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Gnyawali SC, Denune JA, Hockman B, Kristjánsdóttir JV, Ragnarsdóttir MS, Timsina LR, Ghatak S, Lechler K, Sen CK, Roy S. Moisture mitigation using a vented liner and a vented socket system for individuals with transfemoral amputation. Sci Rep 2023; 13:16557. [PMID: 37783779 PMCID: PMC10545693 DOI: 10.1038/s41598-023-43572-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/26/2023] [Indexed: 10/04/2023] Open
Abstract
Sweating and heat buildup at the skin-liner interface is a major challenge for persons with limb loss. Liners made of heat-non-conducting materials may cause sweating of the residual limb and may result in liners slipping off the skin surface especially on a warm day or during high activity, causing skin breakdown and affecting limb health. To address this, we evaluated the efficacy of the vented liner-socket system (VS, Össur) compared to Seal-In silicone liner and non-vented socket (nVS, Össur) in reducing relative humidity (RH) during increased sweat. Nine individuals with limb loss using nVS were randomized to VS or nVS and asked for activity in a 20-min treadmill walk. RH was significantly attenuated (p = 0.0002) and perceived sweating, as reported by prosthesis users, improved (p = 0.028) with VS, patient-reported comprehensive lower limb amputee socket survey (CLASS) outcomes to determine the suspension, stability, and comfort were not significantly different between VS and nVS. There are limited rigorous scientific studies that clearly provide evidence-based guidelines to the prosthetist in the selection of liners from numerous available options. The present study is innovative in clearly establishing objective measures for assessing humidity and temperatures at the skin-liner interface while performing activity. As shown by the measured data and perceived sweat scores provided by the subjects based on their daily experience, this study provided clear evidence establishing relative humidity at the skin-liner interface is reduced with the use of a vented liner-socket system when compared to a similar non-vented system.
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Affiliation(s)
- Surya C Gnyawali
- McGowan Institute for Regenerative Medicine (MIRM), Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jeffrey A Denune
- Indiana Centre for Regenerative Medicine and Engineering (ICRME), Indiana University Health Comprehensive Wound Centre, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bryce Hockman
- Indiana Centre for Regenerative Medicine and Engineering (ICRME), Indiana University Health Comprehensive Wound Centre, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Lava R Timsina
- Indiana Centre for Regenerative Medicine and Engineering (ICRME), Indiana University Health Comprehensive Wound Centre, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Subhadip Ghatak
- McGowan Institute for Regenerative Medicine (MIRM), Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Indiana Centre for Regenerative Medicine and Engineering (ICRME), Indiana University Health Comprehensive Wound Centre, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Knut Lechler
- Össur Ehf., R&D, Medical Office, Reykjavik, Iceland
| | - Chandan K Sen
- McGowan Institute for Regenerative Medicine (MIRM), Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Indiana Centre for Regenerative Medicine and Engineering (ICRME), Indiana University Health Comprehensive Wound Centre, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sashwati Roy
- McGowan Institute for Regenerative Medicine (MIRM), Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Indiana Centre for Regenerative Medicine and Engineering (ICRME), Indiana University Health Comprehensive Wound Centre, Indiana University School of Medicine, Indianapolis, IN, USA.
