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Tangri N, Ferguson T, Leon SJ, Anker SD, Filippatos G, Pitt B, Rossing P, Ruilope LM, Farjat AE, Farag YMK, Schloemer P, Lawatscheck R, Rohwedder K, Bakris GL. Validation of the Klinrisk chronic kidney disease progression model in the FIDELITY population. Clin Kidney J 2024; 17:sfae052. [PMID: 38650758 PMCID: PMC11033844 DOI: 10.1093/ckj/sfae052] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Indexed: 04/25/2024] Open
Abstract
Background Chronic kidney disease (CKD) affects >800 million individuals worldwide and is often underrecognized. Early detection, identification and treatment can delay disease progression. Klinrisk is a proprietary CKD progression risk prediction model based on common laboratory data to predict CKD progression. We aimed to externally validate the Klinrisk model for prediction of CKD progression in FIDELITY (a prespecified pooled analysis of two finerenone phase III trials in patients with CKD and type 2 diabetes). In addition, we sought to identify evidence of an interaction between treatment and risk. Methods The validation cohort included all participants in FIDELITY up to 4 years. The primary and secondary composite outcomes included a ≥40% decrease in estimated glomerular filtration rate (eGFR) or kidney failure, and a ≥57% decrease in eGFR or kidney failure. Prediction discrimination was calculated using area under the receiver operating characteristic curve (AUC). Calibration plots were calculated by decile comparing observed with predicted risk. Results At time horizons of 2 and 4 years, 993 and 1795 patients experienced a primary outcome event, respectively. The model predicted the primary outcome accurately with an AUC of 0.81 for 2 years and 0.86 for 4 years. Calibration was appropriate at both 2 and 4 years, with Brier scores of 0.067 and 0.115, respectively. No evidence of interaction between treatment and risk was identified for the primary composite outcome (P = .31). Conclusions Our findings demonstrate the accuracy and utility of a laboratory-based prediction model for early identification of patients at the highest risk of CKD progression.
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Affiliation(s)
- Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Thomas Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Silvia J Leon
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- University of Manitoba, Community Health Sciences, Winnipeg, Manitoba, Canada
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Alfredo E Farjat
- Research and Development, Clinical Data Sciences and Analytics, Bayer PLC, Reading, UK
| | | | | | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Katja Rohwedder
- Cardio-Renal Medical Affairs Department, Bayer AG, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
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Bansal S, Canziani MEF, Birne R, Anker SD, Bakris GL, Filippatos G, Rossing P, Ruilope LM, Farjat AE, Kolkhof P, Lage A, Brinker M, Pitt B. Finerenone cardiovascular and kidney outcomes by age and sex: FIDELITY post hoc analysis of two phase 3, multicentre, double-blind trials. BMJ Open 2024; 14:e076444. [PMID: 38508632 PMCID: PMC10952937 DOI: 10.1136/bmjopen-2023-076444] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the efficacy and safety of finerenone, a selective, non-steroidal mineralocorticoid receptor antagonist, on cardiovascular and kidney outcomes by age and/or sex. DESIGN FIDELITY post hoc analysis; median follow-up of 3 years. SETTING FIDELITY: a prespecified analysis of the FIDELIO-DKD and FIGARO-DKD trials. PARTICIPANTS Adults with type 2 diabetes and chronic kidney disease receiving optimised renin-angiotensin system inhibitors (N=13 026). INTERVENTIONS Randomised 1:1; finerenone or placebo. PRIMARY AND SECONDARY OUTCOME MEASURES Cardiovascular (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or hospitalisation for heart failure (HHF)) and kidney (kidney failure, sustained ≥57% estimated glomerular filtration rate (eGFR) decline or renal death) composite outcomes. RESULTS Mean age was 64.8 years; 45.2%, 40.1% and 14.7% were aged <65, 65-74 and ≥75 years, respectively; 69.8% were male. Cardiovascular benefits of finerenone versus placebo were consistent across age (HR 0.94 (95% CI 0.81 to 1.10) (<65 years), HR 0.84 (95% CI 0.73 to 0.98) (65-74 years), HR 0.80 (95% CI 0.65 to 0.99) (≥75 years); Pinteraction=0.42) and sex categories (HR 0.86 (95% CI 0.77 to 0.96) (male), HR 0.89 (95% CI 0.35 to 2.27) (premenopausal female), HR 0.87 (95% CI 0.73 to 1.05) (postmenopausal female); Pinteraction=0.99). Effects on HHF reduction were not modified by age (Pinteraction=0.70) but appeared more pronounced in males (Pinteraction=0.02). Kidney events were reduced with finerenone versus placebo in age groups <65 and 65-74 but not ≥75; no heterogeneity in treatment effect was observed (Pinteraction=0.51). In sex subgroups, finerenone consistently reduced kidney events (Pinteraction=0.85). Finerenone reduced albuminuria and eGFR decline regardless of age and sex. Hyperkalaemia increased with finerenone, but discontinuation rates were <3% across subgroups. Gynaecomastia in males was uncommon across age subgroups and identical between treatment groups. CONCLUSIONS Finerenone improved cardiovascular and kidney composite outcomes with no significant heterogeneity between age and sex subgroups; however, the effect on HHF appeared more pronounced in males. Finerenone demonstrated a similar safety profile across age and sex subgroups. TRIAL REGISTRATION NUMBERS NCT02540993, NCT02545049.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | | | - Rita Birne
- Department of Nephrology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
- Nova Medical School, University of Lisbon, Lisbon, Portugal
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; German Centre for Cardiovascular Research (DZHK) partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Alfredo E Farjat
- Research and Development, Clinical Data Sciences and Analytics, Bayer PLC, Reading, UK
| | - Peter Kolkhof
- Research and Early Development, Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
| | - Andrea Lage
- Cardiology and Nephrology Clinical Development, Bayer SA, São Paulo, Brazil
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Agarwal R, Tu W, Farjat AE, Farag YMK, Toto R, Kaul S, Lawatscheck R, Rohwedder K, Ruilope LM, Rossing P, Pitt B, Filippatos G, Anker SD, Bakris GL. Impact of Finerenone-Induced Albuminuria Reduction on Chronic Kidney Disease Outcomes in Type 2 Diabetes : A Mediation Analysis. Ann Intern Med 2023; 176:1606-1616. [PMID: 38048573 DOI: 10.7326/m23-1023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/06/2023] Open
Abstract
BACKGROUND In patients with chronic kidney disease (CKD) and type 2 diabetes (T2D), finerenone, a nonsteroidal mineralocorticoid receptor antagonist, reduces cardiovascular and kidney failure outcomes. Finerenone also lowers the urine albumin-to-creatinine ratio (UACR). Whether finerenone-induced change in UACR mediates cardiovascular and kidney failure outcomes is unknown. OBJECTIVE To quantify the proportion of kidney and cardiovascular risk reductions seen over a 4-year period mediated by a change in kidney injury, as measured by the change in log UACR between baseline and month 4. DESIGN Post hoc mediation analysis using pooled data from 2 phase 3, double-blind trials of finerenone. (ClinicalTrials.gov: NCT02540993 and NCT02545049). SETTING Several clinical sites in 48 countries. PATIENTS 12 512 patients with CKD and T2D. INTERVENTION Finerenone and placebo (1:1). MEASUREMENTS Separate mediation analyses were done for the composite kidney (kidney failure, sustained ≥57% decrease in estimated glomerular filtration rate from baseline [approximately a doubling of serum creatinine], or kidney disease death) and cardiovascular (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) outcomes. RESULTS At baseline, median UACR was 514 mg/g. A 30% or greater reduction in UACR was seen in 3338 (53.2%) patients in the finerenone group and 1684 (27.0%) patients in the placebo group. Reduction in UACR (analyzed as a continuous variable) mediated 84% and 37% of the treatment effect on the kidney and cardiovascular outcomes, respectively. When change in UACR was analyzed as a binary variable (that is, whether the guideline-recommended 30% reduction threshold was met), the proportions mediated for each outcome were 64% and 26%, respectively. LIMITATION The current findings are not readily extendable to other drugs. CONCLUSION In patients with CKD and T2D, early albuminuria reduction accounted for a large proportion of the treatment effect against CKD progression and a modest proportion of the effect against cardiovascular outcomes. PRIMARY FUNDING SOURCE Bayer AG.
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Affiliation(s)
- Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana (R.A.)
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana (W.T.)
| | - Alfredo E Farjat
- Data Science and Analytics, Bayer PLC, Reading, United Kingdom (A.E.F.)
| | | | - Robert Toto
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, Texas (R.T.)
| | - Sanjay Kaul
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California (S.K.)
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany (R.L.)
| | - Katja Rohwedder
- Cardio-Renal Medical Affairs Department, Bayer AG, Berlin, Germany (K.R.)
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, CIBER-CV, Hospital Universitario 12 de Octubre, and Faculty of Sport Sciences, European University of Madrid, Madrid, Spain (L.M.R.)
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (P.R.)
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan (B.P.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece (G.F.)
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany, and Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland (S.D.A.)
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois (G.L.B.)
