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Mandelbaum A, Dzubay S, Chaiken SR, Doshi U, Katlaps I, Caughey AB. Preventing eviction during pregnancy: a cost-effectiveness analysis of a theoretical safety-net program. Am J Obstet Gynecol 2023; 229:331.e1-331.e9. [PMID: 37330122 DOI: 10.1016/j.ajog.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Eviction during pregnancy has been shown to be associated with adverse birth outcomes. A safety net program focused on covering the costs of rent during pregnancy may aid in preventing adverse complications. OBJECTIVE This study aimed to evaluate the cost-effectiveness of a program covering the cost of rent to prevent eviction during pregnancy. STUDY DESIGN A cost-effectiveness model using TreeAge software was designed to evaluate the cost, effectiveness, and incremental cost-effectiveness ratio associated with eviction compared to no eviction during pregnancy. The cost of eviction from a societal perspective was compared to the annual cost of housing in the no eviction group, which was estimated by the median contract rent in the United States from 2021 national census data. Birth outcomes included preterm birth, neonatal death, and major neurodevelopmental delay. Probabilities and costs were derived from the literature. The cost-effectiveness threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to assess the robustness of the results. RESULTS In our theoretical cohort of 30,000 pregnant individuals aged 15 to 44 years facing eviction annually, the no eviction during pregnancy strategy was associated with 1427 fewer preterm births, 47 fewer neonatal deaths, and 44 fewer cases of neurodevelopmental delay compared to eviction. At the median cost of rent in the United States, the no eviction strategy was associated with increased quality-adjusted life-years and decreased costs. Therefore, the no eviction strategy was the dominant strategy. In univariate sensitivity analysis varying the cost of housing, no eviction remained the cost-effective strategy and was cost-saving when rent was below $1016 per month. CONCLUSION The no eviction strategy is cost-effective and reduces cases of preterm birth, neonatal death, and neurodevelopmental delay. When rent is below the median of $1016 per month, no eviction is the cost-saving strategy. These findings suggest that policies supporting social programmatic implementation for rent coverage for pregnant people at risk of eviction have the potential to be highly beneficial in reducing costs and disparities in perinatal outcomes.
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Affiliation(s)
- Ava Mandelbaum
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR.
| | - Sarah Dzubay
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Sarina R Chaiken
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Uma Doshi
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Isabel Katlaps
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
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Katlaps I, Ghafari-Saravi A, Mandelbaum A, Packer CH, Doshi U, Garg B, Caughey AB, Valent A. Adverse Perinatal and Neonatal Outcomes Among Adolescent Pregnancies in the United States. Am J Perinatol 2023. [PMID: 37399846 DOI: 10.1055/a-2121-7698] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Despite a downward trend in recent years, adolescent pregnancies in the United States remain higher than any other Western country. Adolescent pregnancies have been inconsistently associated with adverse perinatal outcomes. OBJECTIVE To investigate the association between adolescent pregnancies and adverse perinatal and neonatal outcomes in the United States. METHODS This is a retrospective cohort study of singleton births in the US from 2014 to 2020 using national vital statistics data. Perinatal outcomes included gestational diabetes (GDM), gestational hypertension (gHTN), preterm delivery <37 weeks (PTB), cesarean delivery (CD), chorioamnionitis, small for gestational age (SGA), large for gestational age (LGA), and neonatal composite outcome. Chi-square tests were used to compare outcomes among adolescent (13-19 years) vs. adult (20-29 years) pregnancies. Multivariable logistic regression models were used to examine association of adolescent pregnancies with perinatal outcomes. For each outcome, we utilized three models: unadjusted logistic regression, adjusted for demographics, and adjusted for demographics and medical comorbidities. Similar analyses were used to compare younger (13-17 years) and older (18-19 years) adolescent pregnancies to adults. RESULTS In a cohort of 14,014,078 pregnancies, we found that adolescents were at an increased risk of PTB (adjusted odds ratio (aOR) 1.12, 99% confidence interval (CI)1.12-1.13) and SGA (aOR 1.02, 99% CI 1.01-1.03) compared to adult pregnancies. We also found that multiparous adolescents with a prior history of CD were at an increased risk of CD, compared to adults. For all other outcomes, adult pregnancies were at higher risk for adverse outcomes in the adjusted models. When comparing birth outcomes among adolescents, we found that older adolescents are at an increased risk of PTB, while younger adolescents are at an increased risk of both PTB and SGA. CONCLUSION After adjusting for confounders, our study demonstrates adolescents have an increased risk of preterm birth and SGA, compared to adults.
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Affiliation(s)
- Isabel Katlaps
- Oregon Health & Science University School of Medicine, Portland, United States
| | | | - Ava Mandelbaum
- Oregon Health & Science University School of Medicine, Portland, United States
| | - Claire H Packer
- Brigham and Women's Hospital Department of Obstetrics and Gynecology, Boston, United States
| | - Uma Doshi
- Oregon Health & Science University School of Medicine, Portland, United States
| | - Bharti Garg
- Obstetrics and Gynecology, Oregon Health & Science University, Portland, United States
| | - Aaron B Caughey
- Obstetrics and Gynecology, Oregon Health & Science University, Portland, United States
| | - Amy Valent
- Obstetrics and Gynecology, OHSU, Portland, United States
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Mandelbaum A, Dzubay SK, Chaiken SR, Doshi U, Katlaps I, Caughey AB. Impact of eviction during pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Katlaps I, Garg B, Ghafari-Saravi A, Chaiken SR, Mandelbaum A, Ronai C, Caughey AB, Madriago E. Early delivery among preeclamptic patients associated with increased risk of congenital heart disease subtypes. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Nakhla M, Eakin CM, Mandelbaum A, Karlan B, Benharash P, Salani R, Cohen JG. Frailty is independently associated with worse outcomes and increased resource utilization following endometrial cancer surgery. Int J Gynecol Cancer 2022; 32:ijgc-2022-003484. [PMID: 35725031 PMCID: PMC9763544 DOI: 10.1136/ijgc-2022-003484] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Frailty has been associated with poorer surgical outcomes and is a critical factor in procedural risk assessment. The objective of this study is to assess the impact of frailty on surgical outcomes in patients with endometrial cancer. METHODS Patients undergoing inpatient gynecologic surgery for endometrial cancer were identified using the 2005-2017 Nationwide Inpatient Sample database. The Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator was used to designate frailty. Multivariate regression models were used to assess the association of frailty with postoperative outcomes and resource use. RESULTS Of 339 846 patients, 2.9% (9868) were considered frail. After adjusting for patient and hospital characteristics, frailty was associated with a four-fold increase in inpatient mortality (adjusted OR (aOR) 4.1; p<0.001), non-home discharge (aOR 5.2; p<0.001), as well as increased respiratory (aOR 2.6; p<0.001), neurologic (aOR 3.3; p<0.001), renal (aOR 2.0; p<0.001), and infectious (aOR 3.2; p<0.001) complications. While frail patients exhibited increased mortality with age, the rate of mortality in this cohort decreased significantly over time. Compared with non-frail counterparts, frail patients had longer lengths of stay (7.6 vs 3.4 days; p<0.001) and increased hospitalization costs with surgical admission ($25 093 vs $13 405; p<0.001). CONCLUSIONS Frailty is independently associated with worse surgical outcomes, including increased mortality and resource use, in women undergoing surgery for endometrial cancer. Though in recent years there have been improvements in mortality in the frail population, further efforts to mitigate the impact of frailty should be explored.