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Sun Cao P, Loewenstein SN, Timsina LR, Adkinson JM. The Association of Insurance Status and Complications After Carpal Tunnel Release. Hand (N Y) 2023; 18:192-197. [PMID: 33631982 PMCID: PMC10035105 DOI: 10.1177/1558944721990818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Carpal tunnel release (CTR) is one of the most commonly performed procedures in hand surgery. Complications from surgery are a rare but significant patient dissatisfier. The purpose of this study was to determine whether insurance status is independently associated with complications after CTR. METHODS We retrospectively identified all patients undergoing CTR between 2008 and 2018 using the Indiana Network for Patient Care, a state-wide health information exchange, and built a database that included patient demographics and comorbidities. Patients were followed for 90 days to determine whether a postoperative complication occurred. To minimize dropout, only patients with 1 year of encounters after surgery were included. RESULTS Of the 26 151 patients who met inclusion criteria, 2662 (10.2%) had Medicare, 7027 (26.9%) had Medicaid, and 16 462 (62.9%) had commercial insurance. Compared with Medicare, Medicaid status (P < .001) and commercial insurance status (P < .001) were independently associated with postoperative CTR complications. The overall complication rate was 2.23%, with infection, wound breakdown, and complex regional pain syndrome being the most common complications. Younger age, alcohol use, diabetes mellitus, hypertension, and depression were also independently associated with complications. CONCLUSIONS The incidence of complications after CTR is low. Insurance status, patient demographics, and medical comorbidities, however, should be evaluated preoperatively to appropriately risk stratify patients. Furthermore, surgeons can use these data to initiate preventive measures such as working to manage current comorbidities and lifestyle choices, and to optimize insurance coverage.
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Wenos CD, Herrmann JL, Timsina LR, Patel PM, Fehrenbacher JW, Brown JW. Perioperative and long-term outcomes of Ross versus mechanical aortic valve replacement. J Card Surg 2022; 37:2963-2971. [PMID: 35989510 PMCID: PMC9542516 DOI: 10.1111/jocs.16831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
Background The ideal aortic valve replacement strategy in young‐ and middle‐aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long‐term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients. Methods Data were retrospectively collected for patients 18–50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well‐matched pairs from a total of 216 eligible patients. Results Demographic and preoperative characteristics were similar between the two groups. Median follow‐up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population (p < .01). Overall survival (p = .93), freedom from reintervention and valve dysfunction free survival (p = .91) were equivalent. Conclusions In this mid‐term propensity score‐matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long‐term anticoagulation. At specialized centers with sufficient expertize, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement.
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Affiliation(s)
- Chelsea D Wenos
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Divison of Pediatric Cardiothoracic Surgery, Riley Children's Health, Indiana University Health, Indianapolis, Indiana, USA
| | - Lava R Timsina
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Surgery, Indiana University School of Medicine, Center for Outcomes Research in Surgery, Indianapolis, Indiana, USA
| | - Parth M Patel
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John W Fehrenbacher
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indianapolis, Indiana, USA
| | - John W Brown
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Divison of Pediatric Cardiothoracic Surgery, Riley Children's Health, Indiana University Health, Indianapolis, Indiana, USA
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Loria CM, Zborek K, Millward JB, Anderson MP, Richardson CM, Namburi N, Faiza Z, Timsina LR, Lee LS. Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use. JTCVS Open 2022; 12:280-296. [PMID: 36590721 PMCID: PMC9801279 DOI: 10.1016/j.xjon.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
Objective Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing multimodal pain control regimens that include both opioid and nonopioid components. We investigated the effects of an Enhanced Recovery After Surgery protocol at our institution on postoperative outcomes with particular focus on analgesia. Methods Single-center retrospective study comparing perioperative opioid use before and after implementation of an Enhanced Recovery After Surgery protocol at our institution. Subjects were divided into 2 cohorts: Enhanced Recovery After Surgery (study group from year 2020) and pre-Enhanced Recovery After Surgery (control group from year 2018). Baseline and perioperative variables including total opioid use from the day of surgery to postoperative day 5 were collected. Opioid use was calculated as morphine milligram equivalents and compared between the 2 cohorts. Results A total of 466 patients were included: 250 in the Enhanced Recovery After Surgery group and 216 in the pre-Enhanced Recovery After Surgery group. Both groups had similar baseline characteristics, but the Enhanced Recovery After Surgery group had significantly more subjects with intravenous drug use history (P < .0001), endocarditis (P < .0001), and liver disease (P = .007) compared with the pre-Enhanced Recovery After Surgery group. Every day from the day of surgery to postoperative day 5, the Enhanced Recovery After Surgery group had significant reduction (57%) in opioid use compared with the pre-Enhanced Recovery After Surgery group. Total opioid use for the entire length of stay was 259 morphine milligram equivalents in the Enhanced Recovery After Surgery group versus 452 morphine milligram equivalents in the pre-Enhanced Recovery After Surgery group (P < .0001). Subgroup analysis of subjects with intravenous drug use history did not demonstrate a significant reduction in opioid use. Conclusions Enhanced Recovery After Surgery protocols with an emphasis on multimodal pain management throughout perioperative care are associated with a significant reduction in the postoperative use of opioid analgesics.
