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Cantu E, Diamond J, Ganjoo N, Nottigham A, Ramon CV, McCurry M, Friskey J, Jin D, Anderson MR, Lisowski J, Le Mahajan A, Localio AR, Gallop R, Hsu J, Christie J, Schaubel DE. Scoring donor lungs for graft failure risk: The Lung Donor Risk Index (LDRI). Am J Transplant 2024; 24:839-849. [PMID: 38266712 DOI: 10.1016/j.ajt.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
Lung transplantation lags behind other solid organ transplants in donor lung utilization due, in part, to uncertainty regarding donor quality. We sought to develop an easy-to-use donor risk metric that, unlike existing metrics, accounts for a rich set of donor factors. Our study population consisted of n = 26 549 adult lung transplant recipients abstracted from the United Network for Organ Sharing Standard Transplant Analysis and Research file. We used Cox regression to model graft failure (GF; earliest of death or retransplant) risk based on donor and transplant factors, adjusting for recipient factors. We then derived and validated a Lung Donor Risk Index (LDRI) and developed a pertinent online application (https://shiny.pmacs.upenn.edu/LDRI_Calculator/). We found 12 donor/transplant factors that were independently predictive of GF: age, race, insulin-dependent diabetes, the difference between donor and recipient height, smoking, cocaine use, cytomegalovirus seropositivity, creatinine, human leukocyte antigen (HLA) mismatch, ischemia time, and donation after circulatory death. Validation showed the LDRI to have GF risk discrimination that was reasonable (C = 0.61) and higher than any of its predecessors. The LDRI is intended for use by transplant centers, organ procurement organizations, and regulatory agencies and to benefit patients in decision-making. Unlike its predecessors, the proposed LDRI could gain wide acceptance because of its granularity and similarity to the Kidney Donor Risk Index.
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Affiliation(s)
- Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nikhil Ganjoo
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ana Nottigham
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christian Vivar Ramon
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Madeline McCurry
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jacqueline Friskey
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dun Jin
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica Lisowski
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Audrey Le Mahajan
- Division of Infectious Disease, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania, USA
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Diamond JM, Anderson MR, Cantu E, Clausen ES, Shashaty MGS, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Lama VN, Patel MG, Singer JP, Hachem RR, Michelson AP, Hsu J, Russell Localio A, Christie JD. Development and validation of primary graft dysfunction predictive algorithm for lung transplant candidates. J Heart Lung Transplant 2024; 43:633-641. [PMID: 38065239 PMCID: PMC10947904 DOI: 10.1016/j.healun.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Accurate prediction of PGD risk could inform donor approaches and perioperative care planning. We sought to develop a clinically useful, generalizable PGD prediction model to aid in transplant decision-making. METHODS We derived a predictive model in a prospective cohort study of subjects from 2012 to 2018, followed by a single-center external validation. We used regularized (lasso) logistic regression to evaluate the predictive ability of clinically available PGD predictors and developed a user interface for clinical application. Using decision curve analysis, we quantified the net benefit of the model across a range of PGD risk thresholds and assessed model calibration and discrimination. RESULTS The PGD predictive model included distance from donor hospital to recipient transplant center, recipient age, predicted total lung capacity, lung allocation score (LAS), body mass index, pulmonary artery mean pressure, sex, and indication for transplant; donor age, sex, mechanism of death, and donor smoking status; and interaction terms for LAS and donor distance. The interface allows for real-time assessment of PGD risk for any donor/recipient combination. The model offers decision-making net benefit in the PGD risk range of 10% to 75% in the derivation centers and 2% to 10% in the validation cohort, a range incorporating the incidence in that cohort. CONCLUSION We developed a clinically useful PGD predictive algorithm across a range of PGD risk thresholds to support transplant decision-making, posttransplant care, and enrich samples for PGD treatment trials.
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Affiliation(s)
- Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Ghundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mrunal G Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Diamond JM, Cantu E, Calfee CS, Anderson MR, Clausen ES, Shashaty MGS, Courtwright AM, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Todd JL, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Weinacker AB, Lama VN, Patel MG, Singer JP, Hsu J, Localio AR, Christie JD. The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation. Am J Respir Crit Care Med 2024; 209:91-100. [PMID: 37734031 PMCID: PMC10870879 DOI: 10.1164/rccm.202303-0358oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).
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Affiliation(s)
- Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Carolyn S. Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Michaela R. Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Emily S. Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | | | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Maria M. Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | | | | | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jamie L. Todd
- Division of Pulmonary and Critical Care Medicine and
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B. Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Ann B. Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and
| | - Mrunal G. Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P. Singer
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
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Anderson MR, Cantu E, Shashaty M, Benvenuto L, Kalman L, Palmer SM, Singer JP, Gallop R, Diamond JM, Hsu J, Localio AR, Christie JD. Body Mass Index and Cause-Specific Mortality after Lung Transplantation in the United States. Ann Am Thorac Soc 2023; 20:825-833. [PMID: 36996331 PMCID: PMC10257034 DOI: 10.1513/annalsats.202207-613oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/29/2023] [Indexed: 04/01/2023] Open
Abstract
Rationale: Low and high body mass index (BMI) are associated with increased mortality after lung transplantation. Why extremes of BMI might increase risk of death is unknown. Objectives: To estimate the association of extremes of BMI with causes of death after transplantation. Methods: We performed a retrospective study of the United Network for Organ Sharing database, including 26,721 adults who underwent lung transplantation in the United States between May 4, 2005, and December 2, 2020. We mapped 76 reported causes of death into 16 distinct groups. We estimated cause-specific hazards for death from each cause using Cox models. Results: Relative to a subject with a BMI of 24 kg/m2, a subject with a BMI of 16 kg/m2 had 38% (hazard ratio [HR], 1.38; 95% confidence interval [95% CI], 0.99-1.90), 82% (HR, 1.82; 95% CI, 1.34-2.46), and 62% (HR, 1.62; 95% CI, 1.18-2.22) increased hazards of death from acute respiratory failure, chronic lung allograft dysfunction (CLAD), and infection, respectively, and a subject with a BMI of 36 kg/m2 had 44% (HR, 1.44; 95% CI, 0.97-2.12), 42% (HR, 1.42; 95% CI, 0.93-2.15), and 185% (HR, 2.85; 95% CI, 1.28-6.33) increased hazards of death from acute respiratory failure, CLAD, and primary graft dysfunction, respectively. Conclusions: Low BMI is associated with increased risk of death from infection, acute respiratory failure, and CLAD after lung transplantation, whereas high BMI is associated with increased risk of death from primary graft dysfunction, acute respiratory failure, and CLAD.
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Affiliation(s)
| | | | - Michael Shashaty
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University, New York, New York
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Scott M. Palmer
- Division of Pulmonary Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Jonathan P. Singer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California; and
| | - Robert Gallop
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
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Guallar E, Goodman SN, Localio AR, Stephens-Shields AJ, Laine C. Seeing the Positive in Negative Studies. Ann Intern Med 2023; 176:561-562. [PMID: 36940441 DOI: 10.7326/m23-0576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Affiliation(s)
- Eliseo Guallar
- Annals of Internal Medicine, Philadelphia, Pennsylvania, and Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (E.G.)
| | - Steven N Goodman
- Annals of Internal Medicine, Philadelphia, Pennsylvania, and Department of Epidemiology and Population Health and Department of Medicine, Stanford University School of Medicine, Stanford, California (S.N.G.)
| | - A Russell Localio
- Annals of Internal Medicine and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.R.L., A.J.S.)
| | - Alisa J Stephens-Shields
- Annals of Internal Medicine and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.R.L., A.J.S.)
| | - Christine Laine
- Annals of Internal Medicine, Philadelphia, Pennsylvania (C.L.)
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Koons B, Suzuki Y, Cevasco M, Bermudez CA, Harmon MT, Dallara L, Ramon CV, Nottingham A, Ganjoo N, Diamond JM, Christie JD, Localio AR, Cantu E. Cryoablation in Lung Transplantation: Its Impact on Pain, Opioid Use, and Outcomes. JTCVS Open 2022; 13:444-456. [PMID: 37063121 PMCID: PMC10091298 DOI: 10.1016/j.xjon.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/09/2022] [Accepted: 10/06/2022] [Indexed: 11/26/2022]
Abstract
Objective To assess the effect of intraoperative cryoablation on postoperative patient-reported pain, opioid use, and clinical outcomes in lung transplantation. Methods We performed a single-center retrospective cohort study of adult lung transplant recipients from August 2017 to September 2018. We compared outcomes of patients who received intraoperative cryoablation of the intercostal nerves with those who did not. Primary outcomes were postoperative patient-reported pain scores and opioid use. Secondary outcomes included postoperative sedation and agitation levels and perioperative outcomes. Data were abstracted from patients' electronic health records. Results Of the 102 patients transplanted, 45 received intraoperative cryoablation (intervention group) and 57 received the standard of care, which did not include intercostal or serratus blocks or immediate postoperative epidural placement (control group). The intervention group had significantly lower median and maximum postoperative pain scores at days 3 and 7 and significantly lower oral opioid use at days 3, 7, and 14 compared with the control group. Chronic opioid use at 3 and 6 months' posttransplant was lower in the intervention group. Differences in perioperative outcomes, including length of mechanical ventilation, sedation and agitation levels, and hospital stay, were not clinically meaningful. Survival at 30 days and 1 year was superior in the intervention compared with the control group. Conclusions Findings suggest that use of intraoperative cryoablation is an effective approach for treating pain and reducing opioid use in patients who undergo lung transplant, but a randomized study across multiple institutions is needed to confirm these findings.
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Affiliation(s)
- Brittany Koons
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pa
- Address for reprints: Brittany Koons, PhD, RN, M. Louise Fitzpatrick College of Nursing, Villanova University, 800 Lancaster Ave, Villanova, PA 19085.
| | - Yoshikazu Suzuki
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Christian A. Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Michael T. Harmon
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Laura Dallara
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Christian V. Ramon
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Ana Nottingham
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Nikhil Ganjoo
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Joshua M. Diamond
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jason D. Christie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Stockwell MS, Shone LP, Nekrasova E, Wynn C, Torres A, Griffith M, Shults J, Unger R, Ware LA, Kolff C, Harris D, Berrigan L, Montague H, Localio AR, Fiks AG. Text Message Reminders for the Second Dose of Influenza Vaccine for Children: An RCT. Pediatrics 2022; 150:e2022056967. [PMID: 35965283 PMCID: PMC9592065 DOI: 10.1542/peds.2022-056967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Among children requiring 2 influenza doses in a given season, second dose receipt nearly halves the odds of influenza. Nationally, many children do not receive both needed doses. This study sought to compare the effectiveness of text message reminders with embedded interactive educational information versus usual care on receipt and timeliness of the second dose of influenza vaccine. METHODS This trial took place over the 2017 to 2018 and 2018 to 2019 influenza seasons among 50 pediatric primary care offices across 24 states primarily from the American Academy of Pediatrics' Pediatric Research in Office Settings practice-based research network. Caregiver-child dyads of children 6 months to 8 years in need of a second influenza vaccination that season were individually randomized 1:1 into intervention versus usual care, stratified by age and language within each practice. Intervention caregivers received automated, personalized text messages, including educational information. Second dose receipt by April 30 (season end) and by day 42 (2 weeks after second dose due date) were assessed using Mantel Haenszel methods by practice and language. Analyses were intention to treat. RESULTS Among 2086 dyads enrolled, most children were 6 to 23 months and half publicly insured. Intervention children were more likely to receive a second dose by season end (83.8% versus 80.9%; adjusted risk difference (ARD) 3.8%; 95% confidence interval [0.1 to 7.5]) and day 42 (62.4% versus 55.7%; ARD 8.3% [3.6 to 13.0]). CONCLUSIONS In this large-scale trial of primary care pediatric practices across the United States, text message reminders were effective in promoting increased and timelier second dose influenza vaccine receipt.
