlling for age and sex in the multivariate regression model, sleep deprivation remained an independent predictor for those variables. In the sleep deprivation group, BMI and central distribution of fat were higher in all categories of adiposity. Sleep deprivation (<8 hours of sleep per night) is associated with centripetal distribution of fat and decreased insulin sensitivity in adolescents. Therefore, investigations of sleep duration and sleep quality in adolescents should be included in clinical practice to promote, through health education, the eradication of the health risks associated with sleep restriction.

Three Year RSA Evaluation of Vitamin E Diffused Highly Cross-linked Polyethylene Liners and Cup Stability.

PubMed

Sillesen, Nanna H; Greene, Meridith E; Nebergall, Audrey K; Nielsen, Poul T; Laursen, Mogens B; Troelsen, Anders; Malchau, Henrik

2015-07-01

Vitamin E diffusion into highly cross-linked polyethylene (E-XLPE) is a method for enhancing oxidative stability of acetabular liners. The purpose of this study was to evaluate in vivo penetration of E-XLPE using radiostereometric analysis (RSA). Eighty-four hips were recruited into a prospective 10-year RSA. This is the first evaluation of the multicenter cohort after 3-years. All patients received E-XLPE liners (E1, Biomet) and porous-titanium coated cups (Regenerex, Biomet). There was no difference (P=0.450) in median femoral head penetration into the E-XLPE liners at 3-years comparing cobalt-chrome heads (-0.028mm; inter-quartile range (IQR) - 0.065 to 0.047) with ceramic heads (-0.043mm, IQR - 0.143to0.042). The 3-year follow-up indicates minimal E-XLPE liner penetration regardless of head material and minimal early cup movement. Copyright © 2015 Elsevier Inc. All rights reserved.

Capsaicin-evoked cough responses in asthmatic patients: Evidence for airway neuronal dysfunction.

PubMed

Satia, Imran; Tsamandouras, Nikolaos; Holt, Kimberley; Badri, Huda; Woodhead, Mark; Ogungbenro, Kayode; Felton, Timothy W; O'Byrne, Paul M; Fowler, Stephen J; Smith, Jaclyn A

2017-03-01

Cough in asthmatic patients is a common and troublesome symptom. It is generally assumed coughing occurs as a consequence of bronchial hyperresponsiveness and inflammation, but the possibility that airway nerves are dysfunctional has not been fully explored. We sought to investigate capsaicin-evoked cough responses in a group of patients with well-characterized mild-to-moderate asthma compared with healthy volunteers and assess the influences of sex, atopy, lung physiology, inflammation, and asthma control on these responses. Capsaicin inhalational challenge was performed, and cough responses were analyzed by using nonlinear mixed-effects modeling to estimate the maximum cough response evoked by any concentration of capsaicin (E max ) and the capsaicin dose inducing half-maximal response (ED 50 ). Ninety-seven patients with stable asthma (median age, 23 years [interquartile range, 21-27 years]; 60% female) and 47 healthy volunteers (median age, 38 years [interquartile range, 29-47 years]; 64% female) were recruited. Asthmatic patients had higher E max and lower ED 50 values than healthy volunteers. E max values were 27% higher in female subjects (P = .006) and 46% higher in patients with nonatopic asthma (P = .003) compared with healthy volunteers. Also, patients with atopic asthma had a 21% lower E max value than nonatopic asthmatic patients (P = .04). The ED 50 value was 65% lower in female patients (P = .0001) and 71% lower in all asthmatic patients (P = .0008). ED 50 values were also influenced by asthma control and serum IgE levels, whereas E max values were related to 24-hour cough frequency. Age, body mass index, FEV 1 , PC 20 , fraction of exhaled nitric oxide, blood eosinophil counts, and inhaled steroid treatment did not influence cough parameters. Patients with stable asthma exhibited exaggerated capsaicin-evoked cough responses consistent with neuronal dysfunction. Nonatopic asthmatic patients had the highest cough responses, suggesting this mechanism might be most important in type 2-low asthma phenotypes. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

One-day quantitative cross-sectional study of family information time in 90 intensive care units in France.

PubMed

Fassier, Thomas; Darmon, Michel; Laplace, Christian; Chevret, Sylvie; Schlemmer, Benoit; Pochard, Frédéric; Azoulay, Elie

2007-01-01

Providing family members with clear, honest, and timely information is a major task for intensive care unit physicians. Time spent informing families has been associated with effectiveness of information but has not been measured in specifically designed studies. To measure time spent informing families of intensive care unit patients. One-day cross-sectional study in 90 intensive care units in France. Clocked time spent by physicians informing the families of each of 951 patients hospitalized in the intensive care unit during a 24-hr period. Median family information time was 16 (interquartile range, 8-30) mins per patient, with 20% of the time spent explaining the diagnosis, 20% on explaining treatments, and 60% on explaining the prognosis. One third of the time was spent listening to family members. Multivariable analysis identified one factor associated with less information time (room with more than one bed) and seven factors associated with more information time, including five patient-related factors (surgery on the study day, higher Logistic Organ Dysfunction score, coma, mechanical ventilation, and worsening clinical status) and two family-related factors (first contact with family and interview with the spouse). Median information time was 20 (interquartile range, 10-39) mins when three factors were present and 106.5 (interquartile range, 103-110) mins when five were present. This study identifies factors associated with information time provided by critical care physicians to family members of critically ill patients. Whether information time correlates with communication difficulties or communication skills needs to be evaluated. Information time provided by residents and nurses should be studied.

Total inpatient treatment costs in patients with severe burns: towards a more accurate reimbursement model.

PubMed

Mehra, Tarun; Koljonen, Virve; Seifert, Burkhardt; Volbracht, Jörk; Giovanoli, Pietro; Plock, Jan; Moos, Rudolf Maria

2015-01-01

Reimbursement systems have difficulties depicting the actual cost of burn treatment, leaving care providers with a significant financial burden. Our aim was to establish a simple and accurate reimbursement model compatible with prospective payment systems. A total of 370 966 electronic medical records of patients discharged in 2012 to 2013 from Swiss university hospitals were reviewed. A total of 828 cases of burns including 109 cases of severe burns were retained. Costs, revenues and earnings for severe and nonsevere burns were analysed and a linear regression model predicting total inpatient treatment costs was established. The median total costs per case for severe burns was tenfold higher than for nonsevere burns (179 949 CHF [167 353 EUR] vs 11 312 CHF [10 520 EUR], interquartile ranges 96 782-328 618 CHF vs 4 874-27 783 CHF, p <0.001). The median of earnings per case for nonsevere burns was 588 CHF (547 EUR) (interquartile range -6 720 - 5 354 CHF) whereas severe burns incurred a large financial loss to care providers, with median earnings of -33 178 CHF (30 856 EUR) (interquartile range -95 533 - 23 662 CHF). Differences were highly significant (p <0.001). Our linear regression model predicting total costs per case with length of stay (LOS) as independent variable had an adjusted R2 of 0.67 (p <0.001 for LOS). Severe burns are systematically underfunded within the Swiss reimbursement system. Flat-rate DRG-based refunds poorly reflect the actual treatment costs. In conclusion, we suggest a reimbursement model based on a per diem rate for treatment of severe burns.

Can Saliva and Plasma Methadone Concentrations Be Used for Enantioselective Pharmacokinetic and Pharmacodynamic Studies in Patients With Advanced Cancer?

PubMed

George, Rani; Haywood, Alison; Good, Phillip; Hennig, Stefanie; Khan, Sohil; Norris, Ross; Hardy, Janet

2017-09-01

Methadone is a potent analgesic used to treat refractory cancer pain. It is administered as a racemic mixture, with the l-enantiomer being primarily a μ-receptor agonist, whereas the d-enantiomer is an N-methyl-d-aspartate antagonist and inhibits serotonin and norepinephrine reuptake. Dose requirements vary greatly among patients to achieve optimal pain control and to avoid the risk of adverse effects. The relationship between plasma and saliva methadone enantiomer concentrations was investigated to determine if saliva could be a substitute for plasma in pharmacodynamic and pharmacokinetic studies for clinical monitoring and dose optimization of methadone in patients with advanced cancer. Patients with advanced cancer who were prescribed varying doses of oral methadone for pain management were recruited to obtain paired plasma and saliva samples. Pain scores were recorded at the time of sampling. The total and unbound plasma and saliva concentrations of the l- and d-enantiomers of methadone were quantified by using an HPLC-MS/MS method. The relationship between plasma (total and unbound) and saliva concentrations were compared. The saliva-to-plasma concentration ratio was compared versus the dose administered and the time after dosing for both enantiomers. The association of methadone concentrations with reported pain scores was compared by using a Mann-Whitney U test for significance. Fifty patients receiving a mean dose of 11mg/d of methadone provided 151 paired plasma and saliva samples. The median age of the population was 61 years with an interquartile range of 53-71 years with total body weight ranging from 59-88 kg. Median (interquartile) total plasma concentrations for l- and d-methadone were 50.78 ng/mL (30.6-113.0 ng/mL) and 62.0 ng/mL (28.7-116.0 ng/mL), respectively. Median (interquartile range) saliva concentrations for l- and d-methadone were 81.5 ng/mL (28.0-203.2 ng/mL) and 44.2 (16.2-149.7 ng/mL). No relationship could be established between plasma and saliva concentrations for l- and d-methadone (r 2 = 0.35 and 0.25). The saliva-to-plasma concentration analyzed with the methadone dose showed higher saliva concentrations at lower doses. Dose-normalized saliva concentrations followed a similar pattern over time compared with plasma concentrations. No correlation was found between l-methadone plasma, d-methadone plasma, l-methadone saliva, d-methadone saliva concentrations, and pain score. Saliva concentration was not a better predictor of pain control than plasma concentration for dose optimization and monitoring studies of methadone in patients with cancer. Although the saliva-to-plasma ratio of the concentration of methadone enantiomers was stable across the dosing range, due to the variability in individual saliva-to-plasma ratios, saliva sampling may not be a valid substitute in pharmacokinetic studies of methadone in cancer. Copyright © 2017 Elsevier HS Journals, Inc. All rights reserved.

Data Analysis and Statistical Methods for the Assessment and Interpretation of Geochronologic Data

NASA Astrophysics Data System (ADS)

Reno, B. L.; Brown, M.; Piccoli, P. M.

2007-12-01

Ages are traditionally reported as a weighted mean with an uncertainty based on least squares analysis of analytical error on individual dates. This method does not take into account geological uncertainties, and cannot accommodate asymmetries in the data. In most instances, this method will understate uncertainty on a given age, which may lead to over interpretation of age data. Geologic uncertainty is difficult to quantify, but is typically greater than analytical uncertainty. These factors make traditional statistical approaches inadequate to fully evaluate geochronologic data. We propose a protocol to assess populations within multi-event datasets and to calculate age and uncertainty from each population of dates interpreted to represent a single geologic event using robust and resistant statistical methods. To assess whether populations thought to represent different events are statistically separate exploratory data analysis is undertaken using a box plot, where the range of the data is represented by a 'box' of length given by the interquartile range, divided at the median of the data, with 'whiskers' that extend to the furthest datapoint that lies within 1.5 times the interquartile range beyond the box. If the boxes representing the populations do not overlap, they are interpreted to represent statistically different sets of dates. Ages are calculated from statistically distinct populations using a robust tool such as the tanh method of Kelsey et al. (2003, CMP, 146, 326-340), which is insensitive to any assumptions about the underlying probability distribution from which the data are drawn. Therefore, this method takes into account the full range of data, and is not drastically affected by outliers. The interquartile range of each population of dates (the interquartile range) gives a first pass at expressing uncertainty, which accommodates asymmetry in the dataset; outliers have a minor affect on the uncertainty. To better quantify the uncertainty, a resistant tool that is insensitive to local misbehavior of data is preferred, such as the normalized median absolute deviations proposed by Powell et al. (2002, Chem Geol, 185, 191-204). We illustrate the method using a dataset of 152 monazite dates determined using EPMA chemical data from a single sample from the Neoproterozoic Brasília Belt, Brazil. Results are compared with ages and uncertainties calculated using traditional methods to demonstrate the differences. The dataset was manually culled into three populations representing discrete compositional domains within chemically-zoned monazite grains. The weighted mean ages and least squares uncertainties for these populations are 633±6 (2σ) Ma for a core domain, 614±5 (2σ) Ma for an intermediate domain and 595±6 (2σ) Ma for a rim domain. Probability distribution plots indicate asymmetric distributions of all populations, which cannot be accounted for with traditional statistical tools. These three domains record distinct ages outside the interquartile range for each population of dates, with the core domain lying in the subrange 642-624 Ma, the intermediate domain 617-609 Ma and the rim domain 606-589 Ma. The tanh estimator yields ages of 631±7 (2σ) for the core domain, 616±7 (2σ) for the intermediate domain and 601±8 (2σ) for the rim domain. Whereas the uncertainties derived using a resistant statistical tool are larger than those derived from traditional statistical tools, the method yields more realistic uncertainties that better address the spread in the dataset and account for asymmetry in the data.

Long-term follow-up and outcome in patients with recurrent respiratory laryngeal papillomatosis.

PubMed

Rasmussen, Eva Rye; Schnack, Didde T; Jørkov, Andreas Schjellerup; Raja, Anna Axelsson; Olsen, Caroline Holkmann; Homøe, Preben

2017-12-01

Recurrent respiratory papillomatosis is characterized by wart-like lesions of the upper airway and is most frequently caused by human papillomavirus (HPV). The disease has significant impact on quality of life due to potential airway obstruction, dysphonia and the need for serial surgeries. The main objective of this study was to describe patient characteristics and long-term follow-up data in a Danish cohort with the disease. The study was a longitudinal retrospective cohort-study using data from electronic medical records and a pathology database. A total of 61 adult and four juvenile patients were identified. The male-to-female ratio was 2.4. In the adult population, the mean age at onset was 45 years. The median number of surgeries was four (interquartile range: 2.8). The mean follow-up time was 8.7 years (range: 7 days-30 years). Three cases of malignant transformation were observed. In the juvenile population, the mean age of onset was 8.5 years (range: 3-12 years). The mean follow-up time was 11.5 years (range: 2-23 years), and the number of surgeries per year at risk was one/year. CO2-laser and microdebrider were the surgical techniques usually employed. 43% of histopathologic analyses could detect HPV infection (subtype 6 or 11). More males than females suffer from respiratory papillomatosis; age of onset was either in childhood or in mid-life. Use of CO2-laser or microdebrider was the preferred surgical approach in this cohort. none. not relevant. Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Falls relate to vitamin D and parathyroid hormone in an Australian nursing home and hostel.

PubMed

Stein, M S; Wark, J D; Scherer, S C; Walton, S L; Chick, P; Di Carlantonio, M; Zajac, J D; Flicker, L

1999-10-01

To determine whether falling relates to serum levels of vitamin D and parathyroid hormone. A cross-sectional study with retrospective analysis. An aged-care institution in Melbourne Australia. Ambulant nursing home and hostel residents (n = 83). Frequency of falling, frequency of going outdoors, use of cane or walker, age, sex, weight, type of accommodation, and duration of residence. Serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and parathyroid hormone (PTH). Plasma concentrations of albumin, calcium, phosphate, and creatinine. Use of furosemide or non-benzodiazepine anticonvulsants. Median age of residents was 84 years. The cohort was vitamin D deficient with a median (interquartile range) 25-hydroxyvitamin D level of 27 (18-37) nmol/L (one-third the reference range median), P < .001. The median (interquartile range) PTH of 5.2 (3.8-7.7) pmol/L exceeded the reference range median, P < .001. Residents who fell (n = 33) had lower serum 25-hydroxyvitamin D levels than other residents (medians 22 vs 29 nmol/L, P = .02) and higher serum PTH levels (medians 6.2 vs 4.8 pmol/L, P < .01). Sixty residents lived in the hostel (72%), and 41 (49%) walked without any walking aid. In a multiple logistic regression for falling, higher serum PTH remained independently associated with falling, with an odds ratio (95% confidence interval) for falling of 5.6 (1.7-18.5) per unit of the natural logarithm of serum PTH. Other terms in the regression were hostel accommodation, odds ratio .04 (.01-.25), and ability to walk without aids, odds ratio .07 (.01-.37). In ambulant nursing home and hostel residents, residents who fall have lower serum 25-hydroxyvitamin D and higher serum parathyroid hormone levels than other residents. The association between falling and serum PTH persists after adjustment for other variables.

Brain abnormalities detected on magnetic resonance imaging of amphetamine users presenting to an emergency department: a pilot study.

PubMed

Fatovich, Daniel M; McCoubrie, David L; Song, Swithin J; Rosen, David M; Lawn, Nick D; Daly, Frank F

2010-09-06

To determine the prevalence of occult brain abnormalities in magnetic resonance imaging of active amphetamine users. Prospective convenience study in a tertiary hospital emergency department (ED). Patients presenting to the ED for an amphetamine-related reason were eligible for inclusion. We collected demographic data, drug use data, and performed a mini-mental state examination (MMSE). The proportion of patients with an abnormality on their MRI scan. Of 38 patients enrolled, 30 had MRI scans. Nineteen were male and their mean age was 26.7 +/- 5.4 years (range 19-41 years). The mean age of first amphetamine use was 18 years (range 13-26 years). Sixteen patients used crystal methamphetamine (mean amount 2.5 g/week), nine used amphetamine ("speed") (mean amount 2.9 g/week), and 23 used ecstasy (mean amount 2.3 tablets/week). Marijuana was smoked by 26 (mean amount 5.9 g/week), and 28 drank alcohol (mean amount 207 g/week). The median MMSE score was 27/30 (interquartile range, 26-29). Abnormalities on brain MRI scans were identified in six patients, most commonly an unidentified bright object (n = 4). In this pilot study of brain MRI of young people attending the ED with an amphetamine-related presentation, one in five had an occult brain lesion. While the significance of this is uncertain, it is congruent with evidence that amphetamines cause brain injury.

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair.

PubMed

Liang, Nathan L; Reitz, Katherine M; Makaroun, Michel S; Malas, Mahmoud B; Tzeng, Edith

2018-05-01

Evidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set. We identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years. We identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results. In this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Efficacy of leukocyte- and platelet-rich fibrin in wound healing: a randomized controlled clinical trial.

PubMed

Chignon-Sicard, Bérengère; Georgiou, Charalambos A; Fontas, Eric; David, Sylvain; Dumas, Pierre; Ihrai, Tarik; Lebreton, Elisabeth

2012-12-01

Application of platelet concentrates to wounds could speed healing. Leukocyte- and platelet-rich fibrin, a relatively recent development, stands out from the other preparations. This prospective, randomized, controlled clinical trial studied the rate of healing of postoperative hand wounds after a single application of leukocyte- and platelet-rich fibrin. Eligible patients were healthy individuals older than 18 years who had been scheduled for elective McCash (open palm) surgery for Dupuytren disease at the Plastic and Hand Surgery Department of Nice's University Hospital between August of 2007 and February of 2010. The control group received the reference care of petroleum jelly mesh (Vaselitulle), and test patients had leukocyte- and platelet-rich fibrin applied. The primary endpoint was healing delay measured in postoperative days. Secondary endpoints included pain, bleeding, and wound exudate. The trial was carried out as a single-blind trial. Among the 68 randomized patients, 33 patients in the leukocyte- and platelet-rich fibrin group and 31 in the Vaselitulle group were analyzed. Primary endpoint analysis showed a median healing delay of 24 days (interquartile range, 18 to 28 days) for the fibrin group and 29 days (interquartile range, 26 to 35 days) for the Vaselitulle group (p = 0.014, log-rank test). Postoperative pain assessment, bleeding, and exudate were always lower for the fibrin group, but not significantly so. The authors trial demonstrates that a single leukocyte- and platelet-rich fibrin application on fresh postoperative hand wounds shows a median improvement of 5 days in comparison with the standard treatment. Therapeutic, II.

Safety and efficiency of emergency department interrogation of cardiac devices

PubMed Central

Neuenschwander, James F.; Peacock, W. Frank; Migeed, Madgy; Hunter, Sara A.; Daughtery, John C.; McCleese, Ian C.; Hiestand, Brian C.

2016-01-01

Objective Patients with implanted cardiac devices may wait extended periods for interrogation in emergency departments (EDs). Our purpose was to determine if device interrogation could be done safely and faster by ED staff. Methods Prospective randomized, standard therapy controlled, trial of ED staff device interrogation vs. standard process (SP), with 30-day follow-up. Eligibility criteria: ED presentation with a self-report of a potential device related complaint, with signed informed consent. SP interrogation was by company representative or hospital employee. Results Of 60 patients, 42 (70%) were male, all were white, with a median (interquartile range) age of 71 (64 to 82) years. No patient was lost to follow up. Of all patients, 32 (53%) were enrolled during business hours. The overall median (interquartile range) ED vs. SP time to interrogation was 98.5 (40 to 260) vs. 166.5 (64 to 412) minutes (P=0.013). While ED and SP interrogation times were similar during business hours, 102 (59 to 138) vs. 105 (64 to 172) minutes (P=0.62), ED interrogation times were shorter vs. SP during non-business hours; 97 (60 to 126) vs. 225 (144 to 412) minutes, P=0.002, respectively. There was no difference in ED length of stay between the ED and SP interrogation, 249 (153 to 390) vs. 246 (143 to 333) minutes (P=0.71), regardless of time of presentation. No patient in any cohort suffered an unplanned medical contact or post-discharge adverse device related event. Conclusion ED staff cardiac device interrogations are faster, and with similar 30-day outcomes, as compared to SP. PMID:28168230

Safety and efficiency of emergency department interrogation of cardiac devices.

PubMed

Neuenschwander, James F; Peacock, W Frank; Migeed, Madgy; Hunter, Sara A; Daughtery, John C; McCleese, Ian C; Hiestand, Brian C

2016-12-01

Patients with implanted cardiac devices may wait extended periods for interrogation in emergency departments (EDs). Our purpose was to determine if device interrogation could be done safely and faster by ED staff. Prospective randomized, standard therapy controlled, trial of ED staff device interrogation vs. standard process (SP), with 30-day follow-up. Eligibility criteria: ED presentation with a self-report of a potential device related complaint, with signed informed consent. SP interrogation was by company representative or hospital employee. Of 60 patients, 42 (70%) were male, all were white, with a median (interquartile range) age of 71 (64 to 82) years. No patient was lost to follow up. Of all patients, 32 (53%) were enrolled during business hours. The overall median (interquartile range) ED vs. SP time to interrogation was 98.5 (40 to 260) vs. 166.5 (64 to 412) minutes (P=0.013). While ED and SP interrogation times were similar during business hours, 102 (59 to 138) vs. 105 (64 to 172) minutes (P=0.62), ED interrogation times were shorter vs. SP during non-business hours; 97 (60 to 126) vs. 225 (144 to 412) minutes, P=0.002, respectively. There was no difference in ED length of stay between the ED and SP interrogation, 249 (153 to 390) vs. 246 (143 to 333) minutes (P=0.71), regardless of time of presentation. No patient in any cohort suffered an unplanned medical contact or post-discharge adverse device related event. ED staff cardiac device interrogations are faster, and with similar 30-day outcomes, as compared to SP.

Napping in English preschool children and the association with parents' attitudes.

PubMed

Jones, Caroline Helen Dorothy; Ball, Helen Louise

2013-04-01

Age-independent variability in childrens' napping duration may be influenced by parental preference and attitudes and childrens' availability or lack of opportunity to nap. Our study examined English preschool childrens' napping duration, frequency and location, and the association of daily nap duration with parents' attitudes towards napping. Parents of three-year-old children in deprived and nondeprived areas of a town in North-East England were interviewed regarding their attitudes towards child napping and completed four-day and five night sleep diaries documenting their childrens' daytime and nighttime sleep. Of 84 children, half had at least one nap during the four-day study period (median [interquartile range] daily nap duration across all children was 1 [21] min; for nappers only was 21 [34] min). Naps tended to be infrequent and short and few (6%) occurred in a bedroom. Children whose parents allowed or encouraged napping had significantly longer daily nap duration (n=25, median [interquartile range] daily nap duration 21 [34] min) compared to those whose parents tried to prevent them from napping (n=29, 1 [21] min), and those whose parents reported that children did not want to nap (n=30, 0 [0] min) (U=23.21; p<.001). Positive parental attitude towards napping was associated with longer child nap duration. Napping appeared to be mainly sporadic and opportunistic and was negatively perceived and prevented by one-third of parents. The consequences of premature nap cessation are not known; given the importance of sufficient sleep in childhood, we should possibly consider enabling young children to nap more freely. Copyright © 2013 Elsevier B.V. All rights reserved.

Effect of virtual reality training on laparoscopic surgery: randomised controlled trial

PubMed Central

Soerensen, Jette L; Grantcharov, Teodor P; Dalsgaard, Torur; Schouenborg, Lars; Ottosen, Christian; Schroeder, Torben V; Ottesen, Bent S

2009-01-01

Objective To assess the effect of virtual reality training on an actual laparoscopic operation. Design Prospective randomised controlled and blinded trial. Setting Seven gynaecological departments in the Zeeland region of Denmark. Participants 24 first and second year registrars specialising in gynaecology and obstetrics. Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls). Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes. Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79. Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures. Trial registration ClinicalTrials.gov NCT00311792. PMID:19443914

Facilitators and barriers to initiating change in medical intensive care unit survivors with alcohol use disorders: a qualitative study.

PubMed

Clark, Brendan J; Jones, Jacqueline; Cook, Paul; Tian, Karen; Moss, Marc

2013-10-01

Alcohol abuse and dependence are collectively referred to as alcohol use disorders (AUD). An AUD is present in up to one third of patients admitted to an intensive care unit (ICU). We sought to understand the barriers and facilitators to change in ICU survivors with an AUD to provide a foundation upon which to tailor alcohol-related interventions. We used a qualitative approach with a broad constructivist framework, conducting semistructured interviews in medical ICU survivors with an AUD. Patients were included if they were admitted to 1 of 2 medical ICUs and were excluded if they refused participation, were unable to participate, or did not speak English. Digitally recorded and professionally transcribed interviews were analyzed using a general inductive approach and grouped into themes. Nineteen patients were included, with an average age of 51 (interquartile range, 36-51) years and an average Acute Physiology and Chronic Health Evaluation II score of 9 (interquartile range, 5-13); 68% were white, 74% were male, and the most common reason for admission was alcohol withdrawal (n=8). We identified 5 facilitators of change: empathy of the inpatient health care environment, recognition of accumulating problems, religion, pressure from others to stop drinking, and trigger events. We identified 3 barriers to change: missed opportunities, psychiatric comorbidity, and cognitive dysfunction. Social networks were identified as either a barrier or facilitator to change depending on the specific context. Alcohol-related interventions to motivate and sustain behavior change could be tailored to ICU survivors by accounting for unique barriers and facilitators. © 2013.

Poor oral status is associated with rehabilitation outcome in older people.

PubMed

Shiraishi, Ai; Yoshimura, Yoshihiro; Wakabayashi, Hidetaka; Tsuji, Yuri

2017-04-01

Poor oral status is associated with increased physical dependency and cognitive decline. Malnutrition, a potential result of poor oral status, is associated with poorer rehabilitation outcome and physical function. However, the association between oral status and rehabilitation outcome is not fully understood. The present study investigated the association of poor oral status with rehabilitation outcome in older patients. A retrospective cohort study was carried out of 108 consecutive patients (mean age 80.5 ± 6.8 years; 50.9% men) who were admitted to convalescent rehabilitation wards. The Revised Oral Assessment Guide was used to evaluate oral status. Rehabilitation outcome was evaluated by the Functional Independence Measure (FIM) on discharge. Multivariate analyses were applied to examine the associations between poor oral status and motor-FIM on discharge. According to the Revised Oral Assessment Guide score, 14.8% of participants had normal oral status, 52.8% had slight to moderate oral problems and 32.4% had severe oral problems. The median scores of motor-FIM on admission and on discharge were 52 (interquartile range 25-70) and 75 (interquartile range 51-89), respectively. Multivariate analysis showed that the Revised Oral Assessment Guide score and the motor-/cognitive-FIM scores on admission were significant independent factors for motor-FIM on discharge, after adjusted for sex, age, length of stay, nutritional status, handgrip and causative diseases (P < 0.001). Poor oral status is associated with rehabilitation outcome in older people. Geriatr Gerontol Int 2017; 17: 598-604. © 2016 Japan Geriatrics Society.

Phenotypic characterization of X-linked retinoschisis: Clinical, electroretinography, and optical coherence tomography variables

PubMed Central

Neriyanuri, Srividya; Dhandayuthapani, Sudha; Arunachalam, Jayamuruga Pandian; Raman, Rajiv

2016-01-01

Aims: To study the phenotypic characteristics of X-linked retinoschisis (XLRS) and report the clinical, electroretinogram (ERG), and optical coherence tomography (OCT) variables in Indian eyes. Design: A retrospective study. Materials and Methods: Medical records of 21 patients with retinoschisis who were genetically confirmed to have RS1 mutation were reviewed. The phenotype characterization included the age of onset, best-corrected visual acuity, refractive error, fundus findings, OCT, and ERG. Statistical Analysis Used: Data from both the eyes were used for analysis. A P < 0.05 was set as statistical significance. Data were not normally distributed (P < 0.05, Shapiro wilk); hence, nonparametric tests were used for statistical analysis. Results: All were males whose mean age of presentation was 9 years. Visual acuity was moderately impaired (median 0.6 logMAR, interquartile range: 0.47, 1) in these eyes with a hyperopic refractive error of median +1.75 Ds (interquartile range: +0.50 Ds, +4.25 Ds). About 54.7% of the eyes had both foveal and peripheral schisis, isolated foveal schisis was seen in 28.5% of the eyes, and schisis with retinal detachment was seen in 16.6% of the eyes. The inner nuclear layer was found to be commonly involved in the schisis, followed by outer nuclear and plexiform layers as evident on OCT. On ERG, a- and b-wave amplitudes were significantly reduced in eyes with foveal and peripheral schisis when compared to the eyes with only foveal schisis (P < 0.05). Conclusions: XLRS has phenotypic heterogeneity as evident on OCT, ERG, and clinical findings. PMID:27609164

Overview of water resources in and near Wichita and Affiliated Tribes treaty lands in western Oklahoma

USGS Publications Warehouse

Abbott, Marvin M.; Tortorelli, R.L.; Becker, M.F.; Trombley, T.J.

2003-01-01

This report is an overview of water resources in and near the Wichita and Affiliated Tribes treaty lands in western Oklahoma. The tribal treaty lands are about 1,140 square miles and are bordered by the Canadian River on the north, the Washita River on the south, 98? west longitude on the east, and 98? 40' west longitude on the west. Seventy percent of the study area lies within the Washita River drainage basin and 30 percent of the area lies within the Canadian River drainage basin. March through June are months of greatest average streamflow, with 49 to 57 percent of the annual streamflow occurring in these four months. November through February, July, and August have the least average streamflow with only 26 to 36 percent of the annual streamflow occurring in these six months. Two streamflow-gaging stations, Canadian River at Bridgeport and Cobb Creek near Fort Cobb, indicated peak streamflows generally decrease with regulation. Two other streamflow-gaging stations, Washita River at Carnegie and Washita River at Anadarko, indicated a decrease in peak streamflows after regulation at less than the 100-year recurrence and an increase in peak streamflows greater than the 100-year recurrence. Canadian River at Bridgeport and Washita River at Carnegie had estimated annual low flows that generally increased with regulation. Cobb Creek near Fort Cobb had a decrease of estimated annual low flows after regulation. There are greater than 900 ground-water wells in the tribal treaty lands. Eighty percent of the wells are in Caddo County.The major aquifers in the study area are the Rush Springs Aquifer and portions of the Canadian River and Washita River valley alluvial aquifers. The Rush Springs Aquifer is used extensively for irrigation as well as industrial and municipal purposes, especially near population centers.The Canadian River and Washita River valley alluvial aquifers are not used extensively in the study area. Well yields from the Rush Springs Aquifer ranged from 11 to greater than 850 gallons per minute. The Rush Springs Aquifer is recharged by the infiltration of precipitation. The estimated recharge is about 1.80 inches per year evenly distributed over the outcrop of the aquifer in the study area. Principal factors affecting the water quality in the study area include geology, agricultural practices,and oil and gas production. Calcium, magnesium, sulfate, and bicarbonate are the dominant dissolved constituents in water in the study area. Interquartile dissolved-solids concentrations in surface-water samples in the study area generally were greater than interquartile concentrations in ground-water samples. Median dissolved-solids concentrations for ground-water samples from Canadian River, Ionine Creek, Spring Creek,and Washita River Basins, which ranged from 535 to 1,195 milligrams per liter,exceeded the U.S. Environmental Protection Agency Secondary Drinking Water Standard of 500 milligrams per liter. Interquartile sulfate concentrations in surface-water samples in the study area generally were greater than interquartile concentrations in ground-water samples. Median sulfate concentrations from ground-water samples in the Canadian River, IonineCreek,and Spring Creek Basins, which ranged from 385 to 570 milligrams per liter, exceeded the U.S. Environmental Protection Agency Secondary Drinking Water Standard of 250 milligrams per liter. Nitrite plus nitrate as nitrogen concentrations in surface-water samples in the study area generally were less than concentrations in ground-water samples. The median nitrite plus nitrate as nitrogen concentration in ground water was 9.8 milligrams per liter, suggesting almost one-half the ground-water samples exceeded the U.S. Environmental Protection Agency Primary Drinking Water Standard (10 milligrams per liter). An estimated 100 million gallons of water per day were withdrawn from surface and ground water for all uses in

Traffic-related air pollution and spectacles use in schoolchildren

PubMed Central

Nieuwenhuijsen, Mark J.; Basagaña, Xavier; Alvarez-Pedrerol, Mar; Dalmau-Bueno, Albert; Cirach, Marta; Rivas, Ioar; Brunekreef, Bert; Querol, Xavier; Morgan, Ian G.; Sunyer, Jordi

2017-01-01

Purpose To investigate the association between exposure to traffic-related air pollution and use of spectacles (as a surrogate measure for myopia) in schoolchildren. Methods We analyzed the impact of exposure to NO2 and PM2.5 light absorbance at home (predicted by land-use regression models) and exposure to NO2 and black carbon (BC) at school (measured by monitoring campaigns) on the use of spectacles in a cohort of 2727 schoolchildren (7–10 years old) in Barcelona (2012–2015). We conducted cross-sectional analyses based on lifelong exposure to air pollution and prevalent cases of spectacles at baseline data collection campaign as well as longitudinal analyses based on incident cases of spectacles use and exposure to air pollution during the three-year period between the baseline and last data collection campaigns. Logistic regression models were developed to quantify the association between spectacles use and each of air pollutants adjusted for relevant covariates. Results An interquartile range increase in exposure to NO2 and PM2.5 absorbance at home was respectively associated with odds ratios (95% confidence intervals (CIs)) for spectacles use of 1.16 (1.03, 1.29) and 1.13 (0.99, 1.28) in cross-sectional analyses and 1.15 (1.00, 1.33) and 1.23 (1.03, 1.46) in longitudinal analyses. Similarly, odds ratio (95% CIs) of spectacles use associated with an interquartile range increase in exposures to NO2 and black carbon at school was respectively 1.32 (1.09, 1.59) and 1.13 (0.97, 1.32) in cross-sectional analyses and 1.12 (0.84, 1.50) and 1.27 (1.03, 1.56) in longitudinal analyses. These findings were robust to a range of sensitivity analyses that we conducted. Conclusion We observed increased risk of spectacles use associated with exposure to traffic-related air pollution. These findings require further confirmation by future studies applying more refined outcome measures such as quantified visual acuity and separating different types of refractive errors. PMID:28369072

Anti-TNF-α therapy in refractory uveitis associated with sarcoidosis: Multicenter study of 17 patients.

PubMed

Riancho-Zarrabeitia, Leyre; Calvo-Río, Vanesa; Blanco, Ricardo; Mesquida, Marina; Adan, Alfredo M; Herreras, José M; Aparicio, Ángel; Peiteado-Lopez, Diana; Cordero-Coma, Miguel; García Serrano, José Luis; Ortego-Centeno, Norberto; Maíz, Olga; Blanco, Ana; Sánchez-Bursón, Juan; González-Suárez, Senén; Fonollosa, Alejandro; Santos-Gómez, Montserrat; González-Vela, Carmen; Loricera, Javier; Pina, Trinitario; González-Gay, Miguel A

2015-12-01

To assess anti-TNF-α therapy response in uveitis associated with sarcoidosis refractory to conventional immunosuppressive therapy. Open-label, multicenter, retrospective study on patients with sarcoid uveitis who underwent anti-TNF-α therapy because of inadequate response to conventional therapy including corticosteroids and at least 1 systemic synthetic immunosuppressive drug. The main outcome measurements were degree of anterior and posterior chamber inflammation, visual acuity, macular thickness, and immunosuppression load. A total of 17 patients (8 men; 29 affected eyes; mean ± standard deviation age 38.4 ± 16.8; range: 13-76 years) were studied. The patients had bilateral hilar lymphadenopathy (58.8%), lung parenchyma involvement (47.1%), peripheral lymph nodes (41.2%), and involvement of other organs (52.9%). Angiotensin-converting enzyme was elevated in 58.8%. The most frequent ocular pattern was bilateral chronic relapsing panuveitis. The first biologic agent used was adalimumab in 10 (58.8%) and infliximab in 7 (41.2%) cases. Infliximab 5mg/kg intravenously every 4-8 weeks and adalimumab 40mg subcutaneously every 2 weeks were the most common administration patterns. In most cases anti-TNF-α therapy was given in combination with immunosuppressive drugs. The mean duration of follow-up was 33.9 ± 17.1 months. Significant improvement was observed following anti-TNF-α therapy. Baseline results versus results at 2 years from the onset of biologic therapy were the following: the median of cells in the ocular anterior chamber (interquartile range-IQR) 0.5 (0-2) versus 0 (0-0) (p = 0.003), vitritis 0 (0-1.25) versus 0 (0-0) (p = 0.008), macular thickness (391.1 ± 58.8 versus 247 ± 40.5µm) (p = 0.028), and visual acuity 0.60 ± 0.33 versus 0.74 ± 0.27; p = 0.009. The median daily (interquartile range) dose of prednisone was also reduced from 10 (0-30)mg at the onset of the anti-TNF-α therapy to 0 (0-0)mg at 2 years (p = 0.02). Significant reduction was also achieved in the immunosuppressive load. Anti-TNF-α therapy is effective in sarcoid uveitis patients refractory to conventional immunosuppressive therapy. Infliximab and adalimumab allowed a substantial reduction in prednisone dose despite having failed standard therapy. Copyright © 2015 Elsevier Inc. All rights reserved.

Macrolide therapy is associated with reduced mortality in acute respiratory distress syndrome (ARDS) patients.

PubMed

Simonis, Fabienne D; de Iudicibus, Gianfranco; Cremer, Olaf L; Ong, David S Y; van der Poll, Tom; Bos, Lieuwe D; Schultz, Marcus J

2018-01-01

Macrolides have been associated with favorable immunological effects in various inflammatory disease states. We investigated the association between macrolide therapy and mortality in patients with the acute respiratory distress syndrome (ARDS). This was an unplanned secondary analysis of patients with ARDS within a large prospective observational study of critically ill patients in the intensive care units (ICUs) of two university-affiliated hospitals in the Netherlands. The exposure of interest was low-dose macrolide use prescribed for another reason than infection; we excluded patients who received high-dose macrolides for an infection. The primary endpoint was 30-day mortality. The association between macrolide therapy and mortality was determined in the whole cohort, as well as in a propensity score matched cohort; the association was compared between pulmonary versus non-pulmonary ARDS, and between two biological phenotypes based on plasma levels of 20 biomarkers. In total, 873 patients with ARDS were analyzed, of whom 158 patients (18%) received macrolide therapy during stay in ICU for a median duration of 3 (interquartile range, 1-4) days. Erythromycin was the most frequent prescribed macrolide (97%). Macrolide therapy was associated with reduced 30-day mortality in the whole cohort [22.8% vs. 31.6%; crude odds ratio (OR), 0.64 (interquartile range, 0.43-0.96), P=0.03]. The association in the propensity score matched cohort remained significant [22.8% vs. 32.9%; OR, 0.62 (interquartile range, 0.39-0.96), P=0.03]. Propensity matched associations with mortality were different in patients with non-pulmonary ARDS vs. pulmonary ARDS and also varied by biological phenotype. These data together show that low-dose macrolide therapy prescribed for another reason than infection is associated with decreased mortality in patients with ARDS.

Liposomal Bupivacaine Block at the Time of Cesarean Delivery to Decrease Postoperative Pain: A Randomized Controlled Trial.

PubMed

Prabhu, Malavika; Clapp, Mark A; McQuaid-Hanson, Emily; Ona, Samsiya; OʼDonnell, Taylor; James, Kaitlyn; Bateman, Brian T; Wylie, Blair J; Barth, William H

2018-07-01

To evaluate whether a liposomal bupivacaine incisional block decreases postoperative pain and represents an opioid-minimizing strategy after scheduled cesarean delivery. In a single-blind, randomized controlled trial among opioid-naive women undergoing cesarean delivery, liposomal bupivacaine or placebo was infiltrated into the fascia and skin at the surgical site, before fascial closure. Using an 11-point numeric rating scale, the primary outcome was pain score with movement at 48 hours postoperatively. A sample size of 40 women per group was needed to detect a 1.5-point reduction in pain score in the intervention group. Pain scores and opioid consumption, in oral morphine milligram equivalents, at 48 hours postoperatively were summarized as medians (interquartile range) and compared using the Wilcoxon rank-sum test. Between March and September 2017, 249 women were screened, 103 women enrolled, and 80 women were randomized. One woman in the liposomal bupivacaine group was excluded after randomization as a result of a vertical skin incision, leaving 39 patients in the liposomal bupivacaine group and 40 in the placebo group. Baseline characteristics between groups were similar. The median (interquartile range) pain score with movement at 48 hours postoperatively was 4 (2-5) in the liposomal bupivacaine group and 3.5 (2-5.5) in the placebo group (P=.72). The median (interquartile range) opioid use was 37.5 (7.5-60) morphine milligram equivalents in the liposomal bupivacaine group and 37.5 (15-75) morphine milligram equivalents in the placebo group during the first 48 hours postoperatively (P=.44). Compared with placebo, a liposomal bupivacaine incisional block at the time of cesarean delivery resulted in similar postoperative pain scores in the first 48 hours postoperatively. ClinicalTrials.gov, NCT02959996.

Response to Antimalarials in Cutaneous Lupus Erythematosus A Prospective Analysis

PubMed Central

Chang, Aileen Y.; Piette, Evan W.; Foering, Kristen P.; Tenhave, Thomas R.; Okawa, Joyce; Werth, Victoria P.

2012-01-01

Objective To demonstrate response to antimalarials in patients with cutaneous lupus erythematosus using activity scores from the Cutaneous Lupus Erythematosus Disease Area and Severity Index, a validated outcome measure. Design Prospective, longitudinal cohort study. Setting University cutaneous autoimmune disease clinic. Participants One hundred twenty-eight patients with cutaneous lupus erythematosus who presented from January 2007-July 2010 and had at least 2 visits with activity scores. Main Outcome Measures Response defined by 4-point or 20% decrease in activity score. Response to initiation determined with score before treatment and first visit at least 2 months after treatment. Response to continuation determined with score at first visit and most recent visit on treatment. Results Of 11 patients initiated on hydroxychloroquine, 55% were responders with a decrease in median (interquartile range) activity score from 8.0 (3.5-13) to 3.0 (1.8-7.3) (p=0.03). Of 15 patients who had failed hydroxychloroquine, 67% were responders to initiation of hydroxychloroquine-quinacrine, with a decrease in median (interquartile range) activity score from 6.0 (4.8-8.3) to 3.0 (0.75-5.0) (p=0.004). Nine out of 21 patients (43%) continued on hydroxychloroquine and 9 out of 21 patients (43%) continued on hydroxychloroquine-quinacrine were responders with a decrease in median (interquartile range) activity score from 6.0 (1.5-9.5) to 1.0 (0-4.5) (p=0.009) and 8.5 (4.25-17.5) to 5.0 (0.5-11.5) (p=0.01), respectively. Conclusion The use of quinacrine with hydroxychloroquine is associated with response in patients who fail hydroxychloroquine monotherapy. Further reduction in disease activity can be associated with continuation of antimalarials. PMID:21768444

Novel dry cryotherapy system for cooling the equine digit

PubMed Central

Stefanovski, Darko; Lenfest, Margret; Chatterjee, Sraboni; Orsini, James

2018-01-01

Objectives Digital cryotherapy is commonly used for laminitis prophylaxis and treatment. Currently validated methods for distal limb cryotherapy involve wet application or compression technology. There is a need for a practical, affordable, dry cryotherapy method that effectively cools the digit. The objective of this study was to evaluate the hoof wall surface temperatures (HWSTs) achieved with a novel dry cryotherapy technology. Design Repeated-measures in vivo experimental study. Setting Experimental intervention at a single site. Participants 6 systemically healthy horses (3 mares, 3 geldings). Interventions Cryotherapy was applied to six horses for eight hours with a commercially available rubber and rubber and welded fabricice boot, which extended proximally to include the foot and pastern. Reusable malleable cold therapy packs were secured against the foot and pastern with the three built-in hook-and-loop fastener panels. Primary and secondary outcome measures HWST and pastern surface temperature of the cryotherapy-treated limb, HWST of the control limb and ambient temperature were recorded every five minutes throughout the study period. Results Results were analysed with mixed-effects multivariable regression analysis. The HWST (median 11.1°C, interquartile range 8.6°C–14.7°C) in the cryotherapy-treated limb was significantly decreased compared with the control limb (median 29.7°C, interquartile range 28.9°C–30.4°C) (P≤0.001). Cryotherapy limb HWST reached a minimum of 6.75°C (median) with an interquartile range of 4.1°C–9.3°C. Minimum HWST was achieved 68 minutes after cryotherapy pack application. Conclusions Dry application of cryotherapy significantly reduced HWST and reached minimums below the therapeutic target of 10°C. This cryotherapy method might offer an effective alternative for digital cooling. PMID:29344364

Diagnostic Delay among Adults with Pulmonary Tuberculosis in a High Gross Domestic Product Per Capita Country: Reasons and Magnitude of the Problem.

PubMed

Ibrahim, Wanis H; Alousi, Faraj H; Al-Khal, Abdulatif; Bener, Abdulbari; AlSalman, Ahmed; Aamer, Aaiza; Khaled, Ahmed; Raza, Tasleem

2016-01-01

To determine the mean and median delays in pulmonary tuberculosis (PTB) diagnosis among adults in one of the world's highest gross domestic product per capita countries and identify patient and health system-related reasons for these delays. This is a cross-sectional, face-to-face, prospective study of 100 subjects with confirmed PTB, conducted at main tuberculosis (TB) admitting facilities in Qatar. The mean and median diagnostic delays were measured. The Chi-square test with two-sided P < 0.05 was considered to determine the association between factors and diagnostic delay. The mean and median total diagnostic delays of PTB were 53 (95% confidence interval [CI] 42.61-63.59) and 30 (interquartile range; Q1-Q3, 15-60) days, respectively. The mean patient factor delay was 45.7 (95% CI 28.1-63.4) days, and the median was 30 (interquartile range; Q1-Q3, 15-60) days. The mean health system factor delay was 46.3 (95% CI 35.46-57.06) days, and the median was 30 (interquartile range; Q1-Q3, 18-60) days. The most common cause of patient factor delay was neglect of TB symptoms by patients (in 39% of cases), and for health-care system factor delay was a failure (mostly at general and private care levels) to suspect PTB by doctors (in 57% of cases). There were no significant associations between the presence of language barrier, patient occupation or nationality, and diagnostic delay. Despite a favorable comparison to other countries, there is a substantial delay in the diagnosis of PTB in Qatar. Relevant actions including health education on TB are required to minimize this delay.

CDH1 gene polymorphisms, plasma CDH1 levels and risk of gastric cancer in a Chinese population.

PubMed

Zhan, Zhen; Wu, Juan; Zhang, Jun-Feng; Yang, Ya-Ping; Tong, Shujuan; Zhang, Chun-Bing; Li, Jin; Yang, Xue-Wen; Dong, Wei

2012-08-01

The genetic polymorphisms in E-cadherin gene (CDH1) may affect invasive/metastatic development of gastric cancer by altering gene transcriptional activity of epithelial cell. Our study aims to explore the associations among CDH1 gene polymorphisms, and predisposition of gastric cancer. We genotyped four potentially functional polymorphisms (rs13689, rs1801552, rs16260 and rs17690554) of the CDH1 gene in a case-control study of 387 incident gastric cancer cases and 392 healthy controls by polymerase chain reaction-ligation detection reaction methods (PCR-LDR) and measured the plasma CDH1 levels using enzyme immunoassay among the subjects. The median and inter-quartile range were adopted for representing the mean level of non-normally distributed data, and we found the level of plasma CDH1 in gastric cancer patients (median: 171.00 pg/ml; inter-quartile range: 257.10 pg/ml) were significantly higher than that of controls (median: 137.40 pg/ml; inter-quartile range: 83.90 pg/ml, P = 0.003). However, none of the four polymorphisms or their haplotypes achieved significant differences in their distributions between gastric cancer cases and controls, and interestingly, in the subgroup analysis of gastric cancer, we found that CA genotype of rs26160 and CG genotype of rs17690554 were associated with the risk of diffuse gastric cancer, compared with their wild genotypes (OR = 2.98, 95 % CI: 1.60-5.53; OR = 2.10, 95 % CI: 1.14-3.85, respectively, P < 0.05). In conclusion, our results indicated that plasma CDH1 levels may serve as a risk marker against gastric cancer and variant genotypes of rs26160 and rs17690554 may contribute to the etiology of diffuse gastric cancer in this study. Further studies are warranted to verify these findings.

Macrolide therapy is associated with reduced mortality in acute respiratory distress syndrome (ARDS) patients

PubMed Central

de Iudicibus, Gianfranco; Cremer, Olaf L.; Ong, David S. Y.; van der Poll, Tom; Bos, Lieuwe D.; Schultz, Marcus J.

2018-01-01

Background Macrolides have been associated with favorable immunological effects in various inflammatory disease states. We investigated the association between macrolide therapy and mortality in patients with the acute respiratory distress syndrome (ARDS). Methods This was an unplanned secondary analysis of patients with ARDS within a large prospective observational study of critically ill patients in the intensive care units (ICUs) of two university-affiliated hospitals in the Netherlands. The exposure of interest was low-dose macrolide use prescribed for another reason than infection; we excluded patients who received high-dose macrolides for an infection. The primary endpoint was 30-day mortality. The association between macrolide therapy and mortality was determined in the whole cohort, as well as in a propensity score matched cohort; the association was compared between pulmonary versus non-pulmonary ARDS, and between two biological phenotypes based on plasma levels of 20 biomarkers. Results In total, 873 patients with ARDS were analyzed, of whom 158 patients (18%) received macrolide therapy during stay in ICU for a median duration of 3 (interquartile range, 1–4) days. Erythromycin was the most frequent prescribed macrolide (97%). Macrolide therapy was associated with reduced 30-day mortality in the whole cohort [22.8% vs. 31.6%; crude odds ratio (OR), 0.64 (interquartile range, 0.43–0.96), P=0.03]. The association in the propensity score matched cohort remained significant [22.8% vs. 32.9%; OR, 0.62 (interquartile range, 0.39–0.96), P=0.03]. Propensity matched associations with mortality were different in patients with non-pulmonary ARDS vs. pulmonary ARDS and also varied by biological phenotype. Conclusions These data together show that low-dose macrolide therapy prescribed for another reason than infection is associated with decreased mortality in patients with ARDS. PMID:29430441

A spatiotemporal analysis of the relationship between near-surface air temperature and satellite land surface temperatures using 17 years of data from the ATSR series

NASA Astrophysics Data System (ADS)

Good, Elizabeth J.; Ghent, Darren J.; Bulgin, Claire E.; Remedios, John J.

2017-09-01

The relationship between satellite land surface temperature (LST) and ground-based observations of 2 m air temperature (T2m) is characterized in space and time using >17 years of data. The analysis uses a new monthly LST climate data record (CDR) based on the Along-Track Scanning Radiometer series, which has been produced within the European Space Agency GlobTemperature project (http://www.globtemperature.info/). Global LST-T2m differences are analyzed with respect to location, land cover, vegetation fraction, and elevation, all of which are found to be important influencing factors. LSTnight ( 10 P.M. local solar time, clear-sky only) is found to be closely coupled with minimum T2m (Tmin, all-sky) and the two temperatures generally consistent to within ±5°C (global median LSTnight-Tmin = 1.8°C, interquartile range = 3.8°C). The LSTday ( 10 A.M. local solar time, clear-sky only)-maximum T2m (Tmax, all-sky) variability is higher (global median LSTday-Tmax = -0.1°C, interquartile range = 8.1°C) because LST is strongly influenced by insolation and surface regime. Correlations for both temperature pairs are typically >0.9 outside of the tropics. The monthly global and regional anomaly time series of LST and T2m—which are completely independent data sets—compare remarkably well. The correlation between the data sets is 0.9 for the globe with 90% of the CDR anomalies falling within the T2m 95% confidence limits. The results presented in this study present a justification for increasing use of satellite LST data in climate and weather science, both as an independent variable, and to augment T2m data acquired at meteorological stations.

Increased inflammation and disease activity among current cigarette smokers with rheumatoid arthritis: a cross-sectional analysis of US veterans.

PubMed

Sokolove, Jeremy; Wagner, Catriona A; Lahey, Lauren J; Sayles, Harlan; Duryee, Michael J; Reimold, Andreas M; Kerr, Gail; Robinson, William H; Cannon, Grant W; Thiele, Geoffrey M; Mikuls, Ted R

2016-11-01

Cigarette smoking is a major risk factor for RA and has been associated with increased disease severity and lower rates of disease remission. We hypothesized that inflammation and disease activity would be associated with smoking status and this would be related to levels of ACPA. RA patients from the Veterans Affairs RA registry were studied (n = 1466): 76.9% anti-CCP2 positive, 89% male, median age 63 years (interquartile range 57-72), median disease duration 8.45 years (interquartile range 2.8-18). Baseline serum samples were evaluated for levels of anti-CCP2, RF, 19 distinct ACPAs and 17 cytokines. Smoking status at baseline was recorded as current, former or never. The association of smoking status with cytokines, autoantibodies and disease activity (DAS28) was evaluated. Among anti-CCP-positive RA patients, RA-associated cytokines (false-discovery rates q < 0.1%) and DAS28 (P < 0.01) were higher in current smokers compared with former or never smokers. DAS28 and cytokine levels were similar between former and never smokers. In contrast, ACPA concentrations were higher among both current and former smokers compared with never smokers, and levels of ACPA were not associated with DAS28 or cytokine levels. Among anti-CCP2-positive RA patients, current smoking status is associated with elevations in pro-inflammatory cytokines and increased RA disease activity. Similar levels of inflammation and disease activity among former and never smokers suggests that the detrimental effects of smoking could be ameliorated through tobacco cessation. The effect of tobacco cessation on RA disease activity should be evaluated prospectively. Published by Oxford University Press on behalf of the British Society for Rheumatology 2016. This work is written by US Government employees and is in the public domain in the United States.

Anatomic characteristics and natural history of renal artery aneurysms during longitudinal imaging surveillance.

PubMed

Wayne, Erik J; Edwards, Matthew S; Stafford, Jeanette M; Hansen, Kimberley J; Corriere, Matthew A

2014-08-01

Renal artery aneurysms (RAAs) are uncommon, and rates of growth and rupture are unknown. Limited evidence therefore exists to guide clinical management of RAAs, particularly small aneurysms that are asymptomatic. To further characterize the natural history of RAAs, we studied anatomic characteristics and changes in diameter during imaging surveillance. Patients evaluated for native RAAs at a single institution during a 5-year period (July 2008 to July 2013) were identified and analyzed retrospectively. Patients with two or more cross-sectional imaging studies (computed tomography or magnetic resonance imaging) more than 1 month apart were included. Demographic and clinical data were collected from medical records, and anatomic data (including aneurysm diameter, calcification, and location) were obtained from electronic images. Changes in RAA diameters over time were evaluated by plots and Wilcoxon signed rank tests. Sixty-eight RAAs in 55 patients were analyzed. Median follow-up was 19.4 months (interquartile range, 11.2-49.0 months). Mean age at presentation was 61.8 ± 9.8 years, and 73% of patients were women. Hypertension was prevalent among 73% of patients. Multiple RAAs were present in 18% of patients, and 24% also had arterial aneurysms of other splanchnic or iliac vessels. The majority of RAAs were calcified and located at the main renal artery bifurcation. Mean initial aneurysm diameter was 16.0 ± 6.4 mm. Median annualized growth rate was 0.06 mm (interquartile range, -0.07 to 0.33 mm; P = .11). No RAA ruptures or acute symptoms occurred during surveillance, and 10.3% of RAAs were repaired electively. Risk of short-term RAA growth or rupture was low. These findings suggest that annual (or less frequent) imaging surveillance is safe in the majority of patients and do not support pre-emptive repair of asymptomatic, small-diameter RAAs. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger.

PubMed

Hale, Diane F; Fitzpatrick, Colleen M; Doski, John J; Stewart, Ronald M; Mueller, Deborah L

2015-05-01

Increased accessibility and rapidity of computed tomography (CT) have led to increased use and radiation exposure to pediatric trauma patients. The thyroid is radiosensitive and therefore at risk for developing malignancy from radiation exposure during cervical spine CT. This analysis aimed to determine which preelementary trauma patients warrant cervical spine CT by defining incidence and clinical characteristics of preelementary cervical spine injury. This was a retrospective review of pre-elementary trauma patients from 1998 to 2010 with cervical spine injury admitted to a Level I trauma center. Patients were identified from the trauma registry using DRG International Classification of Diseases-9th Rev. codes and reviewed for demographics, mechanism of injury, clinical presentation, injury location, injury type, treatment, and outcome. A total of 2,972 preelementary trauma patients were identified. Twenty-two (0.74%) had confirmed cervical spine injuries. Eleven (50%) were boys, and the mean (SD) age was 3 (1.7) years. The most common mechanism of injury was motor vehicle collision (n = 16, 73%). The majority (59%) were in extremis, and 12 (55%) arrived intubated. The median Glasgow Coma Scale (GCS) score was 3 (interquartile range, 3-10); the median Injury Severity Score (ISS) was 33 (interquartile range, 17-56). Nineteen injuries (76%) were at the level of C4 level and higher. The mortality rate was 50%. All patients had clinical findings suggestive of or diagnostic for cervical spine injury; 18 (82%) had abnormal neurologic examination result, 2 (9%) had torticollis, and 2 (9%) had neck pain. The incidence of cervical spine injury in preelementary patients was consistent with previous reports. Missing a cervical spine injury in asymptomatic preelementary patients is extremely low. Reserving cervical spine CT to symptomatic preelementary patients would decrease unnecessary radiation exposure to the thyroid. Therapeutic study, level IV.

Swedish CDKN2A mutation carriers do not present the atypical mole syndrome phenotype.

PubMed

Nielsen, Kari; Harbst, Katja; Måsbäck, Anna; Jönsson, Göran; Borg, Ake; Olsson, Håkan; Ingvar, Christian

2010-08-01

Phenotypic characteristics were examined in melanoma-prone southern Swedish CDKN2A (p16-113insArg/p14ARF-128insSer) mutation families, in relation to the CDKN2A genotype, nevi, clinically atypical nevi (CAN) and melanoma. Individuals from eight melanoma-prone families, with index patients carrying the CDKN2A mutation, were offered skin examinations and genotyping (CDKN2A and MC1R). Ninety-three individuals above 18 years of age participated; 29 invasive melanomas in 16 patients were recorded, all in the 38 verified CDKN2A mutation carriers. Median age at diagnosis was 36 years. Several MC1R variants were observed. A significant correlation to CAN (P=0.01) and red hair colour (P=0.02) could be confirmed in melanoma patients. A positive mutation status (CDKN2A) was correlated to one or more CAN (P=0.007) but neither to blue eyes, red hair colour, heavy freckling nor high number of nevi. For mutation carriers, median total naevus count was 24 and interquartile range was 12-47 (mean 31); whereas for the whole cohort, median total naevus count was 12 and interquartile range was 5-25 (mean 22). No participant fulfilled the atypical mole syndrome phenotype criteria. Melanomas were diagnosed only in mutation carriers, and melanoma diagnosis was statistically correlated to the presence of one or more CAN and red hair colour, supporting the possible synergistic effect of a MC1R mutation on increased risk of melanoma in patients with a CDKN2A mutation. Family history, with verified tumour diagnoses, remains an important clinical tool for finding mutation carriers for referral to clinical geneticists and simultaneous presence of CAN in probable mutation carriers might strengthen this indication. The atypical mole syndrome phenotype was, however, not verified in the studied families and total naevus counts were low.

Single and multiple cardiovascular biomarkers in subjects without a previous cardiovascular event.

PubMed

Pareek, Manan; Bhatt, Deepak L; Vaduganathan, Muthiah; Biering-Sørensen, Tor; Qamar, Arman; Diederichsen, Axel Cp; Møller, Jacob Eifer; Hindersson, Peter; Leósdóttir, Margrét; Magnusson, Martin; Nilsson, Peter M; Olsen, Michael H

2017-10-01

Aims To assess the incremental value of biomarkers, including N-terminal prohormone of brain natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), growth differentiation factor 15 (GDF-15), and procollagen type 1 N-terminal propeptide (P1NP), in predicting incident cardiovascular events and mortality among asymptomatic individuals from the general population, beyond traditional risk factors, including fasting glucose and renal function (cystatin C), medication use, and echocardiographic measures. Methods and results Prospective population-based cohort study of 1324 subjects without a previous cardiovascular event, who underwent baseline echocardiography and biomarker assessment between 2002 and 2006. The clinical endpoint was the composite of myocardial infarction, invasively treated stable/unstable ischemic heart disease, heart failure, stroke, or all-cause mortality. Predictive capabilities were evaluated using Cox proportional-hazards regression, Harrell's concordance index (C-index), and net reclassification improvement. Median age was 66 (interquartile range: 60-70) years, and 413 (31%) were female. During median 8.6 (interquartile range: 8.1-9.2) follow-up years, 368 (28%) composite events occurred. NT-proBNP, hs-TnT, GDF-15, and IL-6 were significantly associated with outcome, independently of traditional risk factors, medications, and echocardiography ( p < 0.05 for all). Separate addition of NT-proBNP and GDF-15 to traditional risk factors, medications, and echocardiographic measurements provided significant improvements in discriminative ability (NT-proBNP: C-index 0.714 vs. 0.703, p = 0.03; GDF-15: C-index 0.721 vs. 0.703, p = 0.02). Both biomarkers remained significant predictors of outcome upon inclusion in the same model ( p < 0.05 for both). Conclusions NT-proBNP and GDF-15 each enhance prognostication beyond traditional risk factors, glucose levels, renal function, and echocardiography in individuals without known cardiovascular disease.

Body temperature change and outcomes in patients undergoing long-distance air medical transport.

PubMed

Nakajima, Mikio; Aso, Shotaro; Yasunaga, Hideo; Shirokawa, Masamitsu; Nakano, Tomotsugu; Miyakuni, Yasuhiko; Goto, Hideaki; Yamaguchi, Yoshihiro

2018-04-30

Short-distance air medical transport for adult emergency patients does not significantly affect patients' body temperature and outcomes. This study aimed to examine the influence of long-distance air medical transport on patients' body temperatures and the relationship between body temperature change and mortality. We retrospectively enrolled consecutive patients transferred via helicopter or plane from isolated islands to an emergency medical center in Tokyo, Japan between April 2010 and December 2016. Patients' average body temperature was compared before and after air transport using a paired t-test, and corrections between body temperature change and flight duration were calculated using Pearson's correlation coefficient. Multivariable logistic regression models were then used to examine the association between body temperature change and in-hospital mortality. Of 1253 patients, the median age was 72 years (interquartile range, 60-82 years) and median flight duration was 71 min (interquartile range, 54-93 min). In-hospital mortality was 8.5%, and average body temperature was significantly different before and after air transport (36.7 °C versus 36.3 °C; difference: -0.36 °C; 95% confidence interval, -0.30 to -0.42; p < 0.001). There was no correlation between body temperature change and flight duration (r = 0.025, p = 0.371). In-hospital death was significantly associated with (i) hyperthermia (>38.0 °C) or normothermia (36.0-37.9 °C) before air transport and hypothermia after air transport (odds ratio, 2.08; 95% confidence interval, 1.20-3.63; p = 0.009), and (ii) winter season (odds ratio, 2.15; 95% confidence interval, 1.08-4.27; p = 0.030). Physicians should consider body temperature change during long-distance air transport in patients with not only hypothermia but also normothermia or hyperthermia before air transport, especially in winter. Copyright © 2018 Elsevier Inc. All rights reserved.