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Affiliation(s)
- Chelsea M. Loria
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Kirsten Zborek
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - James B. Millward
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Matthew P. Anderson
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Cynthia M. Richardson
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Niharika Namburi
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Zainab Faiza
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Lava R. Timsina
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Lawrence S. Lee
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind,Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Mass,Address for reprints: Lawrence S. Lee, MD, MBA, Lahey Hospital and Medical Center, 41 Mall Rd, Suite 5 East, Burlington, MA 01805.
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Obeng-Gyasi S, Graham N, Kumar S, Lee JW, Jacobus S, Weiss M, Cella D, Zhao F, Ip EH, O'Connell N, Hong F, Peipert DJ, Gareen IIF, Timsina LR, Gray R, Wagner LI, Carlos RC. Examining allostatic load, neighborhood socioeconomic status, symptom burden and mortality in multiple myeloma patients. Blood Cancer J 2022; 12:53. [PMID: 35365604 PMCID: PMC8975964 DOI: 10.1038/s41408-022-00648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/06/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
The objective of this study is to examine the association between neighborhood socioeconomic status (nSES) and baseline allostatic load (AL) and clinical trial endpoints in patients enrolled in the E1A11 therapeutic trial in multiple myeloma (MM). Study endpoints were symptom burden (pain, fatigue, and bother) at baseline and 5.5 months, non-completion of induction therapy, overall survival (OS) and progression-free survival (PFS). Multivariable logistic and Cox regression examined associations between nSES, AL and patient outcomes. A 1-unit increase in baseline AL was associated with greater odds of high fatigue at baseline (adjusted OR [95% CI] = 1.21 [1.08–1.36]) and a worse OS (adjusted hazard ratio, [95% CI] = 1.21 [1.06–1.37]). High nSES was associated with worse baseline bother (middle OR = 4.22 [1.11–16.09] and high 4.49 [1.16–17.43]) compared to low nSES. There was no association between AL or nSES and symptom burden at 5.5 months, non-completion of induction therapy or PFS. Additionally, there was no association between nSES and OS. AL may have utility as a predictive marker for OS among patients with MM and may allow individualization of treatment. Future studies should standardize and validate AL patients with MM.
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Affiliation(s)
| | - Noah Graham
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | | | - Ju-Whei Lee
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Susanna Jacobus
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | | | - David Cella
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Fengmin Zhao
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Edward H Ip
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nathaniel O'Connell
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Fangxin Hong
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Devin J Peipert
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - IIana F Gareen
- Brown University Department of Epidemiology and Center for Statistical Sciences, Providence, RI, USA
| | - Lava R Timsina
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert Gray
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Lynne I Wagner
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ruth C Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
