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Ramian H, Sun Z, Yabes J, Jacobs B, Sabik LM. Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds. JCO Oncol Pract 2024; 20:123-130. [PMID: 37590899 PMCID: PMC10827295 DOI: 10.1200/op.22.00851] [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: 12/22/2022] [Revised: 06/08/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.
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Affiliation(s)
- Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Zhaojun Sun
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce Jacobs
- Department of Urology, Division of Health Services Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
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Miller DT, Sun Z, Grajales V, Pekala KR, Eom KY, Yabes J, Davies BJ, Sabik LM, Jacobs BL. Insurance Type and Area Deprivation Are Associated With Worse Overall Mortality for Patients With Muscle-invasive Bladder Cancer. Urology 2023; 177:81-88. [PMID: 37028521 DOI: 10.1016/j.urology.2023.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To examine the association of area-level socioeconomic status, rural-urban residence, and type of insurance with overall and cancer-specific mortality among patients with muscle-invasive bladder cancer. METHODS Using the Pennsylvania Cancer Registry, which collects demographic, insurance, and clinical information on every patient with cancer within the state, we identified all patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2016 based on clinical and pathologic staging. We used the Area Deprivation Index (ADI) as a surrogate for socioeconomic status and Rural-Urban Commuting Area codes to classify urban, large town, and rural communities. ADI was reported in quartiles, with 4 representing the lowest socioeconomic status. We fit multivariable logistic regression and Cox models to assess the relationship of these social determinants with overall and cancer-specific survival adjusting for age, sex, race, stage, treatment, rural-urban classification, insurance and ADI. RESULTS We identified 2597 patients with non-metastatic muscle-invasive bladder cancer. On multivariable analysis, Medicare (hazards ratio [HR] 1.15), Medicaid (HR 1.38), ADI 3 (HR 1.16) and ADI 4 (HR 1.21) were independent predictors of greater overall mortality (all P < 0.05). Female sex and receipt of non-standard treatment were associated with increased overall mortality and bladder cancer-specific mortality. There was no significant difference in both overall and cancer-specific survival between patients who were non-Hispanic White compared to non-White or between those from urban areas, large towns, or rural locations. CONCLUSION Lower socioeconomic status and Medicare and Medicaid insurance were associated with a greater risk of overall mortality while rural residence was not a significant factor. Implementation of public health programs may help reduce the gap in mortality for low SES at-risk populations.
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Affiliation(s)
- David T Miller
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Zhaojun Sun
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Valentina Grajales
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kelly R Pekala
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kirsten Y Eom
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Thomas HN, Brotto LA, de Abril Cameron F, Yabes J, Thurston RC. A virtual, group-based mindfulness intervention for midlife and older women with low libido lowers sexual distress in a randomized controlled pilot study. J Sex Med 2023:qdad081. [PMID: 37353906 PMCID: PMC10390320 DOI: 10.1093/jsxmed/qdad081] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 05/22/2023] [Accepted: 05/03/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Distressing low libido is common among women and has significant negative impacts; mindfulness has shown promise to increase sexual desire in women with low libido, but existing interventions are not tailored to midlife and older women. AIM We adapted a mindfulness intervention to meet the needs of this population and conducted a pilot randomized controlled trial to assess feasibility and acceptability. METHODS Women aged ≥45 years with low libido were randomized to the mindfulness intervention or an education group that met over videoconferencing. The intervention included mindfulness instruction and practice, group discussion, and education on sexuality and aging. The education group included general information on menopause and health. OUTCOMES We defined feasibility by the number of screened women who enrolled and completed their group. We defined acceptability as satisfaction with the group and likelihood of recommending it to another woman with low libido. We assessed sexual function (Female Sexual Function Index) and sexual distress (Female Sexual Distress Scale-Revised) at 6 weeks postconclusion. RESULTS Of 81 women screened, 31 were randomized to mindfulness and 30 to education. Eighteen women in the intervention group and 23 in the control group attended at least 1 session. Time conflict was the main reason for nonattendance. Of the 41 women who started attending groups, 37 (90%) attended at least 5 sessions. In the mindfulness group, 73% of women were very or extremely satisfied. Women in the mindfulness group were more likely to recommend it to another person with low libido as compared with those in the education group (P = .031); 67% said that they would probably or definitely recommend it. There were no significant changes in sexual function in either group (mean Female Sexual Function Index score, 22.6 to 18.6 [P = .101] with mindfulness and 21.2 to 19.7 [P = .537] with education). Women in the mindfulness group had significant improvements in sexual distress (mean Female Sexual Distress Scale-Revised score, 27.1 to 19.7; P = .021) while women in the education group did not (19.0 to 15.8; P = .062). CLINICAL IMPLICATIONS Mindfulness may reduce sexual distress in older women with low libido. STRENGTHS AND LIMITATIONS This is the first trial testing mindfulness for midlife and older women with low libido. CONCLUSION A virtual mindfulness intervention for midlife and older women with low libido is feasible and acceptable and appears to improve sexual distress as compared with an education control; these findings provide data that can be used to design a larger clinical trial.
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Affiliation(s)
- Holly N Thomas
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15217, United States
| | - Lori A Brotto
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver V5Z 4M2, Canada
| | - Flor de Abril Cameron
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15217, United States
| | - Jonathan Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15217, United States
| | - Rebecca C Thurston
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15217, United States
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Ayyash O, Yabes J, Hugar L, Maganty A, Williams SB, Wulff-Burchfield E, Davies B, Jacobs B. New Mental Health Diagnosis as a Prognostic Factor for Muscle-Invasive Bladder Cancer. Clin Genitourin Cancer 2022; 21:e1-e8. [PMID: 36446679 DOI: 10.1016/j.clgc.2022.10.012] [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: 08/29/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND To examine differences in survival outcomes for muscle-invasive bladder cancer patients stratified by new mental health diagnosis. METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified patients diagnosed with muscle-invasive bladder cancer between 2008 and 2014. Our primary outcome was cancer-specific and overall hazards of mortality. As a secondary outcome, we reported predictors of developing a new mental health diagnosis after bladder cancer diagnosis. We used Cox proportional hazards models to determine the impact of palliative care and mental health diagnoses on survival outcomes after adjusting for grade, stage, comorbidity index, and baseline demographics. RESULTS Of the 3794 patients who met inclusion criteria, 1193 (31%) were diagnosed with a mental health illness after their bladder cancer diagnosis during the 6 years in the study period. The most common diagnoses were depression (13%), alcohol and drug abuse (12%), and anxiety (11%). Patients with a post-bladder cancer mental health diagnosis had a 57% higher hazard of overall mortality (HR 1.57, P = .048) and an 80% higher hazard of bladder cancer-specific mortality (HR 1.81, P = .037) CONCLUSIONS: New mental health diagnoses are associated with worse survival in patients with muscle invasive bladder cancer. This suggests that a multimodal approach to bladder cancer treatment should include addressing the non-oncologic needs of the patient to optimize survival outcomes.
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Affiliation(s)
- Omar Ayyash
- Department of Urology, UPMC, Pittsburgh, PA.
| | - Jonathan Yabes
- Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lee Hugar
- Department of Urology, UPMC, Pittsburgh, PA
| | | | - Stephen B Williams
- Department of Surgery, Division of Urology, University of Texas Medical Branch, Galveston, TX
| | - Elizabeth Wulff-Burchfield
- Division of Medical Oncology and Palliative Medicine, University of Kansas Medical Center, Kansas City, KS
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Chang HH, Chiang JH, Wang CS, Chiu PF, Abdel-Kader K, Chen H, Siew ED, Yabes J, Murugan R, Clermont G, Palevsky PM, Jhamb M. Predicting Mortality Using Machine Learning Algorithms in Patients Who Require Renal Replacement Therapy in the Critical Care Unit. J Clin Med 2022; 11:5289. [PMID: 36142936 PMCID: PMC9500742 DOI: 10.3390/jcm11185289] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 01/13/2023] Open
Abstract
Background: General severity of illness scores are not well calibrated to predict mortality among patients receiving renal replacement therapy (RRT) for acute kidney injury (AKI). We developed machine learning models to make mortality prediction and compared their performance to that of the Sequential Organ Failure Assessment (SOFA) and HEpatic failure, LactatE, NorepInephrine, medical Condition, and Creatinine (HELENICC) scores. Methods: We extracted routinely collected clinical data for AKI patients requiring RRT in the MIMIC and eICU databases. The development models were trained in 80% of the pooled dataset and tested in the rest of the pooled dataset. We compared the area under the receiver operating characteristic curves (AUCs) of four machine learning models (multilayer perceptron [MLP], logistic regression, XGBoost, and random forest [RF]) to that of the SOFA, nonrenal SOFA, and HELENICC scores and assessed calibration, sensitivity, specificity, positive (PPV) and negative (NPV) predicted values, and accuracy. Results: The mortality AUC of machine learning models was highest for XGBoost (0.823; 95% confidence interval [CI], 0.791−0.854) in the testing dataset, and it had the highest accuracy (0.758). The XGBoost model showed no evidence of lack of fit with the Hosmer−Lemeshow test (p > 0.05). Conclusion: XGBoost provided the highest performance of mortality prediction for patients with AKI requiring RRT compared with previous scoring systems.