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Flack JM, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, Adler SG, Fried L, Jamerson K, Toto R, Brinker M, Farjat AE, Kolkhof P, Lawatscheck R, Joseph A, Bakris GL. Finerenone in Black Patients With Type 2 Diabetes and CKD: A Post hoc Analysis of the Pooled FIDELIO-DKD and FIGARO-DKD Trials. Kidney Med 2023; 5:100730. [PMID: 38046911 PMCID: PMC10692708 DOI: 10.1016/j.xkme.2023.100730] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Rationale & Objective In FIDELITY, finerenone improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). This analysis explored the efficacy and safety of finerenone in Black patients. Study Design Subanalysis of randomized controlled trials. Setting & Participants Patients with T2D and CKD. Intervention Finerenone or placebo. Outcomes Composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure; composite of kidney failure, sustained ≥57% estimated glomerular filtration rate (eGFR) decline from baseline maintained for ≥4 weeks, or renal death. Results Of the 13,026 patients, 522 (4.0%) self-identified as Black. Finerenone demonstrated similar effects on the cardiovascular composite outcome in Black (HR, 0.79 [95% CI, 0.51-1.24]) and non-Black patients (HR, 0.87 [95% CI, 0.79-0.96; P = 0.5 for interaction]). Kidney composite outcomes were consistent in Black (HR, 0.71 [95% CI, 0.43-1.16]) and non-Black patients (HR, 0.76 [95% CI, 0.66-0.88; P = 0.9 for interaction]). Finerenone reduced urine albumin-to-creatinine ratio by 40% at month 4 (least-squares mean treatment ratio, 0.60 [95% CI, 0.52-0.69; P < 0.001]) in Black patients and 32% at month 4 (least-squares mean treatment ratio, 0.68 [95% CI, 0.66-0.70; P < 0.001]) in non-Black patients, versus placebo. Chronic eGFR decline (month 4 to end-of-study) was slowed in Black and non-Black patients treated with finerenone versus placebo (between-group difference, 1.4 mL/min/1.73 m2 per year [95% CI, 0.33-2.44; P = 0.01] and 1.1 mL/min/1.73 m2 per year [95% CI, 0.89-1.28; P < 0.001], respectively). Safety outcomes were similar between subgroups. Limitations Small number of Black patients; analysis was not originally powered to determine an interaction effect based on Black race. Conclusions The efficacy and safety of finerenone appears consistent in Black and non-Black patients with CKD and T2D. Funding Bayer AG. Trial Registration ClinicalTrials.gov NCT02540993, NCT02545049. Plain-Language Summary Diabetes is a major cause of chronic kidney disease (CKD), affecting more Black adults than White adults. Most adults with CKD ultimately die from heart and vascular complications (eg, heart attack and stroke) rather than kidney failure. This analysis of 2 recent trials shows that the drug finerenone was beneficial for patients with diabetes and CKD. Along with reducing kidney function decline and protein in the urine, it also decreased heart and vascular issues and lowered blood pressure in both Black and non-Black adults with diabetes and CKD. These findings have promising implications for slowing the progression of CKD and protecting against cardiovascular problems in diverse populations.
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Affiliation(s)
- John M. Flack
- Department of Medicine, Division of General Internal Medicine, Hypertension Section Southern Illinois University School of Medicine, Illinois, IL
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sharon G. Adler
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
| | - Linda Fried
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth Jamerson
- Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, MI
| | - Robert Toto
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, TX
| | - Meike Brinker
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
| | - Alfredo E. Farjat
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, United Kingdom
| | - Peter Kolkhof
- Research and Development Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - George L. Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - FIDELIO-DKD and FIGARO-DKD Investigators
- Department of Medicine, Division of General Internal Medicine, Hypertension Section Southern Illinois University School of Medicine, Illinois, IL
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Cardiology Clinic, University of Michigan, Ann Arbor, Michigan, MI
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, TX
- Cardiology and Nephrology Clinical Development, Bayer AG, Wuppertal, Germany
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, United Kingdom
- Research and Development Cardiovascular Precision Medicines, Bayer AG, Wuppertal, Germany
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
- Department of Medicine, University of Chicago Medicine, Chicago, IL
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Filippatos G, Anker SD, Pitt B, McGuire DK, Rossing P, Ruilope LM, Butler J, Jankowska EA, Michos ED, Farmakis D, Farjat AE, Kolkhof P, Scalise A, Joseph A, Bakris GL, Agarwal R. Finerenone efficacy in patients with chronic kidney disease, type 2 diabetes and atherosclerotic cardiovascular disease. Eur Heart J Cardiovasc Pharmacother 2022; 9:85-93. [PMID: 36251465 PMCID: PMC9753093 DOI: 10.1093/ehjcvp/pvac054] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
AIMS Finerenone, a selective, non-steroidal mineralocorticoid receptor antagonist, improves cardiovascular (CV) and kidney outcomes in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). This subgroup analysis of FIDELITY, a pre-specified, pooled, individual patient-data analysis of FIDELIO-DKD (NCT02540993) and FIGARO-DKD (NCT02545049), compared finerenone vs. placebo in patients with and without baseline history of atherosclerotic CV disease (ASCVD). METHODS AND RESULTS Outcomes included a composite CV outcome [CV death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure (HHF)]; CV death or HHF; a composite kidney outcome (kidney failure, sustained estimated glomerular filtration rate decrease ≥57%, or kidney-related death); all-cause mortality; and safety by baseline history of ASCVD.Of 13 026 patients, 5935 (45.6%) had a history of ASCVD. The incidence of the composite CV outcome, CV death or HHF, and all-cause mortality was higher in patients with ASCVD vs. those without, with no difference between groups in the composite kidney outcome. Finerenone consistently reduced outcomes vs. placebo in patients with and without ASCVD (P-interaction for the composite CV outcome, CV death or HHF, the composite kidney outcome, and all-cause mortality 0.38, 0.68, 0.33, and 0.38, respectively). Investigator-reported treatment-emergent adverse events were consistent between treatment arms across ASCVD subgroups. CONCLUSION Finerenone reduced the risk of CV and kidney outcomes consistently across the spectrum of CKD in patients with T2D, irrespective of prevalent ASCVD.
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Affiliation(s)
- Gerasimos Filippatos
- Corresponding author: Department of Cardiology, Attikon University Hospital, Rimini 1, Chaidari 124 62, Greece. Tel: +30 210 583 2195; ; Twitter handle: @Filippatos
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, 10117 Berlin, Germany,Institute of Heart Diseases, Wrocław Medical University, Borowska 213, 50-556 Wrocław , Poland
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Darren K McGuire
- The Division of Cardiology, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX 75390, USA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, 2730 Herlev, Denmark,Department of Clinical Medicine, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, s/n, 28041, Madrid, Spain,CIBER-CV, Hospital Universitario 12 de Octubre, s/n, 28041, Madrid, Spain,Faculty of Sport Sciences, European University of Madrid, s/n, 28670, Villaviciosa de Odón, Madrid, Spain
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX 75204, USA,The Department of Medicine, University of Mississippi School of Medicine, Jackson, MS 39216, USA
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wrocław Medical University, Borowska 213, 50-556 Wrocław , Poland
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dimitrios Farmakis
- Statistics and Data Insights, University of Cyprus Medical School, Nicosia 2029, Cyprus
| | - Alfredo E Farjat
- Research and Development, Statistics and Data Insights, Bayer PLC, Reading, RG2 6AD, UK
| | - Peter Kolkhof
- Research and Development, Cardiovascular Precision Medicines, Bayer AG, 42117, Wuppertal, Germany
| | - Andrea Scalise
- Pharmaceutical Development, Bayer Hispania, S.L., 08970 Barcelona, Spain
| | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin 13353, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, IN 46202, USA
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6
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Haas S, Farjat AE, Pieper K, Ageno W, Angchaisuksiri P, Bounameaux H, Goldhaber SZ, Goto S, Mantovani L, Prandoni P, Schellong S, Turpie AG, Weitz JI, MacCallum P, Cate HT, Panchenko E, Carrier M, Jerjes-Sanchez C, Gibbs H, Jansky P, Kayani G, Kakkar AK. On-treatment Comparative Effectiveness of Vitamin K Antagonists and Direct Oral Anticoagulants in GARFIELD-VTE, and Focus on Cancer and Renal Disease. TH Open 2022; 6:e354-e364. [DOI: 10.1055/s-0042-1757744] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) provide a safe, effective alternative to vitamin K antagonists (VKAs) for venous thromboembolism (VTE) treatment, as shown via intention-to-treat comparative effectiveness analysis. However, on-treatment analysis is imperative in observational studies because anticoagulation choice and duration are at investigators' discretion.
Objectives The aim of the study is to compare the effectiveness of DOACs and VKAs on 12-month outcomes in VTE patients using on-treatment analysis.
Methods The Global Anticoagulant Registry in the FIELD - VTE (GARFIELD-VTE) is a world-wide, prospective, non-interventional study observing treatment of VTE in routine clinical practice.
Results In total, 8,034 patients received VKAs (n = 3,043, 37.9%) or DOACs (n = 4,991, 62.1%). After adjustment for baseline characteristics and follow-up bleeding events, and accounting for possible time-varying confounding, all-cause mortality was significantly lower with DOACs than VKAs (hazard ratio: 0.58 [95% confidence interval 0.42–0.79]). Furthermore, patients receiving VKAs were more likely to die of VTE complications (4.9 vs. 2.2%) or bleeding (4.9 vs. 0.0%). There was no significant difference in rates of recurrent VTE (hazard ratio: 0.74 [0.55–1.01]), major bleeding (hazard ratio: 0.76 [0.47–1.24]), or overall bleeding (hazard ratio: 0.87 [0.72–1.05]) with DOACs or VKAs. Unadjusted analyses suggested that VKA patients with active cancer or renal insufficiency were more likely to die than patients treated with DOAC (52.51 [37.33–73.86] vs. 26.52 [19.37–36.29] and 9.97 [7.51–13.23] vs. 4.70 [3.25–6.81] per 100 person-years, respectively).
