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Naderalvojoud B, Curtin CM, Yanover C, El-Hay T, Choi B, Park RW, Tabuenca JG, Reeve MP, Falconer T, Humphreys K, Asch SM, Hernandez-Boussard T. Towards global model generalizability: independent cross-site feature evaluation for patient-level risk prediction models using the OHDSI network. J Am Med Inform Assoc 2024; 31:1051-1061. [PMID: 38412331 PMCID: PMC11031239 DOI: 10.1093/jamia/ocae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Predictive models show promise in healthcare, but their successful deployment is challenging due to limited generalizability. Current external validation often focuses on model performance with restricted feature use from the original training data, lacking insights into their suitability at external sites. Our study introduces an innovative methodology for evaluating features during both the development phase and the validation, focusing on creating and validating predictive models for post-surgery patient outcomes with improved generalizability. METHODS Electronic health records (EHRs) from 4 countries (United States, United Kingdom, Finland, and Korea) were mapped to the OMOP Common Data Model (CDM), 2008-2019. Machine learning (ML) models were developed to predict post-surgery prolonged opioid use (POU) risks using data collected 6 months before surgery. Both local and cross-site feature selection methods were applied in the development and external validation datasets. Models were developed using Observational Health Data Sciences and Informatics (OHDSI) tools and validated on separate patient cohorts. RESULTS Model development included 41 929 patients, 14.6% with POU. The external validation included 31 932 (UK), 23 100 (US), 7295 (Korea), and 3934 (Finland) patients with POU of 44.2%, 22.0%, 15.8%, and 21.8%, respectively. The top-performing model, Lasso logistic regression, achieved an area under the receiver operating characteristic curve (AUROC) of 0.75 during local validation and 0.69 (SD = 0.02) (averaged) in external validation. Models trained with cross-site feature selection significantly outperformed those using only features from the development site through external validation (P < .05). CONCLUSIONS Using EHRs across four countries mapped to the OMOP CDM, we developed generalizable predictive models for POU. Our approach demonstrates the significant impact of cross-site feature selection in improving model performance, underscoring the importance of incorporating diverse feature sets from various clinical settings to enhance the generalizability and utility of predictive healthcare models.
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Affiliation(s)
| | - Catherine M Curtin
- Department of Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, United States
| | - Chen Yanover
- KI Research Institute, Kfar Malal, 4592000, Israel
| | - Tal El-Hay
- KI Research Institute, Kfar Malal, 4592000, Israel
| | - Byungjin Choi
- Department of Biomedical Informatics, Ajou University Graduate School of Medicine, Suwon, 16499, Korea
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University Graduate School of Medicine, Suwon, 16499, Korea
| | - Javier Gracia Tabuenca
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, 00014, Finland
| | - Mary Pat Reeve
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, 00014, Finland
| | - Thomas Falconer
- Department of Biomedical Informatics, Columbia University, New York, NY 10032, United States
| | - Keith Humphreys
- Department of Psychiatry and the Behavioral Sciences, Stanford University, Stanford, CA 94305, United States
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, United States
| | - Steven M Asch
- Department of Medicine, Stanford University, Stanford, CA 94305, United States
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, United States
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Francoisse CA, Peters BR, Curtin CM, Novak CB, Russo SA, Tam K, Ota DT, Stenson KC, Steeves JD, Kennedy CR, Fox IK. Comparing surgeries to restore upper extremity function in tetraplegia: Impact on function during the perioperative period. J Spinal Cord Med 2024:1-12. [PMID: 38232181 DOI: 10.1080/10790268.2023.2283238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
CONTEXT/OBJECTIVE To assess short-term changes in health outcomes in people with cervical-level spinal cord injury (SCI) who underwent upper extremity (UE) reconstruction via either novel nerve transfer (NT) or traditional tendon transfer (TT) surgery with individuals who did not undergo UE surgical reconstruction. DESIGN Prospective, comparative cohort pilot study. PARTICIPANTS 34 participants with cervical SCI met the following inclusion criteria: age 18 or older, greater than 6 months post-injury, and mid-cervical level SCI American Spinal Injury Association Impairment Scale (AIS) A, B or C. SETTING Two tertiary academic hospitals and their affiliated veterans' hospitals. METHODS Health outcomes were assessed using two previously validated measures, the Spinal Cord Independence Measure (SCIM) and Short-Form Health Survey (SF-36). Demographic, surgical, and survey data were collected at the initial evaluation and one month postoperatively/post-baseline. RESULTS 34 participants with cervical SCI were recruited across three cohorts: no surgery (n = 16), NT (n = 10), and TT (n = 8). The TT group had a decline in SCIM and SF-36 scores whereas the NT and no surgery groups experienced little change in independence or health status in the immediate perioperative period. CONCLUSIONS Surgeons and rehabilitation providers must recognize differences in the perioperative needs of people with cervical SCI who chose to have restorative UE surgery. Future work should focus on further investigation of health outcomes, change in function, and improving preoperative counseling and cross-disciplinary management.
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Affiliation(s)
| | - Blair R Peters
- Division of Plastic Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Christine B Novak
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie A Russo
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, Ohio, USA
| | - Katharine Tam
- St. Louis Veterans' Healthcare System, St. Louis, Missouri, USA
- Division of Physical Medicine and Rehabilitation, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Doug T Ota
- Palo Alto Veterans Healthcare System, Palo Alto, California, USA
| | - Katherine C Stenson
- St. Louis Veterans' Healthcare System, St. Louis, Missouri, USA
- Division of Physical Medicine and Rehabilitation, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John D Steeves
- ICORD, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carie R Kennedy
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ida K Fox
- St. Louis Veterans' Healthcare System, St. Louis, Missouri, USA
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Zammit A, Coquet J, Hah J, el Hajouji O, Asch SM, Carroll I, Curtin CM, Hernandez-Boussard T. Postoperative opioid prescribing patients with diabetes: Opportunities for personalized pain management. PLoS One 2023; 18:e0287697. [PMID: 37616195 PMCID: PMC10449216 DOI: 10.1371/journal.pone.0287697] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/12/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Opioids are commonly prescribed for postoperative pain, but may lead to prolonged use and addiction. Diabetes impairs nerve function, complicates pain management, and makes opioid prescribing particularly challenging. METHODS This retrospective observational study included a cohort of postoperative patients from a multisite academic health system to assess the relationship between diabetes, pain, and prolonged opioid use (POU), 2008-2019. POU was defined as a new opioid prescription 3-6 months after discharge. The odds that a patient had POU was assessed using multivariate logistic regression controlling for patient factors (e.g., demographic and clinical factors, as well as prior pain and opiate use). FINDINGS A total of 43,654 patients were included, 12.4% with diabetes. Patients with diabetes had higher preoperative pain scores (2.1 vs 1.9, p<0.001) and lower opioid naïve rates (58.7% vs 68.6%, p<0.001). Following surgery, patients with diabetes had higher rates of POU (17.7% vs 12.7%, p<0.001) despite receiving similar opioid prescriptions at discharge. Patients with Type I diabetes were more likely to have POU compared to other patients (Odds Ratio [OR]: 2.22; 95% Confidence Interval [CI]:1.69-2.90 and OR:1.44, CI: 1.33-1.56, respectively). INTERPRETATION In conclusion, surgical patients with diabetes are at increased risk for POU even after controlling for likely covariates, yet they receive similar postoperative opiate therapy. The results suggest a more tailored approach to diabetic postoperative pain management is warranted.
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Affiliation(s)
- Alban Zammit
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford, California, United States of America
| | - Jean Coquet
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Jennifer Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Oualid el Hajouji
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford, California, United States of America
| | - Steven M. Asch
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Ian Carroll
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Catherine M. Curtin
- Department of Surgery, VA Palo Alto Health Care System, Menlo Park, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Biomedical Data Science, Stanford University, Stanford, California, United States of America
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Biomedical Data Science, Stanford University, Stanford, California, United States of America
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El Hajouji O, Sun RS, Zammit A, Humphreys K, Asch SM, Carroll I, Curtin CM, Hernandez-Boussard T. Prediction of opioid-related outcomes in a medicaid surgical population: Evidence to guide postoperative opiate therapy and monitoring. PLoS Comput Biol 2023; 19:e1011376. [PMID: 37578969 PMCID: PMC10449152 DOI: 10.1371/journal.pcbi.1011376] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/24/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Treatment of surgical pain is a common reason for opioid prescriptions. Being able to predict which patients are at risk for opioid abuse, dependence, and overdose (opioid-related adverse outcomes [OR-AE]) could help physicians make safer prescription decisions. We aimed to develop a machine-learning algorithm to predict the risk of OR-AE following surgery using Medicaid data with external validation across states. METHODS Five machine learning models were developed and validated across seven US states (90-10 data split). The model output was the risk of OR-AE 6-months following surgery. The models were evaluated using standard metrics and area under the receiver operating characteristic curve (AUC) was used for model comparison. We assessed calibration for the top performing model and generated bootstrap estimations for standard deviations. Decision curves were generated for the top-performing model and logistic regression. RESULTS We evaluated 96,974 surgical patients aged 15 and 64. During the 6-month period following surgery, 10,464 (10.8%) patients had an OR-AE. Outcome rates were significantly higher for patients with depression (17.5%), diabetes (13.1%) or obesity (11.1%). The random forest model achieved the best predictive performance (AUC: 0.877; F1-score: 0.57; recall: 0.69; precision:0.48). An opioid disorder diagnosis prior to surgery was the most important feature for the model, which was well calibrated and had good discrimination. CONCLUSIONS A machine learning models to predict risk of OR-AE following surgery performed well in external validation. This work could be used to assist pain management following surgery for Medicaid beneficiaries and supports a precision medicine approach to opioid prescribing.