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Affiliation(s)
- Hsin-Hsiung Chang
- Division of Nephrology, Department of Internal Medicine, Antai Medical Care Corporation Antai Tian-Sheng Memorial Hospital, Donggang 928, Taiwan
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 701, Taiwan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jung-Hsien Chiang
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 701, Taiwan
| | - Chi-Shiang Wang
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 701, Taiwan
| | - Ping-Fang Chiu
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Hospitality Management, MingDao University, Changhua 500, Taiwan
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37011, USA
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI Research (VIP-AKI), Nashville, TN 37011, USA
| | - Huiwen Chen
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Edward D. Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37011, USA
- Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI Research (VIP-AKI), Nashville, TN 37011, USA
- Tennessee Valley Health Systems (TVHS), Veteran’s Health Administration, Nashville, TN 37212, USA
| | - Jonathan Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Raghavan Murugan
- Program for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Paul M. Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Obregon LL, Jeong K, Hoydich ZP, Yabes J, Pilewski J, Richless C, Moreines LT, Dellon EP, Goss CH, Arnold RM, Kavalieratos D. Associations between demographic characteristics and unmet supportive care needs in adults with cystic fibrosis. BMJ Support Palliat Care 2022; 12:e281-e284. [PMID: 31473650 PMCID: PMC9941977 DOI: 10.1136/bmjspcare-2019-001819] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/08/2019] [Accepted: 07/17/2019] [Indexed: 11/04/2022]
Abstract
CONTEXT Patients living with cystic fibrosis (CF) report impaired quality of life. Little is known about unmet supportive care needs among adults living with CF and how they are associated with demographic characteristics. OBJECTIVES The primary objective of this study was to identify associations between demographic variables and unmet supportive care needs regarding anxiety, sadness, pain and uncertainty about the future of living with CF. METHODS We recruited 165 adults with CF from a single academic medical centre to complete a brief demographic survey and the Supportive Care Needs Survey (SCNS-34), a validated self-reported needs assessment that measures the prevalence of and preferences for support for 34 needs that commonly occur in patients with serious illness. RESULTS Approximately half of the participant sample was male, with a median age of 29 years, varying income levels and a range of lung disease severity. We found statistically significant associations between insufficient income and increased odds of reporting need for support regarding anxiety (OR: 6.48; 95% CI 2.08 to 20.2), sadness (OR: 6.15; 95% CI 2.04 to 18.5), pain (OR: 7.06; 95% CI 2.22 to 22.4) and worries surrounding uncertainty about the future (OR: 3.43; 95% CI 1.18 to 9.99). CONCLUSION Adults with CF report significant unmet needs for support in several physical and emotional domains. Many of these domains were associated with demographic characteristics, most notably, income. Our findings underscore the importance of developing treatment approaches that are sensitive to patient demographics when addressing unmet supportive care needs among adults with CF.
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Affiliation(s)
- Laura Liliana Obregon
- H. John Heinz III College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Kwonho Jeong
- Center for Research on Health Care Data Center, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zachariah P Hoydich
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Connie Richless
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura T Moreines
- Department of Geriatrics, Northeast Medical Group, Yale New Haven Health System, New Haven, Connecticut, USA
| | - Elisabeth P Dellon
- Division of Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Jakubowski KP, Jhamb M, Yabes J, Gujral S, Oberlin LE, Bender FH, Steel JL. Technology-assisted cognitive-behavioral therapy intervention for end-stage renal disease. Transl Behav Med 2021; 10:657-663. [PMID: 31131853 DOI: 10.1093/tbm/ibz077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Technology-assisted cognitive-behavioral therapy (CBT) interventions have been conducted for symptoms including depression, pain, and fatigue in patients with chronic illnesses but not in end-stage renal disease (ESRD). The purpose of this study was to pilot the feasibility and acceptability of a technology-assisted CBT intervention in ESRD patients on hemodialysis (HD), share design and implementation lessons learned, and provide preliminary results on changes in select patient-reported symptoms. This was a single-center pilot feasibility study of adult ESRD patients on HD. Study eligibility required clinically elevated levels of at least one symptom (depression, pain, or fatigue). Patients met weekly with a CBT therapist for eight sessions, each 45-60 min, during HD sessions via a video-conferencing platform. Symptom questionnaires were completed at baseline and 3 months follow-up. Of 10 patients screened, 100% screened positive for at least one symptom, 100% of eligible patients consented, and eight (of 10) completed the intervention (mean age 59 years, 50% male, 50% African American). Patient adherence and satisfaction was high, and seven of the eight patients completed all eight prescribed sessions. Minimal interference with HD was reported. Preliminary results indicate no statistically significant changes in depression, fatigue, or pain at follow-up. However, there was small improvement in SF-36 Physical Component score [t(7) = -2.60, p = .035], and four of the six patients (67%) with clinically elevated pain at baseline reported improvement at follow-up. A technology-assisted CBT intervention for ESRD patients was feasible, well-accepted, and required minimal additional resources in the HD setting. Larger, adequately powered clinical trials are needed to evaluate the effect on ESRD patient-reported outcomes.
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Affiliation(s)
| | - Manisha Jhamb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Swathi Gujral
- Pittsburgh VA Healthcare System, Pittsburgh, PA, USA
| | - Lauren E Oberlin
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Filitsa H Bender
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer L Steel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Ernecoff NC, Abdel-Kader K, Cai M, Yabes J, Shah N, Schell JO, Jhamb M. Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD. Kidney360 2021; 2:966-973. [PMID: 35373084 PMCID: PMC8791363 DOI: 10.34067/kid.0007062020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Background The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice. Objectives The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits. Methods We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m2. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. Results Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary. Conclusions We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.
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Affiliation(s)
- Natalie C. Ernecoff
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee
| | - Manqi Cai
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nirav Shah
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manisha Jhamb
- Division of Renal and Electrolyte, University of Pittsburgh, Pittsburgh, Pennsylvania
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Wallace DJ, Donohue JM, Angus DC, Sabik LM, Davis B, Yabes J, Kahn JM. Association Between State Medicaid Expansion and Emergency Access to Acute Care Hospitals in the United States. JAMA Netw Open 2020; 3:e2025815. [PMID: 33196808 PMCID: PMC7670316 DOI: 10.1001/jamanetworkopen.2020.25815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals. OBJECTIVE To determine the relationship between state Medicaid expansion and emergency access to acute care hospitals in the United States. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study linked hospital-level data from the Centers for Medicare & Medicaid Services from 2007 to 2017 to US Census data for all 50 US states and the District of Columbia. Geospatial analyses and difference-in-differences regression models were used to compare temporal changes in the size of the population without 30-minute access to acute care hospitals between 32 states that expanded Medicaid with the population without access in 19 that did not, before and after expansion. Analyses focused on the total population and those with low incomes; secondary analyses examined emergency access to safety-net hospitals. EXPOSURES State-level Medicaid expansion. MAIN OUTCOMES AND MEASURES Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital. RESULTS States that did not expand Medicaid experienced an increase in the population without access to hospitals overall (without expansion: 6.76% to 6.79% [0.03%]; vs with expansion: 5.65% to 5.35% [-0.30%]; difference-in-differences, 0.33%; 95% CI, 0.33%-0.34%; P < .001) and for low-income persons (without expansion: 7.43% to 7.39% [-0.04%]; vs with expansion: 6.25% to 6.15% [-0.10%]; difference-in-differences, 0.06%; 95% CI, 0.05%-0.07%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 421 000 more persons overall and 48 000 more low-income persons would have retained access. States that did not expand Medicaid experienced an increase in the population without access to safety-net hospitals overall (46.91% to 47.70% [0.79%] vs 33.94% to 33.07% [-0.87%]; difference-in-differences, 1.66%; 95% CI, 1.64%-1.66%; P < .001) and for low-income persons (45.28% to 46.14% [0.86%] vs 33.00% to 32.23% [-0.77%]; difference-in-differences, 1.63%; 95% CI, 1.63%-1.67%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 2 242 000 more persons overall and 364 000 more low-income persons would have retained access. CONCLUSIONS AND RELEVANCE States that did not expand Medicaid under the Patient Protection and Affordable Care Act were associated with worse emergency access to acute care hospitals compared with states that expanded Medicaid.
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Affiliation(s)
- David J Wallace
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Billie Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Shah* A, Ayyash O, Bandari J, Kumar P, Yabes J, Odisho A, Davies B, Jacobs B. MP27-18 STATEWIDE GEOGRAPHIC PRICE VARIATION OF GENERIC BPH MEDICATIONS. J Urol 2020. [DOI: 10.1097/ju.0000000000000866.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jhamb M, Ran X, Abdalla H, Roumelioti ME, Hou S, Davis H, Patel SR, Yabes J, Unruh M. Association of Sleep Apnea with Mortality in Patients with Advanced Kidney Disease. Clin J Am Soc Nephrol 2020; 15:182-190. [PMID: 31969341 PMCID: PMC7015094 DOI: 10.2215/cjn.07880719] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/18/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES In the general population, sleep disorders are associated with mortality. However, such evidence in patients with CKD and ESKD is limited and shows conflicting results. Our aim was to examine the association of sleep apnea with mortality among patients with CKD and ESKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this prospective cohort study, 180 patients (88 with CKD stage 4 or 5, 92 with ESKD) underwent in-home polysomnography, and sleep apnea measures such as apnea hypopnea index (AHI) and nocturnal hypoxemia were obtained. Mortality data were obtained from the National Death Index. Cox proportional hazard models were used for survival analysis. RESULTS Among the 180 patients (mean age 54 years, 37% women, 39% with diabetes, 49% CKD with mean eGFR 18±7 ml/min per 1.73 m2), 71% had sleep apnea (AHI>5) and 23% had severe sleep apnea (AHI>30). Median AHI was 13 (range, 4-29) and was not significantly different in patients with advanced CKD or ESKD. Over a median follow-up of 9 years, there were 84 (47%) deaths. AHI was not significantly associated with mortality after adjusting for age, sex, race, diabetes, body mass index, CKD/ESKD status, and kidney transplant status (AHI>30: hazard ratio [HR], 1.5; 95% confidence interval [95% CI], 0.6 to 4.0; AHI >15 to 30: HR, 2.3; 95% CI, 0.9 to 5.9; AHI >5 to 15: HR, 2.1; 95% CI, 0.8 to 5.4, compared with AHI≤5). Higher proportion of sleep time with oxygen saturation <90% and lower mean oxygen saturation were significantly associated with higher mortality in adjusted analysis (HR, 1.4; 95% CI, 1.1 to 1.7; P=0.007 for every 15% higher proportion, and HR, 1.6; 95% CI, 1.2 to 2.1; P=0.003 for every 2% lower saturation, respectively). Sleep duration, sleep efficiency, or periodic limb movement index were not associated with mortality. CONCLUSIONS Hypoxemia-based measures of sleep apnea are significantly associated with increased risk of death among advanced CKD and ESKD.