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Sadigh G, Gray RJ, Sparano JA, Yanez B, Garcia SF, Timsina LR, Obeng-Gyasi S, Gareen I, Sledge GW, Whelan TJ, Cella D, Wagner LI, Carlos RC. Assessment of Racial Disparity in Survival Outcomes for Early Hormone Receptor-Positive Breast Cancer After Adjusting for Insurance Status and Neighborhood Deprivation: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Oncol 2022; 8:579-586. [PMID: 35175284 PMCID: PMC8855314 DOI: 10.1001/jamaoncol.2021.7656] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Racial disparities in survival outcomes among Black women with hormone receptor-positive breast cancer have been reported. However, the association between individual-level and neighborhood-level social determinants of health on such disparities has not been well studied. OBJECTIVE To evaluate the association between race and clinical outcomes (ie, relapse-free interval and overall survival) adjusting for individual insurance coverage and neighborhood deprivation index (NDI), measured using zip code of residence, in women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS This was a post hoc analysis of 9719 women with breast cancer in the Trial Assigning Individualized Options for Treatment, a randomized clinical trial conducted from April 7, 2006, to October 6, 2010. All participants received a diagnosis of hormone receptor-positive, ERBB2-negative, axillary node-negative breast cancer. The present data analysis was conducted from April 1 to October 22, 2021. MAIN OUTCOMES AND MEASURES A multivariate model was developed to evaluate the association between race and relapse-free interval and overall survival adjusting for insurance and NDI level at study entry, early discontinuation of endocrine therapy 4 years after initiation, and clinicopathologic characteristics of cancer. Median follow-up for clinical outcomes was 96 months. RESULTS A total of 9719 women (4.2% [n = 405] Asian; 7.1% [n = 693] Black; 84.3% [n = 8189] White; 4.4% [n = 403] others/not specified) were included; 9.1% of included women [n = 889] were Hispanic or Latino. Median (SD) age was 56 (9.2) years. In multivariate models, Black race compared with White race was associated with statistically significant shorter relapse-free interval (hazard ratio [HR], 1.39; 95% CI, 1.05-1.84; P = .02) and overall survival (HR, 1.49; 95% CI, 1.10-2.99; P = .009), adjusting for insurance and NDI level at study entry and other factors. Although uninsured status was not associated with clinical outcomes, patients with Medicare (HR, 1.30; 95% CI, 1.01-1.68; P = .04) and Medicaid (HR, 1.44; 95% CI, 1.01-2.05; P = .05) had shorter overall survival compared with those with private insurance. Participants living in neighborhoods in the highest NDI quartile experienced shorter overall survival compared with those in the lowest quartile (HR, 1.34; 95% CI, 1.01-1.77; P = .04), regardless of self-identified race. CONCLUSIONS AND RELEVANCE The findings of this post hoc analysis of a randomized clinical trial suggest that Black women with breast cancer have significantly shorter relapse-free interval and overall survival compared with White women. Early discontinuation of endocrine therapy, clinicopathologic characteristics, insurance coverage, and NDI do not fully explain the observed disparity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00310180.
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Affiliation(s)
- Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Robert J. Gray
- Dana Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | - Joseph A. Sparano
- Department of Hematology and Oncology, The Mount Sinai Hospital, New York, New York
| | - Betina Yanez
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sofia F. Garcia
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lava R. Timsina
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus
| | - Ilana Gareen
- Center for Statistical Sciences, Brown University, Providence, Rhode Island
| | | | - Timothy J. Whelan
- Canadian Cancer Trials Group, McMaster University, Hamilton, Ontario, Canada
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynne I. Wagner