Conclusion DOACs and VKAs had similar rates of recurrent VTE and major bleeding. However, DOACs were associated with reduced all-cause mortality and a lower likelihood of death from VTE or bleeding compared with VKAs.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Karen Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, United States
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | - Lorenzo Mantovani
- Center for Public Health Research, University of Milan-Bicocca, Monza, Italy
| | | | - Sebastian Schellong
- Department of Health Sciences, Medical Department 2, Municipal Hospital Dresden, Germany
| | | | - Jeffrey I. Weitz
- Department of Haematology, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Peter MacCallum
- Thrombosis Research Institute, London, United Kingdom
- Queen Mary University of London, London, United Kingdom
| | - Hugo ten Cate
- Department of Vascular Medicine and Internal Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht; Maastricht, The Netherlands
| | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Carlos Jerjes-Sanchez
- Tecnológico de Monterrey. Escuela de Medicina y Ciencias de la Salud., Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, Sa Pedro Garza Garcia, Mexico
| | - Harry Gibbs
- Vascular Laboratory, The Alfred Hospital, Melbourne, Australia
| | - Petr Jansky
- Motol University Hospital, Department of Cardiovascular Surgery, Prague, Czech Republic
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom
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7
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Cohen O, Ageno W, Farjat AE, Turpie AGG, Weitz JI, Haas S, Goto S, Goldhaber SZ, Angchaisuksiri P, Gibbs H, MacCallum P, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Management strategies and clinical outcomes in patients with inferior vena cava thrombosis: Data from GARFIELD-VTE. J Thromb Haemost 2022; 20:366-374. [PMID: 34714962 PMCID: PMC9299483 DOI: 10.1111/jth.15574] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 07/14/2021] [Revised: 10/08/2021] [Accepted: 10/25/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Inferior vena cava (IVC) thrombosis is a rare form of venous thromboembolism (VTE). The optimal treatment strategies and outcomes are unclear in patients with this presentation. OBJECTIVE We aimed to compare baseline characteristics, treatment patterns and 24-month outcomes in IVC thrombosis patients (n = 100) with lower extremity deep vein thrombosis (LEDVT) patients (n = 7629). METHODS GARFIELD-VTE is a prospective, observational registry of 10 868 patients with objectively diagnosed VTE from 415 sites in 28 countries. RESULTS IVC thrombosis patients were younger (51.9 vs. 59.8 years), more frequently had active cancer (26.0% vs. 8.9%) or history of cancer (21.0% vs. 12.2%), and less frequently had recent trauma or surgery than LEDVT patients. IVC thrombosis was more frequently treated with parenteral anticoagulants alone (35.1% vs. 15.9%), whereas patients with LEDVT more commonly received vitamin K antagonists (32.0% vs. 25.8%) or direct oral anticoagulants (49.0% vs. 35.1%). Thrombolysis (11.0% vs. 3.6%) and surgical/mechanical interventions (4.0% vs. 1.4%) were more frequent in IVC thrombosis. At 24-months, the rate per 100 person-years (95% confidence interval) of all-cause mortality was higher in patients with IVC thrombosis than LEDVT (13.28 [8.57-20.58] vs. 4.91 [4.55-5.3]); the incidence of cancer-associated mortality was comparable as was the incidence of VTE recurrence (4.11 [1.85-9.15] vs. 4.18 [3.84-4.55]). Major bleeding was slightly higher in IVC thrombosis (2.03 [0.66-6.31] vs. 1.66 [1.45-1.89]). CONCLUSION In summary, IVC thrombosis patients have higher all-cause mortality rates than those with LEDVT, a finding only partly attributable to malignancy.
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Affiliation(s)
- Omri Cohen
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
- National Hemophilia CenterInstitute of Thrombosis and HemostasisSheba Medical CenterTel‐HashomerIsrael
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | | | | | - Jeffrey I. Weitz
- McMaster UniversityHamiltonOntarioCanada
- Thrombosis and Atherosclerosis Research InstituteHamiltonOntarioCanada
| | - Sylvia Haas
- Formerly Technical University of MunichMunichGermany
| | - Shinya Goto
- Department of Medicine (Cardiology)Tokai University School of MedicineIseharaJapan
| | | | | | - Harry Gibbs
- Vascular LaboratoryThe Alfred HospitalMelbourneVictoriaAustralia
| | - Peter MacCallum
- Thrombosis Research InstituteLondonUK
- Queen Mary University of LondonLondonUK
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8
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Farjat AE, Virdone S, Thomas LE, Kakkar AK, Pieper KS, Piccini JP. The importance of the design of observational studies in comparative effectiveness research: Lessons from the GARFIELD-AF and ORBIT-AF registries. Am Heart J 2022; 243:110-121. [PMID: 34529945 DOI: 10.1016/j.ahj.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022]
Abstract
Randomized controlled trials (RCTs) are considered the gold standard for estimating the effectiveness of a treatment. However, in many instances they are impractical to conduct because of time limitations, cost restrictions, or ethical reasons. As a consequence, non-randomized observational studies have an important role in comparative effectiveness and safety research since they can address issues that would not be possible using conventional RCT methodology. Observational studies can be strategically designed to reduce the risk of potential sources of bias by emulating the design principles of an equivalent but ideal randomized trial - the target trial - that would answer the research question of interest. In this article, we review some of the necessary components of observational studies required for valid causal inference within the framework of target trial emulation, so as to avoid common methodological pitfalls of study design. We discuss the assumptions of consistency, time-zero specification, exchangeability and positivity. To illustrate these concepts in a context where existing knowledge is well-established through clinical trials, we evaluate and compare the treatment effects of vitamin K antagonists (VKA) against no VKA (No VKA) on the treatment of atrial fibrillation from two real-world observational studies, namely the GARFIELD-AF and ORBIT-AF registries. Results are compared with those of published RCTs.
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9
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Bounameaux H, Haas S, Farjat AE, Ageno W, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Schellong S, Mantovani LG, Prandoni P, Kakkar AK. Corrigendum to "Comparative effectiveness of oral anticoagulants in venous thromboembolism: GARFIELD-VTE" [Thromb. Res. 2020 Jul; 191:103-112]. Thromb Res 2021; 216:129. [PMID: 34863582 DOI: 10.1016/j.thromres.2021.11.023] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | | | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | | | - Lorenzo G Mantovani
- IRCCS Multimedica, Sesto San Giovanni, Italy; University of Milano-Bicocca, Milan, Italy
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom; University College London, London, United Kingdom
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10
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Weitz JI, Farjat AE, Ageno W, Turpie AGG, Haas S, Goto S, Goldhaber SZ, Angchaisuksiri P, Gibbs H, MacCallum P, Carrier M, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Influence of body mass index on clinical outcomes in venous thromboembolism: Insights from GARFIELD-VTE. J Thromb Haemost 2021; 19:3031-3043. [PMID: 34487616 DOI: 10.1111/jth.15520] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 07/20/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is limited information on the influence of body mass index (BMI) on clinical outcomes in patients with venous thromboembolism (VTE). OBJECTIVES Investigate the influence of BMI on baseline characteristics, treatment patterns, and 24-month outcomes in VTE patients. METHODS GARFIELD-VTE is a prospective, non-interventional study of 10 869 patients with objectively confirmed VTE. Patients were grouped according to BMI: <18.5 (underweight; n = 214); 18.5-24.9 (normal; n = 2866); 25.0-29.9 (overweight; n = 3326); ≥30 (obese; n = 3073). RESULTS Compared with patients with a normal BMI, obese patients were more frequently Caucasian (77.4% vs. 57.9%), treated in the outpatient setting (30.4% vs. 23.1%), and had previous VTE (17.5% vs. 11.7%). Active cancer was associated with lower BMI (underweight: 30.4%, normal: 13.5%, overweight: 9.4%, obese: 7.0%). At baseline, overweight and obese patients less often received parenteral therapy alone (16.7% and 14.4%) compared with those with an underweight or normal BMI (30.8% and 21.6%). Obese patients more commonly remained on anticoagulants for ≥2-years compared to those with a normal BMI (52.3% vs. 37.7%). After 24-months, the risk of all-cause mortality was lower in overweight and obese patients than in those with normal BMI (adjusted hazard ratio [95% CI]; 0.75 [0.63-0.89] and 0.59 [0.49-0.72], respectively). Underweight patients more often experienced major bleeding (2.45 [1.41-4.26]) and all-cause mortality (1.90 [1.43-2.53]) than patients with a normal BMI. Recurrent VTE was comparable among groups. CONCLUSION Underweight VTE patients have the highest risk of mortality and major bleeding. The risk of mortality in obese VTE patients is lower than that in VTE patients with a normal BMI.