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Affiliation(s)
| | | | | | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and
| | | | - Herbert Davis
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and
| | - Sanjay R Patel
- Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Jonathan Yabes
- Department of Biostatistics.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and.,Section of Nephrology, New Mexico Veterans Affairs Hospital, Albuquerque, New Mexico
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12
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Gillespie AI, Yabes J, Rosen CA, Gartner-Schmidt JL. Efficacy of Conversation Training Therapy for Patients With Benign Vocal Fold Lesions and Muscle Tension Dysphonia Compared to Historical Matched Control Patients. J Speech Lang Hear Res 2019; 62:4062-4079. [PMID: 31619107 PMCID: PMC7203518 DOI: 10.1044/2019_jslhr-s-19-0136] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 08/08/2019] [Indexed: 05/22/2023]
Abstract
Purpose Conversation training therapy (CTT) is the 1st voice therapy approach to eliminate the traditional therapeutic hierarchy and use patient-driven conversation as the sole therapeutic stimulus. The purpose of this investigation was to determine the efficacy of CTT compared to standard-of-care voice therapy approaches for the treatment of patients with voice disorders. Method A prospective study of CTT treatment outcomes in adults with dysphonia due to primary muscle tension dysphonia or benign vocal fold lesions compared to age, gender, and diagnosis historical matched control (HMC) patients was used. The primary outcome was change in Voice Handicap Index-10 (VHI-10); secondary outcomes included acoustic, aerodynamic, and auditory-perceptual outcomes. Data were collected before treatment (baseline), at the start of each therapy session, 1 week after the final therapy session (short-term follow-up), and 3 months after the final therapy session (long-term follow-up). Results For the CTT group, statistically significant improvements were observed for VHI-10. Though statistically significant improvements were observed for the VHI-10 for the HMC group, the CTT group saw significantly greater improvement in VHI-10. Furthermore, equivalent gains were observed following only 2 sessions of CTT compared to 4-8 sessions of traditional therapy. Significant improvements in the CTT group were observed for cepstral peak prominence in a vowel, fundamental frequency, Cepstral Spectral Index of Dysphonia in a vowel and connected speech, vocal intensity, average airflow in speech in a reading passage, number of breaths and duration of reading passage, and auditory-perceptual measurement of overall voice severity. Conclusions Results support the hypothesis that training voice techniques in the context of spontaneous conversational speech improves patient perception of voice handicap and acoustic, aerodynamic, and auditory-perceptual voice outcomes both immediately following treatment and at long-term follow-up. CTT participants also demonstrated significantly larger decreases in VHI-10 compared to HMC participants who received standard-of-care, nonconversational, hierarchical-based voice therapy.
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Affiliation(s)
| | - Jonathan Yabes
- Department of Biostatistics, University of Pittsburgh, PA
| | - Clark A. Rosen
- Department of Otolaryngology, University of California, San Francisco
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Abstract
BACKGROUND Waterpipe tobacco smoking (WTS or 'hookah') is common among adolescents and college students in the USA. However, there has not yet been a large-scale, nationally representative study independently examining WTS among young adults who are not in college. OBJECTIVE This study sought to examine associations between attitudes, normative beliefs, certain socio-demographic factors and current WTS among young adults not in college and compare them to young adults in college. METHODS A total of 3131 US adults ages 18-30 completed an online survey about WTS behaviour, attitudes, normative beliefs and relevant socio-demographic factors. Multivariable logistic regression was used to examine independent associations between these variables and current WTS stratified by student status. RESULTS Ever WTS was reported by 29% of young adults not in college and by 35% of those in college, and current use rates were 3 and 7%, respectively. Multivariable models demonstrated that positive attitudes and perceived peer acceptability of WTS were significantly associated with increased current WTS for both young adults not in college [adjusted odds ratio (AOR) = 2.72; 95% CI: 2.00-3.71 and AOR = 2.02; 95% CI: 1.50-2.71, respectively] and young adults in college (AOR = 3.37; 95% CI: 2.48-4.58 and AOR = 2.05; 95% CI: 1.49-2.83, respectively). The magnitude of these associations was not significantly different when comparing individuals in college and not in college. CONCLUSIONS Among young adults, WTS is common in non-college-based populations as well as in college-based populations. Therefore, prevention programming should extend to all young adults, not only to those in college.
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Affiliation(s)
- Jaime E Sidani
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore Hospital, Pittsburgh, PA, USA.,Center for Research on Media, Technology, and Health, PA, USA
| | - Ariel Shensa
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore Hospital, Pittsburgh, PA, USA.,Center for Research on Media, Technology, and Health, PA, USA
| | - Jonathan Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore Hospital, Pittsburgh, PA, USA.,Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carl Fertman
- Department of Health and Physical Activity, University of Pittsburgh School of Education, Pittsburgh, PA, USA
| | - Brian A Primack
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, UPMC Montefiore Hospital, Pittsburgh, PA, USA.,Center for Research on Media, Technology, and Health, PA, USA.,Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University Honors College, University of Pittsburgh, Pittsburgh, PA, USA
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14
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Jhamb M, Abdel-Kader K, Yabes J, Wang Y, Weisbord SD, Unruh M, Steel JL. Comparison of Fatigue, Pain, and Depression in Patients With Advanced Kidney Disease and Cancer-Symptom Burden and Clusters. J Pain Symptom Manage 2019; 57:566-575.e3. [PMID: 30552961 PMCID: PMC6382584 DOI: 10.1016/j.jpainsymman.2018.12.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Although symptom clusters have been studied in the context of cancer, few data exist in chronic and end-stage kidney disease (CKD/ESKD) patients. OBJECTIVES The objectives of this study were to 1) characterize and compare symptom cluster phenotypes in patients with advanced CKD, ESKD, and cancer and 2) explore predictors of symptom clusters. METHODS We conducted secondary data analysis of three prospective studies in which pain, depression, and fatigue were assessed in patients with Stage 4-5 CKD, ESKD, and gastrointestinal cancer. Tetrachoric correlations between these symptoms were quantified, and partitioning around medoids algorithm was used for symptom cluster analysis. RESULTS In the 82 CKD, 149 ESKD, and 606 cancer patients, no differences in the average fatigue (P = 0.17) or pain levels (P = 0.21) were observed. Over 80% of patients in each group had at least one symptom. Moderate or severe depressive symptoms were more common in patients with cancer (31% vs. 19% in ESKD vs. 9% in CKD; P < 0.001). Mild-moderate correlations were observed between the three symptoms in ESKD and cancer patients. Three distinct clusters were observed in each group. In ESKD, the HIGH cluster (with high probability of pain, depression, and fatigue) had higher body mass index (P < 0.001) and antidepressant use (P = 0.01). In cancer patients, the HIGH cluster patients were more likely to be female (P = 0.04), use antidepressants (P = 0.04), and have lower serum albumin (P < 0.001) and hemoglobin (P = 0.03) compared to the other two clusters. CONCLUSION Although the burden of fatigue, pain, and depressive symptoms for CKD and ESKD patients is similar to patients with gastrointestinal cancer, symptom cluster phenotypes differed between the groups as did the predictors of symptom clusters.
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Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven D Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Renal Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
We conducted an observational retrospective cohort study to evaluate the risk factors and the maternal morbidity associated with unintended extensions of the hysterotomy during caesarean delivery. We evaluated 2707 women who underwent low-transverse caesarean deliveries in 2011 at an academic, tertiary-care hospital. Hysterotomy extensions were identified through operative reports. Of the 2707 caesarean deliveries, 392 (14.5%) had an unintended hysterotomy extension. On the multivariable regression modelling, neonatal weight (OR 1.42; 95%CI 1.17-1.73), the arrest of labour [first-stage arrest (2.42; 1.73-3.38); second-stage arrest (5.54; 3.88-7.90)] and a non-reassuring foetal status (1.65; 1.20-2.25) were significantly associated with hysterotomy extensions. Hysterotomy extensions were significantly associated with an increased morbidity including an estimated blood loss >1200 millilitres (2.06; 1.41-3.02), a decline in postoperative haemoglobin ≥3.7 g/dL (2.07; 1.35-3.17), an evaluation for lower urinary tract injury (5.58; 3.17-9.81), and a longer operative time (8.11; 6.33-9.88). Based on these results, we conclude that unintended hysterotomy extensions significantly increase the maternal morbidity of caesarean deliveries. Impact statement What is already known on this subject? Maternal morbidity associated with caesarean delivery (CD) is significantly greater than that in vaginal delivery. Unintended extensions of the hysterotomy occur in approximately 4-8% of CDs and are more common after a prolonged second stage of labour. The morbidity associated with hysterotomy extensions has been incompletely evaluated. What do the results of this study add? We demonstrate a rate of hysterotomy extension in a general obstetric population of approximately 15%, which is higher than previously reported estimates, and represents a potential doubling of the rate of the unintended hysterotomy extensions in recent years. The most significant risk factor for a hysterotomy extension was a second-stage labour arrest with a fourfold increase in the frequency of extensions. A hysterotomy extension is a significant independent risk factor for an intraoperative haemorrhage, a drop in postoperative haemoglobin, an intraoperative evaluation for lower urinary tract injury, and longer CD operative times. What are the implications of these findings for clinical practice and/or further research? A second-stage arrest is a strong independent risk factor for a hysterotomy extension. Recent re-evaluations of the labour curve that extend the second stage of labour will likely increase the frequency of CDs performed after a prolonged second stage. In these scenarios, obstetricians should be prepared for an unintended hysterotomy extension and for the possibility of a longer procedure with the increased risks of blood loss and the need for evaluation of the lower urinary tract.