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Affiliation(s)
- Melissa S Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University, New York, NY
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY
| | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
| | - Ekaterina Nekrasova
- Department of Pediatrics, Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Chelsea Wynn
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University, New York, NY
| | | | - Miranda Griffith
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Chelsea Kolff
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University, New York, NY
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY
| | - Donna Harris
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
| | - Lindsay Berrigan
- Department of Pediatrics, Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Montague
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
- American Academy of Dental Sleep Medicine, Lisle, IL
| | - A Russell Localio
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexander G Fiks
- Department of Pediatrics, Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
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Apter AJ, Bryant-Stephens T, Han X, Park H, Morgan A, Klusaritz H, Cidav Z, Banerjee A, Localio AR, Morales KH. Clinic navigation and home visits to improve asthma care in low income adults with poorly controlled asthma: Before and during the pandemic. Contemp Clin Trials 2022; 118:106808. [PMID: 35644376 PMCID: PMC9973549 DOI: 10.1016/j.cct.2022.106808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 01/26/2023]
Abstract
Asthma-related deaths, hospitalizations, and emergency visits are more numerous among low-income patients, yet management guidelines do not address this high-risk group's special needs. We recently demonstrated feasibility, acceptability, and preliminary evidence of effectiveness of two interventions to improve access to care, patient-provider communication, and asthma outcomes: 1) Clinic Intervention (CI): study staff facilitated patient preparations for office visits, attended visits, and afterwards confirmed patient understanding of physician recommendations, and 2) Home Visit (HV) by community health workers for care coordination and informing clinicians of home barriers to managing asthma. The current project, denominated "HAP3," combines these interventions for greater effectiveness, delivery of guideline-based asthma care, and asthma control for low-income patients recruited from 6 primary care and 3 asthma specialty practices. We assess whether patients of clinicians receiving guideline-relevant, real-time feedback on patient health and home status have better asthma outcomes. In a pragmatic factorial longitudinal trial, HAP3 enrolls 400 adults with uncontrolled asthma living in low-income urban neighborhoods. 100 participants will be randomized to each of four interventions: (1) CI, (2) CI with HVs, (3) CI and real-time feedback to asthma clinician of guideline-relevant elements of patients' current care, or (4) both (2) and (3). The outcomes are asthma control, quality of life, ED visits, hospitalizations, prednisone bursts, and intervention costs. The COVID-19 pandemic struck 6.5 months into recruitment. We describe study development, design, methodology, planned analysis, baseline findings and adaptions to achieve the original aims of improving patient-clinician communication and asthma outcomes despite the markedly changed pandemic environment.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 829 Gates/ HUP, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Tyra Bryant-Stephens
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, CHOP Roberts Building, 27616 South Street Room 9364, Philadelphia, PA 19146, USA.
| | - Xiaoyan Han
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 829 Gates/ HUP, 3400 Spruce Street, Philadelphia, PA 19104, USA; Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 600 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA.
| | - Hami Park
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 829 Gates/ HUP, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Anna Morgan
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 6th floor, 3701 Market Street, Philadelphia, PA 19104, USA.
| | - Heather Klusaritz
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Room 143 Anatomy Chemistry, 3620 Hamilton Walk, Philadelphia, PA 19104, USA.
| | - Zuleyha Cidav
- Perelman School of Medicine, University of Pennsylvania 3535 Market Street, Philadelphia, PA 19104, USA.
| | - Audreesh Banerjee
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 9th floor, 3737 Market Street, Philadelphia, PA 19104, USA.
| | - A Russell Localio
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 600 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA.
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 600 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA.
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Daymont C, Ross ME, Localio AR, Fiks AG, Wasserman RC, Grundmeier RW. Corrigendum to: Automated identification of implausible values in growth data from pediatric electronic health records. J Am Med Inform Assoc 2021; 29:223. [PMID: 34791265 DOI: 10.1093/jamia/ocab250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Lee H, Cashin AG, Lamb SE, Hopewell S, Vansteelandt S, VanderWeele TJ, MacKinnon DP, Mansell G, Collins GS, Golub RM, McAuley JH, Localio AR, van Amelsvoort L, Guallar E, Rijnhart J, Goldsmith K, Fairchild AJ, Lewis CC, Kamper SJ, Williams CM, Henschke N. A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies: The AGReMA Statement. JAMA 2021; 326:1045-1056. [PMID: 34546296 PMCID: PMC8974292 DOI: 10.1001/jama.2021.14075] [Citation(s) in RCA: 148] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Mediation analyses of randomized trials and observational studies can generate evidence about the mechanisms by which interventions and exposures may influence health outcomes. Publications of mediation analyses are increasing, but the quality of their reporting is suboptimal. Objective To develop international, consensus-based guidance for the reporting of mediation analyses of randomized trials and observational studies (A Guideline for Reporting Mediation Analyses; AGReMA). Design, Setting, and Participants The AGReMA statement was developed using the Enhancing Quality and Transparency of Health Research (EQUATOR) methodological framework for developing reporting guidelines. The guideline development process included (1) an overview of systematic reviews to assess the need for a reporting guideline; (2) review of systematic reviews of relevant evidence on reporting mediation analyses; (3) conducting a Delphi survey with panel members that included methodologists, statisticians, clinical trialists, epidemiologists, psychologists, applied clinical researchers, clinicians, implementation scientists, evidence synthesis experts, representatives from the EQUATOR Network, and journal editors (n = 19; June-November 2019); (4) having a consensus meeting (n = 15; April 28-29, 2020); and (5) conducting a 4-week external review and pilot test that included methodologists and potential users of AGReMA (n = 21; November 2020). Results A previously reported overview of 54 systematic reviews of mediation studies demonstrated the need for a reporting guideline. Thirty-three potential reporting items were identified from 3 systematic reviews of mediation studies. Over 3 rounds, the Delphi panelists ranked the importance of these items, provided 60 qualitative comments for item refinement and prioritization, and suggested new items for consideration. All items were reviewed during a 2-day consensus meeting and participants agreed on a 25-item AGReMA statement for studies in which mediation analyses are the primary focus and a 9-item short-form AGReMA statement for studies in which mediation analyses are a secondary focus. These checklists were externally reviewed and pilot tested by 21 expert methodologists and potential users, which led to minor adjustments and consolidation of the checklists. Conclusions and Relevance The AGReMA statement provides recommendations for reporting primary and secondary mediation analyses of randomized trials and observational studies. Improved reporting of studies that use mediation analyses could facilitate peer review and help produce publications that are complete, accurate, transparent, and reproducible.
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Affiliation(s)
- Hopin Lee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Aidan G Cashin
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Neuroscience Research Australia, Sydney
| | - Sarah E Lamb
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- College of Medicine and Health, University of Exeter Medical School, Exeter, England
| | - Sally Hopewell
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science, and Statistics, Ghent University, Ghent, Belgium
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, England
| | - Tyler J VanderWeele
- Departments of Epidemiology and Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | | | - Gemma Mansell
- College of Health and Life Sciences, Aston University, Birmingham, England
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Robert M Golub
- JAMA Editorial Office, Chicago, Illinois
- Division of General Internal Medicine and Geriatrics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James H McAuley
- Neuroscience Research Australia, Sydney
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Associate Editor, Annals of Internal Medicine
| | - Ludo van Amelsvoort
- Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Assoicate Editor, Journal of Clinical Epidemiology
| | - Eliseo Guallar
- Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Deputy Editor, Annals of Internal Medicine
| | - Judith Rijnhart
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Kimberley Goldsmith
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, England
| | | | - Cara C Lewis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Steven J Kamper
- School of Health Sciences, University of Sydney, Sydney, Australia
- Nepean Blue Mountains Local Health District, Kingswood, Australia
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11
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Forke CM, Myers RK, Localio AR, Wiebe DJ, Fein JA, Grisso JA, Catallozzi M. Intimate Partner Violence: Childhood Witnessing and Subsequent Experiences of College Undergraduates. J Interpers Violence 2021; 36:NP9670-NP9692. [PMID: 31288610 DOI: 10.1177/0886260519860909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Previous work links witnessing adult violence in the home during childhood ("witnessing") and adolescent relationship violence, but studies are limited to recent experiences with one or two outcomes, missing the holistic viewpoint describing lifetime experiences across multiple types of violence. We measured associations between witnessing and victimization (being harmed by violence) and perpetration (causing harm by violence) among males and females for the three most common types of adolescent relationship violence (physical, sexual, and emotional), and we assessed whether students experienced multiple outcomes ("polyvictimization/ polyperpetration"). We also compared sex-specific differences to assess for additive effect modification. We used an anonymous, cross-sectional survey with 907 undergraduates attending randomly selected classes at three urban East Coast colleges. Multiple logistic regression and marginal standardization were used to estimate predicted probabilities for each outcome among witnesses and non-witnesses; additive interaction by sex was assessed using quantifiable measures. 214 (24%) students reported witnessing and 403 (44%) students experienced adolescent relationship violence, with 162 (17.9%) and 37 (4.1%) experiencing polyvictimization and polyperpetration, respectively. Witnesses had higher risk than non-witnesses for physical, sexual, and emotional victimization and perpetration. Notably, witnesses also had higher risk for polyvictimization and polyperpetration. Additive effect modification by sex was insignificant at 95% confidence bounds, but distinct patterns emerged for males and females. Except for sexual victimization, female witnesses were more likely than female non-witnesses to experience all forms of victimization, including polyvictimization; they also had higher risk for perpetration, particularly physical perpetration. In contrast, victimization outcomes did not differ for male witnesses, but male witnesses were more likely than male non-witnesses to perpetrate all forms of violence, including polyperpetration.
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Affiliation(s)
- Christine M Forke
- Children's Hospital of Philadelphia, PA, USA
- University of Pennsylvania, Philadelphia, USA
| | | | | | | | - Joel A Fein
- Children's Hospital of Philadelphia, PA, USA
| | | | - Marina Catallozzi
- Columbia University Medical Center, New York, NY, USA
- Mailman School of Public Health, New York, NY, USA
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12
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Fisher BT, Zaoutis TE, Xiao R, Wattier RL, Castagnola E, Pana ZD, Fullenkamp A, Boge CLK, Ross RK, Yildirim I, Palazzi DL, Danziger-Isakov L, Vora SB, Arrieta A, Yin DE, Avilés-Robles M, Sharma T, Tribble AC, Maron G, Berman D, Green M, Sung L, Romero J, Hauger SB, Roilides E, Belani K, Nolt D, Soler-Palacin P, López-Medina E, Muller WJ, Halasa N, Dulek D, Hussain IZB, Pong A, Hoffman J, Rajan S, Gonzalez BE, Hanisch B, Aftandilian C, Carlesse F, Abzug MJ, Huppler AR, Salvatore CM, Ardura MI, Chakrabarti A, Santolaya ME, Localio AR, Steinbach WJ. Comparative Effectiveness of Echinocandins vs Triazoles or Amphotericin B Formulations as Initial Directed Therapy for Invasive Candidiasis in Children and Adolescents. J Pediatric Infect Dis Soc 2021:piab024. [PMID: 34374424 DOI: 10.1093/jpids/piab024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 08/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Invasive candidiasis is the most common invasive fungal disease in children and adolescents, but there are limited pediatric-specific antifungal effectiveness data. We compared the effectiveness of echinocandins to triazoles or amphotericin B formulations (triazole/amphotericin B) as initial directed therapy for invasive candidiasis. METHODS This multinational observational cohort study enrolled patients aged >120 days and <18 years with proven invasive candidiasis from January 1, 2014, to November 28, 2017, at 43 International Pediatric Fungal Network sites. Primary exposure was initial directed therapy administered at the time qualifying culture became positive for yeast. Exposure groups were categorized by receipt of an echinocandin vs receipt of triazole/amphotericin B. Primary outcome was global response at 14 days following invasive candidiasis onset, adjudicated by a centralized data review committee. Stratified Mantel-Haenszel analyses estimated risk difference between exposure groups. RESULTS Seven-hundred and fifty invasive candidiasis episodes were identified. After exclusions, 541 participants (235 in the echinocandin group and 306 in the triazole/amphotericin B group) remained. Crude failure rates at 14 days for echinocandin and triazole/amphotericin B groups were 9.8% (95% confidence intervals [CI]: 6.0% to 13.6%) and 13.1% (95% CI: 9.3% to 16.8%), respectively. The adjusted 14-day risk difference between echinocandin and triazole/amphotericin B groups was -7.1% points (95% CI: -13.1% to -2.4%), favoring echinocandins. The risk difference was -0.4% (95% CI: -7.5% to 6.7%) at 30 days. CONCLUSIONS In children with invasive candidiasis, initial directed therapy with an echinocandin was associated with reduced failure rate at 14 days but not 30 days. These results may support echinocandins as initial directed therapy for invasive candidiasis in children and adolescents. CLINICAL TRIALS REGISTRATION NCT01869829.