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Affiliation(s)
- Oualid El Hajouji
- Department of Medicine, Stanford University, Stanford California, United States of America
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford California, United States of America
| | - Ran S. Sun
- Department of Medicine, Stanford University, Stanford California, United States of America
| | - Alban Zammit
- Department of Medicine, Stanford University, Stanford California, United States of America
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford California, United States of America
| | - Keith Humphreys
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Healthcare System, Palo Alto California, United States of America
- Department of Psychiatry and the Behavioral Sciences, Stanford University, Stanford California, United States of America
| | - Steven M. Asch
- Department of Medicine, Stanford University, Stanford California, United States of America
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Healthcare System, Palo Alto California, United States of America
| | - Ian Carroll
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford California, United States of America
| | - Catherine M. Curtin
- Department of Surgery, VA Palo Alto Health Care System, Menlo Park California, United States of America
- Department of Surgery, Stanford University, Stanford California, United States of America
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford California, United States of America
- Department of Surgery, Stanford University, Stanford California, United States of America
- Department of Biomedical Data Science, Stanford University, Stanford California, United States of America
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Cohen SA, Xiao M, Curtin CM, Yao J. Analysis of Website Accessibility and Content for All 92 Accredited Hand Surgery Fellowship Programs in the United States: An Update. Journal of Hand Surgery Global Online 2022; 4:269-275. [PMID: 36157307 PMCID: PMC9492797 DOI: 10.1016/j.jhsg.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/09/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose The internet is an important information source for hand surgery fellowship applicants. A previous analysis of hand fellowship websites in 2014 demonstrated they were often inaccessible and incomplete. Given the increased importance of virtual information, we performed an updated assessment of the accessibility and content of hand fellowship program websites. Methods Websites of 92 accredited hand surgery fellowship programs were evaluated for the following: (1) accessibility; and (2) the presence of 13 fellow recruitment and 13 fellow education criteria, as defined in prior studies. We used Mann-Whitney U and Kruskal-Wallis tests to assess whether the geographic region, number of fellows, or affiliation with a top orthopedic hospital or medical school were associated with website content. Results Functional website links that redirect to the appropriate fellowship program website are provided for 47 (51.1%) of 92 programs on the American Society for Surgery of the Hand fellowship directory. All missing websites were accessible via independent Google searches. Fellowship program websites contained an average of 13.9 ± 4.4 total criteria (range, 3–23). Of the 15 criteria examined in both 2014 and 2021, there were significant (P < .05) increases in the prevalences of 4: current fellow(s), salary, social media links, and operative experience. Conclusions Despite a slight increase in accessibility since 2014, nearly half of hand surgery fellowship program websites remain inaccessible from the American Society for Surgery of the Hand directory. Program websites averaged approximately half of the criteria analyzed, with many websites failing to provide information deemed important by applicants. Clinical relevance Our study provides an impetus for improving the accessibility and content of hand surgery fellowship websites. A website that incorporates criteria examined in this study can serve as an effective recruitment tool by providing consistent baseline information that may help applicants decide which programs align with personal values and future career goals.
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Harris AHS, Ding Q, Trickey AW, Finlay AK, Schmidt EM, Curtin CM, Sears ED, Yoshida R, Lashgari D, Nuckols TK, Kamal RN. Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable? Clin Orthop Relat Res 2022; 480:1743-1750. [PMID: 35274625 PMCID: PMC9384918 DOI: 10.1097/corr.0000000000002175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information. QUESTIONS/PURPOSES (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)? METHODS This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics® Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied. To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size. RESULTS We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60. CONCLUSION The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes. CLINICAL RELEVANCE As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.
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Affiliation(s)
- Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Qian Ding
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Andrea K. Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Eric M. Schmidt
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Catherine M. Curtin
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
| | - Erika D. Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Michigan Medicine Department of Surgery, Ann Arbor, MI, USA
| | - Ryu Yoshida
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Donna Lashgari
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford, CA, USA
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Michigan Medicine Department of Surgery, Ann Arbor, MI, USA
- Cedars Sinai Medical Center, Los Angeles, CA, USA
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Robin N. Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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L'Hotta AJ, James AS, Curtin CM, Kennedy C, Kenney D, Tam K, Ota D, Stenson K, Novak CB, Fox IK. Surgery to Restore Upper Extremity Function in Tetraplegia-Preferences for Early and Frequent Access to Information. PM R 2022. [PMID: 35665476 DOI: 10.1002/pmrj.12862] [Citation(s) in RCA: 4] [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: 11/03/2021] [Revised: 02/25/2022] [Accepted: 05/06/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION People with cervical spinal cord injury (SCI) identify improving upper extremity (UE) function as a top priority. In addition to comprehensive rehabilitation, UE surgeries, including nerve and tendon transfers, enhance function. However, barriers exist to disseminating information about surgical options to enhance UE function. OBJECTIVE To assess the experiences and preferences of people with cervical SCI and their caregivers in accessing information about surgery to enhance UE function. DESIGN Prospective cohort study. Participants were followed for 24 months and completed up to three interviews. SETTING Tertiary care at academic and affiliated Veterans Administration Health Care Centers. PARTICIPANTS Adults with cervical SCI (n=35) ages 18 to 80 years with mid-cervical SCI American Spinal Injury Association Impairment Scale A, B, or C (at least six months post-injury) and their caregivers (n=23) were eligible to participate. Participants were enrolled in three groups: nerve transfer, tendon transfer, or no UE reconstructive surgery. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Semi-structured interviews about surgical knowledge and experiences. RESULTS Data were analyzed and three themes were identified. First, providing information about UE surgical options early post-injury was recommended. The acute or inpatient rehabilitation phases of recovery were the preferred times to receive surgical information. Second, challenges with information dissemination were identified. Participants learned about UE surgery through independent research, medical provider interactions, or peers. Third, peers were identified as valuable resources for SCI needs and surgical information. CONCLUSIONS Following cervical SCI, information about UE reconstructive surgeries should be a standard component of education during rehabilitation. An increased understanding of the reconstructive options available to improve UE function is necessary to educate stakeholders. Future research is needed to support the development of strategies to effectively present surgical information to individuals with SCI and healthcare providers. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Aimee S James
- Washington University School of Medicine in St. Louis
| | | | - Carie Kennedy
- Washington University School of Medicine in St. Louis
| | | | - Katharine Tam
- Washington University School of Medicine in St. Louis.,VA St. Louis Health Care System
| | | | | | | | - Ida K Fox
- Washington University School of Medicine in St. Louis.,VA St. Louis Health Care System
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Conroy B, Silva I, Mehraei G, Damiano R, Gross B, Salvati E, Feng T, Schneider J, Olson N, Rizzo AG, Curtin CM, Frassica J, McFarlane DC. Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19. Sci Rep 2022; 12:3797. [PMID: 35260671 PMCID: PMC8904796 DOI: 10.1038/s41598-022-07764-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/23/2022] [Indexed: 12/23/2022] Open
Abstract
Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.
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Affiliation(s)
- Bryan Conroy
- Philips Research North America, Cambridge, MA, USA
| | - Ikaro Silva
- Philips Research North America, Cambridge, MA, USA
| | | | | | - Brian Gross
- Philips Research North America, Cambridge, MA, USA
| | | | - Ting Feng
- Philips Research North America, Cambridge, MA, USA
| | | | - Niels Olson
- Defense Innovation Unit, Mountain View, CA, USA
| | | | - Catherine M Curtin
- Department of Surgery, Palo Alto Veteran Affairs Healthcare System, Palo Alto, CA, USA
| | - Joseph Frassica
- Philips Research North America, Cambridge, MA, USA.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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Coquet J, Zammit A, Hajouji OE, Humphreys K, Asch SM, Osborne TF, Curtin CM, Hernandez-Boussard T. Changes in postoperative opioid prescribing across three diverse healthcare systems, 2010-2020. Front Digit Health 2022; 4:995497. [PMID: 36561925 PMCID: PMC9763443 DOI: 10.3389/fdgth.2022.995497] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022] Open
Abstract
Objective The opioid crisis brought scrutiny to opioid prescribing. Understanding how opioid prescribing patterns and corresponding patient outcomes changed during the epidemic is essential for future targeted policies. Many studies attempt to model trends in opioid prescriptions therefore understanding the temporal shift in opioid prescribing patterns across populations is necessary. This study characterized postoperative opioid prescribing patterns across different populations, 2010-2020. Data Source Administrative data from Veteran Health Administration (VHA), six Medicaid state programs and an Academic Medical Center (AMC). Data extraction Surgeries were identified using the Clinical Classifications Software. Study Design Trends in average daily discharge Morphine Milligram Equivalent (MME), postoperative pain and subsequent opioid prescription were compared using regression and likelihood ratio test statistics. Principal Findings The cohorts included 595,106 patients, with populations that varied considerably in demographics. Over the study period, MME decreased significantly at VHA (37.5-30.1; p = 0.002) and Medicaid (41.6-31.3; p = 0.019), and increased at AMC (36.9-41.7; p < 0.001). Persistent opioid users decreased after 2015 in VHA (p < 0.001) and Medicaid (p = 0.002) and increase at the AMC (p = 0.003), although a low rate was maintained. Average postoperative pain scores remained constant over the study period. Conclusions VHA and Medicaid programs decreased opioid prescribing over the past decade, with differing response times and rates. In 2020, these systems achieved comparable opioid prescribing patterns and outcomes despite having very different populations. Acknowledging and incorporating these temporal distribution shifts into data learning models is essential for robust and generalizable models.