Children's intake of fruit and selected energy-dense nutrient-poor foods is associated with fathers' intake.

PubMed

Hall, Laura; Collins, Clare E; Morgan, Philip J; Burrows, Tracy L; Lubans, David R; Callister, Robin

2011-07-01

Parental dietary intake, lifestyle behavior, and parenting style influence a child's weight status. Few studies have examined associations between parent-child dietary intake, or specific father-child associations. This cross-sectional study examined associations between father-child dietary intakes of fruit, vegetables, and selected energy-dense nutrient-poor foods. The study population consisted of overweight fathers with 50 father-child dyads included in the analysis; median (interquartile range) age of fathers was 39±8.0 years; body mass index was 32.7±5.3; and their primary school-aged children (n=50) (54% boys aged 8.5±3.0 years, body mass index z score 0.6±1.6) who had been targeted to participate in the Healthy Dads, Healthy Kids pilot trial in the Hunter region, New South Wales, Australia in 2008. Dietary intakes of fathers and children were assessed using validated food frequency questionnaires, with mothers reporting their child's food intake. Descriptive statistics were reported and Spearman's rank order correlations used to test the strength of associations between father-child intakes. Fathers' median (interquartile range) daily fruit and vegetable intakes were 0.9 (1.5) and 2.2 (1.3) servings/day, respectively, whereas children consumed 2.1 (2.4) fruit and 2.9 (2.1) vegetable servings/day. Moderately-strong positive correlations were found between father-child fruit intakes (r=0.40, P<0.01), cookies (r=0.54, P<0.001), and potato chips (r=0.33, P<0.05). There were no associations between intakes of vegetables, ice cream, chocolate, or french fries (P>0.05). Children's intakes of fruit and some energy-dense nutrient-poor foods but not vegetables were related to their father's intakes. The targeting of fathers should be tested in experimental studies as a potential strategy to improve child and family eating habits. Copyright © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.

Medical nutrition therapy is the essential cornerstone for effective treatment of "refractory" severe hypertriglyceridemia regardless of pharmaceutical treatment: Evidence from a Lipid Management Program.

PubMed

Rhodes, Katherine S; Weintraub, Martha; Marchlewicz, Elizabeth H; Rubenfire, Melvyn; Brook, Robert D

2015-01-01

Patients with refractory severe hypertriglyceridemia are at risk of pancreatitis and cardiovascular disease. The role of individualized nutrition therapy in these patients independent of pharmaceutical treatment has not been documented. To document the effect of nutrition intervention on severe hypertriglyceridemia regardless of medication status or prior nutrition counseling. Outcomes of new patients with triglycerides ≥ 500 mg/dL presenting to a Lipid Management Program over a 6-year period were tracked. Patients received comprehensive laboratory assessment, nutrition assessment, and initiation of an individualized diet intervention before seeing the lipidologist. Clinical and behavioral outcomes were recorded. In all, 168 patients (117 men; mean age, 49.03 ± 11.22 years; body mass index, 32.61 ± 5.85 kg/m(2); 110 (65.5%) on lipid-lowering medications) returned for assessment of nutrition intervention. Triglycerides were reduced from median (interquartile range) 961.5 (611.5-1785.3) to 493.0 (337-736.3) mg/dL (P < .0001 for log transformation of triglycerides). There was no difference in median percentage reduction in triglycerides after nutrition intervention between those not on lipid-lowering medication, on a fibric acid derivative, on other lipid-lowering medication, or on a combination of lipid-lowering medications (P = .376) in a median (interquartile range) of 5 (3-7) weeks. Effect was independent of prior nutrition counseling (P = .260). Reported percentage fat in the diet at second visit correlated with log-transformed triglycerides achieved, independent of initial triglycerides level (r = 0.290; P = .001). Individualized nutrition therapy results in changes in eating behavior and reductions in triglyceride levels in patients with refractory severe hypertriglyceridemia independent of lipid-lowering medication(s) and prior nutrition counseling. Copyright © 2015 National Lipid Association. Published by Elsevier Inc. All rights reserved.

Presence of post-systolic shortening is an independent predictor of heart failure in patients following ST-segment elevation myocardial infarction.

PubMed

Brainin, Philip; Haahr-Pedersen, Sune; Sengeløv, Morten; Olsen, Flemming Javier; Fritz-Hansen, Thomas; Jensen, Jan Skov; Biering-Sørensen, Tor

2018-05-01

Following an ischemic event post systolic shortening (PSS) may occur. We investigated the association between PSS in patients with ST-segment elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) and occurrence of cardiovascular events at follow-up. A total of 373 patients admitted with STEMI and treated with pPCI were prospectively included in the study cohort. All patients were examined by echocardiography a median of 2 days after admission (interquartile range, 1-3 days). PSS was measured by color tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in six myocardial walls from all three apical projections. During a median follow-up period of 5.4 years (interquartile range, 4.1-6.0 years), 180 events occurred: 59 deaths, 70 heart failures (HF) and 51 new myocardial infarctions (MI). In multivariable analysis adjusting for: age, sex, peak troponin, left ventricle ejection fraction, TIMI flow grade, left ventricle mass index, hypertension and diabetes, presence of PSS by TDI in the culprit region was associated with a nearly twofold increased risk of HF (HR 1.90, 95% CI 1.02-3.53, P = 0.043) and the risk of HF increased incrementally with increasing numbers of walls displaying PSS. The increased risk of HF was confirmed when assessing the post-systolic index by STE (HR 1.29 95% CI 1.09-1.53, P = 0.003, per 1% increase). A regional analysis showed that PSS by TDI in the septal wall was the strongest predictor of HF (HR 1.77, 95% CI 1.08-2.92, P = 0.024). Presence of PSS was not associated with increased risk of death or MI. In patients with STEMI treated with pPCI, the presence of PSS examined by TDI and STE provides prognostic information on development of HF. Presence of PSS in the septal wall is the strongest predictor of HF.

Impact of Insurance Provider on Overall Costs in Failed Back Surgery Syndrome: A Cost Study of 122,827 Patients.

PubMed

Elsamadicy, Aladine A; Farber, Samuel Harrison; Yang, Siyun; Hussaini, Syed Mohammed Qasim; Murphy, Kelly R; Sergesketter, Amanda; Suryadevara, Carter M; Pagadala, Promila; Parente, Beth; Xie, Jichun; Lad, Shivanand P

2017-06-01

Failed back surgery syndrome (FBSS) affects 40% of patients following spine surgery with estimated costs of $20 billion to the US health care system. The aim of this study was to assess the cost differences across the different insurance providers for FBSS patients. A retrospective longitudinal study was performed using the Truven MarketScan ® database to identify FBSS patients from 2001 to 2012. Patients were grouped into Commercial, Medicaid, or Medicare cohorts. We collected one-year prior to FBSS diagnosis (baseline), then at year of spinal cord stimulation (SCS)-implantation and nine-year post-SCS implantation cost outcomes. We identified 122,827 FBSS patients, with 117,499 patients who did not undergo an SCS-implantation (Commercial: n = 49,075, Medicaid: n = 23,180, Medicare: n = 45,244) and 5328 who did undergo an SCS implantation (Commercial: n = 2279, Medicaid: n = 1003, Medicare: n = 2046). Baseline characteristics were similar between the cohorts, with the Medicare-cohort being significantly older. Over the study period, there were significant differences in overall cost metrics between the cohorts who did not undergo SCS implantation with the Medicaid-cohort had the lowest annual median (interquartile range) total cost (Medicaid: $4530.4 [$1440.6, $11,973.5], Medicare: $7292.0 [$3371.4, $13,989.4], Commercial: $4944.3 [$363.8, $13,294.0], p < 0.0001). However, when comparing the patients who underwent SCS implantation, the commercial-cohort had the lowest annual median (interquartile range) total costs (Medicaid: $4045.6 [$1146.9, $11,533.9], Medicare: $7158.1 [$3160.4, $13,916.6], Commercial: $2098.1 [$0.0, $8919.6], p < 0.0001). Our study demonstrates a significant difference in overall costs between various insurance providers in the management of FBSS, with Medicaid-insured patients having lower overall costs compared to Commercial- and Medicare-patients. SCS is cost-effective across all insurance groups (Commercial > Medicaid > Medicare) beginning at two years and continuing through nine-year follow-up. Further studies are necessary to understand the cost differences between these insurance providers, in hopes of reducing unnecessary health care expenditures for patients with FBSS. © 2017 International Neuromodulation Society.

Excessive daytime sleepiness and falls among older men and women: cross-sectional examination of a population-based sample.

PubMed

Hayley, Amie C; Williams, Lana J; Kennedy, Gerard A; Holloway, Kara L; Berk, Michael; Brennan-Olsen, Sharon L; Pasco, Julie A

2015-07-05

Excessive daytime sleepiness (EDS) has been associated with an increased risk for falls among clinical samples of older adults. However, there is little detailed information among population-representative samples. The current study aimed to assess the relationship between EDS and falls among a cohort of population-based older adults. This study assessed 367 women aged 60-93 years (median 72, interquartile range 65-79) and 451 men aged 60-92 years (median 73, interquartile range 66-80) who participated in the Geelong Osteoporosis Study between the years 2001 and 2008. Falls during the prior year were documented via self-report, and for men, falls risk score was obtained using an Elderly Fall Screening Test (EFST). Sleepiness was assessed using the Epworth Sleepiness Scale (ESS), and scores of  ≥ 10 indicated EDS. Differences among those with and without EDS in regard to falls were tested using logistic regression models. Among women, 50 (13.6%) individuals reported EDS. Women with EDS were more likely to report a fall, and were more likely to report the fall occurring outside. EDS was similarly associated with an increased risk of a fall following adjustment for use of a walking aid, cases of nocturia and antidepressant medication use (adjusted OR = 2.54, 95% CI 1.24-5.21). Multivariate modelling revealed antidepressant use (current) as an effect modifier (p < .001 for the interaction term). After stratifying the data by antidepressant medication use, the association between EDS and falls was sustained following adjustment for nocturia among antidepressant non-users (adjusted OR = 2.63, 95% CI 1.31-5.30). Among men, 72 (16.0%) individuals reported EDS. No differences were detected for men with and without EDS in regard to reported falls, and a trend towards significance was noted between EDS and a high falls risk as assessed by the EFST (p = 0.06), however, age explained this relationship (age adjusted OR = 2.20, 95% CI 1.03-1.10). For women, EDS is independently associated with at least one fall during the previous year, and this is more likely to occur whilst located outside. Amelioration of EDS may assist in improving functional outcomes among these individuals by reducing the risk for falls.

Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football

PubMed Central

Mez, Jesse; Daneshvar, Daniel H.; Kiernan, Patrick T.; Abdolmohammadi, Bobak; Alvarez, Victor E.; Huber, Bertrand R.; Alosco, Michael L.; Solomon, Todd M.; Nowinski, Christopher J.; McHale, Lisa; Cormier, Kerry A.; Kubilus, Caroline A.; Martin, Brett M.; Murphy, Lauren; Baugh, Christine M.; Montenigro, Phillip H.; Chaisson, Christine E.; Tripodis, Yorghos; Kowall, Neil W.; Weuve, Jennifer; McClean, Michael D.; Cantu, Robert C.; Goldstein, Lee E.; Katz, Douglas I.; Stern, Robert A.; Stein, Thor D.; McKee, Ann C.

2018-01-01

IMPORTANCE Players of American football may be at increased risk of long-term neurological conditions, particularly chronic traumatic encephalopathy (CTE). OBJECTIVE To determine the neuropathological and clinical features of deceased football players with CTE. DESIGN, SETTING, AND PARTICIPANTS Case series of 202 football players whose brains were donated for research. Neuropathological evaluations and retrospective telephone clinical assessments (including head trauma history) with informants were performed blinded. Online questionnaires ascertained athletic and military history. EXPOSURES Participation in American football at any level of play. MAIN OUTCOMES AND MEASURES Neuropathological diagnoses of neurodegenerative diseases, including CTE, based on defined diagnostic criteria; CTE neuropathological severity (stages I to IV or dichotomized into mild [stages I and II] and severe [stages III and IV]); informant-reported athletic history and, for players who died in 2014 or later, clinical presentation, including behavior, mood, and cognitive symptoms and dementia. RESULTS Among 202 deceased former football players (median age at death, 66 years [interquartile range, 47–76 years]), CTE was neuropathologically diagnosed in 177 players (87%; median age at death, 67 years [interquartile range, 52–77 years]; mean years of football participation, 15.1 [SD, 5.2]), including 0 of 2 pre–high school, 3 of 14 high school (21%), 48 of 53 college (91%), 9 of 14 semiprofessional (64%), 7 of 8 Canadian Football League (88%), and 110 of 111 National Football League (99%) players. Neuropathological severity of CTE was distributed across the highest level of play, with all 3 former high school players having mild pathology and the majority of former college (27 [56%]), semiprofessional (5 [56%]), and professional (101 [86%]) players having severe pathology. Among 27 participants with mild CTE pathology, 26 (96%) had behavioral or mood symptoms or both, 23 (85%) had cognitive symptoms, and 9 (33%) had signs of dementia. Among 84 participants with severe CTE pathology, 75 (89%) had behavioral or mood symptoms or both, 80 (95%) had cognitive symptoms, and 71 (85%) had signs of dementia. CONCLUSIONS AND RELEVANCE In a convenience sample of deceased football players who donated their brains for research, a high proportion had neuropathological evidence of CTE, suggesting that CTE may be related to prior participation in football. PMID:28742910

Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study.

PubMed

Hasler, Rebecca M; Exadaktylos, Aristomenis K; Bouamra, Omar; Benneker, Lorin M; Clancy, Mike; Sieber, Robert; Zimmermann, Heinz; Lecky, Fiona

2012-04-01

Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma. This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury. A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥ 65 years (odds ratio [OR], 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury. 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥ 35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement.

Automated external defibrillators and simulated in-hospital cardiac arrests.

PubMed

Rossano, Joseph W; Jefferson, Larry S; Smith, E O'Brian; Ward, Mark A; Mott, Antonio R

2009-05-01

To test the hypothesis that pediatric residents would have shorter time to attempted defibrillation using automated external defibrillators (AEDs) compared with manual defibrillators (MDs). A prospective, randomized, controlled trial of AEDs versus MDs was performed. Pediatric residents responded to a simulated in-hospital ventricular fibrillation cardiac arrest and were randomized to using either an AED or MD. The primary end point was time to attempted defibrillation. Sixty residents, 21 (35%) interns, were randomized to 2 groups (AED = 30, MD = 30). Residents randomized to the AED group had a significantly shorter time to attempted defibrillation [median, 60 seconds (interquartile range, 53 to 71 seconds)] compared with those randomized to the MD group [median, 103 seconds (interquartile range, 68 to 288 seconds)] (P < .001). All residents in the AED group attempted defibrillation at <5 minutes compared with 23 (77%) in the MD group (P = .01). AEDs improve the time to attempted defibrillation by pediatric residents in simulated cardiac arrests. Further studies are needed to help determine the role of AEDs in pediatric in-hospital cardiac arrests.

Changing Epidemiology of Human Brucellosis, China, 1955-2014.

PubMed

Lai, Shengjie; Zhou, Hang; Xiong, Weiyi; Gilbert, Marius; Huang, Zhuojie; Yu, Jianxing; Yin, Wenwu; Wang, Liping; Chen, Qiulan; Li, Yu; Mu, Di; Zeng, Lingjia; Ren, Xiang; Geng, Mengjie; Zhang, Zike; Cui, Buyun; Li, Tiefeng; Wang, Dali; Li, Zhongjie; Wardrop, Nicola A; Tatem, Andrew J; Yu, Hongjie

2017-02-01

Brucellosis, a zoonotic disease, was made statutorily notifiable in China in 1955. We analyzed the incidence and spatial-temporal distribution of human brucellosis during 1955-2014 in China using notifiable surveillance data: aggregated data for 1955-2003 and individual case data for 2004-2014. A total of 513,034 brucellosis cases were recorded, of which 99.3% were reported in northern China during 1955-2014, and 69.1% (258, 462/374, 141) occurred during February-July in 1990-2014. Incidence remained high during 1955-1978 (interquartile range 0.42-1.0 cases/100,000 residents), then decreased dramatically in 1979-1994. However, brucellosis has reemerged since 1995 (interquartile range 0.11-0.23 in 1995-2003 and 1.48-2.89 in 2004-2014); the historical high occurred in 2014, and the affected area expanded from northern pastureland provinces to the adjacent grassland and agricultural areas, then to southern coastal and southwestern areas. Control strategies in China should be adjusted to account for these changes by adopting a One Health approach.

Short-term effects of air pollution on oxygen saturation in a cohort of senior adults in Steubenville, Ohio.

PubMed

Luttmann-Gibson, Heike; Sarnat, Stefanie Ebelt; Suh, Helen H; Coull, Brent A; Schwartz, Joel; Zanobetti, Antonella; Gold, Diane R

2014-02-01

We examine whether ambient air pollution is associated with oxygen saturation in 32 elderly subjects in Steubenville, Ohio. We used linear mixed models to examine the effects of fine particulate matter less than 2.5 μm (PM(2.5)), sulfate (SO(4)(-2)), elemental carbon, and gases on median oxygen saturation. An interquartile range increase of 13.4 μg/m in PM(2.5) on the previous day was associated with a decrease of -0.18% (95% confidence interval: -0.31 to -0.06) and a 5.1 μg/m(3) interquartile range increase in SO(4)(-2) on the previous day was associated with a decrease of -0.16% (95% confidence interval: -0.27 to -0.04) in oxygen saturation during the initial 5-minute rest period of the protocol. Increased exposure to air pollution, including the nontraffic pollutant SO(4)(-2) from industrial sources, led to changes in oxygen saturation that may reflect particle-induced pulmonary inflammatory or vascular responses.

Cancer patient experience, hospital performance and case mix: evidence from England.

PubMed

Abel, Gary A; Saunders, Catherine L; Lyratzopoulos, Georgios

2014-01-01

  This study aims to explore differences between crude and case mix-adjusted estimates of hospital performance with respect to the experience of cancer patients. This study analyzed the English 2011/2012 Cancer Patient Experience Survey covering all English National Health Service hospitals providing cancer treatment (n = 160). Logistic regression analysis was used to predict hospital performance for each of the 64 evaluative questions, adjusting for age, gender, ethnic group and cancer diagnosis. The degree of reclassification was explored across three categories (bottom 20%, middle 60% and top 20% of hospitals). There was high concordance between crude and adjusted ranks of hospitals (median Kendall's τ = 0.84; interquartile range: 0.82-0.88). Across all questions, a median of 5.0% (eight) of hospitals (interquartile range: 3.8-6.4%; six to ten hospitals) moved out of the extreme performance categories after case mix adjustment. In this context, patient case mix has only a small impact on measured hospital performance for cancer patient experience.

Use of HCV+ Donors Does Not Affect HCV Clearance With Directly Acting Antiviral Therapy But Shortens the Wait Time to Kidney Transplantation.

PubMed

Sawinski, Deirdre; Patel, Nikunjkumar; Appolo, Brenda; Bloom, Roy

2017-05-01

Hepatitis C virus (HCV) infection is prevalent in the renal transplant population but direct acting antiviral agents (DAA) provide an effective cure of HCV infection without risk of allograft rejection. We report our experience treating 43 renal transplant recipients with 4 different DAA regimens. One hundred percent achieved a sustained viral response by 12 weeks after therapy, and DAA regimens were well tolerated. Recipients transplanted with a HCV+ donor responded equally well to DAA therapy those transplanted with a kidney from an HCV- donor, but recipients of HCV+ organs experienced significantly shorter wait times to transplantation, 485 days (interquartile range, 228-783) versus 969 days (interquartile range, 452-2008; P = 0.02). On this basis, we advocate for a strategy of early posttransplant HCV eradication to facilitate use of HCV+ organs whenever possible. Additional studies are needed to identify the optimal DAA regimen for kidney transplant recipients, accounting for efficacy, timing relative to transplant, posttransplant clinical outcomes, and cost.

Evaluation of the Efficacy of Tranexamic Acid on the Surgical Field in Primary Cleft Palate Surgery on Children-A Prospective, Randomized Clinical Study.

PubMed

Durga, Padmaja; Raavula, Parvathi; Gurajala, Indira; Gunnam, Poojita; Veerabathula, Prardhana; Reddy, Mukund; Upputuri, Omkar; Ramachandran, Gopinath

2015-09-01

To assess the effect of tranexamic acid on the quality of the surgical field. Prospective, randomized, double-blind study. Institutional, tertiary referral hospital. American Society of Anesthesiologists physical status class I patients, aged 8 to 60 months with Group II or III (Balakrishnan's classification) clefts scheduled for cleft palate repair. Children were randomized into two groups. The control group received saline, and the tranexamic acid group received tranexamic acid 10 mg/kg as a bolus, 15 minutes before incision. Grade of surgical field on a 10-point scale, surgeon satisfaction, and primary hemorrhage. Significant improvements were noted in surgeon satisfaction and median grade of assessment of the surgical field (4 [interquartile range, 4 to 6] in the control group vs. 3 [interquartile range, 2 to 4] in the test group; P = .003) in the tranexamic acid group compared to the control group. Preincision administration of 10 mg/kg of tranexamic acid significantly improved the surgical field during cleft palate repair.

The use of composite fingerprints to quantify sediment sources in a wildfire impacted landscape, Alberta, Canada.

PubMed

Stone, M; Collins, A L; Silins, U; Emelko, M B; Zhang, Y S

2014-03-01

There is increasing global concern regarding the impacts of large scale land disturbance by wildfire on a wide range of water and related ecological services. This study explores the impact of the 2003 Lost Creek wildfire in the Crowsnest River basin, Alberta, Canada on regional scale sediment sources using a tracing approach. A composite geochemical fingerprinting procedure was used to apportion the sediment efflux among three key spatial sediment sources: 1) unburned (reference) 2) burned and 3) burned sub-basins that were subsequently salvage logged. Spatial sediment sources were characterized by collecting time-integrated suspended sediment samples using passive devices during the entire ice free periods in 2009 and 2010. The tracing procedure combines the Kruskal-Wallis H-test, principal component analysis and genetic-algorithm driven discriminant function analysis for source discrimination. Source apportionment was based on a numerical mass balance model deployed within a Monte Carlo framework incorporating both local optimization and global (genetic algorithm) optimization. The mean relative frequency-weighted average median inputs from the three spatial source units were estimated to be 17% (inter-quartile uncertainty range 0-32%) from the reference areas, 45% (inter-quartile uncertainty range 25-65%) from the burned areas and 38% (inter-quartile uncertainty range 14-59%) from the burned-salvage logged areas. High sediment inputs from burned and the burned-salvage logged areas, representing spatial source units 2 and 3, reflect the lasting effects of forest canopy and forest floor organic matter disturbance during the 2003 wildfire including increased runoff and sediment availability related to high terrestrial erosion, streamside mass wasting and river bank collapse. The results demonstrate the impact of wildfire and incremental pressures associated with salvage logging on catchment spatial sediment sources in higher elevation Montane regions where forest growth and vegetation recovery are relatively slow. Copyright © 2013 Elsevier B.V. All rights reserved.

Longitudinal association between air pollution exposure at school and cognitive development in school children over a period of 3.5 years.

PubMed

Forns, Joan; Dadvand, Payam; Esnaola, Mikel; Alvarez-Pedrerol, Mar; López-Vicente, Mònica; Garcia-Esteban, Raquel; Cirach, Marta; Basagaña, Xavier; Guxens, Mònica; Sunyer, Jordi

2017-11-01

Recently, we showed that exposure to traffic-related air pollutants (TRAPs) at school was negatively associated with cognitive development, specifically working memory and inattentiveness, in primary schoolchildren during a course of 12 months. The persistence of such associations over longer periods remains as an open question. To study the longitudinal association between TRAPs at school and cognitive development over a period of 3.5 years. Indoor and outdoor levels of TRAPs (elemental carbon (EC), dioxide nitrogen (NO 2 ), particulate matter (PM 2.5 ) from traffic sources and ultrafine particles (UFP)) were measured at 39 schools across Barcelona during 2012/2013. Working memory, as a measure of cognitive development, was evaluated 4 times in 2012/2013 assessment and was re-evaluated one more time in 2015 using computerized n-back test (3-back d' as main outcome). Linear mixed effects models were used to test the association between TRAPs and 3-back d', adding child and school as random effects to account for the multilevel nature of the data, and school air pollutants levels (one at a time) as predictor. We found detrimental associations between all TRAPs and annual change in 3-back d' (working memory) (i.e. slower development of working memory in children attending schools with higher levels of air pollution). The associations (per one interquartile range increase in exposure) were strongest for outdoor NO 2 (Coefficient (Coef) = - 4.22, 95% confidence interval (CI), - 6.22, - 2.22) and indoor UFP (Coef = - 4.12, 95%CI, - 5.68, - 1.83). These reductions were equivalent to - 20% (95%CI, - 30.1, - 10.7) and - 19.9% (95%CI, - 31.5, - 8.4) change in annual working memory development associated with one interquartile range increase in outdoor NO 2 and indoor UFP, respectively. Our findings suggest the persistence of the negative association between TRAPs exposure at school and cognitive trajectory measured by n-back test over a period of 3.5 years. Copyright © 2017 Elsevier Inc. All rights reserved.

Associations between ambient air pollution and daily mortality among elderly persons in Montreal, Quebec.

PubMed

Goldberg, Mark S; Burnett, Richard T; Stieb, David M; Brophy, James M; Daskalopoulou, Stella S; Valois, Marie-France; Brook, Jeffrey R

2013-10-01

Persons with underlying health conditions may be at higher risk for the short-term effects of air pollution. We have extended our original mortality time series study in Montreal, Quebec, among persons 65 years of age and older, for an additional 10 years (1990-2003) to assess whether these associations persisted and to investigate new health conditions. We created subgroups of subjects diagnosed with major health conditions one year before death using billing and prescription data from the Quebec Health Insurance Plan. We used parametric log-linear Poisson models within the distributed lag non-linear models framework, that were adjusted for long-term temporal trends and daily maximum temperature, for which we assessed associations with NO2, O3, CO, SO2, and particles with aerodynamic diameters 2.5 μm in diameter or less (PM2.5). We found positive associations between daily non-accidental mortality and all air pollutants but O3 (e.g., for a cumulative effect over a 3-day lag, with a mean percent change (MPC) in daily mortality of 1.90% [95% confidence interval: 0.73, 3.08%] for an increase of the interquartile range (17.56 μg m(-3)) of NO2). Positive associations were found amongst persons having cardiovascular disease (cumulative MPC for an increase equal to the interquartile range of NO2=2.67%), congestive heart failure (MPC=3.46%), atrial fibrillation (MPC=4.21%), diabetes (MPC=3.45%), and diabetes and cardiovascular disease (MPC=3.50%). Associations in the warm season were also found for acute and chronic coronary artery disease, hypertension, and cancer. There was no persuasive evidence to conclude that there were seasonal associations for cerebrovascular disease, acute lower respiratory disease (defined within 2 months of death), airways disease, and diabetes and airways disease. These data indicate that individuals with certain health conditions, especially those with diabetes and cardiovascular disease, hypertension, atrial fibrillation, and cancer, may be susceptible to the short-term effects of air pollution. © 2013 Elsevier B.V. All rights reserved.

Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study.

PubMed

Brunori, Giuliano; Viola, Battista F; Parrinello, Giovanni; De Biase, Vincenzo; Como, Giovanna; Franco, Vincenzo; Garibotto, Giacomo; Zubani, Roberto; Cancarini, Giovanni C

2007-05-01

A supplemented very-low-protein diet (sVLPD) seems to be safe when postponing dialysis therapy. Prospective multicenter randomized controlled study designed to assess the noninferiority of diet versus dialysis in 1-year mortality assessed by using intention-to-treat and per-protocol analysis. Italian uremic patients without diabetes older than 70 years with glomerular filtration rate of 5 to 7 mL/min (0.08 to 0.12 mL/s). Randomization to an sVLPD (diet group) or dialysis. The sVLPD is a vegan diet (35 kcal; proteins, 0.3 g/kg body weight daily) supplemented with keto-analogues, amino acids, and vitamins. Patients following an sVLPD started dialysis therapy in the case of malnutrition, intractable fluid overload, hyperkalemia, or appearance of uremic symptoms. Mortality, hospitalization, and metabolic markers. 56 patients were randomly assigned to each group, median follow-up was 26.5 months (interquartile range, 40), and patients in the diet group spent a median of 10.7 months (interquartile range, 11) following an sVLPD. Forty patients in the diet group started dialysis treatment because of either fluid overload or hyperkalemia. There were 31 deaths (55%) in the dialysis group and 28 deaths (50%) in the diet group. One-year observed survival rates at intention to treat were 83.7% (95% confidence interval [CI], 74.5 to 94.0) in the dialysis group versus 87.3% (95% CI, 78.9 to 96.5) in the diet group (log-rank test for noninferiority, P < 0.001; for superiority, P = 0.6): the difference in survival was -3.6% (95% CI, -17 to +10; P = 0.002). The hazard ratio for hospitalization was 1.50 for the dialysis group (95% CI, 1.11 to 2.01; P < 0.01). The unblinded nature of the study, exclusion of patients with diabetes, and incomplete enrollment. An sVLPD was effective and safe when postponing dialysis treatment in elderly patients without diabetes.

Trends in gestational age at time of surgical abortion for fetal aneuploidy and structural abnormalities.

PubMed

Davis, Anne R; Horvath, Sarah K; Castaño, Paula M

2017-03-01

Screening for fetal aneuploidy has evolved over the past 2 decades. Whether these advances impact gestational age at abortion has received little study. We sought to describe trends in the gestational age at the time of abortion by fetal diagnosis over an 11-year study period. We hypothesized that gestational age at time of abortion would decrease for fetal aneuploidy but remain unchanged for structural abnormalities. We conducted a retrospective case series of all women undergoing surgical abortion for fetal aneuploidy or structural abnormalities up to 24 weeks' gestation from 2004 through 2014 in a hospital operating room setting at a single, urban medical center. We excluded labor induction abortions (<1% of abortions at our medical center) and suction aspirations performed in the office practice. We performed suction aspiration up to 14 weeks and dilation and evacuation after that gestational age. We describe the median gestational age at abortion by fetal indication and year. For women undergoing abortion for fetal aneuploidy (n = 392), the median gestational age at time of abortion decreased from 19.0 weeks (interquartile range 18.0-21.0) in 2004 to 14.0 weeks (interquartile range 13.0-17.0) in 2014 (Kruskal-Wallis P < .0001). For women undergoing abortion for fetal structural abnormalities (n = 586), the median gestational age was ≥20 weeks for each year during the study interval (P = .1). As gestational age decreased in the fetal aneuploidy group, fewer women underwent dilation and evacuation and more became eligible for suction aspiration (<14 weeks). In 2004, >90% of women underwent dilation and evacuation for either indication. By 2014, 31% of women with fetal aneuploidy were eligible for suction aspiration compared to 11% of those with structural anomalies. Gestational age at the time of abortion for fetal aneuploidy decreased substantially from 2004 through 2014; earlier abortion is safer for women. In contrast, women seeking abortion for fetal structural abnormalities did not experience a change in timing. Legislation restricting gestational age at the time of abortion could disproportionately affect women with fetal structural abnormalities. Copyright © 2016 Elsevier Inc. All rights reserved.

Use of Palliative Care in Patients With End-Stage COPD and Receiving Home Oxygen: National Trends and Barriers to Care in the United States.

PubMed

Rush, Barret; Hertz, Paul; Bond, Alexandra; McDermid, Robert C; Celi, Leo Anthony

2017-01-01

To investigate the use of palliative care (PC) in patients with end-stage COPD receiving home oxygen hospitalized for an exacerbation. A retrospective nationwide cohort analysis was performed, using the Nationwide Inpatient Sample. All patients ≥ 18 years of age with a diagnosis of COPD, receiving home oxygen, and admitted for an exacerbation were included. A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample were examined. There were 181,689 patients with COPD, receiving home oxygen, and admitted for an exacerbation; 3,145 patients (1.7%) also had a PC contact. There was a 4.5-fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%) (P < .01). Patients receiving PC consultations compared with those who did not were older (75.0 years [SD 10.9] vs 70.6 years [SD 9.7]; P < .01), had longer hospitalizations (4.9 days [interquartile range, 2.6-8.2] vs 3.5 days [interquartile range, 2.1-5.6]), and more likely to die in hospital (32.1% vs 1.5%; P < .01). Race was significantly associated with referral to palliative care, with white patients referred more often than minorities (P < .01). Factors associated with PC referral included age (OR, 1.03; 95% CI, 1.02-1.04; P < .01), metastatic cancer (OR, 2.40; 95% CI, 2.02-2.87; P < .01), nonmetastatic cancer (OR, 2.75; 95% CI, 2.43-3.11; P < .01), invasive mechanical ventilation (OR, 4.89; 95% CI, 4.31-5.55; P < .01), noninvasive mechanical ventilation (OR, 2.84; 95% CI, 2.58-3.12; P < .01), and Do Not Resuscitate status (OR, 7.95; 95% CI, 7.29-8.67; P < .01). The use of PC increased dramatically during the study period; however, PC contact occurs only in a minority of patients with end-stage COPD admitted with an exacerbation. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Renal insufficiency, a frequent complication with age in oral-facial-digital syndrome type I.

PubMed

Saal, S; Faivre, L; Aral, Bernard; Gigot, N; Toutain, A; Van Maldergem, L; Destree, A; Maystadt, I; Cosyns, J-P; Jouk, P-S; Loeys, B; Chauveau, D; Bieth, E; Layet, V; Mathieu, M; Lespinasse, J; Teebi, A; Franco, B; Gautier, E; Binquet, C; Masurel-Paulet, A; Mousson, C; Gouyon, J-B; Huet, F; Thauvin-Robinet, C

2010-03-01

The oral-facial-digital syndrome type I (OFD I) is characterized by multiple congenital malformations of the face, oral cavity and digits. A polycystic kidney disease (PKD) is found in about one-third of patients but long-term outcome and complications are not well described in the international literature. Renal findings have been retrospectively collected in a cohort of 34 females all carrying a pathogenic mutation in the OFD1 gene with ages ranging from 1 to 65 years. Twelve patients presented with PKD - 11/16 (69%) if only adults were considered -with a median age at diagnosis of 29 years [IQR (interquartile range) = (23.5-38)]. Among them, 10 also presented with renal impairment and 6 were grafted (median age = 38 years [IQR = (25-48)]. One grafted patient under immunosuppressive treatment died from a tumor originated from a native kidney. The probability to develop renal failure was estimated to be more than 50% after the age of 36 years. Besides, neither genotype-phenotype correlation nor clinical predictive association with renal failure could be evidenced. These data reveal an unsuspected high incidence rate of the renal impairment outcome in OFD I syndrome. A systematic ultrasound (US) and renal function follow-up is therefore highly recommended for all OFD I patients.

Increased ultrafine particles and carbon monoxide concentrations are associated with asthma exacerbation among urban children.

PubMed

Evans, Kristin A; Halterman, Jill S; Hopke, Philip K; Fagnano, Maria; Rich, David Q

2014-02-01

Increased air pollutant concentrations have been linked to several asthma-related outcomes in children, including respiratory symptoms, medication use, and hospital visits. However, few studies have examined effects of ultrafine particles in a pediatric population. Our primary objective was to examine the effects of ambient concentrations of ultrafine particles on asthma exacerbation among urban children and determine whether consistent treatment with inhaled corticosteroids could attenuate these effects. We also explored the relationship between asthma exacerbation and ambient concentrations of accumulation mode particles, fine particles (≤2.5 micrograms [μm]; PM2.5), carbon monoxide, sulfur dioxide, and ozone. We hypothesized that increased 1-7 day concentrations of ultrafine particles and other pollutants would be associated with increases in the relative odds of an asthma exacerbation, but that this increase in risk would be attenuated among children receiving school-based corticosteroid therapy. We conducted a pilot study using data from 3 to 10 year-old children participating in the School-Based Asthma Therapy trial. Using a time-stratified case-crossover design and conditional logistic regression, we estimated the relative odds of a pediatric asthma visit treated with prednisone (n=96 visits among 74 children) associated with increased pollutant concentrations in the previous 7 days. We re-ran these analyses separately for children receiving medications through the school-based intervention and children in a usual care control group. Interquartile range increases in ultrafine particles and carbon monoxide concentrations in the previous 7 days were associated with increases in the relative odds of a pediatric asthma visit, with the largest increases observed for 4-day mean ultrafine particles (interquartile range=2088p/cm(3); OR=1.27; 95% CI=0.90-1.79) and 7-day mean carbon monoxide (interquartile range=0.17ppm; OR=1.63; 95% CI=1.03-2.59). Relative odds estimates were larger among children receiving school-based inhaled corticosteroid treatment. We observed no such associations with accumulation mode particles, black carbon, fine particles (≤2.5μm), or sulfur dioxide. Ozone concentrations were inversely associated with the relative odds of a pediatric asthma visit. These findings suggest a response to markers of traffic pollution among urban asthmatic children. Effects were strongest among children receiving preventive medications through school, suggesting that this group of children was particularly sensitive to environmental triggers. Medication adherence alone may be insufficient to protect the most vulnerable from environmental asthma triggers. However, further research is necessary to confirm this finding. © 2013 Published by Elsevier Inc.

Increased ultrafine particles and carbon monoxide concentrations are associated with asthma exacerbation among urban children

PubMed Central

Evans, Kristin A.; Halterman, Jill S.; Hopke, Philip K.; Fagnano, Maria; Rich, David Q.

2014-01-01

Objectives Increased air pollutant concentrations have been linked to several asthma-related outcomes in children, including respiratory symptoms, medication use, and hospital visits. However, few studies have examined effects of ultrafine particles in a pediatric population. Our primary objective was to examine the effects of ambient concentrations of ultrafine particles on asthma exacerbation among urban children and determine whether consistent treatment with inhaled corticosteroids could attenuate these effects. We also explored the relationship between asthma exacerbation and ambient concentrations of accumulation mode particles, fine particles (≤ 2.5 micrograms [μm]; PM2.5), carbon monoxide, sulfur dioxide, and ozone. We hypothesized that increased 1 to 7 day concentrations of ultrafine particles and other pollutants would be associated with increases in the relative odds of an asthma exacerbation, but that this increase in risk would be attenuated among children receiving school-based corticosteroid therapy. Methods We conducted a pilot study using data from 3–10 year-old children participating in the School-Based Asthma Therapy trial. Using a time-stratified case-crossover design and conditional logistic regression, we estimated the relative odds of a pediatric asthma visit treated with prednisone (n=96 visits among 74 children) associated with increased pollutant concentrations in the previous 7 days. We re-ran these analyses separately for children receiving medications through the school-based intervention and children in a usual care control group. Results Interquartile range increases in ultrafine particles and carbon monoxide concentrations in the previous 7 days were associated with increases in the relative odds of a pediatric asthma visit, with the largest increases observed for 4-day mean ultrafine particles (interquartile range=2088 p/cm3; OR=1.27; 95% CI=0.90–1.79) and 7-day mean carbon monoxide (interquartile range=0.17 ppm; OR=1.63; 95% CI=1.03–2.59). Relative odds estimates were larger among children receiving school-based inhaled corticosteroid treatment. We observed no such associations with accumulation mode particles, black carbon, fine particles (≤ 2.5 μm), or sulfur dioxide. Ozone concentrations were inversely associated with the relative odds of a pediatric asthma visit. Conclusions These findings suggest a response to markers of traffic pollution among urban asthmatic children. Effects were strongest among children receiving preventive medications through school, suggesting that this group of children was particularly sensitive to environmental triggers. Medication adherence alone may be insufficient to protect the most vulnerable from environmental asthma triggers. However, further research is necessary to confirm this finding. PMID:24528997

Prevalence of abnormal anal cytology and high-grade squamous intraepithelial lesions among a cohort of HIV-infected men who have sex with men.

PubMed

Sendagorta, Elena; Herranz, Pedro; Guadalajara, Hector; Bernardino, Jose Ignacio; Viguer, Jose María; Beato, María José; García-Olmo, Damian; Peña, Jose María

2014-04-01

The incidence of anal cancer among HIV-infected patients is higher than that in other populations. Anal high-grade squamous intraepithelial lesions are considered precursors to invasive squamous-cell carcinomas and are strongly associated to high-risk human papillomavirus infection. The aim of this study is to determine the prevalence of anal high-grade squamous intraepithelial lesions through screening based on cytology and high-resolution anoscopy with biopsy in a cohort of HIV-infected men who have sex with men. This investigation is an observational cross-sectional cohort study. The study was conducted in the HIV unit of a tertiary hospital in Spain. Three hundred HIV-infected men who have sex with men participated. Physical examination led to a diagnosis of perianal squamous-cell carcinoma and high-grade squamous intraepithelial lesions in 2 patients who were then excluded. Anal liquid cytology was performed. Patients with cytological abnormalities underwent high-resolution anoscopy and biopsy. The primary outcome measured was biopsy-proven high-grade squamous intraepithelial lesions. The median age was 41 ± 10.5 years. The mean and nadir CD4 cell counts were 651 ± 205 cells/mm(3) (interquartile range, 438-800) and 273 ± 205 cells/mm(3) (interquartile range, 131-362). High-risk human papillomavirus was detected in 80.9% of patients, and human papillomavirus 16 was detected in 35.9% of patients. The mean number of human papillomavirus genotypes was 4.6 ± 2.9 (CI, 2-6). Anal cytology was abnormal in 40.9% of patients (n = 122/298; interquartile range, 35.4%-46.6%). High-resolution anoscopy and biopsies were performed in 119 patients. The results of histological analyses were as follows: normal, 7.7% (n = 23); condyloma, 4.3% (n = 13); anal intraepithelial neoplasia 1, 5.7% (n = 17); anal intraepithelial neoplasia 2, 14% (n = 42); and anal intraepithelial neoplasia 3, 8% (n = 24). The overall prevalence of high-grade squamous intraepithelial lesions among patients with abnormal cytology was 54% (95% CI, 45.1%-62.8%). A diagnosis of high-grade squamous intraepithelial lesions was associated with human papillomavirus 16 and human papillomavirus 51 infection, and with detection of a higher number of human papillomavirus genotypes. High-resolution anoscopy was only performed in patients with abnormal cytology. The prevalence of high-risk human papillomavirus infection and high-grade squamous intraepithelial lesions is high in our cohort. Physical examination enabled straightforward diagnosis of perianal high-grade squamous intraepithelial lesions and squamous-cell carcinoma in 2 patients.

Sexual violence in post-conflict Liberia: survivors and their care.

PubMed

Tayler-Smith, K; Zachariah, R; Hinderaker, S G; Manzi, M; De Plecker, E; Van Wolvelaer, P; Gil, T; Goetghebuer, S; Ritter, H; Bawo, L; Davis-Worzi, C

2012-11-01

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care. © 2012 Blackwell Publishing Ltd.

Functional capacity and treatment data from a community based study of patients with rheumatoid arthritis.

PubMed Central

Owen, S G; Friesen, W T; Roberts, M S; Francis, H; Flux, W

1986-01-01

A community based study of rheumatoid arthritis was undertaken to determine patient characteristics and the patterns of treatment. Three hundred and eighty subjects were visited in their homes throughout Tasmania (pop. 430 000) by a research team. The median age of the sample was 60 years (interquartile range (IR) 49-69), with a female predominance of 2.65 to 1. The average onset age was 41 years (IR 30-53). Prescribing data indicated that polypharmacy was not common in the community, and that the use of slow acting antirheumatic drugs (SAARDs) and oral corticosteroids was not widespread. At the time of the study 26% of subjects were assayed fully functional--class I of the American Rheumatism Association's (ARA) functional classifications. The functional capacity data provided evidence that the spectrum of rheumatoid arthritis found in the community differed from that found in specialist rheumatology clinics. PMID:2939806

The serum level of soluble CD26/dipeptidyl peptidase 4 increases in response to acute hyperglycemia after an oral glucose load in healthy subjects: association with high-molecular weight adiponectin and hepatic enzymes.

PubMed

Aso, Yoshimasa; Terasawa, Tomoko; Kato, Kanako; Jojima, Teruo; Suzuki, Kunihiro; Iijima, Toshie; Kawagoe, Yoshiaki; Mikami, Shigeru; Kubota, Yoshiro; Inukai, Toshihiko; Kasai, Kikuo

2013-11-01

A soluble form of CD26/dipeptidyl peptidase 4 (sCD26/DPP4) is found in serum and it has DPP4 enzymatic activity. We investigated whether the serum level of sCD26/DPP4 was influenced by the oral glucose tolerance test (OGTT) in healthy subjects. The serum sCD26/DPP4 level increased significantly from 824.5 ng/mL (interquartile range, from 699.0 to 1050 ng/mL) at baseline to a peak of 985.0 ng/mL (interquartile range, from 796.5 to 1215 ng/mL) during the OGTT (P < 0.0001). The peak sCD26/DPP4 level correlated positively with the baseline age and body mass index, and fasting plasma glucose (FPG), homeostasis model assessment of insulin resistance (HOMA-IR), triglycerides (TG), alanine aminotransferase, and γ-glutamyl transpeptidase (GGT) levels whereas it correlated negatively with high-density lipoprotein (HDL) cholesterol and the serum levels of total and high-molecular weight (HMW) adiponectin. Stepwise regression analysis was done with forward selection of variables, including age, FPG, HOMA-IR, TG, HDL cholesterol, uric acid, GGT, C-reactive protein, and HMW adiponectin. In a model that explained 57.5% of the variation of the peak sCD26/DPP4 level, GGT (β = 0.382, P = 0.007) and HOMA-IR (β = 0.307, P = 0.034) were independent determinants of the peak serum level of sCD26/DPP4. Serum HMW adiponectin decreased significantly from 4.43 μg/mL (interquartile range, from 2.80 to 6.65 μg/mL) at baseline to 4.17 μg/mL (interquartile range, from 2.48 to 6.96 μg/mL) 120 minutes after the oral glucose load (P < 0.0001). The baseline serum level of sCD26/DPP4 showed a significant negative correlation with the percent change of HMW adiponectin during the OGTT. In conclusion, the serum level of sCD26/DPP4 increased acutely after an oral glucose load in apparently healthy subjects. The abrupt increase of serum sCD26/DPP4 after a glucose load may be a marker of insulin resistance that could come from liver or muscle. Copyright © 2013 Mosby, Inc. All rights reserved.

Seasonal Influenza Infections and Cardiovascular Disease Mortality

PubMed Central

Nguyen, Jennifer L.; Yang, Wan; Ito, Kazuhiko; Matte, Thomas D.; Shaman, Jeffrey; Kinney, Patrick L.

2016-01-01

IMPORTANCE Cardiovascular deaths and influenza epidemics peak during winter in temperate regions. OBJECTIVES To quantify the temporal association between population increases in seasonal influenza infections and mortality due to cardiovascular causes and to test if influenza incidence indicators are predictive of cardiovascular mortality during the influenza season. DESIGN, SETTING, AND PARTICIPANTS Time-series analysis of vital statistics records and emergency department visits in New York City, among cardiovascular deaths that occurred during influenza seasons between January 1, 2006, and December 31, 2012. The 2009 novel influenza A(H1N1) pandemic period was excluded from temporal analyses. EXPOSURES Emergency department visits for influenza-like illness, grouped by age (≥0 years and ≥65 years) and scaled by laboratory surveillance data for viral types and subtypes, in the previous 28 days. MAIN OUTCOMES AND MEASURES Mortality due to cardiovascular disease, ischemic heart disease, and myocardial infarction. RESULTS Among adults 65 years and older, who accounted for 83.0% (73 363 deaths) of nonpandemic cardiovascular mortality during influenza seasons, seasonal average influenza incidence was correlated year to year with excess cardiovascular mortality (Pearson correlation coefficients ≥0.75, P≤.05 for 4 different influenza indicators). In daily time-series analyses using 4 different influenza metrics, interquartile range increases in influenza incidence during the previous 21 days were associated with an increase between 2.3% (95% CI, 0.7%–3.9%) and 6.3% (95% CI, 3.7%–8.9%) for cardiovascular disease mortality and between 2.4% (95% CI, 1.1%–3.6%) and 6.9% (95% CI, 4.0%–9.9%) for ischemic heart disease mortality among adults 65 years and older. The associations were most acute and strongest for myocardial infarction mortality, with each interquartile range increase in influenza incidence during the previous 14 days associated with mortality increases between 5.8% (95% CI, 2.5%–9.1%) and 13.1% (95% CI, 5.3%–20.9%). Out-of-sample prediction of cardiovascular mortality among adults 65 years and older during the 2009–2010 influenza season yielded average estimates with 94.0% accuracy using 4 different influenza metrics. CONCLUSIONS AND RELEVANCE Emergency department visits for influenza-like illness were associated with and predictive of cardiovascular disease mortality. Retrospective estimation of influenza-attributable cardiovascular mortality burden combined with accurate and reliable influenza forecasts could predict the timing and burden of seasonal increases in cardiovascular mortality. PMID:27438105

[Fluoride content of bottled natural mineral waters in Spain and prevention of dental caries].

PubMed

Maraver, Francisco; Vitoria, Isidro; Almerich-Silla, José Manuel; Armijo, Francisco

2015-01-01

The aim of the study was to determine the concentration of fluoride in natural mineral waters marketed in Spain in order to prevent tooth decay without the risk of causing dental fluorosis Descriptive and cross-sectional study during 2012. Natural mineral waters marketed in Spain. Three bottles with different bottling dates of 109 natural mineral waters (97 Spanish and 12 imported brands). Determination of fluoride by ion chromatography Median fluoride concentrations of the natural mineral waters bottled in Spain was 0.22 (range 0.00-4.16; interquartile range:0.37). Most samples (61 brands, 62%) contained less than 0.3mg/L. There are 19 Spanish brands with more than 0.6 mg/L. The median level in imported brands was 0.35 (range 0.10-1.21; interquartile range: 0.23). Only 28 of the 109 brands examined (25.6%) specified the fluoride content on the label. Good correlation was observed between the concentrations indicated and those determined. Fluoride concentrations in natural mineral waters showed high variation. Given the growing consumption of natural mineral waters in Spain, this type of information is important to make proper use of fluoride in the primary prevention of dental caries. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

Fasting target for hyperglycaemia in pregnancy.

PubMed

Moses, Robert G; Wong, Veronica C K; Lambert, Kelly; Morris, Gary J

2016-10-01

Knowledge of the fasting plasma glucose of healthy women may assist in the setting of treatment targets for women with hyperglycaemia in pregnancy (HIP). This study examines the pregnancy glucose tolerance test results of 3344 women without HIP collected over a three-year period. The median fasting plasma glucose was 4.4 mmol/L with an interquartile range of 4.2-4.6 mmol/L and a 5th to 95th centile of 3.8-4.9 mmol/L. As the diagnostic fasting glucose level for HIP is ≥5.1 mmol/L, these data support a treatment target of ≤5.0 mmol/L. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Nurse practitioner coverage is associated with a decrease in length of stay in a pediatric chronic ventilator dependent unit

PubMed Central

Rowan, Courtney M; Cristea, A Ioana; Hamilton, Jennifer C; Taylor, Nicole M; Nitu, Mara E; Ackerman, Veda L

2016-01-01

AIM: To hypothesize a dedicated critical care nurse practitioner (NP) is associated with a decreased length of stay (LOS) from a pediatric chronic ventilator dependent unit (PCVDU). METHODS: We retrospectively reviewed patients requiring care in the PCVDU from May 2001 through May 2011 comparing the 5 years prior to the 5 years post implementation of the critical care NP in 2005. LOS and room charges were obtained. RESULTS: The average LOS decreased from a median of 55 d [interquartile range (IQR): 9.8-108.3] to a median of 12 (IQR: 4.0-41.0) with the implementation of a dedicated critical care NP (P < 1.0001). Post implementation of a dedicated NP, a savings of 25738049 in room charges was noted over 5 years. CONCLUSION: Our data demonstrates a critical care NP coverage model in a PCVDU is associated with a significantly reduced LOS demonstrating that the NP is an efficient and likely cost-effective addition to a medically comprehensive service. PMID:27170929

Tetanus in Southern Vietnam: Current Situation

PubMed Central

Thuy, Duong Bich; Campbell, James I.; Thanh, Tran Tan; Thuy, Cao Thu; Loan, Huynh Thi; Hao, Nguyen Van; Minh, Yen Lam; Tan, Le Van; Boni, Maciej F.; Thwaites, C. Louise

2017-01-01

In Vietnam, there are no accurate data on tetanus incidence to allow assessment of disease burden or vaccination program efficacy. We analyzed age structure of 786 tetanus cases admitted to a tertiary referral center in Vietnam for three separate years during an 18-year period to examine the impact of tetanus prevention programs, namely the Expanded Program on Immunization (EPI) and the Maternal and Neonatal Tetanus (MNT) initiative. Most cases were born before the initiation of EPI. Median age increased from 33 (interquartile range: 20–52) in 1994, to 46 (32–63) in 2012 (P < 0.001). Birth-year distribution was unchanged, indicating the same birth cohorts presented with tetanus in 1994, 2003, and 2012. Enzyme-linked immunosorbent assay measurements in 90 men and 90 women covered by MNT but not EPI showed 73.3% (95% confidence interval [CI]: 62.9–82.1%) of women had anti-tetanus antibody compared with 24.4% (95% CI: 15.9–34.7%) of men, indicating continued tetanus vulnerability in older men in Vietnam. PMID:27821690

Prospective, randomized trial comparing diathermy excision and diathermy coagulation for symptomatic, prolapsed hemorrhoids.

PubMed

Quah, H M; Seow-Choen, F

2004-03-01

This study was designed to compare diathermy excision and diathermy coagulation in the treatment of symptomatic prolapsed piles. Forty-five consecutive patients were randomly assigned to diathermy excision hemorrhoidectomy (Group A, n = 25) and diathermy coagulation (Group B, n = 20) under general anesthesia. The median duration of surgery was ten minutes for both groups. There was no statistical difference in the severity of postoperative pain at rest between the two groups, but Group A patients felt less pain during defecation on the third postoperative day (median, 5 (interquartile range, 3-7) vs. 8 (4-9); P = 0.04) and on the sixth postoperative day (median, 5 (interquartile range, 2-6) vs. 9 (5-10); P = 0.02). There was, however, no statistical difference in postoperative oral analgesics use and patients' satisfaction scores between the two groups. Complication rates were similar except that diathermy coagulation tended to leave some residual skin components of external hemorrhoid especially in very large prolapsed piles. Group A patients resumed work earlier (mean, 12 (range, 4-20) vs. 17 (11-21) days); however, this was not statistically significant ( P = 0.1). Diathermy coagulation of hemorrhoids is a simple technique and may be considered in suitable cases.

Cryopreserved Human Allografts for the Reconstruction of Aortic and Peripheral Prosthetic Graft Infection.

PubMed

Bossi, Matteo; Tozzi, Matteo; Franchin, Marco; Ferraro, Stefania; Rivolta, Nicola; Ferrario, Massimo; Guttadauro, Chiara; Castelli, Patrizio; Piffaretti, Gabriele

2017-12-25

Background : This study aimed to present cases with cryopreserved human allografts (CHAs) for vascular reconstruction in both aortic and peripheral infected prosthetic grafts. Materials and Methods : This is a single center, observational descriptive study with retrospective analysis. In all cases, the infected prosthetic graft material was completely removed. At discharge, patients were administered anticoagulants. Follow-up examinations included clinical visits, echo-color-Doppler ultrasounds, or computed tomography angiography within 30 days and at 3, 6, and 12 months after the treatment, and then twice per year. Results : We treated 21 patients (90% men, n=19) with the mean age of 71±12 years and mean interval between the initial operation and replacement with CHA of 30 months [range, 1-216; interquartile range (IQR), 2-36]. In-hospital mortality was 14% (n=3); no CHA-related complication led to death. Limb salvage was 100%. No patient was lost at the median follow-up of 14 months (range, 2-61; IQR, 6-39). No rupture, aneurysmal degeneration, or re-infection occurred. Estimated freedom from CHA-related adverse events (95% confidence interval, 43-63) was 95% at 3 years. Conclusion : In our experience, CHAs are a viable option for prosthetic graft infections and provide satisfactory clinical results and favorable stability because of a very low rate of CHA-related adverse events during follow-up.

Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery.

PubMed

Cerullo, Marcelo; Chen, Sophia Y; Dillhoff, Mary; Schmidt, Carl; Canner, Joseph K; Pawlik, Timothy M

2017-09-20

Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. Hepatic or pancreatic resection. Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (-5.4%; 95% CI, -10.0% to -0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, -14.0% to -2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, -13.0% to -3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, -19.3% to -7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, -16.2% to -4.4%; P = .001) compared with unconcentrated markets. Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.

Workup for Perinatal Stroke Does Not Predict Recurrence.

PubMed

Lehman, Laura L; Beaute, Jeanette; Kapur, Kush; Danehy, Amy R; Bernson-Leung, Miya E; Malkin, Hayley; Rivkin, Michael J; Trenor, Cameron C

2017-08-01

Perinatal stroke, including neonatal and presumed perinatal presentation, represents the age in childhood in which stroke occurs most frequently. The roles of thrombophilia, arteriopathy, and cardiac anomalies in perinatal ischemic stroke are currently unclear. We took a uniform approach to perinatal ischemic stroke evaluation to study these risk factors and their association with recurrent stroke. We reviewed records of perinatal stroke patients evaluated from August 2008 to February 2016 at a single referral center. Demographics, echocardiography, arterial imaging, and thrombophilia testing were collected. Statistical analysis was performed using Fisher exact test. Across 215 cases, the median follow-up was 3.17 years (1.49, 6.46). Females comprised 42.8% of cases. Age of presentation was neonatal (110, 51.2%) or presumed perinatal (105, 48.8%). The median age at diagnosis was 2.9 days (interquartile range, 2.0-9.9) for neonatal stroke and 12.9 months (interquartile range, 8.7-32.8) for presumed perinatal stroke. Strokes were classified as arterial (149, 69.3%), venous (60, 27.9%), both (4, 1.9%), or uncertain (2, 0.9%) by consensus imaging review. Of the 215 cases, there were 6 (2.8%) recurrent ischemic cerebrovascular events. Abnormal thrombophilia testing was not associated with recurrent stroke, except for a single patient with combined antithrombin deficiency and protein C deficiency. After excluding venous events, 155 patients were evaluated for arteriopathy and cardioembolic risk factors; neither was associated with recurrent stroke. Positive family history of thrombosis was not predictive of abnormal thrombophilia testing. Thrombophilia, arteriopathy, or cardioembolic risk factors were not predictive of recurrent events after perinatal stroke. Thrombophilia evaluation in perinatal stroke should only rarely be considered. © 2017 American Heart Association, Inc.

Oscillometric analysis compared with cardiac magnetic resonance for the assessment of aortic pulse wave velocity in patients with myocardial infarction.

PubMed

Feistritzer, Hans-Josef; Klug, Gert; Reinstadler, Sebastian J; Reindl, Martin; Mayr, Agnes; Schocke, Michael; Metzler, Bernhard

2016-09-01

Measurement of aortic pulse wave velocity (PWV) is the gold standard for assessment of aortic stiffness. In patients with ST-segment elevation myocardial infarction (STEMI), high aortic PWV has deleterious effects on the myocardium. In the present study, we compared a novel oscillometric device with cardiac magnetic resonance (CMR) imaging for the assessment of aortic PWV in STEMI patients. We measured aortic PWV in 60 reperfused STEMI patients using two different methods. The oscillometric method (PWVOSC) is based on mathematical transformation of brachial pressure waveforms, oscillometrically determined using a common cuff (Mobil-O-Graph, I.E.M., Stolberg, North Rhine-Westphalia, Germany). Phase-contrast CMR imaging (1.5 T scanner, Siemens, Erlangen, Bavaria, Germany) at the level of the ascending and abdominal aorta was performed to determine CMR-derived pulse wave velocity with the use of the transit time method. The mean age of the study population was 57 ± 11 years; 11 (18%) were women. Median PWVOSC was 7.4 m/s (interquartile range 6.8-8.9 m/s), and median CMR-derived pulse wave velocity was 6.3 m/s (interquartile range 5.7-8.2 m/s) (P < 0.001). A strong correlation was detected between both methods (r = 0.724, P < 0.001). Bland-Altman analysis revealed a bias of 0.62 m/s (upper and lower limit of agreement: 3.84 and -2.61 m/s). The coefficient of variation between both methods was 21%. In reperfused STEMI patients, aortic PWV assessed noninvasively by transformation of brachial pressure waveforms showed an acceptable agreement with the CMR-derived transit time method.

The effect of perioperative dexamethasone dosing on post-tonsillectomy hemorrhage risk.

PubMed

Yiu, Yin; Mahida, Justin B; Cooper, Jennifer N; Elsey, Nicole M; Deans, Katherine J; Minneci, Peter C; Merrill, Tyler B; Tobias, Joseph D; Elmaraghy, Charles A

2017-07-01

Dexamethasone is currently recommended for routine prophylaxis against postoperative nausea and vomiting after tonsillectomy procedures. However, some studies have raised concern that dexamethasone use may lead to higher rates of post-tonsillectomy hemorrhage. Our objective was to determine whether higher doses of dexamethasone administered perioperatively during tonsillectomy procedures are associated with an increased risk of secondary post-tonsillectomy hemorrhage. We conducted a retrospective review of 9843 patients who underwent tonsillectomy and received dexamethasone at our institution from January 2010 to October 2014. We compared the dose of dexamethasone administered to patients who did and did not develop secondary post-tonsillectomy hemorrhage using Mann Whitney U tests. Multivariable logistic regression models were used to evaluate the association between dexamethasone dose and post-tonsillectomy hemorrhage after adjustment for demographic and clinical characteristics. A total of 280 (2.8%) patients developed secondary post-tonsillectomy hemorrhage. Patients who developed hemorrhage tended to be older (median (interquartile range) 7 (4-11) vs. 5 (3-8) years), p < 0.001) and had undergone tonsillectomy more often for chronic tonsillitis but less often for tonsillar or adenotonsillar hypertrophy or sleep disturbances. Dexamethasone dose was significantly lower on average in patients who experienced secondary post-tonsillectomy hemorrhage (median (interquartile range) 0.19 (0.14, 0.23) mg/kg vs. 0.21 (0.17, 0.30), p < 0.001). Multivariable modeling demonstrated that the dose of dexamethasone was not significantly associated with post-tonsillectomy hemorrhage after adjustment for age. There does not appear to be a dose-related increase in the risk of post-tonsillectomy hemorrhage for patients receiving dexamethasone during tonsillectomy procedures. Copyright © 2017 Elsevier B.V. All rights reserved.

Heart Rate Response in Spectators of the Montreal Canadiens Hockey Team.

PubMed

Khairy, Leia T; Barin, Roxana; Demonière, Fabrice; Villemaire, Christine; Billo, Marie-Josée; Tardif, Jean-Claude; Macle, Laurent; Khairy, Paul

2017-12-01

To our knowledge, heart rate responses have not previously been assessed in hockey fans. We quantified heart rate increases in spectators of the Montreal Canadiens, compared televised with live games, explored features associated with peak heart rates, and assessed whether increases correlate with a fan passion score. Healthy adults were enrolled, with half attending live games and half viewing televised games. All subjects completed questionnaires and had continuous Holter monitoring. Intensity of the physical stress response was defined according to previously published heart rate index thresholds as mild (< 1.33), moderate (1.33-1.83), or vigorous (> 1.83). In 20 participants, 35% women, age 46 ± 10 years, the heart rate increased by a median of 92% during the hockey game, from 60 (interquartile range, 54-65) beats per minute at rest to 114 (interquartile range, 103-129) beats per minute (P < 0.001). The heart rate increased by 110% vs 75% during live vs televised games (P < 0.001). Heart rate index (2.16 ± 0.27 vs 1.73 ± 0.15; P < 0.001) and percent maximum predicted heart rate attained (75% ± 8% vs 58% ± 7%; P < 0.001) were significantly higher during live vs televised games. Number of premature beats was nonsignificantly higher during live games (5 vs 1; P = 0.181). The fan passion score was not predictive of the heart rate response (P = 0.753). Peak heart rates most commonly occurred during overtime (40%) and scoring opportunities for (25%) and against (15%). It is exciting to watch the Montreal Canadiens! Viewing a live hockey game is associated with a heart rate response equivalent to vigorous physical stress and a televised game to moderate physical stress. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

A Preliminary Study on the Effectiveness of Exergame Nintendo "Wii Fit Plus" on the Balance of Nursing Home Residents.