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Affiliation(s)
- Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Harry Gibbs
- Vascular Laboratory, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter MacCallum
- Thrombosis Research Institute, London, UK
- Queen Mary University of London, UK
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Henri Bounameaux
- University Hospital of Geneva and Faculty of Medicine, Geneva, Switzerland
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11
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Angchaisuksiri P, Goto S, Farjat AE, Fryk H, Bang SM, Chiang CE, Jing ZC, Kondo K, Sathar J, Tse E, Phusanti S, Kayani G, Weitz JI, Ageno W, Goldhaber SZ, Kakkar AK. Venous thromboembolism in Asia and worldwide: Emerging insights from GARFIELD-VTE. Thromb Res 2021; 201:63-72. [PMID: 33652328 DOI: 10.1016/j.thromres.2021.02.024] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although epidemiological studies report a lower risk of venous thromboembolism (VTE) than in the Western world, VTE rates in Asia may be underestimated. Furthermore, it is uncertain whether VTE outcomes differ in Asia and the rest of the world (ROW). METHODS GARFIELD-VTE is a global, prospective, non-interventional study of real-world treatment practices. In this study, we compared baseline characteristics, treatment patterns, and 12-month outcomes in Asia and ROW. RESULTS Of the 10,684 enrolled patients, 1822 (17.1%) were Asian (China n = 420, Hong Kong n = 98, Japan n = 148, Malaysia n = 244, South Korea n = 343, Taiwan n = 232, Thailand n = 337). Compared with ROW patients, those from Asia were more often female (57.4% vs. 48.0%), non-smokers (74.0% vs. 58.9%) and had a lower BMI (24.8 kg/m2 vs. 29.1 kg/m2). Asian patients were more likely to be managed in the hospital (86.9% vs. 70.4%) and to have active cancer (19.8% vs. 8.1%) or a history of cancer (19.1% vs. 12.0%). Asian patients received no anticoagulation more frequently than ROW patients (6.5% vs. 2.1%). Over 12-months follow-up, the rate of all-cause mortality (per 100 person-years [95% confidence interval]) was higher in Asians (15.2 [13.4-17.3] vs. 5.9 [5.4-6.5]). Adjusted hazard ratios indicated a higher risk of all-cause mortality in Asian patients than the ROW (1.32 [1.08-1.62]). The frequencies of major bleeding and recurrent VTE were similar. CONCLUSION Asian patients have different risk profiles, treatment patterns and a higher risk of mortality compared with the ROW.
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Affiliation(s)
- Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Thailand.
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | | | - Henrik Fryk
- Thrombosis Research Institute, London, United Kingdom
| | - Soo-Mee Bang
- Division of Hematology-Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, South Korea
| | - Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Katsuhiro Kondo
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Jameela Sathar
- Department of Haematology, Ampang hospital, Selangor, Malaysia
| | - Eric Tse
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Sithakom Phusanti
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom; University College London, London, United Kingdom
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12
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Jerjes-Sánchez C, Rodriguez D, Farjat AE, Kayani G, MacCallum P, Lopes RD, Turpie AGG, Weitz JI, Haas S, Ageno W, Goto S, Goldhaber SZ, Angchaisuksiri P, Nielsen JD, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Pregnancy-Associated Venous Thromboembolism: Insights from GARFIELD-VTE. TH Open 2021; 5:e24-e34. [PMID: 33532693 PMCID: PMC7840428 DOI: 10.1055/s-0040-1722611] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction
The risk of venous thromboembolism (VTE) increases during pregnancy and the puerperium such that VTE is a leading cause of maternal mortality.
Methods
We describe the clinical characteristics, diagnostic strategies, treatment patterns, and outcomes of women with pregnancy-associated VTE (PA-VTE) enrolled in the Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE. Women of childbearing age (<45 years) were stratified into those with PA-VTE (
n
= 183), which included pregnant patients and those within the puerperium, and those with nonpregnancy associated VTE (NPA-VTE;
n
= 1,187). Patients with PA-VTE were not stratified based upon the stage of pregnancy or puerperium.
Results
Women with PA-VTE were younger (30.5 vs. 34.8 years), less likely to have pulmonary embolism (PE) (19.7 vs. 32.3%) and more likely to have left-sided deep vein thrombosis (DVT) (73.9 vs. 54.8%) compared with those with NPA-VTE. The most common risk factors in PA-VTE patients were hospitalization (10.4%), previous surgery (10.4%), and family history of VTE (9.3%). DVT was typically diagnosed by compression ultrasonography (98.7%) and PE by chest computed tomography (75.0%). PA-VTE patients more often received parenteral (43.2 vs. 15.1%) or vitamin K antagonists (VKA) (9.3 vs. 7.6%) therapy alone. NPA-VTE patients more often received a DOAC alone (30.2 vs. 13.7%). The risk (hazard ratio [95% confidence interval]) of all-cause mortality (0.59 [0.18–1.98]), recurrent VTE (0.82 [0.34–1.94]), and major bleeding (1.13 [0.33–3.90]) were comparable between PA-VTE and NPA-VTE patients. Uterine bleeding was the most common complication in both groups.
Conclusion
VKAs or DOACs are widely used for treatment of PA-VTE despite limited evidence for their use in this population. Rates of clinical outcomes were comparable between groups.
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Affiliation(s)
- Carlos Jerjes-Sánchez
- Tecnologico de Monterrey. Escuela de Medicina y Ciencias de la Salud, Instituto de Cardiologia y Medicina Vascular, TecSalud, Monterrey, Mexico
| | - David Rodriguez
- Tecnologico de Monterrey. Escuela de Medicina y Ciencias de la Salud, Instituto de Cardiologia y Medicina Vascular, TecSalud, Monterrey, Mexico
| | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Peter MacCallum
- Thrombosis Research Institute, London, United Kingdom.,Queen Mary University of London, London, United Kingdom
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, United States
| | | | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Tokai, Japan
| | | | | | | | | | | | - Lorenzo G Mantovani
- IRCCS Multimedica Milan, Milan, Italy.,University of Milano, Bicocca, Milan, Italy
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13
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Bounameaux H, Haas S, Farjat AE, Ageno W, Weitz JI, Goldhaber SZ, Turpie AG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Schellong S, Mantovani LG, Prandoni P, Kakkar AK. Comparative effectiveness of oral anticoagulants in venous thromboembolism: GARFIELD-VTE. Thromb Res 2020; 191:103-112. [DOI: 10.1016/j.thromres.2020.04.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/28/2022]
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14
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Weitz JI, Haas S, Ageno W, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Farjat AE, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK, Loualidi A, Colak A, Bezuidenhout A, Abdool-Carrim A, Azeddine A, Beyers A, Dees A, Mohamed A, Aksoy A, Abiko A, Watanabe A, Krichell A, Fernandez AA, Tosetto A, Khotuntsov A, Oropallo A, Slocombe A, Kelly A, Clark A, Gad A, Arouni A, Schmidt A, Berni A, Kleiban AJ, Machowski A, Kazakov A, Galvez A, Lockman A, Falanga A, Chauhan A, Riera-Mestre A, Mazzone A, D’Angelo A, Herdy A, Kato A, Salem AAEEM, Husin A, Erdelyi B, Jacobson B, Amann-Vesti B, Battaloglu B, Wilson B, Cosmi B, Francois BJ, Toufek B, Hunt B, Natha B, Mustafa B, Kho BCS, Carine B, Zidel B, Dominique B, Christophe B, Trimarco B, Luo C, Cuneo CA, Diaz CJS, Schwencke C, Cader C, Yavuz C, Zaidman CJ, Lunn C, Wu CC, Toh CH, Chiang CE, Elisa C, Hsia CH, Huang CL, Kwok CHK, Wu CC, Huang CH, Ward C, Opitz C, Jeanneret-Gris C, Ha CY, Huang CY, Bidi CL, Smith C, Brauer C, Lodigiani C, Francis C, Wu C, Staub D, Theodoro D, Poli D, Acevedo DR, Adler D, Jimenez D, Keeling D, Scott D, Imberti D, Creagh D, Helene DC, Hagemann D, Le Roux D, Skowasch D, Belenky D, Dorokhov D, Petrov D, Zateyshchikov D, Prisco D, Møller D, Kucera D, Esheiba EM, Panchenko E, Dominique E, Dogan E, Kubat E, Diaz ED, Tse EWC, Yeo E, Hashas E, Grochenig E, Tiraferri E, Blessing E, Michèle EO, Usandizaga E, Porreca E, Ferroni F, Nicolas F, Ayala-Paredes F, Koura F, Henry F, Cosmi F, Erdkamp F, Kamalov G, Dalmau GB, Damien G, Klein G, Shah G, Hollanders G, Merli G, Plassmann G, Platt G, Poirier G, Sokurenko G, Haddad G, Ali G, Agnelli G, Gan GG, Kaye-Eddie G, Le Gal G, Allen G, Esperón GAL, Jean-Paul G, Gerofke H, Elali H, Burianova H, Ohler HJ, Wang H, Darius H, Gogia HS, Striekwold H, Gibbs H, Hasanoglu H, Turker H, Franow H, Bounameaux H, De Raedt H, Schroe H, ElDin HS, Zidan H, Nakamura H, Kim HY, Lawall H, Zhu H, Tian H, Yhim HY, Cate HT, Hwang HG, Shim H, Kim I, Libov I, Sonkin I, Suchkov I, Song IC, Kiris I, Staroverov I, Looi I, De La Azuela Tenorio IM, Savas I, Gordeev I, Podpera I, Lee JH, Sathar J, Welker J, Beyer-Westendorf J, Kvasnicka J, Vanwelden J, Kim J, Svobodova J, Gujral J, Marino J, Galvar JT, Kassis J, Kuo JY, Shih JY, Kwon J, Joh JH, Park JH, Kim JS, Yang J, Krupicka J, Lastuvka J, Pumprla J, Vesely J, Souto JC, Correa JA, Duchateau J, Fletcher JP, del Toro J, del Toro J, Paez JGC, Nielsen J, Filho JDA, Saraiva J, Peromingo JAD, Lara JG, Fedele JL, Surinach JM, Chacko J, Muntaner JA, Benitez JCÁ, Abril JMH, Humphrey J, Bono J, Kanda J, Boondumrongsagoon J, Yiu KH, Chansung K, Boomars K, Burbury K, Kondo K, Karaarslan K, Takeuchi K, Kroeger K, Zrazhevskiy K, Svatopluk K, Shyu KG, Vandenbosch K, Chang KC, Chiu KM, Jean-Manuel K, Wern KJ, Ueng KC, Norasetthada L, Binet L, Chew LP, Zhang