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Affiliation(s)
- Morcos Nakhla
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Cortney M Eakin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Beth Karlan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ritu Salani
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Joshua G Cohen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
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Mandelbaum A, Moman P, Mardock A, Zakhour M, Salani R, Benharash P, Cohen J. Racial disparities in surgical approach and clinical outcomes of surgically treated endometrial cancer. Gynecol Oncol 2022. [DOI: 10.1016/j.ygyno.2021.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Moman P, Mardock A, Mandelbaum A, Lai T, Zakhour M, Salani R, Benharash P, Cohen J. Outcomes and resource utilization following surgery for gynecologic malignancies at safety-net hospitals across the United States. Gynecol Oncol 2022. [DOI: 10.1016/j.ygyno.2021.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sidhu S, Mandelbaum A, Dobaria V, Williamson CG, Tran Z, Sullins V, Benharash P. National Trends in the Cost Burden of Pediatric Gunshot Wounds Across the United States. J Pediatr 2021; 236:172-178.e4. [PMID: 33991544 DOI: 10.1016/j.jpeds.2021.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/23/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To characterize hospitalization costs attributable to gun-related injuries in children across the US. STUDY DESIGN The 2005-2017 National Inpatient Sample was used to identify all pediatric admissions for gunshot wounds (GSW). Patients were stratified by International Classification of Diseases procedural codes for trauma-related operations. Annual trends in GSW hospitalizations and costs were analyzed with survey-weighted estimates. Multivariable regressions were used to identify factors associated with high-cost hospitalizations. RESULTS During the study period, an estimated 36 283 pediatric patients were admitted for a GSW, with 43.1% undergoing an operative intervention during hospitalization. Admissions for pediatric firearm injuries decreased from 3246 in 2005 to 3185 in 2017 (NPtrend < .001). The median inflation-adjusted cost was $12 408 (IQR $6253-$24 585). Median costs rose significantly from $10 749 in 2005 to $16 157 in 2017 (P < .001). Compared with those who did not undergo surgical interventions, operative patients incurred increased median costs ($18 576 vs $8942, P < .001). Assault and self-harm injuries as well as several operations were independently associated with classification in the highest cost tertile. CONCLUSIONS Admissions for pediatric firearm injuries were associated with a significant socioeconomic burden in the US, with increasing resource use over time. Pediatric gun violence is a major public health crisis that warrants further research and advocacy to reduce its prevalence and social impact.
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Affiliation(s)
- Sonam Sidhu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Division of Pediatric Critical Care, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Veronica Sullins
- Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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Abstract
BACKGROUND Frailty has been increasingly recognized as a risk factor for inferior surgical outcomes and greater resource use. The present study evaluated the impact of a coding-based frailty tool on outcomes of elective colectomy in a national cohort. STUDY DESIGN Adults undergoing elective colectomy were identified in the 2016-17 Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins 10-domain coding-based binary tool. Generalized linear models were used to examine the association of frailty with in-hospital mortality, nonhome discharge, hospitalization duration (LOS), and inflation-adjusted costs. Kaplan-Meier survival analysis and log-rank test was used to compare readmissions up to 1-year. RESULTS Of 133 175 patients, 10.6% were considered frail. The most common resections were sigmoid (43.9%) and right (34.7%) while total colectomy was least common (2.8%). After adjustment, frailty was associated with greater odds of mortality (3.2, 95% CI 2.8-3.8) and nonhome discharge (6.0, 95% CI 5.5-6.4) as well as a $13,400-increment (95% CI 12,400-14,400) in costs and 4.4-day (95% CI 4.1-4.6) increase in LOS. Nonelective readmissions at 30 days were greater in frail than non-frail groups (14.7% vs. 10.4%, P < .001). CONCLUSION Frailty is associated with inferior clinical outcomes and increased resource use following elective colectomy. Inclusion of frailty in risk models may facilitate risk stratification and shared decision-making.
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Affiliation(s)
- Joseph Hadaya
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ava Mandelbaum
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yas Sanaiha
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Aguayo E, Hadaya J, Nakhla M, Williamson CG, Dobaria V, Mandelbaum A, Busuttil RW, Benharash P, DiNorcia J. Outcomes and resource use for liver transplantation in the United States: Insights from the 2009-2017 National Inpatient Sample. Clin Transplant 2021; 35:e14262. [PMID: 33619740 DOI: 10.1111/ctr.14262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 02/03/2021] [Accepted: 02/13/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Liver transplantation (LT) is a life-saving treatment for end-stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use. METHODS Using the National Inpatient Sample, we identified all patients undergoing LT from 2009 to 2017 and defined high-resource use (HRU) as having costs ≥ 90th percentile. Hierarchical regression models were used to assess factors associated with length of stay (LOS) and HRU. RESULTS Over the study period, approximately 53,000 patients underwent LT, increasing from 5,582 in 2009 to 7,095 in 2017 (nptrend < 0.001). Morbidity and mortality were 42.2% and 3.9%, respectively, with a median post-LT LOS of 10 days. Hospitalization costs increased from $106,866 to $145,868 (nptrend < 0.001). Acute kidney injury (β:4.7 days, P < .001) and end-stage renal disease (ESRD) with dialysis (β:4.3 days, P < .001) were associated with greater LOS while the Northeast region (AOR:5.2, P < .001), ESRD with dialysis (AOR:3.4, P < .001), heart failure (AOR:2.5, P < .001), and fulminant liver disease (AOR:1.8, P = .01) were associated with HRU. CONCLUSION The cost of LT has increased over time. Renal dysfunction, regional practice patterns, and patient acuity were associated with greater resource use. Transplanting patients before health deterioration may help contain costs, mitigate resource use, and improve LT outcomes.
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Affiliation(s)
- Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA
| | - Morcos Nakhla
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, Los Angeles, CA, USA.,Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph DiNorcia
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, Los Angeles, CA, USA
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Williamson CG, Hadaya J, Mandelbaum A, Verma A, Gandjian M, Rahimtoola R, Benharash P. Outcomes and Resource Use Associated With Acute Respiratory Failure in Safety Net Hospitals Across the United States. Chest 2021; 160:165-174. [PMID: 33617805 DOI: 10.1016/j.chest.2021.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/25/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite the frequency and cost of hospitalizations for acute respiratory failure (ARF), the literature regarding the impact of hospital safety net burden on outcomes of these hospitalizations is sparse. RESEARCH QUESTION How does safety net burden impact outcomes of ARF hospitalizations such as mortality, tracheostomy, and resource use? STUDY DESIGN AND METHODS This was a retrospective cohort study using the National Inpatient Sample 2007-2017. All patients hospitalized with a primary diagnosis of ARF were tabulated using the International Classification of Diseases 9th and 10th Revision codes, and safety net burden was calculated using previously published methodology. High- and low-burden hospitals were generated from proportions of Medicaid and uninsured patients. Trends were analyzed using a nonparametric rank-based test, whereas multivariate logistic and linear regression models were used to establish associations of safety net burden with key clinical outcomes. RESULTS Of an estimated 8,941,334 hospitalizations with a primary diagnosis of ARF, 33.9% were categorized as occurring at low-burden hospitals (LBHs) and 31.6% were categorized as occurring at high-burden hospitals (HBHs). In-hospital mortality significantly decreased at HBHs (22.8%-12.6%; nonparametric trend [nptrend] < .001) and LBHs (22.0%-10.9%; nptrend < .001) over the study period, as did tracheostomy placement (HBH, 5.6%-1.3%; LBH, 3.5%-0.8%; all nptrend <.001). After adjustment for patient and hospital factors, an HBH was associated with increased odds of mortality (adjusted OR [AOR], 1.11; 95% CI, 1.10-1.12) and tracheostomy use (AOR, 1.33; 95% CI, 1.29-1.37), as well as greater hospitalization costs (β coefficient, +$1,083; 95% CI, $882-$1,294) and longer lengths of stay (β coefficient, +3.3 days; 95% CI, 3.2-3.3 days). INTERPRETATION After accounting for differences between patient cohorts, high safety net burden was associated independently with inferior clinical outcomes and increased costs after ARF hospitalizations. These findings emphasize the need for health care reform to ameliorate disparities within these safety net centers, which treat our most vulnerable populations.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Rhea Rahimtoola
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Mandelbaum A, Nakhla M, Seo YJ, Dobaria V, Attai DJ, Baker JL, Thompson CK, DiNome ML, Benharash P, Lee MK. National trends and predictors of mastectomy with immediate breast reconstruction. Am J Surg 2021; 222:773-779. [PMID: 33627231 DOI: 10.1016/j.amjsurg.2021.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/14/2021] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy. METHODS The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR. RESULTS Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy. CONCLUSION Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.