- Wake Forest University Health Sciences, Winston Salem, North Carolina
| | - Ruth C. Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor
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Obeng-Gyasi S, ONeill A, Miller KD, Schneider BP, Patridge AH, Timsina LR, Sledge GW, Wagner L, Carlos RC. Abstract PO-219: The implications of genetic ancestry and allostatic load on clinical outcomes in the ECOG-ACRIN adjuvant breast cancer trial E5103. Cancer Epidemiol Biomarkers Prev 2022. [DOI: 10.1158/1538-7755.disp21-po-219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Introduction: Elevated allostatic load (AL) has been associated with poor tumor prognostic features in Black breast cancer patients and worse disease specific and overall survival among cancer patients. To date, there are no studies evaluating the relationship between genetic ancestry, allostatic load and clinical trial endpoints such as completion of chemotherapy per protocol or overall survival. Prior evaluations of the ECOG-ACRIN adjuvant breast cancer trial E5103 suggests African ancestry is associated with a worse invasive disease-free survival and lower odds of chemotherapy completion. The objective of this study is to evaluate the association of genetic ancestry and AL with trial completion per protocol and with overall survival among patients in E5103. Methods: ECOG-ACRIN E5103 was a clinical trial that compared doxorubicin and cyclophosphamide (AC) for four cycles, followed by 12 weeks of weekly paclitaxel with placebo (Arm A) to the same chemotherapy with either concurrent bevacizumab (Arm B) or with concurrent plus sequential bevacizumab (Arm C) among women with node positive or high-risk node negative HER2 negative disease. Genetic ancestry groups of African ancestry (AA), European ancestry (EA) and other ancestry (OA) were determined using genome-wide single nucleotide polymorphisms. AL, at trial entry, was comprised of the biomarkers body mass index, systolic blood pressure, diastolic blood pressure, creatinine, IL6, IL10, and TNF alpha. To calculate AL, patients were awarded a point if their biomarker value was above the 75 percentile of the study sample. Logistic regression and Cox-Proportional Hazard models (odds ratio(OR) and hazard ratio (HR) estimates with corresponding 95% confidence intervals (CI)) were used to assess association with chemotherapy completion and with overall mortality. Estimates for AL were adjusted for genetic ancestry. Results: There were 348 patients in the study. The majority of the sample was of EA (EA 80%, AA 10%, OA 10%). Median (range) of AL was 2(0-6). Patients of AA (2.1(1.3)) and EA (1.88(1.4)) had a higher mean (SD) AL score compared to OA patients (0.91(1.1). On adjusted analysis, a 1 unit increased in AL was associated with a 15% reduction in the odds of completing chemotherapy per protocol (OR 0.85, 95% CI 0.72-0.99). Additionally, a 1 unit increase in AL was associated with a 14% increase in the hazard of death (HR 1.14, 95%CI 1.02-1.29). There was no association between ancestry and chemotherapy completion (AA OR 0.95, 95%CI 0.47-1.93; OA 1.82, 95%CI 0.78-4.23; ref EA) or survival (AA HR 1.40, 95% CI 0.85-2.31), OA 0.89 (0.46-1.73; ref EA). Moreover, there was no interaction between AL and ancestry. Conclusion: Among patients enrolled in E5103, AL appeared to be a better predictor of chemotherapy completion and overall survival than genetic ancestry. These results suggest life course exposure to chronic stress has implication in clinical outcomes even within the context of equivalent access to and quality of care.
Citation Format: Samilia Obeng-Gyasi, Anne ONeill, Kathy D. Miller, Bryan P. Schneider, Ann H. Patridge, Lava R. Timsina, George W. Sledge, Lynne Wagner, Ruth C. Carlos. The implications of genetic ancestry and allostatic load on clinical outcomes in the ECOG-ACRIN adjuvant breast cancer trial E5103 [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-219.