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Affiliation(s)
- Jean Coquet
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Alban Zammit
- Computational & Mathematical Engineering, Stanford University, Stanford, CA, United States
| | - Oualid El Hajouji
- Computational & Mathematical Engineering, Stanford University, Stanford, CA, United States
| | - Keith Humphreys
- United States Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, CA, United States.,Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, United States
| | - Steven M Asch
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.,United States Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Thomas F Osborne
- United States Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, CA, United States.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Catherine M Curtin
- Department of Surgery, VA Palo Alto Health Care System, Menlo Park, CA, United States.,Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Biomedical Data Science, Stanford University, Stanford, CA, United States
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10
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Yoon D, Xu Y, Cipriano PW, Alam IS, Mari Aparici CA, Tawfik VL, Curtin CM, Carroll IR, Biswal S. Neurovascular, muscle, and skin changes on [18F]FDG PET/MRI in complex regional pain syndrome of the foot: A Prospective Clinical Study. Pain Med 2021; 23:339-346. [PMID: 34718774 PMCID: PMC8807071 DOI: 10.1093/pm/pnab315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 08/05/2021] [Accepted: 10/01/2021] [Indexed: 01/10/2023]
Abstract
Objective The goal of this study is to demonstrate the feasibility of simultaneous [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) and magnetic resonance imaging (MRI) for noninvasive visualization of muscular, neurovascular, and skin changes secondary to complex regional pain syndrome (CRPS). Subjects Seven adult patients with CRPS of the foot and seven healthy adult controls participated in our [18F]FDG PET/MRI study. Methods All participants received whole-body PET/MRI scans 1 hour after the injection of 370MBq [18F]FDG. Resulting PET/MRI images were reviewed by two radiologists. Metabolic and anatomic abnormalities identified, were grouped into muscular, neurovascular, and skin lesions. The [18F]FDG uptake of each lesion was compared with that of corresponding areas in controls using a Mann-Whitney U-test. Results On PET images, muscular abnormalities were found in five patients, neurovascular abnormalities in four patients, and skin abnormalities in two patients. However, on MRI images, no muscular abnormalities were detected. Neurovascular abnormalities and skin abnormalities in the affected limb were identified on MRI in one and two patients, respectively. The difference in [18F]FDG uptake between the patients and the controls was significant in muscle (P = .018) and neurovascular bundle (P = .0005). Conclusions The increased uptake of [18F]FDG in the symptomatic areas likely reflects the increased metabolism due to the inflammatory response causing pain. Therefore, our approach combining metabolic [18F]FDG PET and anatomic MR imaging may offer noninvasive monitoring of the distribution and progression of inflammatory changes associated with CRPS.
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Affiliation(s)
- Daehyun Yoon
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Yingding Xu
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Peter W Cipriano
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Israt S Alam
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Carina A Mari Aparici
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Vivianne L Tawfik
- Department of Anesthesiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Catherine M Curtin
- Department of Surgery, Stanford University School of Medicine, 430 Broadway St, ., Redwood City, CA, 94063, USA
| | - Ian R Carroll
- Department of Anesthesiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
| | - Sandip Biswal
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, ., Stanford, CA, 94305, USA
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11
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Osborne TF, Veigulis ZP, Arreola DM, Mahajan SM, Röösli E, Curtin CM. Association of mortality and aspirin prescription for COVID-19 patients at the Veterans Health Administration. PLoS One 2021; 16:e0246825. [PMID: 33571280 PMCID: PMC7877611 DOI: 10.1371/journal.pone.0246825] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/27/2021] [Indexed: 12/25/2022] Open
Abstract
There is growing evidence that thrombotic and inflammatory pathways contribute to the severity of COVID-19. Common medications such as aspirin, that mitigate these pathways, may decrease COVID-19 mortality. This retrospective assessment was designed to quantify the correlation between pre-diagnosis aspirin and mortality for COVID-19 positive patients in our care. Data from the Veterans Health Administration national electronic health record database was utilized for the evaluation. Veterans from across the country with a first positive COVID-19 polymerase chain reaction lab result were included in the evaluation which comprised 35,370 patients from March 2, 2020 to September 13, 2020 for the 14-day mortality cohort and 32,836 patients from March 2, 2020 to August 28, 2020 for the 30-day mortality cohort. Patients were matched via propensity scores and the odds of mortality were then compared. Among COVID-19 positive Veterans, preexisting aspirin prescription was associated with a statistically and clinically significant decrease in overall mortality at 14-days (OR 0.38, 95% CI 0.32–0.46) and at 30-days (OR 0.38, 95% CI 0.33–0.45), cutting the odds of mortality by more than half. Findings demonstrated that pre-diagnosis aspirin prescription was strongly associated with decreased mortality rates for Veterans diagnosed with COVID-19. Prospective evaluation is required to more completely assess this correlation and its implications for patient care.
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Affiliation(s)
- Thomas F. Osborne
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
- Department of Radiology, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
| | - Zachary P. Veigulis
- US Department of Veterans Affairs, Central Iowa Health Care System, Des Moines, Iowa, United States of America
| | - David M. Arreola
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Satish M. Mahajan
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Eliane Röösli
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Catherine M. Curtin
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
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12
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Curtin CM. Determining the Optimal Location for Minor Procedures-Goldilocks Medicine and the Just-Right Surgical Setting. JAMA Netw Open 2020; 3:e2016127. [PMID: 33048124 DOI: 10.1001/jamanetworkopen.2020.16127] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Catherine M Curtin
- Department of Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Division of Plastic Surgery, Stanford University, Palo Alto, California
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13
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Harris AHS, Meerwijk EL, Ding Q, Trickey AW, Finlay AK, Schmidt EM, Curtin CM, Sears ED, Nuckols TK, Kamal RN. Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability. BMC Health Serv Res 2020; 20:861. [PMID: 32917188 PMCID: PMC7488522 DOI: 10.1186/s12913-020-05704-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures. METHODS The measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016-18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center. RESULTS The denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively). CONCLUSIONS Measure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.
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Affiliation(s)
- Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA. .,Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford, CA, USA.
| | - Esther L Meerwijk
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Qian Ding
- Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford, CA, USA
| | - Amber W Trickey
- Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford, CA, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Eric M Schmidt
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Catherine M Curtin
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford, CA, USA
| | - Erika D Sears
- Michigan Medicine Department of Surgery, Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Teryl K Nuckols
- Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, USA
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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14
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Osborne TF, Veigulis ZP, Arreola DM, Röösli E, Curtin CM. Automated EHR score to predict COVID-19 outcomes at US Department of Veterans Affairs. PLoS One 2020; 15:e0236554. [PMID: 32716922 PMCID: PMC7384633 DOI: 10.1371/journal.pone.0236554] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/08/2020] [Indexed: 01/20/2023] Open
Abstract
The sudden emergence of COVID-19 has brought significant challenges to the care of Veterans. An improved ability to predict a patient's clinical course would facilitate optimal care decisions, resource allocation, family counseling, and strategies for safely easing distancing restrictions. The Care Assessment Need (CAN) score is an existing risk assessment tool within the Veterans Health Administration (VA), and produces a score from 0 to 99, with a higher score correlating to a greater risk. The model was originally designed for the nonacute outpatient setting and is automatically calculated from structured data variables in the electronic health record. This multisite retrospective study of 6591 Veterans diagnosed with COVID-19 from March 2, 2020 to May 26, 2020 was designed to assess the utility of repurposing the CAN score as objective and automated risk assessment tool to promptly enhance clinical decision making for Veterans diagnosed with COVID-19. We performed bivariate analyses on the dichotomized CAN 1-year mortality score (high vs. low risk) and each patient outcome using Chi-square tests of independence. Logistic regression models using the continuous CAN score were fit to assess its predictive power for outcomes of interest. Results demonstrated that a CAN score greater than 50 was significantly associated with the following outcomes after positive COVID-19 test: hospital admission (OR 4.6), prolonged hospital stay (OR 4.5), ICU admission (3.1), prolonged ICU stay (OR 2.9), mechanical ventilation (OR 2.6), and mortality (OR 7.2). Repurposing the CAN score offers an efficient way to risk-stratify COVID-19 Veterans. As a result of the compelling statistical results, and automation, this tool is well positioned for broad use across the VA to enhance clinical decision-making.