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Affiliation(s)
- Brian T Fisher
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California-San Francisco, San Francisco, California, USA
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Zoi Dorothea Pana
- Infectious Disease Unit, 3rd Department of Pediatrics, Aristotle University and Hippokration Hospital, Thessaloniki, Greece
| | - Allison Fullenkamp
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Craig L K Boge
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachael K Ross
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Inci Yildirim
- Division of Infectious Diseases, Department of Pediatrics Emory University, Atlanta, Georgia, USA
| | - Debra L Palazzi
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Antonio Arrieta
- Division of Pediatric Infectious Diseases, Children's Hospital - Orange County, Orange, California, US
| | - Dwight E Yin
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Martha Avilés-Robles
- Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Tanvi Sharma
- Division of Infectious Diseases Children's Hospital Boston, Boston, Massachusetts, USA
| | - Alison C Tribble
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Michigan and CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Gabriela Maron
- Department of Infectious Diseases St. Jude Children's Hospital, Memphis, Tennessee, USA
| | - David Berman
- Division of Pediatric Infectious Diseases, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Michael Green
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Lillian Sung
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - José Romero
- Division of Pediatric Infectious Diseases, Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
| | - Sarmistha B Hauger
- Pediatric Infectious Diseases, Dell Children's Medical Center, Austin, Texas, USA
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, Aristotle University and Hippokration Hospital, Thessaloniki, Greece
| | - Kiran Belani
- Pediatric Infectious Diseases, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eduardo López-Medina
- Centro de Estudios en Infectología Pediátrica and Universidad del Valle, Cali Colombia
| | - William J Muller
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, US
| | - Daniel Dulek
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, US
| | - Ibrahim Zaid Bin Hussain
- Pediatric Infectious Diseases King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Alice Pong
- Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Jill Hoffman
- Pediatric Infectious Diseases, University of California Los Angeles, Los Angeles, California, USA
| | - Sujatha Rajan
- Division of Pediatric Infectious Diseases, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Blanca E Gonzalez
- Center for Pediatric Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin Hanisch
- Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Catherine Aftandilian
- Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Fabianne Carlesse
- Instituto de Oncologia Pediatrica-IOP/GRAACC-UNIFESP, Sao Paulo, Brazil
| | - Mark J Abzug
- Division of Pediatric Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anna R Huppler
- Department of Pediatrics, Division of Infectious Diseases, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christine M Salvatore
- Department of Pediatrics, Division of Pediatric Infectious Diseases Weill Cornell Medicine, New York, New York, USA
| | - Monica I Ardura
- Pediatric Infectious Diseases and Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Maria E Santolaya
- Hospital Dr. Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - A Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
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McCaw ZR, Tian L, Kim DH, Localio AR, Wei LJ. Survival Analysis of Treatment Efficacy in Comparative Coronavirus Disease 2019 Studies. Clin Infect Dis 2021; 72:e887-e889. [PMID: 33053155 PMCID: PMC7665361 DOI: 10.1093/cid/ciaa1563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Indexed: 11/24/2022] Open
Abstract
For survival analysis in comparative coronavirus disease 2019 trials, the routinely used hazard ratio may not provide a meaningful summary of the treatment effect. The mean survival time difference/ratio is an intuitive, assumption-free alternative. However, for short-term studies, landmark mortality rate differences/ratios are more clinically relevant and should be formally analyzed and reported.
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Affiliation(s)
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lee-Jen Wei
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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14
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Kaelber DC, Localio AR, Ross M, Leon JB, Pace WD, Wasserman RC, Grundmeier RW, Steffes J, Fiks AG. Persistent Hypertension in Children and Adolescents: A 6-Year Cohort Study. Pediatrics 2020; 146:peds.2019-3778. [PMID: 32948657 PMCID: PMC7786824 DOI: 10.1542/peds.2019-3778] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the natural history of pediatric hypertension. METHODS We conducted a 72-month retrospective cohort study among 165 primary care sites. Blood pressure measurements from two consecutive 36 month periods were compared. RESULTS Among 398 079 primary care pediatric patients ages 3 to 18, 89 347 had ≥3 blood pressure levels recorded during a 36-month period, and 43 825 children had ≥3 blood pressure levels for 2 consecutive 36-month periods. Among these 43 825 children, 4.3% (1881) met criteria for hypertension (3.5% [1515] stage 1, 0.8% [366] stage 2) and 4.9% (2144) met criteria for elevated blood pressure in the first 36 months. During the second 36 months, 50% (933) of hypertensive patients had no abnormal blood pressure levels, 22% (406) had elevated blood pressure levels or <3 hypertensive blood pressure levels, and 29% (542) had ≥3 hypertensive blood pressure levels. Of 2144 patients with elevated blood pressure in the first 36 months, 70% (1492) had no abnormal blood pressure levels, 18% (378) had persistent elevated blood pressure levels, and 13% (274) developed hypertension in the second 36-months. Among the 7775 patients with abnormal blood pressure levels in the first 36-months, only 52% (4025) had ≥3 blood pressure levels recorded during the second 36-months. CONCLUSIONS In a primary care cohort, most children initially meeting criteria for hypertension or elevated blood pressure had subsequent normal blood pressure levels or did not receive recommended follow-up measurements. These results highlight the need for more nuanced initial blood pressure assessment and systems to promote follow-up of abnormal results.
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Affiliation(s)
- David C. Kaelber
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Center for Clinical Informatics Research and Education and,Departments of Internal Medicine, Pediatrics, Population and Quantitative Health Sciences, The MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - A. Russell Localio
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Ross
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Janeen B. Leon
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Center for Clinical Informatics Research and Education and
| | - Wilson D. Pace
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,American Academy of Family Physicians, National Research Network, Leawood, Kansas
| | - Richard C. Wasserman
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Robert W. Grundmeier
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,The Pediatric Research Consortium, Philadelphia, Pennsylvania;,Department of Biomedical and Health Informatics, Philadelphia, Pennsylvania;,Center for Pediatric Clinical Effectiveness, Philadelphia, Pennsylvania; and,PolicyLab at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer Steffes
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Alexander G. Fiks
- Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,The Pediatric Research Consortium, Philadelphia, Pennsylvania;,Department of Biomedical and Health Informatics, Philadelphia, Pennsylvania;,Center for Pediatric Clinical Effectiveness, Philadelphia, Pennsylvania; and,PolicyLab at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Mwananyanda L, Pierre C, Mwansa J, Cowden C, Localio AR, Kapasa ML, Machona S, Musyani CL, Chilufya MM, Munanjala G, Lyondo A, Bates MA, Coffin SE, Hamer DH. Preventing Bloodstream Infections and Death in Zambian Neonates: Impact of a Low-cost Infection Control Bundle. Clin Infect Dis 2020; 69:1360-1367. [PMID: 30596901 DOI: 10.1093/cid/ciy1114] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of neonatal mortality in low-resource settings. As facility-based births become more common, the proportion of neonatal deaths due to hospital-onset sepsis has increased. METHODS We conducted a prospective cohort study in a neonatal intensive care unit in Zambia where we implemented a multifaceted infection prevention and control (IPC) bundle consisting of IPC training, text message reminders, alcohol hand rub, enhanced environmental cleaning, and weekly bathing of babies ≥1.5 kg with 2% chlorhexidine gluconate. Hospital-associated sepsis, bloodstream infection (BSI), and mortality (>3 days after admission) outcome data were collected for 6 months prior to and 11 months after bundle implementation. RESULTS Most enrolled neonates had a birth weight ≥1.5 kg (2131/2669 [79.8%]). Hospital-associated mortality was lower during the intervention than baseline period (18.0% vs 23.6%, respectively). Total mortality was lower in the intervention than prior periods. Half of enrolled neonates (50.4%) had suspected sepsis; 40.8% of cultures were positive. Most positive blood cultures yielded a pathogen (409/549 [74.5%]), predominantly Klebsiella pneumoniae (289/409 [70.1%]). The monthly rate and incidence density rate of suspected sepsis were lower in the intervention period for all birth weight categories, except babies weighing <1.0 kg. The rate of BSI with pathogen was also lower in the intervention than baseline period. CONCLUSIONS A simple IPC bundle can reduce sepsis and death in neonates hospitalized in high-risk, low-resource settings. Further research is needed to validate these findings in similar settings and to identify optimal implementation strategies for improvement and sustainability. CLINICAL TRIALS REGISTRATION NCT02386592.
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Affiliation(s)
- Lawrence Mwananyanda
- Right to Care, Lusaka, Zambia.,Department of Global Health, Boston University School of Public Health
| | - Cassandra Pierre
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts
| | - James Mwansa
- Department of Pathology and Microbiology, University Teaching Hospital.,Lusaka Apex Medical University, Zambia
| | - Carter Cowden
- Division of Infectious Diseases, Children's Hospital of Philadelphia
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Monica L Kapasa
- Neonatal Intensive Care Unit, University Teaching Hospital, Lusaka, Zambia
| | - Sylvia Machona
- Neonatal Intensive Care Unit, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Angela Lyondo
- Department of Pathology and Microbiology, University Teaching Hospital
| | - Matthew A Bates
- School of Life Sciences, University of Lincoln, United Kingdom
| | - Susan E Coffin
- Division of Infectious Diseases, Children's Hospital of Philadelphia
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts
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16
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Stefanovski D, Moate PJ, Frank N, Ward GM, Localio AR, Punjabi NM, Boston RC. Metabolic modeling using statistical and spreadsheet software: Application to the glucose minimal model. Comput Methods Programs Biomed 2020; 191:105353. [PMID: 32113102 DOI: 10.1016/j.cmpb.2020.105353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 06/10/2023]
Abstract
Kinetic non-linear metabolic models are used extensively in medical research and increasingly for clinical diagnostic purposes. An example of such a model is the Glucose Minimal Model by Bergman and colleagues [1]. This model is similar to pharmacokinetic/pharmacodynamic models in that like pharmacokinetic/pharmacodynamic models, it is based on a small number of fairly simple ordinary differential equations and it aims to determine how the changing concentration of one blood constituent influences the concentration of another constituent. Although such models may appear prima facie, to be relatively simple, they have gained a reputation of being difficult to fit to data, especially in a consistent and repeatable fashion. Consequently, researchers and clinicians have generally relied on dedicated software packages to do this type of modeling. This article describes the use of statistical and spreadsheet software for fitting the Glucose Minimal Model to data from an insulin modified intravenous glucose tolerance test (IM-IVGTT). A novel aspect of the modeling is that the differential equations that are normally used to describe insulin action and the disposition of plasma glucose are first solved and expressed in their explicit forms so as to facilitate the estimation of Glucose Minimal Model parameters using the nonlinear (nl) optimization procedure within statistical and spreadsheet software. The most important clinical parameter obtained from the Glucose Minimal Model is insulin sensitivity (SI). Using IM-IVGTT data from 42 horses in one experiment and 48 horses in a second experiment, we demonstrate that estimates of SI derived from the Glucose Minimal Model fitted to data using STATA and Excel, are highly concordant with SI estimates obtained using the industry standard software, MinMod Millennium. This work demonstrates that there is potential for statistical and spreadsheet software to be applied to a wide range of kinetic non-linear modeling problems.
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Affiliation(s)
- D Stefanovski
- Department of Clinical Studies - New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States.
| | - P J Moate
- Agriculture Research Division, Department of Economic Development Jobs Transport and Resources, Ellinbank Centre, Ellinbank, VIC 3821, Australia
| | - N Frank
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA, United States
| | - G M Ward
- Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - A R Localio
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - N M Punjabi
- Division of Pulmonary and Critical Care Medicine (N.M.P.), Johns Hopkins University, Baltimore, MD, United States
| | - R C Boston
- Department of Clinical Studies - New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
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17
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Affiliation(s)
| | - Anne R Meibohm
- American College of Physicians, Philadelphia, Pennsylvania (A.R.M.)
| | - Eliseo Guallar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (E.G.)
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18
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Apter AJ, Bryant-Stephens T, Perez L, Morales KH, Howell JT, Mullen AN, Han X, Canales M, Rogers M, Klusaritz H, Localio AR. Patient Portal Usage and Outcomes Among Adult Patients with Uncontrolled Asthma. J Allergy Clin Immunol Pract 2020; 8:965-970.e4. [PMID: 31622684 PMCID: PMC7064415 DOI: 10.1016/j.jaip.2019.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/30/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patient-clinician communication, essential for favorable asthma outcomes, increasingly relies on information technology including the electronic heath record-based patient portal. For patients with chronic disease living in low-income neighborhoods, the benefits of portal communication remain unclear. OBJECTIVE To describe portal activities and association with 12-month outcomes among low-income patients with asthma formally trained in portal use. METHODS In a longitudinal observational study within a randomized controlled trial, 301 adults with uncontrolled asthma were taught 7 portal tasks: reviewing upcoming appointments, scheduling appointments, reviewing medications, locating laboratory results, locating immunization records, requesting refills, and messaging. Half the patients were randomized to receive up to 4 home visits by community health workers. Patients' portal use by activities, rate of usage over time, frequency of appointments with asthma physicians, and asthma control and quality of life were assessed over time and estimated as of 12 months from randomization. RESULTS Fewer than 60% of patients used the portal independently. Among users, more than half used less than 1 episode per calendar quarter. The most frequent activities were reading messages and viewing laboratory results and least sending messages and making appointments. Higher rates of portal use were not associated with keeping regular appointments during follow-up, better asthma control, or higher quality of life at 12-month postintervention. CONCLUSIONS Patients with uncontrolled asthma used the portal irregularly if at all, despite in-person training. Usage was not associated with regular appointments or with clinical outcomes. Patient portals need modification to accommodate low-income patients with uncontrolled asthma.