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Affiliation(s)
- Lauren E. Giugale
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Sara Sakamoto
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Jonathan Yabes
- Center for Research on Healthcare, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Elizabeth E. Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
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16
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Roumelioti ME, Steel JL, Yabes J, Vowles KE, Vodovotz Y, Beach S, Rollman B, Weisbord SD, Unruh ML, Jhamb M. Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial). Contemp Clin Trials 2018; 73:81-91. [PMID: 30208343 PMCID: PMC6168366 DOI: 10.1016/j.cct.2018.09.002] [Citation(s) in RCA: 6] [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: 05/11/2018] [Revised: 08/17/2018] [Accepted: 09/07/2018] [Indexed: 01/08/2023]
Abstract
Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, United States
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico & Division of Physical Medicine and Rehabilitation, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Yoram Vodovotz
- Department of Immunology and Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Scott Beach
- Department of Psychology, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bruce Rollman
- Department of Medicine, Psychiatry, Biomedical Informatics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, United States
| | - Steven D Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, United States
| | - Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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17
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Huang DT, Yealy DM, Filbin MR, Brown AM, Chang CCH, Doi Y, Donnino MW, Fine J, Fine MJ, Fischer MA, Holst JM, Hou PC, Kellum JA, Khan F, Kurz MC, Lotfipour S, LoVecchio F, Peck-Palmer OM, Pike F, Prunty H, Sherwin RL, Southerland L, Terndrup T, Weissfeld LA, Yabes J, Angus DC. Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. N Engl J Med 2018; 379:236-249. [PMID: 29781385 PMCID: PMC6197800 DOI: 10.1056/nejmoa1802670] [Citation(s) in RCA: 262] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. METHODS In 14 U.S. hospitals with high adherence to quality measures for the treatment of pneumonia, we provided guidance for clinicians about national clinical practice recommendations for the treatment of lower respiratory tract infections and the interpretation of procalcitonin assays. We then randomly assigned patients who presented to the emergency department with a suspected lower respiratory tract infection and for whom the treating physician was uncertain whether antibiotic therapy was indicated to one of two groups: the procalcitonin group, in which the treating clinicians were provided with real-time initial (and serial, if the patient was hospitalized) procalcitonin assay results and an antibiotic use guideline with graded recommendations based on four tiers of procalcitonin levels, or the usual-care group. We hypothesized that within 30 days after enrollment the total antibiotic-days would be lower - and the percentage of patients with adverse outcomes would not be more than 4.5 percentage points higher - in the procalcitonin group than in the usual-care group. RESULTS A total of 1656 patients were included in the final analysis cohort (826 randomly assigned to the procalcitonin group and 830 to the usual-care group), of whom 782 (47.2%) were hospitalized and 984 (59.4%) received antibiotics within 30 days. The treating clinician received procalcitonin assay results for 792 of 826 patients (95.9%) in the procalcitonin group (median time from sample collection to assay result, 77 minutes) and for 18 of 830 patients (2.2%) in the usual-care group. In both groups, the procalcitonin-level tier was associated with the decision to prescribe antibiotics in the emergency department. There was no significant difference between the procalcitonin group and the usual-care group in antibiotic-days (mean, 4.2 and 4.3 days, respectively; difference, -0.05 day; 95% confidence interval [CI], -0.6 to 0.5; P=0.87) or the proportion of patients with adverse outcomes (11.7% [96 patients] and 13.1% [109 patients]; difference, -1.5 percentage points; 95% CI, -4.6 to 1.7; P<0.001 for noninferiority) within 30 days. CONCLUSIONS The provision of procalcitonin assay results, along with instructions on their interpretation, to emergency department and hospital-based clinicians did not result in less use of antibiotics than did usual care among patients with suspected lower respiratory tract infection. (Funded by the National Institute of General Medical Sciences; ProACT ClinicalTrials.gov number, NCT02130986 .).
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Affiliation(s)
- David T Huang
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Donald M Yealy
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael R Filbin
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Aaron M Brown
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Chung-Chou H Chang
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Yohei Doi
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael W Donnino
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Jonathan Fine
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael J Fine
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michelle A Fischer
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - John M Holst
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Peter C Hou
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - John A Kellum
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Feras Khan
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael C Kurz
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Shahram Lotfipour
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Frank LoVecchio
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Octavia M Peck-Palmer
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Francis Pike
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Heather Prunty
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Robert L Sherwin
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Lauren Southerland
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Thomas Terndrup
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Lisa A Weissfeld
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Jonathan Yabes
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Derek C Angus
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
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Bryce CL, Chang CCH, Ren Y, Yabes J, Zenarosa G, Iyer A, Tomko H, Squires RH, Roberts MS. Using time-varying models to estimate post-transplant survival in pediatric liver transplant recipients. PLoS One 2018; 13:e0198132. [PMID: 29851966 PMCID: PMC5978879 DOI: 10.1371/journal.pone.0198132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/14/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To distinguish clinical factors that have time-varying (as opposed to constant) impact upon patient and graft survival among pediatric liver transplant recipients. METHODS Using national data from 2002 through 2013, we examined potential clinical and demographic covariates using Gray's piecewise constant time-varying coefficients (TVC) models. For both patient and graft survival, we estimated univariable and multivariable Gray's TVC, retaining significant covariates based on backward selection. We then estimated the same specification using traditional Cox proportional hazards (PH) models and compared our findings. RESULTS For patient survival, covariates included recipient diagnosis, age, race/ethnicity, ventilator support, encephalopathy, creatinine levels, use of living donor, and donor age. Only the effects of recipient diagnosis and donor age were constant; effects of other covariates varied over time. We retained identical covariates in the graft survival model but found several differences in their impact. CONCLUSION The flexibility afforded by Gray's TVC estimation methods identify several covariates that do not satisfy constant proportionality assumptions of the Cox PH model. Incorporating better survival estimates is critical for improving risk prediction tools used by the transplant community to inform organ allocation decisions.
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Affiliation(s)
- Cindy L Bryce
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Chung Chou H Chang
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Yi Ren
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Gabriel Zenarosa
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Aditya Iyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Heather Tomko
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Robert H Squires
- Department of Pediatrics, School of Medicine; Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark S Roberts
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Shamir AR, Karembelkar A, Yabes J, Yao Y, Miskulin D, Gassman J, Ploth D, Negrea L, Paine S, Rahman M, Kwong RY, Zager P, Jhamb M. Association of Intradialytic Hypertension with Left Ventricular Mass in Hypertensive Hemodialysis Patients Enrolled in the Blood Pressure in Dialysis (BID) Study. Kidney Blood Press Res 2018; 43:882-892. [PMID: 29870977 PMCID: PMC6487648 DOI: 10.1159/000490336] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 05/24/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND/AIMS Intradialytic hypertension (IDH), or paradoxical rise in blood pressure (BP) during hemodialysis (HD) is associated with increased morbidity and mortality. The association between IDH and increased left ventricular mass (LVM), a well-known risk factor for adverse cardiovascular outcomes in HD patients, has not been studied. The aim of our study is to evaluate the cross-sectional association of intradialytic change in BP with cardiac structure and function measured by cardiac MRI in hypertensive HD patients enrolled in the multi-center Blood Pressure in Dialysis (BID) clinical trial. METHODS Participants in the BID study were categorized into 3 groups based on average change (Δ) in systolic blood pressure (SBP) (post-HD SBP minus pre-HD SBP) during HD over a 1 month period: group 1 - patients with an increase in SBP ≥ 10mm Hg during HD (IDH); group 2 -patients with SBP decrease of greater ≥10mm Hg during HD; group 3 - patients with SBP increase or decrease by < 10mm Hg during HD. LVM index (LVMI) was measured using cardiac MRI, which were centrally read. Baseline characteristics were compared in the 3 groups and multivariable regression models were fitted for the adjusted association of IDH with LVMI. RESULTS Among the 80 participants, 7 (8.8%) had IDH and had average Δ SBP 17.0 ± 10.1 mmHg during HD. Patients with IDH were less likely to be diabetic, had lower pre-dialysis SBP and lower percent interdialytic weight gain as compared to the other 2 groups (p=0.02, p< 0.001 and p=0.02 respectively). In multivariable regression analyses, IDH was significantly associated with LVMI (adjusted mean difference relative to SBP decreased group [95% confidence interval (CI)] = 12.5 [3.6, 21.5], p=0.01) after adjusting for age, sex, diabetes, IDWG%, pre-HD SBP and beta blocker use. Every 1 mm rise in ΔSBP during HD was associated with 0.2 g/m2 increase in LVMI in adjusted models (p=0.04). CONCLUSION IDH is independently associated with higher LVMI in hypertensive HD patients and may contribute to increased cardiovascular events.
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Affiliation(s)
- Amith Roy Shamir
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yi Yao
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dana Miskulin
- Nephrology Division, Department of Medicine, Tufts University, Boston, Massachusetts, USA
| | - Jennifer Gassman
- Quantitative Health Sciences Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Ploth
- Nephrology Division, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lavinia Negrea
- Nephrology and Hypertension Division, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Susan Paine
- Dialysis Clinic, Inc., New Mexico, New Mexico, USA
| | - Mahboob Rahman
- Nephrology and Hypertension Division, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Philip Zager
- Dialysis Clinic, Inc., New Mexico, New Mexico, USA
- Nephrology Division, Department of Medicine, University of New Mexico, New Mexico, New Mexico, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,
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Fam M, Yabes J, Hale N, Turner R, Bandari J, Macleod L, Hugar L, Gingrich J, Borza T, Skolarus T, Davies B, Jacobs B. MP71-20 COMPARATIVE EFFECTIVENESS OF NEOADJUVANT AND ADJUVANT CHEMOTHERAPY IN THE MEDICARE BLADDER CANCER POPULATION. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fam M, Yabes J, Hale N, Turner R, Yu M, Macleod L, Hugar L, Gingrich J, Borza T, Skolarus T, Davies B, Jacobs B. MP44-02 CHANGING TRENDS IN THE USE OF CHEMOTHERAPY FOR MUSCLE-INVASIVE BLADDER CANCER IN THE UNITED STATES. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Huang DT, Angus DC, Chang CCH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med 2017; 17:25. [PMID: 28851296 PMCID: PMC5576372 DOI: 10.1186/s12873-017-0138-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/09/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Overuse of antibiotics is a major public health problem, contributing to growing antibiotic resistance. Procalcitonin has been reported to be commonly elevated in bacterial, but not viral infection. Multiple European trials found procalcitonin-guided care reduced antibiotic use in lower respiratory tract infection, with no apparent harm. However, applicability to US practice is limited due to trial design features impractical in the US, between-country differences, and residual safety concerns. METHODS The Procalcitonin Antibiotic Consensus Trial (ProACT) is a multicenter randomized trial to determine the impact of a procalcitonin antibiotic prescribing guideline, implemented with basic reproducible strategies, in US patients with lower respiratory tract infection. DISCUSSION We describe the trial methods using the Consolidated Standards of Reporting Trials (CONSORT) framework, and the rationale for key design decisions, including choice of eligibility criteria, choice of control arm, and approach to guideline implementation. TRIAL REGISTRATION ClinicalTrials.gov NCT02130986 . Registered May 1, 2014.
