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Article

Construction and preliminary evaluation of the inpatient glycemic control questionnaire (IGCQ): a survey tool assessing perceptions and knowledge of resident physicians

by William B. Horton; Sidney Law; Monika Darji; Mark R. Conaway; Nancy T. Kubiak; Jennifer L. Kirby; S. Calvin Thigpen

2019

Subjects
  • Health Sciences, General
  • Health Sciences, Medicine and Surgery
  • File Download
  • View Abstract

Abstract:Close

Background: Uncontrolled hyperglycemia in hospitalized patients, with or without diabetes mellitus, is associated with many adverse outcomes. Resident physicians are the primary managers of inpatient glycemic control (IGC) in many academic and community medical centers; however, no validated survey tools related to their perceptions and knowledge of IGC are currently available. As identification of common barriers to successful IGC amongst resident physicians may help foster better educational interventions (ultimately leading to improvements in IGC and patient care), we sought to construct and preliminarily evaluate such a survey tool. Methods: We developed the IGC questionnaire (IGCQ) by using previously published but unvalidated survey tools related to physician perspectives on inpatient glycemic control as a framework. We administered the IGCQ to a cohort of resident physicians from the University of Mississippi Medical Center, University of Louisville, Emory University, and the University of Virginia. We then used classical test theory and Rasch Partial Credit Model analyses to preliminarily evaluate and revise the IGCQ. The final survey tool contains 16 total items and three answer-choice categories for most items. Results: Two hundred forty-six of 438 (56.2%) eligible resident physicians completed the IGCQ during various phases of development. Conclusions: We constructed and preliminarily evaluated the IGCQ, a survey tool that may be useful for future research into resident physician perceptions and knowledge of IGC. Future studies could seek to externally validate the IGCQ and then utilize the survey tool in pre- and post-intervention assessments.

Article

Known-group validity of patient-reported outcome instruments and hemophilia joint health score v2.1 in US adults with hemophilia: results from the Pain, Functional Impairment, and Quality of life (P-FiQ) study

by Tyler W. Buckner; Michael Wang; David L. Cooper; Neeraj N. Iyer; Christine Kempton

2017

Subjects
  • Health Sciences, Oncology
  • Health Sciences, Medicine and Surgery
  • File Download
  • View Abstract

Abstract:Close

Background: The Pain, Functional Impairment, and Quality of Life (P-FiQ) study was an observational, cross-sectional assessment of the impact of pain on functional impairment and quality of life in adults with hemophilia in the United States who experience joint pain or bleeding. Objective: To describe known-groups validity of assessment tools used in the P-FiQ study. Patients and methods: Participants completed 5 patient-reported outcome (PRO) instruments (5-level EuroQoL 5-dimensional questionnaire [EQ-5D-5L] with visual analog scale [VAS] , Brief Pain Inventory v2 Short Form [BPI], International Physical Activity Questionnaire [IPAQ] , Short-Form Health Survey [SF-36v2], and Hemophilia Activities List [HAL] ) and underwent a musculoskeletal examination (Hemophilia Joint Health Score [HJHS]) during a routine clinical visit. Results: P-FiQ enrolled 381 adults with hemophilia (median age, 34 years). Participants were predominantly white/non-Hispanic (69.2%), 75% had congenital hemophilia A, and 70.5% had severe hemophilia. Most (n=310) reported bleeding within the past 6 months (mean [SD] number of bleeds, 7.1 [13.00]). All instruments discriminated between relevant known (site-or self-reported) participant groups. Domains related to pain on EQ-5D-5L, BPI, and SF-36v2 discriminated self-reported pain (acute/chronic/both; P,0.05), domains related to functional impairment on IPAQ, SF-36v2, and HAL discriminated self-reported functional impairment (restricted/unrestricted; P,0.05), and domains related to mental health on the EQ-5D-5L and SF-36v2 discriminated self-reported anxiety/depression (yes/no; P,0.01). HJHS ankle and global gait domains and global score discriminated self-reported arthritis/bone/joint problems, percentage of lifetime on prophylaxis, current treatment regimen, and hemophilia severity (P,0.01); knee and elbow domains discriminated all of these (P,0.01) except for current treatment regimen. Conclusion: All assessment tools demonstrated known-group validity and may have practical applicability in evaluating adults with hemophilia in clinical and research settings in the United States.