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Affiliation(s)
- Andrea J Apter
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa.
| | | | - Luzmercy Perez
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
| | - Knashawn H Morales
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
| | - John T Howell
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
| | | | - Xiaoyan Han
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
| | | | - Marisa Rogers
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
| | - Heather Klusaritz
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
| | - A Russell Localio
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pa
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19
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Bonafide CP, Miller JM, Localio AR, Khan A, Dziorny AC, Mai M, Stemler S, Chen W, Holmes JH, Nadkarni VM, Keren R. Association Between Mobile Telephone Interruptions and Medication Administration Errors in a Pediatric Intensive Care Unit. JAMA Pediatr 2020; 174:162-169. [PMID: 31860017 PMCID: PMC6990809 DOI: 10.1001/jamapediatrics.2019.5001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Incoming text messages and calls on nurses' mobile telephones may interrupt medication administration, but whether such interruptions are associated with errors has not been established. OBJECTIVE To assess whether a temporal association exists between mobile telephone interruptions and subsequent errors by pediatric intensive care unit (PICU) nurses during medication administration. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was performed using telecommunications and electronic health record data from a PICU in a children's hospital. Data were collected from August 1, 2016, through September 30, 2017. Participants included 257 nurses and the 3308 patients to whom they administered medications. EXPOSURES Primary exposures were incoming telephone calls and text messages received on the institutional mobile telephone assigned to the nurse in the 10 minutes leading up to a medication administration attempt. Secondary exposures were the nurse's PICU experience, work shift (day vs night), nurse to patient ratio, and level of patient care required. MAIN OUTCOMES AND MEASURES Primary outcome, errors during medication administration, was a composite of reported medication administration errors and bar code medication administration error alerts generated when nurses attempted to give medications without active orders for the patient whose bar code they scanned. RESULTS Participants included 257 nurses, of whom 168 (65.4%) had 6 months or more of PICU experience; and 3308 patients, of whom 1839 (55.6%) were male, 1539 (46.5%) were white, and 2880 (87.1%) were non-Hispanic. The overall rate of errors during 238 540 medication administration attempts was 3.1% (95% CI, 3.0%-3.3%) when nurses were uninterrupted by incoming telephone calls and 3.7% (95% CI, 3.4%-4.0%) when they were interrupted by such calls. During day shift, the odds ratios (ORs) for error when interrupted by calls (compared with uninterrupted) were 1.02 (95% CI, 0.92-1.13; P = .73) among nurses with 6 months or more of PICU experience and 1.22 (95% CI, 1.00-1.47; P = .046) among nurses with less than 6 months of experience. During night shift, the ORs for error when interrupted by calls were 1.35 (95% CI, 1.16-1.57; P < .001) among nurses with 6 months or more of PICU experience and 1.53 (95% CI, 1.16-2.03; P = .003) among nurses with less than 6 months of experience. Nurses administering medications to 1 or more patients receiving mechanical ventilation and arterial catheterization while caring for at least 1 other patient had an increased risk of error (OR, 1.21; 95% CI, 1.03-1.42; P = .02). Incoming text messages were not associated with error (OR, 0.97; 95% CI, 0.92-1.02; P = .22). CONCLUSIONS AND RELEVANCE This study's findings suggest that incoming telephone call interruptions may be temporally associated with medication administration errors among PICU nurses. Risk of error varied by shift, experience, nurse to patient ratio, and level of patient care required.
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Affiliation(s)
- Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeffrey M. Miller
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Amina Khan
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Healthcare Quality and Analytics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam C. Dziorny
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Pediatric Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mark Mai
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Pediatric Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Shannon Stemler
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Nursing, Christiana Care Health System, Newark, Delaware
| | - Wanxin Chen
- Department of Mathematics, Temple University, Philadelphia, Pennsylvania
| | - John H. Holmes
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vinay M. Nadkarni
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Ron Keren
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Center for Healthcare Quality and Analytics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Deputy Editor, JAMA Pediatrics
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20
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Sheikh S, Localio AR, Kelly A, Rubenstein RC. Abnormal glucose tolerance and the 50-gram glucose challenge test in Cystic fibrosis. J Cyst Fibros 2020; 19:696-699. [PMID: 31974039 DOI: 10.1016/j.jcf.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 12/06/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
Diabetes has emerged as a major co-morbidity in cystic fibrosis (CF). The 75 g oral glucose tolerance test (OGTT) is used to screen for CF-related diabetes (CFRD) but is inconvenient, and adherence to screening is poor. The 50 g glucose challenge test (GCT) is shorter, performed non-fasting, and may serve to pre-screen the subset of individuals requiring confirmatory OGTT. We performed a pilot study in twenty-seven CF individuals across the glucose tolerance spectrum to test whether the GCT could identify subjects with abnormal glucose tolerance defined as 2-h OGTT glucose ≥7.8 mmol/L (2 h-AGT) or 1-h defined as 1-hr OGTT glucose ≥11.1 mmol/L (1 h-AGT). A GCT threshold of 8.1 mmol/L was 73% sensitive and 63% specific for 2hr-AGT and 80% sensitive and 65% specific for 1hr-AGT. Therefore, a screening GCT may reduce need for confirmatory OGTT for identifying AGT but a larger study is warranted to identify a robust cutoff for CFRD.
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Affiliation(s)
- Saba Sheikh
- Division of Pulmonary Medicine and The Cystic Fibrosis Center, The Children's Hospital of Philadelphia, Philadelphia, PA United States.
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA United States
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA United States
| | - Ronald C Rubenstein
- Division of Pulmonary Medicine and The Cystic Fibrosis Center, The Children's Hospital of Philadelphia, Philadelphia, PA United States
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21
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Affiliation(s)
- A Russell Localio
- Perelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania (A.R.L.)
| | - Cynthia D Mulrow
- Senior Deputy Editor, Annals of Internal Medicine Philadelphia, Pennsylvania (C.D.M.)
| | - Michael E Griswold
- MIND Center, University of Mississippi Medical Center Jackson, Mississippi (M.E.G.)
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22
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Forke CM, Catallozzi M, Localio AR, Grisso JA, Wiebe DJ, Fein JA. Intergenerational effects of witnessing domestic violence: Health of the witnesses and their children. Prev Med Rep 2019; 15:100942. [PMID: 31321205 PMCID: PMC6614529 DOI: 10.1016/j.pmedr.2019.100942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/09/2019] [Accepted: 06/28/2019] [Indexed: 12/04/2022] Open
Abstract
Studies that explore intergenerational effects of witnessing domestic violence during childhood (“witnessing”) are lacking. We examined effects of witnessing on general health status for adults who witnessed domestic violence during childhood and their children. Cross-sectional data from population-based phone interviews conducted in Philadelphia during 2012–2013 provided health information for 329 parents and children, and parent's witnessing exposure. We used propensity scores to predict parent's witnessing status using childhood confounders; response models included inverse probability of treatment weighting and population weights for standardization. Separate standardized multivariate logistic regression models provided average treatment effects and 95% CIs for associations between childhood witnessing and below average health for: 1) adults who witnessed and 2) their children. Sensitivity analyses guided interpretation. Standardized models showed no differences in average treatment effects for below average adult health for witnesses vs. non-witnesses [0.04 (−0.12, 0.19)]. Conversely, children whose parents witnessed had considerably higher probability of having below average health than children whose parents did not witness [0.15 (0.02, 0.28)]. An unmeasured confounder would need 3.0-fold associations with both exposure and outcome to completely remove observed effects, indicating a moderate relationship. However, the lower confidence bound could cross 1.0 in the presence of a weaker unmeasured confounder having 1.2-fold associations with both exposure and outcome, while controlling for our same measured confounders. Witnessing during childhood did not affect adult health in our population, but we found moderate evidence supporting harmful intergenerational effects of witnessing on health, with parent's witnessing exposure affecting their child's health.
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Affiliation(s)
- Christine M Forke
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, United States of America.,Violence Prevention Initiative, Children's Hospital of Philadelphia, United States of America.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, United States of America
| | - Marina Catallozzi
- Department of Pediatrics, Columbia University Medical Center-College of Physicians & Surgeons, United States of America.,Heilbrunn Department of Population & Family Health, Columbia University Medical Center, New York, NY, United States of America.,Mailman School of Public Health, New York, NY, United States of America
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, United States of America
| | - Jeane Ann Grisso
- Departments of Public Health, Nursing, and Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, United States of America
| | - Joel A Fein
- Violence Prevention Initiative, Children's Hospital of Philadelphia, United States of America.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, United States of America.,Division of Emergency Medicine, Children's Hospital of Philadelphia, United States of America
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23
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Gleeson PK, Perez L, Localio AR, Morales KH, Han X, Bryant-Stephens T, Apter AJ. Inhaler Technique in Low-Income, Inner-City Adults with Uncontrolled Asthma. J Allergy Clin Immunol Pract 2019; 7:2683-2688. [PMID: 31173936 DOI: 10.1016/j.jaip.2019.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Poor inhaler technique has been shown to be associated with less asthma control and increased health care utilization. Little is known about the impact of inhaler technique on the most vulnerable patients. OBJECTIVE This study examined inhaler technique in low-income, inner-city adults with uncontrolled asthma. METHODS Inhaler technique data and other patient characteristics were evaluated in adults drawn from 2 studies conducted at the University of Pennsylvania. Subjects were from low-income Philadelphia neighborhoods and had uncontrolled asthma. Baseline characteristics were collected. Inhaler technique was rated by research coordinators who were trained with written materials. RESULTS In 584 adults, 56% of metered dose inhaler users and 64% of dry powder inhaler users had adequate visually assessed inhaler technique. Inhaler technique did not vary by reading comprehension or numeracy levels. CONCLUSIONS In this group of patients with uncontrolled asthma, visually assessed inhaler technique was adequate in more than one-half. Although incorrect inhaler technique is generally common and must be routinely addressed, this study suggests that other factors that lead to poor control must be identified.
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Affiliation(s)
- Patrick K Gleeson
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Luzmercy Perez
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Xiaoyan Han
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Andrea J Apter
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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24
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Gerber JS, Ross R, Xiao R, Localio AR, Grundmeier R, Rettig S, Teszner E, Szymczak JE, Canning D, Coffin SE. 2132. Infections After Pediatric Ambulatory Surgery: Incidence and Risk Factors. Open Forum Infect Dis 2018. [PMCID: PMC6252811 DOI: 10.1093/ofid/ofy210.1788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Approximately 3 million pediatric ambulatory surgical procedures are performed each year in the United States; however, little is known about the incidence of and risk factors for surgical site infections (SSI) after pediatric surgical procedures performed in these settings. Therefore, we aimed to describe the epidemiology of SSI in children after ambulatory surgery. Methods We conducted a prospective, observational study in a single healthcare network with three ambulatory surgical facilities (ASF) and one hospital-based facility. We enrolled children <18 years who had an ambulatory surgical procedure between June 2012 and December 2015. Data on follow-up care were collected via a structured telephone interview (30–45 days post-surgery) and review of the electronic health record (EHR) 60 days post-surgery. We identified SSIs 30 days after surgery by applying 2010 National Healthcare Safety Network (NHSN) definitions. We also developed a broader definition of possible infectious events associated with surgery up to 60 days after surgery. Results We enrolled 8,502 surgical encounters; 64% occurred at the hospital-based facility. Three procedure categories (soft tissue excision, hernia, scrotal/testicular) accounted for 56% of encounters at ASFs. We identified 21 NHSN defined SSIs (2.5 SSIs per 1,000 surgical encounters). In adjusted analysis, there was no difference between hospital-based facility and ASF SSI rates (OR 0.7; 95% CI 0.2–2.3). Using the broader definition, we identified 404 surgical encounters with strong or some evidence of possible infection (48 per 1,000 surgical encounters). There was poor agreement of possible infections identified via parent interview vs. EHR. In multivariable analysis using the broader definition, older age and black race were associated with a reduced risk. Conclusion Using a rigorous surveillance definition, the incidence of surgical site infections was low after pediatric ambulatory surgery although our data suggest there may be additional infectious complications that are not captured by the NHSN definition. Given the annual rate of pediatric ambulatory surgery, even a low rate of infection may result in a significant medical burden. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachael Ross
- Department of Pediatrics, Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Robert Grundmeier
- General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Rettig
- Infection Prevention and Control, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eva Teszner
- Infection Prevention and Control, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia E Szymczak
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas Canning
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan E Coffin
- Center for Pediatric Clinical Effectiveness, Pediatric Infectious Diseases Epidemiology and Antimicrobial Stewardship Research Group, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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25
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Karavite DJ, Miller MW, Ramos MJ, Rettig SL, Ross RK, Xiao R, Muthu N, Localio AR, Gerber JS, Coffin SE, Grundmeier RW. User Testing an Information Foraging Tool for Ambulatory Surgical Site Infection Surveillance. Appl Clin Inform 2018; 9:791-802. [PMID: 30357777 DOI: 10.1055/s-0038-1675179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (< 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders. OBJECTIVE This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability. METHODS Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility. RESULTS Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes, p = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5, p = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes, p = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33, p = 0.02), and significantly higher in measures of usability. CONCLUSION Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.