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Affiliation(s)
- David T. Huang
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Pittsburgh, PA USA
- Department of Critical Care Medicine, University of Pittsburgh, Room 606B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA
- The MACRO (Multidisciplinary Acute Care Research Organization) Center, Pittsburgh, PA USA
| | - Derek C. Angus
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Pittsburgh, PA USA
- Department of Critical Care Medicine, University of Pittsburgh, Room 606B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
- The MACRO (Multidisciplinary Acute Care Research Organization) Center, Pittsburgh, PA USA
| | - Chung-Chou H. Chang
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Pittsburgh, PA USA
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA USA
| | - Michael J. Fine
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA USA
| | - John A. Kellum
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Pittsburgh, PA USA
- Department of Critical Care Medicine, University of Pittsburgh, Room 606B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
| | - Octavia M. Peck-Palmer
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Pittsburgh, PA USA
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA USA
| | | | | | - Jonathan Yabes
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA
- The MACRO (Multidisciplinary Acute Care Research Organization) Center, Pittsburgh, PA USA
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Turner II R, Yabes J, Davies B, Heron D, Jacobs B. PD32-09 DOWNSTREAM PROCEDURES FOLLOWING THE USE OF BONE SCAN IN THE STAGING OF MUSCLE-INVASIVE BLADDER CANCER. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.1400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hale N, Yabes J, Turner R, Fam M, Davies B, Jacobs B. MP96-07 PATIENT TRAVEL DISTANCES TO HIGH-VOLUME CYSTECTOMY CENTERS FOLLOW A COMPLEX RELATIONSHIP. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Little is known about the sexual health of male veterans. This study used nationally representative data from the 2011 to 2013 National Survey of Family Growth to compare sexual behaviors and history of sexually transmitted infections (STIs) between male veterans and nonveterans. The sample included 3,860 men aged 18 to 44 years who reported ever having sex with a man or woman. The key independent variable was veteran status. Sexual behavior outcomes included ≥6 lifetime female partners, ≥10 lifetime partners of either sex, ≥2 past-year partners of either sex, having past-year partners of both sexes, and condom nonuse at last vaginal sex. STI outcomes included past-year history of chlamydia, gonorrhea, or receiving any STI treatment; lifetime history of herpes, genital warts, or syphilis; and an aggregate measure capturing any reported STI history. Logistic regression models were used to evaluate associations between veteran status and each outcome. In models adjusting for age, race/ethnicity, education, income, and marital status, veterans had significantly greater odds than nonveterans of having ≥6 lifetime female partners (OR = 1.5, 95% CI [1.02, 2.31]). In models adjusting for age and marital status, veterans had significantly greater odds of having partners of both sexes in the past year (OR = 4.8, 95% CI [1.2, 19.8]), and gonorrhea in the past year (OR = 3.2, 95% CI [1.2, 8.5]). Male veterans were thus significantly more likely than nonveterans to have STI risk factors. Health care providers should be aware that male veterans may be at higher risk for STIs and assess veterans’ sexual risk behaviors.
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Affiliation(s)
- Mark W Evans
- 1 University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Sonya Borrero
- 2 Division of General Internal Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA.,3 Center for Women's Health Research and Innovation, Pittsburgh, PA, USA.,4 Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jonathan Yabes
- 2 Division of General Internal Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA.,5 Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elian A Rosenfeld
- 3 Center for Women's Health Research and Innovation, Pittsburgh, PA, USA.,4 Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Sharma A, Yabes J, Al Mawed S, Wu C, Stilley C, Unruh M, Jhamb M. Impact of Cognitive Function Change on Mortality in Renal Transplant and End-Stage Renal Disease Patients. Am J Nephrol 2016; 44:462-472. [PMID: 27798939 DOI: 10.1159/000451059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 03/07/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limited evidence from small-scale studies, mainly involving end-stage renal disease (ESRD) patients, suggests that kidney transplantation may improve cognitive function. We examined changes in cognitive function after a kidney transplant and its association with survival in advanced chronic kidney disease (CKD)/ESRD patients. METHODS In a prospective study design, cognitive performance of 90 patients (50.6 ± 13.1 years, 66.7% men, 27.8% blacks, 76% CKD stages 4-5) was assessed at the respective patients' residences using established neurocognitive tests. RESULTS Among the 90 patients, 44 received a kidney transplant (KTx group) while 46 did not (no-KTx group). After a mean follow-up of ∼19 months, there was no significant change in scores for majority of cognitive tests in either group. Older age, but not diabetes or renal function status (CKD vs. ESRD), was a determinant of poor follow-up cognitive performance. Additionally, poor attention/psychomotor speed and executive performance (as measured by Trails A and Stroop test, respectively) was associated with higher mortality over a mean follow-up of 4.7 years, even after adjustment for age, sex, diabetes, CKD or ESRD status and kidney transplant status. CONCLUSION Overall, cognitive function does not significantly improve after kidney transplant or significantly decline in non-transplanted, advanced CKD/ESRD patients. Poor attention, psychomotor speed and executive performance independent of transplant status were associated with higher mortality over time.
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Affiliation(s)
- Akhil Sharma
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pa., USA
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27
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Khurshid K, Yabes J, Weiss PM, Dharia S, Brown L, Unruh M, Jhamb M. Effect of Antihypertensive Medications on the Severity of Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. J Clin Sleep Med 2016; 12:1143-51. [PMID: 27397663 DOI: 10.5664/jcsm.6054] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 04/01/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is an independent risk factor for hypertension (HTN). Increasing evidence from animal and human studies suggests that HTN exacerbates OSA. We performed a systematic review and meta-analysis of studies evaluating the effect of anti-hypertensive medications on the severity of OSA. METHODS A literature search of PubMed and Embase was done using search concepts of OSA, HTN, and drug classes used to treat HTN. Studies that reported changes in the severity of OSA objectively by using apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) were included. Pooled mean difference estimates were calculated. Tests for heterogeneity, publication bias, and subgroup sensitivity analysis were conducted. RESULTS Of 27,376 studies screened, only 11 met inclusion criteria, including 5 randomized controlled trials and 6 single-arm prospective trials. The pooled mean difference estimate (95% confidence interval [CI]), based on a random-effects model, was -5.69 (95% CI -10.74 to -0.65), consistent with an overall decrease in AHI or RDI attributable to antihypertensive medications. The effect size was even more pronounced, -14.52 (95% CI -25.65 to -3.39), when only studies using diuretics were analyzed. There was no significant heterogeneity or publication bias among the studies. Meta-regression indicated neither age, baseline AHI, nor change in systolic/diastolic blood pressure influenced the results. CONCLUSIONS Collectively, findings from these relatively small, short-term studies tend to support the contention that treatment with antihypertensive agents confers a statistically significant, albeit small, reduction in the severity of OSA, which may be more pronounced with the use of diuretics.
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Affiliation(s)
- Kiran Khurshid
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patricia M Weiss
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA
| | - Sushma Dharia
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Lee Brown
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Mark Unruh
- Nephrology Division, Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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28
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Seaman CD, Apostolova M, Yabes J, Comer DM, Ragni MV. Prevalence and Risk Factors Associated With Hypertension in Hemophilia: Cross-Sectional Analysis of a National Discharge Register. Clin Appl Thromb Hemost 2016; 23:871-875. [DOI: 10.1177/1076029616655616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction: Improved life expectancy of persons with hemophilia (PWHs) has led to a greater interest in the role of age-related chronic diseases, such as hypertension, in this cohort. Several observational studies have reported an increased prevalence of hypertension in PWHs; however, this has not been assessed using a large, national database in the United States. Aims: We hypothesized the prevalence of hypertension is increased in PWHs and compared the prevalence of hypertension and associated risk factors among patients with and without hemophilia. Methods: A cross-sectional analysis was performed using discharge data among adult males from the National Inpatient Sample over the 3-year period, 2009 to 2011. Hypertension was compared across groups using Rao-Scott χ2 test. Multivariable logistic regression was used to estimate the odds of hypertension in patients with hemophilia after adjustment for hypertension-associated risk factors. Results: The prevalence of hypertension in patients with hemophilia was less than the prevalence of hypertension in patients without hemophilia (39.5% vs 56.3%, P < .001). Hemophilia was associated with a decreased odds of hypertension after adjusting for associated risk factors (odds ratio: 0.87; 95% confidence interval: 0.81-0.94). Conclusion: In contrast to the findings of several other recent studies, we report a decreased prevalence of hypertension in PWHs. The discrepancy among the reported prevalence of hypertension in our study and several others highlights the potential biases inherent to retrospective and cross-sectional studies and underscores the need for well-designed prospective studies to determine the true incidence of hypertension in PWHs, which may lie somewhere in between our findings and the findings of others.