Article

De novo donor-specific antibodies in belatacept-treated vs cyclosporine-treated kidney-transplant recipients: Post hoc analyses of the randomized phase III BENEFIT and BENEFIT-EXT studies

by Robert A Bray; Howard Gebel; R. Townsend; M. E. Roberts; M. Polinsky; L. Yang; H.‐U. Meier-Kriesche; Christian P Larsen

2018

Subjects
  • Health Sciences, Medicine and Surgery
  • File Download
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Abstract:Close

Donor-specific antibodies (DSAs) are associated with an increased risk of antibody-mediated rejection and graft failure. In BENEFIT and BENEFIT-EXT, kidney-transplant recipients were randomized to receive belatacept more intense (MI)–based, belatacept less intense (LI)–based, or cyclosporine-based immunosuppression for up to 7 years (84 months). The presence/absence of HLA-specific antibodies was determined at baseline, at months 6, 12, 24, 36, 48, 60, and 84, and at the time of clinically suspected episodes of acute rejection, using solid-phase flow-cytometry screening. Samples from anti-HLA-positive patients were further tested with a single-antigen bead assay to determine antibody specificities, presence/absence of DSAs, and mean fluorescence intensity (MFI) of any DSAs present. In BENEFIT, de novo DSAs developed in 1.4%, 3.5%, and 12.1% of belatacept MI-treated, belatacept LI-treated, and cyclosporine-treated patients, respectively. The corresponding values in BENEFIT-EXT were 3.8%, 1.1%, and 11.2%. Per Kaplan-Meier analysis, de novo DSA incidence was significantly lower in belatacept-treated vs cyclosporine-treated patients over 7 years in both studies (P <.01). In patients who developed de novo DSAs, belatacept-based immunosuppression was associated with numerically lower MFI vs cyclosporine-based immunosuppression. Although derived post hoc, these data suggest that belatacept-based immunosuppression suppresses de novo DSA development more effectively than cyclosporine-based immunosuppression.

Conference

Role of Additional Organ Resection in Adrenocortical Carcinoma: Analysis of 167 Patients from the US Adrenocortical Carcinoma Database

by Paula Marincola Smith; Colleen M. Kiernan; Thuy B. Tran; Lauren M. Postlewait; Shishir Kumar Maithel; Jason Prescott; Timothy Pawlik; Tracy S. Wang; Jason Glenn; Ioannis Hatzaras; Rivka Shenoy; John Phay; Lawrence A. Shirley; Ryan C. Fields; Linda Jin; Sharon Weber; Ahmed Salem; Jason Sicklick; Shady Gad; Adam Yopp; John Mansour; Quan-Yang Duh; Natalie Seiser; Konstantinos Votanopoulos; Edward A. Levine; George Poultsides; Carmen C. Solorzano

2018-08-01

Subjects
  • Health Sciences, Oncology
  • Health Sciences, Medicine and Surgery
  • File Download
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Background: Adrenocortical carcinoma (ACC) is a rare and aggressive cancer. This report describes factors and outcomes associated with resection of extra-adrenal organs en bloc during index adrenalectomy. Methods: Patients who underwent ACC resection for non-metastatic disease from 1993 to 2014 at 13 participating institutions of the US-ACC Group were included in the study. Factors associated with en bloc resection were assessed by uni- and multivariate analysis. The primary end point was overall survival. Results: In this study, 167 patients were included and categorized as adrenalectomy with en bloc resection (AdEBR) if they had extra-adrenal organs removed or adrenalectomy (Ad) if they did not. The demographics were similar between the AdEBR (n = 68, 40.7%) and Ad groups, including age, gender, race, American Society of Anesthesiology (ASA) class, and body mass index (BMI). The AdEBR group had larger tumors (13 vs. 10 cm), more open operations (97.1 vs. 63.6%), and more lymph node dissections (LNDs) (36.8 vs. 12.1%). The most common organs removed were kidney (55.9%), liver (27.9%), and spleen (23.5%). Multiple organs were removed in 38.2% (n = 26) of the patients. Margin-negative resections were similar between the two groups. In the multivariate Cox regression adjusted for T and N stages, LND, margin, size, and hormone hypersecretion, en bloc resection was not associated with improved survival (hazard ratio [HR], 1.42; p = 0.323). Conclusion: The study findings validated current practice by showing that en bloc resection should occur at index adrenalectomy for ACC when a T4 lesion is suspected pre- or intraoperatively, or when it is necessary to avoid tumor rupture. However, in this study, when a negative margin resection was otherwise achieved, removal of extra-adrenal organs en bloc was not associated with additional survival benefit.