L, Cristina LM, Tick L, Schiavi LB, Wong LLL, Borges L, Botha L, Capiau L, Timmermans L, López LE, Ria L, Blasco LMH, Guzman LA, Cervera LF, Isabelle M, Bosch MM, de los Rios Ibarra M, Fernandez MN, Carrier M, Barrionuevo MR, Gamba MAA, Cattaneo M, Moia M, Bowers M, Chetanachan M, Berli MA, Fixley M, Faghih M, Stuecker M, Schul M, Banyai M, Koretzky M, Myriam M, Gaffney ME, Hirano M, Kanemoto M, Nakamura M, Tahar M, Emmanuel M, Kovacs M, Leahy M, Levy M, Munch M, Olsen M, De Pauw M, Gustin M, Van Betsbrugge M, Boyarkin M, Homza M, Koto M, Abdool-Gaffar M, Nagib MAF, Dessoki ME, Khan M, Mohamed M, Kim MH, Lee MH, Soliman M, Ahmed MS, Bary MSAE, Moustafa MA, Hameed M, Kanko M, Majumder M, Zubareva N, Mumoli N, Abdullah NAN, Makruasi N, Paruk N, Kanitsap N, Duda N, Nordin N, Nyvad O, Barbarash O, Gurbuz O, Vilamajo OG, Flores ON, Gur O, Oto O, Marchena PJ, Angchaisuksiri P, Carroll P, Lang P, MacCallum P, von Bilderling PB, Blombery P, Verhamme P, Jansky P, Bernadette P, De Vleeschauwer P, Hainaut P, Ferrini PM, Iamsai P, Christian P, Viboonjuntra P, Rojnuckarin P, Ho P, Mutirangura P, Wells R, Martinez R, Miranda RT, Kroening R, Ratsela R, Reyes RL, de Leon RFD, Wong RSM, Alikhan R, Jerwan-Keim R, Otero R, Murena-Schmidt R, Canevascini R, Ferkl R, White R, Van Herreweghe R, Santoro R, Klamroth R, Mendes R, Prosecky R, Cappelli R, Spacek R, Singh R, Griffin S, Na SH, Chunilal S, Middeldorp S, Nakazawa S, Schellong S, Toh SG, Christophe S, Isbir S, Raymundo S, Ting SK, Motte S, Aktogu SO, Donders S, Cha SI, Nam SH, Marie-Antoinette SP, Maasdorp S, Sun S, Wang S, Essameldin SM, Sholkamy SM, Kuki S, Goto S, Yoshida S, Matsuoka S, McRae S, Watt S, Patanasing S, Jean-Léopold SN, Wongkhantee S, Bang SM, Testa S, Zemek S, Behrens S, Dominique S, Mellor S, Singh SSG, Datta S, Chayangsu S, Solymoss S, Everington T, Abdel-Azim TAA, Suwanban T, Adademir T, Hart T, Béatrice T, Luvhengo T, Horacek T, Zeller T, Boussy T, Reynolds T, Biss T, Chao TH, Casabella TS, Onodera T, Numbenjapon T, Gerdes V, Cech V, Krasavin V, Tolstikhin V, Bax WA, Malek WFA, Ho WK, Ageno W, Pharr W, Jiang W, Lin WH, Zhang W, Tseng WK, Lai WT, De Backer W, Haverkamp W, Yoshida W, Korte W, Choi W, Kim YK, Tanabe Y, Ohnuma Y, Mun YC, Balthazar Y, Park Y, Shibata Y, Burov Y, Subbotin Y, Coufal Z, Yang Z, Jing Z, Jing Z, Yang Z. Cancer associated thrombosis in everyday practice: perspectives from GARFIELD-VTE. J Thromb Thrombolysis 2020; 50:267-277. [DOI: 10.1007/s11239-020-02180-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Haas S, Ageno W, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Dalsgaard Nielsen J, Kayani G, Zaghdoun A, Farjat AE, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Anticoagulation therapy patterns for acute treatment of venous thromboembolism in GARFIELD-VTE patients. J Thromb Haemost 2019; 17:1694-1706. [PMID: 31220403 DOI: 10.1111/jth.14548] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 01/11/2019] [Accepted: 06/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Parenteral anticoagulants and vitamin K antagonists (VKAs) have constituted the cornerstone of venous thromboembolism (VTE) treatment. Meanwhile, direct oral anticoagulants (DOACs) provide physicians with an alternative. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE observes real-world treatment practices. OBJECTIVES Describe initial anticoagulation (AC) treatment patterns in VTE patients who received parenteral AC, VKAs, and/or DOACs within ±30 days of diagnosis. METHODS VTE patients were categorized into parenteral AC only, parenteral AC with transition to VKA, VKA only, parenteral AC with transition to DOAC, and DOAC only. RESULTS A total of 9647 patients were initiated on AC treatment alone. 4781 (49.6%) patients received DOACs ± parenteral ACs; 3187 (33.0%), VKA ± parenteral ACs; and 1679 (17.4%) parenteral ACs alone. Rivaroxaban was the most frequently used DOAC (79.4%). DOACs were more frequently used in North America/Australia (58.1%), Europe (52.2%), and Asia (47.6%) than in Latin America (29.7%) and the Middle East/South Africa (32.5%). In patients with suspected VTE, most received parenteral AC monotherapy (67.7%). Patients with deep vein thrombosis were more likely to receive DOACs alone than those with pulmonary embolism with or without deep vein thrombosis (36.2% vs 25.9%). Active cancer patients received parenteral AC alone (58.9%), with 25.5% receiving DOAC ± parenteral AC and 12.8% parenteral AC and VKA. A total of 46.5% of pregnant patients received parenteral AC monotherapy, 34.0% were treated with VKA ± parenteral AC, and 19.5% received a DOAC (± parenteral AC). CONCLUSION AC treatment patterns vary by patient population, geographic region and site of VTE. Guidelines for AC therapy are not always adhered to.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | | | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | | | | | | | | | | | | | - Henri Bounameaux
- Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK
- University College London, London, UK
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Ageno W, Haas S, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Dalsgaard Nielsen J, Kayani G, Farjat AE, Zaghdoun A, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Darius H, Kakkar AK. Upper Extremity DVT versus Lower Extremity DVT: Perspectives from the GARFIELD-VTE Registry. Thromb Haemost 2019; 119:1365-1372. [DOI: 10.1055/s-0039-1688828] [Citation(s) in RCA: 15] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AbstractUpper extremity deep vein thrombosis (UEDVT) is less common than lower extremity DVT (LEDVT) and consequently less well characterized. This study compared clinical characteristics and 1-year outcomes between 438 UEDVT patients and 7,602 LEDVT patients recruited in the GARFIELD-VTE registry. UEDVT patients were significantly more likely to have a central venous catheter than those with LEDVT (11.5% vs. 0.5%; p < 0.0001), and had a higher rate of active cancer (16.2%) or recent hospitalization (19.4%) compared with LEDVT patients (8.7% and 11.2%, respectively). Nearly all patients with UEDVT and LEDVT were initiated on anticoagulant therapy, which was a direct oral anticoagulant in one-third individuals in both groups. At 3, 6, and 12 months, the proportion of UEDVT and LEDVT patients who were receiving anticoagulant therapy was 82.6 and 87.4%, 66.0 and 72.6%, and 45.7 and 54.6%, respectively. In the UEDVT and LEDVT groups, VTE recurrence rate was 4.0 (95% confidence interval [CI], 2.4–6.7) and 5.5 (95% CI, 4.9–6.1) per 100 person-years, respectively; major bleed was noted in 1.3 (95% CI, 0.6–3.2) and 1.6 (95% CI, 1.3–1.9) per 100 person-years and all-cause mortality in 9.7 (95% CI, 7.1–13.4) and 6.7 (95% CI, 6.1–7.3) per 100 person-years, respectively. Hence, risk of recurrence was similar in the two groups whereas all-cause mortality was significantly higher in the UEDVT group than the LEDVT group (p = 0.0338). This latter finding was likely due to the high prevalence of cancer in the UEDVT group.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sylvia Haas
- Department of Medicine, Technical University of Munich, Munich, Germany
| | - Jeffrey I. Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Samuel Z. Goldhaber
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States
| | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Tokyo, Japan
| | | | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | | | | | - Sebastian Schellong
- Medical Division 2, Municipal Hospital Dresden-Friedrichstadt, Dresden, Germany
| | - Henri Bounameaux
- Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Lorenzo G. Mantovani
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | | | | | - Ajay K. Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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Meyer M, Nelson RC, Vernuccio F, González F, Farjat AE, Patel BN, Samei E, Henzler T, Schoenberg SO, Marin D. Virtual Unenhanced Images at Dual-Energy CT: Influence on Renal Lesion Characterization. Radiology 2019; 291:381-390. [DOI: 10.1148/radiol.2019181100] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Introduction Obstructive sleep apnea is diagnosed by identifying obstructive apneas and hypopneas, but no study has shown that it is necessary to distinguish these events from each other. Our goal was to analyze results from polysomnograms to determine if adverse health outcomes were more likely in patients with higher apnea indices relative to their hypopnea indices. Our hypothesis was that scoring apneas separately from hypopneas has no predictive value. Methods A retrospective case series was performed for consecutive diagnostic and split-night polysomnograms with apnea-hypopnea indices greater than five per hour. Clinical data reviewed included the presence of cardiovascular diseases, hypertension, depression, and migraine. Both univariate and multivariate analyses were performed to look for correlations between polysomnographic indices and the comorbidities. Results Three hundred fifty-one records were included. Univariate analysis showed no significant difference between the apnea index (AI) and hypopnea index (HI) based on the presence of any of the comorbidities. Multivariate logistic regression also indicated no significant association between indices and comorbidities, aside from one statistically significant correlation between a higher HI and depression. Conclusions Clinical comorbidities are no more likely in patients with higher apnea indices than hypopnea indices. While apneas are considered a more severe form of obstruction, this distinction does not have any known clinically predictive value. This finding raises the question as to whether scoring hypopneas and apneas as different events on polysomnograms is necessary or helpful. Scoring apneas and hypopneas as “obstructions” could save resources and increase inter-scorer reliability.
