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Taylor JS, Fellman BM, Raty S, Lasala J, Iniesta MD, Cain KE, Horner AA, Bruno M, Folloder JP, Knippel SL, Khanh V, Popovich S, Katz MHG, Best C, Thosani S. Detection and Management of Perioperative Hyperglycemia at a Tertiary Cancer Center. Ann Surg Oncol 2024; 31:3017-3023. [PMID: 38347330 DOI: 10.1245/s10434-024-14986-7] [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: 09/12/2023] [Accepted: 01/15/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION To improve the detection and management of perioperative hyperglycemia at our tertiary cancer center, we implemented a glycemic control quality improvement initiative. The primary goal was to decrease the percentage of diabetic patients with median postoperative glucose levels > 180 mg/dL during hospitalization by 15% within 2 years. METHODS A multidisciplinary team standardized preoperative screening, preoperative, intraoperative, and postoperative hyperglycemia management. We included all patients undergoing nonemergent inpatient and outpatient operations. We used a t test, rank sum, chi-square, or Fisher's exact test to assess differences in outcomes between patients at baseline (BL) (10/2018-4/2019), during the first phase (P1) (10/2019-4/2020), second phase (P2) (5/2020-12/2020), and maintenance phase (M) (1/2021-10/2022). RESULTS The analysis included 9891 BL surgical patients (1470 with diabetes), 8815 P1 patients (1233 with diabetes), 10,401 P2 patients (1531 with diabetes) and 30,410 M patients (4265 with diabetes). The percentage of diabetic patients with median glucose levels >180 mg/dL during hospitalization decreased 32% during the initiative (BL, 20.1%; P1, 16.9%; P2, 12.1%; M, 13.7% [P < .001]). We also saw reductions in the percentages of diabetic patients with median glucose levels >180 mg/dL intraoperatively (BL, 34.0%; P1, 26.6%; P2, 23.9%; M, 20.3% [P < .001]) and in the postanesthesia care unit (BL, 36.0%; P1, 30.4%; P2, 28.5%; M, 25.8% [P < .001]). The percentage of patients screened for diabetes by hemoglobin A1C increased during the initiative (BL, 17.5%; P1, 52.5%; P2, 66.8%; M 74.5% [P < .001]). CONCLUSIONS Our successful initiative can be replicated in other hospitals to standardize and improve glycemic control among diabetic surgical patients.
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Affiliation(s)
- Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, M. D. Anderson Cancer Center, Houston, USA.
| | - Bryan M Fellman
- Department of Biostatistics, M. D. Anderson Cancer Center, Houston, USA
| | - Sally Raty
- Department of Anesthesiology, M. D. Anderson Cancer Center, Houston, USA
| | - Javier Lasala
- Department of Anesthesiology, M. D. Anderson Cancer Center, Houston, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, M. D. Anderson Cancer Center, Houston, USA
| | - Katherine E Cain
- Department of Pharmacy Clinical Programs, M. D. Anderson Cancer Center, Houston, USA
| | - Allison A Horner
- Department of Breast Surgical Oncology, M. D. Anderson Cancer Center, Houston, USA
| | - Morgan Bruno
- Department of Surgical Oncology, M. D. Anderson Cancer Center, Houston, USA
| | - Justin P Folloder
- Department of Surgical Oncology, M. D. Anderson Cancer Center, Houston, USA
| | - Susan L Knippel
- Department of Thoracic and Cardiovascular Surgery, M. D. Anderson Cancer Center, Houston, USA
| | - Vu Khanh
- Department of Internal Medicine, M. D. Anderson Cancer Center, Houston, USA
| | - Shannon Popovich
- Department of Perioperative Medicine, M. D. Anderson Cancer Center, Houston, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, M. D. Anderson Cancer Center, Houston, USA
| | - Conor Best
- Department of Endocrinology, M. D. Anderson Cancer Center, Houston, USA
| | - Sonali Thosani
- Department of Endocrinology, M. D. Anderson Cancer Center, Houston, USA
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Knisely A, Hinchcliff E, Fellman B, Mosley A, Lito K, Hull S, Westin SN, Sood AK, Schmeler KM, Taylor JS, Huang SY, Sheth RA, Lu KH, Jazaeri AA. Phase 1b study of intraperitoneal ipilimumab and nivolumab in patients with recurrent gynecologic malignancies with peritoneal carcinomatosis. Med 2024; 5:311-320.e3. [PMID: 38471508 PMCID: PMC11015975 DOI: 10.1016/j.medj.2024.02.003] [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: 12/04/2023] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Intravenous immune checkpoint blockade (ICB) has shown poor response rates in recurrent gynecologic malignancies. Intraperitoneal (i.p.) ICB may result in enhanced T cell activation and anti-tumor immunity. METHODS In this phase 1b study, registered at Clinical. TRIALS gov (NCT03508570), initial cohorts received i.p. nivolumab monotherapy, and subsequent cohorts received combination i.p. nivolumab every 2 weeks and i.p. ipilimumab every 6 weeks, guided by a Bayesian design. The primary objective was determination of the recommended phase 2 dose (RP2D) of the combination. Secondary outcomes included toxicity, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). FINDINGS The trial enrolled 23 patients: 18 with ovarian cancer, 2 with uterine cancer, and 3 with cervical cancer. Study evaluable patients (n = 16) received a median of 2 prior lines of therapy (range: 1-8). Partial response was observed in 2 patients (12.5%; 1 ovarian, 1 uterine), and complete response was observed in 1 patient (6.3%) with cervical cancer, for an ORR of 18.8% (95% confidence interval: 4.0%-45.6%). The median duration of response was 14.8 months (range: 4.1-20.8), with one complete response ongoing. Median PFS and OS were 2.7 months and not reached, respectively. Grade 3 or higher immune-related adverse events occurred in 2 (8.7%) patients. CONCLUSIONS i.p. administration of dual ICB is safe and demonstrated durable responses in a subset of patients with advanced gynecologic malignancy. The RP2D is 3 mg/kg i.p. nivolumab every 2 weeks plus 1 mg/kg ipilimumab every 6 weeks. FUNDING This work was funded by Bristol Myers Squibb (CA209-9C7), an MD Anderson Cancer Center Support Grant (CA016672), the Ovarian Cancer Moon Shots Program, the Emerson Collective Fund, and a T32 training grant (CA101642).
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Hinchcliff
- Division of Gynecologic Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Medicine, Chicago, IL, USA
| | - Bryan Fellman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann Mosley
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn Lito
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sara Hull
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anil K Sood
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven Y Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rahul A Sheth
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Knisely A, Iniesta MD, Marten CA, Chisholm G, Schmeler KM, Taylor JS. Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center. Am J Obstet Gynecol 2024:S0002-9378(24)00507-6. [PMID: 38599478 DOI: 10.1016/j.ajog.2024.03.043] [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] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy. OBJECTIVE To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center. STUDY DESIGN This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables. RESULTS Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003). CONCLUSION The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire A Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Knisely A, Iniesta MD, Batman S, Meyer LA, Soliman PT, Cain KE, Marten C, Chisholm G, Schmeler KM, Taylor JS, Fleming ND. Efficacy, safety, and feasibility of Apixaban for postoperative venous thromboembolism prophylaxis following open gynecologic cancer surgery at a comprehensive cancer center. Gynecol Oncol 2024:S0090-8258(24)00065-9. [PMID: 38368180 DOI: 10.1016/j.ygyno.2024.01.039] [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] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVES To evaluate safety, efficacy, and feasibility of apixaban for postoperative venous thromboembolism (VTE) prophylaxis following open gynecologic cancer surgery at a comprehensive cancer center. METHODS This retrospective, cohort study included patients with gynecologic cancer who underwent open surgery between 3/2021 and 3/2023 and received 28-day postoperative VTE prophylaxis. Patients on therapeutic anticoagulation preoperatively were excluded. Predictors of 90- and 30-day VTE and 30-day bleeding events were determined using multivariable logistic regression, adjusting for known confounders. RESULTS 452 patients were included in the cohort: 348 received apixaban and 104 received enoxaparin. Those who received enoxaparin were more likely to be American Society of Anesthesiologists class III/IV (compared to I/II) (p = 0.033), current or former smokers (p = 0.012) and have a higher BMI (p < 0.001), Charlson Comorbidity Index (p = 0.005), and age (p = 0.046). 30-day VTE rate was significantly lower in the apixaban group (0.6%) compared to the enoxaparin group (6.2%) (adjusted OR 0.13, 95% CI 0.03-0.56; p = 0.006). 90-day VTE rate was 2.7% and 6.2% in the apixaban and enoxaparin groups, respectively (adjusted OR 0.85, 95% CI 0.38-1.92; p = 0.704). Major bleeding complications (2.4% vs. 2.0%) and minor bleeding complications (0.9% vs. 3.0%) were similar in the apixaban and enoxaparin groups, respectively, on multivariate analyses. The median patient out of pocket cost was $10 (IQR 0.0-40.0) for apixaban and $20 (IQR 3.7-67.7) for enoxaparin (p = 0.001). CONCLUSIONS Our findings along with previously published data suggest that apixaban should be considered the standard of care for VTE prophylaxis in patients undergoing open surgery for gynecologic malignancies.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samantha Batman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine E Cain
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claire Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Basabe MS, Suki TS, Munsell MF, Iniesta MD, Garcia Lopez JE, Hillman RT, Cain K, Huepenbecker S, Mena G, Taylor JS, Ramirez PT, Meyer LA. Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement. Int J Gynecol Cancer 2023; 34:ijgc-2023-004948. [PMID: 38123191 DOI: 10.1136/ijgc-2023-004948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription. OBJECTIVE To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education. METHODS We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis. RESULTS The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99). CONCLUSION Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.