Article

Use of troponin assay 99th percentile as the decision level for myocardial infarction diagnosis

by Akshay Bagai; Karen P. Alexander; Jeffrey S. Berger; Roxy Senior; Chakkanalil Sajeev; Radoslaw Pracon; Kreton Mavromatis; Jose Luis Lopez-Sendon; Gilbert Gosselin; Ariel Diaz; Gian Perna; Jarozlaw Drozdz; Dennis Humen; Birute Petrauskiene; Asim N. Cheema; Denis Phaneuf; Subhash Banerjee; Todd D. Miller; Sasko Kedev; Herwig Schuchlenz; Gregg W. Stone; Shaun G. Goodman; Kenneth W. Mahaffey; Allan S. Jaffe; Yves D. Rosenberg; Sripal Bangalore; L. Kristin Newby; David J. Maron; Judith S. Hochman; Bernard R. Chaitman

2017

Subjects
  • Health Sciences, Medicine and Surgery
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Background The Universal Definition of Myocardial Infarction recommends the 99th percentile concentration of cardiac troponin in a normal reference population as part of the decision threshold to diagnose type 1 spontaneous myocardial infarction. Adoption of this recommendation in contemporary worldwide practice is not well known. Methods We performed a cohort study of 276 hospital laboratories in 31 countries participating in the National Heart, Lung, and Blood Institute–sponsored International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial. Each hospital laboratory's troponin assay manufacturer and model, the recommended assay's 99th percentile upper reference limit (URL) from the manufacturer's package insert, and the troponin concentration used locally as the decision level to diagnose myocardial infarction were ascertained. Results Twenty-one unique troponin assays from 9 manufacturers were used by the surveyed hospital laboratories. The ratio of the troponin concentration used locally to diagnose myocardial infarction to the assay manufacturer–determined 99th percentile URL was <1 at 19 (6.6%) laboratories, equal to 1 at 91 (31.6%) laboratories, >1 to ≤5 at 101 (35.1%) laboratories, >5 to ≤10 at 34 (11.8%) laboratories, and >10 at 43 (14.9%) laboratories. The variability in troponin decision level for myocardial infarction relative to the assay 99th percentile URL was present for laboratories in and outside of the United States, as well as for high- and standard-sensitivity assays. Conclusions There is substantial hospital-level variation in the troponin threshold used to diagnose myocardial infarction; only one-third of hospital laboratories currently follow the Universal Definition of Myocardial Infarction consensus recommendation for use of troponin concentration at the 99th percentile of a normal reference population as the decision level to diagnose myocardial infarction. This variability across laboratories has important implications for both the diagnosis of myocardial infarction in clinical practice as well as adjudication of myocardial infarction in clinical trials.

Article

Temporal Trends in Utilization of Cardiac Therapies and Outcomes for Myocardial Infarction by Degree of Chronic Kidney Disease: A Report From the NCDR Chest Pain MI Registry

by Akshay Bagai; Di Lu; Joseph Lucas; Abhinav Goyal; Charles A. Herzog; Tracy Y. Wang; Shaun G. Goodman; Matthew T. Roe

2018

Subjects
  • Health Sciences, Public Health
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Background-We sought to determine temporal trends in use of evidence-based therapies and clinical outcomes among myocardial infarction (MI) patients with chronic kidney disease (CKD). Methods and Results-MI patients from the NCDR (National Cardiovascular Data Registry) Chest Pain-MI Registry between January 2007 and December 2015 were categorized into 3 groups by degree of CKD (end-stage renal disease on dialysis, CKD [glomerular filtration rate <60 mL/min per 1.73 m 2 ] not requiring dialysis, and no CKD [glomerular filtration rate ≥60 mL/min per 1.73 m 2 ]). Logistic regression modeling was used to determine the association between calendar years (2014-2015 versus 2007- 2008) and each outcome by degree of CKD. Among 325 396 patients with ST-segment-elevation MI, 1.0% had end-stage renal disease requiring dialysis, and 26.1% had CKD not requiring dialysis. Use of primary percutaneous coronary intervention increased over time regardless of the presence or degree of CKD (P=0.40 for interaction). In-hospital mortality was temporally higher among patients with preserved renal function (odds ratio: 1.25; 95% confidence interval, 1.13-1.39; P<0.001) but not among patients with CKD (P=0.035 for interaction). Among 506 876 non-ST-segment-elevation MI patients, 3.4% had end-stage renal disease requiring dialysis, and 34.4% had CKD not requiring dialysis. P2Y 12 inhibitor use within 24 hours increased over time only among dialysis patients (P for interaction <0.001). Use of coronary angiography and percutaneous coronary intervention also increased, with the greatest increase among dialysis patients (P for interaction <0.001 and <0.001, respectively). In-hospital mortality was lower, regardless of the presence or degree of CKD (P=0.64 for interaction). Conclusions-Uptake of evidence-based medical and invasive therapies has increased over the past decade among MI patients with CKD, particularly dialysis patients, with improvement of in-hospital mortality observed among patients with non-ST-segment- elevation MI, but not ST-segment-elevation MI, and CKD.