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Affiliation(s)
- Dean J Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Matthew W Miller
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Mark J Ramos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Susan L Rettig
- Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Rachael K Ross
- Division of Infectious Disease, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - A Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Jeffrey S Gerber
- Division of Infectious Disease, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Susan E Coffin
- Division of Infectious Disease, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Localio AR, Stack CB, Meibohm AR, Ross EA, Guallar E, Wong JB, Cornell JE, Griswold ME, Goodman SN. Inappropriate Statistical Analysis and Reporting in Medical Research: Perverse Incentives and Institutional Solutions. Ann Intern Med 2018; 169:577-578. [PMID: 30304363 DOI: 10.7326/m18-2516] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Catharine B Stack
- American College of Physicians, Philadelphia, Pennsylvania (C.B.S., A.R.M.)
| | - Anne R Meibohm
- American College of Physicians, Philadelphia, Pennsylvania (C.B.S., A.R.M.)
| | - Eric A Ross
- Fox Chase Cancer Center, Philadelphia, Pennsylvania (E.A.R.)
| | | | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts (J.B.W.)
| | - John E Cornell
- University of Texas Health Science Center, San Antonio, Texas (J.E.C.)
| | | | - Steven N Goodman
- Stanford University School of Medicine, Stanford, California (S.N.G.)
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Forke CM, Myers RK, Fein JA, Catallozzi M, Localio AR, Wiebe DJ, Grisso JA. Witnessing intimate partner violence as a child: How boys and girls model their parents' behaviors in adolescence. Child Abuse Negl 2018; 84:241-252. [PMID: 30138781 DOI: 10.1016/j.chiabu.2018.07.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/19/2018] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
Childhood witnesses of adult violence at home are at risk for future violence. It is unclear how gender of the child and adult perpetrator are related to adolescent relationship violence. We explore how childhood witnessing of same-gender, opposite-gender, and bidirectional violence perpetrated by adults is associated with adolescent relationship violence victimization only, perpetration only, and combined victimization/perpetration for male and female undergraduates. We gathered cross-sectional data from 907 undergraduates attending 67 randomly-selected classes at three distinct East-Coast colleges using pencil-and-paper surveys administered at the end of class time. Multiple imputation with chained equations was used to impute missing data. Multinomial regression models controlling for gender, age, race, school, and community violence predicted adolescent outcomes for each witnessing exposure; relative risk ratios and average adjusted probabilities with 95% confidence intervals are presented. Adolescent relationship violence outcomes vary based on gender of the child witness and adult perpetrator. Witnessing adult males perpetrate is associated with higher perpetration for boys and higher combined victimization/perpetration for girls. Witnessing adult females perpetrate - either as the sole perpetrator or in a mutually violent relationship with an adult male - increases risk for combined victimization/perpetration for boys and girls during adolescence.
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Affiliation(s)
- Christine M Forke
- Dept. of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, Univ. of Pennsylvania, Philadelphia, PA, United States; Violence Prevention Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Rachel K Myers
- Violence Prevention Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Joel A Fein
- Violence Prevention Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Div. of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Marina Catallozzi
- Dept. of Pediatrics, Columbia Univ. Medical Center - College of Physicians and Surgeons, New York, NY, United States; Heilbrunn Dept. of Population & Family Health, Columbia Univ. Medical Center, New York, NY, United States; Mailman School of Public Health, New York, NY, United States
| | - A Russell Localio
- Dept. of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, Univ. of Pennsylvania, Philadelphia, PA, United States
| | - Douglas J Wiebe
- Dept. of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, Univ. of Pennsylvania, Philadelphia, PA, United States
| | - Jeane Ann Grisso
- Depts. of Public Health, Nursing, & Medicine, Univ. of Pennsylvania, Philadelphia, PA, United States
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Bonafide CP, Localio AR, Sternler S, Ahumada L, Dewan M, Ely E, Keren R. Safety Huddle Intervention for Reducing Physiologic Monitor Alarms: A Hybrid Effectiveness-Implementation Cluster Randomized Trial. J Hosp Med 2018; 13:609-615. [PMID: 29489921 DOI: 10.12788/jhm.2956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Monitor alarms occur frequently but rarely warrant intervention. OBJECTIVE This study aimed to determine if a safety huddle-based intervention reduces unit-level alarm rates or alarm rates of individual patients whose alarms are discussed, as well as evaluate implementation outcomes. DESIGN Unit-level, cluster randomized, hybrid effectiveness-implementation trial with a secondary patient-level analysis. SETTING Children's hospital. PATIENTS Unit-level: all patients hospitalized on 4 control (n = 4177) and 4 intervention (n = 7131) units between June 15, 2015 and May 8, 2016. Patient-level: 425 patients on randomly selected dates postimplementation. INTERVENTION Structured safety huddle review of alarm data from the patients on each unit with the most alarms, with a discussion of ways to reduce alarms. MEASUREMENTS Unit-level: change in unit-level alarm rates between baseline and postimplementation periods in intervention versus control units. Patient-level: change in individual patients' alarm rates between the 24 hours leading up to huddles and the 24 hours after huddles in patients who were discussed versus not discussed in huddles. RESULTS Alarm data informed 580 huddle discussions. In unit-level analysis, intervention units had 2 fewer alarms/patient-day (95% CI: 7 fewer to 6 more, P = .50) compared with control units. In patient-level analysis, patients discussed in huddles had 97 fewer alarms/patientday (95% CI: 52-138 fewer, P < .001) in the posthuddle period compared with patients not discussed in huddles. Implementation outcome analysis revealed a low intervention dose of 0.85 patients/unit/day. CONCLUSIONS Safety huddle-based alarm discussions did not influence unit-level alarm rates due to low intervention dose but were effective in reducing alarms for individual children.
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Affiliation(s)
- Christopher P Bonafide
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - A Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon Sternler
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Luis Ahumada
- Enterprise Analytics and Reporting, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Ely
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ron Keren
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kumanyika SK, Morales KH, Allison KC, Localio AR, Sarwer DB, Phipps E, Fassbender JE, Tsai AG, Wadden TA. Two-Year Results of Think Health! ¡Vive Saludable!: A Primary Care Weight-Management Trial. Obesity (Silver Spring) 2018; 26:1412-1421. [PMID: 30160061 PMCID: PMC6143399 DOI: 10.1002/oby.22258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 10/31/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Think Health! ¡Vive Saludable! evaluated a moderate-intensity, lifestyle behavior-change weight-loss program in primary care over 2 years of treatment. Final analyses examined weight-change trajectories by treatment group and attendance. METHODS Adult primary care patients (n = 261; 84% female; 65% black; 16% Hispanic) were randomly assigned to Basic Plus (moderate intensity; counseling by primary care clinician and a lifestyle coach) or Basic (clinician counseling only). Intention-to-treat analyses used all available weight measurements from data collection, treatment, and routine clinical visits. Linear mixed-effects regression models adjusted for treatment site, gender, and age, and sensitivity analyses evaluated treatment attendance and the impact of loss to follow-up. RESULTS Model-based estimates for 24-month mean (95% CI) weight change from baseline were -1.34 kg (-2.92 to 0.24) in Basic Plus and -1.16 kg (-2.70 to 0.37) in Basic (net difference -0.18 kg [-2.38 to 2.03]; P = 0.874). Larger initial weight loss in Basic Plus was attenuated by a ~0.5-kg rebound at 12 to 16 months. Each additional coaching visit was associated with a 0.37-kg greater estimated 24-month weight loss (P = 0.01). CONCLUSIONS These findings in mostly black and Hispanic female primary care patients suggest that strategies to improve treatment attendance may improve weight loss resulting from moderate-intensity counseling.
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Affiliation(s)
- Shiriki K. Kumanyika
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Knashawn H. Morales
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kelly C. Allison
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David B. Sarwer
- Center for Obesity Research and Education, Temple University College of Public Health, Philadelphia, PA, USA
| | - Etienne Phipps
- Center for Urban Health Policy and Research, Albert Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
- Public health consultant, Philadelphia, Pennsylvania, USA
| | - Jennifer E. Fassbender
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Adam G. Tsai
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas A. Wadden
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Affiliation(s)
- Christopher P Bonafide
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Daria F Ferro
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evan W Orenstein
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David T Jamison
- Health Devices Group, ECRI Institute, Plymouth Meeting, Pennsylvania
| | - Chris Lavanchy
- Health Devices Group, ECRI Institute, Plymouth Meeting, Pennsylvania
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Affiliation(s)
- A Russell Localio
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.R.L.)
| | - Steven N Goodman
- Stanford University School of Medicine, Stanford, California (S.N.G.)
| | - Anne Meibohm
- American College of Physicians, Philadelphia, Pennsylvania (A.M., C.B.S., C.D.M.)
| | - John E Cornell
- University of Texas Health Science Center, San Antonio, Texas (J.E.C.)
| | - Catharine B Stack
- American College of Physicians, Philadelphia, Pennsylvania (A.M., C.B.S., C.D.M.)
| | - Eric A Ross
- Fox Chase Cancer Center and Temple University, Philadelphia, Pennsylvania (E.A.R.)
| | - Cynthia D Mulrow
- American College of Physicians, Philadelphia, Pennsylvania (A.M., C.B.S., C.D.M.)
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32
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Daymont C, Ross ME, Russell Localio A, Fiks AG, Wasserman RC, Grundmeier RW. Automated identification of implausible values in growth data from pediatric electronic health records. J Am Med Inform Assoc 2018; 24:1080-1087. [PMID: 28453637 DOI: 10.1093/jamia/ocx037] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/17/2017] [Indexed: 11/14/2022] Open
Abstract
Objective Large electronic health record (EHR) datasets are increasingly used to facilitate research on growth, but measurement and recording errors can lead to biased results. We developed and tested an automated method for identifying implausible values in pediatric EHR growth data. Materials and Methods Using deidentified data from 46 primary care sites, we developed an algorithm to identify weight and height values that should be excluded from analysis, including implausible values and values that were recorded repeatedly without remeasurement. The foundation of the algorithm is a comparison of each measurement, expressed as a standard deviation score, with a weighted moving average of a child's other measurements. We evaluated the performance of the algorithm by (1) comparing its results with the judgment of physician reviewers for a stratified random selection of 400 measurements and (2) evaluating its accuracy in a dataset with simulated errors. Results Of 2 000 595 growth measurements from 280 610 patients 1 to 21 years old, 3.8% of weight and 4.5% of height values were identified as implausible or excluded for other reasons. The proportion excluded varied widely by primary care site. The automated method had a sensitivity of 97% (95% confidence interval [CI], 94-99%) and a specificity of 90% (95% CI, 85-94%) for identifying implausible values compared to physician judgment, and identified 95% (weight) and 98% (height) of simulated errors. Discussion and Conclusion This automated, flexible, and validated method for preparing large datasets will facilitate the use of pediatric EHR growth datasets for research.
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Affiliation(s)
- Carrie Daymont
- Departments of Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Michelle E Ross
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - A Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander G Fiks
- Department of Biomedical and Health Informatics
- Pediatric Research Consortium
- Center for Pediatric Clinical Effectiveness
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove, IL, USA
| | - Richard C Wasserman
- Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove, IL, USA
- Department of Pediatrics, University of Vermont, Burlington, VT, USA
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Gerber JS, Ross RK, Bryan M, Localio AR, Szymczak JE, Wasserman R, Barkman D, Odeniyi F, Conaboy K, Bell L, Zaoutis TE, Fiks AG. Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA 2017; 318:2325-2336. [PMID: 29260224 PMCID: PMC5820700 DOI: 10.1001/jama.2017.18715] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 11/10/2017] [Indexed: 11/14/2022]
Abstract
Importance Acute respiratory tract infections account for the majority of antibiotic exposure in children, and broad-spectrum antibiotic prescribing for acute respiratory tract infections is increasing. It is not clear whether broad-spectrum treatment is associated with improved outcomes compared with narrow-spectrum treatment. Objective To compare the effectiveness of broad-spectrum and narrow-spectrum antibiotic treatment for acute respiratory tract infections in children. Design, Setting, and Participants A retrospective cohort study assessing clinical outcomes and a prospective cohort study assessing patient-centered outcomes of children between the ages of 6 months and 12 years diagnosed with an acute respiratory tract infection and prescribed an oral antibiotic between January 2015 and April 2016 in a network of 31 pediatric primary care practices in Pennsylvania and New Jersey. Stratified and propensity score-matched analyses to account for confounding by clinician and by patient-level characteristics, respectively, were implemented for both cohorts. Exposures Broad-spectrum antibiotics vs narrow-spectrum antibiotics. Main Outcomes and Measures In the retrospective cohort, the primary outcomes were treatment failure and adverse events 14 days after diagnosis. In the prospective cohort, the primary outcomes were quality of life, other patient-centered outcomes, and patient-reported adverse events. Results Of 30 159 children in the retrospective cohort (19 179 with acute otitis media; 6746, group A streptococcal pharyngitis; and 4234, acute sinusitis), 4307 (14%) were prescribed broad-spectrum antibiotics including amoxicillin-clavulanate, cephalosporins, and macrolides. Broad-spectrum treatment was not associated with a lower rate of treatment failure (3.4% for broad-spectrum antibiotics vs 3.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 0.3% [95% CI, -0.4% to 0.9%]). Of 2472 children enrolled in the prospective cohort (1100 with acute otitis media; 705, group A streptococcal pharyngitis; and 667, acute sinusitis), 868 (35%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotics were associated with a slightly worse child quality of life (score of 90.2 for broad-spectrum antibiotics vs 91.5 for narrow-spectrum antibiotics; score difference for full matched analysis, -1.4% [95% CI, -2.4% to -0.4%]) but not with other patient-centered outcomes. Broad-spectrum treatment was associated with a higher risk of adverse events documented by the clinician (3.7% for broad-spectrum antibiotics vs 2.7% for narrow-spectrum antibiotics; risk difference for full matched analysis, 1.1% [95% CI, 0.4% to 1.8%]) and reported by the patient (35.6% for broad-spectrum antibiotics vs 25.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 12.2% [95% CI, 7.3% to 17.2%]). Conclusions and Relevance Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.