PubMed

Janssen, Sacha; Tange, Huibert; Arends, Rachele

2013-04-01

This study investigated the effect of playing Nintendo(®) "Wii Fit™ Plus" (Nintendo of America, Inc., Redmond, WA) on body balance and physical activity of nursing home residents. In a nonrandomized controlled trial within a nursing home, two intervention groups (both n=8) were exposed to the same treatment and compared with a control group (n=13). Intervention Group 1 consisted of elderly individuals with regular Nintendo "Wii Fit" experience for at least 1 year. Elderly persons who were novices to the Nintendo "Wii Fit (Plus)" participated in intervention Group 2. Control participants had no experience with the Nintendo "Wii Fit (Plus)" and did not participate in the Nintendo "Wii Fit Plus" sessions. Outcome measurements were taken at baseline and after the intervention, using the Berg Balance Scale and the LASA Physical Activity Questionnaire. Participants of both intervention groups played the Nintendo "Wii Fit Plus" for 10 minutes twice a week during 12 weeks. Although balance improved for all three groups, there was no effect of playing "Wii Fit Plus" (P=0.89). On physical activity, the intervention did have a positive effect (P=0.005); physical activity levels increased with a median of 54.3 (interquartile range, 63.1) minutes/day for intervention Group 1 and a median of 60.7 (interquartile range, 56.8) minutes/day for intervention Group 2. This study showed an effect of Nintendo "Wii Fit Plus" gaming on physical activity of nursing home residents, but not on their balance. The effect of physical activity should be consolidated in a randomized controlled trial in a broader population.

Re-entry using anatomically determined isthmuses: a curable ventricular tachycardia in repaired congenital heart disease.

PubMed

Kapel, Gijsbert F L; Reichlin, Tobias; Wijnmaalen, Adrianus P; Piers, Sebastiaan R D; Holman, Eduard R; Tedrow, Usha B; Schalij, Martin J; Stevenson, William G; Zeppenfeld, Katja

2015-02-01

Ventricular tachycardia (VT) is an important cause of late morbidity and mortality in repaired congenital heart disease. The substrate often includes anatomic isthmuses that can be transected by radiofrequency catheter ablation similar to isthmus block for atrial flutter. This study evaluates the long-term efficacy of isthmus block for treatment of re-entry VT in adults with repaired congenital heart disease. Thirty-four patients (49±13 years; 74% male) with repaired congenital heart disease who underwent radiofrequency catheter ablation of VT in 2 centers were included. Twenty-two (65%) had a preserved left and right ventricular function. Patients were inducible for 1 (interquartile range, 1-2) VT, median cycle length: 295 ms (interquartile range, 242-346). Ablation aimed to transect anatomic isthmuses containing VT re-entry circuit isthmuses. Procedural success was defined as noninducibility of any VT and transection of the anatomic isthmus and was achieved in 25 (74%) patients. During long-term follow-up (46±29 months), all patients with procedural success (18/25 with internal cardiac defibrillators) were free of VT recurrence but 7 of 18 experienced internal cardiac defibrillator-related complications. One patient with procedural success and depressed cardiac function received an internal cardiac defibrillator shock for ventricular fibrillation. None of the 18 patients (12/18 with internal cardiac defibrillators) with complete success and preserved cardiac function experienced any ventricular arrhythmia. In contrast, VT recurred in 4 of 9 patients without procedural success. Four patients died from nonarrhythmic causes. In patients with repaired congenital heart disease with preserved ventricular function and isthmus-dependent re-entry, VT isthmus ablation can be curative. © 2014 American Heart Association, Inc.

Treatment of Atrial Fibrillation and Concordance With the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines: Findings From ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation).

PubMed

Barnett, Adam S; Kim, Sunghee; Fonarow, Gregg C; Thomas, Laine E; Reiffel, James A; Allen, Larry A; Freeman, James V; Naccarelli, Gerald; Mahaffey, Kenneth W; Go, Alan S; Kowey, Peter R; Ansell, Jack E; Gersh, Bernard J; Hylek, Elaine M; Peterson, Eric D; Piccini, Jonathan P

2017-11-01

It is unclear how frequently patients with atrial fibrillation receive guideline-concordant (GC) care and whether guideline concordance is associated with improved outcomes. Using data from ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation), we determined how frequently patients received care that was concordant with 11 recommendations from the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation guidelines pertaining to antithrombotic therapy, rate control, and antiarrhythmic medications. We also analyzed the association between GC care and clinical outcomes at both the patient level and center level. A total of 9570 patients were included. The median age was 75 years (interquartile range, 67-82), and the median CHA 2 DS 2 -VASc score was 4 (interquartile range, 3-5). A total of 5977 patients (62.5%) received care that was concordant with all guideline recommendations for which they were eligible. Rates of GC care were higher in patients treated by providers with greater specialization in arrhythmias (60.0%, 62.4%, and 67.0% for primary care physicians, cardiologists, and electrophysiologists, respectively; P <0.001). During a median of 30 months of follow-up, patients treated with GC care had a higher risk of bleeding hospitalization (hazard ratio=1.21; P =0.021) but a similar risk of death, stroke, major bleeding, and all-cause hospitalization. Over a third of patients with atrial fibrillation in this large outpatient registry received care that differed in some respect from guideline recommendations. There was no apparent association between GC care and improved risk-adjusted outcomes. © 2017 American Heart Association, Inc.

The association between nut consumption and the risk of total and ischemic stroke in a German cohort study.

PubMed

di Giuseppe, R; Fjeld, M K; Dierkes, J; Theoflylaktopoulou, D; Arregui, M; Boeing, H; Weikert, C

2015-04-01

Nuts have beneficial effects on coronary heart disease and many cardiovascular risk factors. However, their effect on stroke is less established, and no studies on the topic are available in Northern and Central European populations. Therefore, we aimed at investigating the association between nut consumption and the risk of stroke in a German population. We used data from a prospective cohort of 26,285 participants of the European Prospective Investigation into the Cancer and Nutrition Potsdam Study. During a median follow-up time of 8.3 years (interquartile range: 7.5-9.2), 288 incident cases of stroke occurred. Nut consumption (standard portion size of 50 g) was assessed at baseline with a semiquantitative food-frequency questionnaire. The median nut intake was 0.82 g per day, interquartile range: 0.41-4.11. In the multivariable model, an increased risk of stroke was observed among participants who never consumed nuts (hazard ratio (HR): 1.56, 95% confidence interval: 1.17-2.08), compared with those consuming <½ portion/week. However, there was no evidence of a dose-response relationship between nut consumption and stroke. Compared with those who consumed <½ portion/week, the multivariable HR for total stroke was 1.06 (0.75-1.52) among those who consumed ½ to 1 portion/week and 1.37 (0.92-2.05) for those who consumed >1 portion/week. Similar nonsignificant associations were observed in stratified analysis for gender, or for fatal and nonfatal stroke. We could not observe an association between nut consumption and the risk of developing stroke (fatal/nonfatal) in a population with low habitual nut consumption.

Mapping Geographic Variation in Infant Mortality and Related Black–White Disparities in the US

PubMed Central

Rossen, Lauren M.; Khan, Diba; Schoendorf, Kenneth C.

2017-01-01

Background In the US, black infants remain more than twice as likely as white infants to die in the first year of life. Previous studies of geographic variation in infant mortality disparities have been limited to large metropolitan areas where stable estimates of infant mortality rates by race can be determined, leaving much of the US unexplored. Methods The objective of this analysis was to describe geographic variation in county-level racial disparities in infant mortality rates across the 48 contiguous US states and District of Columbia using national linked birth and infant death period files (2004–2011). We implemented Bayesian shared component models in OpenBUGS, borrowing strength across both spatial units and racial groups. We mapped posterior estimates of mortality rates for black and white infants as well as relative and absolute disparities. Results Black infants had higher infant mortality rates than white infants in all counties, but there was geographic variation in the magnitude of both relative and absolute disparities. The mean difference between black and white rates was 5.9 per 1,000 (median: 5.8, interquartile range: 5.2 to 6.6 per 1,000), while those for black infants were 2.2 times higher than for white infants (median: 2.1, interquartile range: 1.9–2.3). One quarter of the county-level variation in rates for black infants was shared with white infants. Conclusions Examining county-level variation in infant mortality rates among black and white infants and related racial disparities may inform efforts to redress inequities and reduce the burden of infant mortality in the US. PMID:27196804

Aminocaproic acid administration is associated with reduced perioperative blood loss and transfusion in pediatric craniofacial surgery.

PubMed

Hsu, G; Taylor, J A; Fiadjoe, J E; Vincent, A M; Pruitt, E Y; Bartlett, S P; Stricker, P A

2016-02-01

Severe blood loss is a common complication of craniofacial reconstruction surgery. The antifibrinolytic ε-aminocaproic acid (EACA) reduces transfusion requirements in children undergoing cardiac surgery and in older children undergoing spine surgery. Tranexamic acid (TXA), another antifibrinolytic with a similar mechanism of action, has been shown to reduce blood loss and transfusion requirements in children undergoing craniofacial surgery. However, TXA has been associated with an increase in post-operative seizures and is more expensive than EACA. There is currently little published data evaluating the efficacy of EACA in children undergoing craniofacial surgery. This is a retrospective study of prospectively collected data from our craniofacial perioperative registries for children under 6 years of age who underwent anterior or posterior cranial vault reconstruction. We compared calculated blood loss, blood donor exposures, and post-operative drain output between subjects who received EACA and those who did not. The registry queries returned data from 152 subjects. Eighty-six did not receive EACA and 66 received EACA. The EACA group had significantly lower calculated blood loss (82 ± 43 vs. 106 ± 63 ml/kg, P = 0.01), fewer intraoperative blood donor exposures (median 2, interquartile range 1-2 vs. median 2, interquartile range 1-3; P = 0.02) and lower surgical drain output in the first post-operative 24 h (28 ml/kg vs. 37 ml/kg, P = 0.001) than the non-EACA group. In this analysis of prospectively captured observational data, EACA administration was associated with less calculated blood loss, intraoperative blood donor exposures, and post-operative surgical drain output. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Delirium diagnosis methodology used in research: a survey-based study.

PubMed

Neufeld, Karin J; Nelliot, Archana; Inouye, Sharon K; Ely, E Wesley; Bienvenu, O Joseph; Lee, Hochang Benjamin; Needham, Dale M

2014-12-01

To describe methodology used to diagnose delirium in research studies evaluating delirium detection tools. The authors used a survey to address reference rater methodology for delirium diagnosis, including rater characteristics, sources of patient information, and diagnostic process, completed via web or telephone interview according to respondent preference. Participants were authors of 39 studies included in three recent systematic reviews of delirium detection instruments in hospitalized patients. Authors from 85% (N = 33) of the 39 eligible studies responded to the survey. The median number of raters per study was 2.5 (interquartile range: 2-3); 79% were physicians. The raters' median duration of clinical experience with delirium diagnosis was 7 years (interquartile range: 4-10), with 5% having no prior clinical experience. Inter-rater reliability was evaluated in 70% of studies. Cognitive tests and delirium detection tools were used in the delirium reference rating process in 61% (N = 21) and 45% (N = 15) of studies, respectively, with 33% (N = 11) using both and 27% (N = 9) using neither. When patients were too drowsy or declined to participate in delirium evaluation, 70% of studies (N = 23) used all available information for delirium diagnosis, whereas 15% excluded such patients. Significant variability exists in reference standard methods for delirium diagnosis in published research. Increasing standardization by documenting inter-rater reliability, using standardized cognitive and delirium detection tools, incorporating diagnostic expert consensus panels, and using all available information in patients declining or unable to participate with formal testing may help advance delirium research by increasing consistency of case detection and improving generalizability of research results. Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

Magnetic versus manual catheter navigation for ablation of free wall accessory pathways in children.

PubMed

Kim, Jeffrey J; Macicek, Scott L; Decker, Jamie A; Kertesz, Naomi J; Friedman, Richard A; Cannon, Bryan C

2012-08-01

Transcatheter ablation of accessory pathway (AP)-mediated tachycardia is routinely performed in children. Little data exist regarding the use of magnetic navigation (MN) and its potential benefits for ablation of AP-mediated tachycardia in this population. We performed a retrospective review of prospectively gathered data in children undergoing radiofrequency ablation at our institution since the installation of MN (Stereotaxis Inc, St. Louis, MO) in March 2009. The efficacy and safety between an MN-guided approach and standard manual techniques for mapping and ablation of AP-mediated tachycardia were compared. During the 26-month study period, 145 patients underwent radiofrequency ablation for AP-mediated tachycardia. Seventy-three patients were ablated with MN and 72 with a standard manual approach. There were no significant differences in demographic factors between the 2 groups with a mean cohort age of 13.1±4.0 years. Acute success rates were equivalent with 68 of 73 (93.2%) patients in the MN group being successfully ablated versus 68 of 72 (94.4%) patients in the manual group (P=0.889). During a median follow-up of 21.4 months, there were no recurrences in the MN group and 2 recurrences in the manual group (P=0.388). There were no differences in time to effect, number of lesions delivered, or average ablation power. There was also no difference in total procedure time, but fluoroscopy time was significantly reduced in the MN group at 14.0 (interquartile range, 3.8-23.9) minutes compared with the manual group at 28.1 (interquartile range, 15.3-47.3) minutes (P<0.001). There were no complications in either group. MN is a safe and effective approach to ablate AP-mediated tachycardia in children.

Urinary Biomarkers for Phthalates Associated with Asthma in Norwegian Children

PubMed Central

Carlsen, Karin C. Lødrup; Calafat, Antonia M.; Hoppin, Jane A.; Håland, Geir; Mowinckel, Petter; Carlsen, Kai-Håkon; Løvik, Martinus

2012-01-01

Background: High-molecular-weight phthalates in indoor dust have been associated with asthma in children, but few studies have evaluated phthalate biomarkers in association with respiratory outcomes. Objectives: We explored the association between urinary concentrations of phthalate metabolites and current asthma. Methods: In a cross-sectional analysis, 11 metabolites of 8 phthalates [including four metabolites of di(2-ethylhexyl) phthalate] were measured in one first morning void collected from 2001 through 2004 from 623 10-year-old Norwegian children. Logistic regression models controlling for urine specific gravity, sex, parental asthma, and income were used to estimate associations between current asthma and phthalate metabolite concentrations by quartiles or as log10-transformed variables. Results: Current asthma was associated with both mono(carboxyoctyl) phthalate (MCOP) and mono(carboxynonyl) phthalate (MCNP), although the association was limited to those in the highest quartile of these chemicals. The adjusted odds ratio (aOR) for current asthma was 1.9 (95% CI: 1.0, 3.3) for the highest MCOP quartile compared with the lowest quartile, and 1.3 (95% CI: 0.98, 1.7) for an interquartile-range increase. The aOR for current asthma was 2.2 (95% CI: 1.2, 4.0) for the highest MCNP quartile and 1.3 (95% CI: 1.0, 1.7) for an interquartile-range increase. The other phthalate metabolites were not associated with current asthma. Conclusions: Current asthma was associated with the highest quartiles of MCOP and MCNP, metabolites of two high molecular weight phthalates, diisononyl phthalate and diisodecyl phthalate, respectively. Given the short biological half-life of the phthalates and the cross-sectional design, our findings should be interpreted cautiously. PMID:23164678

Engagement with the National Healthy Schools Programme is associated with higher fruit and vegetable consumption in primary school children.

PubMed

Keyte, J; Harris, S; Margetts, B; Robinson, S; Baird, J

2012-04-01

  Improving children's diets is currently a government focus. However, fruit and vegetable consumption, a key target, is still far below the government guidelines of five portions per day. The present study aimed to assess the impact of engagement with the National Healthy Schools Programme (NHSP) on fruit and vegetable consumption in a sample of primary school children.   A sample of 511 children, aged 7-9 years, who were attending 10 randomly selected schools in Hampshire, completed the Day in the Life Questionnaire, a validated 24-h recall method of dietary assessment. Fruit and vegetable intake in pupils attending schools engaged with the NHSP was compared with that of pupils attending schools not engaged with the programme.   Children attending schools engaged with the NHSP ate a median of two (interquartile range, 0-8.0) portions of fruit and vegetables, compared to one portion (interquartile range, 0-8.0) consumed by pupils attending a school not engaged with the programme (P=0.001). Gender was also a significant predictor of fruit and vegetable consumption, with girls being 1.68 times more likely to consume 2.5 or more portions of fruit and vegetables. After adjustment for free school meal eligibility (as a measure of socio-economic status) and gender, pupils attending schools engaged with NHSP were twice as likely to eat 2.5 portions of fruit and vegetables or more per day.   Engagement with the NHSP may be an effective way of increasing fruit and vegetable consumption in primary school children. Further evaluation of the programme is recommended to determine which aspects of the NHSP are successful in achieving this. © 2011 The Authors. Journal of Human Nutrition and Dietetics © 2011 The British Dietetic Association Ltd.

Hypertension Does Not Alter the Increase in Cardiac Baroreflex Sensitivity Caused by Moderate Cold Exposure

PubMed Central

Hintsala, Heidi E.; Kiviniemi, Antti M.; Tulppo, Mikko P.; Helakari, Heta; Rintamäki, Hannu; Mäntysaari, Matti; Herzig, Karl-Heinz; Keinänen-Kiukaanniemi, Sirkka; Jaakkola, Jouni J. K.; Ikäheimo, Tiina M.

2016-01-01

Exposure to cold increases blood pressure and may contribute to higher wintertime cardiovascular morbidity and mortality in hypertensive people, but the mechanisms are not well-established. While hypertension does not alter responses of vagally-mediated heart rate variability to cold, it is not known how hypertension modifies baroreflex sensitivity (BRS) and blood pressure variability during cold exposure. Our study assessed this among untreated hypertensive men during short-term exposure comparable to habitual winter time circumstances in subarctic areas. We conducted a population-based recruitment of 24 untreated hypertensive and 17 men without hypertension (age 55–65 years) who underwent a whole-body cold exposure (−10°C, wind 3 m/s, winter clothes, 15 min, standing). Electrocardiogram and continuous blood pressure were measured to compute spectral powers of systolic blood pressure and heart rate variability at low (0.04–0.15 Hz) and high frequency (0.15–0.4 Hz) and spontaneous BRS at low frequency (LF). Comparable increases in BRS were detected in hypertensive men, from 2.6 (2.0, 4.2) to 3.8 (2.5, 5.1) ms/mmHg [median (interquartile range)], and in control group, from 4.3 (2.7, 5.0) to 4.4 (3.1, 7.1) ms/mmHg. Instead, larger increase (p < 0.05) in LF blood pressure variability was observed in control group; response as median (interquartile range): 8 (2, 14) mmHg2, compared with hypertensive group [0 (−13, 20) mmHg2]. Untreated hypertension does not disturb cardiovascular protective mechanisms during moderate cold exposure commonly occurring in everyday life. Blunted response of the estimate of peripheral sympathetic modulation may indicate higher tonic sympathetic activity and decreased sympathetic responsiveness to cold in hypertension. PMID:27313543

Direct Vision Internal Urethrotomy for Short Anterior Urethral Strictures and Beyond: Success Rates, Predictors of Treatment Failure, and Recurrence Management.

PubMed

Kluth, Luis A; Ernst, Lukas; Vetterlein, Malte W; Meyer, Christian P; Reiss, C Philip; Fisch, Margit; Rosenbaum, Clemens M

2017-08-01

To determine success rates, predictors of recurrence, and recurrence management of patients treated for short anterior urethral strictures by direct vision internal urethrotomy (DVIU). We identified 128 patients who underwent DVIU of the anterior urethra between December 2009 and March 2016. Follow-up was conducted by telephone interviews. Success rates were assessed by Kaplan-Meier estimators. Predictors of stricture recurrence and different further therapy strategies were identified by uni- and multivariable Cox regression analyses. The mean age was 63.8 years (standard deviation: 16.3) and the overall success rate was 51.6% (N = 66) at a median follow-up of 16 months (interquartile range: 6-43). Median time to stricture recurrence was six months (interquartile range: 2-12). In uni- and multivariable analyses, only repeat DVIU (hazard ratio [HR] = 1.87, 95% confidence interval (CI) = 1.13-3.11, P= .015; and HR=1.78, 95% CI = 1.05-3.03, P = .032, respectively) was a risk factor for recurrence. Of 62 patients with recurrence, 35.5% underwent urethroplasty, 29% underwent further endoscopic treatment, and 33.9% did not undergo further interventional therapy. Age (HR = 1.05, 95% CI = 1.01-1.09, P = .019) and diabetes (HR = 2.90, 95% CI = 1.02-8.26, P = .047) were predictors of no further interventional therapy. DVIU seems justifiable in short urethral strictures as a primary treatment. Prior DVIU was a risk factor for recurrence. In case of recurrence, about one-third of the patients did not undergo any further therapy. Higher age and diabetes predicted the denial of any further treatment. Copyright © 2017 Elsevier Inc. All rights reserved.

Herb-Drug Interaction between Echinacea purpurea and Etravirine in HIV-Infected Patients

PubMed Central

Valle, Marta; Miranda, Cristina; Cedeño, Samandhy; Negredo, Eugenia; Clotet, Bonaventura

2012-01-01

The aim of this open-label, fixed-sequence study was to investigate the potential of the botanical supplement Echinacea purpurea to interact with etravirine, a nonnucleoside reverse transcriptase inhibitor of HIV. Fifteen HIV-infected patients receiving antiretroviral therapy with etravirine (400 mg once daily) for at least 4 weeks were included. E. purpurea root/extract-containing capsules were added to the antiretroviral treatment (500 mg every 8 h) for 14 days. Etravirine concentrations in plasma were determined by high-performance liquid chromatography immediately before and 1, 2, 4, 6, 8, 10, 12, and 24 h after a morning dose of etravirine on day 0 and etravirine plus E. purpurea on day 14. Individual etravirine pharmacokinetic parameters were calculated by noncompartmental analysis and compared between days 0 and 14 by means of the geometric mean ratio (GMR) and its 90% confidence interval (CI). The median age was 46 years (interquartile range, 41 to 50), and the median body weight was 76 kg (interquartile range, 68 to 92). Echinacea was well tolerated, and all participants completed the study. The GMR for etravirine coadministered with E. purpurea relative to etravirine alone was 1.07 (90% CI, 0.81 to 1.42) for the maximum concentration, 1.04 (90% CI, 0.79 to 1.38) for the area under the concentration-time curve from 0 to 24 h, and 1.04 (90% CI, 0.74 to 1.44) for the concentration at the end of the dosing interval. In conclusion, the coadministration of E. purpurea with etravirine was safe and well tolerated in HIV-infected patients; our data suggest that no dose adjustment for etravirine is necessary. PMID:22869560

Heme oxygenase-1 gene promoter microsatellite polymorphism is associated with progressive atherosclerosis and incident cardiovascular disease.

PubMed

Pechlaner, Raimund; Willeit, Peter; Summerer, Monika; Santer, Peter; Egger, Georg; Kronenberg, Florian; Demetz, Egon; Weiss, Günter; Tsimikas, Sotirios; Witztum, Joseph L; Willeit, Karin; Iglseder, Bernhard; Paulweber, Bernhard; Kedenko, Lyudmyla; Haun, Margot; Meisinger, Christa; Gieger, Christian; Müller-Nurasyid, Martina; Peters, Annette; Willeit, Johann; Kiechl, Stefan

2015-01-01

The enzyme heme oxygenase-1 (HO-1) exerts cytoprotective effects in response to various cellular stressors. A variable number tandem repeat polymorphism in the HO-1 gene promoter region has previously been linked to cardiovascular disease. We examined this association prospectively in the general population. Incidence of stroke, myocardial infarction, or vascular death was registered between 1995 and 2010 in 812 participants of the Bruneck Study aged 45 to 84 years (49.4% males). Carotid atherosclerosis progression was quantified by high-resolution ultrasound. HO-1 variable number tandem repeat length was determined by polymerase chain reaction. Subjects with ≥32 tandem repeats on both HO-1 alleles compared with the rest of the population (recessive trait) featured substantially increased cardiovascular disease risk (hazard ratio [95% confidence interval], 5.45 [2.39, 12.42]; P<0.0001), enhanced atherosclerosis progression (median difference in atherosclerosis score [interquartile range], 2.1 [0.8, 5.6] versus 0.0 [0.0, 2.2] mm; P=0.0012), and a trend toward higher levels of oxidized phospholipids on apolipoprotein B-100 (median oxidized phospholipids/apolipoprotein B level [interquartile range], 11364 [4160, 18330] versus 4844 [3174, 12284] relative light units; P=0.0554). Increased cardiovascular disease risk in those homozygous for ≥32 repeats was also detected in a pooled analysis of 7848 participants of the Bruneck, SAPHIR, and KORA prospective studies (hazard ratio [95% confidence interval], 3.26 [1.50, 7.33]; P=0.0043). This study found a strong association between the HO-1 variable number tandem repeat polymorphism and cardiovascular disease risk confined to subjects with a high number of repeats on both HO-1 alleles and provides evidence for accelerated atherogenesis and decreased antioxidant defense in this vascular high-risk group. © 2014 American Heart Association, Inc.

Prenatal fine particulate exposure and early childhood asthma: Effect of maternal stress and fetal sex.

PubMed

Lee, Alison; Leon Hsu, Hsiao-Hsien; Mathilda Chiu, Yueh-Hsiu; Bose, Sonali; Rosa, Maria José; Kloog, Itai; Wilson, Ander; Schwartz, Joel; Cohen, Sheldon; Coull, Brent A; Wright, Robert O; Wright, Rosalind J

2018-05-01

The impact of prenatal ambient air pollution on child asthma may be modified by maternal stress, child sex, and exposure dose and timing. We prospectively examined associations between coexposure to prenatal particulate matter with an aerodynamic diameter of less than 2.5 microns (PM 2.5 ) and maternal stress and childhood asthma (n = 736). Daily PM 2.5 exposure during pregnancy was estimated using a validated satellite-based spatiotemporally resolved prediction model. Prenatal maternal negative life events (NLEs) were dichotomized around the median (high: NLE ≥ 3; low: NLE < 3). We used Bayesian distributed lag interaction models to identify sensitive windows for prenatal PM 2.5 exposure on children's asthma by age 6 years, and determine effect modification by maternal stress and child sex. Bayesian distributed lag interaction models identified a critical window of exposure (19-23 weeks' gestation, cumulative odds ratio, 1.15; 95% CI, 1.03-1.26; per interquartile range [1.7 μg/m 3 ] increase in prenatal PM 2.5 level) during which children concomitantly exposed to prenatal PM 2.5 and maternal stress had increased risk of asthma. No significant association was seen in children born to women reporting low prenatal stress. When examining modifying effects of prenatal stress and fetal sex, we found that boys born to mothers with higher prenatal stress were most vulnerable (19-21 weeks' gestation; cumulative odds ratio, 1.28; 95% CI, 1.15-1.41; per interquartile range increase in PM 2.5 ). Prenatal PM 2.5 exposure during sensitive windows is associated with increased risk of child asthma, especially in boys concurrently exposed to elevated maternal stress. Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Effect of self-measurement of blood pressure on adherence to treatment in patients with mild-to-moderate hypertension.

PubMed

van Onzenoort, Hein A W; Verberk, Willem J; Kroon, Abraham A; Kessels, Alfons G H; Nelemans, Patricia J; van der Kuy, Paul-Hugo M; Neef, Cees; de Leeuw, Peter W

2010-03-01

Poor adherence to treatment is one of the major problems in the treatment of hypertension. Self blood pressure measurement may help patients to improve their adherence to treatment. In this prospective, randomized, controlled study coordinated by a university hospital, a total of 228 mild-to-moderate hypertensive patients were randomized to either a group that performed self-measurements at home in addition to office blood pressure measurements [the self-pressure group (n = 114)] or a group that only underwent office blood pressure measurement [the office pressure group (n = 114)]. Patients were followed for 1 year in which treatment was adjusted, if necessary, at each visit to the physician's office according to the achieved blood pressure. Adherence to treatment was assessed by means of medication event monitoring system TrackCaps. Median adherence was slightly greater in patients from the self-pressure group than in those from the office pressure group (92.3 vs. 90.9%; P = 0.043). Although identical among both groups, in the week directly after each visit to the physician's office, adherence [71.4% (interquartile range 71-79%)] was significantly lower (P < 0.001) than that at the last 7 days prior to each visit [100% (interquartile range 90-100%)]. On the remaining days between the visits, patients from the self-pressure group displayed a modestly better adherence than patients from the office pressure group (97.6 vs. 97.0%; P = 0.024). Although self-blood pressure measurement as an adjunct to office blood pressure measurement led to somewhat better adherence to treatment in this study, the difference was only small and not clinically significant. The time relative to a visit to the doctor seems to be a more important predictor of adherence.

Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation.

PubMed

Lemaignen, A; Birgand, G; Ghodhbane, W; Alkhoder, S; Lolom, I; Belorgey, S; Lescure, F-X; Armand-Lefevre, L; Raffoul, R; Dilly, M-P; Nataf, P; Lucet, J C

2015-07-01

The incidence of surgical site infection (SSI) after cardiac surgery depends on the definition used. A distinction is generally made between mediastinitis, as defined by the US Centers for Disease Control and Prevention (CDC), and superficial SSI. Our objective was to decipher these entities in terms of presentation and risk factors. We performed a 7-year single centre analysis of prospective surveillance of patients with cardiac surgery via median sternotomy. SSI was defined as the need for reoperation due to infection. Among 7170 patients, 292 (4.1%) developed SSI, including 145 CDC-defined mediastinitis (CDC-positive SSI, 2.0%) and 147 superficial SSI without associated bloodstream infection (CDC-negative SSI, 2.1%). Median time to reoperation for CDC-negative SSI was 18 days (interquartile range, 14-26) and 16 (interquartile range, 11-24) for CDC-positive SSI (p 0.02). Microorganisms associated with CDC-negative SSI were mainly skin commensals (62/147, 41%) or originated in the digestive tract (62/147, 42%); only six were due to Staphylococcus aureus (4%), while CDC-positive SSI were mostly due to S. aureus (52/145, 36%) and germs from the digestive tract (52/145, 36%). Risk factors for SSI were older age, obesity, chronic obstructive bronchopneumonia, diabetes mellitus, critical preoperative state, postoperative vasopressive support, transfusion or prolonged ventilation and coronary artery bypass grafting, especially if using both internal thoracic arteries in female patients. The number of internal thoracic arteries used and factors affecting wound healing were primarily associated with CDC-negative SSI, whereas comorbidities and perioperative complications were mainly associated with CDC-positive SSI. These 2 entities differed in time to revision surgery, bacteriology and risk factors, suggesting a differing pathophysiology. Copyright © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Mechanical Thrombectomy in Perioperative Strokes: A Case-Control Study.

PubMed

Premat, Kévin; Clovet, Olivier; Frasca Polara, Giulia; Shotar, Eimad; Bartolini, Bruno; Yger, Marion; Di Maria, Federico; Baronnet, Flore; Pistocchi, Silvia; Le Bouc, Raphaël; Pires, Christine; Sourour, Nader; Alamowitch, Sonia; Samson, Yves; Degos, Vincent; Clarençon, Frédéric

2017-11-01

Perioperative strokes (POS) are rare but serious complications for which mechanical thrombectomy could be beneficial. We aimed to compare the technical results and patients outcomes in a population of POS versus non-POS (nPOS) treated by mechanical thrombectomy. From 2010 to 2017, 25 patients with POS (ie, acute ischemic stroke occurring during or within 30 days after a procedure) who underwent mechanical thrombectomy (POS group) were enrolled and paired with 50 consecutive patients with nPOS (control group), based on the occlusion's site, National Institute of Health Stroke Scale, and age. Respectively, mean age was 68.3±16.6 versus 67.2±16.6 years ( P =0.70), and median National Institute of Health Stroke Scale score at admission was 20 (interquartile range, 15-25) versus 19 (interquartile range, 17-25; P =0.79). Good clinical outcome (modified Rankin Scale score of 0-2 at 3 months) was achieved by 33.3% (POS) versus 56.5% (nPOS) of patients ( P =0.055). Successful reperfusion (modified Thrombolysis In Cerebral Infarction score of ≥2b) was obtained in 76% (POS) versus 86% (nPOS) of cases ( P =0.22). Mortality at 3 months was 33.3% in the POS group versus 4.2% (nPOS) ( P =0.002). The rate of major procedural complications was 4% (POS) versus 6% (nPOS); none were lethal. Average time from symptoms' onset to reperfusion was 4.9 hours (±2.0) in POS versus 5.2 hours (±2.6). Successful reperfusion seems accessible in POS within a reasonable amount of time and with a good level of safety. However, favorable outcome was achieved with a lower rate than in nPOS, owing to a higher mortality rate. © 2017 American Heart Association, Inc.

Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data.

PubMed

Widdifield, Jessica; Bernatsky, Sasha; Thorne, J Carter; Bombardier, Claire; Jaakkimainen, R Liisa; Wing, Laura; Paterson, J Michael; Ivers, Noah; Butt, Debra; Lyddiatt, Anne; Hofstetter, Catherine; Ahluwalia, Vandana; Tu, Karen

2016-01-01

The Wait Time Alliance recently established wait time benchmarks for rheumatology consultations in Canada. Our aim was to quantify wait times to primary and rheumatology care for patients with rheumatic diseases. We identified patients from primary care practices in the Electronic Medical Record Administrative data Linked Database who had referrals to Ontario rheumatologists over the period 2000-2013. To assess the full care pathway, we identified dates of symptom onset, presentation in primary care and referral from electronic medical records. Dates of rheumatologist consultations were obtained by linking with physician service claims. We determined the duration of each phase of the care pathway (symptom onset to primary care encounter, primary care encounter to referral, and referral to rheumatologist consultation) and compared them with established benchmarks. Among 2430 referrals from 168 family physicians, 2015 patients (82.9%) were seen by 146 rheumatologists within 1 year of referral. Of the 2430 referrals, 2417 (99.5%) occurred between 2005 and 2013. The main reasons for referral were osteoarthritis (32.4%) and systemic inflammatory rheumatic diseases (30.6%). Wait times varied by diagnosis and geographic region. Overall, the median wait time from referral to rheumatologist consultation was 74 (interquartile range 27-101) days; it was 66 (interquartile range 18-84) days for systemic inflammatory rheumatic diseases. Wait time benchmarks were not achieved, even for the most urgent types of referral. For systemic inflammatory rheumatic diseases, most of the delays occurred before referral. Rheumatology wait times exceeded established benchmarks. Targeted efforts are needed to promote more timely access to both primary and rheumatology care. Routine linkage of electronic medical records with administrative data may help fill important gaps in knowledge about waits to primary and specialty care.

Male and female hypogonadism are highly prevalent in South Africans with Addison's disease.

PubMed

Ross, I L; Levitt, N S; Blom, D J; Haarburger, D

2014-09-01

Hypogonadism may complicate Addison's disease (primary hypoadrenalism), but prevalence and metabolic sequelae of hypogonadism in Addison's disease are poorly described. We recruited patients from the South African Addison's disease national registry who received stable replacement doses of hydrocortisone and had no acute illness. Male biochemical testosterone deficiency was defined as an early morning basal testosterone<9.9 nmol/l and premature ovarian failure (POF) when menopause occurred before 40 years of age. Cardiometabolic risk variables were measured in males only. Male hypogonadism prevalence was 33% (14/42), and 10 patients had newly diagnosed hypogonadism. Two untreated patients had elevated FSH or LH (>10 or 12 IU/l). Testosterone deficiency did not correlate with age, disease duration or hydrocortisone dose. Untreated male hypogonadal subjects had a higher (mean ± standard deviation) BMI compared to eugonadal subjects 29.2 ± 4.9 kg/m(2) vs. 24.7 ± 3.4 kg/m(2) (p=0.01) and a higher median (interquartile range) high-sensitive-CRP 6.4 (2.5-14.0) mg/l vs. 1.45 (0.6-2.8) mg/l (p=0.002). There were no differences between the 2 groups in lipids, lipoproteins and fasting glucose. The median (interquartile range) DHEAS was lower in the hypogonadal 0.31 (0.27-0.37) μmol/l, compared with the eugonadal group 0.75 (0.50-1.51) μmol/l (p=0.005). POF was documented in 11% of female patients. Male testosterone deficiency was highly prevalent in this cohort and was primarily due to secondary hypogonadism. Only BMI and hs-CRP were increased in untreated male hypogonadal subjects. Male and female hypogonadism appears to be a common complication of Addison's disease and may contribute to its morbidity. © Georg Thieme Verlag KG Stuttgart · New York.

Associations between demographics and health-related quality of life for chronic non-malignant pain patients treated at a multidisciplinary pain centre: a cohort study.

PubMed

Jensen, Hanne Irene; Plesner, Karin; Kvorning, Nina; Krogh, Bo Lunddal; Kimper-Karl, Alan

2016-02-01

To describe the associations between demographics and health-related quality of life for chronic non-malignant pain patients. A cohort study. A multidisciplinary Danish pain centre. All patients treated at the centre between 2007 and 2013. Levels of pain, anxiety and depression, and physical and mental status. The Hospital Anxiety and Depression Scale and the Medical Outcomes Study Short-Form Health Survey (SF-36) were used. A total of 1176 patients were included. The majority were women (64%), the mean age was 46.7 ± 14.4 (range 18-89), and 21% were able to work full or part time. On a Numeric Rating Scale from 0 to 10, median pain-intensity was 8 (interquartile range 7-8) and pain-discomfort 8 (interquartile range 7-9) at time of referral. More than half of the patients had symptoms of anxiety and depression. Most of the individual SF-36 domains had median scores between 0 and 40 (Scale from 0 to 100). Patients younger than 50 years of age as well as patients on sick leave/disability pension had significantly lower SF-36 scores. Level of pain, anxiety and depression decreased and SF-36-scores increased significantly after a course of treatment which in most cases consisted of both medical, physiotherapeutic and psychological treatment as well as health-oriented education. The chi-square test, Mann-Whitney U-test, the Kruskal-Wallis and Wilcoxon Signed-rank test were used for analyses. In order to improve treatment at a multidisciplinary pain centre, it may be of value to target treatments to different patient subgroups based on, amongst other things, age and employment status. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs.

PubMed

Dort, Jonathan M; Trickey, Amber W; Kallies, Kara J; Joshi, Amit R T; Sidwell, Richard A; Jarman, Benjamin T

2015-01-01

This study evaluated characteristics of applicants selected for interview and ranked by independent general surgery residency programs and assessed independent program application volumes, interview selection, rank list formation, and match success. Demographic and academic information was analyzed for 2014-2015 applicants. Applicant characteristics were compared by ranking status using univariate and multivariable statistical techniques. Characteristics independently associated with whether or not an applicant was ranked were identified using multivariable logistic regression modeling with backward stepwise variable selection and cluster-correlated robust variance estimates to account for correlations among individuals who applied to multiple programs. The Electronic Residency Application Service was used to obtain applicant data and program match outcomes at 33 independent surgery programs. All applicants selected to interview at 33 participating independent general surgery residency programs were included in the study. Applicants were 60% male with median age of 26 years. Birthplace was well distributed. Most applicants (73%) had ≥1 academic publication. Median United States Medical Licensing Exams (USMLE) Step 1 score was 228 (interquartile range: 218-240), and median USMLE Step 2 clinical knowledge score was 241 (interquartile range: 231-250). Residency programs in some regions more often ranked applicants who attended medical school within the same region. On multivariable analysis, significant predictors of ranking by an independent residency program were: USMLE scores, medical school region, and birth region. Independent programs received an average of 764 applications (range: 307-1704). On average, 12% interviews, and 81% of interviewed applicants were ranked. Most programs (84%) matched at least 1 applicant ranked in their top 10. Participating independent programs attract a large volume of applicants and have high standards in the selection process. This information can be used by surgery residency applicants to gauge their candidacy at independent programs. Independent programs offer a select number of interviews, rank most applicants that they interview, and successfully match competitive applicants. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions.

PubMed

Bin Jabr, Adel; Lindblad, Bengt; Kristmundsson, Thorarinn; Dias, Nuno; Resch, Timothy; Malina, Martin

2016-03-01

Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions. Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive. Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases. The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

An e-learning course in medical immunology: does it improve learning outcome?

PubMed

Boye, Sondre; Moen, Torolf; Vik, Torstein

2012-01-01

E-learning is used by most medical students almost daily and several studies have shown e-learning to improve learning outcome in small-scale interventions. However, few studies have explored the effects of e-learning in immunology. To study the effect of an e-learning package in immunology on learning outcomes in a written integrated examination and to examine student satisfaction with the e-learning package. All second-year students at a Norwegian medical school were offered an animated e-learning package in basic immunology as a supplement to the regular teaching. Each student's log-on-time was recorded and linked with the student's score on multiple choice questions included in an integrated end-of-the-year written examination. Student satisfaction was assessed through a questionnaire. The intermediate-range students (interquartile range) on average scored 3.6% better on the immunology part of the examination per hour they had used the e-learning package (p = 0.0046) and log-on-time explained 17% of the variance in immunology score. The best and the less skilled students' examination outcomes were not affected by the e-learning. The e-learning was well appreciated among the students. Use of an e-learning package in immunology in addition to regular teaching improved learning outcomes for intermediate-range students.

Live-Birth Rate Associated With Repeat In Vitro Fertilization Treatment Cycles.

PubMed

Smith, Andrew D A C; Tilling, Kate; Nelson, Scott M; Lawlor, Debbie A

The likelihood of achieving a live birth with repeat in vitro fertilization (IVF) is unclear, yet treatment is commonly limited to 3 or 4 embryo transfers. To determine the live-birth rate per initiated ovarian stimulation IVF cycle and with repeated cycles. Prospective study of 156,947 UK women who received 257,398 IVF ovarian stimulation cycles between 2003 and 2010 and were followed up until June 2012. In vitro fertilization, with a cycle defined as an episode of ovarian stimulation and all subsequent separate fresh and frozen embryo transfers. Live-birth rate per IVF cycle and the cumulative live-birth rates across all cycles in all women and by age and treatment type. Optimal, prognosis-adjusted, and conservative cumulative live-birth rates were estimated, reflecting 0%, 30%, and 100%, respectively, of women who discontinued due to poor prognosis and having a live-birth rate of 0 had they continued. Among the 156,947 women, the median age at start of treatment was 35 years (interquartile range, 32-38; range, 18-55), and the median duration of infertility for all 257,398 cycles was 4 years (interquartile range, 2-6; range, <1-29). In all women, the live-birth rate for the first cycle was 29.5% (95% CI, 29.3%-29.7%). This remained above 20% up to and including the fourth cycle. The cumulative prognosis-adjusted live-birth rate across all cycles continued to increase up to the ninth cycle, with 65.3% (95% CI, 64.8%-65.8%) of women achieving a live birth by the sixth cycle. In women younger than 40 years using their own oocytes, the live-birth rate for the first cycle was 32.3% (95% CI, 32.0%-32.5%) and remained above 20% up to and including the fourth cycle. Six cycles achieved a cumulative prognosis-adjusted live-birth rate of 68.4% (95% CI, 67.8%-68.9%). For women aged 40 to 42 years, the live-birth rate for the first cycle was 12.3% (95% CI, 11.8%-12.8%), with 6 cycles achieving a cumulative prognosis-adjusted live-birth rate of 31.5% (95% CI, 29.7%-33.3%). For women older than 42 years, all rates within each cycle were less than 4%. No age differential was observed among women using donor oocytes. Rates were lower for women with untreated male partner-related infertility compared with those with any other cause, but treatment with either intracytoplasmic sperm injection or sperm donation removed this difference. Among women in the United Kingdom undergoing IVF, the cumulative prognosis-adjusted live-birth rate after 6 cycles was 65.3%, with variations by age and treatment type. These findings support the efficacy of extending the number of IVF cycles beyond 3 or 4.

Objective and Subjective Measures of Simultaneous vs Sequential Bilateral Cochlear Implants in Adults: A Randomized Clinical Trial.

PubMed

Kraaijenga, Véronique J C; Ramakers, Geerte G J; Smulders, Yvette E; van Zon, Alice; Stegeman, Inge; Smit, Adriana L; Stokroos, Robert J; Hendrice, Nadia; Free, Rolien H; Maat, Bert; Frijns, Johan H M; Briaire, Jeroen J; Mylanus, E A M; Huinck, Wendy J; Van Zanten, Gijsbert A; Grolman, Wilko

2017-09-01

To date, no randomized clinical trial on the comparison between simultaneous and sequential bilateral cochlear implants (BiCIs) has been performed. To investigate the hearing capabilities and the self-reported benefits of simultaneous BiCIs compared with those of sequential BiCIs. A multicenter randomized clinical trial was conducted between January 12, 2010, and September 2, 2012, at 5 tertiary referral centers among 40 participants eligible for BiCIs. Main inclusion criteria were postlingual severe to profound hearing loss, age 18 to 70 years, and a maximum duration of 10 years without hearing aid use in both ears. Data analysis was conducted from May 24 to June 12, 2016. The simultaneous BiCI group received 2 cochlear implants during 1 surgical procedure. The sequential BiCI group received 2 cochlear implants with an interval of 2 years between implants. First, the results 1 year after receiving simultaneous BiCIs were compared with the results 1 year after receiving sequential BiCIs. Second, the results of 3 years of follow-up for both groups were compared separately. The primary outcome measure was speech intelligibility in noise from straight ahead. Secondary outcome measures were speech intelligibility in noise from spatially separated sources, speech intelligibility in silence, localization capabilities, and self-reported benefits assessed with various hearing and quality of life questionnaires. Nineteen participants were randomized to receive simultaneous BiCIs (11 women and 8 men; median age, 52 years [interquartile range, 36-63 years]), and another 19 participants were randomized to undergo sequential BiCIs (8 women and 11 men; median age, 54 years [interquartile range, 43-64 years]). Three patients did not receive a second cochlear implant and were unavailable for follow-up. Comparable results were found 1 year after simultaneous or sequential BiCIs for speech intelligibility in noise from straight ahead (difference, 0.9 dB [95% CI, -3.1 to 4.4 dB]) and all secondary outcome measures except for localization with a 30° angle between loudspeakers (difference, -10% [95% CI, -20.1% to 0.0%]). In the sequential BiCI group, all participants performed significantly better after the BiCIs on speech intelligibility in noise from spatially separated sources and on all localization tests, which was consistent with most of the participants' self-reported hearing capabilities. Speech intelligibility-in-noise results improved in the simultaneous BiCI group up to 3 years following the BiCIs. This study shows comparable objective and subjective hearing results 1 year after receiving simultaneous BiCIs and sequential BiCIs with an interval of 2 years between implants. It also shows a significant benefit of sequential BiCIs over a unilateral cochlear implant. Until 3 years after receiving simultaneous BiCIs, speech intelligibility in noise significantly improved compared with previous years. trialregister.nl Identifier: NTR1722.

Congenital Factor VII Deficiency in Children at Tertiary Health Care Facility in Pakistan.

PubMed

Alam, Muhammad Matloob; Moiz, Bushra; Rehman, Karim Abdur; Jethwani, Priyanka; Fadoo, Zehra

2015-10-01

This study presents the demographics, clinical spectrum, and outcome of patients with congenital factor VII (FVII) deficiency at a tertiary care center over a period of 12 years. Of the 49 patients, 27 (55%) patients were males. Consanguinity was found in 92% of the patients. The median age of symptom onset was 2.4 (interquartile range [IQR]: 1.1-6.5) years with a median age of 5.8 (IQR: 3.1-10) years at diagnosis. Life-threatening complications like intracranial bleeding (ICB) and intra-abdominal bleeding (IAB) were observed in 8 (16.4%) patients. We found that 11 (55%) of the 20 patients with FVII coagulant activity (FVIIc) <1% were either asymptomatic or showed mild phenotype. In contrast, 9 (53%) of the 17 patients with FVIIc >5% were affected by severe symptoms. Age <1 year was the only identified risk factor associated with development of life-threatening bleeding episodes (P = .042; odds ratio 6.46). Overall, 4 (8.2%) died as a consequence of ICB (3 patients) and IAB (1 patient). © The Author(s) 2013.

[Evaluation of free radical quantity in the anterior chamber following femtosecond laser-assisted capsulotomy].

PubMed

Tóth, Gábor; Sándor, Gábor László; Kleiner, Dénes; Szentmáry, Nóra; Kiss, Huba J; Blázovics, Anna; Nagy, Zoltán Zsolt

2016-11-01

Femtosecond laser is a revolutionary, innovative treatment method used in cataract surgery. To evaluate free radical quantity in the anterior chamber of the eye, during femtosecond laser assisted capsulotomy, in a porcine eye model. Seventy fresh porcine eyes were collected within 2 hours post mortem, were transported at 4 ºC and treated within 7 hours. Thirty-five eyes were used as control and 35 as femtosecond laser assisted capsulotomy group. A simple luminol-dependent chemiluminescence method was used to measure the total scavenger capacity in the aqueous humour, as an indicator of free radical production. The emitted photons were expressed in relative light unit %. The relative light unit % was lower in the control group (median 1%, interquartile range [0.4-3%]) than in the femtosecond laser assisted capsulotomy group (median 4.4%, interquartile range [1.5%-21%]) (p = 0.01). Femtosecond laser assisted capsulotomy decreases the antioxidant defense of the anterior chamber, which refers to a significant free radical production during femtosecond laser assisted capsulotomy. Orv. Hetil., 2016, 157(47), 1880-1883.

Higher sweat chloride levels in patients with asthma: a case-control study.

PubMed

Awasthi, Shally; Dixit, Pratibha; Maurya, Nutan

2015-02-01

To screen asthmatic patients by sweat chloride test to identify proportion with Cystic Fibrosis (CF); (Sweat chloride level >60 mmol/L). Also, to compare sweat chloride levels between cases of bronchial asthma and age and sex matched healthy children aged 5 mo-15 y. The present case-control study was conducted in a tertiary care hospital in India. Cases of bronchial asthma, diagnosed by GINA guideline 2008, and age matched healthy controls were included. Case to control ratio was 2:1. Sweat Chloride test was done by Pilocarpine Iontophoresis method. From April 2010 through May 2012, 216 asthmatics and 112 controls were recruited. Among asthmatics, there was no case of Cystic Fibrosis. Mean sweat chloride levels in asthmatics was 22.39 ± 8.45 mmol/L (inter-quartile range - 15-28 mmol/L) and in controls 19.55 ± 7.04 mmol/L (inter-quartile range - 15-23.5 mmol/L) (p value = 0.048). No Cystic Fibrosis case was identified among asthmatics. Mean sweat chloride levels were higher in asthmatics as compared to controls.

Changing Epidemiology of Human Brucellosis, China, 1955–2014

PubMed Central

Lai, Shengjie; Zhou, Hang; Xiong, Weiyi; Gilbert, Marius; Huang, Zhuojie; Yu, Jianxing; Yin, Wenwu; Wang, Liping; Chen, Qiulan; Li, Yu; Mu, Di; Zeng, Lingjia; Ren, Xiang; Geng, Mengjie; Zhang, Zike; Cui, Buyun; Li, Tiefeng; Wang, Dali; Li, Zhongjie; Wardrop, Nicola A.; Tatem, Andrew J.

2017-01-01

Brucellosis, a zoonotic disease, was made statutorily notifiable in China in 1955. We analyzed the incidence and spatial–temporal distribution of human brucellosis during 1955–2014 in China using notifiable surveillance data: aggregated data for 1955–2003 and individual case data for 2004–2014. A total of 513,034 brucellosis cases were recorded, of which 99.3% were reported in northern China during 1955–2014, and 69.1% (258, 462/374, 141) occurred during February–July in 1990–2014. Incidence remained high during 1955–1978 (interquartile range 0.42–1.0 cases/100,000 residents), then decreased dramatically in 1979–1994. However, brucellosis has reemerged since 1995 (interquartile range 0.11–0.23 in 1995–2003 and 1.48–2.89 in 2004–2014); the historical high occurred in 2014, and the affected area expanded from northern pastureland provinces to the adjacent grassland and agricultural areas, then to southern coastal and southwestern areas. Control strategies in China should be adjusted to account for these changes by adopting a One Health approach. PMID:28098531

Androgenic correlates of genetic variation in the gene encoding 5alpha-reductase type 1.

PubMed

Ellis, Justine A; Panagiotopoulos, Sianna; Akdeniz, Aysel; Jerums, George; Harrap, Stephen B

2005-01-01

Androgens determine male secondary sexual characteristics and influence a variety of metabolic pathways. Circulating levels of androgens are highly heritable; however, the genes involved are largely unknown. The 5alpha-reductase enzymes types 1 and 2 responsible for converting testosterone to the more potent androgen dihydrotestosterone are encoded by the SRD5A1 and SRD5A2 genes, respectively. We performed indirect genetic association studies of SRD5A1 and SRD5A2 and the dihydrotestosterone/testosterone ratio that reflects the activity of 5alpha-reductase in 57 males with type 2 diabetes. We found evidence of significant association between a single nucleotide polymorphism in SRD5A1 and the dihydrotestosterone/testosterone ratio (median 0.10, interquartile range 0.08 vs. median 0.06, interquartile range 0.04, P = 0.009). The polymorphism was not associated with any diabetic phenotypes. These results suggest that functional genetic variants might exist in or around SRD5A1 that affect the activity of the 5alpha-reductase enzyme type 1 and influence androgen levels.

Anxiety Among Patients Undergoing Nail Surgery and Skin Punch Biopsy: Effects of Age, Gender, Educational Status, and Previous Experience.

PubMed

Göktay, Fatih; Altan, Zeynep Müzeyyen; Talas, Anıl; Akpınar, Esma; Özdemir, Ekin Özge; Aytekin, Sema

2016-01-01

Patient anxiety about nail surgery relates mainly to pain associated with needle puncture, anesthetic flow during the procedure, and postoperative care, as well as possible past traumatic experience. The aims of this study were to compare anxiety levels among patients undergoing nail surgery and skin punch biopsy and to assess the effects of demographic characteristics on anxiety. Forty-eight consecutive patients who were referred to a dermatological surgery unit for nail surgery intervention (group 1) and 50 age- and sex-matched patients referred to the same unit for skin punch biopsy (group 2) were enrolled in the study. Patients' anxiety levels were measured using Spielberger's State-Trait Anxiety Inventory. There was no significant difference in median anxiety level between group 1 (42.00; interquartile range, 6.50) and group 2 (41.00; interquartile range, 8.25) (P = .517). The demographic factors of patient sex, educational status, and prior surgery showed no significant effects on anxiety levels. Nail surgery does not seem to cause significantly greater anxiety than skin punch biopsy. © The Author(s) 2015.

Clinical Evidence Supporting US Food and Drug Administration Premarket Approval of High-Risk Otolaryngologic Devices, 2000-2014.

PubMed

Rathi, Vinay K; Wang, Bo; Ross, Joseph S; Downing, Nicholas S; Kesselheim, Aaron S; Gray, Stacey T

2017-02-01

The US Food and Drug Administration (FDA) approves high-risk medical devices based on premarket pivotal clinical studies demonstrating reasonable assurance of safety and effectiveness and may require postapproval studies (PAS) to further inform benefit-risk assessment. We conducted a cross-sectional analysis using publicly available FDA documents to characterize industry-sponsored pivotal studies and PAS of high-risk devices used in the treatment of otolaryngologic diseases. Between 2000 and 2014, the FDA approved 23 high-risk otolaryngologic devices based on 28 pivotal studies. Median enrollment was 118 patients (interquartile range, 67-181), and median duration of longest primary effectiveness end point follow-up was 26 weeks (interquartile range, 16-96). Fewer than half were randomized (n = 13, 46%), blinded (n = 12, 43%), or controlled (n = 10, 36%). The FDA required 23 PASs for 16 devices (70%): almost two-thirds (n = 15, 65%) monitored long-term performance, and roughly one-third (n = 8, 35%) focused on subgroups. Otolaryngologists should be aware of limitations in the strength of premarket evidence when considering the use of newly approved devices.

Comparison Between Retrograde and Antegrade Peripheral Venous Cannulation in Intensive Care Unit Patients: Assessment of Thrombus Formation.

PubMed

Abdelaal Ahmed Mahmoud, Ahmed; El-Shafei, Hassan Ismail; Yassin, Hany Mahmoud; Elramely, Mohamed Adly; Abdelhaq, Mohamed Mohamed; El Kady, Hany Wafiq; Awada, Wael Nabil Fahemy

2017-06-01

Antegrade cannulation of peripheral veins is the usual practice. Blood stasis between a catheter and the wall of the vein or at its tip in addition to catheter-induced phlebitis may initiate a thrombosis. The use of retrograde ventriculojugular shunts against the direction of the blood flow with resultant decrease in the incidence of venous thrombosis encouraged us to compare retrograde versus conventional antegrade peripheral venous cannulation. Monocentric, nonblinded, prospective observational cohort of 40 intensive care unit patients receiving 2 peripheral venous catheters in upper limbs, 1 inserted in the direction of blood flow (antegrade cannula) and the other inserted in an opposite direction to blood flow (retrograde cannula). Daily ultrasound assessment of the angle between the catheter and the vascular wall was done to detect onset and progression of thrombus formation. The study included 40 patients, aged 46.7 ± 10.132 years. The incidence of thrombus formation was 100% in both techniques. The onset time of thrombus formation between the catheter and the wall of a vein was significantly longer with the retrograde catheters than with the antegrade catheters with median time (interquartile range [range]) 6 days (5-6.75 [4-8]) with 95% confidence interval (CI), 5.58-6.42 vs 3 days (3-4 [2-5]) with 95% CI (2.76-3.24), respectively, with a P value <.001. The time needed by the recently detected thrombus to reach the catheter tip determined by ultrasound with or without catheter failure was significantly longer in the retrograde catheters than in the antegrade catheter with median time (interquartile range [range]) 9 days (8-9 [7-10]) with 95% CI, 8.76-9.24 vs 4 days (4-5 [3-6]) with 95% CI, 3.76-4.24, respectively, with a P value <.001. Retrograde cannulation did not decrease the incidence of thrombus formation, but significantly increased the onset time until thrombus formation and prolonged the time needed by the newly formed thrombus to reach the catheter tip compared with conventional antegrade cannulation.

Interpretation of symptoms as a cause of delays in patients with acute myocardial infarction, Istanbul, Turkey.

PubMed

Koc, Sema; Durna, Zehra; Akin, Semiha

2017-06-14

This cross-sectional study aimed to assess interpretation of symptoms as a cause of delays in patients with acute myocardial infarction (AMI). It was conducted at a university hospital in Istanbul, Turkey. The sample included 93 patients: 73 male, mean age 57.89 (12.13) years. Prehospital delay time ranged from 15 minutes to 10 days, with a median of 2 hours (interquartile range: 9.50). Patients waited for pain to go away (48.4%) and tried to calm down (39.8%). Most patients attributed AMI-related symptoms to a reason other than heart disease. In a multivariate logistic regression analysis, the type of AMI was classified based on electrocardiography findings (odds ratio 5.18, 95% confidence interval: 1.69-15.91, P=0.004) and was independently associated with a long prehospital delay time, indicating that patients with ST segment elevation MI would seek early medical care. Misinterpretation of symptoms and misconceptions about emergency treatment during AMI cause delays in admission and may affect treatment.

False-Positive Rate of AKI Using Consensus Creatinine–Based Criteria

PubMed Central

Lin, Jennie; Fernandez, Hilda; Shashaty, Michael G.S.; Negoianu, Dan; Testani, Jeffrey M.; Berns, Jeffrey S.; Parikh, Chirag R.

2015-01-01

Background and objectives Use of small changes in serum creatinine to diagnose AKI allows for earlier detection but may increase diagnostic false–positive rates because of inherent laboratory and biologic variabilities of creatinine. Design, setting, participants, & measurements We examined serum creatinine measurement characteristics in a prospective observational clinical reference cohort of 2267 adult patients with AKI by Kidney Disease Improving Global Outcomes creatinine criteria and used these data to create a simulation cohort to model AKI false–positive rates. We simulated up to seven successive blood draws on an equal population of hypothetical patients with unchanging true serum creatinine values. Error terms generated from laboratory and biologic variabilities were added to each simulated patient’s true serum creatinine value to obtain the simulated measured serum creatinine for each blood draw. We determined the proportion of patients who would be erroneously diagnosed with AKI by Kidney Disease Improving Global Outcomes creatinine criteria. Results Within the clinical cohort, 75.0% of patients received four serum creatinine draws within at least one 48-hour period during hospitalization. After four simulated creatinine measurements that accounted for laboratory variability calculated from assay characteristics and 4.4% of biologic variability determined from the clinical cohort and publicly available data, the overall false–positive rate for AKI diagnosis was 8.0% (interquartile range =7.9%–8.1%), whereas patients with true serum creatinine ≥1.5 mg/dl (representing 21% of the clinical cohort) had a false–positive AKI diagnosis rate of 30.5% (interquartile range =30.1%–30.9%) versus 2.0% (interquartile range =1.9%–2.1%) in patients with true serum creatinine values <1.5 mg/dl (P<0.001). Conclusions Use of small serum creatinine changes to diagnose AKI is limited by high false–positive rates caused by inherent variability of serum creatinine at higher baseline values, potentially misclassifying patients with CKD in AKI studies. PMID:26336912

False-Positive Rate of AKI Using Consensus Creatinine-Based Criteria.

PubMed

Lin, Jennie; Fernandez, Hilda; Shashaty, Michael G S; Negoianu, Dan; Testani, Jeffrey M; Berns, Jeffrey S; Parikh, Chirag R; Wilson, F Perry

2015-10-07

Use of small changes in serum creatinine to diagnose AKI allows for earlier detection but may increase diagnostic false-positive rates because of inherent laboratory and biologic variabilities of creatinine. We examined serum creatinine measurement characteristics in a prospective observational clinical reference cohort of 2267 adult patients with AKI by Kidney Disease Improving Global Outcomes creatinine criteria and used these data to create a simulation cohort to model AKI false-positive rates. We simulated up to seven successive blood draws on an equal population of hypothetical patients with unchanging true serum creatinine values. Error terms generated from laboratory and biologic variabilities were added to each simulated patient's true serum creatinine value to obtain the simulated measured serum creatinine for each blood draw. We determined the proportion of patients who would be erroneously diagnosed with AKI by Kidney Disease Improving Global Outcomes creatinine criteria. Within the clinical cohort, 75.0% of patients received four serum creatinine draws within at least one 48-hour period during hospitalization. After four simulated creatinine measurements that accounted for laboratory variability calculated from assay characteristics and 4.4% of biologic variability determined from the clinical cohort and publicly available data, the overall false-positive rate for AKI diagnosis was 8.0% (interquartile range =7.9%-8.1%), whereas patients with true serum creatinine ≥1.5 mg/dl (representing 21% of the clinical cohort) had a false-positive AKI diagnosis rate of 30.5% (interquartile range =30.1%-30.9%) versus 2.0% (interquartile range =1.9%-2.1%) in patients with true serum creatinine values <1.5 mg/dl (P<0.001). Use of small serum creatinine changes to diagnose AKI is limited by high false-positive rates caused by inherent variability of serum creatinine at higher baseline values, potentially misclassifying patients with CKD in AKI studies. Copyright © 2015 by the American Society of Nephrology.

Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-Method Analysis.

PubMed

Finn Davis, Katherine; Napolitano, Natalie; Li, Simon; Buffman, Hayley; Rehder, Kyle; Pinto, Matthew; Nett, Sholeen; Jarvis, J Dean; Kamat, Pradip; Sanders, Ronald C; Turner, David A; Sullivan, Janice E; Bysani, Kris; Lee, Anthony; Parker, Margaret; Adu-Darko, Michelle; Giuliano, John; Biagas, Katherine; Nadkarni, Vinay; Nishisaki, Akira

2017-10-01

To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders. Mixed methods. Thirteen PICUs of the National Emergency Airway Registry for Children network. Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks. Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182-781). Five sites were early (median, 153 d; interquartile range, 146-267) and eight sites were late adopters (median, 783 d; interquartile range, 773-845). Focus groups identified common "promoter" themes-interdisciplinary approach, influential champions, and quality improvement bundle customization-and "barrier" themes-time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention. Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study

PubMed Central

2011-01-01

Introduction The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Methods Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Results Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Conclusions Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design. PMID:21914222

Evaluation of high-intensity focused ultrasound ablation for uterine fibroids: an IDEAL prospective exploration study.

PubMed

Chen, J; Li, Y; Wang, Z; McCulloch, P; Hu, L; Chen, W; Liu, G; Li, J; Lang, J

2018-02-01

To evaluate the clinical outcomes of high-intensity focused ultrasound (HIFU) and surgery in treating uterine fibroids, and prepare for a definitive randomised trial. Prospective multicentre patient choice cohort study (IDEAL Exploratory study) of HIFU, myomectomy or hysterectomy for treating symptomatic uterine fibroids. 20 Chinese hospitals. 2411 Chinese women with symptomatic fibroids. Prospective non-randomised cohort study with learning curve analysis (IDEAL Stage 2b Prospective Exploration Study). Complications, hospital stay, return to normal activities, and quality of life (measured with UFS-Qol and SF-36 at baseline, 6 and 12 months), and need for further treatment. Quality-of-life outcomes were adjusted using regression modelling. HIFU treatment quality was evaluated using LC-CUSUM to identify operator learning curves. A health economic analysis of costs was performed. 1353 women received HIFU, 472 hysterectomy and 586 myomectomy. HIFU patients were significantly younger (P < 0.001), slimmer (P < 0.001), better educated (P < 0.001), and wealthier (P = 0.002) than surgery patients. Both UFS and QoL improved more rapidly after HIFU than after surgery (P = 0.002 and P = 0.001, respectively at 6 months), but absolute differences were small. Major adverse events occurred in 3 (0.2%) of HIFU and in 133 (12.6%) of surgical cases (P < 0.001). Median time for hospital stay was 4 days (interquartile range, 0-5 days), 10 days (interquartile range, 8-12.5 days) and 8 days (interquartile range, 7-10 days). HIFU caused substantially less morbidity than surgery, with similar longer-term QoL. Despite group baseline differences and lack of blinding, these findings support the need for a randomised controlled trial (RCT) of HIFU treatment for fibroids. The IDEAL Exploratory design facilitated RCT protocol development. HIFU had much better short-term outcomes than surgery for fibroids in 2411-patient Chinese IDEAL format study. © 2017 Royal College of Obstetricians and Gynaecologists.

Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network).

PubMed

Hubert, Gordian J; Meretoja, Atte; Audebert, Heinrich J; Tatlisumak, Turgut; Zeman, Florian; Boy, Sandra; Haberl, Roman L; Kaste, Markku; Müller-Barna, Peter

2016-12-01

Intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke is more effective when delivered early. Timely delivery is challenging particularly in rural areas with long distances. We compared delays and treatment rates of a large, decentralized telemedicine-based system and a well-organized, large, centralized single-hospital system. We analyzed the centralized system of the Helsinki University Central Hospital (Helsinki and Province of Uusimaa, Finland, 1.56 million inhabitants, 9096 km 2 ) and the decentralized TeleStroke Unit network in a predominantly rural area (Telemedical Project for Integrative Stroke Care [TEMPiS], South-East Bavaria, Germany, 1.94 million inhabitants, 14 992 km 2 ). All consecutive tPA treatments were prospectively registered. We compared tPA rates per total ischemic stroke admissions in the Helsinki and TEMPiS catchment areas. For delay comparisons, we excluded patients with basilar artery occlusions, in-hospital strokes, and those being treated after 270 minutes. From January 1, 2011, to December 31, 2013, 912 patients received tPA in Helsinki University Central Hospital and 1779 in TEMPiS hospitals. Area-based tPA rates were equal (13.0% of 7017 ischemic strokes in the Helsinki University Central Hospital area versus 13.3% of 14 637 ischemic strokes in the TEMPiS area; P=0.078). Median prehospital delays were longer (88; interquartile range, 60-135 versus 65; 48-101 minutes; P<0.001) but in-hospital delays were shorter (18; interquartile range, 13-30 versus 39; 26-56 minutes; P<0.001) in Helsinki University Central Hospital compared with TEMPiS with no difference in overall delays (117; interquartile range, 81-168 versus 115; 87-155 minutes; P=0.45). A decentralized telestroke thrombolysis service can achieve similar treatment rates and time delays for a rural population as a centralized system can achieve for an urban population. © 2016 American Heart Association, Inc.

Usefulness of repeated N-terminal pro-B-type natriuretic peptide measurements as incremental predictor for long-term cardiovascular outcome after vascular surgery.

PubMed

Goei, Dustin; van Kuijk, Jan-Peter; Flu, Willem-Jan; Hoeks, Sanne E; Chonchol, Michel; Verhagen, Hence J M; Bax, Jeroen J; Poldermans, Don

2011-02-15

Plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels improve preoperative cardiac risk stratification in vascular surgery patients. However, single preoperative measurements of NT-pro-BNP cannot take into account the hemodynamic stress caused by anesthesia and surgery. Therefore, the aim of the present study was to assess the incremental predictive value of changes in NT-pro-BNP during the perioperative period for long-term cardiac mortality. Detailed cardiac histories, rest left ventricular echocardiography, and NT-pro-BNP levels were obtained in 144 patients before vascular surgery and before discharge. The study end point was the occurrence of cardiovascular death during a median follow-up period of 13 months (interquartile range 5 to 20). Preoperatively, the median NT-pro-BNP level in the study population was 314 pg/ml (interquartile range 136 to 1,351), which increased to a median level of 1,505 pg/ml (interquartile range 404 to 6,453) before discharge. During the follow-up period, 29 patients (20%) died, 27 (93%) from cardiovascular causes. The median difference in NT-pro-BNP in the survivors was 665 pg/ml, compared to 5,336 pg/ml in the patients who died (p = 0.01). Multivariate Cox regression analyses, adjusted for cardiac history and cardiovascular risk factors (age, angina pectoris, myocardial infarction, stroke, diabetes mellitus, renal dysfunction, body mass index, type of surgery and the left ventricular ejection fraction), demonstrated that the difference in NT-pro-BNP level between pre- and postoperative measurement was the strongest independent predictor of cardiac outcome (hazard ratio 3.06, 95% confidence interval 1.36 to 6.91). In conclusion, the change in NT-pro-BNP, indicated by repeated measurements before surgery and before discharge is the strongest predictor of cardiac outcomes in patients who undergo vascular surgery. Copyright © 2011 Elsevier Inc. All rights reserved.

A Review of Online Evidence-based Practice Point-of-Care Information Summary Providers

PubMed Central

Liberati, Alessandro; Moschetti, Ivan; Tagliabue, Ludovica; Moja, Lorenzo

2010-01-01

Background Busy clinicians need easy access to evidence-based information to inform their clinical practice. Publishers and organizations have designed specific tools to meet doctors’ needs at the point of care. Objective The aim of this study was to describe online point-of-care summaries and evaluate their breadth, content development, and editorial policy against their claims of being “evidence-based.” Methods We searched Medline, Google, librarian association websites, and information conference proceedings from January to December 2008. We included English Web-based point-of-care summaries designed to deliver predigested, rapidly accessible, comprehensive, periodically updated, evidence-based information to clinicians. Two investigators independently extracted data on the general characteristics and content presentation of summaries. We assessed and ranked point-of-care products according to: (1) coverage (volume) of medical conditions, (2) editorial quality, and (3) evidence-based methodology. We explored how these factors were associated. Results We retrieved 30 eligible summaries. Of these products, 18 met our inclusion criteria and were qualitatively described, and 16 provided sufficient data for quantitative evaluation. The median volume of medical conditions covered was 80.6% (interquartile range, 68.9% - 84.2%) and varied for the different products. Similarly, differences emerged for editorial policy (median 8.0, interquartile range 5.8 - 10.3) and evidence-based methodology scores (median 10.0, interquartile range 1.0 - 12.8) on a 15-point scale. None of these dimensions turned out to be significantly associated with the other dimensions (editorial quality and volume, Spearman rank correlation r = -0.001, P = .99; evidence-based methodology and volume, r = -0.19, P = .48; editorial and evidence-based methodology, r = 0.43, P =.09). Conclusions Publishers are moving to develop point-of-care summary products. Some of these have better profiles than others, and there is room for improved reporting of the strengths and weaknesses of these products. PMID:20610379

Comparison of extracorporeal shock wave therapy with botulinum toxin type A in the treatment of plantar fasciitis.

PubMed

Roca, Bernardino; Mendoza, María A; Roca, Manuel

2016-10-01

To compare the efficacy of extracorporeal shock wave therapy (ESWT) with botulinum toxin type A (BoNT-A) in the treatment of plantar fasciitis (PF). Open label, prospective, randomized study. A total of 72 patients were included. In all participants the median (and interquartile range) of the visual analog scale (VAS) of pain result, when taking the first steps, was 8 (6-9) points before treatment and 6 (4-8) points after treatment (p < 0.001). In the group of patients that received ESWT, the median (and interquartile range) of improvement in the VAS of pain result, when taking the first steps, was 2 (1-4) points, and in the group of patients that received BoNT-A the same result was 1 (0-2) points (p = 0.009). In the group of patients that received ESWT, the median (and interquartile range) of improvement in the Roles and Maudsley scale of pain result was 1 (0-1) points, and in the group of patients that received BoNT-A the same result was 0 (0-1) points (p = 0.006). In a multivariate analysis use of ESWT and lower weight were associated with improvement of pain with treatment in at least one of the three VAS of pain scales used in the study. ESWT was superior to BoNT-A in the control of pain in patients with PF. Implications for Rehabilitation Plantar fasciitis is characterized by pain at the calcaneal origin of the plantar fascia, exacerbated by weight bearing after prolonged periods of rest. Although studies comparing extracorporeal shock wave therapy or botulinum toxin type A to placebo suggest a superiority of the first one, no reliable data exist about it. Extracorporeal shock wave therapy was superior to botulinum toxin type A in the control of pain in patients with PF.

Antimalarial Activity of KAF156 in Falciparum and Vivax Malaria.

PubMed

White, Nicholas J; Duong, Tran T; Uthaisin, Chirapong; Nosten, François; Phyo, Aung P; Hanboonkunupakarn, Borimas; Pukrittayakamee, Sasithon; Jittamala, Podjanee; Chuthasmit, Kittiphum; Cheung, Ming S; Feng, Yiyan; Li, Ruobing; Magnusson, Baldur; Sultan, Marc; Wieser, Daniela; Xun, Xiaolei; Zhao, Rong; Diagana, Thierry T; Pertel, Peter; Leong, F Joel

2016-09-22

KAF156 belongs to a new class of antimalarial agents (imidazolopiperazines), with activity against asexual and sexual blood stages and the preerythrocytic liver stages of malarial parasites. We conducted a phase 2, open-label, two-part study at five centers in Thailand and Vietnam to assess the antimalarial efficacy, safety, and pharmacokinetic profile of KAF156 in adults with acute Plasmodium vivax or P. falciparum malaria. Assessment of parasite clearance rates in cohorts of patients with vivax or falciparum malaria who were treated with multiple doses (400 mg once daily for 3 days) was followed by assessment of the cure rate at 28 days in a separate cohort of patients with falciparum malaria who received a single dose (800 mg). Median parasite clearance times were 45 hours (interquartile range, 42 to 48) in 10 patients with falciparum malaria and 24 hours (interquartile range, 20 to 30) in 10 patients with vivax malaria after treatment with the multiple-dose regimen and 49 hours (interquartile range, 42 to 54) in 21 patients with falciparum malaria after treatment with the single dose. Among the 21 patients who received the single dose and were followed for 28 days, 1 had reinfection and 7 had recrudescent infections (cure rate, 67%; 95% credible interval, 46 to 84). The mean (±SD) KAF156 terminal elimination half-life was 44.1±8.9 hours. There were no serious adverse events in this small study. The most common adverse events included sinus bradycardia, thrombocytopenia, hypokalemia, anemia, and hyperbilirubinemia. Vomiting of grade 2 or higher occurred in 2 patients, 1 of whom discontinued treatment because of repeated vomiting after receiving the single 800-mg dose. More adverse events were reported in the single-dose cohort, which had longer follow-up, than in the multiple-dose cohorts. KAF156 showed antimalarial activity without evident safety concerns in a small number of adults with uncomplicated P. vivax or P. falciparum malaria. (Funded by Novartis and others; ClinicalTrials.gov number, NCT01753323 .).

Cyclodiode photocoagulation for refractory glaucoma after penetrating keratoplasty.

PubMed

Shah, P; Lee, G A; Kirwan, J K; Bunce, C; Bloom, P A; Ficker, L A; Khaw, P T

2001-11-01

This study analyzes the results of intraocular pressure (IOP) reduction by contact diode cycloablation (cyclodiode) in cases of refractory glaucoma after penetrating keratoplasty. Retrospective noncomparative, interventional case series. Twenty-eight eyes in 28 patients attending the Moorfields Eye Hospital. Cyclodiode (40 applications x 1.5 W x 1.5 seconds over 270-300 degrees ) was used to control the IOP in refractory glaucoma after penetrating keratoplasty. Postoperative IOP, graft status, visual acuity, and number of antiglaucoma medications were recorded after cyclodiode treatment. Cyclodiode resulted in a reduction of IOP from a median of 33 mmHg (interquartile range [28, 40.5]) to a median of 15 mmHg (interquartile range [12, 20.5]). Most patients had a significant lowering in IOP with a median reduction of 16 mmHg (interquartile range [12, 25]; P < 0.0001). IOPs of 6 to 21 mmHg were achieved in 22 patients (79%). Sixteen patients (57%) required more than one treatment with cyclodiode to control the IOP, with three patients (11%) requiring three treatments and two patients (7%) requiring four treatments. Visual acuity improved (> two Snellen lines of acuity) in three patients (11%) and remained the same (+/- one Snellen line) in 17 patients (61%). The mean number of antiglaucoma medications before cycloablation was 2.6 and was 1.8 after treatment (P < 0.001). Of the 19 patients (68%) with originally clear grafts, three grafts (16%) developed opacification. One patient (4%), with a history of nanophthalmos and recurrent uveal effusion, had delayed hypotony (IOP < 6 mmHg) occurring 46 months after the diode treatment. All patients had at least 6 months follow-up. These patients have often undergone multiple previous complicated ocular interventions and are often not suitable for filtration surgery. Reduction of IOP with maintenance of visual acuity and a good safety profile was achieved in most patients in this study but may require multiple treatments. We propose cyclodiode as an effective treatment for many patients in the management of refractory glaucoma after penetrating keratoplasty.

The Influence of Head Impact Threshold for Reporting Data in Contact and Collision Sports: Systematic Review and Original Data Analysis.

PubMed

King, D; Hume, P; Gissane, C; Brughelli, M; Clark, T

2016-02-01

Head impacts and resulting head accelerations cause concussive injuries. There is no standard for reporting head impact data in sports to enable comparison between studies. The aim was to outline methods for reporting head impact acceleration data in sport and the effect of the acceleration thresholds on the number of impacts reported. A systematic review of accelerometer systems utilised to report head impact data in sport was conducted. The effect of using different thresholds on a set of impact data from 38 amateur senior rugby players in New Zealand over a competition season was calculated. Of the 52 studies identified, 42% reported impacts using a >10-g threshold, where g is the acceleration of gravity. Studies reported descriptive statistics as mean ± standard deviation, median, 25th to 75th interquartile range, and 95th percentile. Application of the varied impact thresholds to the New Zealand data set resulted in 20,687 impacts of >10 g, 11,459 (45% less) impacts of >15 g, and 4024 (81% less) impacts of >30 g. Linear and angular raw data were most frequently reported. Metrics combining raw data may be more useful; however, validity of the metrics has not been adequately addressed for sport. Differing data collection methods and descriptive statistics for reporting head impacts in sports limit inter-study comparisons. Consensus on data analysis methods for sports impact assessment is needed, including thresholds. Based on the available data, the 10-g threshold is the most commonly reported impact threshold and should be reported as the median with 25th and 75th interquartile ranges as the data are non-normally distributed. Validation studies are required to determine the best threshold and metrics for impact acceleration data collection in sport. Until in-field validation studies are completed, it is recommended that head impact data should be reported as median and interquartile ranges using the 10-g impact threshold.

Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis.

PubMed

Weiss, Scott L; Fitzgerald, Julie C; Balamuth, Fran; Alpern, Elizabeth R; Lavelle, Jane; Chilutti, Marianne; Grundmeier, Robert; Nadkarni, Vinay M; Thomas, Neal J

2014-11-01

Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock. Retrospective observational study. PICU at an academic medical center. One hundred thirty patients treated for severe sepsis or septic shock. None. We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure-free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74-277 min) and to first appropriate antimicrobial was 177 minutes (90-550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27-12.06) and 3.59 (95% CI, 1.09-11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45-16.2) and 4.92 (95% CI, 1.30-18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure-free days (16 [interquartile range, 1-23] vs 20 [interquartile range, 6-26]; p = 0.04). Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.

Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis

PubMed Central

Weiss, Scott L.; Fitzgerald, Julie C.; Balamuth, Fran; Alpern, Elizabeth R.; Lavelle, Jane; Chilutti, Marianne; Grundmeier, Robert; Nadkarni, Vinay M.; Thomas, Neal J.

2014-01-01

Objectives Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock. Design Retrospective observational study. Setting PICU at an academic medical center. Patients One hundred thirty patients treated for severe sepsis or septic shock. Interventions None. Measurements and Main Results We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure–free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74–277 min) and to first appropriate antimicrobial was 177 minutes (90–550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27–12.06) and 3.59 (95% CI, 1.09–11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45–16.2) and 4.92 (95% CI, 1.30–18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure–free days (16 [interquartile range, 1–23] vs 20 [interquartile range, 6–26]; p = 0.04). Conclusions Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis. PMID:25148597

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study.

PubMed

Levin, Phillip D; Golovanevski, Mila; Moses, Allon E; Sprung, Charles L; Benenson, Shmuel

2011-01-01

The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.

Children in the Syrian Civil War: the Familial, Educational, and Public Health Impact of Ongoing Violence.

PubMed

Elsafti, Abdallah Mohamed; van Berlaer, Gerlant; Al Safadi, Mohammad; Debacker, Michel; Buyl, Ronald; Redwan, Atef; Hubloue, Ives

2016-12-01

The Syrian civil war since 2011 has led to one of the most complex humanitarian emergencies in history. The objective of this study was to document the impact of the conflict on the familial, educational, and public health state of Syrian children. A cross-sectional observational study was conducted in May 2015. Health care workers visited families with a prospectively designed data sheet in 4 Northern Syrian governorates. The 1001 children included in this study originated from Aleppo (41%), Idleb (36%), Hamah (15%), and Lattakia (8%). The children's median age was 6 years (range, 0-15 years; interquartile range, 3-11 years), and 61% were boys. Almost 20% of the children were internally displaced, and 5% had deceased or missing parents. Children lacked access to safe drinking water (15%), appropriate sanitation (23%), healthy nutrition (16%), and pediatric health care providers (64%). Vaccination was inadequate in 72%. More than half of school-aged children had no access to education. Children in Idleb and Lattakia were at greater risk of having unmet public health needs. Younger children were at greater risk of having an incomplete vaccination state. After 4 years of civil war in Syria, children have lost parents, live in substandard life quality circumstances, and are at risk for outbreaks because of worsening vaccination states and insufficient availability of health care providers. (Disaster Med Public Health Preparedness. 2016;10:874-882).

Use and Effectiveness of Adjuvant Endocrine Therapy for Hormone Receptor-Positive Breast Cancer in Men.

PubMed

Venigalla, Sriram; Carmona, Ruben; Guttmann, David M; Jain, Varsha; Freedman, Gary M; Clark, Amy S; Shabason, Jacob E

2018-05-24

Although adjuvant endocrine therapy confers a survival benefit among females with hormone receptor (HR)-positive breast cancer, the effectiveness of this treatment among males with HR-positive breast cancer has not been rigorously investigated. To investigate trends, patterns of use, and effectiveness of adjuvant endocrine therapy among men with HR-positive breast cancer. This retrospective cohort study identified patients in the National Cancer Database with breast cancer who had received treatment from 2004 through 2014. Inclusion criteria for the primary study cohort were males at least 18 years old with nonmetastatic HR-positive invasive breast cancer who underwent surgery with or without adjuvant endocrine therapy. A cohort of female patients was also identified using the same inclusion criteria for comparative analyses by sex. Data analysis was conducted from October 1, 2017, to December 15, 2017. Receipt of adjuvant endocrine therapy. Patterns of adjuvant endocrine therapy use were assessed using multivariable logistic regression analyses. Association between adjuvant endocrine therapy use and overall survival was assessed using propensity score-weighted multivariable Cox regression models. The primary study cohort comprised 10 173 men with HR-positive breast cancer (mean [interquartile range] age, 66 [57-75] years). The comparative cohort comprised 961 676 women with HR-positive breast cancer (mean [interquartile range] age, 62 [52-72] years). The median follow-up for the male cohort was 49.6 months (range, 0.1-142.5 months). Men presented more frequently than women with HR-positive disease (94.0% vs 84.3%, P < .001). However, eligible men were less likely than women to receive adjuvant endocrine therapy (67.3% vs 79.0%; OR, 0.61; 95% CI, 0.58-0.63; P < .001). Treatment at academic facilities (odds ratio, 1.13; 95% CI, 1.02-1.25; P = .02) and receipt of adjuvant radiotherapy (odds ratio, 2.83; 95% CI, 2.55-3.15; P < .001) or chemotherapy (odds ratio, 1.20; 95% CI, 1.07-1.34; P < .001) were statistically significantly associated with adjuvant endocrine therapy use in men. A propensity score-weighted analysis indicated that relative to no use, adjuvant endocrine therapy use in men was associated with improved overall survival (hazard ratio, 0.70; 95% CI, 0.63-0.77; P < .001). There is a sex disparate underuse of adjuvant endocrine therapy among men with HR-positive breast cancer despite the use of this treatment being associated with improved overall survival. Further research and interventions may be warranted to bridge gaps in care in this population.

Microcystic macular oedema in multiple sclerosis is associated with disease severity

PubMed Central

Gelfand, Jeffrey M.; Nolan, Rachel; Schwartz, Daniel M.; Graves, Jennifer

2012-01-01

Macular oedema typically results from blood–retinal barrier disruption. It has recently been reported that patients with multiple sclerosis treated with FTY-720 (fingolimod) may exhibit macular oedema. Multiple sclerosis is not otherwise thought to be associated with macular oedema except in the context of comorbid clinical uveitis. Despite a lack of myelin, the retina is a site of inflammation and microglial activation in multiple sclerosis and demonstrates significant neuronal and axonal loss. We unexpectedly observed microcystic macular oedema using spectral domain optical coherence tomography in patients with multiple sclerosis who did not have another reason for macular oedema. We therefore evaluated spectral domain optical coherence tomography images in consecutive patients with multiple sclerosis for microcystic macular oedema and examined correlations between macular oedema and visual and ambulatory disability in a cross-sectional analysis. Participants were excluded if there was a comorbidity that could account for the presence of macular oedema, such as uveitis, diabetes or other retinal disease. A microcystic pattern of macular oedema was observed on optical coherence tomography in 15 of 318 (4.7%) patients with multiple sclerosis. No macular oedema was identified in 52 healthy controls assessed over the same period. The microcystic oedema predominantly involved the inner nuclear layer of the retina and tended to occur in small, discrete patches. Patients with multiple sclerosis with microcystic macular oedema had significantly worse disability [median Expanded Disability Score Scale 4 (interquartile range 3–6)] than patients without macular oedema [median Expanded Disability Score Scale 2 (interquartile range 1.5–3.5)], P = 0.0002. Patients with multiple sclerosis with microcystic macular oedema also had higher Multiple Sclerosis Severity Scores, a measure of disease progression, than those without oedema [median of 6.47 (interquartile range 4.96–7.98) versus 3.65 (interquartile range 1.92–5.87), P = 0.0009]. Microcystic macular oedema occurred more commonly in eyes with prior optic neuritis than eyes without prior optic neuritis (50 versus 27%) and was associated with lower visual acuity (median logMAR acuity of 0.17 versus −0.1) and a thinner retinal nerve fibre layer. The presence of microcystic macular oedema in multiple sclerosis suggests that there may be breakdown of the blood–retinal barrier and tight junction integrity in a part of the nervous system that lacks myelin. Microcystic macular oedema may also contribute to visual dysfunction beyond that explained by nerve fibre layer loss. Microcystic changes need to be assessed, and potentially adjusted for, in clinical trials that evaluate macular volume as a marker of retinal ganglion cell survival. These findings also have implications for clinical monitoring in patients with multiple sclerosis on sphingosine 1-phosphate receptor modulating agents. PMID:22539259

Validation of a structured interview for telephone assessment of the modified Rankin Scale in Brazilian stroke patients.

PubMed

Baggio, Jussara A O; Santos-Pontelli, Taiza E G; Cougo-Pinto, Pedro T; Camilo, Millene; Silva, Nathalia F; Antunes, Paula; Machado, Laura; Leite, João P; Pontes-Neto, Octavio M

2014-01-01

The modified Rankin Scale (mRS) is a commonly used scale to assess the functional outcome after stroke. Several studies on mRS showed good reliability, feasibility, and interrater agreement of this scale using a face-to-face assessment. However, telephone assessment is a more time-efficient way to obtain an mRS grade than a face-to-face interview. The aim of this study was to validate the telephone assessment of mRS among the Portuguese using a structured interview in a sample of Brazilian stroke patients. We evaluated 50 stroke outpatients twice. The first interview was face-to-face and the second was made by telephone and the time between the two assessments ranged between 7 and 14 days. Four certified raters evaluated the patients using a structured interview based on a questionnaire previously published in the literature. Raters were blinded for the Rankin score given by the other rater. For both assessments, the rater could also interview a caregiver if necessary. The patients' mean age was 62.8 ± 14.7, mean number of years of study 5.2 ± 3.4, 52% were males, 55.2% of patients needed a caregiver's help to answer the questions. The majority of caregivers were female (85%), mean age 49.1 ± 15, and mean number of years of study 8.3 ± 3.4. Perfect agreement between the telephone and face-to-face assessments was obtained for 27 (54%) patients, corresponding to an unweighted Kappa of 0.44 (95% CI 0.27-0.61) and a weighted Kappa of 0.89. The median of telephone assessment mRS was 3.5 (interquartile range = 2-4) and of face-to-face assessment was 4 (interquartile range = 2-5). There was no difference between the two assessments (Wilcoxon test, p = 0.35). Despite the low education level of our sample, the telephone assessment of functional impairment of stroke patients using a translated and culturally adapted Brazilian Portuguese version of the mRS showed good validity and reliability. Therefore, the telephone assessment of mRS can be used in clinical practice and scientific studies in Brazil. © 2014 S. Karger AG, Basel.

Effect of Dexmedetomidine on Mortality and Ventilator-Free Days in Patients Requiring Mechanical Ventilation With Sepsis

PubMed Central

Kawazoe, Yu; Miyamoto, Kyohei; Morimoto, Takeshi; Yamamoto, Tomonori; Fuke, Akihiro; Hashimoto, Atsunori; Koami, Hiroyuki; Beppu, Satoru; Katayama, Yoichi; Itoh, Makoto; Ohta, Yoshinori

2017-01-01

Importance Dexmedetomidine provides sedation for patients undergoing ventilation; however, its effects on mortality and ventilator-free days have not been well studied among patients with sepsis. Objectives To examine whether a sedation strategy with dexmedetomidine can improve clinical outcomes in patients with sepsis undergoing ventilation. Design, Setting, and Participants Open-label, multicenter randomized clinical trial conducted at 8 intensive care units in Japan from February 2013 until January 2016 among 201 consecutive adult patients with sepsis requiring mechanical ventilation for at least 24 hours. Interventions Patients were randomized to receive either sedation with dexmedetomidine (n = 100) or sedation without dexmedetomidine (control group; n = 101). Other agents used in both groups were fentanyl, propofol, and midazolam. Main Outcomes and Measures The co–primary outcomes were mortality and ventilator-free days (over a 28-day duration). Sequential Organ Failure Assessment score (days 1, 2, 4, 6, 8), sedation control, occurrence of delirium and coma, intensive care unit stay duration, renal function, inflammation, and nutrition state were assessed as secondary outcomes. Results Of the 203 screened patients, 201 were randomized. The mean age was 69 years (SD, 14 years); 63% were male. Mortality at 28 days was not significantly different in the dexmedetomidine group vs the control group (19 patients [22.8%] vs 28 patients [30.8%]; hazard ratio, 0.69; 95% CI, 0.38-1.22; P = .20). Ventilator-free days over 28 days were not significantly different between groups (dexmedetomidine group: median, 20 [interquartile range, 5-24] days; control group: median, 18 [interquartile range, 0.5-23] days; P = .20). The dexmedetomidine group had a significantly higher rate of well-controlled sedation during mechanical ventilation (range, 17%-58% vs 20%-39%; P = .01); other outcomes were not significantly different between groups. Adverse events occurred in 8 (8%) and 3 (3%) patients in the dexmedetomidine and control groups, respectively. Conclusions and Relevance Among patients requiring mechanical ventilation, the use of dexmedetomidine compared with no dexmedetomidine did not result in statistically significant improvement in mortality or ventilator-free days. However, the study may have been underpowered for mortality, and additional research may be needed to evaluate this further. Trial Registration clinicaltrials.gov Identifier: NCT01760967 PMID:28322414

Site Variability in Regulatory Oversight for an International Study of Pediatric Sepsis.

PubMed

Michelson, Kelly N; Reubenson, Gary; Weiss, Scott L; Fitzgerald, Julie C; Ackerman, Kate K; Christie, LeeAnn; Bush, Jenny L; Nadkarni, Vinay M; Thomas, Neal J; Schreiner, Mark S

2018-04-01

Duplicative institutional review board/research ethics committee review for multicenter studies may impose administrative burdens and inefficiencies affecting study implementation and quality. Understanding variability in site-specific institutional review board/research ethics committee assessment and barriers to using a single review committee (an increasingly proposed solution) can inform a more efficient process. We provide needed data about the regulatory oversight process for the Sepsis PRevalence, OUtcomes, and Therapies multicenter point prevalence study. Survey. Sites invited to participate in Sepsis PRevalence, OUtcomes, and Therapies. Investigators at sites that expressed interest and/or participated in Sepsis PRevalence, OUtcomes, and Therapies. None. Using an electronic survey, we collected data about 1) logistics of protocol submission, 2) institutional review board/research ethics committee requested modifications, and 3) use of a single institutional review board (for U.S. sites). We collected surveys from 104 of 167 sites (62%). Of the 97 sites that submitted the protocol for institutional review board/research ethics committee review, 34% conducted full board review, 54% expedited review, and 4% considered the study exempt. Time to institutional review board/research ethics committee approval required a median of 34 (range 3-186) days, which took longer at sites that required protocol modifications (median [interquartile range] 50 d [35-131 d] vs 32 d [14-54 d)]; p = 0.02). Enrollment was delayed at eight sites due to prolonged (> 50 d) time to approval. Of 49 U.S. sites, 43% considered using a single institutional review board, but only 18% utilized this option. Time to final approval for U.S. sites using the single institutional review board was 62 days (interquartile range, 34-70 d) compared with 34 days (interquartile range, 15-54 d) for nonsingle institutional review board sites (p = 0.16). Variability in regulatory oversight was evident for this minimal-risk observational research study, most notably in the category of type of review conducted. Duplicative review prolonged time to protocol approval at some sites. Use of a single institutional review board for U.S. sites was rare and did not improve efficiency of protocol approval. Suggestions for minimizing these challenges are provided.

Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility.

PubMed

Fontana, Marianna; Asaria, Perviz; Moraldo, Michela; Finegold, Judith; Hassanally, Khalil; Manisty, Charlotte H; Francis, Darrel P

2014-06-17

Primary prevention guidelines focus on risk, often assuming negligible aversion to medication, yet most patients discontinue primary prevention statins within 3 years. We quantify real-world distribution of medication disutility and separately calculate the average utilities for a range of risk strata. We randomly sampled 360 members of the general public in London. Medication aversion was quantified as the gain in lifespan required by each individual to offset the inconvenience (disutility) of taking an idealized daily preventative tablet. In parallel, we constructed tables of expected gain in lifespan (utility) from initiating statin therapy for each age group, sex, and cardiovascular risk profile in the population. This allowed comparison of the widths of the distributions of medication disutility and of group-average expectation of longevity gain. Observed medication disutility ranged from 1 day to >10 years of life being required by subjects (median, 6 months; interquartile range, 1-36 months) to make daily preventative therapy worthwhile. Average expected longevity benefit from statins at ages ≥50 years ranges from 3.6 months (low-risk women) to 24.3 months (high-risk men). We can no longer assume that medication disutility is almost zero. Over one-quarter of subjects had disutility exceeding the group-average longevity gain from statins expected even for the highest-risk (ie, highest-gain) group. Future primary prevention studies might explore medication disutility in larger populations. Patients may differ more in disutility than in prospectively definable utility (which provides only group-average estimates). Consultations could be enriched by assessing disutility and exploring its reasons. © 2014 American Heart Association, Inc.

Flexible parametric survival models built on age-specific antimüllerian hormone percentiles are better predictors of menopause.

PubMed

Ramezani Tehrani, Fahimeh; Mansournia, Mohammad Ali; Solaymani-Dodaran, Masoud; Steyerberg, Ewout; Azizi, Fereidoun

2016-06-01

This study aimed to improve existing prediction models for age at menopause. We identified all reproductive aged women with regular menstrual cycles who met our eligibility criteria (n = 1,015) in the Tehran Lipid and Glucose Study-an ongoing population-based cohort study initiated in 1998. Participants were examined every 3 years and their reproductive histories were recorded. Blood levels of antimüllerian hormone (AMH) were measured at the time of recruitment. Age at menopause was estimated based on serum concentrations of AMH using flexible parametric survival models. The optimum model was selected according to Akaike Information Criteria and the realness of the range of predicted median menopause age. We followed study participants for a median of 9.8 years during which 277 women reached menopause and found that a spline-based proportional odds model including age-specific AMH percentiles as the covariate performed well in terms of statistical criteria and provided the most clinically relevant and realistic predictions. The range of predicted median age at menopause for this model was 47.1 to 55.9 years. For those who reached menopause, the median of the absolute mean difference between actual and predicted age at menopause was 1.9 years (interquartile range 2.9). The model including the age-specific AMH percentiles as the covariate and using proportional odds as its covariate metrics meets all the statistical criteria for the best model and provides the most clinically relevant and realistic predictions for age at menopause for reproductive-aged women.

Relationship Between Lifelong Exercise Volume and Coronary Atherosclerosis in Athletes.

PubMed

Aengevaeren, Vincent L; Mosterd, Arend; Braber, Thijs L; Prakken, Niek H J; Doevendans, Pieter A; Grobbee, Diederick E; Thompson, Paul D; Eijsvogels, Thijs M H; Velthuis, Birgitta K

2017-07-11

Higher levels of physical activity are associated with a lower risk of cardiovascular events. Nevertheless, there is debate on the dose-response relationship of exercise and cardiovascular disease outcomes and whether high volumes of exercise may accelerate coronary atherosclerosis. We aimed to determine the relationship between lifelong exercise volumes and coronary atherosclerosis. Middle-aged men engaged in competitive or recreational leisure sports underwent a noncontrast and contrast-enhanced computed tomography scan to assess coronary artery calcification (CAC) and plaque characteristics. Participants reported lifelong exercise history patterns. Exercise volumes were multiplied by metabolic equivalent of task (MET) scores to calculate MET-minutes per week. Participants' activity was categorized as <1000, 1000 to 2000, or >2000 MET-min/wk. A total of 284 men (age, 55±7 years) were included. CAC was present in 150 of 284 participants (53%) with a median CAC score of 35.8 (interquartile range, 9.3-145.8). Athletes with a lifelong exercise volume >2000 MET-min/wk (n=75) had a significantly higher CAC score (9.4 [interquartile range, 0-60.9] versus 0 [interquartile range, 0-43.5]; P =0.02) and prevalence of CAC (68%; adjusted odds ratio [OR adjusted ]=3.2; 95% confidence interval [CI], 1.6-6.6) and plaque (77%; OR adjusted =3.3; 95% CI, 1.6-7.1) compared with <1000 MET-min/wk (n=88; 43% and 56%, respectively). Very vigorous intensity exercise (≥9 MET) was associated with CAC (OR adjusted =1.47; 95% CI, 1.14-1.91) and plaque (OR adjusted =1.56; 95% CI, 1.17-2.08). Among participants with CAC>0, there was no difference in CAC score ( P =0.20), area ( P =0.21), density ( P =0.25), and regions of interest ( P =0.20) across exercise volume groups. Among participants with plaque, the most active group (>2000 MET-min/wk) had a lower prevalence of mixed plaques (48% versus 69%; OR adjusted =0.35; 95% CI, 0.15-0.85) and more often had only calcified plaques (38% versus 16%; OR adjusted =3.57; 95% CI, 1.28-9.97) compared with the least active group (<1000 MET-min/wk). Participants in the >2000 MET-min/wk group had a higher prevalence of CAC and atherosclerotic plaques. The most active group, however, had a more benign composition of plaques, with fewer mixed plaques and more often only calcified plaques. These observations may explain the increased longevity typical of endurance athletes despite the presence of more coronary atherosclerotic plaque in the most active participants. © 2017 American Heart Association, Inc.

Duration of untreated psychosis and pathway to care in Riyadh, Saudi Arabia.

PubMed

Al Fayez, Hanan; Lappin, Julia; Murray, Robin; Boydell, Jane

2017-02-01

Recent studies of 'duration of untreated psychosis' (DUP) indicate that some patients remain untreated in the community for some time. Considerable emphasis has been placed on reducing the DUP. However, most studies investigating DUP have been conducted in Western countries, where well-developed primary care systems are available. This study aims to describe DUP and its association with both demographic factors and pathways to care in Riyadh, Saudi Arabia. A retrospective study of 421 new case records of all Saudi schizophrenia patients over a 2-year period in six governmental hospitals in Riyadh, Saudi Arabia. The median DUP was 1.41 years (interquartile range 0.35-2.81 years). The longest time to contact was 9.86 years but 90% had a DUP shorter than 5 years. Older age at onset, single marital status and higher educational level were associated with shorter DUP. Long DUP was associated with help seeking from traditional healers. In Saudi Arabia, it usually takes longer for patients to seek help from psychiatric services after their first psychosis onset than it does in Western countries. The results suggest that the DUP is influenced by both demographic factors and pathways to care. © 2015 Wiley Publishing Asia Pty Ltd.

On the Use of Rank Tests and Estimates in the Linear Model.

DTIC Science & Technology

1982-06-01

assumption A5, McKean and Hettmansperger (1976) show that 10 w (W(N-c) - W (c+l))/ (2Z /2) (14) where 2Z is the 1-a interpercentile range of the standard...r(.75n) - r(.25n)) (13) The window width h incorporates a resistant estimate of scale, then interquartile range of the residuals, and a normalizing...alternative estimate of i is available with the additional assumption of symmetry of the error distribution. ASSUMPTION: A5. Suppose the underlying error

Effects of breastfeeding on weight loss and recovery of pregestational weight in adolescent and adult mothers.

PubMed

Sámano, Reyna; Martínez-Rojano, Hugo; Godínez Martínez, Estela; Sánchez Jiménez, Bernarda; Villeda Rodríguez, Gilda Paulina; Pérez Zamora, Julieta; Casanueva, Esther

2013-06-01

Exclusive breastfeeding (EBF) in adolescent mothers has been associated with greater postpartum maternal weight loss. To assess the associations between EBF and weight loss in adolescent and adult mothers and between EBF and weight and length gain of their children. A cohort of 68 adolescent mothers (15 to 19 years), 64 adult mothers (20 to 29 years), and their infants were studied. Anthropometric measurements were performed at 15, 90, 180, and 365 days postpartum in the mothers and children. EBF was defined as consumption of human milk without supplementation of any type (water, juice, nonhuman milk, or food) for 4 months. Sixty-five percent of mothers sustained EBF for 4 months. There were no significant differences in the weight or length of the infants of adolescent and adult mothers at 365 days postpartum. Among infants of adult mothers, there was a significant difference between the weight gain of those were exclusively breastfed and those who were not exclusively breastfed (6,498 +/- 1,060 vs 6,096 +/- 1,035 g, p < .050) at 365 days postpartum, according to the parameters for weight gain and length established by the World Health Organization (WHO). Among both adult and adolescent mothers, those who practiced EBF lost more weight than those who did not practice EBF (-2.9 kg, 95% interquartile range, -5.7 to 0.8 kg, vs -1.8 kg 95% interquartile range -2.8 to 2.2 kg; p = .004). Gestational weight gain, duration of EBF, and recovery menstruation explained 21% of the variance (F = 28.184, p = .001) in change in postpartum maternal weight (in kilograms) from 0 to 365 days postpartum in all mothers. Pregestational weight, duration of EBF, and maternal age were factors that explained 14% (F = 22.759, p = .001) of the change in the weight and length of the infants from 0 to 365 days of life. EBF in adolescent and adult mothers influences postpartum weight loss and provides adequate infant growth in accordance with the WHO 2006 standards.

Nonesterified fatty acids and cardiovascular mortality in elderly men with CKD.

PubMed

Xiong, Zibo; Xu, Hong; Huang, Xiaoyan; Ärnlöv, Johan; Qureshi, Abdul Rashid; Cederholm, Tommy; Sjögren, Per; Lindholm, Bengt; Risérus, Ulf; Carrero, Juan Jesús

2015-04-07

Although nonesterified fatty acids (NEFAs) are essential as energy substrate for the myocardium, an excess of circulating NEFAs can be harmful. This study aimed to assess plausible relationships between serum NEFA and mortality due to cardiovascular disease (CVD) in individuals with CKD. This was a prospective cohort study from the third examination cycle of the Uppsala Longitudinal Study of Adult Men, a population-based survey of 1221 elderly men aged 70-71 years residing in Uppsala, Sweden. Data collection took place during 1991-1995. All participants had measures of kidney function; this study investigated 623 (51.7%) of these patients with manifest CKD (defined as either eGFR<60 ml/min per 1.73 m(2) or urine albumin excretion rate ≥20 µg/min). Follow-up for mortality was done from examination date until death or December 31, 2007. After a median follow-up of 14 years (interquartile range, 8-16.8), associations of NEFAs with mortality (related to all causes, CVD, ischemic heart disease [IHD], or acute myocardial infarction) were ascertained. The median serum NEFA was 14.1 mg/dl (interquartile range, 11.3-17.8). No association was found with measures of kidney function. Diabetes and serum triglycerides were the only multivariate correlates of NEFA. During follow-up, 453 participants died, of which 209 deaths were due to CVD, including 88 IHD deaths, with 41 attributed to acute myocardial infarction (AMI). In fully adjusted covariates, serum NEFA was an independent risk factor for all-cause mortality (hazard ratio [HR] per log2 increase, 1.22; 95% confidence interval [95% CI], 1.00 to 1.48) and CVD-related death (HR, 1.51; 95% CI, 1.15 to 1.99), including both IHD (HR, 1.51; 95% CI, 1.00 to 2.32) and AMI mortality (HR, 2.08; 95% CI, 1.09 to 3.98). Elevated serum NEFA associated with CVD mortality, and particularly with mortality due to AMI, in a homogeneous population of older men with moderate CKD. Copyright © 2015 by the American Society of Nephrology.

Nonesterified Fatty Acids and Cardiovascular Mortality in Elderly Men with CKD

PubMed Central

Xiong, Zibo; Xu, Hong; Huang, Xiaoyan; Ärnlöv, Johan; Qureshi, Abdul Rashid; Cederholm, Tommy; Sjögren, Per; Lindholm, Bengt; Risérus, Ulf

2015-01-01

Background and objectives Although nonesterified fatty acids (NEFAs) are essential as energy substrate for the myocardium, an excess of circulating NEFAs can be harmful. This study aimed to assess plausible relationships between serum NEFA and mortality due to cardiovascular disease (CVD) in individuals with CKD. Design, setting, participants, & measurements This was a prospective cohort study from the third examination cycle of the Uppsala Longitudinal Study of Adult Men, a population-based survey of 1221 elderly men aged 70–71 years residing in Uppsala, Sweden. Data collection took place during 1991–1995. All participants had measures of kidney function; this study investigated 623 (51.7%) of these patients with manifest CKD (defined as either eGFR<60 ml/min per 1.73 m2 or urine albumin excretion rate ≥20 µg/min). Follow-up for mortality was done from examination date until death or December 31, 2007. After a median follow-up of 14 years (interquartile range, 8–16.8), associations of NEFAs with mortality (related to all causes, CVD, ischemic heart disease [IHD], or acute myocardial infarction) were ascertained. Results The median serum NEFA was 14.1 mg/dl (interquartile range, 11.3–17.8). No association was found with measures of kidney function. Diabetes and serum triglycerides were the only multivariate correlates of NEFA. During follow-up, 453 participants died, of which 209 deaths were due to CVD, including 88 IHD deaths, with 41 attributed to acute myocardial infarction (AMI). In fully adjusted covariates, serum NEFA was an independent risk factor for all-cause mortality (hazard ratio [HR] per log2 increase, 1.22; 95% confidence interval [95% CI], 1.00 to 1.48) and CVD-related death (HR, 1.51; 95% CI, 1.15 to 1.99), including both IHD (HR, 1.51; 95% CI, 1.00 to 2.32) and AMI mortality (HR, 2.08; 95% CI, 1.09 to 3.98). Conclusions Elevated serum NEFA associated with CVD mortality, and particularly with mortality due to AMI, in a homogeneous population of older men with moderate CKD. PMID:25637632

High Burden of 30-Day Readmissions After Acute Venous Thromboembolism in the United States.

PubMed

Secemsky, Eric A; Rosenfield, Kenneth; Kennedy, Kevin F; Jaff, Michael; Yeh, Robert W

2018-06-26

Venous thromboembolism (VTE) is the third leading cause of vascular disease and accounts for $10 billion in annual US healthcare costs. The nationwide burden of 30-day readmissions after such events has not been comprehensively assessed. We analyzed adults ≥18 years of age with hospitalizations associated with acute VTE between January 1, 2010, and December 31, 2014, in the Nationwide Readmissions Database. International Classification of Disease, Ninth Revision, Clinical Modification ( ICD-9- CM ) codes were used to identify hospitalizations associated with acute pulmonary embolism or deep vein thrombosis. The primary outcome was the rate of unplanned 30-day readmission. Hierarchical logistic regression was used to calculate hospital-specific 30-day risk-standardized readmission rates, a marker of healthcare quality. Among 1 176 335 hospitalizations with acute VTE, in-hospital death occurred in 6.2%. VTE was associated with malignancy in 19.7%, recent surgery in 19.3%, recent trauma in 4.6%, hypercoagulability in 3.3%, and pregnancy in 1.0%. Among survivors to discharge, the 30-day readmission rate was 17.5%, with no significant difference in rates across study years (17.4%-17.7%; P =0.10 for trend). Major predictors of readmission were malignancy (relative risk, 1.49, 95% confidence interval 1.47-1.50), Medicaid insurance (relative risk, 1.48, 95% confidence interval 1.46-1.50), and nonelective index admission (relative risk, 1.31, 95% confidence interval 1.29-1.33). Top causes of readmission included sepsis (9.6%) and procedural complications (8.1%). Median rehospitalization costs were $9781.7 (interquartile range, $5430.7-$18 784.1), and 8.1% died during readmission. The interquartile range in risk-standardized readmission rates was 16.6% to 18.3%, suggesting modest interhospital heterogeneity in readmission risk. Nearly 1 in 5 patients with acute VTE were readmitted within 30 days. Predictors and causes of readmission were primarily related to patient characteristics and complications from comorbid conditions, whereas healthcare quality had a moderate impact on readmission risk. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Relationship Between Preoperative Anemia and In-Hospital Mortality in Children Undergoing Noncardiac Surgery.

PubMed

Faraoni, David; DiNardo, James A; Goobie, Susan M

2016-12-01

The relationship between preoperative anemia and in-hospital mortality has not been investigated in the pediatric surgical population. We hypothesized that children with preoperative anemia undergoing noncardiac surgery may have an increased risk of in-hospital mortality. We identified all children between 1 and 18 years of age with a recorded preoperative hematocrit (HCT) in the 2012, 2013, and 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric databases. The endpoint was defined as the incidence of in-hospital mortality. Children with preoperative anemia were identified based on their preoperative HCT. Demographic and surgical characteristics, as well as comorbidities, were considered potential confounding variables in a multivariable logistic regression analysis. A sensitivity analysis was performed using propensity-matched analysis. Among the 183,833 children included in the 2012, 2013, and 2014 ACS NSQIP database, 74,508 had a preoperative HCT recorded (41%). After exclusion of all children <1 year of age (n = 12,063), those with congenital heart disease (n = 8943), and those who received a preoperative red blood cell (RBC) transfusion (n = 1880), 12,551 (24%) children were anemic, and 39,071 (76%) were nonanemic. The median preoperative HCT was 33% (interquartile range, 31-35) in anemic children, and 39% (interquartile range, 37-42) in nonanemic children (P < .001). Using multivariable logistic regression analysis, and after adjustment for RBC transfusion (OR, 2.13; 95% CI, 1.39-3.26; P < .001), we observed that preoperative anemia was associated with higher odds for in-hospital mortality (OR, 2.17; 95% CI, 1.48-3.19; P < .001). After propensity matching, the presence of anemia was also associated with higher odds of in-hospital mortality (OR, 1.75; 95% CI, 1.15-2.65; P = .004). Our study demonstrates that children with preoperative anemia are at increased risk for in-hospital mortality. Further studies are needed to assess whether the correction of preoperative HCT, through the development of a patient blood management program, improves patient outcomes or simply reduces the need for transfusions.

Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects.

PubMed

Weber, Donald; Dulai, Sukhdeep K; Bergman, Joseph; Buckley, Richard; Beaupre, Lauren A

2014-11-01

To evaluate the association between time to surgery, antibiotic administration, Gustilo grade, fracture location, and development of deep infection in open fractures. Prospective cohort between 2001 and 2009. Three Level 1 Canadian trauma centers. A total of 736 (791 fractures) subjects were enrolled and 686 subjects (93%; 737 fractures) provided adequate follow-up data (1-year interview and/or clinical follow-up >90 days). Demographics, injury information, time to surgery, and antibiotics were recorded. Subjects were evaluated using standardized data forms until the fracture(s) healed. Phone interviews were undertaken 1 year after the fracture. Infection requiring unplanned surgical debridement and/or sustained antibiotic therapy. Tibia/fibula fractures were most common (n = 413, 52%), followed by upper extremity (UE) (n = 285, 36%), and femoral (n = 93, 12%) fractures. Infection developed in 46 fractures (6%). The median time to surgery was 9 hours 4 minutes (interquartile range, 6 hours 39 minutes to 12 hours 33 minutes) and 7 hours 39 minutes (interquartile range, 6 hours 10 minutes to 9 hours 54 minutes) for those without and with infection, respectively (P = 0.04). Gustilo grade 3B/3C fractures accounted for 17 of 46 infections (37%) (P < 0.001). Four UE (1.5%), 7 femoral (8%), and 35 tibia/fibula (9%) fractures developed infections (P = 0.001). Multivariate regression found no association between infection and time to surgery [odds ratio (OR), 0.97; 95% confidence interval (95% CI), 0.90-1.06] or antibiotics (OR, 1.0; 95% CI, 0.90-1.05). Grades 3A (OR, 6.37; 95% CI, 1.37-29.56) and 3B/3C (OR, 12.87; 95% CI, 2.72-60.95) relative to grade 1 injuries and tibia/fibula (OR, 3.91; 95% CI, 1.33-11.53) relative to UE fractures were significantly associated with infection. Infection after open fracture was associated with increasing Gustilo grade or tibia/fibula fractures but not time to surgery or antibiotics. Prognostic level I. See instructions for authors for a complete description of levels of evidence.

Association of Patient-Reported Readiness for Discharge and Hospital Consumer Assessment of Health Care Providers and Systems Patient Satisfaction Scores: A Retrospective Analysis.

PubMed

Schmocker, Ryan K; Holden, Sara E; Vang, Xia; Leverson, Glen E; Cherney Stafford, Linda M; Winslow, Emily R

2015-12-01

Patient-reported outcomes (PRO) have been increasingly emphasized, however, determining clinically valuable PRO has been problematic and investigation limited. This study examines the association of readiness for discharge, which has been described previously, with patient satisfaction and readmission. Data from adult patients admitted to our institution from 2009 to 2012 who completed both the Hospital Consumer Assessment of Healthcare Providers and Systems and the Press Ganey surveys post discharge were extracted from an existing database of patients (composed of 220 patients admitted for small bowel obstruction and 98 patients with hospital stays ≥ 21 days). Using the survey question, "Did you feel ready for discharge?" (RFD), 2 groups were constructed, those RFD and those with lesser degrees of readiness (ie, less ready for discharge [LRFD]) using topbox methodology. Outcomes, readmission rates, and satisfaction were compared between RFD and LRFD groups. Three hundred and eighteen patients met the inclusion criteria; 45% were female and 94% were Caucasian. Median age was 62.3 years (interquartile range 52.5 to 70.8 year). Median length of stay was 10 days (interquartile range 6.0 to 24.0 days) and 69.2% were admitted with small bowel obstruction. The 30-day readmission rate was 14.3% and 55% indicated they were RFD. Those RFD and LRFD had similar demographics, comorbidity scores, and rates of surgery. Those RFD had higher overall hospital satisfaction (87.3% RFD vs 62.4% LRFD; p < 0.001), higher physician communication scores (median 3.0 RFD vs 2.0 LRFD; p < 0.001), and higher nursing communication scores (median 3.0 RFD vs 2.0 LRFD, p < 0.001). Readmission rates were similar between the groups (11.4% RFD vs 18.2% LRFD; p = 0.09). Readiness for discharge appears to be a clinically useful patient-reported metric, as those RFD have higher satisfaction with the hospital and physicians. Prospective investigation into variables affecting patient satisfaction in those LRFD is needed. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Positive outcomes influence the rate and time to publication, but not the impact factor of publications of clinical trial results.

PubMed

Suñé, Pilar; Suñé, Josep Maria; Montoro, J Bruno

2013-01-01

Publication bias may affect the validity of evidence based medical decisions. The aim of this study is to assess whether research outcomes affect the dissemination of clinical trial findings, in terms of rate, time to publication, and impact factor of journal publications. All drug-evaluating clinical trials submitted to and approved by a general hospital ethics committee between 1997 and 2004 were prospectively followed to analyze their fate and publication. Published articles were identified by searching Pubmed and other electronic databases. Clinical study final reports submitted to the ethics committee, final reports synopses available online and meeting abstracts were also considered as sources of study results. Study outcomes were classified as positive (when statistical significance favoring experimental drug was achieved), negative (when no statistical significance was achieved or it favored control drug) and descriptive (for non-controlled studies). Time to publication was defined as time from study closure to publication. A survival analysis was performed using a Cox regression model to analyze time to publication. Journal impact factors of identified publications were recorded. Publication rate was 48·4% (380/785). Study results were identified for 68·9% of all completed clinical trials (541/785). Publication rate was 84·9% (180/212) for studies with results classified as positive and 68·9% (128/186) for studies with results classified as negative (p<0·001). Median time to publication was 2·09 years (IC95 1·61-2·56) for studies with results classified as positive and 3·21 years (IC95 2·69-3·70) for studies with results classified as negative (hazard ratio 1·99 (IC95 1·55-2·55). No differences were found in publication impact factor between positive (median 6·308, interquartile range: 3·141-28·409) and negative result studies (median 8·266, interquartile range: 4·135-17·157). Clinical trials with positive outcomes have significantly higher rates and shorter times to publication than those with negative results. However, no differences have been found in terms of impact factor.

Prevalence of serum celiac antibodies in a multiracial Asian population--a first study in the young Asian adult population of Malaysia.

PubMed

Yap, Theresa Wan-Chen; Chan, Weng-Kai; Leow, Alex Hwong-Ruey; Azmi, Ahmad Najib; Loke, Mun-Fai; Vadivelu, Jamuna; Goh, Khean-Lee

2015-01-01

Celiac disease (CD) is an immune-mediated disorder induced by the ingestion of gluten in genetically susceptible persons. The prevalence of CD in Malaysia is unknown. We aim to determine the seroprevalence of CD antibodies and also investigate the correlation between H. pylori infection and CD in the young and healthy multiracial Malaysian population. Healthy young adult volunteers between the ages of 18-30 years were consecutively recruited from June 2012 to May 2014 at the University of Malaya Medical Centre (UMMC), Kuala Lumpur. Serum samples from all the participants were tested for anti-gliadin antibody immunoglobulin A/immunoglobulin G (IgA/IgG) and anti-tissue transglutaminase antibody (tTG) IgA/IgG. Samples positive for both anti-gliadin and anti-tTG were further validated for anti-human endomysial IgA antibodies (EmA). Serological diagnosis of CD was made when anti-gliadin, anti-tTG and anti-EmA were positive. 562 qualified participants with mean age 24 ± 2.4 years old were recruited into our study. CD was found in 7 participants where most of them were asymptomatic and unaware of their CD status. The median of anti-gliadin and anti-tTG IgA/IgG value was 38.2 U/ml (interquartile range, 28.3-60.4 U/ml) and 49.2 U/ml (interquartile range, 41.1-65.9 U/ml), respectively. Seroprevalence of CD antibodies was 1.9% (6 out of 324) in female while only 0.4% (1 out of 238) in male. Seroprevalence among Malay was 0.8% (2 of 236), Chinese was 1.7% (3 of 177) and Indian was 1.3% (2 of 149). Overall, seroprevalence of CD antibodies in healthy asymptomatic adults in the Malaysian population was 1.25% (95% CI, 0.78%-1.72%). No significant relationship was discovered between CD and H. pylori infection. The seroprevalence of CD antibodies in healthy young adults in the Malaysian population was 1.25% (1 in 100). CD is underdiagnosed and it could be a much greater problem in Malaysia than previously thought.

Timing of infant feeding in relation to childhood asthma and allergic diseases.

PubMed

Nwaru, Bright I; Takkinen, Hanna-Mari; Niemelä, Onni; Kaila, Minna; Erkkola, Maijaliisa; Ahonen, Suvi; Haapala, Anna-Maija; Kenward, Michael G; Pekkanen, Juha; Lahesmaa, Riitta; Kere, Juha; Simell, Olli; Veijola, Riitta; Ilonen, Jorma; Hyöty, Heikki; Knip, Mikael; Virtanen, Suvi M

2013-01-01

Emerging evidence questions current recommendations on the timing of infant feeding for the prevention of childhood allergies. The evidence for asthma is inconclusive. We sought to investigate the associations between the duration of breast-feeding and timing of introduction of complementary foods and the development of asthma and allergies by the age of 5 years. Data were analyzed for 3781 consecutively born children. The dietary exposures were categorized into thirds and analyzed as time-dependent variables. Asthma, allergic rhinitis, and atopic eczema end points were assessed by using the International Study of Asthma and Allergies in Childhood questionnaire, whereas IgE antibodies were analyzed from serum samples at the age of 5 years. Cox proportional hazard and logistic regressions were used for the analyses. The median duration of exclusive and total breast-feeding was 1.4 months (interquartile range, 0.2-3.5 months) and 7.0 months (interquartile range, 4.0-11.0 months), respectively. Total breast-feeding of 9.5 months or less was associated with an increased risk of nonatopic asthma. Introduction of wheat, rye, oats, or barley at 5 to 5.5 months was inversely associated with asthma and allergic rhinitis, whereas introduction of other cereals at less than 4.5 months increased the risk of atopic eczema. Introduction of egg at 11 months or less was inversely associated with asthma, allergic rhinitis, and atopic sensitization, whereas introduction of fish at 9 months or less was inversely associated with allergic rhinitis and atopic sensitization. Early introduction of wheat, rye, oats, and barley cereals; fish; and egg (respective to the timing of introduction of each food) seems to decrease the risk of asthma, allergic rhinitis, and atopic sensitization in childhood. Longer duration of total breast-feeding, rather than its exclusivity, was protective against the development of nonatopic but not atopic asthma, suggesting a potential differing effect of breast-feeding on different asthma phenotypes. Copyright © 2012 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.

Impact of mobile intensive care unit use on total ischemic time and clinical outcomes in ST-elevation myocardial infarction patients - real-world data from the Acute Coronary Syndrome Israeli Survey.

PubMed

Koifman, Edward; Beigel, Roy; Iakobishvili, Zaza; Shlomo, Nir; Biton, Yitschak; Sabbag, Avi; Asher, Elad; Atar, Shaul; Gottlieb, Shmuel; Alcalai, Ronny; Zahger, Doron; Segev, Amit; Goldenberg, Ilan; Strugo, Rafael; Matetzky, Shlomi

2017-01-01

Ischemic time has prognostic importance in ST-elevation myocardial infarction patients. Mobile intensive care unit use can reduce components of total ischemic time by appropriate triage of ST-elevation myocardial infarction patients. Data from the Acute Coronary Survey in Israel registry 2000-2010 were analyzed to evaluate factors associated with mobile intensive care unit use and its impact on total ischemic time and patient outcomes. The study comprised 5474 ST-elevation myocardial infarction patients enrolled in the Acute Coronary Survey in Israel registry, of whom 46% ( n=2538) arrived via mobile intensive care units. There was a significant increase in rates of mobile intensive care unit utilization from 36% in 2000 to over 50% in 2010 ( p<0.001). Independent predictors of mobile intensive care unit use were Killip>1 (odds ratio=1.32, p<0.001), the presence of cardiac arrest (odds ratio=1.44, p=0.02), and a systolic blood pressure <100 mm Hg (odds ratio=2.01, p<0.001) at presentation. Patients arriving via mobile intensive care units benefitted from increased rates of primary reperfusion therapy (odds ratio=1.58, p<0.001). Among ST-elevation myocardial infarction patients undergoing primary reperfusion, those arriving by mobile intensive care unit benefitted from shorter median total ischemic time compared with non-mobile intensive care unit patients (175 (interquartile range 120-262) vs 195 (interquartile range 130-333) min, respectively ( p<0.001)). Upon a multivariate analysis, mobile intensive care unit use was the most important predictor in achieving door-to-balloon time <90 min (odds ratio=2.56, p<0.001) and door-to-needle time <30 min (odds ratio=2.96, p<0.001). One-year mortality rates were 10.7% in both groups (log-rank p-value=0.98), however inverse propensity weight model, adjusted for significant differences between both groups, revealed a significant reduction in one-year mortality in favor of the mobile intensive care unit group (odds ratio=0.79, 95% confidence interval (0.66-0.94), p=0.01). Among patients with ST-elevation myocardial infarction, the utilization of mobile intensive care units is associated with increased rates of primary reperfusion, a reduction in the time interval to reperfusion, and a reduction in one-year adjusted mortality.

The occurrence of benign brain tumours in transgender individuals during cross-sex hormone treatment.

PubMed

Nota, Nienke M; Wiepjes, Chantal M; de Blok, Christel J M; Gooren, Louis J G; Peerdeman, Saskia M; Kreukels, Baudewijntje P C; den Heijer, Martin

2018-04-23

Benign brain tumours may be hormone sensitive. To induce physical characteristics of the desired gender, transgender individuals often receive cross-sex hormone treatment, sometimes in higher doses than hypogonadal individuals. To date, long-term (side) effects of cross-sex hormone treatment are largely unknown. In the present retrospective chart study we aimed to compare the incidence of common benign brain tumours: meningiomas, pituitary adenomas (non-secretive and secretive), and vestibular schwannomas in transgender individuals receiving cross-sex hormone treatment, with those reported in general Dutch or European populations. This study was performed at the VU University Medical Centre in the Netherlands and consisted of 2555 transwomen (median age at start of cross-sex hormone treatment: 31 years, interquartile range 23-41) and 1373 transmen (median age 23 years, interquartile range 18-31) who were followed for 23 935 and 11 212 person-years, respectively. For each separate brain tumour, standardized incidence ratios with 95% confidence intervals were calculated. In transwomen (male sex assigned at birth, female gender identity), eight meningiomas, one non-secretive pituitary adenoma, nine prolactinomas, and two vestibular schwannomas occurred. The incidence of meningiomas was higher in transwomen than in a general European female population (standardized incidence ratio 4.1, 95% confidence interval 1.9-7.7) and male population (11.9, 5.5-22.7). Similar to meningiomas, prolactinomas occurred more often in transwomen compared to general Dutch females (4.3, 2.1-7.9) and males (26.5, 12.9-48.6). Noteworthy, most transwomen had received orchiectomy but still used the progestogenic anti-androgen cyproterone acetate at time of diagnosis. In transmen (female sex assigned at birth, male gender identity), two cases of somatotrophinomas were observed, which was higher than expected based on the reported incidence rate in a general European population (incidence rate females = incidence rate males; standardized incidence ratio 22.2, 3.7-73.4). Based on our results we conclude that cross-sex hormone treatment is associated with a higher risk of meningiomas and prolactinomas in transwomen, which may be linked to cyproterone acetate usage, and somatotrophinomas in transmen. Because these conditions are quite rare, performing regular screenings for such tumours (e.g. regular prolactin measurements for identifying prolactinomas) seems not necessary.

Prostate-Specific Antigen (PSA) Bounce After Dose-Escalated External Beam Radiation Therapy Is an Independent Predictor of PSA Recurrence, Metastasis, and Survival in Prostate Adenocarcinoma Patients.

