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  • 2016
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Work 1-10 of 30

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Article

Higher quality and lower cost from improving hospital discharge decision making

by James C. Cox; Vjollca Sadiraj; Kurt E. Schnier; John Sweeney

2016

Subjects
  • Economics, General
  • Health Sciences, Medicine and Surgery
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This paper reports research on improving decisions about hospital discharges – decisions that are now made by physicians based on mainly subjective evaluations of patients’ discharge status. We report an experiment on uptake of our clinical decision support system (CDSS) which presents physicians with evidence-based discharge criteria that can be effectively applied at the point of care where the discharge decision is made. One experimental treatment we report prompts physician attentiveness to the CDSS by replacing the default option of universal “opt in” to patient discharge with the alternative default option of “opt out” from the CDSS recommendations to discharge or not to discharge the patient on each day of hospital stay. We also report results from experimental treatments that implement the CDSS under varying conditions of time pressure on the subjects. The experiment was conducted using resident physicians and fourth-year medical students at a university medical school as subjects.

Article

How Local Annular Force and Collagen Density Govern Mitral Annuloplasty Ring Dehiscence Risk

by Erice L. Pierce; Andrew W. Siefert; Deborah M. Paul; Sarah K. Wells; Charles H. Bloodworth; Satoshi Takebayashi; Chikashi Aoki; Morten O. Jensen; Matthew J. Gillespie; Robert C. Gorman; Joseph H. Gorman; Ajit Yoganathan

2016

Subjects
  • Engineering, Biomedical
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Background Annuloplasty ring dehiscence is a well described mode of mitral valve repair failure. Defining the mechanisms underlying dehiscence may facilitate its prevention. Methods: Factors that govern suture dehiscence were examined with an ovine model. After undersized ring annuloplasty in live animals (n = 5), cyclic force (F C ) that acts on sutures during cardiac contraction was measured with custom transducers. F C was measured at ten suture positions, throughout cardiac cycles with peak left ventricular pressure (LVP max ) of 100, 125, and 150 mm Hg. Suture pullout testing was conducted on explanted mitral annuli (n = 12) to determine suture holding strength at each position. Finally, relative collagen density differences at suture sites around the annulus were assessed by two-photon excitation fluoroscopy. Results: Anterior F C exceeded posterior F C at each LVP max (eg, 2.8 ± 1.3 N versus 1.8 ± 1.2 N at LVP max = 125 mm Hg, p < 0.01). Anterior holding strength exceeded posterior holding strength (6.4 ± 3.6 N versus 3.9 ± 1.6 N, p < 0.0001). On the basis of F C at LVP max of 150 mm Hg, margin of safety before suture pullout was vastly higher between the trigones (exclusive) versus elsewhere (4.8 ± 0.9 N versus 1.9 ± 0.5 N, p < 0.001). Margin of safety exhibited strong correlation to collagen density (R 2 = 0.947). Conclusions: Despite lower cyclic loading on posterior sutures, the weaker posterior mitral annular tissue creates higher risk of dehiscence, apparently because of reduced collagen content. Sutures placed atop the trigones are less secure than predicted, because of a combination of reduced collagen and higher overall rigidity in this region. These findings highlight the inter-trigonal tissue as the superior anchor and have implications on the design and implantation techniques for next-generation mitral prostheses.

Article

Childhood trauma, PTSD, and psychosis: Findings from a highly traumatized, minority sample

by Abigail Powers; Negar Fani; Dorthie Cross; Kerry Ressler; Bekh Bradley-Davino

2016

Subjects
  • Psychology, Clinical
  • Health Sciences, Mental Health
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Trauma, especially early life trauma, is a risk factor for the development of both posttraumatic stress disorder and psychosis. The goal of the present study was to determine specific associations between exposure to childhood abuse, PTSD symptoms, and current psychotic disorder. Subjects were recruited from a public, urban hospital (N = 328, >90% African American). Psychotic disorders were measured using the MINI International Neuropsychiatric Interview, PTSD was measured using the Clinician Administered PTSD Scale, child abuse was measured with the Childhood Trauma Questionnaire, and lifetime trauma exposure was measured with the Traumatic Events Inventory. Logistic regression analyses showed that both child abuse and current PTSD were statistically significant predictors of psychotic disorder beyond the effects of lifetime trauma load. When PTSD symptom clusters were examined, avoidance and numbing symptoms showed unique association with psychotic disorder independent of demographic variables and trauma exposure. Using bootstrapping techniques, we found a full indirect effect of PTSD on the association between child abuse and, suggesting a particularly important role of PTSD symptoms in relation to psychotic disorder in the presence of early life trauma. Because this is a cross-sectional study, continued research is needed to determine causality of such models. Identifying co-occurring psychosis and PTSD, particularly in populations with high levels of trauma exposure, is critical and will likely aid in more successful treatment interventions.