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Affiliation(s)
- Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Morcos Nakhla
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Young Ji Seo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Deanna J Attai
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Jennifer L Baker
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Carlie K Thompson
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Maggie L DiNome
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Minna K Lee
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States.
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Karunungan KL, Hadaya J, Tran Z, Sanaiha Y, Mandelbaum A, Revels SL, Benharash P. Frailty Is Independently Associated With Worse Outcomes After Elective Anatomic Lung Resection. Ann Thorac Surg 2020; 112:1639-1646. [PMID: 33253672 DOI: 10.1016/j.athoracsur.2020.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Frailty has been widely recognized as a predictor of postoperative outcomes. Given the paucity of standardized frailty measurements in thoracic procedures, this study aimed to determine the impact of coding-based frailty on clinical outcomes and resource use after anatomic lung resection. METHODS All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005 to 2014 were identified using the National Inpatient Sample. Patients were categorized as either frail or nonfrail on the basis of the presence of any frailty-defining diagnoses defined by the Johns Hopkins Adjusted Clinical Groups. Multivariable models were used to assess the independent association of frailty with in-hospital mortality, nonhome discharge, complications, duration of stay, and costs. RESULTS Of an estimated 366,357 hospitalizations for elective lung resection during the study period, 4.4% were in frail patients. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to nonfrail patients, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%; P < .001) and nonhome discharge (44.7% vs 10.5%; P < .001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% confidence interval, 2.94 to 4.09). Frailty conferred the greatest increase in mortality, complications, and resource use after pneumonectomy relative to lobectomy or segmentectomy, although significant differences were evident for all 3 operations. CONCLUSIONS Frailty exhibits a strong association with inferior clinical outcomes and increased resource use after elective lung resection, particularly pneumonectomy. This readily available tool may improve preoperative risk assessment and allow for better selection of treatment modalities for frail patients with pulmonary disorders.
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Affiliation(s)
- Krystal L Karunungan
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California
| | - Sha'Shonda L Revels
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; Division of Thoracic Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California.
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Manrriquez E, Mandelbaum A, Aguayo E, Zakhour M, Karlan B, Benharash P, Cohen JG. Factors associated with high-cost hospitalizations in elderly ovarian cancer patients. Gynecol Oncol 2020; 159:767-772. [PMID: 32980126 PMCID: PMC7771656 DOI: 10.1016/j.ygyno.2020.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/13/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To characterize factors associated with high-cost inpatient admissions for ovarian cancer. METHODS Operative hospitalizations for ovarian cancer patients ≥65 years of age were identified using the 2010-2017 National Inpatient Sample. Admissions with high-cost were defined as those incurring ≥90th percentile of hospitalization costs each year, while the remainder were considered low-cost. Multivariable logistic regression models were developed to assess independent predictors of being in the high-cost cohort. RESULTS During the study period, an estimated 58,454 patients met inclusion criteria. 5827 patient admissions (9.98%) were classified as high-cost. Median hospitalization cost for this high-cost group was $55,447 (interquartile range (IQR) $46,744-$74,015) compared to $16,464 (IQR $11,845-$23,286, p < 0.001) for the low-cost group. Patients with high-cost admissions were more likely to have received open (adjusted odds ratio (AOR) 2.23, 1.31-3.79) or extended (AOR 5.64, 4.79-6.66) procedures and be admitted non-electively (AOR 3.32, 2.74-4.02). Being in the top income quartile (AOR 1.77, 1.39-2.27) was also associated with high-cost. Age and hospital factors, including bed size and volume of gynecologic oncology surgery, did not affect cost group. CONCLUSION High-cost ovarian cancer admissions were three times more expensive than low-cost admissions. Fewer open and extended procedures with subsequently shorter lengths of stay may have contributed to decreasing inpatient costs over the study period. In this cohort of patients largely covered by Medicare, clinical factors outweigh socioeconomic factors as cost drivers. Understanding the relationship of disease-specific and social factors to cost will be important in informing future value-based quality improvement efforts in gynecologic cancer care.
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Affiliation(s)
- Erica Manrriquez
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Mae Zakhour
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Beth Karlan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Joshua G Cohen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America.
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15
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Hadaya J, Dobaria V, Aguayo E, Mandelbaum A, Sanaiha Y, Revels SL, Benharash P. Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States. Ann Thorac Surg 2020; 110:1874-1881. [PMID: 32553767 DOI: 10.1016/j.athoracsur.2020.04.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/06/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sha'Shonda L Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California.
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Weinreich T, Ritz E, Passlick-Deetjen J, Colombi A, Echterhoff H, Geberth S, Mandelbaum A, Kiefer T, Mayer-Wehrstein R, Hild P, Leydig M, Birkner IL, Mielke G, Schillinger-Pokorny C, Nebel M, Rieden K. Long Term Dialysis with Low-Calcium Solution (1.0 Mmol/L) in Capd: Effects on Bone Mineral Metabolism. Perit Dial Int 2020. [DOI: 10.1177/089686089601600308] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Peritoneal dialysate solutions with conventionally high-calcium (Ca) concentrations (1.75 mmol/L) are now widely replaced by solutions with a lower, more physiological calcium content to prevent hypercalcemia in patients treated with oral calcium-containing phosphate binders and/or calcitriol. While there is still debate on how far the dialysate calcium should be lowered (1.25 mmol/L or less), little information is available concerning the effects of a long-term treatment with low-calcium solutions on secondary hyperparathyroidism and bone mineral metabolism in general. Design A prospective, randomized, controlled multicenter study to compare the effects of low-calcium (LCa, dialysate calcium 1.0 mmol/L) versus standard calcium dialysate solution (SCa, dialysate calcium 1.75 mmol/L)on bone mineral metabolism in continuous ambulatory peritoneal dialysis (CAPD) patients over 2 years of treatment. Setting Nephrology and dialysis units of primary and tertiary hospitals in Germany and Switzerland. Patients All CAPD patients in the participating centers between 18 and 80 years of age, stable on CAPD for at least 1 month, free of aluminum bone disease or prior parathyroidectomy were invited to enter the study. Sixty-four patients could be randomly allotted to LCa (n = 35) or SCa (n = 29) treatment in a 2-year protocol; 34 finished the study as planned. Interventions Calcium carbonate (CaCO3) was given as oral phosphate binder to maintain serum phosphate <2.0 mmol/L. If hypercalcemia supervened, CaCO3 was exchanged stepwise for aluminium hydroxide (AI(OH)3)’ until normocalcemia was obtained. Patients received calcitriol (0.25 μg/day per os) if parathyroid hormone (PTH) exceeded the upper limit of normal by a factor of 2 or more. Main Outcome Measures We assessed total and ionized serum calcium, phosphate, serum aluminum, alkaline phosphatase, osteocalcin, PTH (intact molecule), and phosphate binder intake at regular intervals. Measurements of bone mineral density and hand skeleton x-rays were obtained at the start and after 6 months and 2 years, respectively. Results With LCa, mean total and ionized serum calcium levels were within the normal range (total Ca: 2.0 2.6 mmol/L; ionized Ca: 1.19–1.32 mmol/L), but throughout the treatment period were significantly lower than with SCa. The incidence of hypercalcemia (>2.8 mmol/L) was three times higher in patients on SCa, despite the significantly higher amount of AI(OH)3 and less CaCO3 given in this group. In parallel, serum aluminum increased with SCa throughout the study, whereas it was slowly decreasing with LCa. Median PTH levels remained stable at about two times the upper limit of normal over the 2 years of study with LCa. However, 23% of the patients on LCa developed severe hyperparathyroidism, with PTH levels exceeding ten times the upper limit of normal compared to only 10.3% of the patients on SCa. With SCa, median PTH decreased towards near normal levels. Alkaline phosphatase and serum osteocalcin correlated positively with PTH levels. Bone mineral density was in the lower normal range in both groups a n d remained unchanged at the end of the study. Skeletal x-ray films showed only minor alterations in very few patients in both groups with no correlation to serum PTH or treatment modality. Conclusion In CAPD patients low-calcium dialysate solutions can be used successfully over prolonged periods of time with stable control of serum calcium. The risk of hypercalcemia resulting from calcium-containing phosphate binders and the need to use aluminum-containing phosphate binders is markedly diminished. However, there is a certain risk that severe secondary hyperparathyroidism with long-term LCa therapy will develop, even if normocalcemia is maintained. Thus, LCa dialysis requires closeand continuous monitoring of PTH and bone metabolism.