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Affiliation(s)
| | - Anne ONeill
- 2Dana Farber Cancer Institute – ECOG-ACRIN Biostatistics Center, Boston, MA,
| | - Kathy D. Miller
- 3Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN,
| | - Bryan P. Schneider
- 3Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN,
| | | | | | | | - Lynne Wagner
- 7Wake Forest University Health sciences, Winston Salem, NC,
| | - Ruth C. Carlos
- 8University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
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Athanasiadis D, Monfared S, Whiteside JA, Timsina LR, Banerjee A, Stefanidis D. Reducing Operating Room Inefficiencies via a Novel Surgical App Shortens the Duration of Laparoscopic Roux-en-y Gastric Bypass. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.013] [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: 10/20/2022]
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Friedman AN, Guirguis J, Kapoor R, Gupta S, Leaf DE, Timsina LR. Obesity, inflammatory and thrombotic markers, and major clinical outcomes in critically ill patients with COVID-19 in the US. Obesity (Silver Spring) 2021; 29:1719-1730. [PMID: 34109768 DOI: 10.1002/oby.23245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study aimed to determine whether obesity is independently associated with major adverse clinical outcomes and inflammatory and thrombotic markers in critically ill patients with COVID-19. METHODS The primary outcome was in-hospital mortality in adults with COVID-19 admitted to intensive care units across the US. Secondary outcomes were acute respiratory distress syndrome (ARDS), acute kidney injury requiring renal replacement therapy (AKI-RRT), thrombotic events, and seven blood markers of inflammation and thrombosis. Unadjusted and multivariable-adjusted models were used. RESULTS Among the 4,908 study patients, mean (SD) age was 60.9 (14.7) years, 3,095 (62.8%) were male, and 2,552 (52.0%) had obesity. In multivariable models, BMI was not associated with mortality. Higher BMI beginning at 25 kg/m2 was associated with a greater risk of ARDS and AKI-RRT but not thrombosis. There was no clinically significant association between BMI and inflammatory or thrombotic markers. CONCLUSIONS In critically ill patients with COVID-19, higher BMI was not associated with death or thrombotic events but was associated with a greater risk of ARDS and AKI-RRT. The lack of an association between BMI and circulating biomarkers calls into question the paradigm that obesity contributes to poor outcomes in critically ill patients with COVID-19 by upregulating systemic inflammatory and prothrombotic pathways.
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Affiliation(s)
- Allon N Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Guirguis
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rajat Kapoor
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Obeng-Gyasi S, O'Neill AM, Miller K, Schneider BP, Partridge AH, Timsina LR, Sledge GW, Wagner LI, Carlos R. Social determinants of health, genetic ancestry, and mortality in ECOG-ACRIN E5103. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.6527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6527 Background: Social determinants of health (SDH) and genetic ancestry have been independently implicated in breast cancer presentation, treatment and mortality. However, little is known about the relationship between SDH and genetic ancestry on clinical trial outcomes. The objective of this study is to assess the association between SDH, genetic ancestry and clinical outcomes in patients enrolled in an adjuvant breast cancer clinical trial. Methods: ECOG-ACRIN (EA) 5103 randomized patients to receive AC + taxane + bevacizumab or placebo. SDH were operationalized as insurance status at trial registration (individual SES) and neighborhood socioeconomic status (nSES). Insurance categories included: (1) Private, 2) Medicare including private/Medicare, military, 3) Medicaid including Medicaid/Medicare, uninsured, 4) self-pay). The nSES index was calculated using zip codes linked to county level data on occupation, income, poverty, wealth, education and crowding. Genome-wide single-nucleotide polymorphism arrays were used to define African ancestry (AA), European ancestry (EA) and other (OA). Multivariable regression and Cox-Proportional Hazard models (odds ratios (OR) and hazard ratios (HR) with corresponding 95% confidence intervals (CI)) were used to assess associations with chemotherapy completion and overall mortality. Estimates were adjusted for the following clinical covariates: age, tumor size, nodal status, hormone receptor status, and primary surgery at randomization. Results: The study cohort included 2453 EA (79.2%), 381 AA (12.2%) and 265 OA (8.6%). Medicaid patients (OR 0.76(0.59-0.99); ref private) and those with AA (OR 0.62(0.49-0.78); ref EA) were less likely to complete chemotherapy. Regarding overall mortality, Medicaid insurance (HR 1.42(1.05-1.92) was associated with a higher mortality than private insurance. Conversely, there was no significant difference in mortality by ancestry (AA HR 1.27 (0.97-1.66); OA HR 0.90 (0.63-1.29): ref EA). Neighborhood socioeconomic status did not appear to be associated with chemotherapy completion or mortality. Conclusions: SDH reflective of individual SES, such as insurance, appear to be stronger drivers of trial completion and mortality compared to nSES among patients enrolled in E5103. Moreover, study results suggest an interplay between ancestry and individual proxies for SDH in trial completion. Nevertheless, the relationship between ancestry and lower rates of chemotherapy completion do not appear to translate into higher mortality rates among patients of AA.