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Affiliation(s)
- Thomas F. Osborne
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
- Department of Radiology, Stanford University School of Medicine, Stanford, California, United States of America
| | - Zachary P. Veigulis
- US Department of Veterans Affairs, Central Iowa Health Care System, Des Moines, Iowa, United States of America
| | - David M. Arreola
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Eliane Röösli
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Catherine M. Curtin
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
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15
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Shinall MC, Arya S, Youk A, Varley P, Shah R, Massarweh NN, Shireman PK, Johanning JM, Brown AJ, Christie NA, Crist L, Curtin CM, Drolet BC, Dhupar R, Griffin J, Ibinson JW, Johnson JT, Kinney S, LaGrange C, Langerman A, Loyd GE, Mady LJ, Mott MP, Patri M, Siebler JC, Stimson CJ, Thorell WE, Vincent SA, Hall DE. Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality. JAMA Surg 2020; 155:e194620. [PMID: 31721994 DOI: 10.1001/jamasurg.2019.4620] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood. Objective To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study. Design, Setting, and Participants This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress. Exposures Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score. Main Outcomes and Measures Postoperative mortality at 30, 90, and 180 days. Results Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures. Conclusions and Relevance We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.
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Affiliation(s)
- Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California.,Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rupen Shah
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha.,Nebraska Western Iowa Veterans Affairs Health System, Omaha
| | - Alaina J Brown
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neil A Christie
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lawrence Crist
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Brian C Drolet
- Deparment of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rajeev Dhupar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer Griffin
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha
| | - James W Ibinson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonja Kinney
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha
| | - Chad LaGrange
- Division of Urology, University of Nebraska Medical Center, Omaha
| | - Alexander Langerman
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gary E Loyd
- Perioperative Surgical Home, Henry Ford Health System, Detroit, Michigan
| | - Leila J Mady
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael P Mott
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Murali Patri
- Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan
| | - Justin C Siebler
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha
| | - C J Stimson
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William E Thorell
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha
| | - Scott A Vincent
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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16
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Abstract
This prospective cohort study used video electromyography synchronized analysis to determine the dynamic use of extrinsic and intrinsic finger flexion during grasp. Light fist formation primarily involved the flexor digitorum profundus with either the flexor digitorum superficialis or intrinsics. In contrast, both the flexor digitorum superficialis and intrinsics were recruited in all tight fist video electromyography. However, the sequence of recruitment differed between patients in tight fist formation. Injured patients demonstrated a unique pattern of recruitment based on injury. The authors conclude that the flexor digitorum profundus is the workhorse in composite fist formation but the roles of the flexor digitorum superficialis and the intrinsic muscles are less consistent across patients. [Orthopedics. 2019; 42(6):e555-e558.].
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17
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Čebron U, Curtin CM. The scratch collapse test: A systematic review. J Plast Reconstr Aesthet Surg 2018; 71:1693-1703. [PMID: 33054988 DOI: 10.1016/j.bjps.2018.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 09/03/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
Abstract
The diagnosis of nerve compression relies on collecting diagnostic clues from the history, physical examination, imaging and diagnostic testing. There are several provocative tests to aid in the diagnosis of nerve compression. The 'Scratch Collapse Test' (SCT) has emerged as a new provocative test to assist in the localisation of peripheral nerve compression. This study aims to perform a systematic review of literature to assess the data on the reliability of the SCT as a diagnostic test for entrapment neuropathy. Ten articles were reviewed. Five articles had sufficient numerical data for analysis, and in these five articles, the positive predictive values and specificity were high, i.e. between 0.71 and 0.99 and 0.6 and 0.99, respectively, whereas other values were very variable, i.e. individual negative predictive values ranged from 0.15 to 0.92 and the sensitivity values ranged from 0.24 to 0.77. Another main finding was the versatility of the test in that it can be used for various nerve entrapments and to localise the exact level of compression. Literature suggests that SCT has potential to be used as a clinical diagnostic tool for entrapment neuropathy. However, wide variations in early literature suggest that SCT should not be used as a sole diagnostic tool but as an adjunct to a surgeon's diagnostic repertoire.
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Affiliation(s)
- Urška Čebron
- Department of Surgery, Palo Alto Veterans Hospital, Division of Plastic Surgery, Stanford University, Suite 400, 770 Welch RD, Palo Alto, CA 94304, United States
| | - Catherine M Curtin
- Department of Surgery, Palo Alto Veterans Hospital, Division of Plastic Surgery, Stanford University, Suite 400, 770 Welch RD, Palo Alto, CA 94304, United States.
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18
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Itoga NK, Rothenberg KA, Suarez P, Ho TV, Mell MW, Xu B, Curtin CM, Dalman RL. Metformin prescription status and abdominal aortic aneurysm disease progression in the U.S. veteran population. J Vasc Surg 2018; 69:710-716.e3. [PMID: 30197158 DOI: 10.1016/j.jvs.2018.06.194] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [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: 03/14/2018] [Accepted: 06/08/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Identification of a safe and effective medical therapy for abdominal aortic aneurysm (AAA) disease remains a significant unmet medical need. Recent small cohort studies indicate that metformin, the world's most commonly prescribed oral hypoglycemic agent, may limit AAA enlargement. We sought to validate these preliminary observations in a larger cohort. METHODS All patients with asymptomatic AAA disease managed in the Veterans Affairs Health Care System between 2003 and 2013 were identified by International Classification of Diseases, Ninth Revision codes. Those with a concomitant diagnosis of diabetes mellitus who also received two or more abdominal imaging studies (computed tomography, magnetic resonance imaging, or ultrasound) documenting the presence and size of an AAA, separated by at least 1 year, were included for review. Maximal AAA diameters were determined from radiologic reports. Further data acquisition was censored after surgical AAA repair, when performed. Comorbidities, active smoking status, and outpatient medication records (within 6 months of AAA diagnosis) were also queried. Yearly AAA enlargement rates, as a function of metformin treatment status, were compared using two statistical models expressed in millimeters per year: a multivariate linear regression (model 1) and a multivariate mixed-effects model with random intercept and random slope (model 2). RESULTS A total of 13,834 patients with 58,833 radiographic records were included in the analysis, with radiology imaging follow-up of 4.2 ± 2.6 years (mean ± standard deviation). The average age of the patients at AAA diagnosis was 69.8 ± 7.8 years, and 39.7% had a metformin prescription within ±6 months of AAA. The mean growth rate for AAAs in the entire cohort was 1.4 ± 2.0 mm/y by model 1 analysis and 1.3 ± 1.6 mm/y by model 2 analysis. The unadjusted mean rate of AAA growth was 1.2 ± 1.9 mm/y for patients prescribed metformin compared with 1.5 ± 2.2 mm/y for those without (P < .001), a 20% decrease. This effect remained significant when adjusted for variables relevant on AAA progression: metformin prescription was associated with a reduction in yearly AAA growth rate of -0.23 mm (95% confidence interval, -0.35 to -0.16; P < .001) by model 1 analysis and 0.20 mm/y (95% confidence interval, -0.26 to -0.14; P < .001) by model 2 analysis. A subset analysis of 7462 patients with baseline AAA size of 35 to 49 mm showed a similar inhibitory effect (1.4 ± 2.0 mm/y to 1.7 ± 2.2 mm/y; P < .001). Patients' factors associated with an increased yearly AAA growth rate were baseline AAA size, metastatic solid tumors, active smoking, chronic obstructive pulmonary disease, and chronic renal disease. Factors associated with decreased yearly AAA growth rates included prescriptions for angiotensin II type 1 receptor blockers or sulfonylureas and the presence of diabetes-related complications. CONCLUSIONS In a nationwide analysis of diabetic Veterans Affairs patients, prescription for metformin was associated with decreased AAA enlargement. These findings provide further support for the conduct of prospective clinical trials to test the ability of metformin to limit progression of early AAA disease.
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Affiliation(s)
- Nathan K Itoga
- Department of Surgery, Stanford University, Stanford, Calif
| | - Kara A Rothenberg
- Department of Surgery, Stanford University, Stanford, Calif; Department of Surgery, UCSF-East Bay, Oakland, Calif
| | - Paola Suarez
- Department of Surgery, Stanford University, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif
| | - Thuy-Vy Ho
- Department of Surgery, Stanford University, Stanford, Calif
| | - Matthew W Mell
- Department of Surgery, Stanford University, Stanford, Calif
| | - Baohui Xu
- Department of Surgery, Stanford University, Stanford, Calif
| | - Catherine M Curtin
- Department of Surgery, Stanford University, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif
| | - Ronald L Dalman
- Department of Surgery, Stanford University, Stanford, Calif.