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Affiliation(s)
- Craig D. Seaman
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Mariya Apostolova
- Division of Hematology/Oncology, Department of Medicine, West Penn Allegheny Health Network, Pittsburgh, PA, USA
| | - Jonathan Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Diane M. Comer
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Margaret V. Ragni
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
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29
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Rajakumar K, Moore CG, Yabes J, Olabopo F, Haralam MA, Comer D, Holick MF, Greenspan SL. Estimations of dietary vitamin D requirements in black and white children. Pediatr Res 2016; 80:14-20. [PMID: 26959482 PMCID: PMC4929030 DOI: 10.1038/pr.2016.46] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/23/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Institute of Medicine (IOM) dietary guidelines for vitamin D are based on limited pediatric data. Our objective was to estimate the dietary vitamin D requirements for maintaining serum 25-hydroxyvitamin D [25(OH)D] concentrations at the various IOM-considered thresholds of vitamin D status (12, 16, and 20 ng/ml) during fall and winter in children. METHODS Ninety-six healthy 8- to 14-y-old Pittsburgh-area black and white children enrolled in a randomized, placebo-controlled trial of vitamin D3 1,000 IU daily for 6 mo with baseline and 2-mo follow-up assessments completed during October through April were studied. Vitamin D intake from diet and study supplement adjusted for adherence and serum 25(OH)D were measured. RESULTS The vitamin D intakes needed to maintain serum 25(OH)D concentrations at 12, 16, and 20 ng/ml in 90% of the children were 581, 1,062, and 1543 IU/day, respectively. The estimated vitamin D intakes needed to maintain serum 25(OH)D concentrations at 20 ng/ml in 97.5% of the children was 2,098 IU/day. CONCLUSION Our data suggest that the current vitamin D recommended dietary allowance (RDA) (600 IU/day) is insufficient to cover the skeletal health needs of at least 50% of black and white children.
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Affiliation(s)
| | - Charity G Moore
- Dickson Advanced Analytics, Carolinas HealthCare System,
Charlotte, NC
| | - Jonathan Yabes
- Center for Research on Health Care, University of
Pittsburgh, Pittsburgh, PA,Department of Medicine, University of Pittsburgh,
Pittsburgh, PA
| | - Flora Olabopo
- Department of Pediatrics, University of Pittsburgh,
Pittsburgh, PA
| | - Mary Ann Haralam
- Department of Pediatrics, University of Pittsburgh,
Pittsburgh, PA
| | - Diane Comer
- Center for Research on Health Care, University of
Pittsburgh, Pittsburgh, PA,Department of Medicine, University of Pittsburgh,
Pittsburgh, PA
| | - Michael F Holick
- Department of Medicine, Boston University School of
Medicine, Boston, MA
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30
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Seaman CD, Yabes J, Comer DM, Ragni MV. Does deficiency of von Willebrand factor protect against cardiovascular disease? Analysis of a national discharge register. J Thromb Haemost 2015; 13:1999-2003. [PMID: 26368360 DOI: 10.1111/jth.13142] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/10/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION von Willebrand factor (VWF) plays a critical role in platelet adhesion and aggregation after vascular injury and at sites of high shear rate. Elevated VWF levels are associated with an increased risk of ischemic cardiovascular events; however, it is unclear whether VWF deficiency is protective against atherosclerosis. We aimed to compare the prevalence of cardiovascular disease (CVD) among patients with and without von Willebrand disease (VWD). METHODS A cross-sectional analysis was performed on discharge data for adults from the Nationwide Inpatient Sample (NIS) between the years 2009 and 2011. CVD was defined as ischemic heart disease, myocardial infarction, ischemic cerebrovascular disease, or peripheral vascular disease. For prevalence calculations and statistical analyses, we used discharge-level weights provided by the NIS to reflect national estimates. CVD was compared across groups by use of the Rao-Scott chi-square test. Multivariable logistic regression was used to estimate the likelihood of CVD in VWD patients after adjustment for age, gender, and CVD-related risk factors. RESULTS The prevalence of CVD in VWD patients was less than the prevalence of CVD in non-VWD patients (15.0% versus 26.0%). VWD was associated with a decreased likelihood of CVD after adjustment for age, gender, and CVD-related risk factors (odds ratio 0.85; 95% confidence interval 0.79-0.92). DISCUSSION These findings indicate that the risk of CVD is decreased among VWD patients, and that VWF deficiency may be protective against CVD.
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Affiliation(s)
- C D Seaman
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - J Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - D M Comer
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - M V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
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31
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Jacobs BL, Sunderland R, Yabes J, Nelson JB, Barnato AE, Bekelman JE. Local coverage determination policy and the use of stereotactic body radiation therapy for prostate cancer. Urol Pract 2015; 2:304-311. [PMID: 27493987 DOI: 10.1016/j.urpr.2015.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Local coverage determinations (LCDs) are local decisions that regulate healthcare coverage. We evaluated the impact of LCDs as well as patient, tumor, and market characteristics on the adoption of stereotactic body radiation therapy (SBRT) for prostate cancer. METHODS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare, we identified men treated with SBRT, intensity-modulated radiotherapy (IMRT), and robotic prostatectomy. We compared demographics, clinical characteristics, and market factors among these three treatments. Our primary exposure was LCD policy; using the Medicare Coverage Database, we categorized LCDs as favorable (SBRT covered), neutral (SBRT covered in the context of a clinical trial or registry), unfavorable (SBRT not covered), or absent (i.e., SBRT not governed by an LCD at the time of treatment). We fit a multivariable multinomial logistic regression model and generated predicted probabilities to examine the relation between LCDs and SBRT. RESULTS During this early period of SBRT adoption, IMRT was the most common of the three treatments followed by robotic prostatectomy and then SBRT. SBRT use was high when governed by favorable and neutral LCDs and lowest when governed by unfavorable LCDs. Compared with favorable LCDs, areas where LCDs were absent were associated with higher SBRT use compared with IMRT (odds ratio [OR] 1.56; 95%CI, 1.07-2.25) and robotic prostatectomy (OR 1.84; 95%CI, 1.25-2.69). CONCLUSIONS When present, LCDs appear to regulate early SBRT adoption, but, when absent, are associated with increased SBRT use. Although SBRT use was uncommon, it varied across a wide range of patient, tumor, and market characteristics.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert Sunderland
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Yabes
- Division of General Internal Medicine, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, Center for Research on Health Care, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Joel B Nelson
- Department of Urology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Amber E Barnato
- Division of General Internal Medicine, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, Center for Research on Health Care, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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32
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Jackson Foster LJ, Phillips CM, Yabes J, Breslau J, O'Brien K, Miller E, Pecora PJ. Childhood behavioral disorders and trauma: Predictors of comorbid mental disorders among adult foster care alumni. ACTA ACUST UNITED AC 2015. [DOI: 10.1037/trm0000036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rajakumar K, Moore CG, Yabes J, Olabopo F, Haralam MA, Comer D, Bogusz J, Nucci A, Sereika S, Dunbar-Jacob J, Holick MF, Greenspan SL. Effect of Vitamin D3 Supplementation in Black and in White Children: A Randomized, Placebo-Controlled Trial. J Clin Endocrinol Metab 2015; 100:3183-92. [PMID: 26091202 PMCID: PMC4524986 DOI: 10.1210/jc.2015-1643] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
CONTEXT Dosages of vitamin D necessary to prevent or treat vitamin D deficiency in children remain to be clarified. OBJECTIVE To determine the effects of vitamin D3 1000 IU/d on serum 25-hydroxyvitamin D [25(OH)D], PTH, and markers of bone turnover (osteocalcin and collagen type 1 cross-linked C-telopeptide) in black children and white children, and to explore whether there is a threshold level of 25(OH)D associated with maximal suppression of serum PTH concentration. DESIGN Healthy 8- to 14-year-old Pittsburgh-area black (n = 84) and white (n = 73) children not receiving vitamin supplements, enrolled from October through March from 2008 through 2011, were randomized to vitamin D3 1000 IU or placebo daily for 6 months. RESULTS The mean baseline concentration of 25(OH)D was <20 ng/mL in both the vitamin D-supplemented group and the placebo group (19.8 ± 7.6 and 18.8 ± 6.9 ng/mL, respectively). The mean concentration was higher in the supplemented group than in the placebo group at 2 months (26.4 ± 8.1 vs 18.9 ± 8.1 ng/mL; P < .0001) and also at 6 months (26.7 ± 7.6 vs 22.4 ± 7.3; P = .003), after adjusting for baseline 25(OH)D, race, gender, pubertal status, dietary vitamin D intake, body mass index, and sunlight exposure. Increases were only significant in black children, when examined by race. The association between 25(OH)D and PTH concentrations was inverse and linear, without evidence of a plateau. Overall, vitamin D supplementation had no effect on PTH and bone turnover. CONCLUSIONS Vitamin D3 supplementation with 1000 IU/d in children with mean baseline 25(OH)D concentration <20 ng/mL effectively raised their mean 25(OH)D concentration to ≥20 ng/mL but failed to reach 30 ng/mL. Vitamin D supplementation had no effect on PTH concentrations.