Article

Curative Resection of Adrenocortical Carcinoma: Rates and Patterns of Postoperative Recurrence

by Neda Amini; Georgios Antonios Margonis; Yuhree Kim; Thuy B. Tran; Lauren M. Postlewait; Shishir Maithel; Tracy S. Wang; Douglas B. Evans; Ioannis Hatzaras; Rivfka Shenoy; John E. Phay; Kara Keplinger; Ryan C. Fields; Linda X. Jin; Sharon M. Weber; Ahmed Salem; Jason K. Sicklick; Shady Gad; Adam C. Yopp; John C. Mansour; Quan-Yang Duh; Natalie Seiser; Carmen C. Solorzano; Colleen M. Kiernan; Konstantinos I. Votanopoulos; Edward A. Levine; George A. Poultsides; Timothy M Pawlik

2016

Subjects
  • Health Sciences, Medicine and Surgery
  • Health Sciences, Oncology
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Background: Adrenocortical carcinoma (ACC) is a rare malignancy. The aim of this study was to determine the incidence and patterns of recurrence after curative-intent surgery for ACC. Methods: Patients who underwent curative-intent resection for ACC between 1993 and 2014 were identified from 13 academic institutions participating in the United States ACC study group. Patients with metastasis or an R2 margin were excluded. Patterns and rates of recurrence were determined and classified as locoregional and distant recurrence. Results: A total of 180 patients with a median age of 52 years (interquartile range 43–61) were identified. Most patients underwent open surgery (n = 111, 64.5 %) and had an R0 resection margin (n = 117, 75.0 %). At last follow-up, 116 patients (64.4 %) had experienced recurrence (locoregional only, n = 41, 36.3 %; distant only, n = 51, 45.1 %; locoregional and distant, n = 21, 18.6 %). Median time to recurrence was 18.8 months. Several factors were associated with locoregional recurrence, including left-sided ACC location (odds ratio [OR] 2.71, 95 % confidence interval [CI] 1.06–6.89) and T3/T4 disease (reference T1/T2, OR 3.04, 95 % CI 1.19–7.80) (both p < 0.05). Distant recurrence was associated with larger tumor size (OR 1.11, 95 % CI 1.01–1.24) and T3/T4 disease (reference T1/T2, OR 5.23, 95 % CI 1.70–16.10) (both p < 0.05). Patients with combined locoregional and distant recurrence had worse survival (3- and 5-year survival: 39.5, 19.7 %) versus patients with distant-only (3- and 5-year survival 55.1, 43.3 %) or locoregional-only recurrence (3- and 5-year survival 81.4, 64.1 %) (p = 0.01). Conclusions: Nearly two-thirds of patients experienced disease recurrence after resection of ACC. Although a subset of patients experienced recurrence with locoregional disease only, many patients experienced recurrence with distant disease as a component of recurrence and had a poor prognosis.

Article

Cost-Effectiveness/Cost-Benefit Analysis of Newborn Screening for Severe Combined Immune Deficiency in Washington State

by Yao Ding; John D. Thompson; Lisa Kobrynski; Jelili Ojodu; Guisou Zarbalian; Scott D. Grosse

2016

Subjects
  • Health Sciences, Public Health
  • Health Sciences, Health Care Management
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Objective To evaluate the expected cost-effectiveness and net benefit of the recent implementation of newborn screening (NBS) for severe combined immunodeficiency (SCID) in Washington State. Study design We constructed a decision analysis model to estimate the costs and benefits of NBS in an annual birth cohort of 86 600 infants based on projections of avoided infant deaths. Point estimates and ranges for input variables, including the birth prevalence of SCID, proportion detected asymptomatically without screening through family history, screening test characteristics, survival rates, and costs of screening, diagnosis, and treatment were derived from published estimates, expert opinion, and the Washington NBS program. We estimated treatment costs stratified by age of identification and SCID type (with or without adenosine deaminase deficiency). Economic benefit was estimated using values of $4.2 and $9.0 million per death averted. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost-effectiveness ratio (ICER) of net direct cost per life-year saved. Results Our model predicts an additional 1.19 newborn infants with SCID detected preclinically through screening, in addition to those who would have been detected early through family history, and 0.40 deaths averted annually. Our base-case model suggests an ICER of $35 311 per life-year saved, and a benefit-cost ratio of either 5.31 or 2.71. Sensitivity analyses found ICER values <$100 000 and positive net benefit for plausible assumptions on all variables. Conclusions Our model suggests that NBS for SCID in Washington is likely to be cost-effective and to show positive net economic benefit.