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Affiliation(s)
- M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina S Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Department of Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Szvalb AD, Marten C, Cain K, Taylor JS, Huang SY, Jiang Y, Raad II, Viola GM. Percutaneous nephrostomy catheter-related infections in patients with gynaecological cancers: a multidisciplinary algorithmic approach. J Hosp Infect 2023; 141:99-106. [PMID: 37696471 DOI: 10.1016/j.jhin.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Percutaneous nephrostomy catheters (PCNs) are commonly utilized in patients with gynaecological cancers due to intrinsic or extrinsic urinary obstruction. Unfortunately, these foreign medical devices may be associated with several infectious complications, including: pyelonephritis, renal abscess, and bacteraemia, which may lead to further delay of life-saving cancer therapy. AIM To evaluate the performance of our multidisciplinary algorithm for diagnosis and treatment of PCN-related infections (PCNIs) and identify risk factors for recurrent urinary device-related infections. METHODS Patients with gynaecological cancers having PCNIs were prospectively evaluated at our institution from July 2019 to September 2021. All patients were managed by our standardized algorithm and followed-up until reinfection or routine PCN exchange. FINDINGS Of 100 consecutive patients with PCNIs, 74 had adequate follow-up, and were analysed in three groups according to clinical outcome: reinfection with the same organism (26%), reinfection with a different organism (23%), and no reinfection (51%). Their median age was 54 years, and the most common cancers were cervical (65%), and ovarian (19%) with 53% being metastatic. The most frequently recovered micro-organisms were Pseudomonas (32%), Enterococcus (27%), and Escherichia (24%) species. The main risk factors for recurrent PCNI with the same organism were pelvic radiation therapy (P=0.032), pelvic fistulas (P=0.014), and a PCNI with the same pathogen within the previous year (P = 0.012). CONCLUSIONS Our algorithm has allowed for accurate diagnosis, staging, and treatment of and identification of several key risk factors for recurrent PCNIs. These results may lead to further preventive measures for these infections.
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Affiliation(s)
- A D Szvalb
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Marten
- Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K Cain
- Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J S Taylor
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Y Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Jiang
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - I I Raad
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G M Viola
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Taylor JS, Iniesta MD, Zorrilla-Vaca A, Cain KE, Lasala JD, Mena GE, Meyer LA, Ramirez PT. Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery. Am J Obstet Gynecol 2023:S0002-9378(23)00283-1. [PMID: 37150284 DOI: 10.1016/j.ajog.2023.04.045] [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] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/15/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Venous thromboembolism is a life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway that facilitates faster recovery from surgery. The rate of venous thromboembolism after gynecologic surgery on an ERAS program is unknown. OBJECTIVE Our objective was to evaluate the rate of venous thromboembolism within 30 days of gynecologic surgery on an ERAS pathway performed at a cancer center. STUDY DESIGN Data were collected prospectively on ERAS pathway gynecologic patients undergoing open (November 3, 2014 -March 31, 2021) and minimally invasive surgery (February 1, 2017 -March 31, 2021). Care was delivered at a tertiary cancer care center located in a large urban area. Patients undergoing emergency surgery or multi-specialty surgeries were excluded. Open surgery patients were to receive heparin prophylaxis prior to surgery, sequential compression devices during surgery and admission, and low molecular weight heparin prophylaxis during admission. If diagnosed with malignancy, patients were to receive extended venous thromboembolism prophylaxis for 28 days after surgery. For minimally invasive surgery, patients received only sequential compression devices during surgery and no heparin prophylaxis before or after surgery. Venous thromboembolism events were included if detected on imaging obtained for symptoms or for other indications. Descriptive statistics and bivariate statistical analyses were performed. RESULTS Of 3,329 patients, 1,519 (45.6%) patients underwent laparotomy, 1,452 (43.6%) laparoscopy, and 358 (10.8%) robotic surgery. The incidence of venous thromboembolism was 0.6% (N=21, 95% confidence interval [CI] 0.4%-0.9%) overall, 1.1% (N=16, 95% CI 0.6%-1.7%) in the open approach and 0.3% (N=5, 95% CI 0.3%-0.6%) in the minimally invasive approach (p=0.02). The incidence of venous thromboembolism among the 1,999 patients with malignancy was 0.9% overall (N=18, 95%CI 0.5%-1.4%), 1.4% (N=15, 95% CI 0.7%-2.2%) in the open approach and 0.3% (N=3, 95% CI 0.1%-0.9%) in the minimally invasive approach. The incidence of venous thromboembolism among the 1,165 patients with benign disease was 0.3% (N=3, 95% CI 0.1%-0.7%) overall, 0.3% (N=1, 95% CI 0.0%-1.7%) in the open approach and 0.2% (N=2, 95% CI 0.0%-0.9%) in the minimally invasive approach. CONCLUSIONS Venous thromboembolism rate among patients undergoing laparotomy and minimally invasive surgery on an ERAS pathway was <1%. This establishes a benchmark for the rate of venous thromboembolism following gynecologic surgery on an ERAS pathway performed at a cancer center.
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Affiliation(s)
- Jolyn S Taylor
- Department of Gynecological Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Maria D Iniesta
- Department of Gynecological Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine E Cain
- Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecological Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Obstetrics & Gynecology, Houston Methodist Hospital, Houston, TX, USA
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Huepenbecker S, Hillman RT, Iniesta MD, Chen T, Cain K, Mena G, Lasala J, Wang XS, Williams L, Taylor JS, Lu KH, Ramirez PT, Meyer LA. Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery. Int J Gynecol Cancer 2021; 31:1052-1060. [PMID: 34135073 DOI: 10.1136/ijgc-2021-002674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/17/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program. METHODS We compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan-Meier curves for symptom recovery. RESULTS Among 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts. CONCLUSIONS After implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.
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Affiliation(s)
- Sarah Huepenbecker
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tsun Chen
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Shelley Wang
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Loretta Williams
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karen H Lu
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Silverberg JI, Warshaw EM, Maibach HI, DeKoven JG, Taylor JS, Atwater AR, Sasseville D, Zug KA, Reeder MJ, Fowler JF, Pratt MD, Fransway AF, Zirwas MJ, Belsito DV, Marks JG, DeLeo VA. Hand eczema in children referred for patch testing: North American Contact Dermatitis Group Data, 2000-2016. Br J Dermatol 2021; 185:185-194. [PMID: 33454963 DOI: 10.1111/bjd.19818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Little is known about the aetiologies and relevant allergens in paediatric patients with hand eczema (HE). OBJECTIVES To characterize the aetiologies and determine the proportion of positive and currently relevant allergens in children/adolescents (age < 18 years) with HE referred for patch testing. METHODS A retrospective analysis (2000-2016) of North American Contact Dermatitis Group data was performed. RESULTS Of 1634 paediatric patients, 237 (14·5%) had involvement of the hands. Final physician diagnoses included allergic contact dermatitis (49·4%), atopic dermatitis (37·1%) and irritant contact dermatitis (16·9%). In multivariable logistic regression models, employment was the only association with increased odds of any HE or primary HE. Children with HE vs. those without HE had similar proportions of positive patch tests (56·1% vs. 61·7%; χ2 -test, P = 0·11). The five most common currently relevant allergens were nickel, methylisothiazolinone, propylene glycol, decyl glucoside and lanolin. In multivariable logistic regression models of the top 20 relevant allergens, HE was associated with significantly higher odds of currently relevant reactions to lanolin, quaternium-15, Compositae mix, thiuram mix, 2-mercaptobenzathiazole and colophony. The allergens with the highest mean significance-prevalence index number were methylisothiazolinone, carba mix, thiuram mix, nickel and methylchloroisothiazolinone/methylisothiazolinone. CONCLUSIONS Children with HE who were referred for patch testing had a high proportion of positive patch tests, which was similar to the proportion found in children without HE. Children with HE had a distinct and fairly narrow profile of currently relevant allergens.
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Affiliation(s)
- J I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Department of Dermatology, The Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - E M Warshaw
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, MN, USA.,Department of Dermatology, University of Minnesota, Minneapolis, MN, USA.,Department of Dermatology, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - H I Maibach
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - J G DeKoven
- Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
| | - J S Taylor
- Department of Dermatology, Cleveland Clinic, OH, USA
| | - A R Atwater
- Department of Dermatology, Duke University Medical Center, Durham, NC, USA
| | - D Sasseville
- Division of Dermatology, Montreal General Hospital, McGill University, Montreal, QC, Canada
| | - K A Zug
- Department of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - M J Reeder
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - J F Fowler
- Division of Dermatology, University of Louisville, KY, USA
| | - M D Pratt
- Division of Dermatology, University of Ottawa, ON, Canada
| | | | - M J Zirwas
- Department of Dermatology, Ohio State University, Columbus, OH, USA
| | - D V Belsito
- Department of Dermatology, Columbia University, New York, NY, USA
| | - J G Marks
- Department of Dermatology, Pennsylvania State University, State College, PA, USA
| | - V A DeLeo
- Department of Dermatology, Keck School of Medicine, Los Angeles, CA, USA
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10
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Hillman RT, Iniesta MD, Shi Q, Suki T, Chen T, Cain K, Williams L, Wang XS, Taylor JS, Mena G, Lasala J, Ramirez PT, Meyer LA. Longitudinal patient-reported outcomes and restrictive opioid prescribing after minimally invasive gynecologic surgery. Int J Gynecol Cancer 2020; 31:114-121. [DOI: 10.1136/ijgc-2020-002103] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 01/09/2023] Open
Abstract
ObjectiveTo determine post-discharge patient-reported symptoms before and after implementation of restrictive opioid prescribing among women undergoing minimally invasive gynecologic surgery.MethodsWe compared clinical outcomes and symptom burden among a cohort of 389 women undergoing minimally invasive gynecologic surgery at a single institution before and after implementation of a restrictive opioid prescribing quality improvement initiative in July 2018. Post-discharge symptom burdens were collected up to 42 days after discharge using the MD Anderson Symptom Inventory and analyzed using linear mixed effects models.ResultsThe majority of women included in this study were white non-smokers and the median age was 55 (range 23–83). Most women underwent hysterectomy (64%), had surgery for malignancy (71%), and were discharged from the hospital on the day of surgery (65%). Women in the restrictive opioid prescribing group had a median reduction in morphine equivalent dose prescribed at discharge of 83%, corresponding to a median reduction in 25 tablets of 5 mg oxycodone per person. There was no difference between opioid prescribing groups in either the rate of refill requests (P=1) or hospital re-admission (P=1) up to 30 days after discharge. After adjustment for co-variates, there was no statistically significant difference in post-discharge symptom burden including patient-reported pain (P=0.08), sleep (P=0.30), walking interference (P=0.64), activity interference (P=0.12), or affective interference (P=0.67). There was a trend toward less reported constiptation in the restrictive opioid prescribing group that did not reach statistical significance (P=0.05).ConclusionWe found that restrictive post-operative opioid prescribing was not associated with differences in longitudinal symptom burden among women undergoing minimally invasive gynecologic surgery. These results provide the most comprehensive picture to date of post-operative symptom recovery under different opioid prescribing approaches, lending additional support for existing recommendations to reduce opioid prescribing following gynecologic surgery.