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Affiliation(s)
- Jeffrey S. Gerber
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachael K. Ross
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Darlene Barkman
- Division of Patient and Family Experience, Family and Patient Services Department, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Folasade Odeniyi
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathryn Conaboy
- Division of Patient and Family Experience, Family and Patient Services Department, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Louis Bell
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theoklis E. Zaoutis
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander G. Fiks
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Affiliation(s)
- A Russell Localio
- From University of Pennsylvania, Philadelphia, Pennsylvania; American College of Physicians, Philadelphia, Pennsylvania; and University of Mississippi Medical Center, Jackson, Mississippi
| | - Catherine B Stack
- From University of Pennsylvania, Philadelphia, Pennsylvania; American College of Physicians, Philadelphia, Pennsylvania; and University of Mississippi Medical Center, Jackson, Mississippi
| | - Michael E Griswold
- From University of Pennsylvania, Philadelphia, Pennsylvania; American College of Physicians, Philadelphia, Pennsylvania; and University of Mississippi Medical Center, Jackson, Mississippi
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35
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Winterbottom CJ, Shah RJ, Patterson KC, Kreider ME, Panettieri RA, Rivera-Lebron B, Miller WT, Litzky LA, Penning TM, Heinlen K, Jackson T, Localio AR, Christie JD. Exposure to Ambient Particulate Matter Is Associated With Accelerated Functional Decline in Idiopathic Pulmonary Fibrosis. Chest 2017; 153:1221-1228. [PMID: 28802694 DOI: 10.1016/j.chest.2017.07.034] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 06/16/2017] [Accepted: 07/03/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF), a progressive disease with an unknown pathogenesis, may be due in part to an abnormal response to injurious stimuli by alveolar epithelial cells. Air pollution and particulate inhalation of matter evoke a wide variety of pulmonary and systemic inflammatory diseases. We therefore hypothesized that increased average ambient particulate matter (PM) concentrations would be associated with an accelerated rate of decline in FVC in IPF. METHODS We identified a cohort of subjects seen at a single university referral center from 2007 to 2013. Average concentrations of particulate matter < 10 and < 2.5 μg/m3 (PM10 and PM2.5, respectively) were assigned to each patient based on geocoded residential addresses. A linear multivariable mixed-effects model determined the association between the rate of decline in FVC and average PM concentration, controlling for baseline FVC at first measurement and other covariates. RESULTS One hundred thirty-five subjects were included in the final analysis after exclusion of subjects missing repeated spirometry measurements and those for whom exposure data were not available. There was a significant association between PM10 levels and the rate of decline in FVC during the study period, with each μg/m3 increase in PM10 corresponding with an additional 46 cc/y decline in FVC (P = .008). CONCLUSIONS Ambient air pollution, as measured by average PM10 concentration, is associated with an increase in the rate of decline of FVC in IPF, suggesting a potential mechanistic role for air pollution in the progression of disease.
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Affiliation(s)
- Christopher J Winterbottom
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale University, New Haven, CT.
| | - Rupal J Shah
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco, CA
| | - Karen C Patterson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Maryl E Kreider
- Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Reynold A Panettieri
- Department of Medicine, Rutgers Biomedical and Health Sciences University, New Brunswick, NJ
| | - Belinda Rivera-Lebron
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Wallace T Miller
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Leslie A Litzky
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Trevor M Penning
- Center of Excellence in Environmental Toxicology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Krista Heinlen
- Cartographic Modeling Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tara Jackson
- Cartographic Modeling Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Bonafide CP, Localio AR, Holmes JH, Nadkarni VM, Stemler S, MacMurchy M, Zander M, Roberts KE, Lin R, Keren R. Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children's Hospital. JAMA Pediatr 2017; 171:524-531. [PMID: 28394995 PMCID: PMC5459660 DOI: 10.1001/jamapediatrics.2016.5123] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Bedside monitor alarms alert nurses to life-threatening physiologic changes among patients, but the response times of nurses are slow. OBJECTIVE To identify factors associated with physiologic monitor alarm response time. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used 551 hours of video-recorded care administered by 38 nurses to 100 children in a children's hospital medical unit between July 22, 2014, and November 11, 2015. EXPOSURES Patient, nurse, and alarm-level factors hypothesized to predict response time. MAIN OUTCOMES AND MEASURES We used multivariable accelerated failure-time models stratified by each nurse and adjusted for clustering within patients to evaluate associations between exposures and response time to alarms that occurred while the nurse was outside the room. RESULTS The study participants included 38 nurses, 100% (n = 38) of whom were white and 92% (n = 35) of whom were female, and 100 children, 51% (n = 51) of whom were male. The race/ethnicity of the child participants was 45% (n = 45) black or African American, 33% (n = 33) white, 4% (n = 4) Asian, and 18% (n = 18) other. Of 11 745 alarms among 100 children, 50 (0.5%) were actionable. The adjusted median response time among nurses was 10.4 minutes (95% CI, 5.0-15.8) and varied based on the following variables: if the patient was on complex care service (5.3 minutes [95% CI, 1.4-9.3] vs 11.1 minutes [95% CI, 5.6-16.6] among general pediatrics patients), whether family members were absent from the patient's bedside (6.3 minutes [95% CI, 2.2-10.4] vs 11.7 minutes [95% CI, 5.9-17.4] when family present), whether a nurse had less than 1 year of experience (4.4 minutes [95% CI, 3.4-5.5] vs 8.8 minutes [95% CI, 7.2-10.5] for nurses with 1 or more years of experience), if there was a 1 to 1 nursing assignment (3.5 minutes [95% CI, 1.3-5.7] vs 10.6 minutes [95% CI, 5.3-16.0] for nurses caring for 2 or more patients), if there were prior alarms requiring intervention (5.5 minutes [95% CI, 1.5-9.5] vs 10.7 minutes [5.2-16.2] for patients without intervention), and if there was a lethal arrhythmia alarm (1.2 minutes [95% CI, -0.6 to 2.9] vs 10.4 minutes [95% CI, 5.1-15.8] for alarms for other conditions). Each hour that elapsed during a nurse's shift was associated with a 15% longer response time (6.1 minutes [95% CI, 2.8-9.3] in hour 2 vs 14.1 minutes [95% CI, 6.4-21.7] in hour 8). The number of nonactionable alarms to which the nurse was exposed in the preceding 120 minutes was not associated with response time. CONCLUSIONS AND RELEVANCE Response time was associated with factors that likely represent the heuristics nurses use to assess whether an alarm represents a life-threatening condition. The nurse to patient ratio and physical and mental fatigue (measured by the number of hours into a shift) represent modifiable factors associated with response time. Chronic alarm fatigue resulting from long-term exposure to nonactionable alarms may be a more important determinant of response time than short-term exposure.
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Affiliation(s)
- Christopher P. Bonafide
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John H. Holmes
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Shannon Stemler
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew MacMurchy
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Miriam Zander
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA,Touro College of Osteopathic Medicine, New York, NY
| | - Kathryn E. Roberts
- Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Richard Lin
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ron Keren
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Affiliation(s)
- Joshua M Liao
- From University of Pennsylvania and American College of Physicians, Philadelphia, Pennsylvania, and University of Mississippi Medical Center, Jackson, Mississippi
| | - Catharine B Stack
- From University of Pennsylvania and American College of Physicians, Philadelphia, Pennsylvania, and University of Mississippi Medical Center, Jackson, Mississippi
| | - Michael E Griswold
- From University of Pennsylvania and American College of Physicians, Philadelphia, Pennsylvania, and University of Mississippi Medical Center, Jackson, Mississippi
| | - A Russell Localio
- From University of Pennsylvania and American College of Physicians, Philadelphia, Pennsylvania, and University of Mississippi Medical Center, Jackson, Mississippi
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Utidjian LH, Fiks AG, Localio AR, Song L, Ramos MJ, Keren R, Bell LM, Grundmeier RW. Pediatric asthma hospitalizations among urban minority children and the continuity of primary care. J Asthma 2017; 54:1051-1058. [PMID: 28332939 DOI: 10.1080/02770903.2017.1294695] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To examine the effect of ambulatory health care processes on asthma hospitalizations. METHODS A retrospective cohort study using electronic health records was completed. Patients aged 2-18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. RESULTS 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09-1.78). CONCLUSIONS In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.
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Affiliation(s)
- Levon H Utidjian
- a Department of Biomedical and Health Informatics , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander G Fiks
- a Department of Biomedical and Health Informatics , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA.,c Center for Pediatric Clinical Effectiveness , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,d Pediatric Research Consortium , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - A Russell Localio
- e Department of Biostatistics and Epidemiology, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | - Lihai Song
- f Healthcare Analytics Unit , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Mark J Ramos
- a Department of Biomedical and Health Informatics , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Ron Keren
- b Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA.,c Center for Pediatric Clinical Effectiveness , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Louis M Bell
- b Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA.,c Center for Pediatric Clinical Effectiveness , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,d Pediatric Research Consortium , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Robert W Grundmeier
- a Department of Biomedical and Health Informatics , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA.,c Center for Pediatric Clinical Effectiveness , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,d Pediatric Research Consortium , Children's Hospital of Philadelphia , Philadelphia , PA , USA
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Borders CF, Suzuki Y, Lasky J, Schaufler C, Mallem D, Lee J, Carney K, Bellamy SL, Bermudez CA, Localio AR, Christie JD, Diamond JM, Cantu E. Massive donor transfusion potentially increases recipient mortality after lung transplantation. J Thorac Cardiovasc Surg 2016; 153:1197-1203.e2. [PMID: 28073574 DOI: 10.1016/j.jtcvs.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 11/18/2016] [Accepted: 12/04/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Donor blood transfusion has been identified as a potential risk factor for primary graft dysfunction and by extension early mortality. We sought to define the contributing risk of donor transfusion on early mortality for lung transplant. METHODS Donor and recipient data were abstracted from the Organ Procurement and Transplantation Network database updated through June 30, 2014, which included 86,398 potential donors and 16,255 transplants. Using the United Network for Organ Sharing 4-level designation of transfusion (no blood, 1-5 units, 6-10 units, and >10 units, massive), we analyzed all-cause mortality at 30-days with the use of logistic regression adjusted for confounders (ischemic time, donor age, recipient diagnosis, lung allocation score and recipient age, and recipient body mass index). Secondary analyses assessed 90-day and 1-year mortality and hospital length of stay. RESULTS Of the 16,255 recipients transplanted, 8835 (54.35%) donors received at least one transfusion. Among those transfused, 1016 (6.25%) received a massive transfusion, defined as >10 units. Those donors with massive transfusion were most commonly young trauma patients. After adjustment for confounding variables, donor massive transfusion was associated significantly with an increased risk in 30-day (P = .03) and 90-day recipient mortality (P = .01) but not 1-year mortality (P = .09). There was no significant difference in recipient length of stay or hospital-free days with respect to donor transfusion. CONCLUSIONS Massive donor blood transfusion (>10 units) was associated with early recipient mortality after lung transplantation. Conversely, submassive donor transfusion was not associated with increased recipient mortality. The mechanism of increased early mortality in recipients of lungs from massively transfused donors is unclear and needs further study but is consistent with excess mortality seen with primary graft dysfunction in the first 90 days posttransplant.