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Affiliation(s)
| | - Daniel Loriaux
- Internal Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, USA
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Hutchins AR, Manson RJ, Lerebours R, Farjat AE, Cox ML, Mann BP, Zani S. Objective Assessment of the Early Stages of the Learning Curve for the Senhance Surgical Robotic System. J Surg Educ 2019; 76:201-214. [PMID: 30098933 DOI: 10.1016/j.jsurg.2018.06.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 12/01/2017] [Revised: 06/15/2018] [Accepted: 06/23/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of this research is to study the early stages of the Senhance learning curve to report how force feedback impacts learning rate. This serves as an exploratory investigation into assumptions that fellows and faculty will adjust faster to the Senhance in comparison with residents, and that force feedback will not hinder skill acquisition. DESIGN In this study, participants completed the peg transfer and precision cutting task from the Fundamentals of Laparoscopic Surgery (FLS) manual skills assessment five times each using the Senhance while instrument motion was tracked. SETTING This study took place in the Surgical Education and Activities Laboratory at Duke University Medical Center. PARTICIPANTS Participants for this study were residents, fellows, and faculty from Duke University Medical Center in general surgery and gynecology specialties (N = 16). RESULTS Postulated linear mixed effects models with participant level random effects showed significant improvement with additional attempts for the peg transfer task after adjusting for surgical experience and force feedback respectively for the primary FLS score metric. The secondary metric of total instrument path length also showed improvement (significant decreases) in path length with additional attempts after respectively adjusting for surgical experience and force feedback. CONCLUSIONS This study investigates the early stages of the learning curve of the Senhance. Exploratory modeling indicates that residents, fellows, and faculty surgeons rapidly adapt to the controls of the Senhance regardless of experience level and force feedback engagement. The results from this study may serve as motivation for future prospective studies that achieve sufficient statistical power with a larger sample size and strict experimental design.
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Affiliation(s)
- Andrew R Hutchins
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina.
| | - Roberto J Manson
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Reginald Lerebours
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Morgan L Cox
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian P Mann
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina
| | - Sabino Zani
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina
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Cheng J, Liu B, Farjat AE, Routh J. National estimations of airway foreign bodies in children in the United States, 2000 to 2009. Clin Otolaryngol 2018; 44:235-239. [PMID: 30450702 DOI: 10.1111/coa.13261] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 05/09/2017] [Revised: 10/24/2017] [Accepted: 11/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Identify risk factors associated with airway foreign bodies in children in the United States and report observed trends over time. DATA SOURCE KID database (2000-2009). METHODS ICD-9-CM codes for airway foreign bodies were used to identify patients. Risk factors were used for univariate analysis and a multivariate model to identify any increased risk of mortality. These factors were then also trended over time. RESULTS Children with airway foreign bodies demonstrate similar risk factors as previously reported, such as male gender, age less than five years and lack of private insurance. The weighted mortality rate for paediatric inpatients with airway foreign bodies was about 2.75%. Fortunately, the rate remained relatively unchanged from 2000 to 2009. Geographically, urban hospital settings appeared to be more affected. Increased risks of mortality were noted for older age, urban hospital setting and teaching hospital status. CONCLUSIONS Our findings confirm previous findings and identified that the diagnosis of airway foreign bodies in children were associated with male gender, age <5 years, lack of private insurance and geographic location in an urban setting. Further investigation may be warranted to provide clarity on other factors found to have increased association with mortality for quality improvement.
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Affiliation(s)
- Jeffrey Cheng
- Pediatric Otolaryngology, Department of Surgery, Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina
| | - Beiyu Liu
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - Alfredo E Farjat
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - Jonathan Routh
- Pediatric Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Cox ML, Farjat AE, Risoli TJ, Peskoe S, Goldstein BA, Turner DA, Migaly J. Documenting or Operating: Where Is Time Spent in General Surgery Residency? J Surg Educ 2018; 75:e97-e106. [PMID: 30522828 PMCID: PMC10765321 DOI: 10.1016/j.jsurg.2018.10.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 04/02/2018] [Revised: 07/25/2018] [Accepted: 10/11/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution. DESIGN For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient. SETTING This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System. PARTICIPANTS All active general surgery residents during the 2016-2017 academic year. RESULTS Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p < 0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038). CONCLUSIONS In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting.
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Affiliation(s)
- Morgan L Cox
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - T J Risoli
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - David A Turner
- Graduate Medical Education, Duke University Hospital and Health System, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
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22
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Schabel C, Patel B, Harring S, Duvnjak P, Ramírez-Giraldo JC, Nikolaou K, Nelson RC, Farjat AE, Marin D. Renal Lesion Characterization with Spectral CT: Determining the Optimal Energy for Virtual Monoenergetic Reconstruction. Radiology 2018; 287:874-883. [DOI: 10.1148/radiol.2018171657] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christoph Schabel
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Bhavik Patel
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Scott Harring
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Petar Duvnjak
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Juan Carlos Ramírez-Giraldo
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Konstantin Nikolaou
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Rendon C. Nelson
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Alfredo E. Farjat
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
| | - Daniele Marin
- From the Departments of Radiology (C.S., B.P., S.H., P.D., R.C.N., D.M.) and Biostatistics and Bioinformatics (A.E.F.), Duke University Medical Center, Box 3808 Erwin Rd, Durham, NC 27710; Department of Diagnostic and Interventional Radiology, University Hospital of Tuebingen, Tuebingen, Germany (C.S., K.N.); and Department of Computed Tomography, Siemens Medical Solutions USA, Malvern, Pa (J.C.R.)
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Hoang JK, Middleton WD, Farjat AE, Langer JE, Reading CC, Teefey SA, Abinanti N, Boschini FJ, Bronner AJ, Dahiya N, Hertzberg BS, Newman JR, Scanga D, Vogler RC, Tessler FN. Reduction in Thyroid Nodule Biopsies and Improved Accuracy with American College of Radiology Thyroid Imaging Reporting and Data System. Radiology 2018; 287:185-193. [PMID: 29498593 DOI: 10.1148/radiol.2018172572] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Jenny K Hoang
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - William D Middleton
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Alfredo E Farjat
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Jill E Langer
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Carl C Reading
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Sharlene A Teefey
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Nicole Abinanti
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Fernando J Boschini
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Abraham J Bronner
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Nirvikar Dahiya
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Barbara S Hertzberg
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Justin R Newman
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Daniel Scanga
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Robert C Vogler
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
| | - Franklin N Tessler
- From the Department of Radiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham, NC 27710 (J.K.H., B.S.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (W.D.M., S.A.T.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (A.E.F.); Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.E.L.); Department of Radiology, Mayo Clinic College of Medicine, Rochester Minn (C.C.R.); Mecklenburg Radiology Associates, Charlotte, NC (N.A., D.S.); Rocky Mountain Radiologists, Denver, Colo (F.J.B.); Radiology Partners Research Institute, El Segundo, Calif (A.J.B.); Department of Radiology, Division of Ultrasound, Mayo Clinic, Phoenix, Ariz (N.D.); Memphis Radiological Professional Corporation, Methodist Le Bonheur Healthcare Memphis, Germantown, Tenn (J.R.H.); Duke Radiology of Raleigh, Duke University School of Medicine, Duke Raleigh Hospital, Raleigh, NC (R.C.V.); and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (F.N.T.)