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Affiliation(s)
| | | | - Kathy Miller
- Indiana University Simon Cancer Center Indianapolis, Indianapolis, IN
| | | | | | | | | | | | - Ruth Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
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11
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Nguyen RH, Vater LB, Timsina LR, Durm GA, Rupp K, Wright K, Spitznagle MH, Paul B, Jalal SI, Carter-Harris L, Hudmon KS, Hanna NH, Loehrer PJ, Ceppa DP. Impact of smoke-free ordinance strength on smoking prevalence and lung cancer incidence. PLoS One 2021; 16:e0250285. [PMID: 33861796 PMCID: PMC8051804 DOI: 10.1371/journal.pone.0250285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/02/2021] [Indexed: 01/22/2023] Open
Abstract
Background Smoke-free ordinances (SFO) have been shown to be effective public health interventions, but there is limited data on the impact SFO on lung cancer outcomes. We explored the effect of county-level SFO strength with smoking prevalence and lung cancer incidence in Indiana. Methods We obtained county-level lung cancer incidence from the Indiana State Cancer Registry and county-level characteristics from the Indiana Tobacco Prevention and Cessation Commission’s policy database between 1995 and 2016. Using generalized estimating equations, we performed multivariable analyses of smoking prevalence and age-adjusted lung cancer rates with respect to the strength of smoke-free ordinances at the county level over time. Results Of Indiana’s 92 counties, 24 had a SFO by 2011. In 2012, Indiana enacted a state-wide SFO enforcing at least moderate level SFO protection. Mean age-adjusted lung cancer incidence per year was 76.8 per 100,000 population and mean smoking prevalence per year was 25% during the study period. Counties with comprehensive or moderate SFO had a smoking prevalence 1.2% (95% CI [-1.88, -0.52]) lower compared with counties with weak or no SFO. Counties that had comprehensive or moderate SFO also had an 8.4 (95% CI [-11.5, -5.3]) decrease in new lung cancer diagnosis per 100,000 population per year compared with counties that had weak or no SFO. Conclusion Counties with stronger smoke-free air ordinances were associated with decreased smoking prevalence and fewer new lung cancer cases per year. Strengthening SFO is paramount to decreasing lung cancer incidence.
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Affiliation(s)
- Ryan H. Nguyen
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- * E-mail:
| | - Laura B. Vater
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Lava R. Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Gregory A. Durm
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Indiana University Health Simon Cancer Center, Indianapolis, IN, United States of America
| | - Katelin Rupp
- Indiana State Department of Health, Indianapolis, IN, United States of America
| | - Keylee Wright
- Indiana State Department of Health, Indianapolis, IN, United States of America
| | | | - Brandy Paul
- Indiana State Department of Health, Indianapolis, IN, United States of America
| | - Shadia I. Jalal
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Indiana University Health Simon Cancer Center, Indianapolis, IN, United States of America
| | - Lisa Carter-Harris
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Karen S. Hudmon
- Indiana University Health Simon Cancer Center, Indianapolis, IN, United States of America
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, United States of America
| | - Nasser H. Hanna
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Indiana University Health Simon Cancer Center, Indianapolis, IN, United States of America
| | - Patrick J. Loehrer
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Indiana University Health Simon Cancer Center, Indianapolis, IN, United States of America
| | - DuyKhanh P. Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Indiana University Health Simon Cancer Center, Indianapolis, IN, United States of America
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12