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11
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Prescott LS, Taylor JS, Enbaya A, Marten CA, Myers KN, Meyer LA, Ramirez PT, Levenback CF, Bodurka DC, Schmeler KM. Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology. Gynecol Oncol 2019; 153:597-603. [PMID: 30872025 DOI: 10.1016/j.ygyno.2019.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery. METHODS We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost. RESULTS We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period. CONCLUSIONS Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.
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Affiliation(s)
- Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ahmed Enbaya
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Claire A Marten
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Keith N Myers
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Charles F Levenback
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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12
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 365] [Impact Index Per Article: 73.0] [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: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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13
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Taylor JS, Zhang N, Rajan SS, Chavez-MacGregor M, Zhao H, Niu J, Meyer LA, Ramondetta LM, Bodurka DC, Lairson DR, Giordano SH. How we use hospice: Hospice enrollment patterns and costs in elderly ovarian cancer patients. Gynecol Oncol 2019; 152:452-458. [PMID: 30876488 PMCID: PMC7152986 DOI: 10.1016/j.ygyno.2018.10.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe disparities in patterns of hospice use and end-of-life costs among ovarian cancer patients. METHODS Using Texas Cancer Registry-Medicare data, ovarian cancer patients deceased 2005-2012 with >12 months of continuous Medicare coverage before death were included. Descriptive statistics and multivariable logistic regressions were used to evaluate patterns of hospice use. Cost and resource utilization was obtained from Medicare claims and analyzed using a non-parametric Mann-Whitney test. RESULTS 2331 patients were assessed: 1788 (77%) white, 359 (15%) Hispanic, 158 (7%) black and 26 (1%) other. 1756 (75%) enrolled in hospice prior to death but only 1580 (68%) died with hospice. 176 (10%) of 1756 patients unenrolled and died without hospice. 346 (20%) unenrolled from hospice multiple times. From 2008 to 2012, patients were less likely to unenroll from hospice prior to death. Black patients were more likely to unenroll from hospice prior to death (OR 2.07 [1.15-3.73]; p = 0.02) compared to white patients. The median amount paid by Medicare during the last six months of life was $38,530 for those in hospice compared to $49,942 if never enrolled in hospice (p < 0.0001) and was higher for black and Hispanic patients compared to white patients. 30% hospice unenrolled patients and 40% multiply enrolled hospice patients received at least one life extending or invasive care procedure following unenrollment from hospice. CONCLUSION Recently, more patients remain enrolled in hospice, but black patients have a higher risk of unenrollment. Hospice enrollment was associated with lower costs as long as a patient did not unenroll from hospice.
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Affiliation(s)
- Jolyn S Taylor
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Ning Zhang
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Suja S Rajan
- The University of Texas School of Public Health, Department of Management, Policy Sciences & Community Health, United States of America
| | - Mariana Chavez-MacGregor
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Hui Zhao
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Jiangong Niu
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Larissa A Meyer
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Lois M Ramondetta
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Diane C Bodurka
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - David R Lairson
- The University of Texas School of Public Health, Department of Management, Policy Sciences & Community Health, United States of America
| | - Sharon H Giordano
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America.
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14
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Taylor JS, He W, Harrison R, Zhao H, Sun CC, Lu KH, Giordano SH, Meyer LA. Disparities in treatment and survival among elderly ovarian cancer patients. Gynecol Oncol 2018; 151:269-274. [PMID: 30253875 DOI: 10.1016/j.ygyno.2018.08.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 05/28/2018] [Revised: 08/25/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine correlation between race and receipt of optimal treatment for ovarian cancer and the impact of this on overall survival. METHODS Using SEER-linked Medicare database, women 66 and older diagnosed with advanced ovarian cancer between 2002 and 2011 were identified. Patients with unclear histology, diagnosed on autopsy and without Medicare Parts A and B were excluded. We used Chi-square test for categorical variables, F test for continuous variables, and multivariable logistic regression to identify characteristics associated with receipt of surgery and chemotherapy. Kaplan-Meier analysis was used to compare overall survival rates. Cox Proportional Hazards regression was performed to identify factors associated with 5-year survival. RESULTS 9016 ovarian cancer patients were included. 2638 had primary chemotherapy, 4854 had primary surgery, and 1524 had no treatment. 7653 (84.9%) were white, 572 (6.3%) black, 479 (5.3%) Hispanic, and 312 (3.5%) were of other race/ethnicity. More white patients (57.2%) received both chemotherapy and surgery compared to black (39.9%), Hispanic (48.9%), or other (54.2%) (p < .001). Receipt of either only surgery or chemotherapy, or receipt of neither, resulted in higher risk of death when compared to receipt of both. On multivariable analysis, black (OR 0.58 [0.46-0.73]) and Hispanic (0.69 [0.54-0.88]) patients were less likely to receive both chemotherapy and surgery. Being of black race was significantly correlated with worse overall survival [HR 1.13 (1.03-1.23); p = .02]. CONCLUSIONS Non-white women are less likely to receive the standard of care treatment for ovarian cancer and more likely to die from their disease than white women.
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Affiliation(s)
- Jolyn S Taylor
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Weiguo He
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Ross Harrison
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Hui Zhao
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Charlotte C Sun
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Karen H Lu
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America
| | - Sharon H Giordano
- The University of Texas MD Anderson Cancer Center, Department of Health Services Research, United States of America
| | - Larissa A Meyer
- The University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine, United States of America.
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15
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Taylor JS, Marten CA, Potts KA, Cloutier LM, Cain KE, Fenton SL, Tatum TN, James DA, Myers KN, Hubbs CA, Burzawa JK, Vachhani S, Nick AM, Meyer LA, Graviss LS, Ware KM, Park AK, Aloia TA, Bodurka DC, Levenback CF, Schmeler KM. What Is the Real Rate of Surgical Site Infection? J Oncol Pract 2017; 12:e878-e883. [PMID: 27460495 DOI: 10.1200/jop.2016.011759] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. METHODS We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fisher's exact test. RESULTS Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). CONCLUSION There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.
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Affiliation(s)
- Jolyn S Taylor
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire A Marten
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Lynn M Cloutier
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Shauna L Fenton
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tara N Tatum
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Deepthi A James
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keith N Myers
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cheryl A Hubbs
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Shital Vachhani
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alpa M Nick
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Linda S Graviss
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathy M Ware
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anne K Park
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane C Bodurka
- The University of Texas MD Anderson Cancer Center, Houston, TX
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16
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Taylor JS, Rajan SS, Zhang N, Meyer LA, Ramondetta LM, Bodurka DC, Lairson DR, Giordano SH. End-of-Life Racial and Ethnic Disparities Among Patients With Ovarian Cancer. J Clin Oncol 2017; 35:1829-1835. [PMID: 28388292 DOI: 10.1200/jco.2016.70.2894] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To assess disparities in end-of-life care among patients with ovarian cancer. Patients and Methods Using Texas Cancer Registry-Medicare data, we assessed patients with ovarian cancer deceased in 2000 to 2012 with at least 13 months of continuous Medicare coverage before death. Descriptive statistics and multivariate logistic regressions were conducted to evaluate end-of-life care, including chemotherapy in the final 14 days of life, intensive care unit (ICU) admission in the final 30 days of life, more than one emergency room (ER) or hospital admission in the final 30 days of life, invasive or life-extending procedures in the final 30 days of life, enrollment in hospice, enrollment in hospice during the final 3 days of life, and enrollment in hospice while not hospitalized. Results A total of 3,666 patients were assessed: 2,819 (77%) were white, 553 (15%) Hispanic, 256 (7%) black, and 38 (1%) other. A total of 2,642 (72%) enrolled in hospice before death, but only 2,344 (64%) died while enrolled. The median hospice enrollment duration was 20 days. In the final 30 days of life, 381 (10%) had more than one ER visit, 505 (14%) more than one hospital admission, 593 (16%) ICU admission, 848 (23%) invasive care, and 418 (11%) life-extending care. In the final 14 days of life, 357 (10%) received chemotherapy. Several outcomes differed for minorities compared with white patients. Hispanic and black patients were less likely to enroll and die in hospice (black odds ratio [OR], 0.66; 95% CI, 0.50 to 0.88; P = .004; Hispanic OR, 0.76; 95% CI, 0.61 to 0.94; P = .01). Hispanic patients were more likely to be admitted to an ICU (OR, 1.37; 95% CI, 1.05 to 1.78; P = .02), and black patients were more likely to have more than one ER visit (OR, 2.20; 95% CI, 1.53 to 3.16; P < .001) and receive a life-extending procedure (OR, 2.13; 95% CI, 1.49 to 3.04; P < .001). Conclusion We found being a minority was associated with receiving intensive and invasive end-of-life care among patients with ovarian cancer.