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Affiliation(s)
- Thomas Weinreich
- Department of Internal Medicine, Nephrology Unit, University Hospital, Zurich, Switzerland
| | | | | | - A. Colombi
- (Kantonsspital Luzern)Luzern, Switzerland
| | | | - S. Geberth
- (University of Heidelberg, Department of Nephrology), Heidelberg, Germany
| | - A. Mandelbaum
- (University of Heidelberg, Department of Nephrology), Heidelberg, Germany
| | - T. Kiefer
- (Robert -Bosch Krankenhaus Stuttgart), Stuttgart, Germany
| | | | - P. Hild
- (University Erlangen-Nürnberg, Städtisches Klinikum IV), N ürnberg, Germany
| | - M. Leydig
- (University Erlangen-Nürnberg, Städtisches Klinikum IV), N ürnberg, Germany
| | - I. Lubrich Birkner
- (University of Freiburg/Breisgau, Clinic for Internal Medicine), Freiburg/Breisgau, Germany
| | - G. Mielke
- (Kreiskrankenhaus Offenburg), Offenburg, Germany
| | | | - M. Nebel
- (Städtisches Krankenhaus Merheim), Köln, Germany
| | - K. Rieden
- (Krankenhaus Holweide), Köln, Germany
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Bommer J, Barth HP, Zeier M, Mandelbaum A, Bommer G, Ritz E, Reichel H, Novack R. Efficacy comparison of intravenous and subcutaneous recombinant human erythropoietin administration in hemodialysis patients. Contrib Nephrol 2015; 88:136-43. [PMID: 2040175 DOI: 10.1159/000419523] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- J Bommer
- I. Medizinische Universitätsklinik Heidelberg, FRG
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Ritz E, Rambausek M, Mall G, Ruffmann K, Mandelbaum A. Cardiac changes in uremia and their possible relation to cardiovascular instability on dialysis. Contrib Nephrol 2015; 78:221-9. [PMID: 2146078 DOI: 10.1159/000418286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- E Ritz
- Department of Internal Medicine, University of Heidelberg, FRG
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Ashkenazi P, Domon B, Gutman A, Mandelbaum A, Müller D, Richter W, Ginsburg D. Propellanes 100. The Nature of the Stereoelectronic Effect in the Highly Stereospecific Hydroxyl Elimination from
syn, anti
‐[4.3.3]Propellane‐8,11‐diol upon Isobutane Chemical Ionization. Isr J Chem 2013. [DOI: 10.1002/ijch.198900019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- P. Ashkenazi
- Department of Chemistry, Technion — Israel Institute of Technology, Haifa 32000, Israel
| | - B. Domon
- Central Function Research, Ciba‐Geigy AG, CH‐4002 Basel, Switzerland
| | - A.L. Gutman
- Department of Chemistry, Technion — Israel Institute of Technology, Haifa 32000, Israel
| | - A. Mandelbaum
- Department of Chemistry, Technion — Israel Institute of Technology, Haifa 32000, Israel
| | - D. Müller
- Department of Chemistry, Technion — Israel Institute of Technology, Haifa 32000, Israel
| | - W.J. Richter
- Department of Chemistry, Technion — Israel Institute of Technology, Haifa 32000, Israel
| | - D. Ginsburg
- Central Function Research, Ciba‐Geigy AG, CH‐4002 Basel, Switzerland
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20
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Sharvit J, Mandelbaum A. Studies in Mass Spectrometry, Part VII. Observations on the Mass Spectrometry of N-Substituted Phthalimides. Isr J Chem 2013. [DOI: 10.1002/ijch.196700006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Matsoukis J, Tabib W, Guiffault P, Mandelbaum A, Walch G, Némoz C, Cortés ZE, Edwards TB. Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation. J Bone Joint Surg Am 2006; 88:547-52. [PMID: 16510821 DOI: 10.2106/jbjs.e.00368] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [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: 02/01/2023]
Abstract
BACKGROUND Reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation are rare. The purpose of this study was to analyze the results following shoulder arthroplasty in patients with a fixed anterior shoulder dislocation. METHODS Eleven patients were evaluated at a minimum of twenty-four months after they underwent an arthroplasty for the treatment of a fixed anterior shoulder dislocation. Four patients underwent a total shoulder arthroplasty, and the remainder were treated with a hemiarthroplasty. Four shoulders had osseous reconstruction of the anterior aspect of the glenoid. The patients were evaluated with use of the Constant score, measurement of active anterior elevation and external rotation, the patient's subjective grading of the result, and a radiographic examination. RESULTS The mean Constant score improved from 21.1 points preoperatively to 46.0 points following the arthroplasty, and the mean active anterior elevation improved from 48.6 degrees to 90.0 degrees . The pain component of the Constant score was the most reliably improved parameter, increasing from a mean of 4.8 points preoperatively to a mean of 11.0 points postoperatively. Eight patients reported that the result was excellent or good, and the remaining three considered it to be fair. We observed seven complications in five patients, including four cases of anterior instability of the shoulder. Two of the four patients treated with a total shoulder replacement were seen to have definite loosening of the glenoid component on follow-up radiographs. CONCLUSIONS Shoulder arthroplasty in patients with a fixed anterior shoulder dislocation is fraught with difficulties and complications. Although arthroplasty reliably relieved shoulder pain in this population, limited functional results should be expected.
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Affiliation(s)
- J Matsoukis
- Department of Orthopaedic Surgery, Clinique Sainte Anne Lumière, Lyon, France
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Edelson-Averbukh M, Mandelbaum A. Intramolecular electrophilic aromatic substitution in gas-phase-protonated difunctional compounds containing one or two arylmethyl groups. J Mass Spectrom 2003; 38:1169-1177. [PMID: 14648824 DOI: 10.1002/jms.537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A variety of dibenzyl esters and ethers undergo a rearrangement process upon isobutane chemical ionization and collision-induced dissociation of their MH(+) ions, whereby a new bond is formed between the two benzyl groups, giving rise to abundant [C(14)H(13)](+) (m/z 181) ions. This rearrangement has been explained as an intramolecular electrophilic substitution in the gas phase occurring in an ion-neutral complex formed by the cleavage of one of the benzyl-oxygen bonds. A similar highly efficient intramolecular electrophilic substitution takes place in di-alpha- and beta-naphthylmethyl adipates affording m/z 281 [C(22)H(17)](+) ions, but not in the sterically hindered di-9-anthracylmethyl adipate. An analogous efficient rearrangement occurs in benzyl alpha- and beta-naphthylmethylcyclohexane-1,4-dicarboxylates and in benzyl alpha- and beta-phenylethylcyclohexane-1,4-dimethanol ethers. The analogous rearrangement is much less efficient in benzylallyl, benzylpropargyl and benzyl-9-anthracylmethyl derivatives, even less in benzylisopropyl and benzylacetyl analogs, and it is absent in benzyltetrahydropyranyl derivatives. The distinctive behavior of the protonated difunctional benzyl derivatives is interpreted in terms of the energy requirements of the O-R bond heterolysis of the protonated functionalities, the ability of the neutral R' groups (non-dissociated from the oxygen atom) to play the role of the nucleophile in the intramolecular electrophilic substitution processes and the electrophilicity of the R(+) ions.