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Affiliation(s)
- Catherine F Borders
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Yoshikazu Suzuki
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Jared Lasky
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Christian Schaufler
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Djamila Mallem
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - James Lee
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Kevin Carney
- Transplant Institute, University of Pennsylvania, Philadelphia, Pa
| | - Scarlett L Bellamy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - A Russell Localio
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pa; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
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Fisher BT, Vendetti N, Bryan M, Prasad PA, Russell Localio A, Damianos A, Coffin SE, Bell LM, Walsh TJ, Gross R, Zaoutis TE. Central Venous Catheter Retention and Mortality in Children With Candidemia: A Retrospective Cohort Analysis. J Pediatric Infect Dis Soc 2016; 5:403-408. [PMID: 26407279 PMCID: PMC5181361 DOI: 10.1093/jpids/piv048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 07/12/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Candidemia causes significant morbidity and mortality among children. Removal of a central venous catheter (CVC) is often recommended for adults with candidemia to reduce persistent and metastatic infection. Pediatric-specific data on the impact of CVC retention are limited. METHODS A retrospective cohort study of inpatients <19 years with candidemia at the Children's Hospital of Philadelphia between 2000 and 2012 was performed. The final cohort included patients that had a CVC in place at time of blood culture and retained their CVC at least 1 day beyond the blood culture being positive. A structured data collection instrument was used to retrieve patient data. A discrete time failure model, adjusting for age and the complexity of clinical care before onset of candidemia, was used to assess the association of CVC retention and 30-day all-cause mortality. RESULTS Two hundred eighty-five patients with candidemia and a CVC in place at the time of blood culture were identified. Among these 285 patients, 30 (10%) died within 30 days. Central venous catheter retention was associated with a significant increased risk of death on a given day (odds ratio, 2.50; 95% confidence interval, 1.06-5.91). CONCLUSIONS Retention of a CVC was associated with an increased risk of death after adjusting for age and complexity of care at candidemia onset. Although there is likely persistence of unmeasured confounding, given the strong association between catheter retention and death, our data suggest that early CVC removal should be strongly considered.
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Affiliation(s)
- Brian T. Fisher
- Divisions of Infectious Diseases,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neika Vendetti
- Divisions of Infectious Diseases,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
| | - Matthew Bryan
- Department of Pediatrics,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Priya A. Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - A. Russell Localio
- Department of Pediatrics,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Susan E. Coffin
- Divisions of Infectious Diseases,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Louis M. Bell
- Divisions of Infectious Diseases,Department of Pediatrics
| | - Thomas J. Walsh
- Transplantation-Oncology Infectious Diseases, New York-Presbyterian Hospital/Weill Cornell Medical Center
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Philadelphia Veterans Affairs Medical Center, Pennsylvania
| | - Theoklis E. Zaoutis
- Divisions of Infectious Diseases,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Fisher BT, Ross RK, Roilides E, Palazzi DL, Abzug MJ, Hoffman JA, Berman DM, Prasad PA, Localio AR, Steinbach WJ, Vogiatzi L, Dutta A, Zaoutis TE. Failure to Validate a Multivariable Clinical Prediction Model to Identify Pediatric Intensive Care Unit Patients at High Risk for Candidemia. J Pediatric Infect Dis Soc 2016; 5:458-461. [PMID: 26407259 PMCID: PMC7243941 DOI: 10.1093/jpids/piv024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/06/2015] [Indexed: 11/12/2022]
Abstract
We attempted to validate a previously derived clinical prediction rule for candidemia in the pediatric intensive care unit. This multicenter case control study did not identify significant association of candidemia with most of the previously identified predictors. Additional study in larger cohorts with other predictor variables is needed.
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Affiliation(s)
- Brian T. Fisher
- Division of Infectious Diseases
- the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
- Department of Pediatrics
- The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corresponding Author: Brian T. Fisher, DO, MSCE, Division of Infectious Diseases, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, CHOP North, Room 1515, Philadelphia, PA 19104. E-mail:
| | - Rachael K. Ross
- Division of Infectious Diseases
- the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Health Sciences and Hippokration Hospital, Thessaloniki, Greece
| | - Debra L. Palazzi
- Infectious Diseases Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Mark J. Abzug
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Jill A. Hoffman
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California
| | | | - Priya A. Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - A. Russell Localio
- the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
- Department of Pediatrics
- The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - William J. Steinbach
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Lambrini Vogiatzi
- Pediatric Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - Ankhi Dutta
- Infectious Diseases Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases
- the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
- Department of Pediatrics
- The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Fiks AG, Ross ME, Mayne SL, Song L, Liu W, Steffes J, McCarn B, Grundmeier RW, Localio AR, Wasserman R. Preschool ADHD Diagnosis and Stimulant Use Before and After the 2011 AAP Practice Guideline. Pediatrics 2016; 138:peds.2016-2025. [PMID: 27940706 PMCID: PMC5127073 DOI: 10.1542/peds.2016-2025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the change in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants to children 4 to 5 years old after release of the 2011 American Academy of Pediatrics guideline. METHODS Electronic health record data were extracted from 63 primary care practices. We included preventive visits from children 48 to 72 months old receiving care from January 2008 to July 2014. We compared rates of ADHD diagnosis and stimulant prescribing before and after guideline release using logistic regression with a spline and clustering by practice. Patterns of change (increase, decrease, no change) were described for each practice. RESULTS Among 87 067 children with 118 957 visits before the guideline and 56 814 with 92 601 visits after the guideline, children had an ADHD diagnosis at 0.7% (95% confidence interval [CI], 0.7% to 0.8%) of visits before and 0.9% (95% CI, 0.8% to 0.9%) after guideline release and had stimulant prescriptions at 0.4% (95% CI, 0.4% to 0.4%) of visits in both periods. A significantly increasing preguideline trend in ADHD diagnosis ended after guideline release. The rate of stimulant medication use remained constant before and after guideline release. Patterns of change from before to after the guideline varied significantly across practices. CONCLUSIONS Release of the 2011 guideline that addressed ADHD in preschoolers was associated with the end of an increasing rate of diagnosis, and the rate of prescribing stimulants remained constant. These are reassuring results given that a standardized approach to diagnosis was recommended and stimulant treatment is not first-line therapy for this age group.
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Affiliation(s)
- Alexander G. Fiks
- Center for Pediatric Clinical Effectiveness,PolicyLab,Pediatric Research Consortium, and,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,Departments of Pediatrics, and
| | - Michelle E. Ross
- Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | - Lihai Song
- Center for Pediatric Clinical Effectiveness,PolicyLab
| | - Weiwei Liu
- Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Jennifer Steffes
- Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Banita McCarn
- Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Robert W. Grundmeier
- Center for Pediatric Clinical Effectiveness,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,Departments of Pediatrics, and
| | - A. Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Richard Wasserman
- Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,University of Vermont College of Medicine, Burlington, Vermont
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Kaelber DC, Liu W, Ross M, Localio AR, Leon JB, Pace WD, Wasserman RC, Fiks AG. Diagnosis and Medication Treatment of Pediatric Hypertension: A Retrospective Cohort Study. Pediatrics 2016; 138:peds.2016-2195. [PMID: 27940711 PMCID: PMC5127074 DOI: 10.1542/peds.2016-2195] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric hypertension predisposes children to adult hypertension and early markers of cardiovascular disease. No large-scale studies have examined diagnosis and initial medication management of pediatric hypertension and prehypertension. The objective of this study was to evaluate diagnosis and initial medication management of pediatric hypertension and prehypertension in primary care. METHODS Retrospective cohort study aggregating electronic health record data on >1.2 million pediatric patients from 196 ambulatory clinics across 27 states. Demographic, diagnosis, blood pressure (BP), height, weight, and medication prescription data extracted. Main outcome measures include proportion of pediatric patients with ≥3 visits with abnormal BPs, documented hypertension and prehypertension diagnoses, and prescribed antihypertensive medications. Marginal standardization via logistic regression produced adjusted diagnosis rates. RESULTS Three hundred ninety-eight thousand seventy-nine patients, ages 3 to 18, had ≥3 visits with BP measurements (48.9% girls, 58.6% <10 years old). Of these, 3.3% met criteria for hypertension and 10.1% for prehypertension. Among practices with ≥50 eligible patients, 2813 of 12 138 patients with hypertension (23.2%; 95% confidence interval, 18.2%-28.2%) and 3990 of 38 874 prehypertensive patients (10.2%; 95% confidence interval, 8.2%-12.2%) were diagnosed. Age, weight, height, sex, and number and magnitude of abnormal BPs were associated with diagnosis rates. Of 2813 diagnosed, persistently hypertensive patients, 158 (5.6%) were prescribed antihypertensive medication within 12 months of diagnosis (angiotensin-converting enzyme inhibitors/angiotensin receptive blockers [35%], diuretics [22%], calcium channel blockers [17%], and β-blockers [10%]). CONCLUSIONS Hypertension and prehypertension were infrequently diagnosed among pediatric patients. Guidelines for diagnosis and initial medication management of abnormal BP in pediatric patients are not routinely followed.
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Affiliation(s)
- David C. Kaelber
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Departments of Internal Medicine, Pediatrics, Epidemiology, and Biostatistics, Case Western Reserve University, Cleveland Ohio;,Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio
| | - Weiwei Liu
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Michelle Ross
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Janeen B. Leon
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio
| | - Wilson D. Pace
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,American Academy of Family Physicians National Research Network, Leawood, Kansas
| | - Richard C. Wasserman
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont; and
| | - Alexander G. Fiks
- Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER) Consortium Research Team, Elk Grove Village; Illinois;,Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;,The Pediatric Research Consortium,,Department of Biomedical and Health Informatics,,Center for Pediatric Clinical Effectiveness, and,PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Bryant-Stephens T, Reed-Wells S, Canales M, Perez L, Rogers M, Localio AR, Apter AJ. Home visits are needed to address asthma health disparities in adults. J Allergy Clin Immunol 2016; 138:1526-1530. [PMID: 27777181 DOI: 10.1016/j.jaci.2016.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/10/2016] [Accepted: 10/18/2016] [Indexed: 11/28/2022]
Abstract
Research on asthma frequently recruits patients from clinics because the ready pool of patients leads to easy access to patients in office waiting areas, emergency departments, or hospital wards. Patients with other chronic conditions, and with mobility problems, face exposures at home that are not easily identified at the clinic. In this article, we describe the perspective of the community health workers and the challenges they encountered when making home visits while implementing a research intervention in a cohort of low-income, minority patients. From their observations, poor housing, often the result of poverty and lack of social resources, is the real elephant in the chronic asthma room. To achieve a goal of reduced asthma morbidity and mortality will require a first-hand understanding of the real-world social and economic barriers to optimal asthma management and the solutions to those barriers.
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Affiliation(s)
- Tyra Bryant-Stephens
- Children's Hospital of Philadelphia, Philadelphia, Pa; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | | | | | - Luzmercy Perez
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Philadelphia, Pa
| | - Marisa Rogers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - A Russell Localio
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pa
| | - Andrea J Apter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Philadelphia, Pa
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Freeman B, Mayne S, Localio AR, Luberti A, Zorc JJ, Fiks AG. Using Video from Mobile Phones to Improve Pediatric Phone Triage in an Underserved Population. Telemed J E Health 2016; 23:130-136. [PMID: 27328326 DOI: 10.1089/tmj.2016.0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Video-capable mobile phones are widely available, but few studies have evaluated their use in telephone triage for pediatric patients. We assessed the feasibility, acceptability, and utility of videos sent via mobile phones to enhance pediatric telephone triage for an underserved population with asthma. MATERIALS AND METHODS We recruited children who presented to an urban pediatric emergency department with an asthma exacerbation along with their parent/guardian. Parents and the research team each obtained a video of the child's respiratory exam, and the research team conducted a concurrent in-person rating of respiratory status. We measured the acceptability of families sending videos as part of telephone triage (survey) and the feasibility of this approach (rates of successful video transmission by parents to the research team). To estimate the utility of the video in appropriately triaging children, four clinicians reviewed each video and rated whether they found the video reassuring, neutral, or raising concerns. RESULTS Among 60 families (78% Medicaid, 85% Black), 80% of parents reported that sending a video would be helpful and 68% reported that a nurse's review of a video would increase their trust in the triage assessment. Most families (75%) successfully transmitted a video to the research team. All clinician raters found the video reassuring regarding the severity of the child's asthma exacerbation for 68% of children. CONCLUSIONS Obtaining mobile phone videos for telephone triage is acceptable to families, feasible, and may help improve the quality of telephone triage in an urban, minority population.
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Affiliation(s)
- Brandi Freeman
- 1 Department of Pediatrics, University of Colorado School of Medicine , Aurora, Colorado
| | - Stephanie Mayne
- 2 Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,3 PolicyLab, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - A Russell Localio
- 4 Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Anthony Luberti
- 5 Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Joseph J Zorc
- 6 Department of Emergency Medicine, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Alexander G Fiks
- 2 Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,3 PolicyLab, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.,5 Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.,7 Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
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Fierro JL, Prasad PA, Localio AR, Grundmeier RW, Wasserman RC, Zaoutis TE, Gerber JS. Variability in the diagnosis and treatment of group a streptococcal pharyngitis by primary care pediatricians. Infect Control Hosp Epidemiol 2016; 35 Suppl 3:S79-85. [PMID: 25222902 DOI: 10.1086/677820] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices. DESIGN Retrospective cohort study. SETTING All encounters to 25 pediatric primary care practices sharing an electronic health record. METHODS Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation. RESULTS Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P < .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing. CONCLUSIONS Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.