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Affiliation(s)
- Kumaravel Rajakumar
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Charity G Moore
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Jonathan Yabes
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Flora Olabopo
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Mary Ann Haralam
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Diane Comer
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Jaimee Bogusz
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Anita Nucci
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Susan Sereika
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Jacqueline Dunbar-Jacob
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Michael F Holick
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
| | - Susan L Greenspan
- Department of Pediatrics (K.R., F.O., M.A.H.), and Center for Research on Health Care (C.G.M., J.Y., D.C.), University of Pittsburgh, Pittsburgh, Pennsylvania 15213; Department of Medicine (J.B., M.F.H.), Boston University School of Medicine, Boston, Massachusetts, 02118; Department of Nutrition (A.N.), Georgia State University, Atlanta, Georgia 30302; University of Pittsburgh School of Nursing (S.S., J.D.-J.), Pittsburgh, Pennsylvania 15213; and Department of Medicine (C.G.M., J.Y., D.C., S.L.G.), University of Pittsburgh, Pittsburgh 15213
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Malec LM, Moore CG, Yabes J, Li J, Ragni MV. Postpartum haemorrhage in women with von Willebrand disease: an observational study of the Pennsylvania Health Care Cost Containment Council (PHC4) database. Haemophilia 2015; 21:e442-5. [DOI: 10.1111/hae.12739] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 11/29/2022]
Affiliation(s)
- L. M. Malec
- Department of Pediatrics; Division of Hematology/Oncology; Children's Hospital of Pittsburgh of UPMC and Hemophilia Center of Western Pennsylvania; Pittsburgh PA USA
| | - C. G. Moore
- Center for Healthcare Research Data Center; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - J. Yabes
- Center for Healthcare Research Data Center; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - J. Li
- Center for Healthcare Research Data Center; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - M. V. Ragni
- Department of Medicine; Division Hematology/Oncology; University of Pittsburgh and Hemophilia Center of Western Pennsylvania; Pittsburgh PA USA
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Torok KS, Kurzinski K, Kelsey C, Yabes J, Magee K, Vallejo AN, Medsger T, Feghali-Bostwick CA. Peripheral blood cytokine and chemokine profiles in juvenile localized scleroderma: T-helper cell-associated cytokine profiles. Semin Arthritis Rheum 2015; 45:284-93. [PMID: 26254121 DOI: 10.1016/j.semarthrit.2015.06.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 04/13/2015] [Accepted: 06/12/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate peripheral blood T-helper (TH) cell-associated cytokine and chemokine profiles in localized scleroderma (LS), and correlate them with clinical disease features, including disease activity parameters. METHODS A 29-plex Luminex platform was used to analyze the humoral profile of plasma samples from 69 pediatric LS patients and 71 healthy pediatric controls. Cytokine/chemokine levels were compared between these two groups and within LS patients, focusing on validated clinical outcome measures of disease activity and damage in LS. RESULTS Plasma levels of IP-10, MCP-1, IL-17a, IL-12p70, GM-CSF, PDGF-bb, IFN-α2, and IFN-γ were significantly higher in LS subjects compared to healthy controls. Analysis within the LS group demonstrated IP-10, TNF-α, and GM-CSF correlated with clinical measures of disease activity. Several cytokines/chemokines correlated with anti-histone antibody, while only a few correlated with positive ANA and single-stranded DNA antibody. CONCLUSION This is the first time that multiple cytokines and chemokines have been examined simultaneously in LS. In general, a TH1 (IFN-γ) and TH17 (IL-17a) predominance was demonstrated in LS compared to healthy controls. There is also an IFN-γ signature with elevated IP-10, MCP-1, and IFN-γ, which has been previously demonstrated in systemic sclerosis, suggesting a shared pathophysiology. Within the LS patients, those with active disease demonstrated IP-10, TNF-α, and GM-CSF, which may potentially serve as biomarkers of disease activity in the clinical setting.
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Affiliation(s)
- Kathryn S Torok
- Division of Pediatric Rheumatology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224; Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA.
| | - Katherine Kurzinski
- Division of Pediatric Rheumatology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224
| | - Christina Kelsey
- Division of Pediatric Rheumatology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224
| | - Jonathan Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Kelsey Magee
- Division of Pediatric Rheumatology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224
| | - Abbe N Vallejo
- Division of Pediatric Rheumatology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224; Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Thomas Medsger
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Carol A Feghali-Bostwick
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, Medical University of South Carolina, Charleston, SC
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Seaman CD, Yabes J, Li J, Moore CG, Ragni MV. Venous thromboembolism in pregnant women with sickle cell disease: a retrospective database analysis. Thromb Res 2014; 134:1249-52. [PMID: 25306185 DOI: 10.1016/j.thromres.2014.09.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [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: 06/09/2014] [Revised: 09/24/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The risk of venous thromboembolism (VTE) is higher during pregnancy, with an incidence between 0.05 and 0.2%, and among persons with sickle cell disease (SCD), yet the rates and risk factors, such as pneumonia, vasooclusive crisis (VOC), and acute chest syndrome (ACS), associated with pregnancy-related VTE are not firmly established in SCD. METHODS Inpatient hospital discharge data from 2007-2011 were obtained from the Pennsylvania Health Care Cost Containment Council to estimate the rate of VTE among African American delivery hospitalizations with SCD and to compare pregnancy complications and medical comorbidities among pregnant women with SCD. RESULTS Among 212 hospitalized deliveries in African-American women with SCD, 6 (2.8%, 95% CI 1.0%-5.9%) had VTE compared to 0.05 to 2.0% in the general population. Risk factors for VTE included pneumonia and diabetes mellitus. Overall, the prevalence of VTE, among hospitalized deliveries in SCD women with pneumonia, VOC, and/or ACS, 6.6%, was significantly greater than among those without these conditions, 2.2%, p<0.001. CONCLUSION Pregnancy-related VTE in women with SCD appears to be 1.5 to 5 times greater than pregnancy-related VTE in the general population. The higher prevalence of VTE among pregnant women with pneumonia, VOC, and/or ACS, and their potential clinical overlap, suggests that VTE may be missed in such women. We conclude that VTE in pregnant women with SCD may be more common than previously reported, and such women might be candidates for thromboprophylaxis.
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Affiliation(s)
- Craig D Seaman
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Jonathan Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jie Li
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charity G Moore
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA.
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Abdel-Kader K, Jhamb M, Mandich LA, Yabes J, Keene RM, Beach S, Buysse DJ, Unruh ML. Ecological momentary assessment of fatigue, sleepiness, and exhaustion in ESKD. BMC Nephrol 2014; 15:29. [PMID: 24502751 PMCID: PMC3927224 DOI: 10.1186/1471-2369-15-29] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 02/05/2014] [Indexed: 11/10/2022] Open
Abstract
Background Many patients on maintenance dialysis experience significant sleepiness and fatigue. However, the influence of the hemodialysis (HD) day and circadian rhythms on patients’ symptoms have not been well characterized. We sought to use ecological momentary assessment to evaluate day-to-day and diurnal variability of fatigue, sleepiness, exhaustion and related symptoms in thrice-weekly maintenance HD patients. Methods Subjects used a modified cellular phone to access an interactive voice response system that administered the Daytime Insomnia Symptom Scale (DISS). The DISS assessed subjective vitality, mood, and alertness through 19 questions using 7- point Likert scales. Subjects completed the DISS 4 times daily for 7 consecutive days. Factor analysis was conducted and a mean composite score of fatigue-sleepiness-exhaustion was created. Linear mixed regression models (LMM) were used to examine the association of time of day, dialysis day and fatigue, sleepiness, and exhaustion composite scores. Results The 55 participants completed 1,252 of 1,540 (81%) possible assessments over the 7 day period. Multiple symptoms related to mood (e.g., feeling sad, feeling tense), cognition (e.g., difficulty concentrating), and fatigue (e.g., exhaustion, feeling sleepy) demonstrated significant daily and diurnal variation, with higher overall symptom scores noted on hemodialysis days and later in the day. In factor analysis, 4 factors explained the majority of the observed variance for DISS symptoms. Fatigue, sleepiness, and exhaustion loaded onto the same factor and were highly intercorrelated. In LMM, mean composite fatigue-sleepiness-exhaustion scores were associated with dialysis day (coefficient and 95% confidence interval [CI] 0.21 [0.02 – 0.39]) and time of day (coefficient and 95% CI 0.33 [0.25 – 0.41]. Observed associations were minimally affected by adjustment for demographics and common confounders. Conclusions Maintenance HD patients experience fatigue-sleepiness-exhaustion symptoms that demonstrate significant daily and diurnal variation. The variability in symptoms may contribute to poor symptom awareness by providers and greater misclassification bias of fatigue related symptoms in clinical studies.
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Affiliation(s)
- Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, MCN S-3223, Nashville, TN 37232-2372, USA.
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Thyvalikakath TP, Dziabiak MP, Johnson R, Torres-Urquidy MH, Acharya A, Yabes J, Schleyer TK. Advancing cognitive engineering methods to support user interface design for electronic health records. Int J Med Inform 2014; 83:292-302. [PMID: 24503391 DOI: 10.1016/j.ijmedinf.2014.01.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 12/17/2013] [Accepted: 01/10/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite many decades of research on the effective development of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow, especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practitioners in the United States. A critical reason for slow adoption is the poor usability of clinical systems, which makes it difficult for providers to navigate through the information and obtain an integrated view of patient data. OBJECTIVE In this study, we documented the cognitive processes and information management strategies used by dentists during a typical patient examination. The results will inform the design of a novel electronic dental record interface. METHODS We conducted a cognitive task analysis (CTA) study to observe ten general dentists (five general dentists and five general dental faculty members, each with more than two years of clinical experience) examining three simulated patient cases using a think-aloud protocol. RESULTS Dentists first reviewed the patient's demographics, chief complaint, medical history and dental history to determine the general status of the patient. Subsequently, they proceeded to examine the patient's intraoral status using radiographs, intraoral images, hard tissue and periodontal tissue information. The results also identified dentists' patterns of navigation through patient's information and additional information needs during a typical clinician-patient encounter. CONCLUSION This study reinforced the significance of applying cognitive engineering methods to inform the design of a clinical system. Second, applying CTA to a scenario closely simulating an actual patient encounter helped with capturing participants' knowledge states and decision-making when diagnosing and treating a patient. The resultant knowledge of dentists' patterns of information retrieval and review will significantly contribute to designing flexible and task-appropriate information presentation in electronic dental records.