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Affiliation(s)
- M Edelson-Averbukh
- Department of Chemistry, Technion-Israel Institute of Technology, Haifa, Israel
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25
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Matsoukis J, Tabib W, Guiffault P, Mandelbaum A, Walch G, Némoz C, Edwards TB. Shoulder arthroplasty in patients with a prior anterior shoulder dislocation. Results of a multicenter study. J Bone Joint Surg Am 2003; 85:1417-24. [PMID: 12925620 DOI: 10.2106/00004623-200308000-00001] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior reports of shoulder arthroplasty performed for dislocation-induced arthropathy have included only patients who had had a prior stabilizing procedure. The purpose of this study was to report the results of shoulder arthroplasty in all patients with a prior anterior shoulder dislocation, including both those previously treated operatively and those previously treated nonoperatively. METHODS Fifty-five shoulders undergoing arthroplasty for arthritis following a prior anterior shoulder dislocation were evaluated. Twenty-seven of the shoulders had undergone a prior anterior stabilization procedure. The measures used to evaluate the shoulders included the Constant score, adjusted Constant score, active mobility, subjective satisfaction, radiographic result, and complications. RESULTS The shoulders were evaluated at a mean of 45.0 months. The Constant score improved from a mean of 30.8 points preoperatively to a mean of 65.8 points at the time of follow-up. The adjusted Constant score improved from a mean of 38.2% to a mean of 79.8%. Active forward flexion improved from a mean of 82.1 degrees to a mean of 138.9 degrees. Active external rotation improved from a mean of 4.0 degrees to a mean of 38.6 degrees. Fifty patients rated the result as good or excellent. Negative prognosticators included an older age at the time of the initial dislocation and a rotator cuff tear. No significant differences in demographic factors, pre-arthroplasty function, post-arthroplasty function, pre-arthroplasty radiographic findings, post-arthroplasty radiographic findings, complication rate, or reoperation rate were noted between the patients treated with a prior operation for the anterior instability and those treated nonoperatively. CONCLUSIONS This investigation documented the good results obtainable with shoulder arthroplasty for the treatment of arthritis following anterior shoulder instability. In addition, our findings suggest that capsulorrhaphy-induced arthropathy may be indistinguishable from arthritis following nonoperatively treated anterior shoulder instability.
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Affiliation(s)
- J Matsoukis
- Department of Orthopaedic Surgery, Clinique Sainte Anne Lumière, Lyon, France
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26
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Matsoukis J, Tabib W, Mandelbaum A, Walch G. [Shoulder arthroplasty for non-operated anterior shoulder instability with secondary osteoarthritis]. Rev Chir Orthop Reparatrice Appar Mot 2003; 89:7-18. [PMID: 12610431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
PURPOSE OF THE STUDY The purpose of this study was to analyze the natural history of osteoarthritis of the shoulder joint secondary to non-operated anterior instability, to evaluate the clinical and radiological outcome after arthroplasty for this indication, and to compare results with data reported in the literature. MATERIAL AND METHODS Twenty-eight Aequalis shoulder arthroplasties were performed for osteoarthritis secondary to anterior shoulder instability in patients who had not undergone any prior stabilizing surgical procedure. This multicentric series was reviewed retrospectively at a mean follow-up of 44 months (range 24-87 month). Preoperative and last follow-up clinical status was compared using the Constant score. Standard operative technique was used and anatomic position of the implants was achieved in 27 patients. Total shoulder arthroplasty was performed in eighteen patients and simple humeral implantation in ten. Patients were divided into two sub-groups for analysis of outcome (age at first dislocation > or < 40 years). RESULTS There were four complications including one early loosening that required revision arthroplasty. Outcome was excellent or good in 54% of the cases. Group 1 (age at first dislocation < 40 years) included 17 patients and exhibited male predominance (13/17), young age at first dislocation (mean 28.5 years), high number of dislocations (mean 13), and a long natural history of osteoarthritis (mean 28 years). In this sub-group, imaging disclosed constructive osteoarthritis reflecting a long history. There was one case with a full-thickness tear of the supraspinatus. Outcome was excellent or good in 64% of these 17 patients (14 underwent total shoulder arthroplasty). The sub-group of 11 patients whose first dislocation occurred after the age of 40 years exhibited female predominance (9/11), a small number of dislocations (mean 1.3), and a short natural history of osteoarthritis (mean 6 years). In this sub-group, imaging disclosed six cases of basically chondrolytic osteoarthritis reflecting a short evolution. There were seven cases of full-thickness tears of the supraspinatus. Outcome was excellent or good in 36% of these 11 patients (4 underwent total shoulder arthroplasty). DISCUSSION The forty-year age cutoff allowed us to distinguish two populations. The first population of patients whose first dislocation had occurred before the age of 40 years was predominantly male, with a long history of constructive osteoarthritis without rotator cuff tears. Most of these patients were treated with total shoulder arthroplasty which gave results similar to those obtained with arthroplasty for primary centered osteoarthritis. The second sub-group of patients aged over 40 years at the time of the first dislocation were predominantly female with a short history of minimally constructive osteoarthritis and frequent rotator cuff tears. Humeral implants were used for most of these patients and gave less favorable results than in the former sub-group, probably due to the high rate of rotator cuff tears.
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Affiliation(s)
- J Matsoukis
- Département de Chirurgie Orthopédique et Traumatologique, Groupe hospitalier du Havre, Hôpital Jacques-Monod, BP 24, 76083 Le Havre Cedex.
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Ashkenazi P, Blum W, Domon B, Gutman AL, Mandelbaum A, Mueller D, Richter WJ, Ginsburg D. Propellanes. 91. Fragmentation mechanism of alcohols under isobutane chemical ionization. Highly stereospecific formation of [M-OH]+ ions from [4.3.3]propellane-8,11-diols. J Am Chem Soc 2002. [DOI: 10.1021/ja00258a014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Etinger A, Idina A, Mandelbaum A. The behavior of stereoisomeric cyclohexane-1,2-, -1,3-, and -1,4-dicarboxylates under chemical ionization and collision induced dissociation. Conformational effects in gas-phase cations. J Am Chem Soc 2002. [DOI: 10.1021/ja00069a043] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Weisz A, Andrzejewski D, Fales HM, Mandelbaum A. Structural assignment of isomeric 2-(2-quinolinyl)-1H-indene-1,3(2H)-dione mono- and disulfonic acids by liquid chromatography electrospray and atmospheric pressure chemical ionization tandem mass spectrometry. J Mass Spectrom 2001; 36:1024-1030. [PMID: 11599080 DOI: 10.1002/jms.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Positionally isomeric 2-(2-quinolinyl)-1H-indene-1,3(2H)-dione mono- and disulfonic acids give rise to similar electrospray ionization (ESI) and atmosphere pressure chemical ionization (APCI) mass spectra, which show very abundant MH(+) ions and negligible fragmentation. The MH(+) ions of these isomeric acids exhibit notably different behavior under collision-induced dissociation (CID) conditions. The acids with a sulfonic group at position 8' in the quinoline moiety, adjacent to the N-atom, exhibit highly abundant [MH - H(2)SO(3)](+) ions (m/z 272 for the mono- and m/z 352 for the disulfonic acids), which are of lower abundance in the CID spectra of isomers with the SO(3)H group at other positions, remote from the nitrogen atom. The latter isomers undergo efficient eliminations of SO(3) and HSO(3). The isomeric diacids with one SO(3)H group at position 4 of the indene-1,3(2H)-dione moiety, adjacent to one of the carbonyl groups, undergo highly efficient elimination of H(2)O. Mechanistic pathways, involving interactions between adjacent groups, are proposed for the above regiospecific fragmentations. Pronounced different behavior has been also observed in negative ion tandem mass spectrometric measurements of the sulfonic acids. The distinctive behavior of the isomeric acids was strongly pronounced when the measurements were performed with an ion trap mass spectrometer (LCQ), and much less so with a triple-stage quadrupole instrument (TSQ).
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Affiliation(s)
- A Weisz
- Office of Cosmetics and Colors, US Food and Drug Administration, Washington, DC 20204, USA.