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19
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Fox IK, Miller AK, Curtin CM. Nerve and Tendon Transfer Surgery in Cervical Spinal Cord Injury: Individualized Choices to Optimize Function. Top Spinal Cord Inj Rehabil 2018; 24:275-287. [PMID: 29997430 PMCID: PMC6037328 DOI: 10.1310/sci2403-275] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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] [Indexed: 12/21/2022]
Abstract
Background: Recent adaption of nerve transfer surgery to improve upper extremity function in cervical spinal cord injury (SCI) is an exciting development. Tendon transfer procedures are well established, reliable, and can significantly improve function. Despite this, few eligible surgical candidates in the United States undergo these restorative surgeries. Evidence Acquisition: The literature on these procedures was reviewed. Results: Options to improve function include surgery to restore elbow extension, wrist extension, and hand opening and closing function. Tendon transfers are reliable and well tolerated but require weeks of immobilization and limits on extremity use. The role of nerve transfers is still being established. Early results indicate variable return of meaningful function with less immobilization but longer periods (up to years) required to gain appreciable function. Conclusion: Nerve and tendon transfer surgery sacrifice an expendable donor to restore a missing and more critical function. These procedures are well described in hand surgery; are reliable, well tolerated, and covered by insurance; and should be part of the SCI rehabilitation discussion.
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Affiliation(s)
- Ida K. Fox
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Amanda K. Miller
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Catherine M. Curtin
- Department of Surgery, Veterans Affairs Healthcare System, Palo Alto, California
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20
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Curtin CM, Hagert CG, Hultling C, Hagert E. Nerve entrapment as a cause of shoulder pain in the spinal cord injured patient. Spinal Cord Ser Cases 2017; 3:17034. [PMID: 28616261 DOI: 10.1038/scsandc.2017.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Many people with chronic spinal cord injury (SCI) develop shoulder pain, which can adversely impact transfers and independence. Yet effective treatments remain elusive. CASE PRESENTATION This report presents two patients with tetraplegia who had long-standing shoulder pain. Our exam showed muscle weakness and point tenderness, suggestive of nerve entrapments of the radial and axillary nerves in the posterior shoulder. These nerves were surgically decompressed and post-operatively the patients' pain resolved. DISCUSSION Shoulder nerve entrapments are uncommon but SCI patients may be at more risk due to their unique upper extremity demands. SCI providers should consider proximal nerve entrapments as a possible cause of shoulder pain.
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Affiliation(s)
- Catherine M Curtin
- Department of Surgery, Palo Alto Veterans Affairs Hospital, Palo Alto, CA, USA.,Division of Plastic Surgery, Stanford University, Palo Alto, CA, USA
| | | | - Claes Hultling
- Spinalis CCI Unit Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Hagert
- Spinalis CCI Unit Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Hand & Foot Surgery Center, Stockholm, Sweden
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21
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Abstract
Traumatic nerve injuries can be devastating and life-changing events, leading to functional morbidity and psychological stress and social constraints. Even in the event of a successful surgical repair with recovered motor function, pain can result in continued disability and poor quality of life. Pain after nerve injury can also prevent recovery and return to preinjury life. It is difficult to predict which patients will develop persistent pain; once incurred, pain can be even challenging to manage. This review seeks to define the types of pain following peripheral nerve injuries, investigate the pathophysiology and causative factors, and evaluate potential treatment options.
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Affiliation(s)
- Gabrielle Davis
- Department of Surgery, Palo Alto VA, Suite 400, 770 Welch Road, Palo Alto, CA 94304, USA
| | - Catherine M Curtin
- Department of Surgery, Palo Alto VA, Suite 400, 770 Welch Road, Palo Alto, CA 94304, USA; Division of Plastic Surgery, Stanford University, Suite 400, 770 Welch Road, Palo Alto, CA 94304, USA.
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22
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Mulcahy LE, Curtin CM, McCoy RJ, O'Brien FJ, Taylor D, Lee TC, Duffy GP. The effect of bisphosphonate treatment on the biochemical and cellular events during bone remodelling in response to microinjury stimulation. Eur Cell Mater 2015; 30:271-81. [PMID: 26614482 DOI: 10.22203/ecm.v030a19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Osteoporosis is one of the most prevalent bone diseases worldwide and is characterised by high levels of bone turnover, a marked loss in bone mass and accumulation of microdamage, which leads to an increased fracture incidence that places a huge burden on global health care systems. Bisphosphonates have been used to treat osteoporosis and have shown great success in conserving bone mass and reducing fracture incidence. In spite of the existing knowledge of the in vivo responses of bone to bisphosphonates, the cellular responses to these drugs have yet to be fully elucidated. In vitro model systems that allow the decoupling of complex highly integrated events, such as bone remodelling, provide a tool whereby these biological processes may be studied in a more simplified context. This study firstly utilised an in vitro model system of bone remodelling and comprising all three major cell types of the bone (osteocytes, osteoclasts and osteoblasts), which was representative of the bone's capacity to sense microdamage and subsequently initiate a basic multicellular unit response. Secondly, this system was used to study the effect of two commonly utilised aminobisphosphonate treatments for osteoporosis, alendronate and zoledronate. We demonstrated that microinjury to osteocyte networks being treated with bisphosphonates modulates receptor activator of nuclear factor kappa-B ligand and osteoprotegerin activity, and subsequently osteoclastogenesis. Furthermore, bisphosphonates increased the osteogenic potential following microinjury. Thus, we have shown for the first time that bisphosphonates act at all three stages of bone remodelling, from microinjury to osteoclastogenesis and ultimately osteogenesis.
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Affiliation(s)
- L E Mulcahy
- Department of Anatomy, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2,
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23
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Nguyen C, Milstein A, Hernandez-Boussard T, Curtin CM. The Effect of Moving Carpal Tunnel Releases Out of Hospitals on Reducing United States Health Care Charges. J Hand Surg Am 2015; 40:1657-62. [PMID: 26070229 PMCID: PMC4516645 DOI: 10.1016/j.jhsa.2015.04.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 04/16/2015] [Accepted: 04/16/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To better understand how perioperative care affects charges for carpal tunnel release (CTR). METHODS We developed a cohort using ICD9-CM procedure code 04.43 for CTR in the National Survey of Ambulatory Surgery 2006 to test perioperative factors potentially associated with CTR costs. We examined factors that might affect costs, including patient characteristics, payer, surgical time, setting (hospital outpatient department vs. freestanding ambulatory surgery center), anesthesia type, anesthesia provider, discharge status, and adverse events. Records were grouped by facility to reduce the impact of surgeon and patient heterogeneity. Facilities were divided into quintiles based on average total facility charges per CTR. This division allowed comparison of factors associated with the lowest and highest quintile of facilities based on average charge per CTR. RESULTS A total of 160,000 CTRs were performed in 2006. Nearly all patients were discharged home without adverse events. Mean charge across facilities was $2,572 (SD, $2,331-$2,813). Patient complexity and intraoperative duration of surgery was similar across quintiles (approximately 13 min). Anesthesia techniques were not significantly associated with patient complexity, charges, and total perioperative time. Hospital outpatient department setting was strongly associated with total charges, with $500 higher charge per CTR. Half of all CTRs were performed in hospital outpatient departments. Facilities in the lowest quintile charge group were freestanding ambulatory surgery centers. CONCLUSIONS Examination of charges for CTR suggests that surgical setting is a large cost driver with the potential opportunity to lower charges for CTRs by approximately 30% if performed in ASCs. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/decision analysis II.
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Affiliation(s)
- Christine Nguyen
- Stanford University School of Medicine, Stanford, CA
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA
| | | | - Catherine M. Curtin
- Department of Surgery, Palo Alto Veterans Administration, Palo Alto, CA
- Division of Plastic Surgery, Stanford University School of Medicine, Stanford, CA
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24
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Fox PM, Suarez P, Hentz VR, Curtin CM. Access to surgical upper extremity care for people with tetraplegia: an international perspective. Spinal Cord 2015; 53:302-5. [PMID: 25687516 DOI: 10.1038/sc.2015.3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/14/2014] [Accepted: 01/02/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Survey. OBJECTIVES To determine whether upper extremity reconstruction in patients with tetraplegia is underutilized internationally and, if so, what are the barriers to care. SETTING International-attendees of a meeting in Paris, France. METHODS One hundred and seventy attendees at the Tetrahand meeting in Paris in 2010 were sent a 13-question survey to determine the access and utilization of upper limb reconstruction in tetraplegic patients in their practice. RESULTS Respondents ranged the globe including North America, South America, Europe, Asia and Australia. Fifty-nine percent of respondents had been practicing for more than 10 years. Sixty-four percent of respondents felt that at least 25% of people with tetraplegia would be candidates for surgery. Yet the majority of respondents found that <15% of potential patients underwent upper extremity reconstruction. Throughout the world direct patient referral was the main avenue of surgeons meeting patients with peer networking a distant second. Designated as the top three barriers to this care were lack of knowledge of surgical options by patients, lack of desire for surgery and poor referral patterns to appropriate upper extremity surgeons. CONCLUSION The results of this survey, of a worldwide audience, indicate that many of the same barriers to care exist regardless of the patient's address. This was a preliminary opinion survey and thus the results are subjective. However, these results provide a roadmap to improving access to care by improving patient education and interdisciplinary physician communication.