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Affiliation(s)
- Jolyn S Taylor
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Suja S Rajan
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Ning Zhang
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Larissa A Meyer
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Lois M Ramondetta
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Diane C Bodurka
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - David R Lairson
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Sharon H Giordano
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
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Geynisman-Tan JM, Taylor JS, Edersheim T, Taubel D. All the darkness we don't see. Am J Obstet Gynecol 2017; 216:135.e1-135.e5. [PMID: 27664496 DOI: 10.1016/j.ajog.2016.09.088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/31/2016] [Accepted: 09/14/2016] [Indexed: 12/01/2022]
Abstract
Trafficking of women and children for sexual exploitation is the fastest growing criminal enterprise in the world. This is a public health crisis; as physicians who have direct contact with victims, we have a unique opportunity to intervene. The authors developed a specialty clinic for survivors of sex trafficking in 2013 at an academic medical center in New York City. Twenty of the 24 women seen in the Survivor Clinic saw a physician while being trafficked. Sex trafficking violates basic human rights, which include the rights to bodily integrity, dignity, health, and freedom from violence and torture. The stories of the patients seen in the Survivor Clinic bear witness to the health consequences of commercial sexual exploitation and reinforce the previous literature on the rates of physical and psychologic harms of trafficking. Health consequences of trafficking include traumatic brain injuries, drug addiction, depression, and neglect of chronic health conditions. All physicians, but gynecologists especially, need more education about the prevalence and dynamics of trafficking and how to assess and intervene on behalf of survivors.
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Affiliation(s)
- Julia M Geynisman-Tan
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY
| | - Jolyn S Taylor
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY; Division of Gynecologic Oncology, MD Anderson Cancer Center, Houston, TX
| | - Terri Edersheim
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY
| | - Debra Taubel
- Department of Clinical Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY
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Taylor JS, Marten CA, Munsell MF, Sun CC, Potts KA, Burzawa JK, Nick AM, Meyer LA, Myers K, Bodurka DC, Aloia TA, Levenback CF, Lairson DR, Schmeler KM. The DISINFECT Initiative: Decreasing the Incidence of Surgical INFECTions in Gynecologic Oncology. Ann Surg Oncol 2016; 24:362-368. [PMID: 27573526 DOI: 10.1245/s10434-016-5517-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) lead to increased patient morbidity and healthcare costs. Our objective was to decrease the SSI rate following gynecologic surgery. METHODS Adult patients undergoing abdominal surgery for gynecologic malignancy or benign disease received the following: patient education; preoperative antibacterial soap; appropriate antibiotic prophylaxis; change of gloves and use of clean instruments at surgical closure; surgical dressing for 48 h; and a post-discharge phone call. The baseline SSI rate was determined retrospectively (1 April 2014-30 June 2014), while the post-intervention SSI rate was determined prospectively (16 February 2015-15 October 2015). The main outcome was the overall SSI rate with secondary outcomes, including the rate of superficial, deep, incisional and organ space infection, as well as the cost effectiveness of the bundle. RESULTS A total of 232 baseline and 555 post-intervention patients were included in the study. No differences were observed between the baseline and post-intervention groups with regard to median body mass index (BMI), surgical approach, receipt of preoperative chemotherapy and/or radiation therapy, and cases including bowel surgery. Overall, the SSI rate decreased significantly from baseline [12.5 %] to post-intervention [7.4 %] (odds ratio [OR] 0.56, 90 % confidence interval [CI] 0.37-0.85; p = 0.01). A 40 % decrease was noted in the rate of superficial and deep infections (9.5 vs. 5.9 %; OR 0.60, 90 % CI 0.38-0.97; p = 0.04) and SSIs after open surgery (21.4 vs. 13.2 %; OR 0.56, 90 % CI 0.34-0.92; p = 0.03). The estimated cost of the intervention was $19.26/case and the net total amount saved during the post-intervention period was $65,625 month. CONCLUSIONS This bundled intervention led to a significant decrease in the overall SSI rate and was cost effective. The largest decreases in SSIs were in incisional infections and following open surgery.
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Affiliation(s)
- Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claire A Marten
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kimberly A Potts
- Department of Perioperative Services, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer K Burzawa
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alpa M Nick
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith Myers
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diane C Bodurka
- Department of Clinical Education, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles F Levenback
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David R Lairson
- Department of Management and Policy Sciences, The University of Texas School of Public Health, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Prescott LS, Taylor JS, Lopez-Olivo MA, Munsell MF, VonVille HM, Lairson DR, Bodurka DC. How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology. Cancer Treat Rev 2016; 46:1-8. [PMID: 27046422 DOI: 10.1016/j.ctrv.2016.03.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. METHODS A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. RESULTS Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49-0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32-3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. CONCLUSION Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.
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Affiliation(s)
- Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria A Lopez-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Helena M VonVille
- The University of Texas School of Public Health, Houston, TX 77030, USA
| | - David R Lairson
- The University of Texas School of Public Health, Houston, TX 77030, USA
| | - Diane C Bodurka
- Department of Clinical Education, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Taylor JS, Brown AJ, Prescott LS, Sun CC, Ramondetta LM, Bodurka DC. Dying well: How equal is end of life care among gynecologic oncology patients? Gynecol Oncol 2016; 140:295-300. [PMID: 26706661 PMCID: PMC4724523 DOI: 10.1016/j.ygyno.2015.12.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 09/22/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify disparities in utilization of end of life (EoL) resources by gynecologic oncology (GO) patients. METHODS This retrospective analysis of the medical records of GO patients treated 1/2007-12/2011 and deceased 1/2012-8/2014 evaluated patient demographics, disease characteristics, and utilization of EoL resources. Chi-square, Fisher's exact test, Mann Whitney and Kruskal-Wallis tests were used for statistical analysis. RESULTS Of 189 patients analyzed, 113 (60%) were white, 38 (20%) Hispanic, 31 (16%) black, and seven (4%) Asian. Ninety-five (48%) had ovarian cancer, 51 (26%) uterine, 47 (23%) cervical, seven (3%) vulvar/vaginal. In the last 30days of life (DoL), 18 (10%) had multiple hospital admissions, 10 (5%) admitted to the Intensive Care Unit (ICU), 30 (16%) multiple Emergency Room (ER) visits, 45 (24%) received aggressive medical care and eight (4%) received chemotherapy in the final 14 DoL. Furthermore, 54 (29%) had no Supportive Care referral and 29 (15%) no hospice referral. Only 46 (24%) had a Medical Power of Attorney (PoA) or Living Will (LW) on file. Non-white race was associated with increased odds of dying without hospice (OR 3.07; 95%CI [1.27, 2.46], p=0.013). However, non-white patients who enrolled in hospice did so earlier than white patients (42 v. 27days before death, p=0.054). Non-white patients were also significantly less likely to have PoA/LW documentation (24% v. 76%, p=0.009) even if enrolled in hospice (12% v. 31%, p=0.007). CONCLUSIONS Significant racial disparities in hospice enrollment and PoA/LW documentation were seen in GO patients. This warrants further study to identify barriers to use of EoL resources.
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Affiliation(s)
- Jolyn S Taylor
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Alaina J Brown
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lauren S Prescott
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Charlotte C Sun
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lois M Ramondetta
- The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Diane C Bodurka
- The Department of Medical Education, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Prescott LS, Dickens AS, Guerra SL, Tanha JM, Phillips DG, Patel KT, Umberson KM, Lozano MA, Lowe KB, Brown AJ, Taylor JS, Soliman PT, Garcia EA, Levenback CF, Bodurka DC. Fighting cancer together: Development and implementation of shared medical appointments to standardize and improve chemotherapy education. Gynecol Oncol 2015; 140:114-9. [PMID: 26549108 DOI: 10.1016/j.ygyno.2015.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. METHODS We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. RESULTS From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. CONCLUSIONS This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted.
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Affiliation(s)
- Lauren S Prescott
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Andrea S Dickens
- Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sandra L Guerra
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jila M Tanha
- The Learning Center, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Desiree G Phillips
- Patient Education, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Katherine T Patel
- Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Katie M Umberson
- Clinical Operations, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Miguel A Lozano
- Performance Improvement, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kathryn B Lowe
- Department of Supportive Medicine, Memorial Hermann Healthcare System, Houston, TX, United States
| | - Alaina J Brown
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jolyn S Taylor
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pamela T Soliman
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Elizabeth A Garcia
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Charles F Levenback
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Diane C Bodurka
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Brown AJ, Sun CC, Prescott LS, Taylor JS, Ramondetta LM, Bodurka DC. Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients. Gynecol Oncol 2014; 135:244-8. [PMID: 25192878 DOI: 10.1016/j.ygyno.2014.08.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/24/2014] [Accepted: 08/27/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. METHODS Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007-2011 were identified. Statistical analyses included Wilcoxon-Mann-Whitney, Chi-square analysis, and multivariate analysis. RESULTS 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p=<0.001), with a median hospice stay of 18days before death. Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378days prior to death, respectively. CONCLUSIONS Many ovarian cancer patients underwent some form of aggressive medical care in the last 30days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.
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Affiliation(s)
- Alaina J Brown
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diane C Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Frey MK, Taylor JS, Pauk SJ, Hughes D, Turbendian HK, Sapra KJ, Holcomb K. Knowledge of Lynch syndrome among obstetrician/gynecologists and general surgeons. Int J Gynaecol Obstet 2014; 126:161-4. [PMID: 24950908 DOI: 10.1016/j.ijgo.2014.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 02/06/2014] [Accepted: 04/20/2014] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine comfort and knowledge among obstetrician/gynecologists and general surgeons regarding recommendations for cancer screening for women with Lynch syndrome. METHODS A questionnaire on Lynch syndrome was administered to all obstetrician/gynecologists and general surgeons at a hospital in New York, USA. RESULTS Fifty obstetrician/gynecologists and 62 general surgeons completed the survey (67% response rate). Physicians were more comfortable counseling on colon cancer than endometrial cancer screening (51% vs 28%; P<0.001). Obstetrician/gynecologists were more comfortable than general surgeons counseling patients on endometrial cancer screening (36% vs 21%; P=0.090) but less comfortable counseling patients on colon cancer screening (36% vs 63%; P=0.008). There was no significant difference between the specialties in the number of knowledge-based questions answered correctly. Furthermore, there was no correlation between a physician's perceived knowledge and number of correct answers. CONCLUSION Most physicians did not report being comfortable counseling about recommendations for endometrial cancer screening. While obstetrician/gynecologists reported greater comfort than general surgeons, we found no significant difference in disease knowledge between the groups. Because appropriate cancer screening can improve the outcomes of patients with Lynch syndrome, physicians must be knowledgeable and comfortable with screening recommendations for both endometrial and colon cancer, regardless of clinical specialty.