Article

Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base

by Rachel L. Medbery; Theresa Gillespie; Yuan Liu; Dana C Nickleach; Joseph Lipscomb; Manu Sancheti; Allan Pickens; Seth Force; Felix Fernandez

2016

Subjects
  • Health Sciences, Oncology
  • Health Sciences, Medicine and Surgery
  • Biology, Biostatistics
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Introduction Questions remain regarding nodal evaluation and upstaging between thoracotomy (open) and Video Assisted Thoracic Surgery (VATS) approaches to lobectomy for early stage lung cancer. Potential differences in nodal staging based on operative approach remains as the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy. Methods The National Cancer Data Base was queried for lung cancer patients with clinical stage ≤T2N0M0 who underwent lobectomy in 2010-2011. Propensity score matching was performed to compare rate of nodal upstaging in VATS vs. open approaches. Additional sub-group analysis was performed to assess whether or not rates of upstaging differed by specific clinical settings. Results A total of 16,983lobectomies were analyzed; 4935 (29.1%) were performed via VATS. Nodal upstaging was more frequent in the open group (12.8 vs. 10.3%; p<0.001). In 4,437 matched pairs, nodal upstaging remained more common for open approaches. For a sub-group of patients whose number of lymph nodes examined was ≥7, propensity matching revealed that nodal upstaging remained more common following open vs. VATS (14.0 vs. 12.1%; p=0.03). However, for patients who were treated in an Academic/Research Facility, the difference in nodal upstaging was no longer significant between an open vs. VATS approach (12.2 vs. 10.5%, p=0.08). Conclusions Nodal upstaging was more frequently observed with thoracotomy compared to VATS for early stage lung cancer. However, nodal upstaging appears to be impacted by facility type, which may represent a surrogate for minimally invasive expertise.

Article

Acute toxicity in comprehensive head and neck radiation for nasopharynx and paranasal sinus cancers: cohort comparison of 3D conformal proton therapy and intensity modulated radiation therapy

by Mark McDonald; Yuan Liu; Michael G. Moore; Peter A. S. Johnstone

2016

Subjects
  • Health Sciences, Oncology
  • Health Sciences, General
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Background: To evaluate acute toxicity endpoints in a cohort of patients receiving head and neck radiation with proton therapy or intensity modulated radiation therapy (IMRT). Methods: Forty patients received comprehensive head and neck radiation including bilateral cervical nodal radiation, given with or without chemotherapy, for tumors of the nasopharynx, nasal cavity or paranasal sinuses, any T stage, N0-2. Fourteen received comprehensive treatment with proton therapy, and 26 were treated with IMRT, either comprehensively or matched to proton therapy delivered to the primary tumor site. Toxicity endpoints assessed included g-tube dependence at the completion of radiation and at 3 months after radiation, opioid pain medication requirement compared to pretreatment normalized as equivalent morphine dose (EMD) at completion of treatment, and at 1 and 3 months after radiation. Results: In a multivariable model including confounding variables of concurrent chemotherapy and involved nodal disease, comprehensive head and neck radiation therapy using proton therapy was associated with a lower opioid pain requirement at the completion of radiation and a lower rate of gastrostomy tube dependence by the completion of radiation therapy and at 3 months after radiation compared to IMRT. Proton therapy was associated with statistically significant lower mean doses to the oral cavity, esophagus, larynx, and parotid glands. In subgroup analysis of 32 patients receiving concurrent chemotherapy, there was a statistically significant correlation with a greater opioid pain medication requirement at the completion of radiation and both increasing mean dose to the oral cavity and to the esophagus. Conclusions: Proton therapy was associated with significantly reduced radiation dose to assessed non-target normal tissues and a reduced rate of gastrostomy tube dependence and opioid pain medication requirements. This warrants further evaluation in larger studies, ideally with patient-reported toxicity outcomes and quality of life endpoints.