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Mandelbaum A, Pertzborn F, Martin-Facklam M, Wiesel M. Unexplained decrease of cyclosporin trough levels in a compliant renal transplant patient. Nephrol Dial Transplant 2000; 15:1473-4. [PMID: 10978415 DOI: 10.1093/ndt/15.9.1473] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A Mandelbaum
- Department of Internal Medicine-Nephrology, University of Heidelberg, Heidelberg, Germany
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Vais V, Etinger A, Mandelbaum A. Intramolecular proton transfers in stereoisomeric gas-phase ions and the kinetic nature of the protonation process upon chemical ionization. J Mass Spectrom 1999; 34:755-760. [PMID: 10407360 DOI: 10.1002/(sici)1096-9888(199907)34:7<755::aid-jms831>3.0.co;2-j] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The isobutane chemical ionization (CI) mass spectra of cis- and trans-1-butyl-3- and -4-dimethylaminocyclohexanols and of their methyl ethers exhibit abundant [MH - H(2)O](+) and [MH - MeOH](+) ions respectively. On the other hand, only the MH(+) ions of the cis-isomers exhibit significant [MH - H(2)O](+) and [MH - MeOH](+) ions under collision-induced dissociation (CID) conditions. The non-occurrence of water and methanol elimination in the CID spectra of the trans-isomers indicates retention of the external proton at the dimethylamino group in the MH(+) ions that survive after leaving the ion source and the first quadrupole of the triple-stage quadrupole ion separating system, and the trans-orientation of the two basic sites does not allow proton transfer from the dimethylamino group to the hydroxyl or methoxyl. Such transfer is allowed in the cis-amino alcohols and amino ethers via internal hydrogen-bonded (proton-bridged) structures, resulting in the elimination of water and methanol from the surviving MH(+) ions of these particular stereoisomers upon CID. The abundant [MH - ROH](+) ions in the isobutane-CI mass spectra of the trans-isomers indicates protonation at both basic sites, affording two isomeric MH(+) ions in each case, one protonated at the dimethylamino group and the other at the less basic oxygen function. These results show that the isobutane-CI protonation of the amino ethers and amino alcohols is a kinetically controlled process, occurring competitively at both basic sites of the molecules, despite the large difference between their proton affinities ( approximately 25 and approximately 35 kcal mol(-1); 1 kcal = 4.184 kJ). Copyright 1999 John Wiley & Sons, Ltd.
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Affiliation(s)
- V Vais
- Department of Chemistry, Technion-Israel Institute of Technology, Haifa, Israel
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Mandelbaum A, Podjarny E, Bernheim J, Green J, Rathaus M. Role of thromboxane in the altered vascular reactivity of pregnant rats with adriamycin nephropathy. Nephrol Dial Transplant 1999; 14:1124-8. [PMID: 10344349 DOI: 10.1093/ndt/14.5.1124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pregnant rats with adriamycin nephropathy (ADRP rats) develop hypertension and have an increased vascular reactivity to noradrenaline in the isolated mesenteric bed in vitro. We have shown previously that the administration of daltroban, a specific thromboxane receptor antagonist, prevented hypertension in ADRP rats. METHODS We measured the effect of daltroban (10(-5) mol/l) on the vasoconstrictory response to noradrenaline (1-10 micromol/l) in the isolated mesenteric bed of ADRP rats at the end of pregnancy, as compared with normal pregnant and adriamycin-treated virgin rats. In further experiments, we measured the changes of flow induced by increasing concentrations of the thromboxane analogue, U46619 (10(-7)-10(-6) mol/l). Finally, changes of flow were assessed in arteries maximally constricted with U46619 (10(-6) mol/l), during perfusion in the presence of increasing concentrations of daltroban (10(-7)-10(-5) mol/l). RESULTS Daltroban diminished the response to noradrenaline in all groups, shifting the concentration-effect curve to the right. However, at maximal concentrations of noradrenaline, daltroban was ineffective in all rats, except in ADRP animals. The vasoconstrictory response to U46619 was significantly reduced in all pregnant rats, both normal and adriamycin-treated. Daltroban progressively released the vasoconstriction induced by U46619 in all groups. However, this vasodilator response was attenuated in the adriamycin-treated rats, the slopes of their curves being smaller than those of the respective untreated groups (0.038 +/- 0.006 in virgin rats vs 0.063 +/- 0.011 in controls, P < 0.05; and 0.015 +/- 0.005 in ADRP vs 0.028 +/- 0.008 in normal pregnancy, P < 0.05). CONCLUSIONS The findings could be explained by enhanced occupancy of thromboxane receptors by an endogenous agonist, possibly PGH2, as a consequence of either increased levels of the autacoid or increased number of affinity receptors.
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Affiliation(s)
- A Mandelbaum
- Department of Nephrology, Meir Hospital, Kfar Saba and Sackler School of Medicine, Tel Aviv University, Israel
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Melk A, Daniel V, Weimer R, Mandelbaum A, Wiesel M, Staehler G, Opelz G. P-glycoprotein expression is not a useful predictor of acute or chronic kidney graft rejection. Transpl Int 1999; 12:10-7. [PMID: 10080401 DOI: 10.1007/s001470050179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Because of the role of P-glycoprotein (P-gp) in multidrug resistance (MDR), it has been suggested that P-gp might play a role in acute and chronic rejection after organ transplantation. The purpose of the present work was to investigate a possible relationship between graft outcome and P-gp expression on peripheral mononuclear cells of renal transplant recipients. We determined P-gp expression in 27 patients with long-term, stable graft function (ST) and in 15 patients with chronic deterioration of graft function (CR). In addition, 40 patients were studied prior to, and at intervals after, transplantation with 21 healthy individuals serving as controls. P-gp values were highest in healthy controls and in ST patients. We found no correlation between P-gp values and acute rejection. CR patients tended to have lower levels of P-gp expression. Our results contradict the opinion that an overexpression of P-gp induces acute or chronic rejection by inhibiting the efficacy of immunosuppressive treatment.
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Affiliation(s)
- A Melk
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Germany
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Melk A, Daniel V, Weimer R, Mandelbaum A, Wiesel M, Staehler G, Opelz G. P-glycoprotein expression in patients before and after kidney transplantation. Transplant Proc 1999; 31:299-300. [PMID: 10083115 DOI: 10.1016/s0041-1345(98)01634-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A Melk
- Department of Transplantation Immunology, University of Heidelberg, Germany
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Benchetrit S, Mandelbaum A, Bernheim J, Podjarny E, Green J, Katz B, Rathaus M. Altered vascular reactivity following partial nephrectomy in the rat: a possible mechanism of the blood-pressure-lowering effect of heparin. Nephrol Dial Transplant 1999; 14:64-9. [PMID: 10052479 DOI: 10.1093/ndt/14.1.64] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This study was designed to assess whether the antihypertensive effect of heparin in rats after renal mass reduction (RMR) is related to changes in nitric oxide activity, and to study in vitro the altered behaviour of resistance-sized arteries induced by chronic administration of heparin. METHODS Male Wistar rats were assigned to one of two experimental protocols. In the first protocol, RMR rats received heparin (250 units/day s.c.) and tail systolic blood pressure (SBP) was measured weekly for 4 weeks. In a subgroup, urinary nitrate excretion (UNO3) and in vitro vascular reactivity of isolated perfused mesenteric arterial beds were measured 2 weeks after RMR. The second protocol assessed whether inhibition of NO synthesis with L-NAME (70 mg/l added to the drinking water) prevents the blood-pressure-lowering effect of heparin. RESULTS In untreated RMR rats SBP increased from 111+/-3 mmHg to 127+/-5 mmHg at 2 weeks and 139+/-5 mmHg at 4 weeks. In contrast, in RMR rats treated with heparin, SBP was 114 +/-3 mmHg at 2 weeks and 115+/-4 mmHg at 4 weeks (P<0.05 for both). Treatment with L-NAME increased SBP both in untreated and heparin-treated RMR groups. Two weeks after nephrectomy daily urinary nitrate increased significantly more in RMR rats treated with heparin than in untreated RMR rats (22+/-2 vs 14.2+/-2.3 micromol/day, P<0.05). In vitro studies performed at 2 weeks showed that vessels of untreated RMR rats had a blunted vasodilator response to acetylcholine that was restored to levels similar to that of controls in the heparin-treated group. CONCLUSIONS These results suggest that, in rats after renal ablation, heparin may exert its antihypertensive effect, at least in part, by affecting the altered behaviour of resistance vessels during the development phase of hypertension. Increased NO production may contribute to this effect.