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Affiliation(s)
- Melissa K Frey
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New York University Langone Medical Center, NY, USA.
| | - Jolyn S Taylor
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, NY, USA
| | | | - Duncan Hughes
- Department of General Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, NY, USA
| | - Harma K Turbendian
- Department of General Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, NY, USA
| | - Katherine J Sapra
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, USA
| | - Kevin Holcomb
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, NY, USA
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Taylor JS, Panico V, Caputo T, Gerber D, Gupta D, Pirog E, Holcomb K. Clinical outcomes of patients with adenocarcinoma in situ of the cervix treated by conization. EUR J GYNAECOL ONCOL 2014; 35:641-645. [PMID: 25556268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe the clinical outcomes of histologically confirmed adenocarcinoma in situ (AIS) of the cervix treated with cervical conization. MATERIALS AND METHODS A retrospective chart review of patients with histologically confirmed AIS from July 1998 to February 2011 included 52 patients. The rates of residual disease in subsequent excisions, the clinical recurrence rate, the average disease-free interval, and risk of progression to adenocarcinoma were described. The clinical outcomes of patients treated with cold knife cone (CKC) and loop electrosurgical excisional procedure (LEEP) were compared. RESULTS Fifteen LEEPs and 37 CKC procedures were performed as initial treatment and 26 patients (50%) had positive margins. There was no significant difference in rate of positive margins between LEEP and CKC (40% vs. 54%, respectively. p = 0.55). LEEPs and CKCs resulted in similar volumes of cervical tissue resected (4.98 cm3 vs. 5.04 cm3, p = 0.40). Of patients with positive margins, ten underwent immediate hysterectomy, six underwent a second cone biopsy, seven were managed expectantly, and four were lost to follow up. Residual AIS was found in 47% (eight of 17) of repeat cone biopsy and hysterectomy specimens performed for positive cone margins. Of the 26 patients with negative cone margins, no residual or recurrent disease was found after an average follow-up of 32 months. CONCLUSIONS A positive surgical margin was associated with residual disease in 47% of patients with AIS treated with conization. No patient with negative cone margins had recurrent or progressive disease. Cervical conization with negative margins appears to be a safe treatment option for patients with AIS but requires further investigation. CKC and LEEP were equally efficacious treatments in our study population.
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Affiliation(s)
- J S Taylor
- New York Presbyterian Weil Cornell Department of Obstetrics and Gynecology, New York, NY, USA.
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Brown LJ, Rosatte RC, Fehlner-Gardiner C, Bachmann P, Ellison JA, Jackson FR, Taylor JS, Davies C, Donovan D. Oral vaccination and protection of red foxes (Vulpes vulpes) against rabies using ONRAB, an adenovirus-rabies recombinant vaccine. Vaccine 2013; 32:984-9. [PMID: 24374501 DOI: 10.1016/j.vaccine.2013.12.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/29/2013] [Accepted: 12/10/2013] [Indexed: 12/19/2022]
Abstract
Twenty-seven red foxes (Vulpes vulpes) were each offered a bait containing ONRAB, a recombinant oral rabies vaccine that uses a human adenovirus vector to express the immunogenic rabies virus glycoprotein; 10 controls received no vaccine baits. Serum samples collected from all foxes before treatment, and each week post-treatment for 16 weeks, were tested for the presence of rabies virus neutralizing antibody (RVNA). In the bait group, a fox was considered a responder to vaccination if serum samples from 3 or more consecutive weeks had RVNA ≥0.5 IU/ml. Using this criterion, 79% of adult foxes (11/14) and 46% of juveniles (6/13) responded to vaccination with ONRAB. Serum RVNA of adults first tested positive (≥0.5 IU/ml) between weeks 1 and 3, about 4 weeks earlier than in juveniles. Adults also responded with higher levels of RVNA and these levels were maintained longer. Serum samples from juveniles tested positive for 1-4 consecutive weeks; in adults the range was 2-15 weeks, with almost half of adults maintaining titres above 0.5 IU/ml for 9 or more consecutive weeks. Based on the kinetics of the antibody response to ONRAB, the best time to sample sera of wild adult foxes for evidence of vaccination is 7-11 weeks following bait distribution. Thirty-four foxes (25 ONRAB, 9 controls) were challenged with vulpine street virus 547 days post-vaccination. All controls developed rabies whereas eight of 13 adult vaccinates (62%) and four of 12 juvenile vaccinates (33%) survived. All foxes classed as non-responders to vaccination developed rabies. Of foxes considered responders to vaccination, 80% of adults (8/10) and 67% of juveniles (4/6) survived challenge. The duration of immunity conferred to foxes would appear adequate for bi-annual and annual bait distribution schedules as vaccinates were challenged 1.5 years post-vaccination.
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Affiliation(s)
- L J Brown
- Wildlife Research and Monitoring Section, Ontario Ministry of Natural Resources, Trent University, DNA Building, 2140 East Bank Drive, Peterborough, Ontario K9J 7B8, Canada.
| | - R C Rosatte
- Wildlife Research and Monitoring Section, Ontario Ministry of Natural Resources, Trent University, DNA Building, 2140 East Bank Drive, Peterborough, Ontario K9J 7B8, Canada
| | - C Fehlner-Gardiner
- Centre of Expertise for Rabies, Canadian Food Inspection Agency, 3851 Fallowfield Road, P.O. Box 11300, Station H, Ottawa, Ontario K2H 8P9, Canada
| | - P Bachmann
- Wildlife Research and Monitoring Section, Ontario Ministry of Natural Resources, Trent University, DNA Building, 2140 East Bank Drive, Peterborough, Ontario K9J 7B8, Canada
| | - J A Ellison
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop G-33, Atlanta, GA 30329, USA
| | - F R Jackson
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop G-33, Atlanta, GA 30329, USA
| | - J S Taylor
- Wildlife Research and Monitoring Section, Ontario Ministry of Natural Resources, Trent University, DNA Building, 2140 East Bank Drive, Peterborough, Ontario K9J 7B8, Canada
| | - C Davies
- Wildlife Research and Monitoring Section, Ontario Ministry of Natural Resources, Trent University, DNA Building, 2140 East Bank Drive, Peterborough, Ontario K9J 7B8, Canada
| | - D Donovan
- Wildlife Research and Monitoring Section, Ontario Ministry of Natural Resources, Trent University, DNA Building, 2140 East Bank Drive, Peterborough, Ontario K9J 7B8, Canada
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Abstract
In this article the principles of human locomotion are revisited and reviewed. This has been done in the framework of two European projects, where the elicitation of these mechanisms inform, on the one hand, the design of artificial bipedal walkers (H2R), and on the other hand the design of lower limb exoskeletons (BETTER) for rehabilitation of gait in post-stroke patients. Passive dynamics emerging from the morphology of the human musculoskeletal system, reflexes as stabilization mechanisms, modular control of movement as well as supra-spinal control of gait are reviewed to get insight on how these mechanisms can be used to explain human locomotion.
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Taylor JS, Frey MK, Fatemi D, Robinson S. Burkitt's lymphoma presenting as ovarian torsion. Am J Obstet Gynecol 2012; 207:e4-6. [PMID: 22742781 DOI: 10.1016/j.ajog.2012.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 05/24/2012] [Accepted: 05/28/2012] [Indexed: 11/28/2022]
Abstract
A 33 year old woman with human immune deficiency virus presented to the emergency room for the evaluation of abdominal pain. At laparotomy, she was found to have bilateral ovarian torsion. On final pathology, bilateral ovaries were found to be involved with Burkitt's lymphoma.
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Affiliation(s)
- Jolyn S Taylor
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical Center, NY 10021, USA.
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Frey MK, Biewald MA, Worley MJ, Taylor JS, Lin SN, Holcomb K. Lynch Syndrome: Awareness among Medical Students at a United States Medical School. Curr Womens Health Rev 2012; 8:242-247. [PMID: 23316129 PMCID: PMC3537120 DOI: 10.2174/157340412803760667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 07/15/2012] [Accepted: 07/18/2012] [Indexed: 11/22/2022]
Abstract
INTRODUCTION: Lynch syndrome was first described in the 1950s however until recently it was rarely included in medical school curricula. As a result, many practicing physicians have limited exposure, potentially contributing to significant under diagnosis. As identification of Lynch syndrome prior to malignancy allows for intensified screening, prophylactic surgery and improved patient outcomes, all physicians should be aware of the characteristics of affected families. We aim to determine the overall level of awareness of Lynch syndrome among medical students at an American medical school. METHODS: A voluntary and anonymous questionnaire was delivered to students at an American medical school. The survey instrument assessed the respondent's perceived knowledge regarding the genetics and recommended screening for carriers of Lynch syndrome mutations. RESULTS: The questionnaire was distributed to the entire student body (405 students) with a response rate of 50%. Fifty-nine percent of students reported that they had learned about Lynch syndrome; 27% of first year students, 44% of second year students; 90% of third year students and 100% of fourth year students. Of the students familiar with Lynch syndrome, the reported knowledge of the underlying genetics was 46%, available genetic screening, 18%, criteria used to screen for the syndrome, 24%, recommendations for colon screening, 31% and recommendations for endometrial cancer screening, 17%. CONCLUSION: The majority of medical students surveyed had been exposed to Lynch syndrome and awareness increased over each year of education. Significantly more students were aware of recommendations for colon cancer screening than endometrial cancer screening (32% versus 17%, p = 0.01). Studies of the natural history of Lynch syndrome indicate that affected women are more likely to present with endometrial cancer than colon cancer and while there are no prospective data proving the efficacy of endometrial cancer screening in this high-risk population, the endometrium is easily accessible and can be sampled using simple office techniques. In addition, prophylactic hysterectomy and bilateral salpingo-oophorectomy are reasonable risk reducing interventions for the prevention of both uterine and ovarian cancer. Our findings suggest that increased emphasis must be placed on teaching the gynecologic manifestations of Lynch Syndrome in order to avoid the misconception that it is simply a colon cancer syndrome.