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Affiliation(s)
- Julie L Fierro
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Gerber JS, Bryan M, Ross RK, Daymont C, Parks EP, Localio AR, Grundmeier RW, Stallings VA, Zaoutis TE. Antibiotic Exposure During the First 6 Months of Life and Weight Gain During Childhood. JAMA 2016; 315:1258-65. [PMID: 27002447 DOI: 10.1001/jama.2016.2395] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Early-life antibiotic exposure has been associated with increased adiposity in animal models, mediated through the gut microbiome. Infant antibiotic exposure is common and often inappropriate. Studies of the association between infant antibiotics and childhood weight gain have reported inconsistent results. OBJECTIVE To assess the association between early-life antibiotic exposure and childhood weight gain. DESIGN AND SETTING Retrospective, longitudinal study of singleton births and matched longitudinal study of twin pairs conducted in a network of 30 pediatric primary care practices serving more than 200,000 children of diverse racial and socioeconomic backgrounds across Pennsylvania, New Jersey, and Delaware. PARTICIPANTS Children born between November 1, 2001, and December 31, 2011, at 35 weeks' gestational age or older, with birth weight of 2000 g or more and in the fifth percentile or higher for gestational age, and who had a preventive health visit within 14 days of life and at least 2 additional visits in the first year of life. Children with complex chronic conditions and those who received long-term antibiotics or multiple systemic corticosteroid prescriptions were excluded. We included 38,522 singleton children and 92 twins (46 matched pairs) discordant in antibiotic exposure. Final date of follow-up was December 31, 2012. EXPOSURE Systemic antibiotic use in the first 6 months of life. MAIN OUTCOMES AND MEASURES Weight, measured at preventive health visits from age 6 months through 7 years. RESULTS Of 38,522 singleton children (50% female; mean birth weight, 3.4 kg), 5287 (14%) were exposed to antibiotics during the first 6 months of life (at a mean age of 4.3 months). Antibiotic exposure was not significantly associated with rate of weight change (0.7%; 95% CI, -0.1% to 1.5%; P = .07, equivalent to approximately 0.05 kg; 95% CI, -0.004 to 0.11 kg of added weight gain between age 2 years and 5 years). Among 92 twins (38% female; mean birth weight, 2.8 kg), the 46 twins who were exposed to antibiotics during the first 6 months of life received them at a mean age of 4.5 months. Antibiotic exposure was not significantly associated with a weight difference (-0.09 kg; 95% CI, -0.26 to 0.08 kg; P = .30). CONCLUSIONS AND RELEVANCE Exposure to antibiotics within the first 6 months of life compared with no exposure was not associated with a statistically significant difference in weight gain through age 7 years. There are many reasons to limit antibiotic exposure in young, healthy children, but weight gain is likely not one of them.
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Affiliation(s)
- Jeffrey S Gerber
- Center for Pediatric Clinical Effectiveness, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Matthew Bryan
- Division of Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachael K Ross
- Center for Pediatric Clinical Effectiveness, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carrie Daymont
- Department of Pediatrics and Child Health, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Elizabeth P Parks
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia5Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert W Grundmeier
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia6Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Virginia A Stallings
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia5Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theoklis E Zaoutis
- Center for Pediatric Clinical Effectiveness, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Utidjian LH, Hogan A, Michel J, Localio AR, Karavite D, Song L, Ramos MJ, Fiks AG, Lorch S, Grundmeier RW. Clinical Decision Support and Palivizumab: A Means to Protect from Respiratory Syncytial Virus. Appl Clin Inform 2015; 6:769-84. [PMID: 26767069 DOI: 10.4338/aci-2015-08-ra-0096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/08/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Palivizumab can reduce hospitalizations due to respiratory syncytial virus (RSV), but many eligible infants fail to receive the full 5-dose series. The efficacy of clinical decision support (CDS) in fostering palivizumab receipt has not been studied. We sought a comprehensive solution for identifying eligible patients and addressing barriers to palivizumab administration. METHODS We developed workflow and CDS tools targeting patient identification and palivizumab administration. We randomized 10 practices to receive palivizumab-focused CDS and 10 to receive comprehensive CDS for premature infants in a 3-year longitudinal cluster-randomized trial with 2 baseline and 1 intervention RSV seasons. RESULTS There were 356 children eligible to receive palivizumab, with 194 in the palivizumab-focused group and 162 in the comprehensive CDS group. The proportion of doses administered to children in the palivizumab-focused intervention group increased from 68.4% and 65.5% in the two baseline seasons to 84.7% in the intervention season. In the comprehensive intervention group, proportions of doses administered declined during the baseline seasons (from 71.9% to 62.4%) with partial recovery to 67.9% during the intervention season. The palivizumab-focused group improved by 19.2 percentage points in the intervention season compared to the prior baseline season (p < 0.001), while the comprehensive intervention group only improved 5.5 percentage points (p = 0.288). The difference in change between study groups was significant (p = 0.05). CONCLUSIONS Workflow and CDS tools integrated in an EHR may increase the administration of palivizumab. The support focused on palivizumab, rather than comprehensive intervention, was more effective at improving palivizumab administration.
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Affiliation(s)
- L H Utidjian
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biomedical and Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A Hogan
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - J Michel
- Department of Biomedical and Health, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - A R Localio
- Departments of Biostatics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - D Karavite
- Department of Biomedical and Health, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - L Song
- Healthcare Analytics Unit, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - M J Ramos
- Department of Biomedical and Health, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - A G Fiks
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biomedical and Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - S Lorch
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - R W Grundmeier
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biomedical and Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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49
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Gerber JS, Prasad PA, Russell Localio A, Fiks AG, Grundmeier RW, Bell LM, Wasserman RC, Keren R, Zaoutis TE. Variation in Antibiotic Prescribing Across a Pediatric Primary Care Network. J Pediatric Infect Dis Soc 2015; 4:297-304. [PMID: 26582868 PMCID: PMC6281136 DOI: 10.1093/jpids/piu086] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/30/2014] [Indexed: 11/12/2022]
Abstract
BACKGROUND Outpatient respiratory tract infections are the most common reason for antibiotic prescribing to children. Although prior studies suggest that antibiotic overuse occurs, patient-specific data or data exploring the variability and determinants of variability across practices and practitioners is lacking. METHODS This study was conducted from a retrospective cohort of encounters to 25 diverse pediatric practices with 222 clinicians, from January 1 to December 31, 2009. Diagnoses, medications, comorbid conditions, antibiotic allergy, and demographic data were obtained from a shared electronic health record and validated by manual review. Practice-specific antibiotic prescription and acute respiratory tract infection diagnosis rates were calculated to assess across-practice differences after adjusting for patient demographics and clustering of encounters within clinicians. RESULTS A total of 102 102 (28%) of 399 793 acute visits by 208 015 patients resulted in antibiotic prescriptions. After adjusting for patient age, sex, race, and insurance type, and excluding encounters by patients with chronic conditions, antibiotic prescribing by practice ranged from 18% to 36% of acute visits, and the proportion of antibiotic prescriptions that were broad-spectrum ranged from 15% to 58% across practices, despite additional exclusion of patients with antibiotic allergies or prior antibiotic use. Diagnosis of (Dx) and broad-spectrum antibiotic prescribing (Broad) for acute otitis media (Dx: 8%-20%; Broad: 18%-60%), sinusitis (Dx: 0.5%-9%; Broad: 12%-78%), Streptococcal pharyngitis (Dx: 1.8%-6.4%; Broad: 2%-30%), and pneumonia (Dx: 0.4%-2%; Broad: 1%-70%) also varied by practice (P < 0.001 for all comparisons). CONCLUSIONS Antibiotic prescribing for common pediatric infections varied substantially across practices. This variability could not be explained by patient-specific factors. These data suggest the need for and provide high-impact targets for outpatient antimicrobial stewardship interventions.
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Affiliation(s)
- Jeffrey S. Gerber
- Divisions ofInfectious Diseases,The Center for Pediatric Clinical Effectiveness,Departments ofPediatrics,Biostatistics and Epidemiology,Center for Clinical Epidemiology and Biostatistics
,
Perelman School of Medicine at the University of Pennsylvania
,
Philadelphia,Corresponding Author:
Jeffrey S. Gerber, MD, PhD, Division of Infectious Diseases, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1518, Philadelphia, PA 19104. E-mail:
| | - Priya A. Prasad
- Divisions ofInfectious Diseases,The Center for Pediatric Clinical Effectiveness
| | - A. Russell Localio
- Departments ofPediatrics,Biostatistics and Epidemiology,Center for Clinical Epidemiology and Biostatistics
,
Perelman School of Medicine at the University of Pennsylvania
,
Philadelphia
| | - Alexander G. Fiks
- General Pediatrics,The Center for Pediatric Clinical Effectiveness,PolicyLab,Departments ofPediatrics
| | - Robert W. Grundmeier
- General Pediatrics,The Center for Biomedical Informatics
,
The Children's Hospital of Philadelphia
, Pennsylvania
,Departments ofPediatrics
| | - Louis M. Bell
- Divisions ofInfectious Diseases,General Pediatrics,The Center for Pediatric Clinical Effectiveness,Departments ofPediatrics
| | - Richard C. Wasserman
- Center for Clinical Epidemiology and Biostatistics
,
Perelman School of Medicine at the University of Pennsylvania
,
Philadelphia
| | - Ron Keren
- General Pediatrics,The Center for Pediatric Clinical Effectiveness,Departments ofPediatrics,Biostatistics and Epidemiology
| | - Theoklis E. Zaoutis
- Divisions ofInfectious Diseases,The Center for Pediatric Clinical Effectiveness,Departments ofPediatrics,Biostatistics and Epidemiology,Center for Clinical Epidemiology and Biostatistics
,
Perelman School of Medicine at the University of Pennsylvania
,
Philadelphia
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50
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Byrne DD, Newcomb CW, Carbonari DM, Nezamzadeh MS, Leidl KBF, Herlim M, Yang YX, Hennessy S, Kostman JR, Leonard MB, Localio AR, Re VL. Increased risk of hip fracture associated with dually treated HIV/hepatitis B virus coinfection. J Viral Hepat 2015; 22:936-47. [PMID: 25754215 PMCID: PMC4561220 DOI: 10.1111/jvh.12398] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 01/07/2015] [Indexed: 01/14/2023]
Abstract
HIV and hepatitis B virus (HBV) infections are each associated with reduced bone mineral density, but it is unclear whether HIV/HBV coinfection is associated with an increased risk of fracture. We determined whether dually treated HIV/HBV patients had a higher incidence of hip fracture compared to treated HBV-monoinfected, antiretroviral therapy (ART)-treated HIV-monoinfected and HIV/HBV-uninfected patients. We conducted a cohort study among 4156 dually treated HIV/HBV-coinfected, 2053 treated HBV-monoinfected, 96,253 ART-treated HIV-monoinfected, and 746,794 randomly sampled uninfected persons within the US Medicaid populations of California, Florida, New York, Ohio and Pennsylvania (1999-2007). Coinfected patients were matched on propensity score to persons in each comparator cohort. Weighted survival models accounting for competing risks were used to estimate cumulative incidences and hazard ratios (HRs) with 95% confidence intervals (CIs) of incident hip fracture for dually treated coinfected patients compared to (i) HBV-monoinfected receiving nucleos(t)ide analogue or interferon alfa therapy, (ii) HIV-monoinfected on ART and (iii) uninfected persons. Dually treated coinfected patients had a higher cumulative incidence of hip fracture compared to ART-treated HIV-monoinfected (at 5 years: 1.70% vs 1.24%; adjusted HR, 1.37 [95% CI, 1.03-1.83]) and uninfected (at 5 years: 1.64% vs 1.22%; adjusted HR, 1.35 [95% CI, 1.03-1.84]) persons. The cumulative incidence of hip fracture was higher among coinfected than treated HBV-monoinfected patients (at 5 years: 0.70% vs 0.27%), but this difference was not statistically significant in competing risk analysis (adjusted HR, 2.62 [95% CI, 0.92-7.51]). Among Medicaid enrollees, the risk of hip fracture was higher among dually treated HIV/HBV-coinfected patients than ART-treated HIV-monoinfected and uninfected persons.
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Affiliation(s)
- Dana D. Byrne
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Craig W. Newcomb
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dena M. Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Melissa S. Nezamzadeh
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly B. F. Leidl
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Maximilian Herlim
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yu-Xiao Yang
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean Hennessy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jay R. Kostman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for AIDS Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary B. Leonard
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for AIDS Research, University of Pennsylvania, Philadelphia, PA, USA,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for AIDS Research, University of Pennsylvania, Philadelphia, PA, USA
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