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Affiliation(s)
- P M Fox
- 1] Veterans Affairs Palo Alto Health Care System-Rehabilitation Research and Development, Palo Alto, CA, USA [2] Division of Plastic Surgery, Stanford University, Palo Alto, CA, USA
| | - P Suarez
- Veterans Affairs Palo Alto Health Care System-Rehabilitation Research and Development, Palo Alto, CA, USA
| | - V R Hentz
- 1] Veterans Affairs Palo Alto Health Care System-Rehabilitation Research and Development, Palo Alto, CA, USA [2] Division of Plastic Surgery, Stanford University, Palo Alto, CA, USA
| | - C M Curtin
- 1] Veterans Affairs Palo Alto Health Care System-Rehabilitation Research and Development, Palo Alto, CA, USA [2] Division of Plastic Surgery, Stanford University, Palo Alto, CA, USA
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Abstract
PURPOSE To assess the rates and associated diagnoses of readmissions for patients having received an intervention for treatment of distal radius fracture. METHODS We analyzed patient discharges from 2005-2011 for California, Florida, and New York. We used Agency for Healthcare Research and Quality data sets: (1) State Inpatient Database, (2) State Ambulatory Surgery Database, and (3) State Emergency Department Database. We examined inpatient, outpatient, and emergency room treatment locations. We identified patients by diagnosis code for distal radius fracture (813.41). Patients were stratified based on procedure codes for open reduction, closed reduction, and external fixation. The cohort was followed for 30 days to examine all-cause 30-day inpatient admissions and emergency department visits. RESULTS We identified 35,241 discharges with a primary diagnosis of distal radius facture. Of those, 18,388 patients underwent a procedure for their fracture, and 1,679 (9%) were readmitted within 30 days of discharge. Readmission rates varied by procedure type: internal fixation 8%, closed reduction 14%, and external fixation 11%. The most common diagnosis codes associated with readmission were general distal radius fracture codes (11%) and pain diagnoses (10%). Open procedures had higher odds of having a readmission associated with pain compared with closed treatment and external fixation. CONCLUSIONS Readmissions after treatment of distal radius fracture care are common. Our results show many distal radius fracture patients return to the health care system for pain-related issues. As more emphasis is placed on quality health care delivery, implementation of better pain management will be important to health care providers and patients. CLINICAL RELEVANCE This study highlights that improved perioperative pain control may improve patient care and reduce readmissions.
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Affiliation(s)
- Catherine M Curtin
- Department of Surgery, Palo Alto Veterans Hospital, Palo Alto, CA; Division of Plastic Surgery, Stanford University, Palo Alto, CA; Division of General Surgery, Stanford University, Palo Alto, CA.
| | - Tina Hernandez-Boussard
- Department of Surgery, Palo Alto Veterans Hospital, Palo Alto, CA; Division of Plastic Surgery, Stanford University, Palo Alto, CA; Division of General Surgery, Stanford University, Palo Alto, CA
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26
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Affiliation(s)
- C M Curtin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - K C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
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27
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Nguyen C, Hernandez-Boussard T, Davies SM, Bhattacharya J, Khosla RK, Curtin CM. Cleft Palate Surgery: An Evaluation of Length of Stay, Complications, and Costs by Hospital Type. Cleft Palate Craniofac J 2014; 51:412-9. [DOI: 10.1597/12-150] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The purpose of this study was to assess length of stay (LOS), complication rates, costs, and charges of cleft palate repair by various hospital types. We hypothesized that pediatric hospitals would have shorter LOS, fewer complications, and lower costs and charges. Methods Patients were identified by ICD-9-CM code for cleft palate repair (27.62) using databases from the Agency for Health Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database from 1997, 2000, 2003, and 2006. Patient characteristics (age, race, gender, insurer, comorbidities) and facility resources (hospital beds, cleft palate surgery volume, nurse-to-bed ratio, pediatric intensive care unit [PICU], PICU intensivist, burn unit) were examined. Hospitals types included pediatric hospitals, general hospitals, and nonaccredited children's hospital. For each hospital type, mean LOS, extended LOS (LOS > 2), and complications were assessed. Results A total of 14,153 patients had cleft repair with a mean LOS of 2 days (SD, 0.04), mortality 0.01%, transfusion 0.3%, and complication <3%. Pediatric hospitals had fewer patients with extended hospital stays. Patients with an LOS >2 days were associated with fourfold higher complications. Comorbidities increased the relative rate of LOS >2 days by 90%. Pediatric hospitals had the highest comorbidities, yet 35% decreased the relative rate of LOS >2 days. Median total charges of $10,835 increased to $15,104 with LOS >2 days; median total costs of $4367 increased to $6148 with a LOS >2 days. Conclusion Pediatric hospitals had higher comorbidities yet shorter LOS. Pediatric resources significantly decreased the relative rate of LOS >2 days. Median costs and charges increased by 41% with LOS >2 days. Further research is needed to understand additional aspects of pediatric hospitals associated with lower LOS.
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Affiliation(s)
| | | | - Sheryl M. Davies
- Center for Health Policy/Primary Care Outcomes Research, Stanford University, Stanford, California
| | - Jay Bhattacharya
- Center for Health Policy/Primary Care Outcomes Research, Stanford University, Stanford, California
| | - Rohit K. Khosla
- Division of Plastic and Reconstructive Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, California
| | - Catherine M. Curtin
- Department of Surgery, Palo Alto Veterans Administration, Palo Alto, California
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28
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Gajendran VK, Hentz V, Kenney D, Curtin CM. Multiple collagenase injections are safe for treatment of Dupuytren's contractures. Orthopedics 2014; 37:e657-60. [PMID: 24992063 DOI: 10.3928/01477447-20140626-64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 12/27/2013] [Indexed: 02/03/2023]
Abstract
The authors report the case of a 65-year-old, right-hand-dominant man who had severe Dupuytren's disease with multiple cords and flexion contractures of the metacarpophalangeal and proximal interphalangeal joints of both hands and underwent repeated collagenase injections for treatment. Collagenase has been shown to be safe and effective in the treatment of Dupuytren's contractures when administered as a single dose, but the results of multiple injections over a prolonged period are unknown. Antibodies to collagenase develop in all patients after several treatments, raising concerns about safety and efficacy as a result of sensitization from repeated exposures. The antibodies generated as a result of repeated exposure to collagenase could theoretically render it less effective with time and could also lead to immune reactions as severe as anaphylaxis. The authors present the case of a single patient who experienced continued correction of his contractures with only minor and self-limited adverse reactions after administration of 12 collagenase doses through 15 injections during a 4-year period. Over time, the injections continued to be effective at correcting metacarpophalangeal joint contractures, but less effective at correcting proximal interphalangeal joint contractures. The patient did eventually require a fasciectomy, but the safety and modest success of the repeated collagenase injections shows promise for a less invasive treatment with a better risk profile than open fasciectomy. Although further studies are needed, repeated administration of collagenase appears to be safe and modestly effective for severe Dupuytren's contractures, although a fasciectomy may ultimately be required in the most severe cases.
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Abstract
Objective Our study aimed to use national data to assess the perioperative outcomes of craniosynostosis surgical repair. Design Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids Inpatient Database from 1997, 2000, 2003, and 2006. Setting Community hospitals in the United States. Patients The cohort was identified using the ICD-9-CM procedure codes for craniosynostosis surgical repair (2.01, 2.03, 2.04, 2.06). Main Outcome Measures(s) We determined patient and hospital characteristics. We clustered patients by age group (7 months, 7 to 12 months, 1 to 3 years) and assessed mortality, comorbidities, mean length of stay (LOS), and total charge. We performed logistic regression with our dependent variable being longer average hospital stay: LOS > 4.2 days. Results We found 3426 patients. Average age at the time of surgery was 181 days (SD 84). Average length of stay was 4.2 days. The majority of the patients were boys (66%), white (71%), and insured (93%). Nearly all patients underwent surgery in a teaching hospital (98%) in urban centers (99%). Approximately 10% of patients experienced an acute complication, most commonly hemorrhages or hematomas and airway or respiratory failure. Patients ages 1 to 3 years had the highest rates of comorbidities and a longer LOS. Mortality rate was <1%. Conclusions Craniosynostosis surgery is safe with low rates of mortality and acute complications. LOS >4.2 appears to be associated more with comorbidities than with complications. Higher rates of comorbidities and LOS >4.2 days for patients age 1 to 3 years warrant addition research to assess potential barriers to care.
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Affiliation(s)
| | | | - Rohit K. Khosla
- Division of Plastic Surgery, Stanford University School of Medicine, and Staff Physician Palo Alto VA Hospital, Palo Alto, California
| | - Catherine M. Curtin
- Division of Plastic Surgery, Stanford University School of Medicine, and Staff Physician Palo Alto VA Hospital, Palo Alto, California
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30
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Abstract
Chronic pain affects quality of life and adversely affects functional outcomes. Chronic postoperative pain is a frustrating problem for the surgeon because it ruins a technically perfect procedure, and the surgeon may be unsure of treatment strategies. There is much information on chronic pain and its treatment, but it is often published outside of surgery and diffusion of this information across disciplines is slow. This article synthesizes some of this literature and provides a systematic presentation of the evidence on pain associated with peripheral nerve injury. It highlights the use of perioperative and early intervention to decrease this debilitating problem.