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Affiliation(s)
- Melissa K Frey
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York 10065, USA
| | - Mollie A Biewald
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York 10065, USA
| | - Michael J Worley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts 02115, USA
| | - Jolyn S Taylor
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York 10065, USA
| | - Stephanie N Lin
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York 10065, USA
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology New York Presbyterian Hospital, Weill Cornell Medical Center, New York New York, 10065, USA
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Glenzer SH, MacGowan BJ, Meezan NB, Adams PA, Alfonso JB, Alger ET, Alherz Z, Alvarez LF, Alvarez SS, Amick PV, Andersson KS, Andrews SD, Antonini GJ, Arnold PA, Atkinson DP, Auyang L, Azevedo SG, Balaoing BNM, Baltz JA, Barbosa F, Bardsley GW, Barker DA, Barnes AI, Baron A, Beeler RG, Beeman BV, Belk LR, Bell JC, Bell PM, Berger RL, Bergonia MA, Bernardez LJ, Berzins LV, Bettenhausen RC, Bezerides L, Bhandarkar SD, Bishop CL, Bond EJ, Bopp DR, Borgman JA, Bower JR, Bowers GA, Bowers MW, Boyle DT, Bradley DK, Bragg JL, Braucht J, Brinkerhoff DL, Browning DF, Brunton GK, Burkhart SC, Burns SR, Burns KE, Burr B, Burrows LM, Butlin RK, Cahayag NJ, Callahan DA, Cardinale PS, Carey RW, Carlson JW, Casey AD, Castro C, Celeste JR, Chakicherla AY, Chambers FW, Chan C, Chandrasekaran H, Chang C, Chapman RF, Charron K, Chen Y, Christensen MJ, Churby AJ, Clancy TJ, Cline BD, Clowdus LC, Cocherell DG, Coffield FE, Cohen SJ, Costa RL, Cox JR, Curnow GM, Dailey MJ, Danforth PM, Darbee R, Datte PS, Davis JA, Deis GA, Demaret RD, Dewald EL, Di Nicola P, Di Nicola JM, Divol L, Dixit S, Dobson DB, Doppner T, Driscoll JD, Dugorepec J, Duncan JJ, Dupuy PC, Dzenitis EG, Eckart MJ, Edson SL, Edwards GJ, Edwards MJ, Edwards OD, Edwards PW, Ellefson JC, Ellerbee CH, Erbert GV, Estes CM, Fabyan WJ, Fallejo RN, Fedorov M, Felker B, Fink JT, Finney MD, Finnie LF, Fischer MJ, Fisher JM, Fishler BT, Florio JW, Forsman A, Foxworthy CB, Franks RM, Frazier T, Frieder G, Fung T, Gawinski GN, Gibson CR, Giraldez E, Glenn SM, Golick BP, Gonzales H, Gonzales SA, Gonzalez MJ, Griffin KL, Grippen J, Gross SM, Gschweng PH, Gururangan G, Gu K, Haan SW, Hahn SR, Haid BJ, Hamblen JE, Hammel BA, Hamza AV, Hardy DL, Hart DR, Hartley RG, Haynam CA, Heestand GM, Hermann MR, Hermes GL, Hey DS, Hibbard RL, Hicks DG, Hinkel DE, Hipple DL, Hitchcock JD, Hodtwalker DL, Holder JP, Hollis JD, Holtmeier GM, Huber SR, Huey AW, Hulsey DN, Hunter SL, Huppler TR, Hutton MS, Izumi N, Jackson JL, Jackson MA, Jancaitis KS, Jedlovec DR, Johnson B, Johnson MC, Johnson T, Johnston MP, Jones OS, Kalantar DH, Kamperschroer JH, Kauffman RL, Keating GA, Kegelmeyer LM, Kenitzer SL, Kimbrough JR, King K, Kirkwood RK, Klingmann JL, Knittel KM, Kohut TR, Koka KG, Kramer SW, Krammen JE, Krauter KG, Krauter GW, Krieger EK, Kroll JJ, La Fortune KN, Lagin LJ, Lakamsani VK, Landen OL, Lane SW, Langdon AB, Langer SH, Lao N, Larson DW, Latray D, Lau GT, Le Pape S, Lechleiter BL, Lee Y, Lee TL, Li J, Liebman JA, Lindl JD, Locke SF, Loey HK, London RA, Lopez FJ, Lord DM, Lowe-Webb RR, Lown JG, Ludwigsen AP, Lum NW, Lyons RR, Ma T, MacKinnon AJ, Magat MD, Maloy DT, Malsbury TN, Markham G, Marquez RM, Marsh AA, Marshall CD, Marshall SR, Maslennikov IL, Mathisen DG, Mauger GJ, Mauvais MY, McBride JA, McCarville T, McCloud JB, McGrew A, McHale B, MacPhee AG, Meeker JF, Merill JS, Mertens EP, Michel PA, Miller MG, Mills T, Milovich JL, Miramontes R, Montesanti RC, Montoya MM, Moody J, Moody JD, Moreno KA, Morris J, Morriston KM, Nelson JR, Neto M, Neumann JD, Ng E, Ngo QM, Olejniczak BL, Olson RE, Orsi NL, Owens MW, Padilla EH, Pannell TM, Parham TG, Patterson RW, Pavel G, Prasad RR, Pendlton D, Penko FA, Pepmeier BL, Petersen DE, Phillips TW, Pigg D, Piston KW, Pletcher KD, Powell CL, Radousky HB, Raimondi BS, Ralph JE, Rampke RL, Reed RK, Reid WA, Rekow VV, Reynolds JL, Rhodes JJ, Richardson MJ, Rinnert RJ, Riordan BP, Rivenes AS, Rivera AT, Roberts CJ, Robinson JA, Robinson RB, Robison SR, Rodriguez OR, Rogers SP, Rosen MD, Ross GF, Runkel M, Runtal AS, Sacks RA, Sailors SF, Salmon JT, Salmonson JD, Saunders RL, Schaffer JR, Schindler TM, Schmitt MJ, Schneider MB, Segraves KS, Shaw MJ, Sheldrick ME, Shelton RT, Shiflett MK, Shiromizu SJ, Shor M, Silva LL, Silva SA, Skulina KM, Smauley DA, Smith BE, Smith LK, Solomon AL, Sommer S, Soto JG, Spafford NI, Speck DE, Springer PT, Stadermann M, Stanley F, Stone TG, Stout EA, Stratton PL, Strausser RJ, Suter LJ, Sweet W, Swisher MF, Tappero JD, Tassano JB, Taylor JS, Tekle EA, Thai C, Thomas CA, Thomas A, Throop AL, Tietbohl GL, Tillman JM, Town RPJ, Townsend SL, Tribbey KL, Trummer D, Truong J, Vaher J, Valadez M, Van Arsdall P, Van Prooyen AJ, Vergel de Dios EO, Vergino MD, Vernon SP, Vickers JL, Villanueva GT, Vitalich MA, Vonhof SA, Wade FE, Wallace RJ, Warren CT, Warrick AL, Watkins J, Weaver S, Wegner PJ, Weingart MA, Wen J, White KS, Whitman PK, Widmann K, Widmayer CC, Wilhelmsen K, Williams EA, Williams WH, Willis L, Wilson EF, Wilson BA, Witte MC, Work K, Yang PS, Young BK, Youngblood KP, Zacharias RA, Zaleski T, Zapata PG, Zhang H, Zielinski JS, Kline JL, Kyrala GA, Niemann C, Kilkenny JD, Nikroo A, Van Wonterghem BM, Atherton LJ, Moses EI. Demonstration of ignition radiation temperatures in indirect-drive inertial confinement fusion hohlraums. Phys Rev Lett 2011; 106:085004. [PMID: 21405580 DOI: 10.1103/physrevlett.106.085004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Indexed: 05/30/2023]
Abstract
We demonstrate the hohlraum radiation temperature and symmetry required for ignition-scale inertial confinement fusion capsule implosions. Cryogenic gas-filled hohlraums with 2.2 mm-diameter capsules are heated with unprecedented laser energies of 1.2 MJ delivered by 192 ultraviolet laser beams on the National Ignition Facility. Laser backscatter measurements show that these hohlraums absorb 87% to 91% of the incident laser power resulting in peak radiation temperatures of T(RAD)=300 eV and a symmetric implosion to a 100 μm diameter hot core.
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Affiliation(s)
- S H Glenzer
- Lawrence Livermore National Laboratory, Livermore, California 94550, USA
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Thyssen JP, Menné T, Schalock PC, Taylor JS, Maibach HI. Pragmatic approach to the clinical work-up of patients with putative allergic disease to metallic orthopaedic implants before and after surgery. Br J Dermatol 2011; 164:473-8. [PMID: 21087227 DOI: 10.1111/j.1365-2133.2010.10144.x] [Citation(s) in RCA: 24] [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: 11/26/2022]
Abstract
Allergic complications following insertion of metallic orthopaedic implants include allergic dermatitis reactions but also extracutaneous complications. As metal-allergic patients and/or surgeons may ask dermatologists and allergologists for advice prior to planned orthopaedic implant surgery, and as surgeons may refer patients with complications following total joint arthroplasty for diagnostic work-up, there is a continuous need for updated guidelines. This review presents published evidence for patch testing prior to surgery and proposes tentative diagnostic criteria which clinicians can rely on in the work-up of patients with putative allergic complications following surgery. Few studies have investigated whether subjects with metal contact allergy have increased risk of developing complications following orthopaedic implant insertion. Metal allergy might in a minority increase the risk of complications caused by a delayed-type hypersensitivity reaction. At present, we do not know how to identify the subgroups of metal contact allergic patients with a potentially increased risk of complications following insertion of a metal implant. We recommend that clinicians should refrain from routine patch testing prior to surgery unless the patient has already had implant surgery with complications suspected to be allergic or has a history of clinical metal intolerance of sufficient magnitude to be of concern to the patient or a health provider. The clinical work-up of a patient suspected of having an allergic reaction to a metal implant should include patch testing and possibly in vitro testing. We propose diagnostic criteria for allergic dermatitis reactions as well as noneczematous complications caused by metal implants.