Article

Effects of State-Level Earned Income Tax Credit Laws on Birth Outcomes by Race and Ethnicity.

by Kelli Komro; Sara Markowitz; Melvin Livingston III; Alexander Wagenaar

2019

Subjects
  • Health Sciences, Public Health
  • Sociology, Public and Social Welfare
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Purpose: Health disparities persist in birth outcomes by mother's income, education, and race in the United States. Disadvantaged mothers may experience benefit from supplements to family income, such as the earned income tax credit (EITC). We examined the effects of state-level EITCs on birth outcomes among women with a high school education or less, stratified by race and ethnicity. Methods: A quasi-experimental multistate and multiyear difference-in-differences design is used to assess effects of the presence and generosity of 23 state-level EITC laws on birth outcomes from 1994 to 2013. The methods utilized the U.S. National Vital Statistics System birth data for the outcomes: birth weight, probability of low birth weight (LBW; <2500 g), and gestation weeks. Results: Across all subgroups, any level of state EITC is associated with better birth outcomes with the largest effects seen among states with more generous EITCs. Black mothers experience larger percentage point reductions in the probability of LBW and increases in gestation duration. Among mothers with a high school education or less, results translate into 3760 fewer LBW babies with black mothers and 8364 fewer LBW babies with white mothers per year at the most generous state EITC level (i.e., 10% or more of federal and refundable). Hispanic and non-Hispanic mothers display relatively similar effects. Conclusions: The EITC at the federal and state level is an effective policy tool to reduce poverty and improve birth outcomes across racial and ethnic subgroups. Given the historically higher risk among black mothers, state-level EITC expansions offer one policy option to address this persistent health disparity.

Article

Association Between Driving Distance From Nearest Fire Station and Survival of Out-of-Hospital Cardiac Arrest

by Steen M. Hansen; Carolina Malta Hansen; Christopher B. Fordyce; Matthew E. Dupre; Lisa Monk; Clark Tyson; Christian Torp-Pedersen; Bryan McNally; Kimberly Vellano; James Jollis; Christopher B. Granger

2018

Subjects
  • Health Sciences, Epidemiology
  • Health Sciences, Public Health
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Background-Firefighter first responders dispatched in parallel with emergency medical services (EMS) personnel for out-ofhospital cardiac arrests (OHCA) can provide early defibrillation to improve survival. We examined whether survival following first responder defibrillation differed according to driving distance from nearest fire station to OHCA site. Methods and Results-From the CARES (Cardiac Arrest Registry to Enhance Survival) registry, we identified non-EMS witnessed OHCAs of presumed cardiac cause from 2010 to 2014 in Durham, Mecklenburg, and Wake counties, North Carolina. We used logistic regression to estimate the association between calculated driving distances (≤1, 1-1.5, 1.5-2, and >2 miles) and survival to hospital discharge following first responder defibrillation compared with defibrillation by EMS personnel. In total, 5020 OHCAs were included in the study. First responders more often applied the first automated external defibrillators at the shortest distances (≤1 mile) versus longest distances (>2 miles) (53.4% versus 46.6%, respectively, P<0.001). When compared with EMS defibrillation, first responder defibrillation within 1 mile and 1 to 1.5 miles of the nearest fire station was associated with increased survival to hospital discharge (odds ratio 2.01 [95% confidence interval 1.46-2.78] and odds ratio 1.61 [95% confidence interval 1.10-2.35], respectively). However, at the longest distances (1.5-2.0 and >2.0 miles), survival following first responder defibrillation did not differ from EMS defibrillation (odds ratio 0.77 [95% confidence interval 0.48-1.21] and odds ratio 0.97 [95% confidence interval 0.67-1.41], respectively). Conclusions-Shorter driving distance from nearest fire station to OHCA location was associated with improved survival following defibrillation by first responders. These results suggest that the location of first responder units should be considered when organizing prehospital systems of OHCA care.