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Abstract
Objective To identify predictors of adverse events and highlight areas for quality improvement for children who underwent laryngeal or tracheal dilation, without prior tracheostomy placement. Study Design Cross-sectional analysis using a US national database. Setting American College of Surgeons (ACS) National Surgical Quality Improvement Program (ACS NSQIP-pediatric), years 2012 to 2015. Subjects and Methods Patients 18 years and younger were included. Patients without prior tracheostomy placement were identified using 2017 Current Procedural Terminology ( CPT) codes: 31528, 31529, and 31630. Results We identified a total of 160 children who met inclusion criteria. Forty-three (26.9%) patients experienced an adverse event. Mortality was observed postoperatively in 1 patient (0.6%) 1 day after the operation. Younger age, increased number of days from hospital admission to operation, and increased number of days from operation to discharge were noted to be associated with adverse events. Last, the risk of adverse events appears to be mitigated by concurrent other laryngeal procedures. Conclusions There is a high rate of adverse events reported with airway dilation in children. Unplanned reoperations and hospital readmissions are highlighted areas for quality improvement. Airway dilation in children appears to avoid tracheostomy and open laryngotracheoplasty in most cases for at least 30 days postoperatively. Further investigation may be helpful to understand if younger age and delayed operative intervention contribute to increased adverse events.
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Affiliation(s)
- Jeffrey Cheng
- 1 Pediatric Otolaryngology, Department of Surgery, Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Beiyu Liu
- 2 Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Alfredo E Farjat
- 2 Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
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Ibrahim MM, Poveromo LP, Glisson RR, Cornejo A, Farjat AE, Gall K, Levinson H. Modifying hernia mesh design to improve device mechanical performance and promote tension-free repair. J Biomech 2018; 71:43-51. [PMID: 29426630 DOI: 10.1016/j.jbiomech.2018.01.022] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 11/18/2017] [Accepted: 01/14/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE Approximately 348,000 ventral hernia repairs are performed annually in the United States and the incisional hernia recurrence rate is approximately 20% as a result of suture and mesh device failure. Device failure is related to changes at the suture/tissue interface that leads to acute or chronic suture pull-through and surgical failure. To better manage mechanical tension, we propose a modified mesh design with extensions and demonstrate its mechanical superiority. METHODS Comparative uniaxial static tensile testing was conducted on polypropylene suture and a modified mesh. Subsequently, a standard of care (SOC) mesh and modified mesh were evaluated using a tensometer in an acute hernia bench-top model. RESULTS Modified mesh breaking strength, extension knot breaking strength, extension disruption, and extension anchoring were superior to suture (p < .05). Modified mesh ultimate tensile strength of anchoring was superior to SOC mesh (p < .05). Various stitch patterns and modifications in device design significantly improved device tension-free performance far beyond clinically relevant benchmarks (p < .05). CONCLUSIONS Testing demonstrates that the modified mesh outperforms SOC mesh and suture in all tested failure modes. SOC hernia mesh tears through tissue at stress levels below maximum physiologic stress, whereas, the modified hernia mesh is up to 200% stronger than SOC mesh at resisting suture tearing through tissue and maintains anchoring at stresses far beyond clinically relevant benchmarks. Modifying hernia mesh design significantly improves device mechanical performance and enhances tension-free repair.
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Affiliation(s)
- Mohamed M Ibrahim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Luke P Poveromo
- Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Richard R Glisson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Agustin Cornejo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC 27710, USA
| | - Ken Gall
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC 27710, USA
| | - Howard Levinson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA; Department of Dermatology, Duke University, Durham, NC 27710, USA; Department of Pathology, Duke University, Durham, NC 27710, USA.
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Creed JA, Son J, Farjat AE, Swisher CB. Early withdrawal of non-anesthetic antiepileptic drugs after successful termination of nonconvulsive seizures and nonconvulsive status epilepticus. Seizure 2017; 54:45-50. [PMID: 29248799 DOI: 10.1016/j.seizure.2017.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 06/07/2017] [Revised: 11/30/2017] [Accepted: 12/02/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Multiple antiepileptic drugs (AEDs) are often necessary to treat nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE). AED polypharmacy places patients at risk for adverse side effects and drug-drug interactions. Identifying the likelihood of seizure relapse when weaning non-anesthetic AEDs may provide guidance in the critical care unit. METHOD Ninety-nine adult patients with successful treatment of electrographic-proven NCS or NCSE on continuous critical care EEG (CCEEG) monitoring were identified retrospectively. Patients were determined to undergo an AED wean if the number of non-anesthetic AEDs was reduced at the time of discharge compared to the number of non-anesthetic AEDs at primary seizure cessation. Primary outcome was recurrent seizures either clinically or by CCEEG during hospitalization. Secondary outcome measures included hospital length of stay and discharge disposition. RESULTS The rate of recurrent seizures in the wean group was not statistically different when compared to the group that did not undergo an AED wean (17% vs. 13%, respectively; p = 0.77). The wean group had a median value of 4 (IQR: 3-4) non-anesthetic AEDs at the time of primary seizure cessation compared with 3 (IQR: 2-3) in the non-wean group (p < 0.0001). However, both groups had similar values of AEDs at discharge (median of 2 (IQR: 2-3) vs. 3 (IQR: 2-3) for wean and non-wean groups respectively; p = 0.40). Discharge disposition (favorable, acceptable, or unfavorable) was similar between groups (p = 0.32). CONCLUSIONS Early weaning of non-anesthetic AEDs does not increase the risk of recurrent seizures in patients treated for NCS or NCSE during their hospitalization.
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Affiliation(s)
- Jennifer A Creed
- Department of Neurology, Duke University Medical Center, Durham, NC, United States
| | - Jake Son
- Duke University, School of Engineering, Durham, NC, United States
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, United States
| | - Christa B Swisher
- Department of Neurology, Duke University Medical Center, Durham, NC, United States
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Cheng J, Liu B, Farjat AE, Routh J. The Public Health Burden of Lymphatic Malformations in Children: National Estimates in the United States, 2000-2009. Lymphat Res Biol 2017; 15:241-245. [PMID: 28759318 DOI: 10.1089/lrb.2017.0009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Describe inpatient resource utilization trends in children with lymphatic malformations using a national database. DATA SOURCE Kids' inpatient database, years 2000-2009. METHODS Subjects included children 18 years and under with International Classification of Diseases (ICD), 9th revision code: 228.1-lymphangioma, any site. Data elements were extracted and used to calculate related inpatient costs and trended over time. RESULTS No significant increase in admission rates was noted over time, p = 0.5128. Average total charges per admission were $30,995. There is a clear and increasing trend of total charges per admission; even when adjusted for inflation, this has increased disproportionately. In 2009, the mortality rate increased to 2.58%, which was significantly higher than in previous years, p = 0.0346. In multivariate analysis for mortality, the only factor that was noted to be significant was between survey years 2000 and 2009. The odds ratio (OR) for mortality was 2.97, 95% CI: [1.423-6.202], which indicated that there was an almost three times higher likelihood of mortality in 2009 than in 2000. CONCLUSIONS Admission rates appear to remain stable for pediatric inpatients with lymphatic malformations but resource utilization related to charges has been increasing from 2000 to 2009. Controlling for inflation does not explain our observed trend in total charge increases. Previously, surgical resection was the most commonly performed procedure, and now the trend has shifted away from operative intervention. Mortality rates, while low, experienced a rise in 2009. Further investigation may be warranted.
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Affiliation(s)
- Jeffrey Cheng
- 1 Pediatric Otolaryngology, Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center , Durham, North Carolina
| | - Beiyu Liu
- 2 Department of Biostatistics and Bioinformatics, Duke University Medical Center , Durham, North Carolina
| | - Alfredo E Farjat
- 2 Department of Biostatistics and Bioinformatics, Duke University Medical Center , Durham, North Carolina
| | - Jonathan Routh
- 3 Pediatric Urology, Division of Urology, Department of Surgery, Duke University Medical Center , Durham, North Carolina
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Cheng J, Liu B, Farjat AE, Jang DW. Adverse Events in Endoscopic Sinus Surgery for Infectious Orbital Complications of Sinusitis: 30-Day NSQIP Pediatric Outcomes. Otolaryngol Head Neck Surg 2017; 157:716-721. [PMID: 28675096 DOI: 10.1177/0194599817717675] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Identify predictors of adverse events for children who underwent endoscopic sinus surgery for treatment of orbital complications associated with sinusitis. Study Design Cross-sectional analysis of a US national database. Setting American College of Surgeons National Surgical Quality Improvement Program (NSQIP), pediatric version (2012-2015). Subjects and Methods Patients were identified with a combination of codes from the International Classification of Diseases, Ninth Revision and 2014 Current Procedural Terminology. Our primary outcome measure was adverse events, which were compared with clinical risk factors to examine for any associations. Results A total of 57 patients were included for analysis. No significant relationship was identified between 30-day postoperative adverse events and age, sex, race, body mass index, prematurity, history of asthma, steroid use (within 30 days), and preoperative white blood cell count. There was a statistically significant increase in adverse events for those patients who underwent delayed surgery ( P < .0001). No serious adverse events related to death, sepsis, nerve injury (eg, visual loss), or other organ space infections (eg, intracranial infection) were identified. After controlling for age group and race, delayed operative intervention was a significant clinical predictor of adverse events (odds ratio = 25.65; 95% CI, 3.86-170.45; P = .0008). We observed unplanned reoperation and readmission rates of 5.3% and 7%, respectively. Conclusions Endoscopic surgical drainage for infectious orbital complications of sinusitis in children appears to be safe. Serious or significant adverse events were uncommon. Areas for improvement include limiting and reducing unplanned reoperations and readmissions.