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Affiliation(s)
- S Benchetrit
- Department of Nephrology and Hypertension, Meir Hospital and Sapir Medical Center, Sackler School of Medicine, Tel-Aviv University, Israel
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Abstract
Hypertension is a common finding after renal transplantation, and it has a variety of underlying mechanisms. One reason is the type of immunosuppressive therapy, with a higher prevalence of hypertension in cyclosporine-treated patients. Cyclosporine interferes with several humoral and neural systems which are involved in blood pressure regulation such as the renin-angiotensin system, endothelins, nitric oxide, prostaglandins and the sympathetic nervous system. Other pathomechanisms for posttransplant hypertension are uncontrolled renin secretion of the native kidneys, polycythemia, recurrence of renal disease in the graft and renal failure. Renal transplant artery stenosis is a potentially treatable cause of post-transplant hypertension and several techniques such MRT angiography, Doppler sonography and conventional angiography are available. The diagnosis and treatment of hypertension are of high importance in general for the transplanted patient, and especially for the long-term prognosis of graft function.
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Affiliation(s)
- M Zeier
- Department of Medicine/Nephrology, University of Heidelberg, Germany
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Zeier M, Mandelbaum A, Ritz E. Hypertension in the transplanted patient. Contrib Nephrol 1998; 124:146-57; discussion 158-65. [PMID: 9761979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- M Zeier
- Department of Medicine/Nephrology, University of Heidelberg, Germany
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Weber LT, Shipkova M, Lamersdorf T, Niedmann PD, Wiesel M, Mandelbaum A, Zimmerhackl LB, Schütz E, Mehls O, Oellerich M, Armstrong VW, Tönshoff B. Pharmacokinetics of mycophenolic acid (MPA) and determinants of MPA free fraction in pediatric and adult renal transplant recipients. German Study group on Mycophenolate Mofetil Therapy in Pediatric Renal Transplant Recipients. J Am Soc Nephrol 1998; 9:1511-20. [PMID: 9697675 DOI: 10.1681/asn.v981511] [Citation(s) in RCA: 174] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Dosage guidelines for mycophenolate mofetil (MMF), an ester prodrug of the immunosuppressant mycophenolic acid (MPA), are still preliminary in children. This study compares the pharmacokinetics of MPA and its major metabolite MPA glucuronide (MPAG) in pediatric renal transplant recipients receiving 600 mg MMF/m2 body surface area twice a day to those of adults on the currently recommended oral dose of 1 g of MMF twice a day. Concentration-time profiles of 18 children (age, 10.7+/-0.72 yr; range, 5.9 to 15.3 yr) and 10 adults were investigated 1 and 3 wk after transplantation. Plasma concentrations of MPA and MPAG were measured by reverse-phase HPLC. Because MPA is extensively bound to serum albumin and only the free fraction is presumed to be pharmacologically active, the MPA free fraction was also analyzed by HPLC after separation through ultrafiltration. The areas under the concentration-time curves (AUC0-12) of total and free MPA throughout the 12-h dosing interval in children were, in general, comparable to the corresponding data in adult patients. The mean AUC0-12 of MPA and free MPA did not change significantly over the first 3 wk after transplantation, but there was substantial intra- and interindividual variation. MPAG-AUC0-12 values in children with primary renal transplant dysfunction were threefold higher than in those with functioning transplants. Renal impairment had no consistent effect on total MPA-AUC0-12 values, but the MPA free fraction in children (median, 1.65%; range, 0.40 to 13.8%) was significantly (r2=0.46) modulated by renal transplant function and serum albumin levels. In conclusion, concentration-time profiles of pediatric renal transplant recipients administered 600 mg MMF/m2 body surface area twice a day are comparable to those in adults on 1 g MMF twice a day in the first 3 wk after transplantation. Renal impairment and decreased serum albumin levels led to an increase in the free fraction of MPA and the free MPA-AUC0-12 values. Because the pharmacologic activity of MPA is a function of unbound drug concentration, these findings might be relevant for the pharmacodynamic effects of MPA.
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Affiliation(s)
- L T Weber
- Division of Pediatric Nephrology, University Children's Hospital Heidelberg, Germany
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Schütz E, Armstrong VW, Shipkova M, Weber L, Niedmann PD, Lammersdorf T, Wiesel M, Mandelbaum A, Zimmerhackl LB, Mehls O, Tönshoff B, Oellerich M. Limited sampling strategy for the determination of mycophenolic acid area under the curve in pediatric kidney recipients. German Study Group on MMF Therapy in Pediatric Renal Transplant Recipients. Transplant Proc 1998; 30:1182-4. [PMID: 9636478 DOI: 10.1016/s0041-1345(98)00200-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E Schütz
- Department of Clinical Chemistry, Georg-August Universität, Goettingen, Germany
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Carl S, Dörsam J, Mandelbaum A, Staehler G, Wiesel M. Combining FK 506 and mycophenolate mofetil for the treatment of acute corticosteroid-resistant rejection following kidney transplantation: a new therapeutic concept. Transplant Proc 1998; 30:1236-7. [PMID: 9636502 DOI: 10.1016/s0041-1345(98)00224-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- S Carl
- Department of Urology, University of Heidelberg, Germany
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Morlender-Vais N, Mandelbaum A. Proton transfer between functional groups in MH+ ions of stereoisomeric diethers on chemical ionization and collision-induced dissociation conditions. ACTA ACUST UNITED AC 1997. [DOI: 10.1016/s0168-1176(97)00029-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Amann K, Mandelbaum A, Schwarz U, Ritz E. Hypertension and left ventricular hypertrophy in the CAPD patient. Kidney Int Suppl 1996; 56:S37-S40. [PMID: 8914052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- K Amann
- Department Pathology, Ruperto Carola University Heidelberg, Heidelberg, Germany
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Abstract
A bilateral, exercise-mediated renal functional abnormality was first described more than a decade ago. The disturbance is specific for hypertension, is seen in different forms of hypertension, and has been studied most extensively in hypertensives with renovascular disease. The bilateral-abnormal exercise renogram identifies the disturbance. Hypertensives with unilateral renovascular disease were studied in the continuing evaluation of the bilateral function disturbance. We examined 31 hypertensives with documented unilateral renovascular disease, all of whom had renography at rest and during 60 to 80 W ergometric exercise. An additional seven normotensives and 17 essential hypertensives served as controls, and had the same sequence of studies. All patients reported upon continued on to an infusion clearance with 131I-hippurate and 111In-diethylenetriamine pentaacetic acid to determine glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) at rest, and during 25 W ergometric exercise. Eighteen of 31 hypertensives with unilateral renovascular disease were found to have a bilateral-abnormal exercise renogram. Clearance examinations in these identified a prominent reduction of the GFR and a lesser decrease in the ERPF during exercise. Hypertensives with normal exercise renograms did not have the exercise mediated abnormal clearance pattern. Similar results were observed in the control population of essential hypertensives, 65% of whom developed the functional disturbance. The seven normotensives controls did not exhibit the exercise mediated function changes. We conclude that an exercise-mediated bilaterally occurring functional disturbance exists in certain hypertensives, who then have a bilateral-abnormal exercise renogram. Associated with this is a distinctly abnormal clearance during exercise which is characterized by a low filtration fraction.
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Affiliation(s)
- J H Clorius
- German Cancer Research Center, Heidelberg, Germany
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Abstract
The isomeric 2-, 3-, 5-, 6- and 8-quinolinylphthalimides give rise to different electron impact ionization mass spectra, which permit easy distinction. The specific fragmentation process are rationalized in terms of proximity effects and stabilization of cyclic ion structures. Collision-induced dissociation spectra were used to support the proposed ion structures of major fragment ions.