PubMed

Romesser, Paul B; Pei, Xin; Shi, Weiji; Zhang, Zhigang; Kollmeier, Marisa; McBride, Sean M; Zelefsky, Michael J

2018-01-01

To evaluate the difference in prostate-specific antigen (PSA) recurrence-free, distant metastasis-free, overall, and cancer-specific survival between PSA bounce (PSA-B) and non-bounce patients treated with dose-escalated external beam radiation therapy (DE-EBRT). During 1990-2010, 1898 prostate adenocarcinoma patients were treated with DE-EBRT to ≥75 Gy with ≥5 years follow-up. Patients receiving neoadjuvant/concurrent androgen-deprivation therapy (n=1035) or with fewer than 4 PSA values obtained 6 months or more after post-EBRT completion (n=87) were excluded. The evaluable 776 patients were treated (median, 81.0 Gy). Prostate-specific antigen bounce was defined as a ≥0.2-ng/mL increase above the interval PSA nadir, followed by a decrease to nadir or below. Prostate-specific antigen relapse was defined as post-radiation therapy PSA nadir + 2 ng/mL. Median follow-up was 9.2 years (interquartile range, 6.9-11.3 years). One hundred twenty-three patients (15.9%) experienced PSA-B after DE-EBRT at a median of 24.6 months (interquartile range, 16.1-38.5 months). On multivariate analysis, younger age (P=.001), lower Gleason score (P=.0003), and higher radiation therapy dose (P=.0002) independently predicted PSA-B. Prostate-specific antigen bounce was independently associated with decreased risk for PSA relapse (hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.33-0.85; P=.008), distant metastatic disease (HR 0.34; 95% CI 0.12-0.94; P=.04), and all-cause mortality (HR 0.53; 95% CI 0.29-0.96; P=.04) on multivariate Cox analysis. Because all 50 prostate cancer-specific deaths in patients without PSA-B were in the non-bounce cohort, competing-risks analysis was not applicable. A nonparametric competing-risks test demonstrated that patients with PSA-B had superior cancer-specific survival compared with patients without PSA-B (P=.004). Patients treated with dose-escalated radiation therapy for prostate adenocarcinoma who experience posttreatment PSA-B have improved PSA recurrence-free survival, distant metastasis-free survival, overall survival, and cancer-specific survival outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

From 9-1-1 call to death: evaluating traumatic deaths in seven regions for early recognition of high-risk patients.

PubMed

Dean, Dylan; Wetzel, Brian; White, Nathan; Kuppermann, Nathan; Wang, Nancy Ewen; Haukoos, Jason S; Hsia, Renee Y; Mann, N Clay; Barton, Erik D; Newgard, Craig D

2014-03-01

This study aimed to characterize initial clinical presentations of patients served by emergency medical services (EMS) who die following injury, with particular attention to patients with occult ("talk-and-die") presentations. This was a population-based, multiregion, mixed-methods retrospective cohort study of fatally injured children and adults evaluated by 94 EMS agencies transporting to 122 hospitals in seven Western US regions from 2006 to 2008. Fatalities were divided into two main groups: occult injuries (talk-and-die; Glasgow Coma Scale [GCS] score ≥ 13, no cardiopulmonary arrest, and no intubation) versus overt injuries (all other patients). These groups were further subdivided by timing of death: early (<48 hours) versus late (>48 hours). We then compared demographic, physiologic, procedural, and injury patterns using descriptive statistics. We also used qualitative methods to analyze available EMS chart narratives for contextual information from the out-of-hospital encounter. During the 3-year study period, 3,358 persons served by 9-1-1 EMS providers died, with 1,225 (37.1%) in the field, 1,016 (30.8%) early in the hospital, and 1,060 (32.1%) late in the hospital. Of the 2,133 patients transported to a hospital, there were 612 (28.7%) talk-and-die patients, of whom 114 (18.6%) died early. Talk-and-die patients were older (median age, 81 years; interquartile range, 67-87 years), normotensive (median systolic blood pressure, 138 mm Hg; interquartile range, 116-160 mm Hg), commonly injured by falls (71.3%), and frequently (52.4%) died in nontrauma hospitals. Compared with overtly injured patients, talk-and-die patients had relatively fewer serious head injuries (13.7%) but more frequent extremity injuries (20.3% vs. 10.6%) and orthopedic interventions (25.3% vs. 5.0%). EMS personnel often found talk-and-die patients lying on the ground with hip pain or extremity injuries. Patients served by EMS who "talk-and-die" are typically older adults with falls, transported to nontrauma hospitals, with subtle clinical indications of the severity of their injuries. Improving recognition of talk-and-die patients may avoid fatal outcomes in a portion of these patients. Epidemiologic study, level III.

Evaluation of Nine Consensus Indices in Delphi Foresight Research and Their Dependency on Delphi Survey Characteristics: A Simulation Study and Debate on Delphi Design and Interpretation.

PubMed

Birko, Stanislav; Dove, Edward S; Özdemir, Vural

2015-01-01

The extent of consensus (or the lack thereof) among experts in emerging fields of innovation can serve as antecedents of scientific, societal, investor and stakeholder synergy or conflict. Naturally, how we measure consensus is of great importance to science and technology strategic foresight. The Delphi methodology is a widely used anonymous survey technique to evaluate consensus among a panel of experts. Surprisingly, there is little guidance on how indices of consensus can be influenced by parameters of the Delphi survey itself. We simulated a classic three-round Delphi survey building on the concept of clustered consensus/dissensus. We evaluated three study characteristics that are pertinent for design of Delphi foresight research: (1) the number of survey questions, (2) the sample size, and (3) the extent to which experts conform to group opinion (the Group Conformity Index) in a Delphi study. Their impacts on the following nine Delphi consensus indices were then examined in 1000 simulations: Clustered Mode, Clustered Pairwise Agreement, Conger's Kappa, De Moivre index, Extremities Version of the Clustered Pairwise Agreement, Fleiss' Kappa, Mode, the Interquartile Range and Pairwise Agreement. The dependency of a consensus index on the Delphi survey characteristics was expressed from 0.000 (no dependency) to 1.000 (full dependency). The number of questions (range: 6 to 40) in a survey did not have a notable impact whereby the dependency values remained below 0.030. The variation in sample size (range: 6 to 50) displayed the top three impacts for the Interquartile Range, the Clustered Mode and the Mode (dependency = 0.396, 0.130, 0.116, respectively). The Group Conformity Index, a construct akin to measuring stubbornness/flexibility of experts' opinions, greatly impacted all nine Delphi consensus indices (dependency = 0.200 to 0.504), except the Extremity CPWA and the Interquartile Range that were impacted only beyond the first decimal point (dependency = 0.087 and 0.083, respectively). Scholars in technology design, foresight research and future(s) studies might consider these new findings in strategic planning of Delphi studies, for example, in rational choice of consensus indices and sample size, or accounting for confounding factors such as experts' variable degrees of conformity (stubbornness/flexibility) in modifying their opinions.

Evaluation of Nine Consensus Indices in Delphi Foresight Research and Their Dependency on Delphi Survey Characteristics: A Simulation Study and Debate on Delphi Design and Interpretation

PubMed Central

Birko, Stanislav; Dove, Edward S.; Özdemir, Vural

2015-01-01

The extent of consensus (or the lack thereof) among experts in emerging fields of innovation can serve as antecedents of scientific, societal, investor and stakeholder synergy or conflict. Naturally, how we measure consensus is of great importance to science and technology strategic foresight. The Delphi methodology is a widely used anonymous survey technique to evaluate consensus among a panel of experts. Surprisingly, there is little guidance on how indices of consensus can be influenced by parameters of the Delphi survey itself. We simulated a classic three-round Delphi survey building on the concept of clustered consensus/dissensus. We evaluated three study characteristics that are pertinent for design of Delphi foresight research: (1) the number of survey questions, (2) the sample size, and (3) the extent to which experts conform to group opinion (the Group Conformity Index) in a Delphi study. Their impacts on the following nine Delphi consensus indices were then examined in 1000 simulations: Clustered Mode, Clustered Pairwise Agreement, Conger’s Kappa, De Moivre index, Extremities Version of the Clustered Pairwise Agreement, Fleiss’ Kappa, Mode, the Interquartile Range and Pairwise Agreement. The dependency of a consensus index on the Delphi survey characteristics was expressed from 0.000 (no dependency) to 1.000 (full dependency). The number of questions (range: 6 to 40) in a survey did not have a notable impact whereby the dependency values remained below 0.030. The variation in sample size (range: 6 to 50) displayed the top three impacts for the Interquartile Range, the Clustered Mode and the Mode (dependency = 0.396, 0.130, 0.116, respectively). The Group Conformity Index, a construct akin to measuring stubbornness/flexibility of experts’ opinions, greatly impacted all nine Delphi consensus indices (dependency = 0.200 to 0.504), except the Extremity CPWA and the Interquartile Range that were impacted only beyond the first decimal point (dependency = 0.087 and 0.083, respectively). Scholars in technology design, foresight research and future(s) studies might consider these new findings in strategic planning of Delphi studies, for example, in rational choice of consensus indices and sample size, or accounting for confounding factors such as experts’ variable degrees of conformity (stubbornness/flexibility) in modifying their opinions. PMID:26270647

Quantitative electromyography in ambulatory boys with Duchenne muscular dystrophy.

PubMed

Verma, Sumit; Lin, Jenny; Travers, Curtis; McCracken, Courtney; Shah, Durga

2017-12-01

This study's objective was to evaluate quantitative electromyography (QEMG) using multiple-motor-unit (multi-MUP) analysis in Duchenne muscular dystrophy (DMD). Ambulatory DMD boys, aged 5-15 years, were evaluated with QEMG at 6-month intervals over 14 months. EMG was performed in the right biceps brachii (BB) and tibialis anterior (TA) muscles. Normative QEMG data were obtained from age-matched healthy boys. Wilcoxon signed-rank tests were performed. Eighteen DMD subjects were enrolled, with a median age of 7 (interquartile range 7-10) years. Six-month evaluations were performed on 14 subjects. QEMG showed significantly abnormal mean MUP duration in BB and TA muscles, with no significant change over 6 months. QEMG is a sensitive electrophysiological marker of myopathy in DMD. Preliminary data do not reflect a significant change in MUP parameters over a 6-month interval; long-term follow-up QEMG studies are needed to understand its role as a biomarker for disease progression. Muscle Nerve 56: 1361-1364, 2017. © 2017 Wiley Periodicals, Inc.

A comparative view of the new journal: Assessment.

PubMed

Blashfield, R K; Archer, G

2001-09-01

The reference sections from all articles in the 1997 volumes of Assessment, Journal of Personality Assessment, and Psychological Assessment were entered into a database and analyzed. An article published in Assessment averaged almost 31 references. An article published in Journal of Personality Assessment contained an average of 33 references. Psychological Assessment averaged 38 references per article. The median age of the references in the three journals was 8 years with an interquartile range of 4 to 14 years. The Journal of Personality Assessment had the largest number of citations in this database of 5,316 references. Each of these received a relatively large number of their citations from articles published in the same journal (self-citations). Randomly selected articles from the 1997 volume of Assessment received fewer citations in the Social Science Citation Index than a similar set of articles from the other two journals. However, the data on Assessment, when compared with data available on other new scientific publications, suggests that Assessment is doing as well as other fledgling journals.

Suitability of Varicose Veins for Endovenous Treatments

DOE Office of Scientific and Technical Information (OSTI.GOV)

Goode, S. D., E-mail: s.goode@sheffield.ac.u; Kuhan, G.; Altaf, N.

2009-09-15

The aim of the study was to assess the suitability of radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy (FS) for patients with symptomatic varicose veins (VVs). The study comprised 403 consecutive patients with symptomatic VVs. Data on 577 legs from 403 consecutive patients with symptomatic VVs were collected for the year 2006. Median patient age was 55 years (interquartile range 45-66), and 62% patients were women. A set of criteria based on duplex ultrasonography was used to select patients for each procedure. Great saphenous vein (GSV) reflux was present in 77% (446 of 577) of legs. Overall,more » 328 (73%) of the legs were suitable for at least one of the endovenous options. Of the 114 legs with recurrent GSV reflux disease, 83 (73%) were suitable to receive endovenous therapy. Patients with increasing age were less likely to be suitable for endovenous therapy (P = 0.03). Seventy-three percent of patients with VVs caused by GSV incompetence are suitable for endovenous therapy.« less

Tetanus in Southern Vietnam: Current Situation.

PubMed

Thuy, Duong Bich; Campbell, James I; Thanh, Tran Tan; Thuy, Cao Thu; Loan, Huynh Thi; Hao, Nguyen Van; Minh, Yen Lam; Tan, Le Van; Boni, Maciej F; Thwaites, C Louise

2017-01-11

In Vietnam, there are no accurate data on tetanus incidence to allow assessment of disease burden or vaccination program efficacy. We analyzed age structure of 786 tetanus cases admitted to a tertiary referral center in Vietnam for three separate years during an 18-year period to examine the impact of tetanus prevention programs, namely the Expanded Program on Immunization (EPI) and the Maternal and Neonatal Tetanus (MNT) initiative. Most cases were born before the initiation of EPI. Median age increased from 33 (interquartile range: 20-52) in 1994, to 46 (32-63) in 2012 (P < 0.001). Birth-year distribution was unchanged, indicating the same birth cohorts presented with tetanus in 1994, 2003, and 2012. Enzyme-linked immunosorbent assay measurements in 90 men and 90 women covered by MNT but not EPI showed 73.3% (95% confidence interval [CI]: 62.9-82.1%) of women had anti-tetanus antibody compared with 24.4% (95% CI: 15.9-34.7%) of men, indicating continued tetanus vulnerability in older men in Vietnam. © The American Society of Tropical Medicine and Hygiene.

Hospital Variation in Time to Epinephrine for Non-Shockable In-Hospital Cardiac Arrest

PubMed Central

Khera, Rohan; Chan, Paul S.; Donnino, Michael; Girotra, Saket

2016-01-01

Background For patients with in-hospital cardiac arrests due to non-shockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its impact on hospital-level outcomes is unknown. Methods Within Get with the Guidelines-Resuscitation, we identified 103,932 adult patients (≥18 years) at 548 hospitals with an in-hospital cardiac arrest due to a non-shockable rhythm who received at least 1 dose of epinephrine between 2000 to 2014. We constructed two-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery. Results Overall, 13,213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range: 0% to 53.8%). The odds of delay in epinephrine administration were 58% higher at one randomly selected hospital compared to a similar patient at another randomly selected hospitals (median odds ratio [OR] 1.58; 95% C.I. 1.51 – 1.64). Median risk-standardized survival rate was 12.0% (range: 5.4% to 31.9%) and risk-standardized survival with functional recovery was 7.4% (range: 0.9% to 30.8%). There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (ρ= −0.22, P<0.0001) and survival with functional recovery (ρ= −0.14, P=0.001). Compared to a median survival rate of 12.9% (interquartile range 11.1% to 15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8%, interquartile range: 9.7% to 12.7%). Conclusions Delays in epinephrine administration following in-hospital cardiac arrest are common and varies across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest due to non-shockable rhythm. Further studies are needed to determine if improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric will lead to improved outcomes. PMID:27908910

Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest.

PubMed

Khera, Rohan; Chan, Paul S; Donnino, Michael; Girotra, Saket

2016-12-20

For patients with in-hospital cardiac arrests attributable to nonshockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its effect on hospital-level outcomes is unknown. Within Get With The Guidelines-Resuscitation, we identified 103 932 adult patients (≥18 years) at 548 hospitals with an in-hospital cardiac arrest attributable to a nonshockable rhythm who received at least 1 dose of epinephrine between 2000 and 2014. We constructed 2-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery. Overall, 13 213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range, 0%-53.8%). The odds of delay in epinephrine administration were 58% higher at 1 randomly selected hospital in comparison with a similar patient at another randomly selected hospital (median odds ratio, 1.58; 95% confidence interval, 1.51-1.64). The median risk-standardized survival rate was 12.0% (range, 5.4%-31.9%), and the risk-standardized survival with functional recovery was 7.4% (range, 0.9%-30.8%). There was an inverse correlation between a hospital's rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (ρ=-0.22, P<0.0001) and survival with functional recovery (ρ=-0.14, P=0.001). In comparison with a median survival rate of 12.9% (interquartile range, 11.1%-15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8%; interquartile range, 9.7%-12.7%). Delays in epinephrine administration following in-hospital cardiac arrest are common and variy across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest attributable to nonshockable rhythm. Further studies are needed to determine whether improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric, will lead to improved outcomes. © 2016 American Heart Association, Inc.

Addison’s Disease Symptoms – A Cross Sectional Study in Urban South Africa

PubMed Central

Ross, Ian Louis; Levitt, Naomi S.

2013-01-01

Background Addison’s disease is a potentially life-threatening disorder, and prompt diagnosis, and introduction of steroid replacement has resulted in near normal life-expectancy. There are limited data describing the clinical presentation of Addison’s disease in South Africa. It is hypothesised that patients may present in advanced state of ill-health, compared to Western countries. Patients A national database of patients was compiled from primary care, referral centres and private practices. 148 patients were enrolled (97 white, 34 mixed ancestry, 5 Asian and 12 black). Methods Demographic and clinical data were elicited using questionnaires. Biochemical data were obtained from folder reviews and laboratory archived results. Results The majority of the cohort was women (62%). The median and inter-quartile age range (IQR) of patients at enrolment was 46.0 (32.0–61.0) years, with a wide range from 2.8–88.0 years. The median and IQR age at initial diagnosis was 34.0 (20.0–45.0) years (range 0.02–77.0) years, indicating that at the time of enrolment, the patients, on average, were diagnosed with Addison’s disease 12 years previously. Hyperpigmentation was observed in 76%, nausea and vomiting occurred in more than 40%, and weight loss was noted in 25%. Loss of consciousness as a presenting feature was recorded in 20%. with a 95% confidence interval [CI] of (14–28%) and shock occurred in 5% CI (1.5–8.5%). Case-finding was recorded at 3.1 per million. Conclusions The usual constellation of hyperpigmentation, nausea, vomiting and weight loss suggests Addison’s disease, but a significant proportion present with an advanced state of ill-health and Addisonian crises. A lower prevalence rate, compared to Western countries is suggested. PMID:23308244

Addison's disease symptoms--a cross sectional study in urban South Africa.

PubMed

Ross, Ian Louis; Levitt, Naomi S

2013-01-01

Addison's disease is a potentially life-threatening disorder, and prompt diagnosis, and introduction of steroid replacement has resulted in near normal life-expectancy. There are limited data describing the clinical presentation of Addison's disease in South Africa. It is hypothesised that patients may present in advanced state of ill-health, compared to Western countries. A national database of patients was compiled from primary care, referral centres and private practices. 148 patients were enrolled (97 white, 34 mixed ancestry, 5 Asian and 12 black). Demographic and clinical data were elicited using questionnaires. Biochemical data were obtained from folder reviews and laboratory archived results. The majority of the cohort was women (62%). The median and inter-quartile age range (IQR) of patients at enrolment was 46.0 (32.0-61.0) years, with a wide range from 2.8-88.0 years. The median and IQR age at initial diagnosis was 34.0 (20.0-45.0) years (range 0.02-77.0) years, indicating that at the time of enrolment, the patients, on average, were diagnosed with Addison's disease 12 years previously. Hyperpigmentation was observed in 76%, nausea and vomiting occurred in more than 40%, and weight loss was noted in 25%. Loss of consciousness as a presenting feature was recorded in 20%. with a 95% confidence interval [CI] of (14-28%) and shock occurred in 5% CI (1.5-8.5%). Case-finding was recorded at 3.1 per million. The usual constellation of hyperpigmentation, nausea, vomiting and weight loss suggests Addison's disease, but a significant proportion present with an advanced state of ill-health and Addisonian crises. A lower prevalence rate, compared to Western countries is suggested.

Long-term cardiac (valvulopathy) safety of cabergoline in prolactinoma

PubMed Central

Khare, Shruti; Lila, Anurag R.; Patil, Rishikesh; Phadke, Milind; Kerkar, Prafulla; Bandgar, Tushar; Shah, Nalini S.

2017-01-01

Background: Clinical relevance of association of cabergoline use for hyperprolactinemia and cardiac valvulopathy remains unclear. Objective: The aim of the study was to determine the prevalence of valvular heart abnormalities in patients taking cabergoline for the treatment of prolactinoma and to explore any associations with the cumulative dose of drug used. Design: A cross-sectional echocardiographic study was performed in patients who were receiving cabergoline therapy for prolactinoma. Results: Hundred (61 females, 39 males) prolactinoma cases (81 macroprolactinoma and 19 microprolactinoma) were included in the study. The mean age at presentation was 33.9 ± 9.0 years (range: 16–58 years). The mean duration of treatment was 53.11 ± 43.15 months (range: 12–155 months). The mean cumulative dose was 308.6 ± 290.2 mg (range: 26–1196 mg; interquartile range: 104–416 mg). Mild mitral regurgitation was present in one patient (cumulative cabergoline dose 104 mg). Mild tricuspid regurgitation was present in another two patients (cumulative cabergoline dose 52 mg and 104 mg). Aortic and pulmonary valve functioning was normal in all the cases. There were no cases of significant valvular regurgitation (moderate to severe, Grade 3–4). None of the patients had morphological abnormalities such as thickening, calcification, and restricted mobility of any of the cardiac valves. Conclusion: Cabergoline appears to be safe in patients with prolactinoma up to the cumulative dose of ~300 mg. The screening for valvulopathy should be restricted to those with higher cumulative cabergoline exposure. PMID:28217516

Precut cornea for Descemet's stripping endothelial keratoplasty: experience at a single eye bank.

PubMed

Mohamed, Ashik; Chaurasia, Sunita; Chandragiri, Venkataswamy; Kandhibanda, Srinivas; Gunnam, Srinivas; Garg, Prashant

2017-06-01

The aim of the study is to describe the experience with precut facility for endothelial keratoplasty at a single eye bank affiliated to a tertiary eye care center in India. Data on precut tissues from Nov 2012 to Dec 2014 were retrospectively reviewed from the electronic database of the eye bank of a tertiary eye care center in South India. Donor characteristic data including donor age, precut and postcut endothelial cell density (ECD), recipient age, and thickness of graft were collected. The number of precuts increased from 42 in 2012 (Nov and Dec) and 422 in 2013 to 584 in 2014. Of the total of 1048 precuts, seven (0.67 %) were miscut and could not be utilized for transplants. The donor age ranged from 2 to 89 years. A mean change of 43.6 ± 325.2 cells/mm 2 in ECD was noted after cut, proportional increase in mean being 1.9 %. The change in ECD after cut was negatively correlated with ECD before cut. The recipient age ranged from 1 to 89 years. The median thickness of donor lenticule after cut was 148 µm (interquartile range 131-166 µm). Analysis of precut donor corneas from a single eye bank shows that the ECD of the processed tissues was excellent for transplantation. The tissue wastage in the hands of eye bank personal was minimal.

The utility of the Total Neuropathy Score as an instrument to assess neuropathy severity in chronic kidney disease: A validation study.

PubMed

Issar, Tushar; Arnold, Ria; Kwai, Natalie C G; Pussell, Bruce A; Endre, Zoltan H; Poynten, Ann M; Kiernan, Matthew C; Krishnan, Arun V

2018-05-01

To demonstrate construct validity of the Total Neuropathy Score (TNS) in assessing peripheral neuropathy in subjects with chronic kidney disease (CKD). 113 subjects with CKD and 40 matched controls were assessed for peripheral neuropathy using the TNS. An exploratory factor analysis was conducted and internal consistency of the scale was evaluated using Cronbach's alpha. Construct validity of the TNS was tested by comparing scores between case and control groups. Factor analysis revealed valid item correlations and internal consistency of the TNS was good with a Cronbach's alpha of 0.897. Subjects with CKD scored significantly higher on the TNS (CKD: median, 6, interquartile range, 1-13; controls: median, 0, interquartile range, 0-1; p < 0.001). Subgroup analysis revealed construct validity was maintained for subjects with stages 3-5 CKD with and without diabetes. The TNS is a valid measure of peripheral neuropathy in patients with CKD. The TNS is the first neuropathy scale to be formally validated in patients with CKD. Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

A strategy for optimizing staffing to improve the timeliness of inpatient phlebotomy collections.

PubMed

Morrison, Aileen P; Tanasijevic, Milenko J; Torrence-Hill, Joi N; Goonan, Ellen M; Gustafson, Michael L; Melanson, Stacy E F

2011-12-01

The timely availability of inpatient test results is a key to physician satisfaction with the clinical laboratory, and in an institution with a phlebotomy service may depend on the timeliness of blood collections. In response to safety reports filed for delayed phlebotomy collections, we applied Lean principles to the inpatient phlebotomy service at our institution. Our goal was to improve service without using additional resources by optimizing our staffing model. To evaluate the effect of a new phlebotomy staffing model on the timeliness of inpatient phlebotomy collections. We compared the median time of morning blood collections and average number of safety reports filed for delayed phlebotomy collections during a 6-month preimplementation period and 5-month postimplementation period. The median time of morning collections was 17 minutes earlier after implementation (7:42 am preimplementation; interquartile range, 6:27-8:48 am; versus 7:25 am postimplementation; interquartile range, 6:20-8:26 am). The frequency of safety reports filed for delayed collections decreased 80% from 10.6 per 30 days to 2.2 per 30 days. Reallocating staff to match the pattern of demand for phlebotomy collections throughout the day represents a strategy for improving the performance of an inpatient phlebotomy service.

The Effect of Manual Restraint on Physiological Parameters in Barred Owls ( Strix varia ).

PubMed

Doss, Grayson A; Mans, Christoph

2017-03-01

Manual restraint is commonly necessary when working with avian species in medical, laboratory, and field settings. Despite their prevalence, little is known about the stress response in raptorial bird species. To further understand the effect of restraint on the stress response in birds of prey, 12 barred owls ( Strix varia ) were manually restrained for 15 minutes. Physiological parameters (cloacal temperature, respiratory rate, heart rate) were followed over time and recorded at defined points during the restraint period. Heart rate decreased significantly over the restraint period by a mean ± SD of -73 ± 46 beats/min. Respiratory rate also decreased significantly (median: -11 breaths/min, interquartile range: -8 to -18). Cloacal temperature increased significantly over time in manually restrained owls (median: +1.5°C [+2.7°F], interquartile range: 1.3°C-2.1°C [2.3°F-3.8°F]). This study is the first to document stress hyperthermia in an owl species. Similar to another raptorial bird, the red-tailed hawk ( Buteo jamaicensis ), both heart rate and respiratory rate decreased and cloacal temperature increased over time in restrained barred owls. Barred owls appear to cope differently to restraint stress when compared to psittacine species.

Multidrug-resistant tuberculosis around the world: what progress has been made?

PubMed Central

Mirzayev, Fuad; Wares, Fraser; Baena, Inés Garcia; Zignol, Matteo; Linh, Nguyen; Weyer, Karin; Jaramillo, Ernesto; Floyd, Katherine; Raviglione, Mario

2015-01-01

Multidrug-resistant tuberculosis (MDR-TB) (resistance to at least isoniazid and rifampicin) will influence the future of global TB control. 88% of estimated MDR-TB cases occur in middle- or high-income countries, and 60% occur in Brazil, China, India, the Russian Federation and South Africa. The World Health Organization collects country data annually to monitor the response to MDR-TB. Notification, treatment enrolment and outcome data were summarised for 30 countries, accounting for >90% of the estimated MDR-TB cases among notified TB cases worldwide. In 2012, a median of 14% (interquartile range 6–50%) of estimated MDR-TB cases were notified in the 30 countries studied. In 15 of the 30 countries, the number of patients treated for MDR-TB in 2012 (71 681) was >50% higher than in 2011. Median treatment success was 53% (interquartile range 40–70%) in the 25 countries reporting data for 30 021 MDR-TB cases who started treatment in 2010. Although progress has been noted in the expansion of MDR-TB care, urgent efforts are required in order to provide wider access to diagnosis and treatment in most countries with the highest burden of MDR-TB. PMID:25261327

Use of Intranasal Dexmedetomidine as a Solo Sedative for MRI of Infants.

PubMed

Olgun, Gokhan; Ali, Mir Hyder

2018-01-23

Dexmedetomidine, a selective α-2 receptor agonist, can be delivered via the intranasal (IN) route and be used for procedural sedation. The drug's favorable hemodynamic profile and relative ease of application make it a promising agent for sedation during radiologic procedures, although there are few studies on its efficacy for MRI studies. A retrospective chart review was performed between June 2014 and December 2016. Outpatients between 1 and 12 months of age who received 4 μg/kg of IN dexmedetomidine for MRI were included in the analysis. Our aim with this study was to determine the rate of successful completion of the sedation procedure without the need for a rescue drug (other than repeat IN dexmedetomidine). A total of 52 subjects were included in our study. Median (interquartile range) patient age was 7 (5-8) months. Median (interquartile range) procedure length was 40 (35-50) minutes. Overall success rate (including first dose and any rescue dose IN) of dexmedetomidine was 96.2%. None of the patients had significant adverse effects related to dexmedetomidine. IN dexmedetomidine is an effective solo sedative agent for MRI in infants. Copyright © 2018 by the American Academy of Pediatrics.

The effect of incentive spirometry on postoperative pulmonary function following laparotomy: a randomized clinical trial.

PubMed

Tyson, Anna F; Kendig, Claire E; Mabedi, Charles; Cairns, Bruce A; Charles, Anthony G

2015-03-01

Changes in pulmonary dynamics following laparotomy are well documented. Deep breathing exercises, with or without incentive spirometry, may help counteract postoperative decreased vital capacity; however, the evidence for the role of incentive spirometry in the prevention of postoperative atelectasis is inconclusive. Furthermore, data are scarce regarding the prevention of postoperative atelectasis in sub-Saharan Africa. To determine the effect of the use of incentive spirometry on pulmonary function following exploratory laparotomy as measured by forced vital capacity (FVC). This was a single-center, randomized clinical trial performed at Kamuzu Central Hospital, Lilongwe, Malawi. Study participants were adult patients who underwent exploratory laparotomy and were randomized into the intervention or control groups (standard of care) from February 1 to November 30, 2013. All patients received routine postoperative care, including instructions for deep breathing and early ambulation. We used bivariate analysis to compare outcomes between the intervention and control groups. Adult patients who underwent exploratory laparotomy participated in postoperative deep breathing exercises. Patients in the intervention group received incentive spirometers. We assessed pulmonary function using a peak flow meter to measure FVC in both groups of patients. Secondary outcomes, such as hospital length of stay and mortality, were obtained from the medical records. A total of 150 patients were randomized (75 in each arm). The median age in the intervention and control groups was 35 years (interquartile range, 28-53 years) and 33 years (interquartile range, 23-46 years), respectively. Men predominated in both groups, and most patients underwent emergency procedures (78.7% in the intervention group and 84.0% in the control group). Mean initial FVC did not differ significantly between the intervention and control groups (0.92 and 0.90 L, respectively; P=.82 [95% CI, 0.52-2.29]). Although patients in the intervention group tended to have higher final FVC measurements, the change between the first and last measured FVC was not statistically significant (0.29 and 0.25 L, respectively; P=.68 [95% CI, 0.65-1.95]). Likewise, hospital length of stay did not differ significantly between groups. Overall postoperative mortality was 6.0%, with a higher mortality rate in the control group compared with the intervention group (10.7% and 1.3%, respectively; P=.02 [95% CI, 0.01-0.92]). Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. clinicaltrials.gov Identifier: NCT01789177.

Structural Predictors of Loss of Renal Function in American Indians with Type 2 Diabetes.

PubMed

Fufaa, Gudeta D; Weil, E Jennifer; Lemley, Kevin V; Knowler, William C; Brosius, Frank C; Yee, Berne; Mauer, Michael; Nelson, Robert G

2016-02-05

Diabetes is the leading cause of kidney failure in the United States, but early structural determinants of renal function loss in type 2 diabetes are poorly defined. We examined the association between morphometrically determined renal structural variables and loss of renal function in 111 American Indians with type 2 diabetes who volunteered for a research kidney biopsy at the end of a 6-year clinical trial designed to test the renoprotective efficacy of losartan versus placebo. Participants were subsequently followed in an observational study, in which annual measurements of GFR (iothalamate) initiated during the clinical trial were continued. Renal function loss was defined as ≥40% loss of GFR from the research examination performed at the time of kidney biopsy. Associations with renal function loss were evaluated by Cox proportional hazards regression. Hazard ratios (HRs) were reported per 1-SD increment for each morphometric variable. Of 111 participants (82% women; baseline mean [±SD] age, 46 years old [±10]; diabetes duration, 16 years [±6]; hemoglobin A1c =9.4% [±2.2]; GFR=147 ml/min [±56]; median albumin-to-creatinine ratio, 41 mg/g [interquartile range, 13-158]), 51 (46%) developed renal function loss during a median follow-up of 6.6 years (interquartile range, 3.1-9.0). Fourteen had baseline GFR <90 ml/min, and three had baseline GFR <60 ml/min. Higher mesangial fractional volume (HR, 2.27; 95% confidence interval [95% CI], 1.58 to 3.26), percentage of global glomerular sclerosis (HR, 1.63; 95% CI, 1.21 to 2.21), nonpodocyte cell number per glomerulus (HR, 1.50; 95% CI, 1.10 to 2.05), glomerular basement membrane width (HR, 1.48; 95% CI, 1.05 to 2.08), mean glomerular volume (HR, 1.42; 95% CI, 1.02 to 1.96), and podocyte foot process width (HR, 1.28; 95% CI, 1.03 to 1.60); lower glomerular filtration surface density (HR, 0.62; 95% CI, 0.41 to 0.94); and fewer endothelial fenestrations (HR, 0.68; 95% CI, 0.48 to 0.95) were each associated with GFR decline after adjustment for baseline age, sex, duration of diabetes, hemoglobin A1c, GFR, and treatment assignment during the clinical trial. Quantitative measures of glomerular structure predict loss of renal function in type 2 diabetes. Copyright © 2016 by the American Society of Nephrology.

Comorbidity Assessment Using Charlson Comorbidity Index and Simplified Comorbidity Score and Its Association With Clinical Outcomes During First-Line Chemotherapy for Lung Cancer.

PubMed

Singh, Navneet; Singh, Potsangbam Sarat; Aggarwal, Ashutosh N; Behera, Digambar

2016-05-01

Limited data is available on comorbidity assessment in patients with lung cancer. The present prospective study assessed the prevalence and association of the Charlson comorbidity index (CCI) and simplified comorbidity score (SCS) with clinical outcomes in patients with newly diagnosed lung cancer undergoing chemotherapy. All patients received histology-guided platinum doublets. The outcomes assessed were overall survival (OS), radiologic responses using Response Evaluation Criteria in Solid Tumors and toxicity using the Common Toxicity Criteria, version 3.0. The groups analyzed were SCS ≤ 9 (n = 173) and > 9 (n = 65) and CCI = 0 (n = 88), 1 (n = 97), and ≥ 2 (n = 53). Correlations of the CCI and SCS were assessed using Spearman's (rho) method. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for the factors affecting OS using Cox proportional hazard (CPH) modeling. Most patients had advanced disease (stage IIIB in 33.6%, stage IV in 42.4%). The median SCS was 7 (interquartile range, 7-11), and the median CCI was 1 (interquartile range, 0-1). The correlation between the CCI and SCS was moderate (rho = 0.474; P < .001). Age correlated weakly with both SCS (rho = 0.293; P < .001) and CCI (rho = 0.205; P < .001). The SCS > 9 group (vs. SCS ≤ 9) had a significantly older mean age, patients aged ≥ 70 years, men, smokers, and squamous cell histologic type. The mean age in the CCI groups was 55.2 years for a CCI of 0, 59.6 years for a CCI of 1, and 60.3 years for a CCI of 2, with a statistically significant difference (P = .002). The radiologic responses and toxicity profiles were similar between the SCS and CCI groups. The median OS was 287 days (95% CI, 232-342 days) and did not differ between the SCS and CCI groups. On multivariate CPH analyses, worse OS was independently associated with stage IV disease (adjusted HR, 2.0; 95% CI, 1.4-2.7) and poor performance status (Eastern Cooperative Oncology Group score ≥ 2; adjusted HR, 1.8; 95% CI, 1.1-2.8) but not with comorbidity, histologic type, or age. The SCS and CCI scores correlated moderately with each other and weakly with age. The presence of comorbidities did not adversely influence clinical outcomes in this Indian cohort of lung cancer patients undergoing first-line chemotherapy. Copyright © 2015 Elsevier Inc. All rights reserved.

Multi-institutional Prospective Evaluation of Bowel Quality of Life After Prostate External Beam Radiation Therapy Identifies Patient and Treatment Factors Associated With Patient-Reported Outcomes: The PROSTQA Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hamstra, Daniel A., E-mail: dhamm@med.umich.edu; Conlon, Anna S.C.; Daignault, Stephanie

Purpose: To evaluate patients treated with external beam radiation therapy as part of the multicenter Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment (PROSTQA), to identify factors associated with posttreatment patient-reported bowel health-related quality of life (HRQOL). Methods and Materials: Pretreatment characteristics and treatment details among 292 men were evaluated using a general linear mixed model for their association with measured HRQOL by the Expanded Prostate Cancer Index Composite instrument through 2 years after enrollment. Results: Bowel HRQOL had a median score of 100 (interquartile range 91.7-100) pretreatment and 95.8 (interquartile range 83.3-100) at 2 years, representing new moderate/bigmore » problems in 11% for urgency, 7% for frequency, 4% for bloody stools, and 8% for an overall bowel problems. Baseline bowel score was the strongest predictor for all 2-year endpoints. In multivariable models, a volume of rectum ≥25% treated to 70 Gy (V70) yielded a clinically significant 9.3-point lower bowel score (95% confidence interval [CI] 16.8-1.7, P=.015) and predicted increased risks for moderate to big fecal incontinence (P=.0008). No other radiation therapy treatment-related variables influenced moderate to big changes in rectal HRQOL. However, on multivariate analyses V70 ≥25% was associated with increases in small, moderate, or big problems with the following: incontinence (3.9-fold; 95% CI 1.1-13.4, P=.03), rectal bleeding (3.6-fold; 95% CI 1.3-10.2, P=.018), and bowel urgency (2.9-fold; 95% CI 1.1-7.6, P=.026). Aspirin use correlated with a clinically significant 4.7-point lower bowel summary score (95% CI 9.0-0.4, P=.03) and an increase in small, moderate, or big problems with bloody stools (2.8-fold; 95% CI 1.2-6.4, P=.018). Intensity modulated radiation therapy was associated with higher radiation therapy doses to the prostate and lower doses to the rectum but did not independently correlate with bowel HRQOL. Conclusion: After contemporary dose-escalated external beam radiation therapy up to 11% of patients have newly identified moderate/big problems with bowel HRQOL 2 years after treatment. Bowel HRQOL is related to baseline function, rectal V70, and aspirin use. Finally, our findings validate the commonly utilized cut-point of rectal V70 ≥25% as having significant impact on patient-reported outcomes.« less

Stroke Laterality Bias in the Management of Acute Ischemic Stroke.

PubMed

McCluskey, Gavin; Wade, Carrie; McKee, Jacqueline; McCarron, Peter; McVerry, Ferghal; McCarron, Mark O

2016-11-01

Little is known of the impact of stroke laterality on the management process and outcome of patients with acute ischemic stroke (AIS). Consecutive patients admitted to a general hospital over 1 year with supratentorial AIS were eligible for inclusion in the study. Baseline characteristics and risk factors, delays in hospital admission, imaging, intrahospital transfer to an acute stoke unit, stroke severity and classification, length of hospital admission, as well as 10-year mortality were measured and compared among right and left hemisphere AIS patients. There were 141 patients (77 men, 64 women; median age 73 [interquartile range 63-79] years), There were 71 patients with left hemisphere AIS and 70 with right hemisphere AIS. Delays to hospital admission from stroke onset to neuroimaging were similar among right and left hemisphere AIS patients. Delay in transfer to an acute stroke unit (ASU) following hospital admission was on average 14 hours more for right hemisphere compared to left hemisphere AIS patients (P = .01). Laterality was not associated with any difference in 10-year survival. Patients with mild and nondominant AIS merit particular attention to minimize their intrahospital transfer time to an ASU. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Large measles outbreak introduced by asylum seekers and spread among the insufficiently vaccinated resident population, Berlin, October 2014 to August 2015

PubMed Central

Werber, Dirk; Hoffmann, Alexandra; Santibanez, Sabine; Mankertz, Annette; Sagebiel, Daniel

2017-01-01

The largest measles outbreak in Berlin since 2001 occurred from October 2014 to August 2015. Overall, 1,344 cases were ascertained, 86% (with available information) unvaccinated, including 146 (12%) asylum seekers. Median age was 17 years (interquartile range: 4–29 years), 26% were hospitalised and a 1-year-old child died. Measles virus genotyping uniformly revealed the variant ‘D8-Rostov-Don’ and descendants. The virus was likely introduced by and initially spread among asylum seekers before affecting Berlin’s resident population. Among Berlin residents, the highest incidence was in children aged < 2 years, yet most cases (52%) were adults. Post-exposure vaccinations in homes for asylum seekers, not always conducted, occurred later (median: 7.5 days) than the recommended 72 hours after onset of the first case and reached only half of potential contacts. Asylum seekers should not only have non-discriminatory, equitable access to vaccination, they also need to be offered measles vaccination in a timely fashion, i.e. immediately upon arrival in the receiving country. Supplementary immunisation activities targeting the resident population, particularly adults, are urgently needed in Berlin. PMID:28857043

Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation.

PubMed

Black-Maier, Eric; Kim, Sunghee; Steinberg, Benjamin A; Fonarow, Gregg C; Freeman, James V; Kowey, Peter R; Ansell, Jack; Gersh, Bernard J; Mahaffey, Kenneth W; Naccarelli, Gerald; Hylek, Elaine M; Go, Alan S; Peterson, Eric D; Piccini, Jonathan P

2017-09-01

Oral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non-vitamin K antagonist oral anticoagulants (NOACs) have not been characterized. Anticoagulation strategies and outcomes differ by anticoagulant type in patients undergoing CIED implantation. Using the nationwide Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we assessed how atrial fibrillation (AF) patients undergoing CIED implantation were cared for and their subsequent outcomes. Outcomes were compared by oral anticoagulant therapy (none, warfarin, or NOAC) as well as by anticoagulation interruption status. Among 9129 AF patients, 416 (5%) underwent CIED implantation during a median follow-up of 30 months (interquartile range, 24-36). Of these, 60 (14%) had implantation on a NOAC. Relative to warfarin therapy, those on a NOAC were younger (70.5 years [range, 65-77.5 years] vs 77 years [range, 70-82 years]), had less valvular heart disease (15.0% vs 31.3%), higher creatinine clearance (67.3 [range, 59.7-99.0] vs 65.8 [range, 50.0-91.6]), were more likely to have persistent AF (26.7% vs 22.9%), and use concomitant aspirin (51.7% vs 35.2%). OAC therapy was commonly interrupted for CIED in 64% (n = 183 of 284) of warfarin patients and 65% (n = 39 of 60) of NOAC patients. Many interrupted patients received intravenous bridging anticoagulation: 33/183 (18%) interrupted warfarin and 4/39 (10%) interrupted NOAC patients. Thirty-day periprocedure bleeding and stroke adverse events were infrequent. Management of anticoagulation among AF patients undergoing CIED implantation is highly variable, with OAC being interrupted in more than half of both warfarin- and NOAC-treated patients. Bleeding and stroke events were infrequent in both warfarin and NOAC-treated patients. © 2017 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.

A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case.

PubMed

Taylor, Lauren J; Nabozny, Michael J; Steffens, Nicole M; Tucholka, Jennifer L; Brasel, Karen J; Johnson, Sara K; Zelenski, Amy; Rathouz, Paul J; Zhao, Qianqian; Kwekkeboom, Kristine L; Campbell, Toby C; Schwarze, Margaret L

2017-06-01

Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.

T2 relaxation times of the glenohumeral joint at 3.0 T MRI in patients with and without primary and secondary osteoarthritis.

PubMed

Lee, So-Yeon; Park, Hee-Jin; Kwon, Heon-Ju; Kim, Mi Sung; Choi, Seon Hyeong; Choi, Yoon Jung; Kim, Eugene

2015-11-01

Quantitative magnetic resonance imaging (MRI) of cartilage has recently been applied to patients with osteoarthritis (OA). T2 mapping is a sensitive method of detecting changes in the chemical composition and structure of cartilage. To establish baseline T2 values of glenohumeral joint cartilage at 3.0 T and compare T2 values among subjects with and without OA. The study involved 30 patients (18 women, 12 men; median age, 67 years; age range, 51-78 years) with primary (n = 7) and secondary OA (n = 23) in the glenohumeral joint and 34 subjects without OA (19 women, 15 men; median age, 49 years; age range, 23-63 years). All subjects were evaluated by radiography and 3.0 T MRI including a multi-echo T2-weighted spin echo pulse sequence. The T2 value of the cartilage was measured by manually drawing the region of interest on the T2 map. Per-zone comparison of T2 values was performed using Mann-Whitney U test. Median T2 values differed significantly between subjects without OA (36.00 ms [interquartile range, 33.89-37.31 ms]) and those with primary (37.52 ms [36.84-39.11], P = 0.028), but not secondary (36.87 ms [34.70-41.10], P = 0.160) OA. Glenohumeral cartilage T2 values were higher in different zones between patients with primary and secondary OA than in subjects without OA. These T2 values can be used for comparison to assess cartilage degeneration in patients with shoulder OA. Significant differences in T2 were observed among subjects without OA and those with primary and secondary OA. © The Foundation Acta Radiologica 2014.

Is the MARS questionnaire a reliable measure of medication adherence in childhood asthma?

PubMed

Garcia-Marcos, Patricia W; Brand, Paul L P; Kaptein, Adrian A; Klok, Ted

2016-12-01

To assess the reliability of the Medication Adherence Report Scale (MARS-5) for assessing adherence in clinical practice and research. Prospective cohort study following electronically measured inhaled corticosteroids (ICS) adherence for 1 year in 2-13-year-old children with persistent asthma. The relationship between electronically measured adherence and MARS-5 scores (ranging from 5 to 25) was assessed by Spearman's rank correlation coefficient. A ROC (receiver operating characteristic) curve was performed testing MARS-5 against electronically measured adherence. Sensitivity, specificity, positive and negative likelihood ratios of the closest MARS-5 cut-off values to the top left-hand corner of the ROC curve were calculated. High MARS scores were obtained (median 24, interquartile range 22-24). Despite a statistically significant correlation between MARS-5 and electronically assessed adherence (Spearman's rho = 0.47; p < 0.0001), there was considerable variation of adherence rates at every MARS-5 score. The area under the ROC curve was 0.7188. A MARS-5 score ≥23 had the best predictive ability for electronically assessed adherence, but positive and negative likelihood ratios were too small to be useful (1.65 and 0.27, respectively). Self-report using MARS-5 is too inaccurate to be a useful measure of adherence in children with asthma, both in clinical practice and in research.

Brain lesions in septic shock: a magnetic resonance imaging study.

PubMed

Sharshar, Tarek; Carlier, Robert; Bernard, Francis; Guidoux, Céline; Brouland, Jean-Philippe; Nardi, Olivier; de la Grandmaison, Geoffroy Lorin; Aboab, Jérôme; Gray, Françoise; Menon, David; Annane, Djillali

2007-05-01

Understanding of sepsis-induced brain dysfunction remains poor, and relies mainly on data from animals or post-mortem studies in patients. The current study provided findings from magnetic resonance imaging of the brain in septic shock. Nine patients with septic shock and brain dysfunction [7 women, median age 63 years (interquartile range 61-79 years), SAPS II: 48 (44-56), SOFA: 8 (6-10)] underwent brain magnetic resonance imaging including gradient echo T1-weighted, fluid-attenuated inversion recovery (FLAIR), T2-weighted and diffusion isotropic images, and mapping of apparent diffusion coefficient. Brain imaging was normal in two patients, showed multiple ischaemic strokes in two patients, and in the remaining patients showed white matter lesions at the level of the centrum semiovale, predominating around Virchow-Robin spaces, ranging from small multiple areas to diffuse lesions, and characterised by hyperintensity on FLAIR images. The main lesions were also characterised by reduced signal on diffusion isotropic images and increased apparent diffusion coefficient. The lesions of the white matter worsened with increasing duration of shock and were correlated with Glasgow Outcome Score. This preliminary study showed that sepsis-induced brain lesions can be documented by magnetic resonance imaging. These lesions predominated in the white matter, suggesting increased blood-brain barrier permeability, and were associated with poor outcome.

Epidemiology of Kidney Discard from Expanded Criteria Donors Undergoing Donation after Circulatory Death.

PubMed

Singh, Sunita K; Kim, S Joseph

2016-02-05

The broader use of combined expanded criteria donor and donation after circulatory death (ECD/DCD) kidneys may help expand the deceased donor pool. The purpose of our study was to evaluate discard rates of kidneys from ECD/DCD donors and factors associated with discard. ECD/DCD donors and kidneys were evaluated from January 1, 2000 to March 31, 2011 using data from the Scientific Registry of Transplant Recipients. The kidney donor risk index was calculated for all ECD/DCD kidneys. Multivariable logistic regression models were used to determine risk factors for discarding both donor kidneys. The Kaplan-Meier product limit method and the log-rank statistic were used to assess the cumulative probability of graft failure for transplants from ECD/DCD donors where the mate kidney was discarded versus both kidneys were used. There were 896 ECD/DCD donors comprising 1792 kidneys. Both kidneys were discarded in 44.5% of donors, whereas 51.0% of all available kidneys were discarded. The kidney donor risk index scores were higher among donors of discarded versus transplanted kidneys (median, 1.82; interquartile range, 1.60, 2.07 versus median, 1.67; interquartile range, 1.49, 1.87, respectively; P<0.001); however, the distributions showed considerable overlap. The adjusted odds ratios for discard were higher among donors who were older, diabetic, AB blood type, and hepatitis C positive. The cumulative probabilities of total graft failure at 1, 3, and 5 years were 17.3%, 36.5%, and 55.4% versus 13.8%, 24.7%, and 40.5% among kidneys from donors where only one versus both kidneys were transplanted, respectively (log rank P=0.04). Our study shows a significantly higher discard rate for ECD/DCD kidneys versus prior reports. Some discarded ECD/DCD kidneys may be acceptable for transplantation. Additional studies are needed to evaluate the factors that influence decision making around the use of ECD/DCD kidneys. Copyright © 2016 by the American Society of Nephrology.

An acute cough-specific quality-of-life questionnaire for children: Development and validation.

PubMed

Anderson-James, Sophie; Newcombe, Peter A; Marchant, Julie M; O'Grady, Kerry-Ann F; Acworth, Jason P; Stone, D Grant; Turner, Catherine T; Chang, Anne B

2015-05-01

Patient-relevant outcome measures are essential for high-quality clinical research, and quality-of-life (QoL) tools are the current standard. Currently, there is no validated children's acute cough-specific QoL questionnaire. The objective of this study was to develop and validate the Parent-proxy Children's Acute Cough-specific QoL Questionnaire (PAC-QoL). Using focus groups, a 48-item PAC-QoL questionnaire was developed and later reduced to 16 items by using the clinical impact method. Parents of children with a current acute cough (<2 weeks) at enrollment completed 2 validated cough score measures, the preliminary 48-item PAC-QoL, and 3 other questionnaires (the State Trait Anxiety Inventory [STAI], the Short-Form 8-item 24-hour recall Health Survey [SF-8], and the Depression, Anxiety, and Stress 21-item Scale [DASS21]). All measures were repeated on days 3 and 14. The median age of the 155 children enrolled was 2.3 years (interquartile range, 1.3-4.6). Median cough duration at enrollment was 3 days (interquartile range, 2-5). The reduced 16-item scale had high internal consistency (Cronbach α = 0.95). Evidence for repeatability and criterion validity was shown by significant correlations between the domains and total PAC-QoL scores and the SF-8 (r = -0.36 and -0.51), STAI (r = -0.27 and -0.39), and DASS21 (r = -0.32 and -0.41) scales on days 0 and 3, respectively. The final PAC-QoL questionnaire was sensitive to change over time, with changes significantly relating to changes in cough score measures (P < .001). The 16-item PAC-QoL is a reliable and valid outcome measure that assesses QoL related to childhood acute cough at a given time point and reflects changes in acute cough-specific QoL over time. Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin.

PubMed

Haeusler, Karl Georg; Wollboldt, Christian; Bentheim, Laura Zu; Herm, Juliane; Jäger, Sebastian; Kunze, Claudia; Eberle, Holger-Carsten; Deluigi, Claudia Christina; Bruder, Oliver; Malsch, Carolin; Heuschmann, Peter U; Endres, Matthias; Audebert, Heinrich J; Morguet, Andreas J; Jensen, Christoph; Fiebach, Jochen B

2017-05-01

Etiology of acute ischemic stroke remains undetermined (cryptogenic) in about 25% of patients after state-of-the-art diagnostic work-up. One-hundred and three patients with magnetic resonance imaging (MRI)-proven acute ischemic stroke of undetermined origin were prospectively enrolled and underwent 3-T cardiac MRI and magnetic resonance angiography of the aortic arch in addition to state-of-the-art diagnostic work-up, including transesophageal echocardiography (TEE). We analyzed the feasibility, diagnostic accuracy, and added value of cardiovascular MRI (cvMRI) compared with TEE for detecting sources of stroke. Overall, 102 (99.0%) ischemic stroke patients (median 63 years [interquartile range, 53-72], 24% female, median NIHSS (National Institutes of Health Stroke Scale) score on admission 2 [interquartile range, 1-4]) underwent cvMRI and TEE in hospital; 89 (86.4%) patients completed the cvMRI examination. In 93 cryptogenic stroke patients, a high-risk embolic source was found in 9 (8.7%) patients by cvMRI and in 11 (11.8%) patients by echocardiography, respectively. cvMRI and echocardiography findings were consistent in 80 (86.0%) patients, resulting in a degree of agreement of κ=0.24. In 82 patients with cryptogenic stroke according to routine work-up, including TEE, cvMRI identified stroke etiology in additional 5 (6.1%) patients. Late gadolinium enhancement consistent with previous myocardial infarction was found in 13 (14.6%) out of 89 stroke patients completing cvMRI. Only 2 of these 13 patients had known coronary artery disease. Our study demonstrated that cvMRI was feasible in the vast majority of included patients with acute ischemic stroke. The diagnostic information of cvMRI seems to be complementary to TEE but is not replacing echocardiography after acute ischemic stroke. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01917955. © 2017 American Heart Association, Inc.

Fate of Manuscripts Rejected From the Red Journal

DOE Office of Scientific and Technical Information (OSTI.GOV)

Holliday, Emma B., E-mail: emmaholliday@gmail.com; Yang, George; Jagsi, Reshma

Purpose: To evaluate characteristics associated with higher rates of acceptance for original manuscripts submitted for publication to the International Journal of Radiation Oncology • Biology • Physics (IJROBP) and describe the fate of rejected manuscripts. Methods and Materials: Manuscripts submitted to the IJROBP from May 1, 2010, to August 31, 2010, and May 1, 2012, to August 31, 2012, were evaluated for author demographics and acceptance status. A PubMed search was performed for each IJROBP-rejected manuscript to ascertain whether the manuscript was ultimately published elsewhere. The Impact Factor of the accepting journal and the number of citations of the publishedmore » manuscript were also collected. Results: Of the 500 included manuscripts, 172 (34.4%) were accepted and 328 (65.6%) were rejected. There was no significant difference in acceptance rates according to gender or degree of the submitting author, but there were significant differences seen based on the submitting author's country, rank, and h-index. On multivariate analysis, earlier year submitted (P<.0001) and higher author h-index (P=.006) remained significantly associated with acceptance into the IJROBP. Two hundred thirty-five IJROBP-rejected manuscripts (71.7%) were ultimately published in a PubMed-listed journal as of July 2014. There were no significant differences in any submitting author characteristics. Journals accepting IJROBP-rejected manuscripts had a lower median [interquartile range] 2013 impact factor compared with the IJROBP (2.45 [1.53-3.71] vs 4.176). The IJROBP-rejected manuscripts ultimately published elsewhere had a lower median [interquartile range] number of citations (1 [0-4] vs 6 [2-11]; P<.001), which persisted on multivariate analysis. Conclusions: The acceptance rate for manuscripts submitted to the IJROBP is approximately one-third, and approximately 70% of rejected manuscripts are ultimately published in other PubMed-listed journals, but these ultimate-destination journals usually have a lower impact factor, leading to fewer citations and overall visibility.« less

Patient attitudes about financial incentives for diabetes self-management: A survey.

PubMed

Blondon, Katherine S

2015-06-10

To study the acceptability of incentives for behavior changes in individuals with diabetes, comparing financial incentives to self-rewards and non-financial incentives. A national online survey of United States adults with diabetes was conducted in March 2013 (n = 153). This survey was designed for this study, with iterative testing and modifications in a pilot population. We measured the demographics of individuals, their interest in incentives, as well as the perceived challenge of diabetes self-management tasks, and expectations of incentives to improve diabetes self-management (financial, non-financial and self-rewards). Using an ordered logistic regression model, we assessed the association between a 32-point score of the perceived challenge of the self-management tasks and the three types of rewards. Ninety-six percent of individuals were interested in financial incentives, 60% in non-financial incentives and 72% in self-rewards. Patients were less likely to use financial incentives when they perceived the behavior to be more challenging (odds ratio of using financial incentives of 0.82 (95%CI: 0.72-0.93) for each point of the behavior score). While the effectiveness of incentives may vary according to the perceived level of challenge of each behavior, participants did not expect to need large amounts to motivate them to modify their behavior. The expected average amounts needed to motivate a 5 lb weight loss in our population and to maintain this weight change for a year was $258 (interquartile range of $10-100) and $713 (interquartile range of $25-250) for a 15 lb weight loss. The difference in mean amount estimates for 5 lb and 15 lb weight loss was significant (P < 0.001). Individuals with diabetes are willing to consider financial incentives to improve diabetes self-management. Future studies are needed to explore incentive programs and their effectiveness for diabetes.

Patient attitudes about financial incentives for diabetes self-management: A survey

PubMed Central

Blondon, Katherine S

2015-01-01

AIM: To study the acceptability of incentives for behavior changes in individuals with diabetes, comparing financial incentives to self-rewards and non-financial incentives. METHODS: A national online survey of United States adults with diabetes was conducted in March 2013 (n = 153). This survey was designed for this study, with iterative testing and modifications in a pilot population. We measured the demographics of individuals, their interest in incentives, as well as the perceived challenge of diabetes self-management tasks, and expectations of incentives to improve diabetes self-management (financial, non-financial and self-rewards). Using an ordered logistic regression model, we assessed the association between a 32-point score of the perceived challenge of the self-management tasks and the three types of rewards. RESULTS: Ninety-six percent of individuals were interested in financial incentives, 60% in non-financial incentives and 72% in self-rewards. Patients were less likely to use financial incentives when they perceived the behavior to be more challenging (odds ratio of using financial incentives of 0.82 (95%CI: 0.72-0.93) for each point of the behavior score). While the effectiveness of incentives may vary according to the perceived level of challenge of each behavior, participants did not expect to need large amounts to motivate them to modify their behavior. The expected average amounts needed to motivate a 5 lb weight loss in our population and to maintain this weight change for a year was $258 (interquartile range of $10-100) and $713 (interquartile range of $25-250) for a 15 lb weight loss. The difference in mean amount estimates for 5 lb and 15 lb weight loss was significant (P < 0.001). CONCLUSION: Individuals with diabetes are willing to consider financial incentives to improve diabetes self-management. Future studies are needed to explore incentive programs and their effectiveness for diabetes. PMID:26069724

Hip Synovial Fluid Cell Counts in Children From a Lyme Disease Endemic Area.

PubMed

Dart, Arianna H; Michelson, Kenneth A; Aronson, Paul L; Garro, Aris C; Lee, Thomas J; Glerum, Kimberly M; Nigrovic, Peter A; Kocher, Mininder S; Bachur, Richard G; Nigrovic, Lise E

2018-05-01

Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated. We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type. Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303-209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789-73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis. In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis. Copyright © 2018 by the American Academy of Pediatrics.

Disease Severity and Exercise Testing Reduce Subcutaneous Implantable Cardioverter-Defibrillator Left Sternal ECG Screening Success in Hypertrophic Cardiomyopathy.

PubMed

Srinivasan, Neil T; Patel, Kiran H; Qamar, Kashif; Taylor, Amy; Bacà, Marco; Providência, Rui; Tome-Esteban, Maria; Elliott, Perry M; Lambiase, Pier D

2017-04-01

The features of the hypertrophic cardiomyopathy (HCM) ECG make it a challenge for subcutaneous implantable cardioverter-defibrillator (S-ICD) screening. We aimed to investigate the causes of screening failure at rest and on exercise to inform optimal S-ICD ECG vector development. One hundred and thirty-one HCM patients (age, 50±16 years; 92 males and 39 females) with ≥1 HCM risk factor for sudden death underwent S-ICD ECG screening at rest and on exercise. Fifty patients (38%) were ineligible for S-ICD because of screening failure in every lead vector: 33 (66%) failed in the supine position, 12 (24%) failed in the standing position, and 5 (10%) failed on exercise. In patients who could exercise and passed screening at rest, 31 (44%) had 1 vector safety, 16 (23%) had 2 vector safety, and 24 (33%) had 3 vector safety. Increased R:T wave ratio in the S-ICD screening ECG (odds ratio, 4.0; confidence interval, 3.0-5.3; P <0.001) was associated with screening failure, while R/T ratio <3 in aVF (odds ratio, 0.3; confidence interval, 0.12-0.69; P =0.006) and increasing age (odds ratio, 0.97; confidence interval, 0.95-0.99; P =0.03) was associated with reduced screening failure. European Society of Cardiology risk score was higher in those failing screening (risk score 5.5% [interquartile range, 3.2-8.7] in failed versus 4.5% [interquartile range, 2.9-7.4] in passed; P =0.04). HCM patients have a significant incidence of screening failure, which is determined primarily by the increased R:T ratio on the screening ECG and lead aVF. High-risk patients have an increased screening failure rate. Optimization of sensing algorithms is required to ensure that the highest risk HCM patients can benefit from S-ICD implantation. © 2017 American Heart Association, Inc.

Risk of Asthmatic Episodes in Children Exposed to Sulfur Dioxide Stack Emissions from a Refinery Point Source in Montreal, Canada

PubMed Central

Smargiassi, Audrey; Kosatsky, Tom; Hicks, John; Plante, Céline; Armstrong, Ben; Villeneuve, Paul J.; Goudreau, Sophie

2009-01-01

Background Little is known about the respiratory effects of short-term exposures to petroleum refinery emissions in young children. This study is an extension of an ecologic study that found an increased rate of hospitalizations for respiratory conditions among children living near petroleum refineries in Montreal (Canada). Methods We used a time-stratified case–crossover design to assess the risk of asthma episodes in relation to short-term variations in sulfur dioxide levels among children 2–4 years of age living within 0.5–7.5 km of the refinery stacks. Health data used to measure asthma episodes included emergency department (ED) visits and hospital admissions from 1996 to 2004. We estimated daily levels of SO2 at the residence of children using a) two fixed-site SO2 monitors located near the refineries and b) the AERMOD (American Meteorological Society/Environmental Protection Agency Regulatory Model) atmospheric dispersion model. We used conditional logistic regression to estimate odds ratios associated with an increase in the interquartile range of daily SO2 mean and peak exposures (31.2 ppb for AERMOD peaks). We adjusted for temperature, relative humidity, and regional/urban background air pollutant levels. Results The risks of asthma ED visits and hospitalizations were more pronounced for same-day (lag 0) SO2 peak levels than for mean levels on the same day, or for other lags: the adjusted odds ratios estimated for same-day SO2 peak levels from AERMOD were 1.10 [95% confidence interval (CI), 1.00–1.22] and 1.42 (95% CI, 1.10–1.82), over the interquartile range, for ED visits and hospital admissions, respectively. Conclusions Short-term episodes of increased SO2 exposures from refinery stack emissions were associated with a higher number of asthma episodes in nearby children. PMID:19440507

TNFα dynamics during the oral glucose tolerance test vary according to the level of insulin resistance in pregnant women.

PubMed

Guillemette, Laetitia; Lacroix, Marilyn; Battista, Marie-Claude; Doyon, Myriam; Moreau, Julie; Ménard, Julie; Ardilouze, Jean-Luc; Perron, Patrice; Hivert, Marie-France

2014-05-01

TNFα is suspected to play a role in inflammation and insulin resistance leading to higher risk of metabolic impairment. Controversies exist concerning the role of TNFα in gestational insulin resistance. We investigated the interrelations between TNFα and insulin resistance in a large population-based cohort of pregnant women. Women (n = 756) were followed prospectively at 5-16 weeks and 24-28 weeks of pregnancy. Anthropometric measures and blood samples were collected at both visits. A 75-g oral glucose tolerance test (OGTT) was conducted at the second trimester to assess insulin sensitivity status (homeostasis model of assessment of insulin resistance and Matsuda index). TNFα was measured at the first trimester (nonfasting) and at each time point of the OGTT. Participants were 28.4 ± 4.4 years old and had a mean body mass index of 25.5 ± 5.5 kg/m(2) at first trimester. Median TNFα levels were 1.56 (interquartile range, 1.18-2.06) pg/mL at first trimester and 1.61 (interquartile range, 1.12-2.13) pg/mL at second trimester (1 h after glucose load). At second trimester, higher TNFα levels were associated with higher insulin resistance index levels (r = 0.37 and -0.30 for homeostasis model of assessment of insulin resistance and Matsuda index, respectively; P < .0001), even after adjustment for age, body mass index, triglycerides, and adiponectin. Women with higher insulin resistance showed a continuing decrease in TNFα levels during the OGTT, whereas women who were more insulin sensitive showed an increase in TNFα at hour 1 and a decrease at hour 2 of the test. Higher insulin resistance is associated with higher levels of circulating TNFα at first and second trimesters of pregnancy. TNFα level dynamics during an OGTT at second trimester vary according to insulin-resistance state.