Article

Incentivizing cost-effective reductions in hospital readmission rates

by James C. Cox; Vjollca Sadiraj; Kurt E. Schnier; John Sweeney

2016

Subjects
  • Economics, General
  • Health Sciences, Medicine and Surgery
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The recent regulatory changes enacted by the Centers for Medicare and Medicaid Services (CMS) have identified hospital readmission rates as a critical healthcare quality metric. This research focuses on the utilization of pay-for-performance (P4P) mechanisms to cost effectively reduce hospital readmission rates and meet the regulatory standards set by CMS. Using the experimental economics laboratory we find that both of the P4P mechanisms researched, bonus and bundled payments, cost-effectively meet the performance criteria set forth by CMS. The bundled payment mechanism generates the largest reduction in patient length of stay (LOS) without altering the probability of readmission. Combined these results indicate that utilizing P4P mechanisms incentivizes cost effective reductions in hospital readmission rates.

Article

Why Do Women Justify Violence Against Wives More Often Than Do Men in Vietnam?

by Kathleen Helen Krause; Rachel Gordon-Roberts; Kristin VanderEnde; Sidney Ruth Schuler; Kathryn Yount

2016

Subjects
  • Health Sciences, Public Health
  • Psychology, General
  • Sociology, Individual and Family Studies
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Background: Intimate partner violence (IPV) harms the health of women and their children. In Vietnam, 31% of women report lifetime exposure to physical IPV, and surprisingly, women justify physical IPV against wives more often than do men. Objective: We compare men’s and women’s rates of finding good reason for wife hitting and assess whether differences in childhood experiences and resources and constraints in adulthood account for observed differences. Methods: Probability samples of married men (N = 522) and women (N = 533) were surveyed in Vietnam. Ordered logit models assessed the proportional odds for women versus men of finding more “good reasons” to hit a wife (never, 1–3 situations, 4–6 situations). Results: In all situations, women found good reason to hit a wife more often than did men. The unadjusted odds for women versus men of reporting more good reasons to hit a wife were 6.55 (95% CI 4.82 – 8.91). This gap disappeared in adjusted models that included significant interactions of gender with age, number of children ever born, and experience of physical IPV as an adult. Discussion: Having children was associated with justifying wife hitting among women but not men. Exposure to IPV in adulthood was associated with justifying wife hitting among men but was negatively associated with justification of IPV among women. Further study of the gendered effects of resources and constraints in adulthood on attitudes about IPV against women will clarify women’s more frequent reporting than men’s that IPV against women is justified.

Article

Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy

by Rabih Hage; Sheila R. Eshraghi; Nelson Oyesiku; Adriana Ioachimescu; Nancy Newman; Valerie Biousse; Beau Bruce

2016

Subjects
  • Biology, Neuroscience
  • Health Sciences, Opthamology
  • Health Sciences, Epidemiology
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Background Pituitary apoplexy (PA) often presents with acute headache and neuro-ophthalmic manifestations, including ocular motility dysfunction (OMD) from cranial nerve palsies (CNPs). Our goal was to describe the epidemiology and outcomes of OMD in a large, single-center series of patients with PA. Methods We conducted a retrospective chart review of all patients with PA seen in our pituitary center between January 1995 and December 2012. Presenting neuro-ophthalmic, endocrine, and radiologic data, as well as neuro-ophthalmology follow-up data, were collected. Results We identified 235 patients with PA, 59 of whom (25%) had OMD. Twenty-seven of those 59 patients underwent neuro-ophthalmic evaluation. Preoperatively, 23 of these 27 patients had unilateral OMD, 18 (78%) with a single CNP and 5 (22%) with multiple CNPs. Bilateral OMD was present in 4 of the 27 patients. Postoperatively, 24 of the 27 patients with OMD had follow-up (median duration, 7 months; interquartile range [IQR], 3–17 months). At the last postoperative follow-up, 7 of these 24 patients (29%) had OMD (5 unilateral, 2 bilateral). OMD resolved in 3 of the 24 patients (12%) within 1 month, in 13 of 21 patients (62%) within 6 months (3 lost to follow-up), and in 17 of 19 patients (89%) within 1 year (2 lost to follow-up). Surgery was performed at ≤14 days after presentation in 16 of 18 (89%) resolved cases and in 4 of 6 (67%) unresolved cases. Patients with OMD were more likely than those without OMD to have larger tumors (2.6 vs. 2.0 cm; P < 0.001), panhypopituitarism (31% vs. 14%; P = 0.005), and necrosis (58% vs. 37%; P = 0.03). Conclusions OMD from CNPs is common in PA, occurring in one-quarter of patients, and is frequently associated with certain radiologic, endocrinologic, and pathological features. The prognosis is excellent, with 90% of cases of OMD resolving by 1 year after early pituitary surgery.
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