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Affiliation(s)
- A Weisz
- Office of Cosmetics and Colors, US Food and Drug Administration, Washington, DC 20204, USA
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Abstract
A correct estimation of volume status and so-called dry weight in dialysis patients remains a difficult clinical problem. Clinical status and chest X-ray are not sensitive enough, while invasively measured central venous pressures are not routinely available. Recently, the sonographic determination of the diameter and collapse of the inferior vena cava (IVC) has been proposed as a noninvasive method for estimating intravascular volume. We tried to evaluate the clinical relevance of this method in dialysis patients by comparing it with central venous pressures (CVP) and atrial natriuretic peptide (ANP). To establish a normal range and to control for confounding variables, we examined a large number of healthy controls. Furthermore, the influence of tricuspid insufficiency was examined echocardiographically. Measurements of the IVC diameters were well reproducible, with a coefficient of variation for interobserver error of 2.2%, and a coefficient of variation of 1.4% for intraobserver error. The collapse index was less well reproducible and therefore not used for further analysis. In 86 normal controls (age 18 to 76 years), IVC diameters showed a wide variation, and they were not correlated to age, height, weight, or body surface area. However, there was a significant correlation of IVCex to heart rate (r = 0.63, P < 0.001). Therefore, we calculated percentiles of the heart rate-IVCex relation in normals, and compared the results in patients to these. In 10 overhydrated haemodialysis patients, CVP was closely correlated to IVCex (r = 0.72, P < 0.001), but there was a wide interindividual variation of the slope of this relation. An IVCex above the 95th percentile of normal was a good predictor of an elevated CVP (i.e. > 12 cmH2O). In another 39 stable, chronic haemodialysis patients, there was a significant correlation of the intradialytic decrease of ANP and IVCex (r = 0.69, P < 0.001). However, this correlation existed only in patients without tricuspid insufficiency. In summary, sonography of the inferior vena cava is a valuable tool for estimating dry weight in dialysis patients, provided that some caveats are kept in mind: (i) there is a wide variation of IVC diameters in normals, and single measurements are not helpful in individual patients; (ii) there is a significant, inverse correlation between IVC diameters and heart rate, and the precision of intravascular volume assessment is enhanced by interpreting heart rate corrected diameters; (iii) the presence of tricuspid insufficiency leads to unreliable results, as it influences IVC diameters per se. Intravascular volume changes are reflected by IVC measurements, as shown by the correlation to other indices of intravascular volume, such as CVP and alpha-hANP. IVC sonography is noninvasive and easily available; serial measurements allow an estimation of changes of intravascular volume in patients without cardiac filling impairment. However, unlike with body impedance, interstitial volume is not reflected by IVC diameters.
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Affiliation(s)
- A Mandelbaum
- Medizinische Universitätsklinik, Sektion Nephrologie, Heidelburg, Germany
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Clorius JH, Hupp T, Mandelbaum A, Schmölder H, van Kaick G. Repeat exercise renograms in hypertension identify persistent renal dysfunction. J Hypertens 1995; 13:33-9. [PMID: 7759849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hypertensives may develop bilateral trapping of para-aminohippurate analogues in the tissue of the kidneys during light exercise, as can be demonstrated using radioactively labelled [131I]-hippurate or [99mTc]-mercaptoacetyl-triglycine. Tracer accumulation in the kidneys during exercise results in a typical renographic pattern, the bilateral-abnormal exercise renogram. The disturbance is common during exercise, being found in almost 60% of all hypertensives, regardless of aetiology. OBJECTIVE To determine whether bilateral-abnormal exercise renograms are spurious phenomena, or whether the results of exercise renography are reproducible. DESIGN We reviewed the renographic examinations of 27 hypertensive patients, each of whom had undergone at least one resting and two [131I]-hippurate or [99mTc]-mercaptoacetyl-triglycine gamma-camera exercise renograms. The status of the renal artery at the time of scintigraphy was documented, using available arteriograms. The causes of vascular lesions were noted, as were revascularization procedures and the antihypertensive medication being taken at the time of scintigraphy. RESULTS The average time between exercise renograms was 15.5 months, and 24 of the 27 hypertensive patients had comparable results in the first and the follow-up exercise renogram, divergent results being noted for the other three patients. Re-evaluation of the scintigrams of the three hypertensive patients with divergent results suggested that intermittent pelvic retention might have caused errors of interpretation in two. We found it notable that neither revascularization nor a change in antihypertensive drug therapy influenced the results of exercise renography. Exercise renograms were reproducible over long periods, and potential extraneous influences on blood flow, such as antihypertensive drugs or revascularization, failed to alter the results. CONCLUSION The results are considered relevant, because a direct relationship appears probable between hypertension and the disturbance investigated. Reproducible results suggest that the exercise-mediated disturbance is fixed to the kidneys, that it can be reactivated repeatedly and that it may play a role in maintaining hypertension.
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Affiliation(s)
- J H Clorius
- German Cancer Research Center, University of Heidelberg, Germany
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Denekamp C, Mandelbaum A, Weisz A, Ito Y. Preparative separation of stereoisomeric 1-methyl-4-methoxymethylcyclohexanecarboxylic acids by pH-zone-refining counter-current chromatography. J Chromatogr A 1994; 685:253-7. [PMID: 7842145 DOI: 10.1016/0021-9673(94)00669-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The application of pH-zone-refining counter-current chromatography (CCC) to the preparative separation of stereoisomeric acids is described. The separation was accomplished on the basis of the difference in acidity of the two stereoisomers. pH-Zone-refining CCC of 400 mg of a crude synthetic mixture of stereoisomeric 1-methyl-4-methoxymethylcyclohexanecarboxylic acids yielded 49.5 and 40 mg of the pure Z- and E-stereoisomers respectively. The two-phase solvent system consisted of hexane-ethyl acetate-methanol-water (1:1:1:1). Trifluoro acetic and octanoic acids were used as retainer acids. The eluent base was aqueous ammonia. The eluted fraction were monitored by gas chromatography-mass spectrometry.
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Affiliation(s)
- C Denekamp
- Department of Chemistry, Technion-Israel Institute of Technology, Haifa
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49
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Clorius JH, Hupp T, Schmidlin P, Mandelbaum A. The diagnosis of renovascular hypertension: the role of captopril renal scintigraphy and related issues. Eur J Nucl Med 1994; 21:264-7. [PMID: 8200397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
Vena cava diameter (VCD) was measured by ultrasonography in 10 acutely hypervolemic dialysis patients (6 men, 4 women; mean age 61.3 +/- 15.4 years), results being compared with the level of the central venous pressure (CVP) and, in 39 long-term dialysis patients (18 men, 21 women; mean age 56 +/- 15 years), with the plasma concentration of atrial natriuretic peptide (ANP). In 86 subjects without renal disease (43 men, 43 women; mean age 39.4 +/- 14.6 years) there was a statistically highly significant correlation between the end-expiratory VCD and heart rate (r = -0.63; P < 0.001). These data were used to construct a VCD/heart rate (HR) nomogram. In the ten dialysis patients HR-adjusted VCD correlated significantly at various hydration states (54 measurements) with the CVP (r = 0.72; P < 0.001). The steep slope for the relationship between CVP and VCD showed marked interindividual variations. However, in all patients (except one) with a raised CVP (> 12 cm H2O) the HR-adjusted VCD was above the 95th percentile. In the 39 patients on long-term dialysis (13 with, 25 without predialysis tricuspid regurgitation [TR] there occurred a parallel decrease in VCP and ANP during removal of fluid. In the 25 patients without TR, the fall in ANP concentration and VCD correlated significantly (r = 0.70; P < 0.001). These results indicate that, in patients with renal failure but normal cardiac function, measurement of the VCD by ultrasonography provides an adequate index of hydration.
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Affiliation(s)
- A Mandelbaum
- Sektion Nephrologie, Medizinische Universitätsklinik Heidelberg
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