Article

Mortality Following Pediatric Congenital Heart Surgery: An Analysis of the Causes of Death Derived From the National Death Index

by Courtney McCracken; Logan G. Spector; Jeremiah S. Menk; Jessica H. Knight; Jeffrey M. Vinocur; Amanda S. Thomas; Matthew Oster; James D. St Louis; James H. Moller; Lazaros Kochilas

2018

Subjects
  • Health Sciences, General
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Background—Prior research has focused on early outcomes after congenital heart surgery, but less is known about later risks. We aimed to determine the late causes of death among children (<21 years of age) surviving their initial congenital heart surgery. Methods and Results—This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a US-based registry of interventions for congenital heart defects (CHD). Excluding patients with chromosomal anomalies or inadequate identifiers, we matched those surviving their first congenital heart surgery (1982–2003) against the National Death Index through 2014. Causes of death were obtained from the National Death Index to calculate cause-specific standardized mortality ratios (SMRs). Among 31 132 patients, 2527 deaths (8.1%) occurred over a median follow-up period of 18 years. Causes of death varied by time after surgery and severity of CHD but, overall, 69.9% of deaths were attributed to the CHD or another cardiovascular disorder, with a SMR for CHD/cardiovascular disorder of 67.7 (95% confidence interval: 64.5–70.8). Adjusted odds ratios revealed increased risk of death from CHD/cardiovascular disorder in females [odds ratio=1.28; 95% confidence interval (1.04–1.58); P=0.018] with leading cardiovascular disorder contributing to death being cardiac arrest (16.8%), heart failure (14.8%), and arrhythmias (9.1%). Other major causes of death included coexisting congenital malformations (4.7%, SMR: 7.0), respiratory diseases (3.6%, SMR: 8.2), infections (3.4%, SMR: 8.2), and neoplasms (2.1%, SMR: 1.9). Conclusions—Survivors of congenital heart surgery face long-term risks of premature mortality mostly related to residual CHD pathology, heart failure, and arrhythmias, but also to other noncardiac conditions. Ongoing monitoring is warranted to identify target factors to address residual morbidities and improve long-term outcomes.

Article

Spatial distribution of extensively drugresistant tuberculosis (XDR TB) patients in KwaZulu-Natal, South Africa

by Thandi Kapwata; Natashia Morris; Angela Campbell; Thuli Mthiyane; Primrose Mpangase; Kristin N. Nelson; Salim Allana; James C. M. Brust; Pravi Moodley; Koleka Mlisana; Neel Gandhi; Nippie Shah

2017

Subjects
  • Health Sciences, Public Health
  • Health Sciences, Epidemiology
  • Biology, Virology
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Background: KwaZulu-Natal province, South Africa, has among the highest burden of XDR TB worldwide with the majority of cases occurring due to transmission. Poor access to health facilities can be a barrier to timely diagnosis and treatment of TB, which can contribute to ongoing transmission. We sought to determine the geographic distribution of XDR TB patients and proximity to health facilities in KwaZulu-Natal. Methods: We recruited adults and children with XDR TB diagnosed in KwaZulu-Natal. We calculated distance and time from participants’ home to the closest hospital or clinic, as well as to the actual facility that diagnosed XDR TB, using tools within ArcGIS Network analyst. Speed of travel was assigned to road classes based on Department of Transport regulations. Results: were compared to guidelines for the provision of social facilities in South Africa: 5km to a clinic and 30km to a hospital. Results During 2011–2014, 1027 new XDR TB cases were diagnosed throughout all 11 districts of KwaZulu-Natal, of whom 404 (39%) were enrolled and had geospatial data collected. Participants would have had to travel a mean distance of 2.9 km (CI 95%: 1.8–4.1) to the nearest clinic and 17.6 km (CI 95%: 11.4–23.8) to the nearest hospital. Actual distances that participants travelled to the health facility that diagnosed XDR TB ranged from < 10 km (n = 143, 36%) to > 50 km (n = 109, 27%), with a mean of 69 km. The majority (77%) of participants travelled farther than the recommended distance to a clinic (5 km) and 39% travelled farther than the recommended distance to a hospital (30 km). Nearly half (46%) of participants were diagnosed at a health facility in eThekwini district, of whom, 36% resided outside the Durban metropolitan area. Conclusions: XDR TB cases are widely distributed throughout KwaZulu-Natal province with a denser focus in eThekwini district. Patients travelled long distances to the health facility where they were diagnosed with XDR TB, suggesting a potential role for migration or transportation in the XDR TB epidemic.
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