Cardiac magnetic resonance findings predict increased resource utilization in elective coronary artery bypass grafting.

PubMed

Berry, Colin; Zimmerli, Lukas U; Steedman, Tracey; Foster, John E; Dargie, Henry J; Berg, Geoffrey A; Dominiczak, Anna F; Delles, Christian

2008-03-01

Morbidity following CABG (coronary artery bypass grafting) is difficult to predict and leads to increased healthcare costs. We hypothesized that pre-operative CMR (cardiac magnetic resonance) findings would predict resource utilization in elective CABG. Over a 12-month period, patients requiring elective CABG were invited to undergo CMR 1 day prior to CABG. Gadolinium-enhanced CMR was performed using a trueFISP inversion recovery sequence on a 1.5 tesla scanner (Sonata; Siemens). Clinical data were collected prospectively. Admission costs were quantified based on standardized actual cost/day. Admission cost greater than the median was defined as 'increased'. Of 458 elective CABG cases, 45 (10%) underwent pre-operative CMR. Pre-operative characteristics [mean (S.D.) age, 64 (9) years, mortality (1%) and median (interquartile range) admission duration, 7 (6-8) days] were similar in patients who did or did not undergo CMR. In the patients undergoing CMR, eight (18%) and 11 (24%) patients had reduced LV (left ventricular) systolic function by CMR [LVEF (LV ejection fraction) <55%] and echocardiography respectively. LE (late enhancement) with gadolinium was detected in 17 (38%) patients. The average cost/day was $2723. The median (interquartile range) admission cost was $19059 ($10891-157917). CMR LVEF {OR (odds ratio), 0.93 [95% CI (confidence interval), 0.87-0.99]; P=0.03} and SV (stroke volume) index [OR 1.07 (95% CI, 1.00-1.14); P=0.02] predicted increased admission cost. CMR LVEF (P=0.08) and EuroScore tended to predict actual admission cost (P=0.09), but SV by CMR (P=0.16) and LV function by echocardiography (P=0.95) did not. In conclusion, in this exploratory investigation, pre-operative CMR findings predicted admission duration and increased admission cost in elective CABG surgery. The cost-effectiveness of CMR in risk stratification in elective CABG surgery merits prospective assessment.

Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure.

PubMed

Hicks, Caitlin W; Poruk, Katherine E; Baltodano, Pablo A; Soares, Kevin C; Azoury, Said C; Cooney, Carisa M; Cornell, Peter; Eckhauser, Frederic E

2016-08-01

Sandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and surgical site infections (SSIs). Previously, we found that a modified negative pressure wound therapy (hybrid vacuum-assisted closure [HVAC]) system reduced SSOs and SSIs after ventral hernia repair. We aimed to describe our outcomes after SVHR paired with HVAC closure. We conducted a 4-y retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be reapproximated primarily using anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence. A total of 60 patients (59.3 ± 11.4 y, 58.3% male, 75% American Society of Anesthesiologists class ≥3) with complex ventral hernias being underwent sandwich repair with HVAC closure. Major postoperative morbidity (Dindo-Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n = 13, 21.7%) and SSI (n = 4, 6.7%) was low compared with historical reports. Median follow-up time for all patients was 12 mo (interquartile range 5.8-26.5 mo). Hernia recurrence occurred in eight patients (13.3%) after a median time of 20.6 months (interquartile range 16.4- 25.4 months). Use of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at 1 year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique and deserves consideration in future prospective studies assessing optimization of ventral hernia repair approaches. Copyright © 2016 Elsevier Inc. All rights reserved.

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program.

PubMed

Sandhu, Amneet; Stanislawski, Maggie A; Grunwald, Gary K; Guinn, Kathryn; Valle, Javier; Matlock, Daniel; Ho, P Michael; Maddox, Thomas M; Bradley, Steven M

2017-09-12

Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Tuberculosis in Anti-Tumour Necrosis Factor-treated Inflammatory Bowel Disease Patients After the Implementation of Preventive Measures: Compliance With Recommendations and Safety of Retreatment.

PubMed

Carpio, D; Jauregui-Amezaga, A; de Francisco, R; de Castro, L; Barreiro-de Acosta, M; Mendoza, J L; Mañosa, M; Ollero, V; Castro, B; González-Conde, B; Hervías, D; Sierra Ausin, M; Sancho Del Val, L; Botella-Mateu, B; Martínez-Cadilla, J; Calvo, M; Chaparro, M; Ginard, D; Guerra, I; Maroto, N; Calvet, X; Fernández-Salgado, E; Gordillo, J; Rojas Feria, M

2016-10-01

Despite having adopted preventive measures, tuberculosis (TB) may still occur in patients with inflammatory bowel disease (IBD) treated with anti-tumour necrosis factor (anti-TNF). Data on the causes and characteristics of TB cases in this scenario are lacking. Our aim was to describe the characteristics of TB in anti-TNF-treated IBD patients after the publication of the Spanish TB prevention guidelines in IBD patients and to evaluate the safety of restarting anti-TNF after a TB diagnosis. In this multicentre, retrospective, descriptive study, TB cases from Spanish hospitals were collected. Continuous variables were reported as mean and standard deviation or median and interquartile range. Categorical variables were described as absolute and relative frequencies and their confidence intervals when necessary. We collected 50 TB cases in anti-TNF-treated IBD patients, 60% male, median age 37.3 years (interquartile range [IQR] 30.4-47). Median latency between anti-TNF initiation and first TB symptoms was 155.5 days (IQR 88-301); 34% of TB cases were disseminated and 26% extrapulmonary. In 30 patients (60%), TB cases developed despite compliance with recommended preventive measures; *not performing 2-step TST (tuberculin skin test) was the main failure in compliance with recommendations. In 17 patients (34%) anti-TNF was restarted after a median of 13 months (IQR 7.1-17.3) and there were no cases of TB reactivation. Tuberculosis could still occur in anti-TNF-treated IBD patients despite compliance with recommended preventive measures. A significant number of cases developed when these recommendations were not followed. Restarting anti-TNF treatment in these patients seems to be safe. Copyright © 2016 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Factors Associated With Time to Site Activation, Randomization, and Enrollment Performance in a Stroke Prevention Trial.

PubMed

Demaerschalk, Bart M; Brown, Robert D; Roubin, Gary S; Howard, Virginia J; Cesko, Eldina; Barrett, Kevin M; Longbottom, Mary E; Voeks, Jenifer H; Chaturvedi, Seemant; Brott, Thomas G; Lal, Brajesh K; Meschia, James F; Howard, George

2017-09-01

Multicenter clinical trials attempt to select sites that can move rapidly to randomization and enroll sufficient numbers of patients. However, there are few assessments of the success of site selection. In the CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trials), we assess factors associated with the time between site selection and authorization to randomize, the time between authorization to randomize and the first randomization, and the average number of randomizations per site per month. Potential factors included characteristics of the site, specialty of the principal investigator, and site type. For 147 sites, the median time between site selection to authorization to randomize was 9.9 months (interquartile range, 7.7, 12.4), and factors associated with early site activation were not identified. The median time between authorization to randomize and a randomization was 4.6 months (interquartile range, 2.6, 10.5). Sites with authorization to randomize in only the carotid endarterectomy study were slower to randomize, and other factors examined were not significantly associated with time-to-randomization. The recruitment rate was 0.26 (95% confidence interval, 0.23-0.28) patients per site per month. By univariate analysis, factors associated with faster recruitment were authorization to randomize in both trials, principal investigator specialties of interventional radiology and cardiology, pre-trial reported performance >50 carotid angioplasty and stenting procedures per year, status in the top half of recruitment in the CREST trial, and classification as a private health facility. Participation in StrokeNet was associated with slower recruitment as compared with the non-StrokeNet sites. Overall, selection of sites with high enrollment rates will likely require customization to align the sites selected to the factor under study in the trial. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02089217. © 2017 American Heart Association, Inc.

Lower serum potassium associated with increased mortality in dialysis patients: A nationwide prospective observational cohort study in Korea

PubMed Central

Lee, Sunhwa; Kang, Eunjeong; Yoo, Kyung Don; Choi, Yunhee; Kim, Dong Ki; Joo, Kwon Wook; Yang, Seung Hee; Kim, Yong-Lim; Kang, Shin-Wook; Yang, Chul Woo; Kim, Nam Ho; Kim, Yon Su; Lee, Hajeong

2017-01-01

Background Abnormal serum potassium concentration has been suggested as a risk factor for mortality in patients undergoing dialysis patients. We investigated the impact of serum potassium levels on survival according to dialysis modality. Methods A nationwide, prospective, observational cohort study for end stage renal disease patients has been ongoing in Korea since August 2008. Our analysis included patients whose records contained data regarding serum potassium levels. The relationship between serum potassium and mortality was analyzed using competing risk regression. Results A total of 3,230 patients undergoing hemodialysis (HD, 64.3%) or peritoneal dialysis (PD, 35.7%) were included. The serum potassium level was significantly lower (P < 0.001) in PD (median, 4.5 mmol/L; interquartile range, 4.0–4.9 mmol/L) than in HD patients (median, 4.9 mmol/L; interquartile range, 4.5–5.4 mmol/L). During 4.4 ± 1.7 years of follow-up, 751 patients (23.3%) died, mainly from cardiovascular events (n = 179) and infection (n = 120). In overall, lower serum potassium level less than 4.5 mmol/L was an independent risk factor for mortality after adjusting for age, comorbidities, and nutritional status (sub-distribution hazard ratio, 1.30; 95% confidence interval 1.10–1.53; P = 0.002). HD patients showed a U-shaped survival pattern, suggesting that both lower and higher potassium levels were deleterious, although insignificant. However, in PD patients, only lower serum potassium level (<4.5 mmol/L) was an independent predictor of mortality (sub-distribution hazard ratio, 1.35; 95% confidence interval 1.00–1.80; P = 0.048). Conclusion Lower serum potassium levels (<4.5 mmol/L) occur more commonly in PD than in HD patients. It represents an independent predictor of survival in overall dialysis, especially in PD patients. Therefore, management of dialysis patients should focus especially on reducing the risk of hypokalemia, not only that of hyperkalemia. PMID:28264031

HIV Infection Is Not Associated With Aortic Stiffness. Traditional Cardiovascular Risk Factors Are the Main Determinants-Cross-sectional Results of INI-ELSA-BRASIL.

PubMed

Moreira, Rodrigo C; Mill, José G; Grinsztejn, Beatriz; Veloso, Valdilea; Fonseca, Maria de Jesus; Griep, Rosane H; Bensenor, Isabela; Cardoso, Sandra W; Lotufo, Paulo; Chor, Dora; Pacheco, Antonio G

2018-05-01

Aortic stiffness measured by carotid-femoral pulse wave velocity (cf-PWV) is a marker of subclinical atherosclerosis. We propose to assess whether HIV infection is associated with arterial stiffness and their determinants in HIV-infected subjects. We compared data from an HIV cohort (644 patients, HIV+) in Rio de Janeiro with 2 groups: 105 HIV-negative (HIV-) individuals and 14,873 participants of the ELSA-Brasil study. We used multivariable linear regression to investigate factors associated with cf-PWV and whether HIV was independently associated with aortic stiffness and propensity score weighting to control for imbalances between groups. From 15,860 participants, cf-PWV was obtained in 15,622 (98.5%). Median age was 51 (interquartile range 45-58), 44.41 (35.73, 54.72), and 43.60 (36.01, 50.79) years (P < 0.001), and median cf-PWV (m/s; interquartile range) was 9.0 (8.10, 10.20), 8.70 (7.90, 10.20), and 8.48 (7.66, 9.40) for ELSA-Brasil, HIV- and HIV+, respectively (P < 0.001). In the final weighted multivariable models, HIV group was not associated with cf-PWV when compared either with ELSA-Brasil [β = -0.05; 95% confidence interval (CI) = -0.23; P = 0.12; P = 0.52] or with the HIV- groups (β = 0.10; 95% CI = -0.10; 0, 31; P = 0.32). Traditional risk factors were associated with higher cf-PWV levels in the HIV+ group, particularly waist-to-hip ratio (β = 0.20; 95% CI = 0.10; 0.30; P < 0.001, result per one SD change). HIV infection was not associated with higher aortic stiffness according to our study. In HIV-infected subjects, the stiffness of large arteries is mainly associated with traditional risk factors and not to the HIV infection per se.

Quality of reporting of surveys in critical care journals: a methodologic review.

PubMed

Duffett, Mark; Burns, Karen E; Adhikari, Neill K; Arnold, Donald M; Lauzier, François; Kho, Michelle E; Meade, Maureen O; Hayani, Omar; Koo, Karen; Choong, Karen; Lamontagne, François; Zhou, Qi; Cook, Deborah J

2012-02-01

Adequate reporting is needed to judge methodologic quality and assess the risk of bias of surveys. The objective of this study is to describe the methodology and quality of reporting of surveys published in five critical care journals. All issues (1996-2009) of the American Journal of Respiratory and Critical Care Medicine, Critical Care, Critical Care Medicine, Intensive Care Medicine, and Pediatric Critical Care Medicine. Two reviewers hand-searched all issues in duplicate. We included publications of self-administered questionnaires of health professionals and excluded surveys that were part of a multi-method study or measured the effect of an intervention. Data were abstracted in duplicate. We included 151 surveys. The frequency of survey publication increased at an average rate of 0.38 surveys per 1000 citations per year from 1996-2009 (p for trend = 0.001). The median number of respondents and reported response rates were 217 (interquartile range 90 to 402) and 63.3% (interquartile range 45.0% to 81.0%), respectively. Surveys originated predominantly from North America (United States [40.4%] and Canada [18.5%]). Surveys most frequently examined stated practice (78.8%), attitudes or opinions (60.3%), and less frequently knowledge (9.9%). The frequency of reporting on the survey design and methods were: 1) instrument development: domains (59.1%), item generation (33.1%), item reduction (12.6%); 2) instrument testing: pretesting or pilot testing (36.2%) and assessments of clarity (25.2%) or clinical sensibility (15.7%); and 3) clinimetric properties: qualitative or quantitative description of at least one of face, content, construct validity, intra- or inter-rater reliability, or consistency (28.5%). The reporting of five key elements of survey design and conduct did not significantly change over time. Surveys, primarily conducted in North America and focused on self-reported practice, are increasingly published in highly cited critical care journals. More uniform and comprehensive reporting will facilitate assessment of methodologic quality.

Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study.

PubMed

Grewal, Keerat; Austin, Peter C; Kapral, Moira K; Lu, Hong; Atzema, Clare L

2015-01-01

The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30- and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12-4.62) and 1.94 (95% confidence interval, 1.10-3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0-33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5-204.5) in unexposed patients. One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes. © 2014 American Heart Association, Inc.

Epidemiology of Kidney Discard from Expanded Criteria Donors Undergoing Donation after Circulatory Death

PubMed Central

Singh, Sunita K.

2016-01-01

Background and objectives The broader use of combined expanded criteria donor and donation after circulatory death (ECD/DCD) kidneys may help expand the deceased donor pool. The purpose of our study was to evaluate discard rates of kidneys from ECD/DCD donors and factors associated with discard. Design, setting, participants, & measurements ECD/DCD donors and kidneys were evaluated from January 1, 2000 to March 31, 2011 using data from the Scientific Registry of Transplant Recipients. The kidney donor risk index was calculated for all ECD/DCD kidneys. Multivariable logistic regression models were used to determine risk factors for discarding both donor kidneys. The Kaplan–Meier product limit method and the log-rank statistic were used to assess the cumulative probability of graft failure for transplants from ECD/DCD donors where the mate kidney was discarded versus both kidneys were used. Results There were 896 ECD/DCD donors comprising 1792 kidneys. Both kidneys were discarded in 44.5% of donors, whereas 51.0% of all available kidneys were discarded. The kidney donor risk index scores were higher among donors of discarded versus transplanted kidneys (median, 1.82; interquartile range, 1.60, 2.07 versus median, 1.67; interquartile range, 1.49, 1.87, respectively; P<0.001); however, the distributions showed considerable overlap. The adjusted odds ratios for discard were higher among donors who were older, diabetic, AB blood type, and hepatitis C positive. The cumulative probabilities of total graft failure at 1, 3, and 5 years were 17.3%, 36.5%, and 55.4% versus 13.8%, 24.7%, and 40.5% among kidneys from donors where only one versus both kidneys were transplanted, respectively (log rank P=0.04). Conclusions Our study shows a significantly higher discard rate for ECD/DCD kidneys versus prior reports. Some discarded ECD/DCD kidneys may be acceptable for transplantation. Additional studies are needed to evaluate the factors that influence decision making around the use of ECD/DCD kidneys. PMID:26668028

40 CFR Appendix B to Part 434 - Baseline Determination and Compliance Monitoring for Pre-existing Discharges at Remining Operations

Code of Federal Regulations, 2011 CFR

2011-07-01

... Wilcoxon-Mann-Whitney Test (a) When n and m are less than 21, use Table 1. In order to find the appropriate... trigger (Step 3). The interquartile range (R) is the difference between the quartiles M-1 and M1; these... baseline observations were obtained, calculate the median (M) of all baseline observations: Instructions...

40 CFR Appendix B to Part 434 - Baseline Determination and Compliance Monitoring for Pre-existing Discharges at Remining Operations

Code of Federal Regulations, 2010 CFR

2010-07-01

... Wilcoxon-Mann-Whitney Test (a) When n and m are less than 21, use Table 1. In order to find the appropriate... trigger (Step 3). The interquartile range (R) is the difference between the quartiles M-1 and M1; these... baseline observations were obtained, calculate the median (M) of all baseline observations: Instructions...

Antihyperglycemic Medication Use Among Medicare Beneficiaries With Heart Failure, Diabetes Mellitus, and Chronic Kidney Disease.

PubMed

Patel, Priyesh A; Liang, Li; Khazanie, Prateeti; Hammill, Bradley G; Fonarow, Gregg C; Yancy, Clyde W; Bhatt, Deepak L; Curtis, Lesley H; Hernandez, Adrian F

2016-07-01

Diabetes mellitus, heart failure (HF), and chronic kidney disease are common comorbidities, but overall use and safety of antihyperglycemic medications (AHMs) among patients with these comorbidities are poorly understood. Using Get With the Guidelines-Heart Failure and linked Medicare Part D data, we assessed AHM use within 90 days of hospital discharge among HF patients with diabetes mellitus discharged from Get With the Guidelines-Heart Failure hospitals between January 1, 2006, and October 1, 2011. We further summarized use by renal function and assessed renal contraindicated AHM use for patients with estimated glomerular filtration rate <30 mL/min/1.73m(2). Among 8791 patients meeting inclusion criteria, the median age was 77 (interquartile range 71-83), 62.3% were female, median body mass index was 29.7 (interquartile range 25.5-35.3), median hemoglobin A1c was 6.8 (interquartile range 6.2-7.8), and 34% had ejection fraction <40%. 74.9% of patients filled a prescription for an AHM, with insulin (39.5%), sulfonylureas (32.4%), and metformin (17%) being the most commonly used AHMs. Insulin use was higher and sulfonylurea/metformin use was lower among patients with lower renal function classes. Among 1512 patients with estimated glomerular filtration rate <30 mL/min/1.73m(2), 35.4% filled prescriptions for renal contraindicated AHMs per prescribing information, though there was a trend toward lower renal contraindicated AHM use over time (Cochran-Mantel-Haenszel row-mean score test P=0.048). Although use of other AHMs was low overall, thiazolidinediones were used in 6.6% of HF patients, and dipeptidyl peptidase-4 inhibitors were used in 5.1%, with trends for decreasing thiazolidinedione use and increased dipeptidyl peptidase-4 inhibitor use over time (P<0.001). Treatment of diabetes mellitus in patients with HF and chronic kidney disease is complex, and these patients are commonly treated with renal contraindicated AHMs, including over 6% receiving a thiazolidinedione, despite known concerns regarding HF. More research regarding safety and efficacy of various AHMs among HF patients is needed. © 2016 American Heart Association, Inc.

Antibiotic prophylaxis and risk of Clostridium difficile infection after coronary artery bypass graft surgery.

PubMed

Poeran, Jashvant; Mazumdar, Madhu; Rasul, Rehana; Meyer, Joanne; Sacks, Henry S; Koll, Brian S; Wallach, Frances R; Moskowitz, Alan; Gelijns, Annetine C

2016-02-01

Antibiotic use, particularly type and duration, is a crucial modifiable risk factor for Clostridium difficile. Cardiac surgery is of particular interest because prophylactic antibiotics are recommended for 48 hours or less (vs ≤24 hours for noncardiac surgery), with increasing vancomycin use. We aimed to study associations between antibiotic prophylaxis (duration/vancomycin use) and C difficile among patients undergoing coronary artery bypass grafting. We extracted data on coronary artery bypass grafting procedures from the national Premier Perspective claims database (2006-2013, n = 154,200, 233 hospitals). Multilevel multivariable logistic regressions measured associations between (1) duration (<2 days, "standard" vs ≥2 days, "extended") and (2) type of antibiotic used ("cephalosporin," "cephalosporin + vancomycin," "vancomycin") and C difficile as outcome. Overall C difficile prevalence was 0.21% (n = 329). Most patients (59.7%) received a cephalosporin only; in 33.1% vancomycin was added, whereas 7.2% received vancomycin only. Extended prophylaxis was used in 20.9%. In adjusted analyses, extended prophylaxis (vs standard) was associated with significantly increased C difficile risk (odds ratio, 1.43; confidence interval, 1.07-1.92), whereas no significant associations existed for vancomycin use as adjuvant or primary prophylactic compared with the use of cephalosporins (odds ratio, 1.21; confidence interval, 0.92-1.60, and odds ratio, 1.39; confidence interval, 0.94-2.05, respectively). Substantial inter-hospital variation exists in the percentage of extended antibiotic prophylaxis (interquartile range, 2.5-35.7), use of adjuvant vancomycin (interquartile range, 4.2-61.1), and vancomycin alone (interquartile range, 2.3-10.4). Although extended use of antibiotic prophylaxis was associated with increased C difficile risk after coronary artery bypass grafting, vancomycin use was not. The observed hospital variation in antibiotic prophylaxis practices suggests great potential for efforts aimed at standardizing practices that subsequently could reduce C difficile risk. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aberrant GSTP1 promoter methylation predicts short-term prognosis in acute-on-chronic hepatitis B liver failure.

PubMed

Gao, S; Sun, F-K; Fan, Y-C; Shi, C-H; Zhang, Z-H; Wang, L-Y; Wang, K

2015-08-01

Glutathione-S-transferase P1 (GSTP1) methylation has been demonstrated to be associated with oxidative stress induced liver damage in acute-on-chronic hepatitis B liver failure (ACHBLF). To evaluate the methylation level of GSTP1 promoter in acute-on-chronic hepatitis B liver failure and determine its predictive value for prognosis. One hundred and five patients with acute-on-chronic hepatitis B liver failure, 86 with chronic hepatitis B (CHB) and 30 healthy controls (HC) were retrospectively enrolled. GSTP1 methylation level in peripheral mononuclear cells (PBMC) was detected by MethyLight. Clinical and laboratory parameters were obtained. GSTP1 methylation levels were significantly higher in patients with acute-on-chronic hepatitis B liver failure (median 16.84%, interquartile range 1.83-59.05%) than those with CHB (median 1.25%, interquartile range 0.48-2.47%; P < 0.01) and HC (median 0.80%, interquartile range 0.67-1.27%; P < 0.01). In acute-on-chronic hepatitis B liver failure group, nonsurvivors showed significantly higher GSTP1 methylation levels (P < 0.05) than survivors. GSTP1 methylation level was significantly correlated with total bilirubin (r = 0.29, P < 0.01), prothrombin time activity (r = -0.24, P = 0.01) and model for end-stage liver disease (MELD) score (r = 0.26, P = 0.01). When used to predict 1- or 2-month mortality of acute-on-chronic hepatitis B liver failure, GSTP1 methylation showed significantly better predictive value than MELD score [area under the receiver operating characteristic curve (AUC) 0.89 vs. 0.72, P < 0.01; AUC 0.83 vs. 0.70, P < 0.05 respectively]. Meanwhile, patients with GSTP1 methylation levels above the cut-off points showed significantly poorer survival than those below (P < 0.05). Aberrant GSTP1 promoter methylation exists in acute-on-chronic hepatitis B liver failure and shows high predictive value for short-term mortality. It might serve as a potential prognostic marker for acute-on-chronic hepatitis B liver failure. © 2015 John Wiley & Sons Ltd.

Effect of adding postoperative noninvasive ventilation to usual care to prevent pulmonary complications in patients undergoing coronary artery bypass grafting: a randomized controlled trial.

PubMed

Al Jaaly, Emad; Fiorentino, Francesca; Reeves, Barnaby C; Ind, Philip W; Angelini, Gianni D; Kemp, Scott; Shiner, Robert J

2013-10-01

We compared the efficacy of noninvasive ventilation with bilevel positive airway pressure added to usual care versus usual care alone in patients undergoing coronary artery bypass grafting. We performed a 2-group, parallel, randomized controlled trial. The primary outcome was time until fit for discharge. Secondary outcomes were partial pressure of carbon dioxide, forced expiratory volume in 1 second, atelectasis, adverse events, duration of intensive care stay, and actual postoperative stay. A total of 129 patients were randomly allocated to bilevel positive airway pressure (66) or usual care (63). Three patients allocated to bilevel positive airway pressure withdrew. The median duration of bilevel positive airway pressure was 16 hours (interquartile range, 11-19). The median duration of hospital stay until fit for discharge was 5 days for the bilevel positive airway pressure group (interquartile range, 4-6) and 6 days for the usual care group (interquartile range, 5-7; hazard ratio, 1.68; 95% confidence interval, 1.08-2.31; P = .019). There was no significant difference in duration of intensive care, actual postoperative stay, and mean percentage of predicted forced expiratory volume in 1 second on day 3. Mean partial pressure of carbon dioxide was significantly reduced 1 hour after bilevel positive airway pressure application, but there was no overall difference between the groups up to 24 hours. Basal atelectasis occurred in 15 patients (24%) in the usual care group and 2 patients (3%) in the bilevel positive airway pressure group. Overall, 30% of patients in the bilevel positive airway pressure group experienced an adverse event compared with 59% in the usual care group. Among patients undergoing elective coronary artery bypass grafting, the use of bilevel positive airway pressure at extubation reduced the recovery time. Supported by trained staff, more than 75% of all patients allocated to bilevel positive airway pressure tolerated it for more than 10 hours. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Retrospective Application of New Pediatric Ventilator-Associated Pneumonia Criteria Identifies a High-Risk Population.

PubMed

Gionfriddo, Ashley; Nonoyama, Mika L; Laussen, Peter C; Cox, Peter N; Clarke, Megan; Floh, Alejandro A

2018-06-01

To promote standardization, the Centers for Disease Control and Prevention introduced a new ventilator-associated pneumonia classification, which was modified for pediatrics (pediatric ventilator-associated pneumonia according to proposed criteria [PVAP]). We evaluated the frequency of PVAP in a cohort of children diagnosed with ventilator-associated pneumonia according to traditional criteria and compared their strength of association with clinically relevant outcomes. Retrospective cohort study. Tertiary care pediatric hospital. Critically ill children (0-18 yr) diagnosed with ventilator-associated pneumonia between January 2006 and December 2015 were identified from an infection control database. Patients were excluded if on high frequency ventilation, extracorporeal membrane oxygenation, or reintubated 24 hours following extubation. None. Patients were assessed for PVAP diagnosis. Primary outcome was the proportion of subjects diagnosed with PVAP. Secondary outcomes included association with intervals of care. Two hundred seventy-seven children who had been diagnosed with ventilator-associated pneumonia were eligible for review; 46 were excluded for being ventilated under 48 hours (n = 16), on high frequency ventilation (n = 12), on extracorporeal membrane oxygenation (n = 8), ineligible bacteria isolated from culture (n = 8), and other causes (n = 4). ICU admission diagnoses included congenital heart disease (47%), neurological (16%), trauma (7%), respiratory (7%), posttransplant (4%), neuromuscular (3%), and cardiomyopathy (3%). Only 16% of subjects (n = 45) met the new PVAP definition, with 18% (n = 49) having any ventilator-associated condition. Failure to fulfill new definitions was based on inadequate increase in mean airway pressure in 90% or FIO2 in 92%. PVAP was associated with prolonged ventilation (median [interquartile range], 29 d [13-51 d] vs 16 d [8-34.5 d]; p = 0.002), ICU (median [interquartile range], 40 d [20-100 d] vs 25 d [14-61 d]; p = 0.004) and hospital length of stay (median [interquartile range], 81 d [40-182 d] vs 54 d [31-108 d]; p = 0.04), and death (33% vs 16%; p = 0.008). Few children with ventilator-associated pneumonia diagnosis met the proposed PVAP criteria. PVAP was associated with increased morbidity and mortality. This work suggests that additional study is required before new definitions for ventilator-associated pneumonia are introduced for children.

Patient Advocacy Organizations, Industry Funding, and Conflicts of Interest.

PubMed

Rose, Susannah L; Highland, Janelle; Karafa, Matthew T; Joffe, Steven

2017-03-01

Patient advocacy organizations (PAOs) are influential health care stakeholders that provide direct counseling and education for patients, engage in policy advocacy, and shape research agendas. Many PAOs report having financial relationships with for-profit industry, yet little is known about the nature of these relationships. To describe the nature of industry funding and partnerships between PAOs and for-profit companies in the United States. A survey was conducted from September 1, 2013, to June 30, 2014, of a nationally representative random sample of 439 PAO leaders, representing 5.6% of 7865 PAOs identified in the United States. Survey questions addressed the nature of their activities, their financial relationships with industry, and the perceived effectiveness of their conflict of interest policies. Amount and sources of revenue as well as organizational experiences with and policies regarding financial conflict of interest. Of the 439 surveys mailed to PAO leaders, 289 (65.8%) were returned with at least 80% of the questions answered. The PAOs varied widely in terms of size, funding, activities, and disease focus. The median total revenue among responding organizations was $299 140 (interquartile range, $70 000-$1 200 000). A total of 165 of 245 PAOs (67.3%) reported receiving industry funding, with 19 of 160 PAOs (11.9%) receiving more than half of their funding from industry. Among the subset of PAOs that received industry funding, the median amount was $50 000 (interquartile range, $15 000-$200 000); the median proportion of industry support derived from the pharmaceutical, device, and/or biotechnology sectors was 45% (interquartile range, 0%-100%). A total of 220 of 269 respondents (81.8%) indicated that conflicts of interest are very or moderately relevant to PAOs, and 94 of 171 (55.0%) believed that their organizations' conflict of interest policies were very good. A total of 22 of 285 PAO leaders (7.7%) perceived pressure to conform their positions to the interests of corporate donors. Patient advocacy organizations engage in wide-ranging health activities. Although most PAOs receive modest funding from industry, a minority receive substantial industry support, raising added concerns about independence. Many respondents report a need to improve their conflict of interest policies to help maintain public trust.

Pesticides and nitrate in groundwater underlying citrus croplands, Lake Wales Ridge, central Florida, 1999-2005.

USGS Publications Warehouse

Choquette, Anne F.

2014-01-01

This report summarizes pesticide and nitrate (as nitrogen) results from quarterly sampling of 31 surficial-aquifer wells in the Lake Wales Ridge Monitoring Network during April 1999 through January 2005. The wells, located adjacent to citrus orchards and used for monitoring only, were generally screened (sampled) within 5 to 40 feet of the water table. Of the 44 citrus pesticides and pesticide degradates analyzed, 17 were detected in groundwater samples. Parent pesticides and degradates detected in quarterly groundwater samples, ordered by frequency of detection, included norflurazon, demethyl norflurazon, simazine, diuron, bromacil, aldicarb sulfone, aldicarb sulfoxide, deisopropylatrazine (DIA), imidacloprid, metalaxyl, thiazopyr monoacid, oxamyl, and aldicarb. Reconnaissance sampling of five Network wells yielded detection of four additional pesticide degradates (hydroxysimazine, didealkylatrazine, deisopropylhydroxyatrazine, and hydroxyatrazine). The highest median concentration values per well, based on samples collected during the 1999–2005 period (n=14 to 24 samples per well), included 3.05 µg/L (micrograms per liter) (simazine), 3.90 µg/L (diuron), 6.30 µg/L (aldicarb sulfone), 6.85 µg/L (aldicarb sulfoxide), 22.0 µg/L (demethyl norflurazon), 25.0 µg/ (norflurazon), 89 µg/ (bromacil), and 25.5 mg/L (milligrams per liter) (nitrate). Nitrate concentrations exceeded the 10 mg/L (as nitrogen) drinking water standard in one or more groundwater samples from 28 of the wells, and the median nitrate concentration among these wells was 14 mg/L. Sampled groundwater pesticide concentrations exceeded Florida’s health-guidance benchmarks for aldicarb sulfoxide and aldicarb sulfone (4 wells), the sum of aldicarb and its degradates (6 wells), simazine (2 wells), the sum of simazine and DIA (3 wells), diuron (2 wells), bromacil (1 well), and the sum of norflurazon and demethyl norflurazon (1 well). The magnitude of fluctuations in groundwater pesticide concentrations varied between wells and between pesticide compounds. Of the 10 pesticide compounds detected at sufficient frequency to assess temporal variability in quarterly sampling records, median values of the relative interquartile range (ratio of the interquartile range to the median) among wells typically ranged from about 100 to 150 percent. The relative interquartile range of pesticide concentrations at individual wells could be much higher, sometimes exceeding 200 to 500 percent. No distinct spatial patterns were apparent among median pesticide concentrations in sampled wells; nitrate concentrations tended to be greater in samples from wells in the northern part of the study area.

Length of stay of stroke rehabilitation inpatients: prediction through the functional independence measure.

PubMed

Franchignoni, F; Tesio, L; Martino, M T; Benevolo, E; Castagna, M

1998-01-01

A model for prediction of length of stay (LOS, in days) of stroke rehabilitation inpatients was developed, based on patients' age (years) and function at admission (scored on the Functional Independence Measure, FIMSM). One hundred and twenty-nine cases, consecutively admitted to three free-standing rehabilitation centres in Italy, were analyzed. A multiple linear regression using forward stepwise selection procedure was adopted. Median admission and discharge scores were: 57 and 75 for the total FIM score, 29 and 48 for the 13-item motor FIM subscore, 29 and 30 for the 5-item cognitive FIM subscore (potential range: 18-126, 13-91, 5-35, respectively). Median LOS was 44 days (interquartile range 30-62). The logLOS predictive model included three FIM items ("toilet transfer", TTr; "social interaction"; "expression") and patient's age (R2 = 0.48). TTr alone explained 31.3% of the variance of logLOS. These results are consistent with previous American studies, showing that FIM scores at admission are strong predictors of patients' LOS, with the transfer items having the greatest predictive power.

Virilized external genitalia in young girls: clinical characteristics and management challenges in a low-resource setting.

PubMed

Ekenze, S O; Adiri, C O; Igwilo, I O; Onumaegbu, O O

2014-02-01

Virilization of the external genitalia in young girls (VEG) manifests mostly as ambiguity of the genitalia and elicits concerns and uncertainties especially in settings with poor awareness. This study evaluates the profile and challenges of VEG in southeast Nigeria. We analyzed 23 children with VEG managed in 2 referral centers in southeast Nigeria from June 2005 to January 2013. They presented at median age of 13.3 months (interquartile range [IQR] 3 months-3 years). The cases included 3 (13%) of Prader type 1, 6 (26%) of type 2, 11 (48%) of type 3, and 3 (13%) of type 4. Five of the Prader type 3 and all 3 cases of Prader type 4 were reared as male prior to presentation. Following evaluation, all the cases were assigned female gender at a mean age of 2.7 years (range 2 months-10.5 years). Appropriate feminizing genitoplasty was undertaken in all the cases and after a follow-up period of 3 months to 5 years (mean 2 years), 2 patients developed vaginal stenosis, and 3 cases had surgical wound infection. Poor awareness, delayed presentation, inadequate facilities, and lack of trained manpower were the challenges in the management of the cases. VEG in our setting is associated with delayed management. Focused health education and public awareness programs, and improved healthcare funding may improve outcome and minimize the need for gender reassignment. Copyright © 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Management of Primary Tectal Plate Low-Grade Glioma in Pediatric Patients: Results of the Multicenter Treatment Study SIOP-LGG 2004.

PubMed

Kaufmann, Ariane; Gerber, Nicolas U; Kandels, Daniela; Azizi, Amedeo A; Schmidt, Rene; Warmuth-Metz, Monika; Pietsch, Torsten; Kortmann, Rolf-Dieter; Gnekow, Astrid K; Grotzer, Michael A

2018-06-11

 Tectal plate low-grade gliomas (LGGs) most often present with increased intracranial pressure and sometimes as incidental findings from brain imaging. Prognostic factors predicting outcome are largely unknown.  From 2004 until 2012, 71 patients with tectal plate LGG from Germany and Switzerland were followed within the SIOP-LGG 2004 study. Median age at diagnosis was 9.7 (range: 0.1-17.5) years, and median follow-up time of surviving patients was 6.3 (interquartile range: 4.9-8.3) years.  A total of 41 out of 71 patients received no tumor treatment (12 with and 29 without biopsy). The 10-year event-free survival (EFS) rate (± standard error ) for patients with an initial tumor volume of ≤3 cm 3 was 56% (±7%), as opposed to 12% (±8%) for those with tumors >3 cm 3 ( p  < 0.001). The 10-year EFS for patients without contrast enhancement on initial magnetic resonance imaging (MRI) was 52% (±9%), and for those with enhancement, it was 23% (±9%) ( p  = 0.003). The 10-year overall survival rate was 96% (±3%) (death due to disease, 1; ventriculoperitoneal shunt infection, 1). Sixty-three (89%) patients had at least one cerebrospinal fluid diversion procedure.  More than half of patients were managed without tumor treatment. Favorable prognostic factors for EFS were small initial tumor volume (≤3cm 3 ) and the absence of initial contrast enhancement on MRI. Overall survival was excellent. Georg Thieme Verlag KG Stuttgart · New York.

Human T-lymphotropic virus type 1 infection is frequent in rural communities of the southern Andes of Peru.

PubMed

Ita, Fanny; Mayer, Erick F; Verdonck, Kristien; Gonzalez, Elsa; Clark, Daniel; Gotuzzo, Eduardo

2014-02-01

To evaluate the presence of human T-lymphotropic virus type 1 (HTLV-1) infection in isolated rural communities in the southern Andes of Peru. We conducted a cross-sectional study in five communities located in three provinces in Ayacucho, Peru. The five communities are located at >3000 meters above sea level and are mainly rural, and more than 85% of the population speaks Quechua. Volunteers aged 12 years and older were included. Clinical and epidemiological data were collected, along with a blood sample for serological testing. We included 397 participants; their median age was 41 years (interquartile range 31-57 years) and 69% were women. According to our definitions, 98% were of Quechua origin. HTLV-1 was diagnosed in 11 people: 0/164 in Cangallo, 3/154 (2%) in Vilcashuaman, and 8/79 (10%) in Parinacochas. There were no cases of HTLV-2. All the HTLV-1-positive participants were born in Ayacucho and were of Quechua origin; they ranged in age from 29 to 87 years (median 56 years) and 10/11 were women. Ten were apparently healthy, and one woman was diagnosed with HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Three out of 11 had a family member with a lower limb impairment compatible with HAM/TSP. The fact that HTLV-1 infection was present in two out of three provinces suggests that HTLV-1 could be highly endemic in the southern Andes in the Quechua population. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.

Association Between Prophylactic Implantable Cardioverter-Defibrillators and Survival in Patients With Left Ventricular Ejection Fraction Between 30% and 35%

PubMed Central

Al-Khatib, Sana M.; Hellkamp, Anne S.; Fonarow, Gregg C.; Mark, Daniel B.; Curtis, Lesley H.; Hernandez, Adrian F.; Anstrom, Kevin J.; Peterson, Eric D.; Sanders, Gillian D.; Al-Khalidi, Hussein R.; Hammill, Bradley G.; Heidenreich, Paul A.; Hammill, Stephen C.

2014-01-01

IMPORTANCE Clinical trials of prophylactic implantable cardioverter-defibrillators (ICDs) have included a minority of patients with a left ventricular ejection fraction (LVEF) between 30% and 35%. Because a large number of ICDs in the United States are implanted in such patients, it is important to study survival associated with this therapy. OBJECTIVE To characterize patients with LVEF between 30% and 35% and compare the survival of those with and without ICDs. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of Medicare beneficiaries in the National Cardiovascular Data Registry ICD registry (January 1, 2006, through December 31, 2007) with an LVEF between 30% and 35% who received an ICD during a heart failure hospitalization and similar patients in the Get With The Guidelines–Heart Failure (GWTG-HF) database (January 1, 2005, through December 31, 2009) with no ICD. The analysis was repeated in patients with an LVEF less than 30%. There were 3120 patients with an LVEF between 30% and 35% (816 in matched cohorts) and 4578 with an LVEF less than 30% (2176 in matched cohorts). Propensity score matching and Cox models were applied. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality; data were obtained from Medicare claims through December 31, 2011. RESULTS There were no significant differences in the baseline characteristics of the matched groups (n = 408 for both groups). Among patients with an LVEF between 30% and 35%, there were 248 deaths in the ICD Registry group, within a median follow-up of 4.4 years (interquartile range, 2.7-4.9) and 249 deaths in the GWTG HF group, within a median follow-up of 2.9 years (interquartile range, 2.1-4.4). The risk of all-cause mortality in patients with an LVEF between 30% and 35% and an ICD was significantly lower than that in matched patients without an ICD (3-year mortality rates: 51.4% vs 55.0%; hazard ratio, 0.83 [95% CI, 0.69-0.99]; P = .04). Presence of an ICD also was associated with better survival in patients with an LVEF less than 30% (3-year mortality rates: 45.0% vs 57.6%; 634 and 660 total deaths; hazard ratio, 0.72 [95% CI, 0.65-0.81]; P < .001) (P = .20 for interaction). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries hospitalized for heart failure and with an LVEF between 30% and 35% and less than 30%, survival at 3 years was better in patients who received a prophylactic ICD than in comparable patients with no ICD. These findings support guideline recommendations to implant prophylactic ICDs in eligible patients with an LVEF of 35% or less. PMID:24893088

Quantification of the Arrhythmogenic Effects of Spontaneous Atrial Extrasystole Using High-Resolution Epicardial Mapping.

PubMed

Teuwen, Christophe P; Kik, Charles; van der Does, Lisette J M E; Lanters, Eva A H; Knops, Paul; Mouws, Elisabeth M J P; Bogers, Ad J J C; de Groot, Natasja M S

2018-01-01

Atrial extrasystoles (AES) can initiate atrial fibrillation. However, the impact of spontaneous AES on intra-atrial conduction is unknown. The aims of this study were to examine conduction disorders provoked by AES and to correlate these conduction differences with patient characteristics, mapping locations, and type of AES. High-resolution epicardial mapping (electrodes N=128 or N=192; interelectrode distance, 2 mm) of the entire atrial surface was performed in patients (N=164; 69.5% male; age 67.2±10.5 years) undergoing open-chest cardiac surgery. AES were classified as premature, aberrant, or prematurely aberrant. Conduction delay and conduction block were quantified during sinus rhythm and AES and subsequently compared. Median incidence of conduction delay and conduction block during sinus rhythm was 1.2% (interquartile, 0%-2.3%) and 0.4% (interquartile, 0%-2.1%). In comparison, the median incidence of conduction delay and conduction block during 339 AES was respectively 2.8% (interquartile, 1.3%-4.6%) and 2.2% (interquartile, 0.3%-5.1%) and differed between the types of AES (prematurely aberrant>aberrant>premature). The degree of prematurity was not associated with a higher incidence of conduction disorders ( P >0.05). In contrast, a higher degree of aberrancy was associated with a higher incidence of conduction disorders; AES emerging as epicardial breakthrough provoked most conduction disorders ( P ≥0.002). AES caused most conduction disorders in patients with diabetes mellitus and left atrial dilatation ( P <0.05). Intraoperative high-resolution epicardial mapping showed that conduction disorders are mainly provoked by prematurely aberrant AES, particularly in patients with left atrial dilation and diabetes mellitus or emerging as epicardial breakthrough. © 2017 American Heart Association, Inc.

A 3-year surveillance on causes of death or reasons for euthanasia of domesticated dogs in Taiwan.

PubMed

Huang, Wei-Hsiang; Liao, Albert Taiching; Chu, Pei-Yi; Zhai, Shao-Hua; Yen, I-Feng; Liu, Chen-Hsuan

2017-11-01

Over the last 2 decades, there has been growing interest in research on the mortality of domesticated pets. These studies relied on an effective data-collecting system. During 2012-2014, a real-time reporting system was designed for mortality data in owned dogs and cats. The present retrospective study aimed to report on the causes of death (CODs) or reasons for euthanasia (RFEs) in domesticated dogs in Taiwan, and to investigate CODs/RFEs segregated by demographic variables. Data from 2306 domesticated dogs were acquired during the 3-year period in the present study. The median age at death of the study population was 10.2 years (median interquartile range 7.0-14.0; range 0.0-25.0). Crossbred, female, and neutered dogs showed greater ages at death than other groups. The most common COD/RFE was neoplasia, followed by multiple organ involvement (MOI) and cardiovascular diseases. Segregated by cut-off ages, the most common COD/RFE was infection among dogs younger than 3 years or 1year, and neoplasia among dogs at or older than 3 years or 1year of age; the most common COD/RFE was neoplasia among dogs younger than median age, and MOI among dogs at or older than median age. Segregated by geographic variables, the ranking and frequency of CODs/RFEs displayed different patterns between the capital city/non-capital areas, and among areas stratified by human population densities. The study provides various insights into age at death and CODs/RFEs in owned-dog population in Taiwan, and provides new directions for future research. Copyright © 2017 Elsevier B.V. All rights reserved.

Trends in infective endocarditis hospitalisations at United States children's hospitals from 2003 to 2014: impact of the 2007 American Heart Association antibiotic prophylaxis guidelines.

PubMed

Bates, Katherine E; Hall, Matthew; Shah, Samir S; Hill, Kevin D; Pasquali, Sara K

2017-05-01

National organisations in several countries have recently released more restrictive guidelines for infective endocarditis prophylaxis, including the American Heart Association 2007 guidelines. Initial studies demonstrated no change in infective endocarditis rates over time; however, a recent United Kingdom study suggested an increase; current paediatric trends are unknown. Children (5 years of age. Interrupted time series analysis was used to evaluate rates over time indexed to total hospitalisations. A total of 841 cases were identified. The median age was 13 years (interquartile range 9-15 years). In the pre-guideline period, there was a slight increase in the rate of infective endocarditis by 0.13 cases/10,000 hospitalisations per semi-annual period. In the post-guideline period, the rate of infective endocarditis increased by 0.12 cases/10,000 hospitalisations per semi-annual period. There was no significant difference in the rate of change in the pre- versus post-guidelines period (p=0.895). Secondary analyses in children >5 years of age with CHD and in children hospitalised with any type of infective endocarditis at any age revealed similar results. We found no significant change in infective endocarditis hospitalisation rates associated with revised prophylaxis guidelines over 11 years across 29 United States children's hospitals.

Adverse drug reactions in children: a ten-year review of reporting to the Portuguese Pharmacovigilance System.

PubMed

Nogueira Guerra, Leonor; Herdeiro, Maria Teresa; Ribeiro-Vaz, Inês; Clérigo, Maria Inês Pinto; Rocha, Cristina; Araújo, Ana; Pêgo, Alexandra; Rebelo Gomes, Eva

2015-01-01

Adverse drug reactions (ADR) are a public health problem. They cause significant morbidity, mortality and health costs. Less is known about pediatric ADR. Our goal was to characterize a pediatric case series of ADR reported to the Portuguese Pharmacovigilance System (PPS) during the past 10 years. Retrospective analysis of ADR reports concerning patients till 17 years old received by the PPS between 2003 and 2012. We evaluated patients' demographic data and involved drugs, as well as characteristics and seriousness of reactions, stratified by age groups. We found 1742 reports (50% females) corresponding to 9.7% of the total received. The age of the patients varied from 0 to 17 years (median: 5 years, interquartile range: 10.6), with 566 cases (32%) occurring in patients younger than 2y. Among the 1195 serious cases, 31% (370) episodes led to hospitalization. In 32 cases (2%) there was a fatal outcome. Most of the ADR reported referred to general disorders and administration site conditions, followed by skin and subcutaneous tissue reactions. Vaccines were the most represented group (42%) followed by antibacterials for systemic use (17%). Pediatric ADR represents about 10% of the reports received by the PPS. Most ADR were considered serious. Major findings varied according to age groups.

Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA.

PubMed

Molena, Daniela; Stem, Miloslawa; Blackford, Amanda L; Lidor, Anne O

2017-01-01

Large numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment. Using Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001-2009), we identified regional esophageal cancer patients ≥65 years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model. There were 5072 patients (median age, 75 years; interquartile range (IQR), 71-81 years). Majority were treated with definitive chemoradiation (48.49 %). Factors associated with lack of treatment included West geographic region and ≥80 years old. Patients who received therapy had better OS (log-rank, p < 0.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95 % confidence interval (CI), 1.33-1.55; p < 0.001). Elderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.

Parental Understanding of Tuberous Sclerosis Complex.

PubMed

Samia, Pauline; Donald, Kirsten A; Schlegel, Birgit; Wilmshurst, Jo M

2015-09-01

Tuberous sclerosis complex is a genetic disorder with multisystem involvement that poses significant challenges to the affected child and family. Caregiver knowledge in the South African population has not previously been reported. A prospective study of the parents of 21 children with tuberous sclerosis complex was undertaken. Median parental age was 38 (interquartile range 34.5-45) years. Parents were randomly allocated to receive written information about the condition, or to receive verbal counseling already established in clinic. A significant difference (P = .001) was observed in the change in the mean knowledge scores for the parent group that received written information (34.2 at baseline, 51.7 at the second visit. This impact was higher in parents with an education level of at least grade 8 (P = .003). Parental understanding of tuberous sclerosis complex can be improved by provision of written information and should be routinely available in a readily understandable format. © The Author(s) 2014.

Risk factors in lateral epicondylitis (tennis elbow): a case-control study.

PubMed

Titchener, A G; Fakis, A; Tambe, A A; Smith, C; Hubbard, R B; Clark, D I

2013-02-01

Lateral epicondylitis is a common condition, but relatively little is known about its aetiology and associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and quantify the relative contributions of some constitutional and environmental risk factors for lateral epicondylitis in the community. Our dataset included 4998 patients with lateral epicondylitis who were individually matched with a single control by age, sex, and general practice. The median age at diagnosis was 49 (interquartile range 42-56) years . Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology (OR 4.95), De Quervain's disease (OR 2.48), carpal tunnel syndrome (OR 1.50), oral corticosteroid therapy (OR 1.68), and previous smoking history (OR 1.20). Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis.

Hospital implementation of resuscitation guidelines and review of CPR training programmes: a nationwide study.

PubMed

Schmidt, Anders S; Lauridsen, Kasper G; Adelborg, Kasper; Løfgren, Bo

2016-06-01

This study aimed to investigate cardiopulmonary resuscitation (CPR) guideline implementation and CPR training in hospitals. This nationwide study included mandatory resuscitation protocols from each Danish hospital. Protocols were systematically reviewed for adherence to the European Resuscitation Council (ERC) 2010 guidelines and CPR training in each hospital. Data were included from 45 of 47 hospitals. Adherence to the ERC basic life support (BLS) algorithm was 49%, whereas 63 and 58% of hospitals adhered to the recommended chest compression depth and rate. Adherence to the ERC advanced life support (ALS) algorithm was 81%. Hospital BLS course duration was [median (interquartile range)] 2.3 (1.5-2.5) h, whereas ALS course duration was 4.0 (2.5-8.0) h. Implementation of ERC 2010 guidelines on BLS is limited in Danish hospitals 2 years after guideline publication, whereas the majority of hospitals adhere to the ALS algorithm. CPR training differs among hospitals.

Carotid artery wall shear stress is independently correlated with renal function in the elderly.

PubMed

Guo, Yuqi; Wei, Fang; Wang, Juan; Zhao, Yingxin; Sun, Shangwen; Zhang, Hua; Liu, Zhendong

2018-01-12

Hemodynamic has increasingly been regarded as an important factor of renal function. However, the relationship between carotid artery wall shear stress (WSS) and renal function is not clarified. To investigate the relationship between carotid WSS and renal function, we recruited 761 older subjects aged 60 years and over from community-dwelling in the Shandong area, China. Carotid WSS, endothelial function, and estimated glomerular filtration rate (eGFR) were assessed in all subjects. Subjects were grouped by the interquartile of the carotid artery mean WSS. We found that the eGFRs derived from serum creatinine and/or cystatin C using three CKD-EPI equations were significantly higher and albumin/creatinine ratio was lower in the higher interquartile groups than in the lower interquartile groups ( P <0.05). The mean WSS was independently correlated with eGFRs even after adjustment for confounders. Similar findings were found between carotid artery peak WSS and eGFRs and albumin/creatinine ratio. In addition, we found that endothelial function was strongly related to carotid WSS and renal function after adjustment for confounders. In conclusion, there is an independent correlation of carotid WSS with renal function in the elderly. The local rheologic forces may play an important role in renal function changing. The correlation may be mediated by regulation of endothelial function.

Electromagnetic Navigation Bronchoscopy for Identifying Lung Nodules for Thoracoscopic Resection.

PubMed

Marino, Katy A; Sullivan, Jennifer L; Weksler, Benny

2016-08-01

Pulmonary nodules smaller than 1 cm can be difficult to identify during minimally invasive resection, necessitating conversion to thoracotomy. We hypothesized that localizing nodules with electromagnetic navigation bronchoscopy and marking them with methylene blue would allow minimally invasive resection and reduce conversion to thoracotomy. We retrospectively identified all patients who underwent electromagnetic navigation bronchoscopy followed by minimally invasive resection of a pulmonary nodule from 2011 to 2014. Lung nodules smaller than 10 mm and nodules smaller than 20 mm that were also located more than 10 mm from the pleural surface were localized and marked with methylene blue. Immediately after marking, all patients underwent resection. Seventy patients underwent electromagnetic navigation bronchoscopy marking followed by minimally invasive resection. The majority of patients (68/70, 97%) had one nodule localized; 2 patients (2/70, 3%) had two nodules localized. The median nodule size was 8 mm (range, 4-17 mm; interquartile range, 5 mm). The median distance from the pleural surface was 6 mm (range, 1-19 mm; interquartile range, 6 mm). There were no conversions to thoracotomy. Nodule marking was successful in 70 of 72 attempts (97.2%); two nodules were identified by palpation. The nodules were most commonly metastases from other sites (31/70, 44.3%). There were no adverse events related to electromagnetic navigation bronchoscopy-guided marking or wedge resection, and minimal adverse events after resections that were more extensive. Localizing and marking small pulmonary nodules using electromagnetic navigation bronchoscopy is safe and effective for nodule identification before minimally invasive resection. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The Kidney Donor Profile Index (KDPI) of Marginal Donors Allocated by Standardized Pre-Transplant Donor Biopsy Assessment: Distribution and Association with Graft Outcomes

PubMed Central

Gandolfini, I.; Buzio, C.; Zanelli, P.; Palmisano, A.; Cremaschi, E.; Vaglio, A.; Piotti, G.; Melfa, L.; La Manna, G.; Feliciangeli, G.; Cappuccilli, M.; Scolari, M.P.; Capelli, I.; Panicali, L.; Baraldi, O.; Stefoni, S.; Buscaroli, A.; Ridolfi, L.; D'Errico, A.; Cappelli, G.; Bonucchi, D.; Rubbiani, E.; Albertazzi, A.; Mehrotra, A.; Cravedi, P.; Maggiore, U.

2015-01-01

Pre-transplant donor biopsy (PTDB)-based marginal-donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the US. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score <4 [median KDPI:87; interquartile range(IQR):78-94] and 62 with a score =4 [median KDPI:87; IQR:76-93]; 102 dual transplants [median KDPI: 93; IQR:86-96]) and 248 single standard transplant controls [median KDPI:36; IQR:18-51]. PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year eGFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9, and -18.8ml/min, for dual transplants, single kidneys with PTDB score <4, and =4, respectively; P<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80 to 1.79; P=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded. PMID:25155294

Effects of fast food branding on young children's taste preferences.

PubMed

Robinson, Thomas N; Borzekowski, Dina L G; Matheson, Donna M; Kraemer, Helena C

2007-08-01

To examine the effects of cumulative, real-world marketing and brand exposures on young children by testing the influence of branding from a heavily marketed source on taste preferences. Experimental study. Children tasted 5 pairs of identical foods and beverages in packaging from McDonald's and matched but unbranded packaging and were asked to indicate if they tasted the same or if one tasted better. Preschools for low-income children. Sixty-three children (mean +/- SD age, 4.6 +/- 0.5 years; range, 3.5-5.4 years). Branding of fast foods. A summary total taste preference score (ranging from -1 for the unbranded samples to 0 for no preference and +1 for McDonald's branded samples) was used to test the null hypothesis that children would express no preference. The mean +/- SD total taste preference score across all food comparisons was 0.37 +/- 0.45 (median, 0.20; interquartile range, 0.00-0.80) and significantly greater than zero (P<.001), indicating that children preferred the tastes of foods and drinks if they thought they were from McDonald's. Moderator analysis found significantly greater effects of branding among children with more television sets in their homes and children who ate food from McDonald's more often. Branding of foods and beverages influences young children's taste perceptions. The findings are consistent with recommendations to regulate marketing to young children and also suggest that branding may be a useful strategy for improving young children's eating behaviors.

Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story.

PubMed

Stewart, Barclay T; Gyedu, Adam; Gaskill, Cameron; Boakye, Godfred; Quansah, Robert; Donkor, Peter; Volmink, Jimmy; Mock, Charles

2018-03-13

Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives. A standardized surgical capacity assessment was performed at 37 hospitals nationwide using WHO guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability) for each hospital. Data regarding the number of essential operations performed over 1 year, surgical specialties available, hospital beds, and functional operating rooms were also collected. The relationship between capacity and output was explored. The median surgical capacity score was 37 [interquartile range (IQR) 29-48; range 20-56]. The median number of essential operations per year was 1480 (IQR 736-1932) at first-level hospitals; 1545 operations (IQR 984-2452) at referral hospitals; and 11,757 operations (IQR 3769-21,256) at tertiary hospitals. Surgical capacity and output were not correlated (p > 0.05). Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including demand-side factors; supply-side factors and process elements; and health administration and management factors.

Time averaging and stratigraphic disorder of molluscan assemblages in the Holocene sediments in the NE Adriatic (Piran)

NASA Astrophysics Data System (ADS)

Tomasovych, Adam; Gallmetzer, Ivo; Haselmair, Alexandra; Kaufman, Darrell S.; Zuschin, Martin

2016-04-01

Stratigraphic changes in temporal resolution of fossil assemblages and the degree of their stratigraphic mixing in the Holocene deposits are of high importance in paleoecology, conservation paleobiology and paleoclimatology. However, few studies quantified downcore changes in time averaging and in stratigraphic disorder on the basis of dating of multiple shells occurring in individual stratigraphic layers. Here, we investigate downcore changes in frequency distribution of postmortem ages of the infaunal bivalve Gouldia minima in two, ~150 cm-thick piston cores (separated by more than 1 km) in the northern Adriatic Sea, close to the Slovenian city Piran at a depth of 24 m. We use radiocarbon-calibrated amino acid racemization to obtain postmortem ages of 564 shells, and quantify age-frequency distributions in 4-5 cm-thick stratigraphic intervals (with 20-30 specimens sampled per interval). Inter-quartile range for individual 4-5 cm-thick layers varies between 850 and 1,700 years, and range encompassing 95% of age data varies between 2,000 and 5,000 years in both cores. The uppermost sediments (20 cm) are age-homogenized and show that median age of shells is ~700-800 years. The interval between 20 and 90 cm shows a gradual increase in median age from ~2,000 to ~5,000 years, with maximum age ranging to ~8,000 years. However, the lowermost parts of both cores show a significant disorder, with median age of 3,100-3,300 years. This temporal disorder implies that many shells were displaced vertically by ~1 m. Absolute and proportional abundance of the bivalve Gouldia minima strongly increases towards the top of the both cores. We hypothesize that such increase in abundance, when coupled with depth-declining reworking, can explain stratigraphic disorder because numerically abundant young shells from the top of the core were more likely buried to larger sediment depths than less frequent shells at intermediate sediment depths.

Similar Occurrence of Febrile Episodes Reported in Non-Atopic Children at Three to Five Years of Age after Prebiotics Supplemented Infant Formula

PubMed Central

van Stuijvenberg, Margriet; Stam, José; Grüber, Christoph; Mosca, Fabio; Arslanoglu, Sertac; Chirico, Gaetano; Braegger, Christian P.; Riedler, Josef; Boehm, Günther; Sauer, Pieter J. J.

2015-01-01

This is a follow up study of a multicenter randomised placebo-controlled trial in seven centres in five West European countries. The RCT assessed the effect of infant formula supplemented with a mixture of prebiotics (with neutral short-chain and long-chain oligosaccharides and pectin-derived acidic oligosaccharides) during infancy in term-born children (n=1130). In the follow-up study 672 children (60% of the study population) participated: 232 (56%) from the prebiotics group (PG), 243 (58%) from the control group (CG), and 197 (66%) from the non-randomised breast-fed group (BG). The primary outcome was the occurrence of febrile episodes at three to five years of age prospectively documented by the parents: in the PG 1.17 (interquartile range 0.50-2.08) episodes per year versus 1.20 (0.52-2.57) in the CG; and 1.48 (0.65-2.60) in the BG. This specific prebiotics mixture given during infancy in healthy non-atopic subjects does not decrease febrile episodes and therefore seems not to prevent infection between their third and fifth birthday. PMID:26076141

[Intravenous thrombolysis for acute ischemic stroke. A four years’ experience in a Chilean public hospital].

PubMed

Soto V, Álvaro; Morales I, Gladys; Grandjean B, Marcela; Pollak W, Débora; Del Castillo C, Carolina; García F, Pía; Von Johnn A, Alexis; Riquelme G, Alfonso

2017-04-01

Intravenous thrombolysis (IVT) with alteplase (tissue plasminogen activator) is the standard pharmacological treatment in acute ischemic stroke (AIS), reducing disability in patients. To report the results a thrombolysis protocol during four years in a regional public hospital. Data from 106 consecutive patients aged 68 ± 13 years (57% men) who were treated with IVT, from May 2012 until April 2016, was analyzed. The median door-to-needle time was 80 minutes (interquartile range = 57-113). The median National Institute of Health Stroke Scale (NIHSS) scores on admission and at discharge were was 11.5 and 5 points respectively. At discharge, 27% of hospitalized patients had a favorable outcome (n = 99), defined as having 0 to 1 points in the modified Rankin scale. Symptomatic intracerebral hemorrhage and mortality rates were 5.7 and 13.1%, respectively. The thrombolysis rate rose from 0.7% in 2012 to 6% in 2016. The implementation of 24/7 neurology shifts in the Emergency Department allowed us to increase the amount and quality of IVT in our hospital, as measured by the rate of thrombolysis and by process indicators such as door-to-needle time.

Similar Occurrence of Febrile Episodes Reported in Non-Atopic Children at Three to Five Years of Age after Prebiotics Supplemented Infant Formula.

PubMed

van Stuijvenberg, Margriet; Stam, José; Grüber, Christoph; Mosca, Fabio; Arslanoglu, Sertac; Chirico, Gaetano; Braegger, Christian P; Riedler, Josef; Boehm, Günther; Sauer, Pieter J J

2015-01-01

This is a follow up study of a multicenter randomised placebo-controlled trial in seven centres in five West European countries. The RCT assessed the effect of infant formula supplemented with a mixture of prebiotics (with neutral short-chain and long-chain oligosaccharides and pectin-derived acidic oligosaccharides) during infancy in term-born children (n=1130). In the follow-up study 672 children (60% of the study population) participated: 232 (56%) from the prebiotics group (PG), 243 (58%) from the control group (CG), and 197 (66%) from the non-randomised breast-fed group (BG). The primary outcome was the occurrence of febrile episodes at three to five years of age prospectively documented by the parents: in the PG 1.17 (interquartile range 0.50-2.08) episodes per year versus 1.20 (0.52-2.57) in the CG; and 1.48 (0.65-2.60) in the BG. This specific prebiotics mixture given during infancy in healthy non-atopic subjects does not decrease febrile episodes and therefore seems not to prevent infection between their third and fifth birthday.

Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility.

PubMed

Poola, Ashwini Suresh; Rentea, Rebecca M; Weaver, Katrina L; St Peter, Shawn David

2017-05-01

While there is literature on techniques for pectus bar removal, there are limited reports on post-operative management. This can include obtaining a postoperative chest radiograph (CXR) despite the minimal risk of associated intra-thoracic complications. This is a review of our experience with bar removal and lack of routine post-operative CXR. A single institution retrospective chart review was performed from 2000 to 2015. Patients who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, procedure length, intra-operative and post-operative complications and post-operative CXR findings, specifically the rate of pneumothoraces. 450 patients were identified in this study. Median duration of bar placement prior to removal was 35 months (interquartile range 30 and 36 months). Sixtey-four patients obtained a post-operative CXR. Of these, only one (58%) film revealed a pneumothorax; this was not drained. A CXR was not obtained in 386 (86%) patients with no immediate or delayed complications from this practice. Median follow-up time for all patients was 11 months (interquartile range 7.5-17 months). The risk for a clinically relevant pneumothorax is minimal following bar removal. This suggests that not obtaining routine imaging following bar removal may be a safe practice.

Randomised controlled trial comparing oral and intravenous paracetamol (acetaminophen) plasma levels when given as preoperative analgesia.

PubMed

van der Westhuizen, J; Kuo, P Y; Reed, P W; Holder, K

2011-03-01

Gastric absorption of oral paracetamol (acetaminophen) may be unreliable perioperatively in the starved and stressed patient. We compared plasma concentrations of parenteral paracetamol given preoperatively and oral paracetamol when given as premedication. Patients scheduled for elective ear; nose and throat surgery or orthopaedic surgery were randomised to receive either oral or intravenous paracetamol as preoperative medication. The oral dose was given 30 minutes before induction of anaesthesia and the intravenous dose given pre-induction. All patients were given a standardised anaesthetic by the same specialist anaesthetist who took blood for paracetamol concentrations 30 minutes after the first dose and then at 30 minute intervals for 240 minutes. Therapeutic concentrations of paracetamol were reached in 96% of patients who had received the drug parenterally, and 67% of patients who had received it orally. Maximum median plasma concentrations were 19 mg.l(-1) (interquartile range 15 to 23 mg.l(-1)) and 13 mg.l(-1) (interquartile range 0 to 18 mg.l(-1)) for the intravenous and oral group respectively. The difference between intravenous and oral groups was less marked after 150 minutes but the intravenous preparation gave higher plasma concentrations throughout the study period. It can be concluded that paracetamol gives more reliable therapeutic plasma concentrations when given intravenously.

The impact of a dedicated research education month for anesthesiology residents.

PubMed

Freundlich, Robert E; Newman, Jessica W; Tremper, Kevin K; Mhyre, Jill M; Kheterpal, Sachin; Sanford, Theodore J; Tait, Alan R

2015-01-01

An educational intervention was implemented at the University of Michigan starting in 2008, in which anesthesiology interns complete a dedicated month-long didactic rotation in evidence-based medicine (EBM) and research methodology. We sought to assess its utility. Scores on a validated EBM test before and after the rotation were compared and assessed for significance of improvement. A survey was also given to gauge satisfaction with the quality of the rotation and self-reported improvement in understanding of EBM topics. Fourteen consecutive interns completed the research rotation during the study period. One hundred percent completed both the pre- and postrotation test. The mean pretest score was 7.78 ± 2.46 (median = 7.5, 0-15 scale, and interquartile range 7.0-10.0) and the mean posttest score was 10.00 ± 2.35 (median = 9.5, interquartile range 8.0-12.3), which represented a statistically significant increase (P = 0.011, Wilcoxon signed-rank test). All fourteen of the residents "agreed" or "strongly agreed" that they would recommend the course to future interns and that the course increased their ability to critically review the literature. Our findings demonstrate that this can be an effective means of improving understanding of EBM topics and anesthesiology research.

Alpha-synuclein is present in dental calculus but not altered in Parkinson's disease patients in comparison to controls.

PubMed

Schmid, Sabrina; Goldberg-Bockhorn, Eva; Schwarz, Silke; Rotter, Nicole; Kassubek, Jan; Del Tredici, Kelly; Pinkhardt, Elmar; Otto, Markus; Ludolph, Albert C; Oeckl, Patrick

2018-06-01

In autopsy cases staged for sporadic Parkinson's disease (PD), the neuropathology is characterized by a preclinical phase that targets the enteric nervous system of the gastrointestinal tract (GIT). Therefore, the ENS might be a source of potential (presymptomatic) PD biomarkers. In this clinically based study, we examined the alpha-synuclein (αSyn) concentration in an easily accessible protein storage medium of the GIT, dental calculus, in 21/50 patients with PD and 28/50 age- and gender-matched controls using ELISA. αSyn was detectable in dental calculus and the median concentration in the control patients was 8.6 pg/mg calculus (interquartile range 2.6-13.1 pg/mg). αSyn concentrations were significantly influenced by blood contamination and samples with a hemoglobin concentration of > 4000 ng/mL were excluded. There was no significant difference of αSyn concentrations in the dental calculus of PD patients (5.76 pg/mg, interquartile range 2.91-9.74 pg/mg) compared to those in controls (p = 0.40). The total αSyn concentration in dental calculus is not a suitable biomarker for sporadic PD. Disease-related variants such as oligomeric or phosphorylated αSyn in calculus might prove to be more specific.

Dietary antioxidant and anti-inflammatory intake modifies the effect of cadmium exposure on markers of systemic inflammation and oxidative stress

PubMed Central

Colacino, Justin A.; Arthur, Anna E.; Ferguson, Kelly K.; Rozek, Laura S.

2014-01-01

Chronic cadmium exposure may cause disease through induction of systemic oxidative stress and inflammation. Factors that mitigate cadmium toxicity and could serve as interventions in exposed populations have not been well characterized. We used data from the 2003–2010 National Health and Nutrition Examination Survey to quantify diet’s role in modifying associations between cadmium exposure and oxidative stress and inflammation. We created a composite antioxidant and anti-inflammatory diet score (ADS) by ranking participants by quintile of intake across a panel of 19 nutrients. We identified associations and effect modification between ADS, urinary cadmium, and markers of oxidative stress and inflammation by multiple linear regression. An interquartile range increase in urinary cadmium was associated with a 47.5%, 8.8%, and 3.7% increase in C-reactive protein (CRP), gamma glutamyl transferase (GGT), and alkaline phosphatase (ALP), respectively. An interquartile range increase in ADS was associated with an 7.4%, 3.3%, 5.2%, and 2.5% decrease in CRP, GGT, ALP, and total white blood cell count respectively, and a 3.0% increase in serum bilirubin. ADS significantly attenuated the association between cadmium exposure, CRP and ALP. Dietary interventions may provide a route to reduce the impact of cadmium toxicity on the population level. PMID:24607659

Effect of an Integrated Pest Management Intervention on Asthma Symptoms Among Mouse-Sensitized Children and Adolescents With Asthma: A Randomized Clinical Trial.

PubMed

Matsui, Elizabeth C; Perzanowski, Matthew; Peng, Roger D; Wise, Robert A; Balcer-Whaley, Susan; Newman, Michelle; Cunningham, Amparito; Divjan, Adnan; Bollinger, Mary E; Zhai, Shuyan; Chew, Ginger; Miller, Rachel L; Phipatanakul, Wanda

2017-03-14

Professionally delivered integrated pest management (IPM) interventions can reduce home mouse allergen concentrations, but whether they reduce asthma morbidity among mouse-sensitized and exposed children and adolescents is unknown. To determine the effect of an IPM intervention on asthma morbidity among mouse-sensitized and exposed children and adolescents with asthma. Randomized clinical trial conducted in Baltimore, Maryland, and Boston, Massachusetts. Participants were mouse-sensitized and exposed children and adolescents (aged 5-17 years) with asthma randomized to receive professionally delivered IPM plus pest management education or pest management education alone. Enrollment occurred between May 2010 and August 2014; the final follow-up visit occurred on September 25, 2015. Integrated pest management consisted of application of rodenticide, sealing of holes that could serve as entry points for mice, trap placement, targeted cleaning, allergen-proof mattress and pillow encasements, and portable air purifiers. Infestation was assessed every 3 months, and if infestation persisted or recurred, additional treatments were delivered. All participants received pest management education, which consisted of written material and demonstration of the materials needed to set traps and seal holes. The primary outcome was maximal symptom days defined as the highest number of days of symptoms in the previous 2 weeks among 3 types of symptoms (days of slowed activity due to asthma; number of nights of waking with asthma symptoms; and days of coughing, wheezing, or chest tightness) across 6, 9, and 12 months. Of 361 children and adolescents who were randomized (mean [SD] age, 9.8 [3.2] years; 38% female; 181 in IPM plus pest management education group and 180 in pest management education alone group), 334 were included in the primary analysis. For the primary outcome, there was no statistically significant between-group difference for maximal symptom days across 6, 9, and 12 months with a median of 2.0 (interquartile range, 0.7-4.7) maximal symptom days in the IPM plus pest management education group and 2.7 (interquartile range, 1.3-5.0) maximal symptom days in the pest management education alone group (P = .16) and a ratio of symptom frequencies of 0.86 (95% CI, 0.69-1.06). Among mouse-sensitized and exposed children and adolescents with asthma, an intensive year-long integrated pest management intervention plus pest management education vs pest management education alone resulted in no significant difference in maximal symptom days from 6 to 12 months. clinicaltrials.gov Identifier: NCT01251224.

A Spatio-Temporal Analysis of the Relationship Between Near-Surface Air Temperature and Satellite Land Surface Temperatures Using 17 Years of Data from the ATSR Series

NASA Astrophysics Data System (ADS)

Ghent, D.; Good, E.; Bulgin, C.; Remedios, J. J.

2017-12-01

Surface temperatures (ST) over land have traditionally been measured at weather stations. There are many parts of the globe with very few stations, e.g. across much of Africa, leading to gaps in ST datasets, affecting our understanding of how ST is changing, and the impacts of extreme events. Satellites can provide global ST data but these observations represent how hot the land ST (LST; including the uppermost parts of e.g. trees, buildings) is to touch, whereas stations measure the air temperature just above the surface (T2m). Satellite LST data may only be available in cloud-free conditions and data records are frequently <10-15 years in length. Consequently, satellite LST data have not yet featured widely in climate studies. In this study, the relationship between clear-sky satellite LST and all-sky T2m is characterised in space and time using >17 years of data. The analysis uses a new monthly LST climate data record (CDR) based on the Along-Track Scanning Radiometer (ATSR) series, which has been produced within the European Space Agency GlobTemperature project. The results demonstrate the dependency of the global LST-T2m differences on location, land cover, vegetation and elevation. LSTnight ( 10 pm local solar time) is found to be closely coupled with minimum T2m (Tmin) and the two temperatures generally consistent to within ±5 °C (global median LSTnight- Tmin= 1.8 °C, interquartile range = 3.8 °C). The LSTday ( 10 am local time)-maximum T2m (Tmax) variability is higher because LST is strongly influenced by insolation and surface regime (global median LSTday-Tmax= -0.1 °C, interquartile range = 8.1 °C). Correlations for both temperature pairs are typically >0.9 outside of the tropics. A crucial aspect of this study is a comparison between the monthly global anomaly time series of LST and CRUTEM4 T2m. The time series agree remarkably well, with a correlation of 0.9 and 90% of the CDR anomalies falling within the T2m 95% confidence limits (see figure). This analysis provides independent verification of the 1995-2012 T2m anomaly time series, suggesting that LST can provide a complementary perspective on global ST change. The results presented give justification for increasing use of satellite LST data in climate and weather science, both as an independent variable, and to augment T2m data acquired at weather stations.

Seizure burden is independently associated with short term outcome in critically ill children

PubMed Central

Payne, Eric T.; Zhao, Xiu Yan; Frndova, Helena; McBain, Kristin; Sharma, Rohit; Hutchison, James S.

2014-01-01

Seizures are common among critically ill children, but their relationship to outcome remains unclear. We sought to quantify the relationship between electrographic seizure burden and short-term neurological outcome, while controlling for diagnosis and illness severity. Furthermore, we sought to determine whether there is a seizure burden threshold above which there is an increased probability of neurological decline. We prospectively evaluated all infants and children admitted to our paediatric and cardiac intensive care units who underwent clinically ordered continuous video-electroencephalography monitoring over a 3-year period. Seizure burden was quantified by calculating the maximum percentage of any hour that was occupied by electrographic seizures. Outcome measures included neurological decline, defined as a worsening Paediatric Cerebral Performance Category score between hospital admission and discharge, and in-hospital mortality. Two hundred and fifty-nine subjects were evaluated (51% male) with a median age of 2.2 years (interquartile range: 0.3 days–9.7 years). The median duration of continuous video-electroencephalography monitoring was 37 h (interquartile range: 21–56 h). Seizures occurred in 93 subjects (36%, 95% confidence interval = 30–42%), with 23 (9%, 95% confidence interval = 5–12%) experiencing status epilepticus. Neurological decline was observed in 174 subjects (67%), who had a mean maximum seizure burden of 15.7% per hour, compared to 1.8% per hour for those without neurological decline (P < 0.0001). Above a maximum seizure burden threshold of 20% per hour (12 min), both the probability and magnitude of neurological decline rose sharply (P < 0.0001) across all diagnostic categories. On multivariable analysis adjusting for diagnosis and illness severity, the odds of neurological decline increased by 1.13 (95% confidence interval = 1.05–1.21, P = 0.0016) for every 1% increase in maximum hourly seizure burden. Seizure burden was not associated with mortality (odds ratio: 1.003, 95% confidence interval: 0.99–1.02, P = 0.613). We conclude that in this cohort of critically ill children, increasing seizure burden was independently associated with a greater probability and magnitude of neurological decline. Our observation that a seizure burden of more than 12 min in a given hour was strongly associated with neurological decline suggests that early antiepileptic drug management is warranted in this population, and identifies this seizure burden threshold as a potential therapeutic target. These findings support the hypothesis that electrographic seizures independently contribute to brain injury and worsen outcome. Our results motivate and inform the design of future studies to determine whether more aggressive seizure treatment can improve outcome. PMID:24595203

Systematic Review with Meta-analysis: Recurrence of Crohn's disease after Total Colectomy with Permanent Ileostomy

PubMed Central

Fumery, Mathurin; Dulai, Parambir S.; Meirick, Paul; Farrell, Ann M.; Ramamoorthy, Sonia; Sandborn, William J.; Singh, Siddharth

2016-01-01

Background Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC-PI) may be a treatment option for medically refractory colonic Crohn's disease (CD). Aim To perform a systematic review and meta-analysis to evaluate the rate, risk factors and outcomes of CD recurrence after TC-PI. Methods In a systematic review ending March 31, 2016, we identified 18 cohort studies (1438 adults) who underwent TC-PI for colonic CD (median follow-up, 7.4 years; interquartile range, 5.3-9.0). We estimated pooled rates (with 95% confidence interval [CI]) of clinical and surgical recurrence, and risk factors for disease recurrence. Results On meta-analysis, the risk of clinical recurrence after TC-PI was 28.0% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients), with a 5- and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60), respectively. The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients), with a 5- and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34), respectively. The risk of clinical and surgical recurrence in patients without ileal disease at baseline was 11.5% (95% CI, 7.7-16.8) and 10.4% (95% CI, 4.5-22.5), respectively. History of ileal disease was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6). Other inconsistent risk factors for disease recurrence were penetrating disease and young age at disease onset. Conclusions Small bowel clinical recurrence occurs in about 28% of patients after TC-PI for colonic CD. Disease recurrence risk is 3.2 times higher in patients with history of ileal disease, and continued medical therapy may be advisable in this population. In patients without ileal inflammation at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy. PMID:27928830

Randomized double-blind trial of darbepoetin alfa in patients with symptomatic heart failure and anemia.

PubMed

Ghali, Jalal K; Anand, Inder S; Abraham, William T; Fonarow, Gregg C; Greenberg, Barry; Krum, Henry; Massie, Barry M; Wasserman, Scott M; Trotman, Marie-Louise; Sun, Yan; Knusel, Beat; Armstrong, Paul

2008-01-29

Substantial evidence suggests that anemia is an independent risk factor for worse outcomes in patients with heart failure (HF). The Study of Anemia in Heart Failure Trial (STAMINA-HeFT) is the largest multicenter, randomized, double-blind, placebo-controlled trial to date evaluating the effect of treating anemia in HF. Patients (N=319) with symptomatic HF, left ventricular ejection fraction < or = 40%, and hemoglobin > or = 9.0 g/dL and < or = 12.5 g/dL were randomized (double-blind) to placebo (N=157) or darbepoetin alfa (N=162) subcutaneously every 2 weeks for 1 year (target hemoglobin, 14.0+/-1.0 g/dL). The primary end point was change from baseline to week 27 in treadmill exercise time. Secondary end points were change from baseline in New York Heart Association class and quality of life at week 27. An additional prespecified efficacy analysis included the time to death by any cause or first HF-related hospitalization by 1 year. At baseline, the median (interquartile range) hemoglobin was 11.4 (10.9, 12.0) g/dL. At week 27, darbepoetin alfa treatment increased median (interquartile range) hemoglobin by 1.8 (1.1, 2.5) g/dL (placebo, 0.3 [-0.2, 1.0] g/dL; P<0.001). Of the patients treated with darbepoetin alfa, 85% achieved 2 consecutive hemoglobin levels of 14.0+/-1.0 g/dL during the study and experienced a hemoglobin increase of > or = 1.0 g/dL from baseline. By intent-to-treat analysis, darbepoetin alfa treatment did not significantly improve exercise duration, New York Heart Association class, or quality of life score compared with placebo. A nonsignificant trend was observed toward a lower risk of all-cause mortality or first HF hospitalization in darbepoetin alfa-treated patients compared with placebo (hazard ratio, 0.68; 95% CI, 0.43, 1.08; P=0.10). Occurrences of adverse events were similar in both treatment groups. In this study of patients with symptomatic HF and anemia, treatment with darbepoetin alfa was not associated with significant clinical benefits. Darbepoetin alfa treatment was well tolerated and effectively raised hemoglobin. A trend of lower risk of morbidity and mortality was observed.

Increased anatomic severity in appendicitis is associated with outcomes in a South African population.

PubMed

Hernandez, Matthew C; Kong, Victor Y; Aho, Johnathon M; Bruce, John L; Polites, Stephanie F; Laing, Grant L; Zielinski, Martin D; Clarke, Damian L

2017-07-01

Severity of emergency general surgery (EGS) diseases has not been standardized until recently. The American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system for EGS diseases to facilitate communication and quality comparisons between providers and hospitals. Previous work has demonstrated validity of the system for appendicitis in the United States. To demonstrate generalizability, we aim to externally validate this grading system in South African patients with appendicitis. Patients with acute appendicitis during 2010 to 2016 were identified at multi-institutional sites within South Africa. Baseline demographics and procedure types were recorded, and AAST grades were assigned based on intraoperative findings. Outcomes included duration of stay, mortality, and Clavien-Dindo complications. Summary statistical univariate and nominal logistic regression analyses were performed to compare AAST grade and outcomes. A total of 1,415 patients with a median (interquartile range) age of 19 years (14-28 years) were included (55% men). One hundred percent underwent appendectomy: 63.5% completed via midline laparotomy, 36.5% via limited incision (31.8% via McBurney incision and 4.7% via laparoscopy). Overall, 30-day mortality rate was 1.4% with an overall complication rate of 44%. Most common complications included surgical site infection (n = 147, 10.4%), pneumonia (n = 105, 7.4%), and renal failure (n = 64, 4.5%). Distribution of AAST grade is as follows: Grade 0 (10, 0.7%), Grade 1 (247, 17.4%), Grade 2 (280, 19.8%), Grade 3 (158, 11.3%), Grade 4 (179, 12.6%), and Grade 5 (541, 38.2%). Increased median (interquartile range) AAST grades were recorded in patients with complications, 5 (3-5) compared with those without (2 [1-3], p = 0.001). Duration of stay was increased for patients with higher AAST grades: 4 and 5 (10.6 ± 5.9 days) versus I and II (3.6 ± 4.3 days; p = 0.001). Area under the receiver operating characteristic analysis to predict presence of any complication based on AAST grade was 0.90. The AAST EGS grading system is valid to predict important clinical outcomes in a South African population with an increased degree of severity on presentation. These results support generalizability of the AAST EGS grading system for appendicitis in a developing nation. Prognostic, level II.

Association of Distinct Mutational Signatures With Correlates of Increased Immune Activity in Pancreatic Ductal Adenocarcinoma.

PubMed

Connor, Ashton A; Denroche, Robert E; Jang, Gun Ho; Timms, Lee; Kalimuthu, Sangeetha N; Selander, Iris; McPherson, Treasa; Wilson, Gavin W; Chan-Seng-Yue, Michelle A; Borozan, Ivan; Ferretti, Vincent; Grant, Robert C; Lungu, Ilinca M; Costello, Eithne; Greenhalf, William; Palmer, Daniel; Ghaneh, Paula; Neoptolemos, John P; Buchler, Markus; Petersen, Gloria; Thayer, Sarah; Hollingsworth, Michael A; Sherker, Alana; Durocher, Daniel; Dhani, Neesha; Hedley, David; Serra, Stefano; Pollett, Aaron; Roehrl, Michael H A; Bavi, Prashant; Bartlett, John M S; Cleary, Sean; Wilson, Julie M; Alexandrov, Ludmil B; Moore, Malcolm; Wouters, Bradly G; McPherson, John D; Notta, Faiyaz; Stein, Lincoln D; Gallinger, Steven

2017-06-01

Outcomes for patients with pancreatic ductal adenocarcinoma (PDAC) remain poor. Advances in next-generation sequencing provide a route to therapeutic approaches, and integrating DNA and RNA analysis with clinicopathologic data may be a crucial step toward personalized treatment strategies for this disease. To classify PDAC according to distinct mutational processes, and explore their clinical significance. We performed a retrospective cohort study of resected PDAC, using cases collected between 2008 and 2015 as part of the International Cancer Genome Consortium. The discovery cohort comprised 160 PDAC cases from 154 patients (148 primary; 12 metastases) that underwent tumor enrichment prior to whole-genome and RNA sequencing. The replication cohort comprised 95 primary PDAC cases that underwent whole-genome sequencing and expression microarray on bulk biospecimens. Somatic mutations accumulate from sequence-specific processes creating signatures detectable by DNA sequencing. Using nonnegative matrix factorization, we measured the contribution of each signature to carcinogenesis, and used hierarchical clustering to subtype each cohort. We examined expression of antitumor immunity genes across subtypes to uncover biomarkers predictive of response to systemic therapies. The discovery cohort was 53% male (n = 79) and had a median age of 67 (interquartile range, 58-74) years. The replication cohort was 50% male (n = 48) and had a median age of 68 (interquartile range, 60-75) years. Five predominant mutational subtypes were identified that clustered PDAC into 4 major subtypes: age related, double-strand break repair, mismatch repair, and 1 with unknown etiology (signature 8). These were replicated and validated. Signatures were faithfully propagated from primaries to matched metastases, implying their stability during carcinogenesis. Twelve of 27 (45%) double-strand break repair cases lacked germline or somatic events in canonical homologous recombination genes-BRCA1, BRCA2, or PALB2. Double-strand break repair and mismatch repair subtypes were associated with increased expression of antitumor immunity, including activation of CD8-positive T lymphocytes (GZMA and PRF1) and overexpression of regulatory molecules (cytotoxic T-lymphocyte antigen 4, programmed cell death 1, and indolamine 2,3-dioxygenase 1), corresponding to higher frequency of somatic mutations and tumor-specific neoantigens. Signature-based subtyping may guide personalized therapy of PDAC in the context of biomarker-driven prospective trials.

Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry.

PubMed

Brenner, Megan; Inaba, Kenji; Aiolfi, Alberto; DuBose, Joseph; Fabian, Timothy; Bee, Tiffany; Holcomb, John B; Moore, Laura; Skarupa, David; Scalea, Thomas M

2018-05-01

Aortic occlusion is a potentially valuable tool for early resuscitation in patients nearing extremis or in arrest from severe hemorrhage. The American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry identified trauma patients without penetrating thoracic injury undergoing aortic occlusion at the level of the descending thoracic aorta (resuscitative thoracotomy [RT] or zone 1 resuscitative endovascular balloon occlusion of the aorta [REBOA]) in the emergency department (ED). Survival outcomes relative to the timing of CPR need and admission hemodynamic status were examined. Two hundred and eighty-five patients were included: 81.8% were males, with injury due to penetrating mechanisms in 41.4%; median age was 35.0 years (interquartile range 29 years) and median Injury Severity Score was 34.0 (interquartile range 18). Resuscitative thoracotomy was used in 71%, and zone 1 REBOA in 29%. Overall survival beyond the ED was 50% (RT 44%, REBOA 63%; p = 0.004) and survival to discharge was 5% (RT 2.5%, REBOA 9.6%; p = 0.023). Discharge Glasgow Coma Scale score was 15 in 85% of survivors. Prehospital CPR was required in 60% of patients with a survival beyond the ED of 37% and survival to discharge of 3% (all p > 0.05). Patients who did not require any CPR before had a survival beyond the ED of 70% (RT 48%, REBOA 93%; p < 0.001) and survival to discharge of 13% (RT 3.4%, REBOA 22.2%, p = 0.048). If aortic occlusion patients did not require CPR but presented with hypotension (systolic blood pressure <90 mmHg; 9% [65% RT; 35% REBOA]), they achieved survival beyond the ED in 65% (p = 0.009) and survival to discharge of 15% (RT 0%, REBOA 44%; p = 0.008). Overall, REBOA can confer a survival benefit over RT, particularly in patients not requiring CPR. Considerable additional study is required to definitively recommend REBOA for specific subsets of injured patients. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database.

PubMed

Ruth, Amanda; McCracken, Courtney E; Fortenberry, James D; Hall, Matthew; Simon, Harold K; Hebbar, Kiran B

2014-11-01

To 1) describe the characteristics and outcomes over time of PICU patients with severe sepsis within the dedicated U.S. children's hospitals, 2) identify patient subgroups at risk for mortality from pediatric severe sepsis, and 3) describe overall pediatric severe sepsis resource utilization. Retrospective review of a prospectively collected multi-institutional children's hospital database. PICUs in 43 U.S. children's hospitals. PICU patients from birth to younger than 19 years were identified with severe sepsis by modified Angus criteria and International Classification of Diseases, 9th Revision, codes for severe sepsis and septic shock. None. Data from the Pediatric Health Information System database collected by the Children's Hospital Association from 2004 to 2012. Pediatric severe sepsis was defined by 1) International Classification of Diseases, 9th Revision, codes reflecting severe sepsis and septic shock and 2) International Classification of Diseases, 9th Revision, codes of infection and organ dysfunction as defined by modified Angus criteria. From 2004 to 2012, 636,842 patients were identified from 43 hospitals. Pediatric severe sepsis prevalence was 7.7% (49,153) with an associated mortality rate of 14.4%. Age less than 1 year (vs age 10 to < 19) (odds ratio, 1.4), underlying cardiovascular condition (odds ratio, 1.4) and multiple organ dysfunction, conferred higher odds of mortality. Resource burden was significant with median hospital length of stay of 17 days (interquartile range, 8-36 d) and PICU length of stay of 7 days (interquartile range, 2-17 d), with median cost/day of $4,516 and median total hospitalization cost of $77,446. There was a significant increase in the severe sepsis prevalence rate from 6.2% to 7.7% from 2004 to 2012 (p < 0.001) and a significant decrease in mortality from 18.9% to 12.0% (p < 0.001). Center mortality was negatively correlated with prevalence (rs = -0.48) and volume (rs = -0.39) and positively correlated with cost (rs = 0.36). In this largest reported pediatric severe sepsis cohort to date, prevalence increased from 2004 to 2012 while associated mortality decreased. Age, cardiovascular comorbidity, and organ dysfunction were significant prognostic factors. Pediatric severe sepsis remains an important cause for PICU admission and mortality and leads to a substantial burden in healthcare costs. Individual center's prevalence and volume are associated with improved outcomes.

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery.

PubMed

Myles, Paul S; Bellomo, Rinaldo; Corcoran, Tomas; Forbes, Andrew; Peyton, Philip; Story, David; Christophi, Chris; Leslie, Kate; McGuinness, Shay; Parke, Rachael; Serpell, Jonathan; Chan, Matthew T V; Painter, Thomas; McCluskey, Stuart; Minto, Gary; Wallace, Sophie

2018-05-09

Background Guidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the supporting evidence is limited, and there is concern about impaired organ perfusion. Methods In a pragmatic, international trial, we randomly assigned 3000 patients who had an increased risk of complications while undergoing major abdominal surgery to receive a restrictive or liberal intravenous-fluid regimen during and up to 24 hours after surgery. The primary outcome was disability-free survival at 1 year. Key secondary outcomes were acute kidney injury at 30 days, renal-replacement therapy at 90 days, and a composite of septic complications, surgical-site infection, or death. Results During and up to 24 hours after surgery, 1490 patients in the restrictive fluid group had a median intravenous-fluid intake of 3.7 liters (interquartile range, 2.9 to 4.9), as compared with 6.1 liters (interquartile range, 5.0 to 7.4) in 1493 patients in the liberal fluid group (P<0.001). The rate of disability-free survival at 1 year was 81.9% in the restrictive fluid group and 82.3% in the liberal fluid group (hazard ratio for death or disability, 1.05; 95% confidence interval, 0.88 to 1.24; P=0.61). The rate of acute kidney injury was 8.6% in the restrictive fluid group and 5.0% in the liberal fluid group (P<0.001). The rate of septic complications or death was 21.8% in the restrictive fluid group and 19.8% in the liberal fluid group (P=0.19); rates of surgical-site infection (16.5% vs. 13.6%, P=0.02) and renal-replacement therapy (0.9% vs. 0.3%, P=0.048) were higher in the restrictive fluid group, but the between-group difference was not significant after adjustment for multiple testing. Conclusions Among patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury. (Funded by the Australian National Health and Medical Research Council and others; RELIEF ClinicalTrials.gov number, NCT01424150 .).

Prevalence of Serum Celiac Antibodies in a Multiracial Asian Population-A First Study in the Young Asian Adult Population of Malaysia

PubMed Central

Yap, Theresa Wan-Chen; Chan, Weng-Kai; Leow, Alex Hwong-Ruey; Azmi, Ahmad Najib; Loke, Mun-Fai; Vadivelu, Jamuna; Goh, Khean-Lee

2015-01-01

Background Celiac disease (CD) is an immune-mediated disorder induced by the ingestion of gluten in genetically susceptible persons. The prevalence of CD in Malaysia is unknown. We aim to determine the seroprevalence of CD antibodies and also investigate the correlation between H. pylori infection and CD in the young and healthy multiracial Malaysian population. Methods Healthy young adult volunteers between the ages of 18–30 years were consecutively recruited from June 2012 to May 2014 at the University of Malaya Medical Centre (UMMC), Kuala Lumpur. Serum samples from all the participants were tested for anti-gliadin antibody immunoglobulin A/immunoglobulin G (IgA/IgG) and anti-tissue transglutaminase antibody (tTG) IgA/IgG. Samples positive for both anti-gliadin and anti-tTG were further validated for anti-human endomysial IgA antibodies (EmA). Serological diagnosis of CD was made when anti-gliadin, anti-tTG and anti-EmA were positive. Results 562 qualified participants with mean age 24 ± 2.4 years old were recruited into our study. CD was found in 7 participants where most of them were asymptomatic and unaware of their CD status. The median of anti-gliadin and anti-tTG IgA/IgG value was 38.2 U/ml (interquartile range, 28.3–60.4 U/ml) and 49.2 U/ml (interquartile range, 41.1–65.9 U/ml), respectively. Seroprevalence of CD antibodies was 1.9% (6 out of 324) in female while only 0.4% (1 out of 238) in male. Seroprevalence among Malay was 0.8% (2 of 236), Chinese was 1.7% (3 of 177) and Indian was 1.3% (2 of 149). Overall, seroprevalence of CD antibodies in healthy asymptomatic adults in the Malaysian population was 1.25% (95% CI, 0.78%-1.72%). No significant relationship was discovered between CD and H. pylori infection. Conclusions The seroprevalence of CD antibodies in healthy young adults in the Malaysian population was 1.25% (1 in 100). CD is underdiagnosed and it could be a much greater problem in Malaysia than previously thought. PMID:25799401

Prevalence, Clinical Presentation, and Factors Associated With Diabetic Foot Ulcer in Two Regional Hospitals in Cameroon.

PubMed

Tindong, Maxime; Palle, John N; Nebongo, Daniel; Aminde, Leopold Ndemnge; Mboue-Djieka, Yannick; Mbarga, Nicole T Fouda; Dehayem, Mesmin Y; Choukem, Siméon-Pierre

2018-03-01

This study aimed to determine the prevalence of diabetic foot ulcer and high risk for ulceration, describe the clinical presentation, and identify factors associated with diabetic foot ulcer in the Southwest regional hospitals of Cameroon. In this cross-sectional study, data were collected using a structured questionnaire administered to consecutive patients with diabetes. Findings from detailed foot examination were recorded. Diabetic foot ulcer was diagnosed according to the International Working Group on Diabetic Foot (IWGDF) definition. Data were analyzed with Stata IC version 12. Of the 203 participants included, 63.1% were females. Age ranged from 26 to 96 years. The median duration of diabetes was 4.0 years (interquartile range 1.0-8.0 years). The prevalence of diabetic foot ulcer was 11.8% (24), of whom 29.2% (7) had high grade (grades 2 to 4), and most of the ulcers 58.3% (14) were located at the plantar region. The prevalence of high risk for ulceration was 21.8% (39). Loss of protective sensation (OR = 3.73, 95% CI = 1.43-9.71; P = .007), and peripheral arterial disease (OR = 3.48, 95% CI = 1.14-10.56; P = .028) were independently associated with diabetic foot. Diabetic foot ulcer is a common complication among patients with diabetes attending these regional hospitals. Loss of protective sensation, and peripheral arterial disease increase the odds of having diabetic foot ulcer, and we suggest them as the main target of interest for prevention.

Natural history of medial clavicle fractures.

PubMed

Salipas, Andrew; Kimmel, Lara A; Edwards, Elton R; Rakhra, Sandeep; Moaveni, Afshin Kamali

2016-10-01

Fractures of the medial third of the clavicle comprise less than 3% of all clavicle fractures. The natural history and optimal management of these rare injuries are unknown. The aim of our study is to describe the demographics, management and outcomes of patients with medial clavicle fractures treated at a Level 1 Trauma Centre. A retrospective review was conducted of patients presenting to our institution between January 2008 and March 2013 with a medial third clavicle fracture. Clinical and radiographic data were recorded including mechanism of injury, fracture pattern and displacement, associated injuries, management and complications. Functional outcomes were assessed using the Glasgow Outcome Scale Extended (GOS-E) scores from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Shoulder outcomes were assessed using two patient reported outcomes scores, the American Shoulder and Elbow Society Score (ASES) and the Subjective Shoulder Value (SSV). Sixty eight medial clavicle fractures in 68 patients were evaluated. The majority of patients were male (n=53), with a median age of 53.5 years (interquartile range (IQR) 37.5-74.5 years). The most common mechanism of injury was motor vehicle accident (n=28). The in-hospital mortality rate was 4.4%. The fracture pattern was almost equally distributed between extra articular (n=35) and intra-articular (n=33). Fifty-five fractures (80.9%) had minimal or no displacement. Associated injuries were predominantly thoracic (n=31). All fractures were initially managed non-operatively, with a broad arm sling. Delayed operative fixation was performed for painful atrophic delayed union in two patients (2.9%). Both patients were under 65 years of age and had a severely displaced fracture of the medial clavicle. One intra-operative vascular complication was seen, with no adverse long-term outcome. Follow-up was obtained in 85.0% of the surviving cohort at an average of three years post injury (range 1-6 years). The mean ASES score was 80.3 (SD 24.8, range 10-100,), and the mean SSV score was 77.0 (SD 24.6, range 10-100). Sixty eight patients with medial clavicle fractures were identified over a 5year period, with excellent functional results seen following conservative management. Copyright © 2016 Elsevier Ltd. All rights reserved.

Air pollution and ED visits for asthma in Australian children: a case-crossover analysis.

PubMed

Jalaludin, Bin; Khalaj, Behnoosh; Sheppeard, Vicky; Morgan, Geoff

2008-08-01

We aimed to determine the effects of ambient air pollutants on emergency department (ED) visits for asthma in children. We obtained routinely collected ED visit data for asthma (ICD9 493) and air pollution (PM(10), PM(2.5), O(3), NO(2), CO and SO(2)) and meteorological data for metropolitan Sydney for 1997-2001. We used the time stratified case-crossover design and conditional logistic regression to model the association between air pollutants and ED visits for four age-groups (1-4, 5-9, 10-14 and 1-14 years). Estimated relative risks for asthma ED visits were calculated for an exposure corresponding to the inter-quartile range in pollutant level. We included same day average temperature, same day relative humidity, daily temperature range, school holidays and public holidays in all models. Associations between ambient air pollutants and ED visits for asthma in children were most consistent for all six air pollutants in the 1-4 years age-group, for particulates and CO in the 5-9 years age-group and for CO in the 10-14 years age-group. The greatest effects were most consistently observed for lag 0 and effects were greater in the warm months for particulates, O(3) and NO(2). In two pollutant models, effect sizes were generally smaller compared to those derived from single pollutant models. We observed the effects of ambient air pollutants on ED attendances for asthma in a city where the ambient concentrations of air pollutants are relatively low.

The population distribution of the sagittal abdominal diameter (SAD) and SAD/height ratio among Finnish adults.

PubMed

Kahn, H S; Rissanen, H; Bullard, K M; Knekt, P

2014-12-01

Sagittal abdominal diameter (SAD; 'abdominal height' measured in supine position) may improve upon conventional anthropometry for predicting incident cardiometabolic diseases. However, the SAD is used infrequently by practitioners and epidemiologists. A representative survey of Finnish adults in 2000-2001 collected body measurements including SAD (by sliding-beam calliper) using standardized protocols. Sampled non-pregnant adults (ages 30+ years; 79% participation) provided 6123 SAD measurements from 80 health centre districts. Through stratified, complex survey design, these data represented 2.86 million adults at ages 30+ years. SAD ranged from 13.5 to 38.0 cm, with a population mean (standard error) of 21.7 (0.05) cm and median (interquartile range) of 21.0 (19.1-23.4). Median SAD was higher at ages 50+ years compared with ages 30-49 both for men (22.4 [20.5-24.6] vs. 20.8 [19.3-22.7]) and women (21.7 [19.6-23.9] vs. 19.4 [17.8-21.4]). The SAD/height ratio was similar (0.118) for both sexes at 30-39 years, rising more steeply with age for women than men. Attaining only a basic education, compared with a high level, was associated with increased mean (95% confidence interval) SADs for men (22.6 [22.3-22.8] vs. 22.0 [21.7-22.2]) and women (21.8 [21.5-22.0] vs. 20.6 [20.4-20.8]). Finland's early experience with nationally representative SAD measurements provides normative reference values and physiological insights useful for investigations of cardiometabolic risk. © 2014 World Obesity.

Embolic strokes of undetermined source: Prevalence and patient features in the ESUS Global Registry.

PubMed

Perera, Kanjana S; Vanassche, Thomas; Bosch, Jackie; Giruparajah, Mohana; Swaminathan, Balakumar; Mattina, Katie R; Berkowitz, Scott D; Arauz, Antonio; O'Donnell, Martin J; Ameriso, Sebastian F; Hankey, Graeme J; Yoon, Byung-Woo; Lavallee, Philippa; Cunha, Luis; Shamalov, Nikolay; Brouns, Raf; Gagliardi, Rubens J; Kasner, Scott E; Pieroni, Alessio; Vermehren, Philipp; Kitagawa, Kazuo; Wang, Yongjun; Muir, Keith; Coutinho, Jonathan; Vastagh, Ildiko; Connolly, Stuart J; Hart, Robert G

2016-07-01

Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS). We undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions. Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS. Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic stroke patients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation (n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic stroke patients was 64 years (p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2-8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation. This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions. © 2016 World Stroke Organization.

Incidence and mortality of herpes simplex encephalitis in Denmark: A nationwide registry-based cohort study.

PubMed

Jørgensen, Laura Krogh; Dalgaard, Lars Skov; Østergaard, Lars Jørgen; Nørgaard, Mette; Mogensen, Trine Hyrup

2017-01-01

We aimed to investigate the incidence and mortality of herpes simplex encephalitis (HSE) in a nationwide cohort. From the Danish National Patient Registry, we identified all adults hospitalised with a first-time diagnosis of HSE in Denmark during 2004-2014. The HSE diagnoses were verified using medical records and microbiological data. Patients were followed for mortality through the Danish Civil Registry System. We estimated age-standardised incidence rates of HSE and 30-day, 60-day, and 1-year cumulative mortality. Furthermore, we assessed whether calendar year, age, gender, level of comorbidity, virus type, and department type was associated with HSE mortality. We identified a total of 230 cases of HSE. Median age was 60.7 years (interquartile range: 49.3-71.6). The overall incidence rate was 4.64 cases per million population per year (95% confidence interval: 4.06-5.28). The cumulative mortality within 30 days, 60 days, and 1 year of the HSE admission was 8.3%, 11.3%, and 18.6%, respectively. Advanced age and presence of comorbidity were associated with increased 60-day and 1-year mortality. This nationwide study of verified HSE found a higher incidence than reported in previous nationwide studies. Presence of comorbidity was identified as a novel adverse prognostic factor. Mortality rates following HSE remain high. Copyright © 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Long-term disability trajectories in primary progressive MS patients: A latent class growth analysis.

PubMed

Signori, Alessio; Izquierdo, Guillermo; Lugaresi, Alessandra; Hupperts, Raymond; Grand'Maison, Francois; Sola, Patrizia; Horakova, Dana; Havrdova, Eva; Prat, Alexandre; Girard, Marc; Duquette, Pierre; Boz, Cavit; Grammond, Pierre; Terzi, Murat; Singhal, Bhim; Alroughani, Raed; Petersen, Thor; Ramo, Cristina; Oreja-Guevara, Celia; Spitaleri, Daniele; Shaygannejad, Vahid; Butzkueven, Helmut; Kalincik, Tomas; Jokubaitis, Vilija; Slee, Mark; Fernandez Bolaños, Ricardo; Sanchez-Menoyo, Jose Luis; Pucci, Eugenio; Granella, Franco; Lechner-Scott, Jeannette; Iuliano, Gerardo; Hughes, Stella; Bergamaschi, Roberto; Taylor, Bruce; Verheul, Freek; Edite Rio, Maria; Amato, Maria Pia; Sajedi, Seyed Aidin; Majdinasab, Nastaran; Van Pesch, Vincent; Sormani, Maria Pia; Trojano, Maria

2018-04-01

Several natural history studies on primary progressive multiple sclerosis (PPMS) patients detected a consistent heterogeneity in the rate of disability accumulation. To identify subgroups of PPMS patients with similar longitudinal trajectories of Expanded Disability Status Scale (EDSS) over time. All PPMS patients collected within the MSBase registry, who had their first EDSS assessment within 5 years from onset, were included in the analysis. Longitudinal EDSS scores were modeled by a latent class mixed model (LCMM), using a nonlinear function of time from onset. LCMM is an advanced statistical approach that models heterogeneity between patients by classifying them into unobserved groups showing similar characteristics. A total of 853 PPMS (51.7% females) from 24 countries with a mean age at onset of 42.4 years (standard deviation (SD): 10.8 years), a median baseline EDSS of 4 (interquartile range (IQR): 2.5-5.5), and 2.4 years of disease duration (SD: 1.5 years) were included. LCMM detected three different subgroups of patients with a mild ( n = 143; 16.8%), moderate ( n = 378; 44.3%), or severe ( n = 332; 38.9%) disability trajectory. The probability of reaching EDSS 6 at 10 years was 0%, 46.4%, and 81.9% respectively. Applying an LCMM modeling approach to long-term EDSS data, it is possible to identify groups of PPMS patients with different prognosis.

Current Epidemiology and Outcome of Infective Endocarditis

PubMed Central

Muñoz, Patricia; Kestler, Martha; De Alarcon, Arístides; Miro, José María; Bermejo, Javier; Rodríguez-Abella, Hugo; Fariñas, Maria Carmen; Cobo Belaustegui, Manuel; Mestres, Carlos; Llinares, Pedro; Goenaga, Miguel; Navas, Enrique; Oteo, José Antonio; Tarabini, Paola; Bouza, Emilio

2015-01-01

Abstract The aim of the study was to describe the epidemiologic and clinical characteristics and identify the risk factors of short-term and 1-year mortality in a recent cohort of patients with infective endocarditis (IE). From January 2008, multidisciplinary teams have prospectively collected all consecutive cases of IE, diagnosed according to the Duke criteria, in 25 Spanish hospitals. Overall, 1804 patients were diagnosed. The median age was 69 years (interquartile range, 55–77), 68.0% were men, and 37.1% of the cases were nosocomial or health care-related IE. Gram-positive microorganisms accounted for 79.3% of the episodes, followed by Gram-negative (5.2%), fungi (2.4%), anaerobes (0.9%), polymicrobial infections (1.9%), and unknown etiology (9.1%). Heart surgery was performed in 44.2%, and in-hospital mortality was 28.8%. Risk factors for in-hospital mortality were age, previous heart surgery, cerebrovascular disease, atrial fibrillation, Staphylococcus or Candida etiology, intracardiac complications, heart failure, and septic shock. The 1-year independent risk factors for mortality were age (odds ratio [OR], 1.02), neoplasia (OR, 2.46), renal insufficiency (OR, 1.59), and heart failure (OR, 4.42). Surgery was an independent protective factor for 1-year mortality (OR, 0.44). IE remains a severe disease with a high rate of in-hospital (28.9%) and 1-year mortality (11.2%). Surgery was the only intervention that significantly reduced 1-year mortality. PMID:26512582

Current Epidemiology and Outcome of Infective Endocarditis: A Multicenter, Prospective, Cohort Study.

PubMed

Muñoz, Patricia; Kestler, Martha; De Alarcon, Arístides; Miro, José María; Bermejo, Javier; Rodríguez-Abella, Hugo; Fariñas, Maria Carmen; Cobo Belaustegui, Manuel; Mestres, Carlos; Llinares, Pedro; Goenaga, Miguel; Navas, Enrique; Oteo, José Antonio; Tarabini, Paola; Bouza, Emilio

2015-10-01

The aim of the study was to describe the epidemiologic and clinical characteristics and identify the risk factors of short-term and 1-year mortality in a recent cohort of patients with infective endocarditis (IE).From January 2008, multidisciplinary teams have prospectively collected all consecutive cases of IE, diagnosed according to the Duke criteria, in 25 Spanish hospitals.Overall, 1804 patients were diagnosed. The median age was 69 years (interquartile range, 55-77), 68.0% were men, and 37.1% of the cases were nosocomial or health care-related IE. Gram-positive microorganisms accounted for 79.3% of the episodes, followed by Gram-negative (5.2%), fungi (2.4%), anaerobes (0.9%), polymicrobial infections (1.9%), and unknown etiology (9.1%). Heart surgery was performed in 44.2%, and in-hospital mortality was 28.8%. Risk factors for in-hospital mortality were age, previous heart surgery, cerebrovascular disease, atrial fibrillation, Staphylococcus or Candida etiology, intracardiac complications, heart failure, and septic shock. The 1-year independent risk factors for mortality were age (odds ratio [OR], 1.02), neoplasia (OR, 2.46), renal insufficiency (OR, 1.59), and heart failure (OR, 4.42). Surgery was an independent protective factor for 1-year mortality (OR, 0.44).IE remains a severe disease with a high rate of in-hospital (28.9%) and 1-year mortality (11.2%). Surgery was the only intervention that significantly reduced 1-year mortality.

PRISMA and AMSTAR Show Systematic Reviews of Health Literacy and Cancer Screening are Good Quality.

PubMed

Sharma, Sakshi; Oremus, Mark

2018-04-11

To evaluate the reporting and methodological quality of systematic reviews (SRs) in health literacy and cancer screening; to investigate factors that may influence overall quality. A review of SRs published between 2009 and 2017. We calculated indices to represent the included SRs' adherence to PRISMA and AMSTAR. To assess possible determinants of SR quality, we regressed the index scores on year and region of publication, journal impact factor, authors' reported use of PRISMA, and presence of funding statements. We included 19 SRs and median index scores were 0.86 for PRISMA (interquartile range [IQR] = 0.11; range = 0.32 to 1.00) and 0.67 for AMSTAR (IQR = 0.30; range = 0.22 to 1.00). Methodological and reporting problems pertained to protocol registration or publication, number of raters used, gray literature searches, excluded article lists, and unintegrated discussions of risk of bias and efficacy. Only journal impact factor was statistically significantly associated (positively) with PRISMA and AMSTAR index scores. The quality of SRs in health literacy and cancer screening was generally good. Systematic reviewers should register or publish their protocols, include PRISMA and AMSTAR checklists when submitting SRs to journals, and self-evaluate their SRs before submission. Copyright © 2018. Published by Elsevier Inc.

Amisulpride overdose is frequently associated with QT prolongation and torsades de pointes.

PubMed

Isbister, Geoffrey K; Balit, Corrine R; Macleod, Dawson; Duffull, Stephen B

2010-08-01

This study aimed to describe the effects of the antipsychotic amisulpride in overdose, including the frequency of QT prolongation and torsades de pointes. Cases of amisulpride overdose (>1 g) were recruited from 2 state poison centers and a tertiary toxicology unit over 5 years. A 1-page clinical research form was used to collect clinical information. Copies of all electrocardiograms were obtained. Electrocardiogram parameters (QRS and QT intervals) were manually measured as previously described, and plots of QT-heart rate (HR) pairs were compared with the QT nomogram. There were 83 patients with amisulpride overdoses with a median age of 29 years (interquartile range [IQR], 23-40 years), and 42 (51%) were female. The median dose ingested was 6 g (IQR, 3-13 g, range, 1.2-120 g). The median HR was 66 beats/min (IQR, 60-81 beats/min). Bradycardia occurred in 20 cases (24%), and hypotension in 19 (23%). From 440 electrocardiograms (average of 5 per case; range, 1-15), an abnormal QT-HR pair occurred in 61 cases (73%). Torsades de pointes developed in 6 cases (7%), with doses of 4, 4.6, 18, 24, 32, and 80 g. The patient taking 32 g died after a cardiac arrest. Widened QRS did not occur except transient rate-dependent bundle-branch block in 3 cases. There were significant associations of bradycardia, hypokalemia, and hypocalcaemia, with QT prolongation and torsades de pointes. Central nervous system effects were uncommon with coma in 7 cases, seizures in 2, and dystonic reactions in 2. Amisulpride overdose commonly causes QT prolongation, bradycardia, and hypotension. Torsades de pointes occurred commonly enough to suggest that amisulpride is highly cardiotoxic in overdose.

Prevalence of anal high-risk human papillomavirus infections among HIV-positive and HIV-negative men who have sex with men (MSM) in Nigeria

PubMed Central

Nowak, Rebecca G.; Gravitt, Patti E.; He, Xin; Ketende, Sosthenes; Anom, Wuese; Omuh, Helen; Blattner, William A.; Charurat, Manhattan E.

2016-01-01

Background Prevalence estimates of anal high-risk human papillomavirus (HR-HPV) are needed in sub-Saharan Africa where HIV is endemic. This study evaluated anal HR-HPV in Nigeria among HIV-positive and HIV-negative men who have sex with men (MSM) for future immunization recommendations. Methods We conducted a cross-sectional study to compare the prevalence of anal HR-HPV infections between 64 HIV-negative and 90 HIV-positive MSM. Multivariate Poisson regression analyses were used to examine demographic and behavioral risk factors associated with any HR-HPV infections. Results The median age of the 154 participants was 25 years (interquartile range [IQR]: 22-28, range: 16-38) and the median age at initiation of anal sex with another man was 16 years (IQR: 13-18, range: 7-29). The prevalence of anal HR-HPV was higher among HIV-positive than HIV-negative MSM (91.1% vs. 40.6%, p<0.001). In the multivariate analysis, HIV infection (adjusted prevalence ratio [aPR]: 2.02, 95% CI: 1.49-2.72), ten years or more since anal sexual debut (aPR: 1.26, 95% CI: 1.07-1.49), and concurrent relationships with men (aPR: 1.32, 95% CI: 1.04-1.67) were associated with increased anal HR-HPV prevalence. Conclusions Anal HR-HPV infection is high for young Nigerian MSM and rates are amplified in those co-infected with HIV. Providing universal coverage as well as catchup immunization for young MSM may be an effective anal cancer prevention strategy in Nigeria. PMID:26967301

Adolescents' Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms.

PubMed

Kemigisha, Elizabeth; Nyakato, Viola N; Bruce, Katharine; Ndaruhutse Ruzaaza, Gad; Mlahagwa, Wendo; Ninsiima, Anna B; Coene, Gily; Leye, Els; Michielsen, Kristien

2018-02-22

Measures of sexual wellbeing and positive aspects of sexuality in the World Health Organization definition for sexual health are rarely studied and remain poorly understood, especially among adolescents in Sub-Saharan Africa. The objective of this study was to assess sexual wellbeing in its broad sense-i.e., body image, self-esteem, and gender equitable norms-and associated factors in young adolescents in Uganda. A cross-sectional survey of adolescents ages 10-14 years in schools was carried out between June and July 2016. Among 1096 adolescents analyzed, the median age was 12 (Inter-Quartile Range (IQR): 11, 13) and 58% were female. Self-esteem and body image scores were high with median 24 (IQR: 22, 26, possible range: 7-28) and median 22 (IQR: 19, 24, possible range: 5-25) respectively. Gender equitable norms mean score was 28.1 (SD 5.2: possible range 11-44). We noted high scores for self-esteem and body image but moderate scores on gender equitable norms. Girls had higher scores compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increasing age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms are recommended.

Adolescents’ Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms

PubMed Central

Kemigisha, Elizabeth; Nyakato, Viola N.; Bruce, Katharine; Ndaruhutse Ruzaaza, Gad; Mlahagwa, Wendo; Ninsiima, Anna B.; Coene, Gily; Leye, Els; Michielsen, Kristien

2018-01-01

Measures of sexual wellbeing and positive aspects of sexuality in the World Health Organization definition for sexual health are rarely studied and remain poorly understood, especially among adolescents in Sub-Saharan Africa. The objective of this study was to assess sexual wellbeing in its broad sense—i.e., body image, self-esteem, and gender equitable norms—and associated factors in young adolescents in Uganda. A cross-sectional survey of adolescents ages 10–14 years in schools was carried out between June and July 2016. Among 1096 adolescents analyzed, the median age was 12 (Inter-Quartile Range (IQR): 11, 13) and 58% were female. Self-esteem and body image scores were high with median 24 (IQR: 22, 26, possible range: 7–28) and median 22 (IQR: 19, 24, possible range: 5–25) respectively. Gender equitable norms mean score was 28.1 (SD 5.2: possible range 11–44). We noted high scores for self-esteem and body image but moderate scores on gender equitable norms. Girls had higher scores compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increasing age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms are recommended. PMID:29470388

Type 2 diabetes in youth from the Western Pacific region: glycaemic control, diabetes care and complications.

PubMed

Eppens, Maike C; Craig, Maria E; Jones, Timothy W; Silink, Martin; Ong, Stephanie; Ping, Yeo Jing

2006-05-01

To describe the glycaemic control, diabetes care and prevalence of complications in youth with type 2 diabetes from the Western Pacific Region. Cross-sectional, clinic-based audit of 331 patients aged < 18 years from 56 centres in Australia, China-Beijing, China-Shanghai, China-Hong Kong, Indonesia, Japan, South Korea, Malaysia, Philippines, Singapore, Taiwan and Thailand. Clinical and management data were recorded along with glycated haemoglobin (HbA(1c)), lipids and complication rates. Glycaemic control, complications, diabetes management. Median age was 14.9 years (interquartile range 13.2-16.4 years) and median diabetes duration 2.3 years (1.4-3.6 years). Median HbA(1c) was 7% (5.9-9.9%) and HbA(1c) was > 7.5% in 40% of patients. In multiple regression analysis, glycaemic control varied significantly between countries (p = 0.02); higher HbA(1c) was associated with fewer home blood glucose measurements (p = 0.005) and higher insulin dose/kg (p < 0.0001). Blood glucose monitoring was performed by 65% of patients (range 33-96% by country). In 25% of patients, management consisted of diet alone or no treatment (range 0-53% by country); oral anti-diabetic drugs alone were used in 49%, insulin alone in 11% and both in 15%. Microalbuminuria was found in 8% and hypertension in 24%. The risk of hypertension increased with higher BMI (OR 1.16, 95% CI 1.09-1.24, p < 0.0001); antihypertensive agents were used in 4% of patients. The management of type 2 diabetes in youth from the Western Pacific Region varies widely. Hypertension and microalbuminuria were frequent, but not commonly treated. Further investigation into the natural history and risk factors for complications in youth with type 2 diabetes is required to assist in developing evidence based management guidelines.

Comprehensive evaluation of long-term trends in occupational exposure: Part 1. Description of the database

PubMed Central

Symanski, E.; Kupper, L. L.; Rappaport, S. M.

1998-01-01

OBJECTIVES: To conduct a comprehensive evaluation of long term changes in occupational exposure among a broad cross section of industries worldwide. METHODS: A review of the scientific literature identified studies that reported historical changes in exposure. About 700 sets of data from 119 published and several unpublished sources were compiled. Data were published over a 30 year period in 25 journals that spanned a range of disciplines. For each data set, the average exposure level was compiled for each period and details on the contaminant, the industry and location, changes in the threshold limit value (TLV), as well as the type of sampling method were recorded. Spearman rank correlation coefficients were used to identify monotonic changes in exposure over time and simple linear regression analyses were used to characterise trends in exposure. RESULTS: About 78% of the natural log transformed data showed linear trends towards lower exposure levels whereas 22% indicated increasing trends. (The Spearman rank correlation analyses produced a similar breakdown between exposures monotonically increasing or decreasing over time.) Although the rates of reduction for the data showing downward trends ranged from -1% to -62% per year, most exposures declined at rates between -4% and -14% per year (the interquartile range), with a median value of -8% per year. Exposures seemed to increase at rates that were slightly lower than those of exposures which have declined over time. Data sets that showed downward (versus upward) trends were influenced by several factors including type and carcinogenicity of the contaminant, type of monitoring, historical changes in the threshold limit values (TLVs), and period of sampling. CONCLUSIONS: This review supports the notion that occupational exposures are generally lower today than they were years or decades ago. However, such trends seem to have been affected by factors related to the contaminant, as well as to the period and type of sampling.   PMID:9764107

External Beam Accelerated Partial-Breast Irradiation Using 32 Gy in 8 Twice-Daily Fractions: 5-Year Results of a Prospective Study

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pashtan, Itai M.; Recht, Abram; Ancukiewicz, Marek

Purpose: External beam accelerated partial breast irradiation (APBI) is an increasingly popular technique for treatment of patients with early stage breast cancer following breast-conserving surgery. Here we present 5-year results of a prospective trial. Methods and Materials: From October 2003 through November 2005, 98 evaluable patients with stage I breast cancer were enrolled in the first dose step (32 Gy delivered in 8 twice-daily fractions) of a prospective, multi-institutional, dose escalation clinical trial of 3-dimensional conformal external beam APBI (3D-APBI). Median age was 61 years; median tumor size was 0.8 cm; 89% of tumors were estrogen receptor positive; 10% hadmore » a triple-negative phenotype; and 1% had a HER-2-positive subtype. Median follow-up was 71 months (range, 2-88 months; interquartile range, 64-75 months). Results: Five patients developed ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial IBTR rate of 5% (95% confidence interval [CI], 1%-10%). Three of these cases occurred in patients with triple-negative disease and 2 in non-triple-negative patients, for 5-year actuarial IBTR rates of 33% (95% CI, 0%-57%) and 2% (95% CI, 0%-6%; P<.0001), respectively. On multivariable analysis, triple-negative phenotype was the only predictor of IBTR, with borderline statistical significance after adjusting for tumor grade (P=.0537). Conclusions: Overall outcomes were excellent, particularly for patients with estrogen receptor-positive disease. Patients in this study with triple-negative breast cancer had a significantly higher IBTR rate than patients with other receptor phenotypes when treated with 3D-APBI. Larger, prospective 3D-APBI clinical trials should continue to evaluate the effect of hormone receptor phenotype on IBTR rates.« less

External beam accelerated partial-breast irradiation using 32 gy in 8 twice-daily fractions: 5-year results of a prospective study.

PubMed

Pashtan, Itai M; Recht, Abram; Ancukiewicz, Marek; Brachtel, Elena; Abi-Raad, Rita F; D'Alessandro, Helen A; Levy, Antonin; Wo, Jennifer Y; Hirsch, Ariel E; Kachnic, Lisa A; Goldberg, Saveli; Specht, Michelle; Gadd, Michelle; Smith, Barbara L; Powell, Simon N; Taghian, Alphonse G

2012-11-01

External beam accelerated partial breast irradiation (APBI) is an increasingly popular technique for treatment of patients with early stage breast cancer following breast-conserving surgery. Here we present 5-year results of a prospective trial. From October 2003 through November 2005, 98 evaluable patients with stage I breast cancer were enrolled in the first dose step (32 Gy delivered in 8 twice-daily fractions) of a prospective, multi-institutional, dose escalation clinical trial of 3-dimensional conformal external beam APBI (3D-APBI). Median age was 61 years; median tumor size was 0.8 cm; 89% of tumors were estrogen receptor positive; 10% had a triple-negative phenotype; and 1% had a HER-2-positive subtype. Median follow-up was 71 months (range, 2-88 months; interquartile range, 64-75 months). Five patients developed ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial IBTR rate of 5% (95% confidence interval [CI], 1%-10%). Three of these cases occurred in patients with triple-negative disease and 2 in non-triple-negative patients, for 5-year actuarial IBTR rates of 33% (95% CI, 0%-57%) and 2% (95% CI, 0%-6%; P<.0001), respectively. On multivariable analysis, triple-negative phenotype was the only predictor of IBTR, with borderline statistical significance after adjusting for tumor grade (P=.0537). Overall outcomes were excellent, particularly for patients with estrogen receptor-positive disease. Patients in this study with triple-negative breast cancer had a significantly higher IBTR rate than patients with other receptor phenotypes when treated with 3D-APBI. Larger, prospective 3D-APBI clinical trials should continue to evaluate the effect of hormone receptor phenotype on IBTR rates. Copyright © 2012 Elsevier Inc. All rights reserved.

Coital frequency and infertility: which male factors predict less frequent coitus among infertile couples?

PubMed

Perlis, Nathan; Lo, Kirk C; Grober, Ethan D; Spencer, Leia; Jarvi, Keith

2013-08-01

To determine the coital frequency among infertile couples and which factors are associated with less frequent coitus. Cross-sectional study. Tertiary-level male infertility clinic. A total of 1,298 infertile men. Administration of computer-based survey, semen analysis, and serum hormone evaluation. Monthly coital frequency. A total of 1,298 patients presented to clinic for infertility consultation and completed the computer-based survey. The median male age was 35 years (interquartile range [IQR] 32-39 years) and the median duration of infertility was 2 years (IQR 1-4 years) before consultation. Median monthly coital frequency was seven (IQR 5-10; range 0-40); 24% of couples were having intercourse ≤ 4 times per month. Overall, 0.6%, 2.7%, 4.8%, 5.8%, and 10.8% of the men reported having intercourse 0, 1, 2, 3, and 4 times per month, respectively. When simultaneously taking into account the influence of age, libido, erectile function, and semen volume on coital frequency, older patients had 1.05 times higher odds (per year of age) of less frequent coitus (odds ratio 1.05, 95% confidence interval 1.03-1.08). In addition, patients with better erectile function had 1.12 times higher odds (per point on Sexual Health Inventory for Men scale) of more frequent coitus (odds ratio 1.12, 95% confidence interval 1.09-1.18). Similar to the general population, most infertile couples report having coitus more than four times per month. Older male age and erectile dysfunction are independent risk factors for less frequent coitus among infertile men, which could have an impact on fertility. Coital frequency should be considered in infertility assessments. Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

PREDICT: a diagnostic accuracy study of a tool for predicting mortality within one year: who should have an advance healthcare directive?