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Affiliation(s)
- Ian Carroll
- Department of Anesthesia, Stanford University, 450 Broadway, Redwood City, CA 94603, USA
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31
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Pepper A, Li W, Kingery WS, Angst MS, Curtin CM, Clark JD. Changes resembling complex regional pain syndrome following surgery and immobilization. J Pain 2013; 14:516-24. [PMID: 23453564 DOI: 10.1016/j.jpain.2013.01.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/03/2012] [Accepted: 01/03/2013] [Indexed: 01/26/2023]
Abstract
UNLABELLED The study of complex regional pain syndrome (CRPS) in humans is complicated by inhomogeneities in available study cohorts. We hoped to characterize early CRPS-like features in patients undergoing hand surgery. Forty-three patients were recruited from a hand surgery clinic that had elective surgeries followed by cast immobilization. On the day of cast removal, patients were assessed for vasomotor, sudomotor, and trophic changes, and edema and pain sensitization using quantitative sensory testing. Pain intensity was assessed at the time of cast removal and after 1 additional month, as was the nature of the pain using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS). Skin biopsies were harvested for the analysis of expression of inflammatory mediators. We identified vascular and trophic changes in the surgical hands of most patients. Increased sensitivity to punctate, pressure, and cold stimuli were observed commonly as well. Moreover, levels of IL-6, TNF-alpha, and the mast cell marker tryptase were elevated in the skin of hands ipsilateral to surgery. Moderate-to-severe pain persisted in the surgical hands for up to 1 month after cast removal. Exploratory analyses suggested interrelationships between the physical, quantitative sensory testing, and gene expression changes and pain-related outcomes. PERSPECTIVE This study has identified CPRS-like features in the limbs of patients undergoing surgery followed by immobilization. Further studies using this population may be useful in refining our understanding of CRPS mechanisms and treatments for this condition.
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Affiliation(s)
- Alison Pepper
- Department of Anesthesia, Stanford University, Palo Alto, California, USA
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32
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Curtin CM, Suarez PA, Di Ponio LA, Frayne SM. Who are the women and men in Veterans Health Administration's current spinal cord injury population? ACTA ACUST UNITED AC 2012; 49:351-60. [PMID: 22773195 DOI: 10.1682/jrrd.2010.11.0220] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spinal cord injury (SCI) care is a high priority for the Veterans Health Administration (VHA). Aging Veterans, new cases of SCI from recent conflicts, and increasing numbers of women Veterans have likely changed the profile of the VHA SCI population. This study characterizes the current Veteran population with SCI with emphasis on healthcare utilization and women Veterans. We analyzed VHA administrative data from 2002-2003 and 2007-2008, analyzing composition, demographics, and healthcare use. The population is mostly male (>97%) and largely between 45 and 64 years old. Over 30% are over the age of 65. They are frequent users of healthcare, with an average of 21 visits per year. Women Veterans with SCI form a small but distinct subpopulation, being younger and less likely to be married and having a higher burden of disease. We must understand how the VHA population with SCI is changing to anticipate and provide the best care for these complex patients.
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Affiliation(s)
- Catherine M Curtin
- VA Palo Alto Health Care System-Rehabilitation Research and Development, 770 Welch Rd, Suite 400, Palo Alto, CA 94304, USA.
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Abstract
OBJECTIVE Carpal tunnel syndrome (CTS) is a common disorder among individuals with spinal cord injury (SCI). Although carpal tunnel release is highly effective, the procedure may be under-utilized in this population. This study attempts to identify if CTS is under-treated in Veterans with SCI. DESIGN The Veterans Affairs (VA) National Patient Care Database was used for data compilation within fiscal years 2007 and 2008. Using ICD-9-CM diagnoses codes, individuals with SCIs were identified, including those diagnosed with CTS. Current procedural terminology (CPT) codes further showed those who had undergone surgical intervention including open and endoscopic release of the transverse carpal ligament. The VA SCI cohort was compared to the general VA population with regard to demographics, diagnosis, surgical intervention, and treatment location. RESULTS A total of 19 296 veterans with SCI were identified within the 2-year period. The prevalence of CTS within this cohort was 3.5%, compared to 2.1% in the general VA population. The rate of transverse carpal ligament release was similar between the VA SCI cohort and general population (0.24 and 0.17%, respectively). The majority of surgical treatment (89%) occurred within the VA 'hub-and-spoke' system of SCI care. CONCLUSION CTS appears to be under-diagnosed and under-treated in veterans with SCI.
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Affiliation(s)
- Cameron Barr
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Paola Suarez
- Center for Health Care Evaluation, Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, CA, USA
| | - Doug Ota
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA,Spinal Cord Injury Service, Department of Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA, USA
| | - Catherine M. Curtin
- Rehabilitation and Research and Development, Department of Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, CA, USA,Division of Plastic Surgery, Stanford University, Stanford, CA, USA,Correspondence to: Catherine M. Curtin, Rehabilitation and Research and Development, Spinal Cord Injury Service, Department of Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (MC-128), Palo Alto, CA 94304, USA.
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34
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Watt AJ, Curtin CM, Hentz VR. Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up. J Hand Surg Am 2010; 35:534-9, 539.e1. [PMID: 20353858 DOI: 10.1016/j.jhsa.2010.01.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [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: 11/18/2009] [Revised: 12/24/2009] [Accepted: 01/06/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture. METHODS Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner. RESULTS Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease. CONCLUSIONS Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.
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Affiliation(s)
- Andrew J Watt
- Department of Surgery, Stanford University Hospitals and Clinics, Palo Alto, CA 94304, USA.
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35
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Abstract
This is a case report of a 61-year-old cardiac transplant patient who developed a disseminated infection involving the upper extremity with a rare fungus known as Aspergillus ustus. The patient was successfully treated with aggressive serial debridements, antifungal medications, and reduction of immunosuppression. With these interventions, the patient avoided amputation despite the aggressive nature of this infection.
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Affiliation(s)
- Olushola Olorunnipa
- Division of Plastic Surgery, School of Medicine, Stanford University, Suite 400, 770 Welch Rd., Palo Alto, CA 94304 USA
| | - Andrew Y. Zhang
- Division of Plastic Surgery, School of Medicine, Stanford University, Suite 400, 770 Welch Rd., Palo Alto, CA 94304 USA
| | - Catherine M. Curtin
- Division of Plastic Surgery, School of Medicine, Stanford University, Suite 400, 770 Welch Rd., Palo Alto, CA 94304 USA ,Department of Surgery, Palo Alto VA, 3801 Miranda Ave., Palo Alto, CA 94304 USA
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Ram AN, Curtin CM, Chung KC. Population-based utilities for upper extremity functions in the setting of tetraplegia. J Hand Surg Am 2009; 34:1674-81.e1. [PMID: 19896010 PMCID: PMC4414024 DOI: 10.1016/j.jhsa.2009.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 07/02/2009] [Accepted: 07/08/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE People with tetraplegia face substantial physical and financial hardships. Although upper extremity reconstruction has been advocated for people with tetraplegia, these procedures are markedly underused in the United States. Population-based preference evaluation of upper extremity reconstruction is important to quantify the value of these reconstructive procedures. This study sought to establish the preferences for 3 health states: tetraplegia, tetraplegia with corrected pinch function, and tetraplegia with corrected elbow extension function. METHODS A computer-based, time trade-off survey was administered to a cohort of 81 able-bodied second-year medical students who served as a surrogate for the general public. This survey instrument has undergone pilot testing and has established face validity to evaluate the 3 health states of interest. Utilities were calculated based on an estimated 20 years of remaining life. RESULTS The mean utility for the tetraplegic health state was low. On average, respondents gave up 10.8 +/- 5.0 out of a hypothetical 20 years for perfect health, for a utility of tetraplegia equal to 0.46. For recovery of pinch function, respondents gave up an average of 6.5 +/- 4.3 years, with a corresponding health utility of 0.68. For recovery of elbow extension function, respondents gave up an average of 7.6 +/- 4.5 years, with a corresponding health utility of 0.74. CONCLUSIONS This study established the preferences for 2 upper extremity surgical interventions: tetraplegia with pinch and tetraplegia with elbow extension. The findings from this study place a high value on upper-limb reconstructive procedures with tetraplegia.