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Affiliation(s)
- Thankam P Thyvalikakath
- Dental Informatics Core, Indiana University School of Dentistry, 1121 W Michigan Street, S316, Indianapolis, IN, USA; Center for Biomedical Informatics, Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN, USA.
| | - Michael P Dziabiak
- Office of Faculty Affairs, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raymond Johnson
- School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Amit Acharya
- Biomedical Informatics Research Center, Marshfield Clinic, Marshfield, WI, USA
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Titus K Schleyer
- Center for Biomedical Informatics, Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN, USA
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Jhamb M, Liang K, Yabes J, Steel JL, Dew MA, Shah N, Unruh M. Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue? Am J Nephrol 2013; 38:489-95. [PMID: 24335380 DOI: 10.1159/000356939] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [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: 09/18/2013] [Accepted: 10/31/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Fatigue is an important symptom to patients with advanced chronic kidney disease (CKD). The aim of this study is to examine the prevalence and severity of fatigue among non-dialysis-dependent CKD and end-stage renal disease (ESRD) patients, to examine the association of fatigue with subjective and objective sleep quality, and to identify other modifiable factors associated with fatigue. METHODS A cross-sectional survey of 87 non-dialysis-dependent CKD (eGFR ≤45 ml/min/1.73 m(2)) and 86 ESRD patients was done using the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) and 36-Item Short-Form (SF-36) vitality scale. Higher FACIT-F score denoted less fatigue. Objective sleep was assessed using in-home polysomnography. Predictors of fatigue were determined using a linear regression model. RESULTS The mean FACIT-F score among all participants was 34.5 ± 11.0. Mean scores were similar among CKD and ESRD groups (34.25 ± 11.28 vs. 34.73 ± 10.86; p = 0.73). On univariate analyses, patients with higher levels of fatigue were more likely to have cardiovascular disease, benzodiazepine use, depressive symptoms, and slightly lower hemoglobin and serum albumin levels. There was no significant association between severity of sleep apnea and level of fatigue (Apnea Hypopnea Index 20.1 ± 27.6 vs. 20.3 ± 22.0; p = 0.69). Presence of cardiovascular disease, low serum albumin, depressive symptoms, poor subjective sleep quality, excessive daytime sleepiness and restless legs syndrome were independently associated with greater fatigue in multivariable regression models. The FACIT-F score correlated closely with the SF-36 vitality score (r = 0.81, p < 0.0001). CONCLUSIONS Patients with advanced CKD and ESRD experience profound fatigue. Depressive symptoms, restless legs syndrome, excessive daytime sleepiness, and low albumin levels may provide targets for interventions to improve fatigue in patients with advanced CKD.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pa., USA
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Su CT, Yabes J, Pike F, Weiner DE, Beddhu S, Burrowes JD, Rocco MV, Unruh ML. Changes in anthropometry and mortality in maintenance hemodialysis patients in the HEMO Study. Am J Kidney Dis 2013; 62:1141-50. [PMID: 23859719 DOI: 10.1053/j.ajkd.2013.05.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 05/16/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Poor nutritional status has been associated with worse patient survival in maintenance hemodialysis patients. Anthropometric values are important nutritional measures, incorporating muscle and fat mass. However, the association of changes in anthropometry, including midarm circumference (MAC) and skinfold measurements, with mortality in hemodialysis patients remains unknown. Accordingly, we explored this association in the Hemodialysis (HEMO) Study. STUDY DESIGN Post hoc analysis of cohort data from a clinical trial. SETTING & PARTICIPANTS 1,846 hemodialysis patients enrolled in the HEMO Study. PREDICTORS MAC and skinfold measurements. OUTCOMES Longitudinal changes in MAC and skinfolds were jointly modeled using repeated measures and survival modeling. Time-to-event outcomes were all-cause mortality, cardiac death and hospitalization, and infection-related death. RESULTS Mean MAC was 30.1 cm, and mean baseline sum of subscapular, biceps, and triceps skinfolds was 42.4 mm. During a median follow-up of 2.5 years, there were 845 deaths. During follow-up, MAC and the skinfold measurement declined 0.26 cm and 1.1 mm per year, respectively. Declines in MAC (per cm) and skinfold (per mm) measurements were associated with higher all-cause mortality (HRs of 1.58 [95% CI, 1.29-1.94; P < 0.001] and 1.06 [95% CI, 0.99-1.13; P = 0.09], respectively), poorer cardiac outcomes (HRs of 1.49 [95% CI, 1.23-1.81; P < 0.001] and 1.05 [95% CI, 0.99-1.10; P = 0.09], respectively), and higher infection-related hospitalization (HRs of 2.45 [95% CI, 1.55-3.88; P < 0.001] and 1.16 [95% CI, 0.98-1.37; P = 0.08], respectively). The association between declining MAC and skinfold with patient survival was most notable for those with body mass index (BMI) ≤25 kg/m2 (HRs of 2.41 [95% CI, 1.81-3.19; P < 0.001] and 1.22 [95% CI, 1.10-1.35; P < 0.001], respectively). LIMITATIONS Prevalent dialysis patients only, excluding individuals weighing >85 kg. CONCLUSIONS Declines in skinfold thickness were not associated significantly with outcomes except for participants with BMI ≤25 kg/m2. Declines in MAC are associated significantly with all-cause mortality and cardiac outcomes in hemodialysis patients, most notably in those with BMI ≤25 kg/m2.
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Affiliation(s)
- Chi-Ting Su
- Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Division of Nephrology, National Taiwan University Hospital, Yun-Lin branch, Taiwan
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Grady CD, Schwarz EB, Emeremni CA, Yabes J, Akers A, Zite N, Borrero S. Does a history of unintended pregnancy lessen the likelihood of desire for sterilization reversal? J Womens Health (Larchmt) 2013; 22:501-6. [PMID: 23621776 PMCID: PMC3678583 DOI: 10.1089/jwh.2012.3885] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Unintended pregnancy has been significantly associated with subsequent female sterilization. Whether women who are sterilized after experiencing an unintended pregnancy are less likely to express desire for sterilization reversal is unknown. METHODS This study used national, cross-sectional data collected by the 2006-2010 National Survey of Family Growth. The study sample included women ages 15-44 who were surgically sterile from a tubal sterilization at the time of interview. Multivariable logistic regression was used to examine the relationship between a history of unintended pregnancy and desire for sterilization reversal while controlling for potential confounders. RESULTS In this nationally representative sample of 1,418 women who were sterile from a tubal sterilization, 78% had a history of at least one unintended pregnancy and 28% expressed a desire to have their sterilization reversed. In unadjusted analysis, having a prior unintended pregnancy was associated with higher odds of expressing desire for sterilization reversal (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.15-2.79). In adjusted analysis controlling for sociodemographic factors, unintended pregnancy was no longer significantly associated with desire for reversal (OR: 1.46; 95% CI: 0.91-2.34). CONCLUSION Among women who had undergone tubal sterilization, a prior history of unintended pregnancy did not decrease desire for sterilization reversal.
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Affiliation(s)
- Cynthia D. Grady
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eleanor Bimla Schwarz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chetachi A. Emeremni
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Jonathan Yabes
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aletha Akers
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nikki Zite
- Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee
| | - Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Puttarajappa C, Yabes J, Bei L, Shah N, Bernardo J, McCauley J, Basu A, Tan H, Shapiro R, Unruh M, Wu C. Cancer risk with alemtuzumab following kidney transplantation. Clin Transplant 2013; 27:E264-71. [PMID: 23480032 DOI: 10.1111/ctr.12094] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2012] [Indexed: 12/16/2022]
Abstract
Alemtuzumab has been employed for induction therapy in kidney transplantation with low rates of acute rejection and excellent graft and patient survival. Antibody induction therapy has been linked to increased vulnerability to cancer. Data regarding malignancy rates with alemtuzumab are limited. We studied 1350 kidney transplant recipients (between 2001 and 2009) at the University of Pittsburgh Starzl Transplant Institute, for post-transplant de novo and recurrent malignancy, excluding non-melanoma skin cancer, among patients receiving alemtuzumab, thymoglobulin, and no induction therapies. Of the 1350 patients, 1002 (74.2%) received alemtuzumab, 205 (15.2%) received thymoglobulin, and 122 (9%) received no induction therapy. After excluding cancers occurring within 60 d post-transplantation, 43 (3.25%) malignancies were observed during a median follow-up time of 4.0 yr. The incidence of malignancy was 5.4% (1.09 per 100 patient-years [PY]) with thymoglobulin, 2.8% (0.74 per 100 PY) with alemtuzumab, and 3.3% (0.66 per 100 PY) with no induction (across all groups; p = 0.2342, thymoglobulin vs. alemtuzumab; p = 0.008). Thus, with the exception of non-melanoma skin cancer which we did not evaluate, alemtuzumab induction was not associated with increased cancer incidence post-kidney transplantation when compared to no induction therapy and was associated with lower cancer incidence when compared to thymoglobulin.
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Affiliation(s)
- C Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Kang EW, Abdel-Kader K, Yabes J, Glover K, Unruh M. Association of sleep-disordered breathing with cognitive dysfunction in CKD stages 4-5. Am J Kidney Dis 2012; 60:949-58. [PMID: 23063144 DOI: 10.1053/j.ajkd.2012.08.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 08/13/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sleep-disordered breathing and cognitive impairment are common in patients with chronic kidney disease (CKD). Sleep-disordered breathing is known to be a risk factor for cognitive dysfunction in the general population, but this association has not been studied in patients with CKD. STUDY DESIGN Cross-sectional study. SETTINGS & PARTICIPANTS A cohort of 169 patients with CKD stages 4-5. PREDICTORS Sleep-disordered breathing; covariates included demographics, diabetes, cardiovascular disease, depression, and dialysis modality. OUTCOMES Cognitive impairment, generally defined as a score 1.5 standard deviations or more from the age- and education level-adjusted normative cognitive test score. MEASUREMENTS Standardized health interview, neurocognitive assessment, sleep-related questionnaires, and polysomnography. RESULTS Sleep-disordered breathing (apnea-hypopnea index >15) was diagnosed in 83 (49.1%) individuals. This group had a significantly higher prevalence of nocturnal hypoxemia (65.8% vs 26.8%; P < 0.001) and excessive daytime sleepiness (38.6% vs 20.7%; P = 0.01). In addition, this group had significantly lower scores in tests measuring verbal memory, working memory, attention, and psychomotor speed. Sleep-disordered breathing was associated with higher risk of immediate verbal memory impairment after adjustment for known confounders (adjusted OR, 2.67; 95% CI, 1.17-6.08). However, in a subgroup analysis of older adults (aged >60 years), there were no significant differences in cognitive testing between the groups with and without sleep-disordered breathing. LIMITATIONS Cross-sectional design, limited sample size. CONCLUSIONS Sleep-disordered breathing is associated with cognitive impairments, especially impaired verbal memory, in patients with advanced CKD. However, the impact appeared limited in older adults. Early evaluation and management of sleep-disordered breathing in patients with CKD may provide an opportunity to improve cognitive function.
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Affiliation(s)
- Ea Wha Kang
- Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
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