PubMed

Richardson, Philip; Greenslade, Jaimi; Shanmugathasan, Sulochana; Doucet, Katherine; Widdicombe, Neil; Chu, Kevin; Brown, Anthony

2015-01-01

CARING is a screening tool developed to identify patients who have a high likelihood of death in 1 year. This study sought to validate a modified CARING tool (termed PREDICT) using a population of patients presenting to the Emergency Department. In total, 1000 patients aged over 55 years who were admitted to hospital via the Emergency Department between January and June 2009 were eligible for inclusion in this study. Data on the six prognostic indicators comprising PREDICT were obtained retrospectively from patient records. One-year mortality data were obtained from the State Death Registry. Weights were applied to each PREDICT criterion, and its final score ranged from 0 to 44. Receiver operator characteristic analyses and diagnostic accuracy statistics were used to assess the accuracy of PREDICT in identifying 1-year mortality. The sample comprised 976 patients with a median (interquartile range) age of 71 years (62-81 years) and a 1-year mortality of 23.4%. In total, 50% had ≥1 PREDICT criteria with a 1-year mortality of 40.4%. Receiver operator characteristic analysis gave an area under the curve of 0.86 (95% confidence interval: 0.83-0.89). Using a cut-off of 13 points, PREDICT had a 95.3% (95% confidence interval: 93.6-96.6) specificity and 53.9% (95% confidence interval: 47.5-60.3) sensitivity for predicting 1-year mortality. PREDICT was simpler than the CARING criteria and identified 158 patients per 1000 admitted who could benefit from advance care planning. PREDICT was successfully applied to the Australian healthcare system with findings similar to the original CARING study conducted in the United States. This tool could improve end-of-life care by identifying who should have advance care planning or an advance healthcare directive. © The Author(s) 2014.

Short-term outcomes of mothers and newborn infants with comorbid psychiatric disorders and drug dependency.

PubMed

Oei, Ju Lee; Abdel-Latif, Mohamed E; Craig, Fiona; Kee, Aivy; Austin, Marie-Paule; Lui, Kei

2009-04-01

The aim of the present study was to determine the characteristics and short-term outcomes of mother-infant pairs with comorbid drug dependency and psychiatric disorders. A population-based retrospective chart review was carried out of 879 drug-dependent mother and infant pairs in New South Wales (NSW) and the Australian Capital Territory (ACT) who delivered between 1 January and 31 December 2004. Psychiatric comorbidity (dual diagnosis, DD) was identified in 396 (45%) of the 879 drug-dependent women. DSM-IV depression (79%), followed by anxiety (20%), was most prevalent. DD women were more likely to use amphetamines (29% vs 18%, p < 0.05), less likely to use opiates (42% vs 51%, p < 0.05) and to have had no antenatal care (24% vs 8%, p < 0.05). They also had more previous pregnancies (4, range = 2-5 vs 3, range = 2-5, p < 0.05) and domestic violence (29% vs 14%, p < 0.05) was more common. DD infants were less likely to be admitted to a nursery (47% vs 55%, p < 0.05). Withdrawal scores were similar (maximum median Finnegan scores = 4 (interquartile range = 3-8) vs 10 (interquartile range = 7-12, p = 0.30) but fewer needed withdrawal medication (19% vs 27%, p < 0.05). Maternal psychotropic agents did not worsen the severity of neonatal withdrawal. Psychiatric comorbidity, especially depression, is common and affects almost half of drug-using mothers. Antenatal care, drug use and social outcomes are worse for DD mothers and their infants. It is recommended that all drug-using women be assessed antenatally for psychosocial disorders so that timely mental health intervention can be offered, if required.

Increased prevalence of gallbladder polyps in acromegaly.

PubMed

Annamalai, Anand K; Gayton, Emma L; Webb, Alison; Halsall, David J; Rice, Caiomhe; Ibram, Ferda; Chaudhry, Afzal N; Simpson, Helen L; Berman, Laurence; Gurnell, Mark

2011-07-01

Several studies have suggested an increased prevalence of benign and malignant tumors in acromegaly, particularly colonic neoplasms. The gallbladder's epithelial similarity to the colon raises the possibility that gallbladder polyps (GBP) may occur more frequently in acromegaly. Thirty-one patients with newly diagnosed acromegaly (14 females, 17 males; mean age 54.7 yr, range 27-76 yr) were referred to our center between 2004 and 2008. All had pituitary adenomas and were treated with somatostatin analogs prior to transsphenoidal surgery. Biliary ultrasonography was performed at the time of referral. In a retrospective case-cohort study, we compared the prevalence of GBP in these scans with those of 13,234 consecutive patients (age range 20-80 yr) presenting at the hospital for abdominal/biliary ultrasound during the same time interval. Associations between GH and IGF-I levels and GBP in acromegaly were also examined. There was a higher prevalence of GBP in patients with acromegaly compared with controls (29.03 vs 4.62%, P = 0.000008); relative risk was 6.29 (95% confidence interval 3.61-10.96). Eight of nine patients with acromegaly and GBP were older than 50 yr of age. GH levels were higher in those with GBP (median 30.8 μg/liter, interquartile range 10.9-39.1) than those without (8.2 μg/liter, interquartile range 6.0-16.0), but IGF-I levels were comparable. This is the first study to demonstrate an increased prevalence of GBP in patients with newly diagnosed acromegaly. Further studies are required to determine whether these patients are at increased risk of developing gallbladder carcinoma and to define the role, if any, of biliary ultrasound surveillance.

A radiobiological model of metastatic burden reduction for molecular radiotherapy: application to patients with bone metastases

NASA Astrophysics Data System (ADS)

Denis-Bacelar, Ana M.; Chittenden, Sarah J.; Murray, Iain; Divoli, Antigoni; McCready, V. Ralph; Dearnaley, David P.; O'Sullivan, Joe M.; Johnson, Bernadette; Flux, Glenn D.

2017-04-01

Skeletal tumour burden is a biomarker of prognosis and survival in cancer patients. This study proposes a novel method based on the linear quadratic model to predict the reduction in metastatic tumour burden as a function of the absorbed doses delivered from molecular radiotherapy treatments. The range of absorbed doses necessary to eradicate all the bone lesions and to reduce the metastatic burden was investigated in a cohort of 22 patients with bone metastases from castration-resistant prostate cancer. A metastatic burden reduction curve was generated for each patient, which predicts the reduction in metastatic burden as a function of the patient mean absorbed dose, defined as the mean of all the lesion absorbed doses in any given patient. In the patient cohort studied, the median of the patient mean absorbed dose predicted to reduce the metastatic burden by 50% was 89 Gy (interquartile range: 83-105 Gy), whilst a median of 183 Gy (interquartile range: 107-247 Gy) was found necessary to eradicate all metastases in a given patient. The absorbed dose required to eradicate all the lesions was strongly correlated with the variability of the absorbed doses delivered to multiple lesions in a given patient (r  =  0.98, P  <  0.0001). The metastatic burden reduction curves showed a potential large reduction in metastatic burden for a small increase in absorbed dose in 91% of patients. The results indicate the range of absorbed doses required to potentially obtain a significant survival benefit. The metastatic burden reduction method provides a simple tool that could be used in routine clinical practice for patient selection and to indicate the required administered activity to achieve a predicted patient mean absorbed dose and reduction in metastatic tumour burden.

Prospective study estimating healthcare associated infections in a paediatric hemato-oncology unit of a tertiary care hospital in North India.

PubMed

Gupta, Ayush; Kapil, Arti; Kabra, S K; Lodha, Rakesh; Sood, Seema; Dhawan, Benu; Das, Bimal K; Sreenivas, V

2013-12-01

Healthcare associated infections (HAIs) are responsible for morbidity and mortality among immunocompromised and critically ill patients. We undertook this study to estimate the burden of HAIs in the paediatric cancer patients in a tertiary care hospital in north India. This prospective, observational study, based on active surveillance for a period of 11 months was undertaken in a 4-bedded isolated, cubicle for paediatric cancer patients. Patients who stayed in the cubicle for ≥48 h, were followed prospectively for the development of HAIs. Of the 138 patients, 13 developed 14 episodes of HAIs during the study period. Patient-days calculated were 1273 days. Crude infection rate (CIR) and incidence density (ID) of all HAIs were 9.4/100 patients and 11/1000 patient-days, respectively. Of the 14 episodes of HAIs, seven (50%) were of blood stream infections (HA-BSI), five (36%) of pneumonia (HAP) and two (14%) urinary tract infections (HA-UTI). The CIRs of HA-BSI, HAP and HA-UTI were 5.1, 3.6 and 1.4/100 patients, respectively. The corresponding IDs were 5.5, 3.9 and 1.6/1000 patient-days, respectively. Mean length of stay was significantly higher in patients who developed an HAI [13.8 (range 7-30), median (Interquartile range) 12 (11-14)] vs 7.5 days [range 2-28, median (interquartile range) 7 (5-9); P<0.0001]. Also mortality was significantly higher in patients who developed an HAI [23% (3/13) vs 3% (4/125), P<0.05]. The incidence of HAIs in the paediatric cancer patients in the study was 11/1000 patient days, of which HA-BSIs were the commonest. HAIs were associated with an increase in morbidity and mortality amongst this high risk patient population.

Multimarker Analysis for New Biomarkers in Relation to Central Arterial Stiffness and Hemodynamics in a Chinese Community-Dwelling Population.

PubMed

Fu, Shihui; Luo, Leiming; Ye, Ping; Xiao, Wenkai

2015-11-01

Central arterial stiffness and hemodynamics independently reflect the risk of cardiovascular events. This Chinese community-based analysis was performed to evaluate the relationships of new biomarkers with central arterial stiffness and hemodynamics by a multimarker method. This analysis consisted of 1540 participants who were fully tested for the new biomarkers including N-terminal prohormone of brain natriuretic peptide, lipid accumulation product, triglyceride-high-density lipoprotein cholesterol (TG-HDL-c) ratio, uric acid, high-sensitivity C-reactive protein, and homocysteine. Carotid-femoral pulse wave velocity (cfPWV), central pulse pressure (cPP), and central augmentation index (cAIx) were measured. The median (range) age of entire cohort was 62 years (21-96 years), and 40.5% were males. The median (interquartile range) of cfPWV, cPP, and cAIx was 11.0 m/s (9.6-13.0 m/s), 42 mm Hg (35-52 mm Hg), and 28% (21%-33%), respectively. In multivariate analysis, participants with higher cfPWV had significantly higher age, peripheral pulse pressure, TG, TG-HDL-c ratio, and homocysteine levels compared with others (P < .05 for all). Multimarker analysis in a Chinese community-dwelling population reinforced the potential clinical value of plasma TG-HDL-c ratio and homocysteine levels as the biomarkers of increased arterial stiffness. © The Author(s) 2015.

MP3 player listening sound pressure levels among 10 to 17 year old students.

PubMed

Keith, Stephen E; Michaud, David S; Feder, Katya; Haider, Ifaz; Marro, Leonora; Thompson, Emma; Marcoux, Andre M

2011-11-01

Using a manikin, equivalent free-field sound pressure level measurements were made from the portable digital audio players of 219 subjects, aged 10 to 17 years (93 males) at their typical and "worst-case" volume levels. Measurements were made in different classrooms with background sound pressure levels between 40 and 52 dBA. After correction for the transfer function of the ear, the median equivalent free field sound pressure levels and interquartile ranges (IQR) at typical and worst-case volume settings were 68 dBA (IQR = 15) and 76 dBA (IQR = 19), respectively. Self-reported mean daily use ranged from 0.014 to 12 h. When typical sound pressure levels were considered in combination with the average daily duration of use, the median noise exposure level, Lex, was 56 dBA (IQR = 18) and 3.2% of subjects were estimated to exceed the most protective occupational noise exposure level limit in Canada, i.e., 85 dBA Lex. Under worst-case listening conditions, 77.6% of the sample was estimated to listen to their device at combinations of sound pressure levels and average daily durations for which there is no known risk of permanent noise-induced hearing loss, i.e., ≤  75 dBA Lex. Sources and magnitudes of measurement uncertainties are also discussed.

Pertussis surveillance and control: exploring variations and delays in testing, laboratory diagnostics and public health service notifications, the Netherlands, 2010 to 2013

PubMed Central

Heil, Jeanne; ter Waarbeek, Henriëtte L G; Hoebe, Christian J P A; Jacobs, Peter H A; van Dam, Dirk W; Trienekens, Thera A M; Cals, Jochen W L; van Loo, Inge H M; Dukers-Muijrers, Nicole H T M

2017-01-01

Pertussis is most severe among unvaccinated infants (< 1 year of age), and still leads to several reported deaths in the Netherlands every year. In order to avoid pertussis-related infant morbidity and mortality, pertussis surveillance data are used to guide pertussis control measures. However, more insight into the accuracy of pertussis surveillance and control, and into the range of healthcare and public health-related factors that impede this are needed. We analysed a unique combination of data sources from one Dutch region of 1.1 million residents, including data from laboratory databases and local public health notifications between 2010 and 2013. This large study (n = 12,090 pertussis tests) reveals possible misdiagnoses, substantial under-notification (18%, 412/2,301 laboratory positive episodes) and a delay between patient symptoms and notification to the local public health services (median 34 days, interquartile range (IQR): 27–54). It is likely that the misdiagnoses, under-notification and overall delay in surveillance data are not unique to this area of the Netherlands, and are generalisable to other countries in Europe. In addition to preventive measures such as maternal immunisation, based on current findings, we further recommend greater adherence to testing guidelines, standardisation of test interpretation guidelines, use of automatic notification systems and earlier preventive measures. PMID:28749331

Development of anti-velaglucerase alfa antibodies in clinical trial-treated patients with Gaucher disease.

PubMed

Pastores, Gregory M; Turkia, Hadhami Ben; Gonzalez, Derlis E; Ida, Hiroyuki; Tantawy, Azza A G; Qin, Yulin; Qiu, Yongchang; Dinh, Quinn; Zimran, Ari

2016-07-01

Anti-drug antibodies may develop with biological therapies, possibly leading to a reduction of treatment efficacy and to allergic and other adverse reactions. Patients with Gaucher disease were tested for anti-drug antibodies every 6 or 12weeks in clinical studies of velaglucerase alfa enzyme replacement therapy, as part of a range of safety endpoints. In 10 studies between April 2004 and March 2015, 289 patients aged 2-84years (median 43years) were assessed for the development of anti-velaglucerase alfa antibodies. Sixty-four patients were treatment-naïve at baseline and 225 patients were switched to velaglucerase alfa from imiglucerase treatment. They received velaglucerase alfa treatment for a median of 36.4weeks (interquartile range 26.4-155.4weeks). Four patients (1.4%) became positive for anti-velaglucerase alfa IgG antibodies, two of whom had antibodies that were neutralizing in vitro, but there were no apparent changes in patients' platelet counts, hemoglobin levels or levels of CCL18 and chitotriosidase, suggestive of clinical deterioration after anti-velaglucerase alfa antibodies were detected, and no infusion-related adverse events were reported. Less than 2% of patients exposed to velaglucerase alfa tested positive for antibodies and there was no apparent correlation between anti-velaglucerase alfa antibodies and adverse events or pharmacodynamic or clinical responses. Copyright © 2016. Published by Elsevier Inc.

Transdermal testosterone pretreatment in poor responders undergoing ICSI: a randomized clinical trial.

PubMed

Bosdou, J K; Venetis, C A; Dafopoulos, K; Zepiridis, L; Chatzimeletiou, K; Anifandis, G; Mitsoli, A; Makedos, A; Messinis, I E; Tarlatzis, B C; Kolibianakis, E M

2016-05-01

Does pretreatment with transdermal testosterone increase the number of cumulus-oocyte complexes (COCs) retrieved by more than 1.5 in poor responders undergoing intracytoplasmic sperm injection (ICSI), using recombinant follicle stimulating hormone (FSH) and gonadotrophin releasing hormone agonists (GnRHa)? Testosterone pretreatment failed to increase the number of COCs by more than 1.5 as compared with no pretreatment in poor responders undergoing ICSI (difference between medians: 0.0, 95% CI: -1.0 to +1.0). Androgens are thought to play an important role in early follicular development by enhancing ovarian sensitivity to FSH. In a recent meta-analysis, testosterone pretreatment resulted in an increase of 1.5 COCs as compared with no pretreatment. However, this effect was based on the analysis of only two randomized controlled trials (RCTs) including 163 patients. Evidently, there is a need for additional RCTs that will allow firmer conclusions to be drawn. The present RCT was designed to detect a difference of 1.5 COCs (sample size required = 48 patients). From 02/2014 until 04/2015, 50 poor responders fulfilling the Bologna criteria have been randomized (using a randomization list) to either testosterone pretreatment for 21 days ( ITALIC! n = 26) or no pretreatment ( ITALIC! n = 24). All patients underwent a long follicular GnRHa protocol. Recombinant FSH stimulation was started on Day 22 following GnRHa initiation. In the testosterone pretreatment group, a daily dose of 10 mg of testosterone gel was applied transdermally for 21 days starting from GnRHa initiation. Results are expressed as median (interquartile range). No differences in baseline characteristics were observed between the two groups compared. Testosterone levels [median (interquartile range)] were significantly higher in the testosterone pretreatment on the day of initiation of FSH stimulation [114 (99.5) ng/dl versus 20 (20) ng/dl, respectively, ITALIC! P < 0.001]. Duration of FSH stimulation [median (interquartile range)] was similar between the groups compared [12.5 (3.0) days versus 12 (3.0) days, respectively, ITALIC! P = 0.52]. The number of COCs retrieved [median (interquartile range)] was not different between the testosterone pretreatment and the no pretreatment groups [3.5 (4.0) versus 3.0 (3.0), 95% CI for the median: 2.0-5.0 versus 2.7-4.3, respectively; difference between medians: 0.0, 95% CI: +1.0 to -1.0). Similarly no differences were observed regarding fertilization rates [median (interquartile range)] [66.7% (32.5) versus 66.7% (42.9), respectively, ITALIC! P = 0.97] and live birth rates per randomized patient (7.7% versus 8.3%, respectively, rate difference: -0.6%, 95% CI: -19.0 to +16.9). The study was not powered to detect differences less than 1.5 COCs, although it is doubtful whether these differences would be clinically relevant. Moreover, due to sample size restrictions, no conclusions can be drawn regarding the probability of live birth. The results of this randomized clinical trial, suggesting that pretreatment with 10 mg of transdermal testosterone for 21 days does not improve ovarian response by more than 1.5 oocytes, could be used to more accurately consult patients with poor ovarian response. However, an improvement in IVF outcome using a higher dose of testosterone or a longer pretreatment period cannot be excluded. The study was partially funded by a Scholarship from the Academy of Athens. C.A.V. reports personal fees and non-financial support from Merck, Sharp and Dome, personal fees and non-financial support from Merck Serono, personal fees and non-financial support from IPSEN Hellas S.A., outside the submitted work. B.C.T. reports grants from Merck Serono, grants from Merck Sharp & Dohme, personal fees from Merck Serono, personal fees from Merck Sharp & Dohme, personal fees from IBSA & Ferring, outside the submitted work. NCT01961336. 10 October 2013. 02/2014. © The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Autologous Bone Plug Supplemented With Autologous Chondrocyte Implantation in Osteochondral Defects of the Knee.

PubMed

Bhattacharjee, Atanu; McCarthy, Helen S; Tins, Bernhard; Roberts, Sally; Kuiper, J H; Harrison, Paul E; Richardson, James B

2016-05-01

Structural and functional outcome of bone graft with first- or second-generation autologous chondrocyte implantation (ACI) in treating cartilage and subchondral bone defect has not been reported previously. To evaluate the outcome of simultaneous transplantation of an autologous bone plug with first- or second-generation ACI for restoration of concomitant subchondral bone and full-thickness cartilage defect in the femoral condyle of the knee. Case series; Level of evidence, 4. Seventeen patients (mean ± SD age, 27 ± 7 years; range, 17-40 years)-12 with osteochondritis dissecans (International Cartilage Repair Society [ICRS] grades 3 and 4) and 5 with an isolated osteochondral defect (ICRS grade 4)-had the defect reconstructed with implantation of a unicortical autologous bone graft combined with ACI (the OsPlug technique). Functional outcome was assessed with Lysholm scores obtained preoperatively and at 1 and 5 years postoperatively. The repair site was evaluated with the Oswestry Arthroscopy Score (OAS), MOCART score (magnetic resonance observation of cartilage repair tissue), and ICRS II histology score. Formation of a subchondral lamina and lateral integration of the bone grafts were evaluated from magnetic resonance imaging scans. The mean defect size was 4.5 ± 2.6 cm(2) (range, 1-9 cm(2)), and the mean depth was 11.3 ± 5 mm (range, 5-18 mm). The preoperative Lysholm score improved from 45 (interquartile range [IQR], 24; range, 16-79) to 77 (IQR, 28; range, 41-100) at 1 year (P = .001) and 70 (IQR, 35; range, 33-91) at 5 years (P = .009). The mean OAS of the repair site was 6.2 (range, 0-9) at a mean of 1.3 years. The mean MOCART score was 61 ± 22 (range, 20-85) at 2.6 ± 1.8 years. Histology demonstrated generally good integration of the repair cartilage with the underlying bone. Poor lateral integration of the bone graft, as assessed on magnetic resonance imaging scan, and a low OAS were significantly associated with a poor Lysholm score and failure. A total of 3 patients had treatment failure, with 1 requiring total knee replacement at 5 years (Lysholm score of 33 at failure) and the other 2 requiring further surgical intervention because of persistent symptoms at 2 and 4 years, respectively (both had Lysholm score of 45 at failure). The Lysholm score in these patients before failure were still noted to be higher than at the preoperative level. The OsPlug technique shows significant improvement of functional outcome for up to 5 years in patients with high-grade osteochondritis dissecans or osteochondral defect. This is the first report describing association of bone graft integration with functional outcome after such a procedure. It also demonstrates histologic evidence of integration of the repair cartilage with the underlying bone graft. © 2016 The Author(s).

Prevalence of the metabolic syndrome and cardiovascular disease risk in chemotherapy-treated testicular germ cell tumour survivors.

PubMed

Willemse, P M; Burggraaf, J; Hamdy, N A T; Weijl, N I; Vossen, C Y; van Wulften, L; van Steijn-van Tol, A Q M J; Rosendaal, F R; Osanto, S

2013-07-09

Testicular cancer patients have an increased risk for cardiovascular disease (CVD), which might be related to the increased prevalence of the metabolic syndrome (MetS) in this group of patients. We assessed the prevalence of MetS and calculated the 10-year CVD risk in a cohort of 255 testicular germ cell tumour survivors (median age, 38.7 years; interquartile range, 31-48) at a mean of 7.8 years after anti-cancer treatment, and compared these with data obtained from 360 healthy men. Survivors had an age-adjusted increased risk for MetS of 1.9 compared with that of healthy controls. The risk for MetS was highest in survivors treated with combination chemotherapy (CT) 2.3 (Adult Treatment Panel of the National Cholesterol Education Program classification) and 2.2 (International Diabetes Federation classification). The risk of MetS was especially increased in survivors with testosterone levels in the lowest quartile (OR, 2.5). Ten-year cardiovascular risk as assessed by the Framingham Risk Score (3.0%) and Systemic Coronary Risk Evaluation (1.7%) algorithms was low, independent of treatment, and was comparable to controls. Testicular germ cell tumour survivors have an increased prevalence of MetS, with hypogonadism and CT treatment being clear risk factors for the development of the syndrome. The increased prevalence of MetS was not associated with an increased 10-year cardiovascular risk.

Long-term functional outcomes after artificial urinary sphincter implantation in women with stress urinary incontinence.

PubMed

Phé, Véronique; Benadiba, Steeve; Rouprêt, Morgan; Granger, Benjamin; Richard, François; Chartier-Kastler, Emmanuel

2014-06-01

To assess the long-term outcomes obtained after artificial urinary sphincter (AUS) implantation in women with stress urinary incontinence (SUI). Women with SUI caused by intrinsic sphincter deficiency who underwent an AUS placement between 1984 and 1992 were included. Explantation, revision and deactivation rates of the AUS were reported. Continence, defined as no pad use, was assessed at the end of the follow-up. Kaplan-Meier survival curves were generated to evaluate the survival rate of the device without explantation or revision. A total of 34 patients were included. The median (interquartile range [IQR]) age of the patients at surgery was 56.5 (50-64.7) years and the median (IQR) follow-up was 17 (12-19) years. Overall, 26 women (74%) still had their AUS in place at the end of the follow-up, while eight patients underwent an explantation of the device. The 10-, 15- and 20-year device survival rates without explantation were 80, 80 and 74%, respectively. The 10-, 15- and 20-year survival rates of the device without revision were 79, 65 and 40%, respectively. After 20 years of follow-up, 11 women still had successful outcomes (61%). The AUS provided satisfactory very long-term functional results among women with SUI caused by intrinsic sphincter deficiency. © 2013 The Authors. BJU International © 2013 BJU International.

Low bone mineral density among HIV-infected patients in Brazil

PubMed Central

Chaba, Daniela Cardeal da Silva; Soares, Lisméia R.; Pereira, Rosa M. R.; Rutherford, George W.; Assone, Tatiane; Takayama, Liliam; Fonseca, Luiz A. M.; Duarte, Alberto J. S.; Casseb, Jorge

2017-01-01

ABSTRACT Decrease in bone mineral density (BMD) has been a complication among people living with HIV/AIDS. To investigate the prevalence of osteopenia/osteoporosis among HIV-infected people living in São Paulo city, we studied 108 HIV-infected patients (79 men and 29 women). We extracted data from patients’ medical records and BMD was measured by dual-energy X-ray absorptiometry (DXA). Median age of participants was 42 years (interquartile range [IQR] 36-48 years), and the median time since HIV diagnosis was 4.01 years (IQR 2-11 years). Patients had acquired HIV primarily by the sexual route (men who have sex with men 44%, heterosexual 49%). Median age, duration of HIV infection, duration of ART and CD4 nadir were similar for men and women. Plasma viral load was undetectable for 53 patients (49%). Median CD4 T cell count was 399 cells/µL (IQR 247 - 568). Twenty five patients (23%) had LBMD, and there was no statistically significant difference between men and women (<-1). The associated risk factors for LBMD were older age (≥ 50 years old) and smoking with a RR of 3.87 and 2.80, respectively. Thus, despite the lack of statistically significant relationship between the use of ART and LBMD or between duration of ART and LBMD, these factors should be addressed in larger studies. PMID:29267597

Geographic clustering of elevated blood heavy metal levels in pregnant women.

PubMed

King, Katherine E; Darrah, Thomas H; Money, Eric; Meentemeyer, Ross; Maguire, Rachel L; Nye, Monica D; Michener, Lloyd; Murtha, Amy P; Jirtle, Randy; Murphy, Susan K; Mendez, Michelle A; Robarge, Wayne; Vengosh, Avner; Hoyo, Cathrine

2015-10-09

Cadmium (Cd), lead (Pb), mercury (Hg), and arsenic (As) exposure is ubiquitous and has been associated with higher risk of growth restriction and cardiometabolic and neurodevelopmental disorders. However, cost-efficient strategies to identify at-risk populations and potential sources of exposure to inform mitigation efforts are limited. The objective of this study was to describe the spatial distribution and identify factors associated with Cd, Pb, Hg, and As concentrations in peripheral blood of pregnant women. Heavy metals were measured in whole peripheral blood of 310 pregnant women obtained at gestational age ~12 weeks. Prenatal residential addresses were geocoded and geospatial analysis (Getis-Ord Gi* statistics) was used to determine if elevated blood concentrations were geographically clustered. Logistic regression models were used to identify factors associated with elevated blood metal levels and cluster membership. Geospatial clusters for Cd and Pb were identified with high confidence (p-value for Gi* statistic <0.01). The Cd and Pb clusters comprised 10.5 and 9.2 % of Durham County residents, respectively. Medians and interquartile ranges of blood concentrations (μg/dL) for all participants were Cd 0.02 (0.01-0.04), Hg 0.03 (0.01-0.07), Pb 0.34 (0.16-0.83), and As 0.04 (0.04-0.05). In the Cd cluster, medians and interquartile ranges of blood concentrations (μg/dL) were Cd 0.06 (0.02-0.16), Hg 0.02 (0.00-0.05), Pb 0.54 (0.23-1.23), and As 0.05 (0.04-0.05). In the Pb cluster, medians and interquartile ranges of blood concentrations (μg/dL) were Cd 0.03 (0.02-0.15), Hg 0.01 (0.01-0.05), Pb 0.39 (0.24-0.74), and As 0.04 (0.04-0.05). Co-exposure with Pb and Cd was also clustered, the p-values for the Gi* statistic for Pb and Cd was <0.01. Cluster membership was associated with lower education levels and higher pre-pregnancy BMI. Our data support that elevated blood concentrations of Cd and Pb are spatially clustered in this urban environment compared to the surrounding areas. Spatial analysis of metals concentrations in peripheral blood or urine obtained routinely during prenatal care can be useful in surveillance of heavy metal exposure.

The Influence of Prednisone on the Efficacy of Cabazitaxel in Men with Metastatic Castration-Resistant Prostate Cancer.

PubMed

Buonerba, Carlo; Sonpavde, Guru; Vitrone, Francesca; Bosso, Davide; Puglia, Livio; Izzo, Michela; Iaccarino, Simona; Scafuri, Luca; Muratore, Margherita; Foschini, Francesca; Mucci, Brigitta; Tortora, Vincenzo; Pagliuca, Martina; Ribera, Dario; Riccio, Vittorio; Morra, Rocco; Mosca, Mirta; Cesarano, Nicola; Di Costanzo, Ileana; De Placido, Sabino; Di Lorenzo, Giuseppe

2017-01-01

Background: Cabazitaxel is a second-generation taxane that is approved for use with concomitant low dose daily prednisone in metastatic castration resistant prostate cancer (mCRPC) after docetaxel failure. Since the role of daily corticosteroids in improving cabazitaxel efficacy or ameliorating its safety profile has not been adequately investigated so far, we compared outcomes of patients receiving cabazitaxel with or without daily corticosteroids in a retrospective single-Institution cohort of mCRPC patients. Patients and methods: Medical records of deceased patients with documented mCRPC treated with cabazitaxel following prior docetaxel between January, 2011 and January, 2017 were reviewed at the single participating center. Patients who were receiving daily doses of systemic corticosteroids other than low dose daily prednisone or prednisolone (<= 10 mg a day) were excluded. The primary end point of this analysis was overall survival (OS). Secondary end-points were exposure to cabazitaxel as well as incidence of grade 3-4 adverse events. Univariable and multivariable Cox proportional hazards regression was used to evaluate prednisone use and other variables as potentially prognostic for overall survival. Results: Overall, among 91 patients, 57 patients received cabazitaxel concurrently with low dose prednisone and 34 patients did not receive concurrent prednisone. The median overall survival of the population was 9.8 months (interquartile range, 9 to 14). Patients receiving prednisone had an overall survival of 9 months (interquartile range, 8 to 12) vs.14 months (interquartile range, 9.4 to 16.7) for patients not treated with prednisone. Approximately 45% of patients had a >30% PSA decline at 12 weeks. Prednisone use was not significantly prognostic for overall survival or PSA decline ≥30% rates on regression analyses. Importantly, a >30% PSA decline at 12, but not at 3, 6, 9 weeks, was prognostic for improved survival at multivariate analysis Conclusions: The data presented here support the hypothesis that omitting daily corticosteroids in cabazitaxel-treated patients has no negative impact on either survival or safety profile. In the large prospective trial CABACARE, cabazitaxel-treated patients will be randomized to receive or not receive daily prednisone. The CABACARE (EudraCT n. 2016-003646-81) study is currently ongoing at University Federico II of Naples and at other multiple participating centers in Italy.

The Influence of Prednisone on the Efficacy of Cabazitaxel in Men with Metastatic Castration-Resistant Prostate Cancer

PubMed Central

Buonerba, Carlo; Sonpavde, Guru; Vitrone, Francesca; Bosso, Davide; Puglia, Livio; Izzo, Michela; Iaccarino, Simona; Scafuri, Luca; Muratore, Margherita; Foschini, Francesca; Mucci, Brigitta; Tortora, Vincenzo; Pagliuca, Martina; Ribera, Dario; Riccio, Vittorio; Morra, Rocco; Mosca, Mirta; Cesarano, Nicola; Di Costanzo, Ileana; De Placido, Sabino; Di Lorenzo, Giuseppe

2017-01-01

Background: Cabazitaxel is a second-generation taxane that is approved for use with concomitant low dose daily prednisone in metastatic castration resistant prostate cancer (mCRPC) after docetaxel failure. Since the role of daily corticosteroids in improving cabazitaxel efficacy or ameliorating its safety profile has not been adequately investigated so far, we compared outcomes of patients receiving cabazitaxel with or without daily corticosteroids in a retrospective single-Institution cohort of mCRPC patients. Patients and methods: Medical records of deceased patients with documented mCRPC treated with cabazitaxel following prior docetaxel between January, 2011 and January, 2017 were reviewed at the single participating center. Patients who were receiving daily doses of systemic corticosteroids other than low dose daily prednisone or prednisolone (<= 10 mg a day) were excluded. The primary end point of this analysis was overall survival (OS). Secondary end-points were exposure to cabazitaxel as well as incidence of grade 3-4 adverse events. Univariable and multivariable Cox proportional hazards regression was used to evaluate prednisone use and other variables as potentially prognostic for overall survival. Results: Overall, among 91 patients, 57 patients received cabazitaxel concurrently with low dose prednisone and 34 patients did not receive concurrent prednisone. The median overall survival of the population was 9.8 months (interquartile range, 9 to 14). Patients receiving prednisone had an overall survival of 9 months (interquartile range, 8 to 12) vs.14 months (interquartile range, 9.4 to 16.7) for patients not treated with prednisone. Approximately 45% of patients had a >30% PSA decline at 12 weeks. Prednisone use was not significantly prognostic for overall survival or PSA decline ≥30% rates on regression analyses. Importantly, a >30% PSA decline at 12, but not at 3, 6, 9 weeks, was prognostic for improved survival at multivariate analysis Conclusions: The data presented here support the hypothesis that omitting daily corticosteroids in cabazitaxel-treated patients has no negative impact on either survival or safety profile. In the large prospective trial CABACARE, cabazitaxel-treated patients will be randomized to receive or not receive daily prednisone. The CABACARE (EudraCT n. 2016-003646-81) study is currently ongoing at University Federico II of Naples and at other multiple participating centers in Italy. PMID:28928853

Hourly differences in air pollution and risk of respiratory disease in the elderly: a time-stratified case-crossover study.

PubMed

Yorifuji, Takashi; Suzuki, Etsuji; Kashima, Saori

2014-08-13

Epidemiological studies have shown adverse effects of short-term exposure to air pollution on respiratory disease outcomes; however, few studies examined this association on an hourly time scale. We evaluated the associations between hourly changes in air pollution and the risk of respiratory disease in the elderly, using the time of the emergency call as the disease onset for each case. We used a time-stratified case-crossover design. Study participants were 6,925 residents of the city of Okayama, Japan, aged 65 or above who were taken to hospital emergency rooms between January 2006 and December 2010 for onset of respiratory disease. We calculated city-representative hourly average concentrations of air pollutants from several monitoring stations. By using conditional logistic regression models, we estimated odds ratios per interquartile-range increase in each pollutant by exposure period prior to emergency call, adjusting for hourly ambient temperature, hourly relative humidity, and weekly numbers of reported influenza cases aged ≥60. Suspended particulate matter (SPM) exposure 24 to <72 hours prior to the onset and ozone exposure 48 to <96 hours prior to the onset were associated with the increased risk of respiratory disease. For example, following one interquartile-range increase, odds ratios were 1.05 (95% confidence interval: 1.01, 1.09) for SPM exposure 24 to <48 hours prior to the onset and 1.13 (95% confidence interval: 1.04, 1.23) for ozone exposure 72 to <96 hours prior to the onset. Sulfur dioxide (SO2) exposure 0 to <24 hours prior to onset was associated with the increased risk of pneumonia and influenza: odds ratio was 1.07 per one interquartile-range increase (95% confidence interval: 1.00, 1.14). Elevated risk for pneumonia and influenza of SO2 was observed at shorter lags (i.e., 8-18 hours) than the elevated risks for respiratory disease of SPM or ozone. Overall, the effect estimates for chronic obstructive pulmonary disease and allied conditions were equivocal. This study provides further evidence that hourly changes in air pollution exposure increase the risks of respiratory disease, and that SO2 may be related with more immediate onset of the disease than other pollutants.

Estimation of distributional parameters for censored trace level water quality data: 1. Estimation techniques

USGS Publications Warehouse

Gilliom, Robert J.; Helsel, Dennis R.

1986-01-01

A recurring difficulty encountered in investigations of many metals and organic contaminants in ambient waters is that a substantial portion of water sample concentrations are below limits of detection established by analytical laboratories. Several methods were evaluated for estimating distributional parameters for such censored data sets using only uncensored observations. Their reliabilities were evaluated by a Monte Carlo experiment in which small samples were generated from a wide range of parent distributions and censored at varying levels. Eight methods were used to estimate the mean, standard deviation, median, and interquartile range. Criteria were developed, based on the distribution of uncensored observations, for determining the best performing parameter estimation method for any particular data set. The most robust method for minimizing error in censored-sample estimates of the four distributional parameters over all simulation conditions was the log-probability regression method. With this method, censored observations are assumed to follow the zero-to-censoring level portion of a lognormal distribution obtained by a least squares regression between logarithms of uncensored concentration observations and their z scores. When method performance was separately evaluated for each distributional parameter over all simulation conditions, the log-probability regression method still had the smallest errors for the mean and standard deviation, but the lognormal maximum likelihood method had the smallest errors for the median and interquartile range. When data sets were classified prior to parameter estimation into groups reflecting their probable parent distributions, the ranking of estimation methods was similar, but the accuracy of error estimates was markedly improved over those without classification.

Assessing the Influence of Traffic-related Air Pollution on Risk of Term Low Birth Weight on the Basis of Land-Use-based Regression Models and Measures of Air Toxics

PubMed Central

Ghosh, Jo Kay C.; Wilhelm, Michelle; Su, Jason; Goldberg, Daniel; Cockburn, Myles; Jerrett, Michael; Ritz, Beate

2012-01-01

Few studies have examined associations of birth outcomes with toxic air pollutants (air toxics) in traffic exhaust. This study included 8,181 term low birth weight (LBW) children and 370,922 term normal-weight children born between January 1, 1995, and December 31, 2006, to women residing within 5 miles (8 km) of an air toxics monitoring station in Los Angeles County, California. Additionally, land-use-based regression (LUR)-modeled estimates of levels of nitric oxide, nitrogen dioxide, and nitrogen oxides were used to assess the influence of small-area variations in traffic pollution. The authors examined associations with term LBW (≥37 weeks’ completed gestation and birth weight <2,500 g) using logistic regression adjusted for maternal age, race/ethnicity, education, parity, infant gestational age, and gestational age squared. Odds of term LBW increased 2%–5% (95% confidence intervals ranged from 1.00 to 1.09) per interquartile-range increase in LUR-modeled estimates and monitoring-based air toxics exposure estimates in the entire pregnancy, the third trimester, and the last month of pregnancy. Models stratified by monitoring station (to investigate air toxics associations based solely on temporal variations) resulted in 2%–5% increased odds per interquartile-range increase in third-trimester benzene, toluene, ethyl benzene, and xylene exposures, with some confidence intervals containing the null value. This analysis highlights the importance of both spatial and temporal contributions to air pollution in epidemiologic birth outcome studies. PMID:22586068

Estimation of distributional parameters for censored trace level water quality data. 1. Estimation Techniques

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gilliom, R.J.; Helsel, D.R.

1986-02-01

A recurring difficulty encountered in investigations of many metals and organic contaminants in ambient waters is that a substantial portion of water sample concentrations are below limits of detection established by analytical laboratories. Several methods were evaluated for estimating distributional parameters for such censored data sets using only uncensored observations. Their reliabilities were evaluated by a Monte Carlo experiment in which small samples were generated from a wide range of parent distributions and censored at varying levels. Eight methods were used to estimate the mean, standard deviation, median, and interquartile range. Criteria were developed, based on the distribution of uncensoredmore » observations, for determining the best performing parameter estimation method for any particular data det. The most robust method for minimizing error in censored-sample estimates of the four distributional parameters over all simulation conditions was the log-probability regression method. With this method, censored observations are assumed to follow the zero-to-censoring level portion of a lognormal distribution obtained by a least squares regression between logarithms of uncensored concentration observations and their z scores. When method performance was separately evaluated for each distributional parameter over all simulation conditions, the log-probability regression method still had the smallest errors for the mean and standard deviation, but the lognormal maximum likelihood method had the smallest errors for the median and interquartile range. When data sets were classified prior to parameter estimation into groups reflecting their probable parent distributions, the ranking of estimation methods was similar, but the accuracy of error estimates was markedly improved over those without classification.« less

Estimation of distributional parameters for censored trace-level water-quality data

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gilliom, R.J.; Helsel, D.R.

1984-01-01

A recurring difficulty encountered in investigations of many metals and organic contaminants in ambient waters is that a substantial portion of water-sample concentrations are below limits of detection established by analytical laboratories. Several methods were evaluated for estimating distributional parameters for such censored data sets using only uncensored observations. Their reliabilities were evaluated by a Monte Carlo experiment in which small samples were generated from a wide range of parent distributions and censored at varying levels. Eight methods were used to estimate the mean, standard deviation, median, and interquartile range. Criteria were developed, based on the distribution of uncensored observations,more » for determining the best-performing parameter estimation method for any particular data set. The most robust method for minimizing error in censored-sample estimates of the four distributional parameters over all simulation conditions was the log-probability regression method. With this method, censored observations are assumed to follow the zero-to-censoring level portion of a lognormal distribution obtained by a least-squares regression between logarithms of uncensored concentration observations and their z scores. When method performance was separately evaluated for each distributional parameter over all simulation conditions, the log-probability regression method still had the smallest errors for the mean and standard deviation, but the lognormal maximum likelihood method had the smallest errors for the median and interquartile range. When data sets were classified prior to parameter estimation into groups reflecting their probable parent distributions, the ranking of estimation methods was similar, but the accuracy of error estimates was markedly improved over those without classification. 6 figs., 6 tabs.« less

Accurate assessment of adherence: self-report and clinician report vs electronic monitoring of nebulizers.

PubMed

Daniels, Tracey; Goodacre, Lynne; Sutton, Chris; Pollard, Kim; Conway, Steven; Peckham, Daniel

2011-08-01

People with cystic fibrosis have a high treatment burden. While uncertainty remains about individual patient level of adherence to medication, treatment regimens are difficult to tailor, and interventions are difficult to evaluate. Self- and clinician-reported measures are routinely used despite criticism that they overestimate adherence. This study assessed agreement between rates of adherence to prescribed nebulizer treatments when measured by self-report, clinician report, and electronic monitoring suitable for long-term use. Seventy-eight adults with cystic fibrosis were questioned about their adherence to prescribed nebulizer treatments over the previous 3 months. Self-report was compared with clinician report and stored adherence data downloaded from the I-Neb nebulizer system. Adherence measures were expressed as a percentage of the prescribed regimen, bias was estimated by the paired difference in mean (95% CI) patient and clinician reported and actual adherence. Agreement between adherence measures was calculated using intraclass correlation coefficients (95% CI), and disagreements for individuals were displayed using Bland-Altman plots. Patient-identified prescriptions matched the medical record prescription. Median self-reported adherence was 80% (interquartile range, 60%-95%), whereas median adherence measured by nebulizer download was 36% (interquartile range, 5%-84.5%). Nine participants overmedicated and underreported adherence. Median clinician report ranged from 50% to 60%, depending on profession. Extensive discrepancies between self-report and clinician report compared with nebulizer download were identified for individuals. Self- and clinician-reporting of adherence does not provide accurate measurement of adherence when compared with electronic monitoring. Using inaccurate measures has implications for treatment burden, clinician prescribing practices, cost, and accuracy of trial data.

Assessing the influence of traffic-related air pollution on risk of term low birth weight on the basis of land-use-based regression models and measures of air toxics.

PubMed

Ghosh, Jo Kay C; Wilhelm, Michelle; Su, Jason; Goldberg, Daniel; Cockburn, Myles; Jerrett, Michael; Ritz, Beate

2012-06-15

Few studies have examined associations of birth outcomes with toxic air pollutants (air toxics) in traffic exhaust. This study included 8,181 term low birth weight (LBW) children and 370,922 term normal-weight children born between January 1, 1995, and December 31, 2006, to women residing within 5 miles (8 km) of an air toxics monitoring station in Los Angeles County, California. Additionally, land-use-based regression (LUR)-modeled estimates of levels of nitric oxide, nitrogen dioxide, and nitrogen oxides were used to assess the influence of small-area variations in traffic pollution. The authors examined associations with term LBW (≥37 weeks' completed gestation and birth weight <2,500 g) using logistic regression adjusted for maternal age, race/ethnicity, education, parity, infant gestational age, and gestational age squared. Odds of term LBW increased 2%-5% (95% confidence intervals ranged from 1.00 to 1.09) per interquartile-range increase in LUR-modeled estimates and monitoring-based air toxics exposure estimates in the entire pregnancy, the third trimester, and the last month of pregnancy. Models stratified by monitoring station (to investigate air toxics associations based solely on temporal variations) resulted in 2%-5% increased odds per interquartile-range increase in third-trimester benzene, toluene, ethyl benzene, and xylene exposures, with some confidence intervals containing the null value. This analysis highlights the importance of both spatial and temporal contributions to air pollution in epidemiologic birth outcome studies.

Sympathetic nerve dysfunction is common in patients with chronic intestinal pseudo-obstruction.

PubMed

Mattsson, Tomas; Roos, Robert; Sundkvist, Göran; Valind, Sven; Ohlsson, Bodil

2008-02-01

To clarify whether disturbances in the autonomic nervous system, reflected in abnormal cardiovascular reflexes, could explain symptoms of impaired heat regulation in patients with intestinal pseudo-obstruction. Chronic intestinal pseudo-obstruction is a clinical syndrome characterized by diffuse, unspecific gastrointestinal symptoms due to damage to the enteric nervous system or the smooth muscle cells. These patients often complain of excessive sweating or feeling cold, suggesting disturbances in the autonomic nervous system. Earlier studies have pointed to a coexistence of autonomic disturbances in the enteric and cardiovascular nervous system. Thirteen consecutive patients (age range 23 to 79, mean 44 y) fulfilling the criteria for chronic intestinal pseudo-obstruction were investigated. Six of them complained of sweating or a feeling of cold. Examination of autonomic reflexes included heart rate variation to deep-breathing (expiration/inspiration index), heart rate reaction to tilt (acceleration index, brake index), and vasoconstriction (VAC) due to indirect cooling by laser doppler (VAC-index; high index indicates impaired VAC). Test results in patients were compared with healthy individuals. Patients had significantly higher (more abnormal) median VAC-index compared with healthy controls [1.79 (interquartile ranges 1.89) vs. 0.08 (interquartile ranges 1.29); P=0.0007]. However, symptoms of impaired heat regulation were not related to the VAC-index. There were no differences in expiration/inspiration, acceleration index, or brake index between patients and controls. The patients with severe gastrointestinal dysmotility showed impaired sympathetic nerve function which, however, did not seem to be associated with symptoms of impaired heat regulation.

Outcome of repeated prostatic biopsy during active surveillance: implications for focal therapy.

PubMed

Barayan, Ghassan A; Aprikian, Armen G; Hanley, James; Kassouf, Wassim; Brimo, Fadi; Bégin, Louis R; Tanguay, Simon

2015-09-01

Active surveillance (AS) is commonly recommended for men with localized low-intermediate-risk prostate cancer (PCa). The aim of our study was to assess the probability that patients with PCa would develop unfavorable disease features (UDF) while under AS for the purpose of evaluating whether immediate hemiablation therapy (HAT) could bring clinical benefit to selected patients. In our cohort of AS patients, 157 were diagnosed with unilateral PCa. Using five different definitions of UDF, patients' data were used to simulate the theoretical outcome whether these patients were managed by immediate unilateral HAT or remained on AS. The mean age at the time of diagnosis was 67 years (range 47-81). The median follow-up was 5.4 years [interquartile range (IQR) 3.4-8]. Baseline characteristics included a median PSA value of 5.5 ng/ml (IQR 4.5-7), median number of biopsy taken of 10 (IQR 6-10), and maximum cancer percentage on any core of 10 (IQR 5-20). Of the 157 patients, 144 (92 %) had a Gleason score (GS) of ≤6. Using the whole range of definition for UDF, 10-47 % of patients developed UDF while under AS. Using baseline GS, maximum percentage of cancer on any core, and PSA density, we found significant trends for higher development of UDF for patients under AS. The majority of our patients did not develop UDF while under AS. Our study, thus, suggests that careful patient selection for focal therapy should be performed to avoid subjecting patients to unnecessary treatment.

Lentigo Maligna - Not Always a Face and Neck Disease of the Elderly.

PubMed

Duarte, Ana Filipa; Sousa-Pinto, Bernardo; Barros, Ana Margarida; Haneke, Eckart; Correia, Osvaldo

2018-06-12

Lentigo maligna (LM) is a rare form of in situ melanoma, frequently seen as a large patch in elderly patients. The aim of this study was to assess clinical and dermoscopic features of LM. A retrospective study of LM patients presenting to our center between July 2007 and July 2017 was performed. Demographic data, anatomical location, laterality, diameter, Clark level, Breslow stage, "ABCD" signs and dermoscopic features were registered. Facial versus extrafacial LM were compared. We found 21 LM, of which 12 had an extrafacial location and 9 a facial location. Half of the extrafacial lesions were located on an upper limb. The median age at diagnosis was 63 years (ranging from 38 to 84 years). Most LM cases were female (16/21) with phototype II (13/21). More than half of the patients (11/21) had a history of a skin neoplasm or actinic keratosis. The median diameter found was 6 mm (interquartile range = 4.5 mm), ranging from 1 to 15 mm. Five lesions were invasive (median Breslow depth of 0.2 mm), and 4 of them were extrafacial. In this study LM was more frequently found in an extrafacial location and as a small patch with a 6-mm diameter medium. The epidemiology of LM/LM melanoma might be changing. Full body examination and dermoscopy are of the utmost importance for the diagnosis. Dermatologists should be aware and search for small lesions outside the face and neck, particularly in middle-aged female patients with photo-damaged skin. © 2018 S. Karger AG, Basel.

Transplacental Passage of Acetaminophen in Term Pregnancy.

PubMed

Nitsche, Joshua F; Patil, Avinash S; Langman, Loralie J; Penn, Hannah J; Derleth, Douglas; Watson, William J; Brost, Brian C

2017-05-01

Objective  The objective of this study was to determine the maternal and fetal pharmacokinetic (PK) profiles of acetaminophen after administration of a therapeutic oral dose. Study Design  After obtaining Institutional Review Board approval and their written informed consent, pregnant women were given a single oral dose (1,000 mg) of acetaminophen upon admission for scheduled cesarean delivery. Maternal venous blood and fetal cord blood were obtained at the time of delivery and acetaminophen levels were measured using gas chromatography-mass spectroscopy. PK parameters were calculated by noncompartmental analysis. Nonparametric correlation of maternal/fetal acetaminophen levels and PK curves were calculated. Results  In this study, 34 subjects were enrolled (median, 32 years; range, 25-39 years). The median maternal weight was 82 kg (range, 62-100 kg). All but two subjects were delivered beyond 39 weeks' gestation. The median newborn birth weight was 3,590 g (interquartile range, 3,403-3,848 g). Noncompartmental analysis described similar PK parameters in the maternal ( T 1/2 , 84 minutes; apparent clearance [Cl/F], 28.8 L/h; apparent volume of distribution [V d /F], 57.5 L) and fetal compartments ( T 1/2 , 82 minutes; Cl/F, 31.2 L/h; V d /F, 61.2 L). Paired maternal/fetal acetaminophen levels were highly correlated ( p  < 0.0001). Conclusion  Fetal acetaminophen PKs in the fetus parallels that in the mother suggesting that placental transfer is flow limited. Maternal acetaminophen levels can be used as a surrogate for fetal exposure. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The natural history of fibroids.

PubMed

Mavrelos, D; Ben-Nagi, J; Holland, T; Hoo, W; Naftalin, J; Jurkovic, D

2010-02-01

Fibroids are common, hormone-dependent, benign uterine tumors. They can cause significant morbidity and the symptoms depend largely on their size. The aim of this study was to describe the natural history of fibroids and identify factors that may influence their growth. This was a retrospective longitudinal study of premenopausal women who were diagnosed with uterine fibroids on ultrasound examination. All women underwent at least two transvaginal ultrasound scans, which were all performed by a single operator. Fibroids were measured in three perpendicular planes and the mean diameter was calculated. The size and position of every individual fibroid was assessed and recorded on a computerized database. The volume of each fibroid was calculated using the formula for a sphere. A total of 122 women were included in the study. Their median age at the initial examination was 40 (range, 27-45) years. Seventy-two (59.0%) were nulliparous and 74 (60.7%) had multiple fibroids. The median interval between the initial and final examination was 21.5 (range, 8-90) months. The median fibroid volume increased by 35.2% per year. Small fibroids (< 20 mm mean diameter) grew significantly faster than larger fibroids (P = 0.007). The median increase in size was significantly higher in cases of intramural fibroids (53.2 (interquartile range (IQR), 11.2-217)%) than in subserous fibroids (25.1 (IQR, 1.1-87.1)%) and submucous fibroids (22.8 (IQR, - 11.7 to 48.3)%) (P = 0.012). Multivariate analysis retained only fibroid size at presentation as an independent predictor of fibroid growth. The growth of fibroids in premenopausal women is influenced by the tumor's size at presentation.

The Kidney Donor Profile Index (KDPI) of marginal donors allocated by standardized pretransplant donor biopsy assessment: distribution and association with graft outcomes.

PubMed

Gandolfini, I; Buzio, C; Zanelli, P; Palmisano, A; Cremaschi, E; Vaglio, A; Piotti, G; Melfa, L; La Manna, G; Feliciangeli, G; Cappuccilli, M; Scolari, M P; Capelli, I; Panicali, L; Baraldi, O; Stefoni, S; Buscaroli, A; Ridolfi, L; D'Errico, A; Cappelli, G; Bonucchi, D; Rubbiani, E; Albertazzi, A; Mehrotra, A; Cravedi, P; Maggiore, U

2014-11-01

Pretransplant donor biopsy (PTDB)-based marginal donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the United States. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score<4 [median KDPI: 87; interquartile range (IQR): 78-94] and 62 with a score=4 [median KDPI: 87; IQR: 76-93]; 102 dual transplants [median KDPI: 93; IQR: 86-96]) and 248 single standard transplant controls (median KDPI: 36; IQR: 18-51). PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year estimated GFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9 and -18.8 mL/min, for dual transplants, single kidneys with PTDB score<4 and =4, respectively; p<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80-1.79; p=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded. © Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.

Anomaly Detection for Data Reduction in an Unattended Ground Sensor (UGS) Field

DTIC Science & Technology

2014-09-01

information (shown with solid lines in the diagram). Typically, this would be a mobile ad - hoc network (MANET). The clusters are connected to other nodes...interquartile ranges MANET mobile ad - hoc network OSUS Open Standards for Unattended Sensors TOC tactical operations center UAVs unmanned aerial vehicles...19b. TELEPHONE NUMBER (Include area code ) 301-394-1221 Standard Form 298 (Rev. 8/98) Prescribed by ANSI Std. Z39.18 iii Contents List of

Compact near-IR and mid-IR cavity ring down spectroscopy device

NASA Technical Reports Server (NTRS)

Miller, J. Houston (Inventor)

2011-01-01

This invention relates to a compact cavity ring down spectrometer for detection and measurement of trace species in a sample gas using a tunable solid-state continuous-wave mid-infrared PPLN OPO laser or a tunable low-power solid-state continuous wave near-infrared diode laser with an algorithm for reducing the periodic noise in the voltage decay signal which subjects the data to cluster analysis or by averaging of the interquartile range of the data.

Maternal serum amyloid A level as a novel marker of primary unexplained recurrent early pregnancy loss.

PubMed

Ibrahim, Moustafa I; Ramy, Ahmed R; Abdelhamid, Ahmed S; Ellaithy, Mohamed I; Omar, Amna; Harara, Rany M; Fathy, Hayam; Abolouz, Ashraf S

2017-03-01

To assess maternal serum amyloid A (SAA) levels among women with primary unexplained recurrent early pregnancy loss (REPL). A prospective study was conducted among women with missed spontaneous abortion in the first trimester at Ain Shams University Maternity Hospital, Cairo, Egypt, between January 21 and December 25, 2014. Women with at least two consecutive primary unexplained REPLs and no previous live births were enrolled. A control group was formed of women with no history of REPL who had at least one previous uneventful pregnancy with no adverse outcomes. Serum samples were collected to measure SAA levels. The main outcome was the association between SAA and primary unexplained REPL. Each group contained 96 participants. Median SAA level was significantly higher among women with REPL (50.0 μg/mL, interquartile range 26.0-69.0) than among women in the control group (11.6 μg/mL, interquartile range 6.2-15.5; P<0.001). The SAA level was an independent indicator of primary unexplained REPL, after adjusting for maternal age and gestational age (odds ratio 1.12, 95% confidence interval 1.06-1.19; P<0.001). Elevated SAA levels found among women with primary unexplained REPL could represent a novel biomarker for this complication of pregnancy. © 2016 International Federation of Gynecology and Obstetrics.

Autonomic regulation in fetuses with Congenital Heart Disease

PubMed Central

Siddiqui, Saira; Wilpers, Abigail; Myers, Michael; Nugent, J. David; Fifer, William P.; Williams, Ismée A.

2015-01-01

Background Exposure to antenatal stressors affects autonomic regulation in fetuses. Whether the presence of congenital heart disease (CHD) alters the developmental trajectory of autonomic regulation is not known. Aims/Study Design This prospective observational cohort study aimed to further characterize autonomic regulation in fetuses with CHD; specifically hypoplastic left heart syndrome (HLHS), transposition of the great arteries (TGA), and tetralogy of Fallot (TOF). Subjects From 11/2010 – 11/2012, 92 fetuses were enrolled: 41 controls and 51 with CHD consisting of 19 with HLHS, 12 with TGA, and 20 with TOF. Maternal abdominal fetal electrocardiogram (ECG) recordings were obtained at 3 gestational ages: 19-27 weeks (F1), 28-33 weeks (F2), and 34-38 weeks (F3). Outcome measures Fetal ECG was analyzed for mean heart rate along with 3 measures of autonomic variability of the fetal heart rate: interquartile range, standard deviation, and root mean square of the standard deviation of the heart rate (RMSSD), a measure of parasympathetic activity. Results During F1 and F2 periods, HLHS fetuses demonstrated significantly lower mean HR than controls (p<0.05). Heart rate variability at F3, as measured by standard deviation, interquartile range, and RMSSD was lower in HLHS than controls (p<0.05). Other CHD subgroups showed a similar, though non-significant trend towards lower variability. Conclusions Autonomic regulation in CHD fetuses differs from controls with HLHS fetuses most markedly affected. PMID:25662702

High volume ultrasound guided injections at the interface between the patellar tendon and Hoffa's body are effective in chronic patellar tendinopathy: A pilot study.

PubMed

Crisp, Tom; Khan, Faisal; Padhiar, Nat; Morrissey, Dylan; King, John; Jalan, Rosy; Maffulli, Nicola; Frcr, Otto Chan

2008-01-01

To evaluate a novel conservative management modality for patellar tendinopathy. We recruited nine patients with patellar tendinopathy who had failed conservative management and showed evidence of neovascularisation on power Doppler scanning. A high volume ultrasound guided injection at the interface between the patellar tendon and Hoffa's body. The injection contained 10 ml 0.5% Bupivacaine, 25 mg Hydrocortisone, and between 12 and 40 ml normosaline. 100 mm visual analogue scales (VAS) for pain and for function, and Victorian Institute of Sport Assessment - Patellar tendon (VISA-P) questionnaires at an average of 9 months from the injection. All but one patient (whose pain was unchanged) improved (p = 0.028). The mean improvement in function 2 weeks after injection was 58 mm on VAS (interquartile range 27 - 88, p = 0.018). The mean improvement in pain 2 weeks after injection was 56 mm on a VAS scale (interquartile range 32 - 80, p = 0.018). At a mean follow up of 9 months, an improvement of 22 points from a baseline score of 46 on the VISA-P questionnaire (100 being normal) was established. High volume injections to mechanically disrupt the neovascularisation in patellar tendinopathy are helpful in the management of this condition. Controlled trials would be warranted to investigate in a more conclusive fashion this management modality.

Soil organic carbon and total nitrogen pools in permafrost zones of the Qinghai-Tibetan Plateau.

PubMed

Zhao, Lin; Wu, Xiaodong; Wang, Zhiwei; Sheng, Yu; Fang, Hongbing; Zhao, Yonghua; Hu, Guojie; Li, Wangping; Pang, Qiangqiang; Shi, Jianzong; Mo, Bentian; Wang, Qian; Ruan, Xirui; Li, Xiaodong; Ding, Yongjian

2018-02-26

There are several publications related to the soil organic carbon (SOC) on the Qinghai-Tibetan Plateau (QTP). However, most of these reports were from different parts of the plateau with various sampling depth. Here, we present the results from a systematic sampling and analysis of 200 soil pits. Most of the pits were deeper than 2 m from an east-west transect across the plateau. The SOC and total nitrogen (TN) pools of the 148 × 10 4  km 2 , the area of the permafrost zone, for the upper 2 m soils calculated from the vegetation map were estimated to be 17.07 Pg (interquartile range: 11.34-25.33 Pg) and 1.72 Pg (interquartile range: 1.08-2.06 Pg), respectively. We also predicted the distribution of land cover types in 2050 and 2070 using decision tree rules and climate scenarios, and then predicted SOC and TN pools of this region. The results suggested that the SOC and TN pools will decrease in the future. The results not only contribute to the carbon and nitrogen storage and stocks in the permafrost regions as a whole but most importantly, to our knowledge of the possible changes of C and N storage on the QTP in the future.

B-type natriuretic peptide-guided management and outcome in patients with obesity and dyspnea--results from the BASEL study.

PubMed

Noveanu, Markus; Breidthardt, Tobias; Cayir, Sevgi; Potocki, Mihael; Laule, Kirsten; Mueller, Christian

2009-09-01

Obesity may reduce diagnostic accuracy of B-type natriuretic peptide (BNP) and affect long-term outcome. This study evaluated patients included in the BASEL study (N = 452). We compared BNP levels in patients with (n = 86) and without (n = 366) obesity (body mass index <30 and >30 kg/m(2)) and determined sensitivities and specificities of BNP in both patient groups by receiver-operating characteristic analysis. Impact of BNP measurements on patient management and outcome in obesity, as well as 360-day mortality, was assessed. The BNP levels were lower in obese patients (172 pg/mL [interquartile range 31-515] vs 306 [interquartile range 75-1,040]). The optimal BNP cut-point to detect heart failure was 182 pg/mL in obese patients and 298 pg/mL nonobese patients. Obese patients had lower in-hospital mortality (3.5% vs 8.5%, P = .045) and 360-day mortality (15% vs 30%, P = .001). In obese patients, the determination of BNP levels reduced time to initiation of the appropriate treatment (96 +/- 98 vs 176 +/- 230, P < .05) without impacting other end points. Adjustment of BNP values in the assessment of obese patients presenting with acute dyspnea seems necessary to improve diagnostic accuracy and patient management. Obese patients had half the short- and long-term mortality of nonobese patients, independent of their final discharge diagnosis.

Autonomic regulation in fetuses with congenital heart disease.

PubMed

Siddiqui, Saira; Wilpers, Abigail; Myers, Michael; Nugent, J David; Fifer, William P; Williams, Ismée A

2015-03-01

Exposure to antenatal stressors affects autonomic regulation in fetuses. Whether the presence of congenital heart disease (CHD) alters the developmental trajectory of autonomic regulation is not known. This prospective observational cohort study aimed to further characterize autonomic regulation in fetuses with CHD; specifically hypoplastic left heart syndrome (HLHS), transposition of the great arteries (TGA), and tetralogy of Fallot (TOF). From 11/2010 to 11/2012, 92 fetuses were enrolled: 41 controls and 51 with CHD consisting of 19 with HLHS, 12 with TGA, and 20 with TOF. Maternal abdominal fetal electrocardiogram (ECG) recordings were obtained at 3 gestational ages: 19-27 weeks (F1), 28-33 weeks (F2), and 34-38 weeks (F3). Fetal ECG was analyzed for mean heart rate along with 3 measures of autonomic variability of the fetal heart rate: interquartile range, standard deviation, and root mean square of the standard deviation of the heart rate (RMSSD), a measure of parasympathetic activity. During F1 and F2 periods, HLHS fetuses demonstrated significantly lower mean HR than controls (p<0.05). Heart rate variability at F3, as measured by standard deviation, interquartile range, and RMSSD was lower in HLHS than controls (p<0.05). Other CHD subgroups showed a similar, though non-significant trend towards lower variability. Autonomic regulation in CHD fetuses differs from controls, with HLHS fetuses most markedly affected. Copyright © 2015 Elsevier Ltd. All rights reserved.