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Affiliation(s)
- J P Thyssen
- Department of Dermato-Allergology, National Allergy Research Centre, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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Gómez-Soriano J, Castellote JM, Pérez-Rizo E, Esclarin A, Taylor JS. Voluntary ankle flexor activity and adaptive coactivation gain is decreased by spasticity during subacute spinal cord injury. Exp Neurol 2010; 224:507-16. [PMID: 20580713 DOI: 10.1016/j.expneurol.2010.05.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 05/18/2010] [Indexed: 11/24/2022]
Abstract
Although spasticity has been defined as an increase in velocity-dependent stretch reflexes and muscle hypertonia during passive movement, the measurement of flexor muscle paresis may better characterize the negative impact of this syndrome on residual motor function following incomplete spinal cord injury (iSCI). In this longitudinal study Tibialis Anterior (TA) muscle paresis produced by a loss in maximal voluntary contraction during dorsiflexion and ankle flexor muscle coactivation during ramp-and-hold controlled plantarflexion was measured in ten patients during subacute iSCI. Tibialis Anterior activity was measured at approximately two-week intervals between 3-5 months following iSCI in subjects with or without spasticity, characterized by lower-limb muscle hypertonia and/or involuntary spasms. Following iSCI, maximal voluntary contraction ankle flexor activity was lower than that recorded from healthy subjects, and was further attenuated by the presence of spasticity. Furthermore the initially high percentage value of TA coactivation increased at 75% but not at 25% maximal voluntary torque (MVT), reflected by an increase in TA coactivation gain (75%/25% MVT) from 2.5+/-0.4 to 7.5+/-1.9, well above the control level of 2.9+/-0.2. In contrast contraction-dependent TA coactivation gain decreased from 2.4+/-0.3 to 1.4+/-0.1 during spasticity. In conclusion the adaptive increase in TA coactivation gain observed in this pilot study during subacute iSCI was also sensitive to the presence of spasticity. The successful early diagnosis and treatment of spasticity would be expected to further preserve and promote adaptive motor function during subacute iSCI neurorehabilitation.
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Affiliation(s)
- J Gómez-Soriano
- Grupo Funcion Sensitivomotora, Hospital Nacional de Parapléjicos, SESCAM, Finca La Peraleda s/n, 45071 Toledo, Spain
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Taylor JS, Thomson BM, Lang CN, Sin FYT, Podivinsky E. Estrogenic pyrethroid pesticides regulate expression of estrogen receptor transcripts in mouse Sertoli cells differently from 17beta-estradiol. J Toxicol Environ Health A 2010; 73:1075-1089. [PMID: 20574910 DOI: 10.1080/15287394.2010.482915] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Studies suggested that exposure to agricultural pesticides may affect male fertility. Pyrethroids are widely used pesticides due to their insecticidal potency and low mammalian toxicity. A recombinant yeast assay system incorporating the human alpha-estrogen receptor was used to analyze the estrogenicity of a range of readily available pyrethroid pesticides. The commercial product Ripcord Plus showed estrogenic activity by this assay. To determine whether pyrethroid compounds might exert an effect on male fertility, mouse Sertoli cells were exposed in vitro to the endogenous estrogen, 17beta-estradiol, and selected estrogenic pyrethroids. Following exposure, transcript levels of the alpha- and beta-estrogen receptors were assessed. Exposure of Sertoli cells to the pyrethroid compounds, both at high and at low published serum concentrations, affected the expression of the two estrogen receptors; however, the influence on estrogen receptor gene expression was different from the effect from exposure to 17beta-estradiol. These results from our model systems suggest that (1) estrogenic pyrethroid pesticides affect the estrogen receptors, and therefore potentially the endocrine system, in a different manner from that of endogenous estrogen, and (2) should cells in the male testes be exposed to pyrethroid pesticides, male fertility may be affected through molecular mechanisms involving estrogen receptors.
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Gómez-Nicola D, Valle-Argos B, Suardíaz M, Taylor JS, Nieto-Sampedro M. Role of IL-15 in spinal cord and sciatic nerve after chronic constriction injury: regulation of macrophage and T-cell infiltration. J Neurochem 2008; 107:1741-52. [PMID: 19014377 DOI: 10.1111/j.1471-4159.2008.05746.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
The release of inflammatory mediators from immune and glial cells either in the peripheral or CNS may have an important role in the development of physiopathological processes such as neuropathic pain. Microglial, then astrocytic activation in the spinal cord, lead to chronic inflammation, alteration of neuronal physiology and neuropathic pain. Standard experimental models of neuropathic pain include an important peripheral inflammatory component, which involves prominent immune cell activation and infiltration. Among potential immunomodulators, the T-cell cytokine interleukin-15 (IL-15) has a key role in regulating immune cell activation and glial reactivity after CNS injury. Here we show, using the model of chronic constriction of the sciatic nerve (CCI), that IL-15 is essential for the development of the early inflammatory events in the spinal cord after a peripheral lesion that generates neuropathic pain. IL-15 expression in the spinal cord was identified in both astroglial and microglial cells and was present during the initial gliotic and inflammatory (NFkappaB) response to injury. The expression of IL-15 was also identified as a cue for macrophage and T-cell activation and infiltration in the sciatic nerve, as shown by intraneural injection of the cytokine and activity blockage approaches. We conclude that the regulation of IL-15 and hence the initial events following its expression after peripheral nerve injury could have a future therapeutic potential in the reduction of neuroinflammation.
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Taylor JS, Spital A. Uncertainty does not preclude rationality. Am J Transplant 2008; 8:1965; author reply 1966. [PMID: 18671681 DOI: 10.1111/j.1600-6143.2008.02334.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Affiliation(s)
- B E Hippen
- Metrolina Nephrology Associates, P.A. Charlotte, NC, USA.
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Spital A, Taylor JS. Another missed opportunity: routine recovery of cadaveric organs. Am J Transplant 2007; 7:1311. [PMID: 17456204 DOI: 10.1111/j.1600-6143.2007.01766.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Taylor JS. A "Queen of Hearts" trial of organ markets: why Scheper-Hughes's objections to markets in human organs fail. J Med Ethics 2007; 33:201-4. [PMID: 17400616 PMCID: PMC2652773 DOI: 10.1136/jme.2006.016527] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2006] [Revised: 05/05/2006] [Accepted: 05/09/2006] [Indexed: 05/14/2023]
Abstract
Nancy Scheper-Hughes is one of the most prominent critics of markets in human organs. Unfortunately, Scheper-Hughes rejects the view that markets should be used to solve the current (and chronic) shortage of transplant organs without engaging with the arguments in favour of them. Scheper-Hughes's rejection of such markets is of especial concern, given her influence over their future, for she holds, among other positions, the status of an adviser to the World Health Organization (Geneva) on issues related to global transplantation. Given her influence, it is important that Scheper-Hughes's moral condemnation of markets in human organs be subject to critical assessment. Such critical assessment, however, has not generally been forthcoming. A careful examination of Scheper-Hughes's anti-market stance shows that it is based on serious mischaracterisations of both the pro-market position and the medical and economic realities that underlie it. In this paper, the author will expose and correct these mischaracterisations and, in so doing, show that her objections to markets in human organs are unfounded.
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Affiliation(s)
- J S Taylor
- Department of Philosophy, The College of New Jersey, 2000 Pennington Road, PO Box 7718, Ewing, NJ 08628-0718, USA.
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Abstract
One of the most common arguments against legalising markets in human kidneys is that this would result in the widespread misuse that is present in the black market becoming more prevalent. In particular, it is argued that if such markets were to be legalised, this would lead to an increase in the number of people being coerced into selling their kidneys. Moreover, such coercion would occur even if markets in kidneys were regulated, for those subject to such coercion would not be able to avail themselves of the legal protections that regulation would afford them. Despite the initial plausibility of this argument, there are three reasons to reject it. Firstly, the advantages of legalising markets in human kidneys would probably outweigh its possible disadvantages. Secondly, if it is believed that no such coercion can ever be tolerated, markets in only those human kidneys that fail to do away with coercion should be condemned. Finally, if coercion is genuinely opposed, then legalising kidney markets should be supported rather than opposed, for more people would be coerced (ie, into not selling) were such markets to be prohibited.
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Affiliation(s)
- J S Taylor
- Department of Philosophy, The College of New Jersey, 2000 Pennington Road, PO Box 7718, Ewing, NJ 08628-0718, USA.
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Burke RD, Angerer LM, Elphick MR, Humphrey GW, Yaguchi S, Kiyama T, Liang S, Mu X, Agca C, Klein WH, Brandhorst BP, Rowe M, Wilson K, Churcher AM, Taylor JS, Chen N, Murray G, Wang D, Mellott D, Olinski R, Hallböök F, Thorndyke MC. A genomic view of the sea urchin nervous system. Dev Biol 2006; 300:434-60. [PMID: 16965768 PMCID: PMC1950334 DOI: 10.1016/j.ydbio.2006.08.007] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.1] [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: 06/01/2006] [Revised: 07/29/2006] [Accepted: 08/02/2006] [Indexed: 10/24/2022]
Abstract
The sequencing of the Strongylocentrotus purpuratus genome provides a unique opportunity to investigate the function and evolution of neural genes. The neurobiology of sea urchins is of particular interest because they have a close phylogenetic relationship with chordates, yet a distinctive pentaradiate body plan and unusual neural organization. Orthologues of transcription factors that regulate neurogenesis in other animals have been identified and several are expressed in neurogenic domains before gastrulation indicating that they may operate near the top of a conserved neural gene regulatory network. A family of genes encoding voltage-gated ion channels is present but, surprisingly, genes encoding gap junction proteins (connexins and pannexins) appear to be absent. Genes required for synapse formation and function have been identified and genes for synthesis and transport of neurotransmitters are present. There is a large family of G-protein-coupled receptors, including 874 rhodopsin-type receptors, 28 metabotropic glutamate-like receptors and a remarkably expanded group of 161 secretin receptor-like proteins. Absence of cannabinoid, lysophospholipid and melanocortin receptors indicates that this group may be unique to chordates. There are at least 37 putative G-protein-coupled peptide receptors and precursors for several neuropeptides and peptide hormones have been identified, including SALMFamides, NGFFFamide, a vasotocin-like peptide, glycoprotein hormones and insulin/insulin-like growth factors. Identification of a neurotrophin-like gene and Trk receptor in sea urchin indicates that this neural signaling system is not unique to chordates. Several hundred chemoreceptor genes have been predicted using several approaches, a number similar to that for other animals. Intriguingly, genes encoding homologues of rhodopsin, Pax6 and several other key mammalian retinal transcription factors are expressed in tube feet, suggesting tube feet function as photosensory organs. Analysis of the sea urchin genome presents a unique perspective on the evolutionary history of deuterostome nervous systems and reveals new approaches to investigate the development and neurobiology of sea urchins.