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Affiliation(s)
- Jeffrey Cheng
- 1 Pediatric Otolaryngology, Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Beiyu Liu
- 2 Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Alfredo E Farjat
- 2 Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - David W Jang
- 3 Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Cheng J, Liu B, Farjat AE, Routh J. The public health resource utilization impact of airway foreign bodies in children. Int J Pediatr Otorhinolaryngol 2017; 96:68-71. [PMID: 28390617 DOI: 10.1016/j.ijporl.2017.03.009] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/25/2017] [Accepted: 03/02/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Quantify the resource utilization associated with airway foreign bodies in children in the United States using a national database and report observed trends over time. STUDY TYPE Cross-sectional analysis of national inpatient database with weighted estimates. DATA SOURCE The KID database (2000-2009). METHODS ICD-9-DM codes for foreign body aspiration were used to identify patients to be included for investigation. Admission rates and charges were aggregated and compared among geographic region, location, and teaching hospital status. These factors were then also trended over time. RESULTS From 2000 to 2009, airway foreign body diagnoses in children accounted for an estimated 4000 to 5000 admissions, resulting in a mean admission rate of 6.6 per 10,000 pediatric patients annually. Charges related to airway foreign bodies in children rose from a total of $93 million to $486 million in the observed period. There is an increasing trend over time of total charges per patient. Charges appear to be higher in urban locations and teaching hospitals. CONCLUSIONS The public health and economic burden of pediatric airway foreign bodies appears to be rising. Further investigation may be helpful to examine factors that may be contributing to increasing charges and creating strategies to improve cost effectiveness, as well as why there seems to be increased resource utilization in urban locations and teaching hospitals.
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Affiliation(s)
- Jeffrey Cheng
- Pediatric Otolaryngology, Department of Surgery, Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC, United States.
| | - Beiyu Liu
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
| | - Alfredo E Farjat
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
| | - Jonathan Routh
- Pediatric Urology, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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Lin C, Vakani R, Kussin P, Guhwe M, Farjat AE, Choudhury K, Renner D, Oduor C, Graffagnino C. Assessment of healthcare personnel knowledge of stroke care at a large referral hospital in sub-Saharan Africa - A survey based approach. J Clin Neurosci 2017; 42:71-74. [PMID: 28457860 DOI: 10.1016/j.jocn.2017.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 01/23/2017] [Accepted: 04/03/2017] [Indexed: 10/19/2022]
Abstract
There is no published literature regarding sub-Saharan health-care providers' understanding of stroke management patterns. Understanding current stroke management knowledge is important in formulating future education opportunities for providers to optimize patient outcomes. A cross-sectional survey of acute stroke diagnosis, hospital management, and secondary prevention questions was administered to health-care providers working in one large Kenyan acute referral hospital. Due to the prevalence of medical students (61.8%), an experienced-focused analysis contrasted students with more experienced providers. Providers (n=199) anonymously responded to the surveys. Among the acute diagnosis most respondents stated that stroke scales should always used (58.3% of respondents), 3h was the time period for alteplase (t-PA) (53.8% of respondents), and CT scan should be always be obtained prior to administration of anticoagulant therapy (61.3% of respondents). Neither VTE prophylaxis nor dysphagia/swallowing screening were considered to be done a majority of time. Secondary prevention results were variable. The respondent's level of clinical experience made the most difference in correctly answering the most appropriate IV Fluid to use in stroke patients (adjusted p=0.003) and the ideal initiation time for antithrombotic therapy (adjusted p=0.0017). Healthcare providers demonstrated a wide variability in their responses. Future efforts to improve stroke care in sub-Saharan Africa should include education and process improvement initiatives to focus on more specific aspects of stroke management based on the results from this survey.
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Affiliation(s)
- Chen Lin
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA.
| | - Ravi Vakani
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Peter Kussin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mary Guhwe
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Kingshuk Choudhury
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - David Renner
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Chrispine Oduor
- Department of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Lin C, Loochtan AI, Dresser B, Chang J, Farjat AE, Choudhury K, Hobson-Webb LD. Is carpal tunnel syndrome present in acute stroke patients? An investigative study using clinical and imaging screening tools. J Clin Neurosci 2017; 39:111-113. [PMID: 28209312 DOI: 10.1016/j.jocn.2017.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 10/17/2016] [Accepted: 01/22/2017] [Indexed: 11/25/2022]
Abstract
Carpal tunnel syndrome (CTS) is known to develop post-stroke. Median nerve ultrasound (US) is an inexpensive, effective means of screening. In this prospective feasibility study, we compared the ability of the physical exam, the Boston Carpal Tunnel Questionnaire (BCTQ) and median nerve US to screen for carpal tunnel syndrome (CTS) within 72hours of stroke onset. We enrolled 24 consecutive patients. Using US, 19 (79%, p=0.0386) of the 24 patients screened positive for CTS on the paretic side and 20 (83%, p=0.0042) on the nonparetic side. With clinical examination, only 11 out of 24 (46%) screened positive for CTS on the paretic side and 8 (33%) on the nonparetic side. The BCTQ did not predict CTS. US can be an effective screening tool post-stroke. Further research is needed to determine specificity and efficacy compared to electrodiagnostic testing in this population.
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Affiliation(s)
- Chen Lin
- Department of Neurology, Duke University Hospital, Durham, NC, USA; Department of Neurology, Northwestern University Hospital, Chicago, IL, USA.
| | - Aaron I Loochtan
- Department of Neurology, Duke University Hospital, Durham, NC, USA
| | - Brian Dresser
- Department of Neurology, Duke University Hospital, Durham, NC, USA
| | - Jianhong Chang
- Department of Neurology, Duke University Hospital, Durham, NC, USA
| | - Alfredo E Farjat
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Kingshuk Choudhury
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
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Ramprasad VH, Ryan MA, Farjat AE, Eapen RJ, Raynor EM. Practice patterns in supraglottoplasty and perioperative care. Int J Pediatr Otorhinolaryngol 2016; 86:118-23. [PMID: 27260594 PMCID: PMC4894349 DOI: 10.1016/j.ijporl.2016.04.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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] [Received: 02/19/2016] [Revised: 04/30/2016] [Accepted: 04/30/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Supraglottoplasty is the first-line surgical treatment for severe laryngomalacia. The purpose of this study is to determine the current trends of practice patterns in managing children who require supraglottoplasty. METHODS A 25-question survey regarding supraglottoplasty techniques and perioperative management was sent by e-mail to 274 physician members of the Society for Ear, Nose and Throat Advances in Children (SENTAC). RESULTS 101 surgeons responded and 72% of respondents were in academic practice (p < 0.0001). All four United States regions, Canada and the United Kingdom were represented. The most commonly reported age of patients undergoing supraglottoplasty was 1-3 months (62% of respondents). Indications include worsening airway symptoms (43%), failure to thrive (41%) and worsening feeding (10%). The majority of respondents (89%) treat these patients for reflux with 54% prescribing PPIs and 41% prescribing H2 blockers. Cold steel is the most popular surgical technique (73%) followed by laser (14%), microdebrider (10%) and coblator (3%) (p < 0.0001). Most respondents (92%) administer intraoperative steroids with the majority of them choosing dexamethasone (99%). Perioperative antibiotics are administered by 23% of respondents. Almost all respondents admit their patients for post-operative observation (99%) and 53% of these admit to PICU rather than step-down or floor status. The level of care is associated with the number of supraglottoplasties performed per year (p = 0.009) and with the geographic region (p = 0.02). Surgeons who perform fewer supraglottoplasties tend to admit to a higher level of care. Those in the South and Northeast regions tend to admit more to floor status. Only 13% routinely keep patients intubated post-operatively. CONCLUSIONS This provider survey study highlights some significant variations and trends in practice patterns of otolaryngologists who perform supraglottoplasty. The majority utilizes anti-reflux pharmacotherapy; however, there is no consensus in which type. The method for supraglottoplasty also varies with cold steel being the most popular, although no single method has been shown to be superior. There is variation in post-operative care with trends for keeping patients extubated and admitting them to an intensive care. With the importance of safe, effective, and also cost-conscious care, further studies are needed to understand the optimal management of those who undergo supraglottoplasty.
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Affiliation(s)
- Vaibhav H Ramprasad
- Division of Otolaryngology-Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, DUMC 3805, Durham, NC 27710, USA
| | - Marisa A Ryan
- Division of Otolaryngology-Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, DUMC 3805, Durham, NC 27710, USA.
| | - Alfredo E Farjat
- Department of Biostatics and Bioinformatics, Duke University School of Medicine, 2424 Erwin Road, Suite 1102 Hock Plaza, Box 2721, Durham, NC 27710, USA
| | - Rose J Eapen
- Division of Otolaryngology-Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, DUMC 3805, Durham, NC 27710, USA
| | - Eileen M Raynor
- Division of Otolaryngology-Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center, DUMC 3805, Durham, NC 27710, USA
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