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Affiliation(s)
- Ashwin N. Ram
- Medical Student, the University of Michigan Medical School; Ann Arbor, MI
| | - Catherine M. Curtin
- Assistant Professor of Surgery, Section of Plastic Surgery, Department of Surgery, Stanford University Health System; Palo Alto, CA; Staff physician, Palo Alto VA
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, MI
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Hamou C, Shah NR, DiPonio L, Curtin CM. Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature. J Hand Surg Am 2009; 34:692-9. [PMID: 19345872 PMCID: PMC2794307 DOI: 10.1016/j.jhsa.2008.12.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 11/26/2008] [Accepted: 12/02/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE We conducted a systematic review of the literature to summarize the available data on reconstructive surgeries involving pinch reconstruction and elbow extension restoration in people with tetraplegia. METHODS English-language and French-language articles and abstracts published between 1966 and February 2007, identified through MEDLINE and EMBASE searches, bibliography review, and expert consultation, were reviewed for original reports of outcomes with pinch reconstruction and elbow extension restoration in tetraplegic patients after a spinal cord injury. Two reviewers independently extracted data on patient characteristics, surgical methods, and patient outcomes. RESULTS Our search identified 765 articles, of which 37 met eligibility criteria (one article contained information on both elbow and pinch procedures). Results from 377 pinch reconstructions in 23 studies and 201 elbow extension restorations in 14 studies were summarized. The mean Medical Research Council score for elbow extension went from 0 to 3.3 after reconstruction. The overall mean postoperative strength measured after surgery for pinch reconstruction was 2 kg. CONCLUSIONS More than 500 patients having these procedures experienced a clinically important improvement for both procedures-one restoring elbow extension, and the other, pinch strength. Upper-limb surgeries markedly improved the hand function of people with tetraplegia. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Cynthia Hamou
- Division of Hand Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA
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38
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Wagner JP, Curtin CM, Gater DR, Chung KC. Perceptions of people with tetraplegia regarding surgery to improve upper-extremity function. J Hand Surg Am 2007; 32:483-90. [PMID: 17398358 DOI: 10.1016/j.jhsa.2007.01.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 01/18/2007] [Accepted: 01/19/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE In the United States, more than 100,000 Americans live with the disability of tetraplegia. These individuals must struggle through long and complicated rehabilitations. Upper-extremity reconstructive surgery can improve use of the upper limb for appropriate candidates; however, a prior national study showed that these procedures rarely are performed. This cross-sectional survey identified the attitudes and beliefs of people with tetraplegia that may dissuade potential candidates from receiving these procedures. METHODS An oral survey was designed to determine priorities of reconstruction in individuals with tetraplegia. This survey was administered to 50 people with tetraplegia. RESULTS Among those surveyed, 13 (26%) had never heard of upper-extremity reconstructive surgery, but 22 (44%) were interested in upper-extremity reconstruction. People with tetraplegia who had a negative first impression of these procedures were far less likely to want reconstruction 0 (0%) vs. 11 (45%). Of patients who learned about these procedures from their physicians, 10 (67%) had a negative first impression after the physician consultation. CONCLUSIONS Although many people with tetraplegia understand the benefits of upper-extremity reconstruction, a large number of them are unaware of or have unfavorable attitudes toward these procedures. These negative attitudes may account for the marked underuse of upper-extremity reconstructive procedures in the United States.
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Affiliation(s)
- Jared P Wagner
- University of Michigan School of Medicine, the Department of Physical Medicine and Rehabilitation, and the Veterans Hospital, Department of Veterans Affairs, Ann Arbor, MI 48109-0340, USA
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39
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Abstract
BACKGROUND/OBJECTIVE Upper-extremity reconstruction for people with tetraplegia is underused, and we felt that physicians' beliefs could be contributing to this phenomenon. This research sought to determine whether (a) physicians underestimate the importance of upper-extremity function for people with tetraplegia, (b) physiatrists and hand surgeons disagree on the quality of life of those with tetraplegia, (c) surgeons believe that social issues make people with tetraplegia poor surgical candidates, and (d) the 2 specialties disagree on the benefits of upper-extremity reconstruction. METHODS A self-administered questionnaire was mailed to a national sample of 384 physiatrists and 379 hand surgeons. The data were analyzed with bivariate statistics. RESULTS The response rate was 62%. 65% of surgeons and 49% of physiatrists (P < 0.001) ranked upper-extremity function as the most important rehabilitative goal for people with tetraplegia. Both specialties believed the quality of life with tetraplegia was low (less than 60 on a scale of 0 to 100, with 100 representing perfect health). The 2 specialties have significantly different opinions regarding patient compliance, social support, and the effectiveness of surgery. CONCLUSIONS The majority of physicians believe that upper-extremity function is a rehabilitative priority for people with tetraplegia. However, physiatrists and hand surgeons have significantly different views about people with tetraplegia and the benefits of reconstructive surgery. Physician preconceptions and interdisciplinary divergence may be contributing to the underuse of these procedures, and these issues should be considered when designing programs to improve access to these procedures.
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40
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Curtin CM, Gater DR, Chung KC. Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study. J Hand Surg Am 2005; 30:94-9. [PMID: 15680562 DOI: 10.1016/j.jhsa.2004.10.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2004] [Accepted: 10/06/2004] [Indexed: 02/02/2023]
Abstract
PURPOSE More than 100,000 Americans live with the disability of tetraplegia. For these people their level of independence often is related to the function of the upper extremity. Reconstructive procedures can improve the use of the upper limb and multiple case series have shown benefit from these procedures for appropriate candidates. Discussions with patients and surgeons, however, suggest that these procedures rarely are performed. This study attempted to assess whether upper extremity reconstruction for the tetraplegic population is being used properly. METHODS Data from 2 inpatient national databases were used (the National Inpatient Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000. Patients were selected by International Classification of Diseases (ICD-9) diagnosis codes for tetraplegia and procedure codes that could represent upper extremity reconstruction. The recommended rate of these surgeries was based on the annual incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these people would benefit from upper extremity surgery. RESULTS Our health care data analysis showed that fewer than 355 of these surgeries were performed in the United States in any year queried. The calculated recommended rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates were receiving upper extremity reconstruction. We also found changes in the expected primary payor, with Medicaid paying for far fewer procedures in 2000 compared with 1988 claims. Finally over the course of time it appears that far fewer of these procedures are being performed. CONCLUSIONS Functional upper extremity reconstruction for the tetraplegic population is profoundly underused in the United States. Various factors could be causing this disparity of care and we recommend further research into the potential barriers to health care for this vulnerable population.
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Affiliation(s)
- Catherine M Curtin
- Robert Wood Johnson Clinical Scholar Program, University of Michigan-Ann Arbor, Medical Science Building 1, 11560 W. Medical Center Drive, Ann Arbor, MI 48109, USA
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41
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Curtin CM, Hayward RA, Kim HM, Gater DR, Chung KC. Physician perceptions of upper extremity reconstruction for the person with tetraplegia. J Hand Surg Am 2005; 30:87-93. [PMID: 15680561 DOI: 10.1016/j.jhsa.2004.08.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2004] [Accepted: 08/31/2004] [Indexed: 02/02/2023]
Abstract
PURPOSE Upper extremity reconstruction for people with tetraplegia can improve upper-limb function substantially and enhance independence; however, these surgical procedures rarely are performed. This study attempted to identify barriers preventing appropriate candidates from receiving these procedures. METHODS A questionnaire was mailed to a national sample of 379 hand surgeons and 384 physiatrists with an interest in spinal cord medicine. The statistical model assessed 2 main outcomes of the physician survey: (1) whether the provider had been involved in at least one of these procedures in the past year and (2) whether the provider desired to be more involved. We hypothesized that these outcomes were associated with provider attitudes and beliefs and failures of the health care system referral networks. RESULTS Most hand surgeons and physiatrists believed that these procedures were beneficial; however, few had either performed or referred even one case over the past year. Multivariable models suggested that a predominant factor in whether these procedures were being performed was the presence of a relationship between the surgeon and physiatrist. CONCLUSIONS A lack of coordinated cross-specialty relationships appears to present the largest barrier to the appropriate use of upper extremity reconstruction for people with tetraplegia.
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Affiliation(s)
- Catherine M Curtin
- Robert Wood Johnson Clinical Scholar Program, University of Michigan-Ann Arbor, Medical Science Building 1, 11560 W. Medical Center Drive, Ann Arbor, MI 48109, USA
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Abstract
Plastic surgeons are integral to the management team for patients with spinal cord injuries, with responsibilities including pressure sore management and upper extremity reconstruction. Injury to the spinal cord profoundly disrupts the body's ability to maintain homeostasis. In particular, the autonomic system can become unregulated, resulting in a massive sympathetic discharge called autonomic dysreflexia. Autonomic dysreflexia occurs in the majority of patients with injuries above the sixth thoracic vertebra and causes sudden, severe hypertension. If left untreated, autonomic dysreflexia can result in stroke or death. Because this syndrome causes morbidity and mortality, it is crucial for plastic surgeons to be able to recognize and treat autonomic dysreflexia. This article reviews the etiology, symptoms, and treatment of this syndrome.
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Affiliation(s)
- Catherine M Curtin
- Robert Wood Johnson Clinical Scholars Program, The University of Michigan Medical Center, 6312 Medical Science Building 1, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-0604, USA
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Abstract
The authors present a series of 16 unstable phalangeal fractures (13 patients) treated by open reduction and internal fixation using the eight-hole titanium miniplate system from Synthes (Paoli, PA). Thirteen fractures were finger fractures whereas three were thumb fractures. Most fractures (n = 15) were crush injuries with concomitant soft tissue trauma. Six patients with finger fractures had good to excellent range of motion (total active motion > or =180). Two patients with thumb fractures had moderate range of motion (range of motion 70-97), whereas the remaining patient with thumb fracture had poor motion because the interphalangeal joint was destroyed. Complications included two cases of plate exposure because of insufficient soft tissue cover. Although no malunion occurred in this series, there was one case of delayed union. Three patients had extensor tenolysis to improve motion. The eight-hole miniplate system adds to the versatility of the many options available for fixation of unstable phalangeal fractures. Rigid fixation using this system is particularly helpful in initiating early motion in severely crushed fingers with concomitant soft tissue injury.
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Affiliation(s)
- Catherine M Curtin
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 1500 E. Medical Center Drive, 2130 Taubman Center, Ann Arbor, MI 48109-0340, USA
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