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Affiliation(s)
- R D Burke
- Department of Biology, University of Victoria, Victoria, POB 3020, STN CSC, Victoria, BC, Canada V8W 3N5.
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Taylor JS. An overview of neurolaw for the clinician: what every potential witness should know. NeuroRehabilitation 2005; 16:69-77. [PMID: 11568464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
This article reviews the field of medical jurisprudence known as neurolaw which deals with the medicolegal ramifications of brain and spinal cord injuries. Placing emphasis upon how clinicians may work effectively with trial lawyers, it provides practical guidance to neurorehabilitation professionals who testify in personal injury cases.
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Affiliation(s)
- J S Taylor
- Taylor, Harp and Callier, P.O. Box 2645, Columbus, GA 31902-2645, USA
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Abstract
AIM To investigate primiparous women's primary reason for not breastfeeding. METHODS We used the 1995 National Survey of Family Growth to analyze the breastfeeding behaviors of a national probability sample of 6733 first-time US mothers, aged 15 to 44 y. Main outcome measures in this cross-sectional study were the reasons for never breastfeeding and reasons for stopping breastfeeding using closed-ended, multiple choice questions. RESULTS Most commonly, women did not breastfeed because they "preferred to bottle feed" (66.3%). The most common reason for stopping breastfeeding was that the child was "old enough to wean" (35.7%), although 15%, 34%, 54%, and 78% of those women had stopped breastfeeding by 3, 6, 9, and 12 mo, respectively. "Physical or medical problem" was reported by 14.9% of women who did not breastfeed and 26.9% of women who had stopped breastfeeding, making it the second most common reason for not breastfeeding in each group. There were significant differences across racial and ethnic groups. CONCLUSION Additional studies are needed to better understand why women "prefer to bottle feed", especially black women. Increasingly effective programs and policies to promote breastfeeding will logically follow. Since physical and medical problems are such common reasons both for never breastfeeding and for stopping breastfeeding, individual healthcare providers can have a significant impact on breastfeeding rates and duration.
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Affiliation(s)
- J S Taylor
- Department of Family Medicine, Brown University Medical School, Providence, Rhode Island, USA.
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Taylor JS. Reappraising the role of autonomy in medical ethics. Prof Ethics 2003; 8:19-33. [PMID: 12568069 DOI: 10.5840/profethics2000816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J S Taylor
- Philosophy, St. Norbert College, De Pere, WI 54115, USA.
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Brunn SD, Dahlman CT, Taylor JS. GIS uses and constraints on diffusion in Eastern European and the former USSR. Post Sov Geogr Econ 2002; 39:566-87. [PMID: 12321797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
The authors examine the emerging uses of geographic information systems (GIS) in Eastern Europe and the countries that formerly were part of the USSR. "The paper, based on a communications survey, conference participation, and local sources, devotes particular attention to GIS applications in planning and services delivery and to variable rates of adoption of GIS technology in the region, as documented in a table of public-sector applications compiled by the authors. Factors limiting the utility of traditional innovation-diffusion models in understanding current patterns are identified."
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Nieto-Sampedro M, Collazos-Castro JE, Taylor JS, Gudiño-Cabrera G, Verdú-Navarro E, Pascual-Piédrola JI, Insausti-Serrano R. [Traumatic injuries to the central nervous system and their repair]. Rev Neurol 2002; 35:534-52. [PMID: 12389172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
DEVELOPMENT Brain and spinal cord lesions have an increasing social and economic importance. Accidental trauma of various kinds is the main cause of mortality of children and young adults in developed countries. Only cardiac disease and cancer surpass the number of death caused by accidents and, examining the number of potential work years lost, CNS lesions surpass all other problems. Most brain and spinal cord injuries cause chronic incapacity and frequently occur to individuals under 45 years of age. Edema and other acute events can be efficiently treated and CNS lesions may not be mortal, but are incurable. CONCLUSION The final outcome of CNS injury depend on the area damaged and the extent of the lesion, but the best present therapies can offer is relief of the symptoms and rehabilitation. This review examines the present state of functional repair of experimental central nervous system trauma.
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Abstract
In the central nervous system of fish and frogs, some, but not all, axons can regenerate. Retinal ganglion cells are among those that can. The retinae of fish and frogs produce new retinal neurons, including ganglion cells, for months or years after hatching. We have evaluated the hypothesis that retinal axonal regeneration is obligatorily linked to continued production of new ganglion cells. We used bromodeoxyuridine immunocytochemistry to assess retinal neurogenesis in juvenile, yearling, and 10 year old Xenopus laevis. Retinal ganglion cell genesis was vigorous in the marginal retina of the juveniles, but in the yearlings and the 10 year olds, no new ganglion cells were produced there. Cellular proliferation in the central retina was evident at all three ages, but none of the cells produced centrally were in the ganglion cell layer. Regeneration was examined in vivo by cutting one optic nerve and then, weeks later, injecting the eye with tritiated proline. Autoradiographs of brain sections showed that the optic nerves of all three ages regenerated. Regeneration in vitro was assessed using retinal explants from frogs of all three ages. In all cases, the cultures produced neurites, with some age-specific differences in the patterns of outgrowth. We conclude that retinal axonal regeneration is not linked obligatorily to maintained neurogenesis.
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Affiliation(s)
- J S Taylor
- The MRC Neural Development and Regeneration Group, Department of Zoology, University of Edinburgh, Edinburgh EH9 3JT, UK
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Wang Y, Taylor JS, Gross ML. Fragmentation of photomodified oligodeoxynucleotides adducted with metal ions in an electrospray-ionization ion-trap mass spectrometer. J Am Soc Mass Spectrom 2001; 12:1174-1179. [PMID: 11720392 DOI: 10.1016/s1044-0305(01)00302-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
We report the effect of metal-ion adduction on the fragmentation of oligodeoxynucleotides (ODNs) bearing DNA photoproducts. When protons on backbone phosphates of ODNs are completely replaced with metal ions, cleavages occur readily within the photoproduct moiety, whereas those cleavages do not occur in photomodified ODNs in which the phosphates are associated with protons. For example, thymine/adenine (TA*) photoproducts revert to their undamaged precursors upon collisional activation, the pyrimidine(6-4)pyrimidone product and its Dewar valence isomer show a characteristic neutral loss of C4H3NO3, and dimeric adenine photoproducts show a distinctive loss of NH2CN from the adenine six-membered ring. The product-ion mass spectra of photodamaged ODNs that are adducted to metal ions are complementary in terms of structure information to those spectra of ODNs in which the phosphates are associated with protons. The results also demonstrate that the energy required for strand cleavages is higher for ODNs adducted with metal ions than that for ODNs bound with protons. Furthermore, the loss of a pyrimidine is more favorable than the loss of a purine in the fragmentation of ODNs associated with metal ions.
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Affiliation(s)
- Y Wang
- Department of Chemistry, Washington University, St. Louis, Missouri 63130, USA
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Taylor JS, Van de Peer Y, Braasch I, Meyer A. Comparative genomics provides evidence for an ancient genome duplication event in fish. Philos Trans R Soc Lond B Biol Sci 2001; 356:1661-79. [PMID: 11604130 PMCID: PMC1088543 DOI: 10.1098/rstb.2001.0975] [Citation(s) in RCA: 362] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There are approximately 25 000 species in the division Teleostei and most are believed to have arisen during a relatively short period of time ca. 200 Myr ago. The discovery of 'extra' Hox gene clusters in zebrafish (Danio rerio), medaka (Oryzias latipes), and pufferfish (Fugu rubripes), has led to the hypothesis that genome duplication provided the genetic raw material necessary for the teleost radiation. We identified 27 groups of orthologous genes which included one gene from man, mouse and chicken, one or two genes from tetraploid Xenopus and two genes from zebrafish. A genome duplication in the ancestor of teleost fishes is the most parsimonious explanation for the observations that for 15 of these genes, the two zebrafish orthologues are sister sequences in phylogenies that otherwise match the expected organismal tree, the zebrafish gene pairs appear to have been formed at approximately the same time, and are unlinked. Phylogenies of nine genes differ a little from the tree predicted by the fish-specific genome duplication hypothesis: one tree shows a sister sequence relationship for the zebrafish genes but differs slightly from the expected organismal tree and in eight trees, one zebrafish gene is the sister sequence to a clade which includes the second zebrafish gene and orthologues from Xenopus, chicken, mouse and man. For these nine gene trees, deviations from the predictions of the fish-specific genome duplication hypothesis are poorly supported. The two zebrafish orthologues for each of the three remaining genes are tightly linked and are, therefore, unlikely to have been formed during a genome duplication event. We estimated that the unlinked duplicated zebrafish genes are between 300 and 450 Myr. Thus, genome duplication could have provided the genetic raw material for teleost radiation. Alternatively, the loss of different duplicates in different populations (i.e. 'divergent resolution') may have promoted speciation in ancient teleost populations.
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Affiliation(s)
- J S Taylor
- Department of Biology, University of Konstanz, 78457, Konstanz, Germany
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