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Sadigh G, Gray RJ, Sparano JA, Yanez B, Garcia SF, Timsina LR, Sledge GW, Cella D, Wagner LI, Carlos RC. Breast cancer patients' insurance status and residence zip code correlate with early discontinuation of endocrine therapy: An analysis of the ECOG-ACRIN TAILORx trial. Cancer 2021; 127:2545-2552. [PMID: 33793979 DOI: 10.1002/cncr.33527] [Citation(s) in RCA: 7] [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: 12/17/2020] [Revised: 01/25/2021] [Accepted: 02/02/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Early discontinuation is a substantial barrier to the delivery of endocrine therapies (ETs) and may influence recurrence and survival. The authors investigated the association between early discontinuation of ET and social determinants of health, including insurance coverage and the neighborhood deprivation index (NDI), which was measured on the basis of patients' zip codes, in breast cancer. METHODS In this retrospective analysis of a prospective randomized clinical trial (Trial Assigning Individualized Options for Treatment), women with hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer who started ET within a year of study entry were included. Early discontinuation was calculated as stopping ET within 4 years of its start for reasons other than distant recurrence or death via Kaplan-Meier estimates. A Cox proportional hazards joint model was used to analyze the association between early discontinuation of ET and factors such as the study-entry insurance and NDI, with adjustments made for other variables. RESULTS Of the included 9475 women (mean age, 55.6 years; White race, 84%), 58.0% had private insurance, whereas 11.7% had Medicare, 5.8% had Medicaid, 3.8% were self-pay, and 19.1% were treated at international sites. The early discontinuation rate was 12.3%. Compared with those with private insurance, patients with Medicaid (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.23-1.92) and self-pay patients (HR, 1.65; 95% CI, 1.25-2.17) had higher early discontinuation. Participants with a first-quartile NDI (highest deprivation) had a higher probability of discontinuation than those with a fourth-quartile NDI (lowest deprivation; HR, 1.34; 95% CI, 1.11-1.62). CONCLUSIONS Patients' insurance and zip code at study entry play roles in adherence to ET, with uninsured and underinsured patients having a high rate of treatment nonadherence. Early identification of patients at risk may improve adherence to therapy. LAY SUMMARY In this retrospective analysis of 9475 women with breast cancer participating in a clinical trial (Trial Assigning Individualized Options for Treatment), Medicaid and self-pay patients (compared with those with private insurance) and those in the highest quartile of neighborhood deprivation scores (compared with those in the lowest quartile) had a higher probability of early discontinuation of endocrine therapy. These social determinants of health assume larger importance with the expected increase in unemployment rates and loss of insurance coverage in the aftermath of the coronavirus disease 2019 pandemic. Early identification of patients at risk and enrollment in insurance optimization programs may improve the persistence of therapy.
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Affiliation(s)
| | - Robert J Gray
- ECOG-ACRIN Biostatistics Center, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph A Sparano
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | | | | | - Lava R Timsina
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Lynne I Wagner
- Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Ruth C Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
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13
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Obeng-Gyasi S, Timsina LR, Bhattacharyya O, Fisher CS, Haggstrom DA. Bankruptcy among insured surgical patients with breast cancer: Who is at risk? Cancer 2021; 127:2083-2090. [PMID: 33606915 DOI: 10.1002/cncr.33468] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/17/2020] [Accepted: 12/24/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND The rising cost of cancer treatment has been linked to higher bankruptcy rates and worse mortality among patients with cancer. The objective of this study was to identify the characteristics of insured patients with breast cancer who underwent surgery and filed for bankruptcy. METHODS Insured patients with breast cancer who underwent surgery were identified in the Indiana State Cancer Registry (ISCR) from January 1, 2008 to December 31, 2014. Patients who filed for Chapter 7 or 13 bankruptcy in the Public Access to Courts Electronic Records (PACER) database were linked to patients in the ISCR. The cohort was divided into 2 groups: no bankruptcy (NB) and bankruptcy after diagnosis (BAD). Bivariate analysis and a logistic regression model were used to identify patients who were at increased risk of filing for bankruptcy after their diagnosis. RESULTS Of 23,012 patients, 207 (0.9%) filed for bankruptcy after diagnosis and 22,805 (99.1%) did not file for bankruptcy. The patients who filed for bankruptcy after diagnosis were younger (BAD vs NB: median age, 53 years [interquartile range (IQR), 46-61 years] vs 62 years [IQR, 52-71 years], non-White (BAD vs NB, 20.5% vs 8.5%), and lived in lower income neighborhoods (BAD vs NB: median annual income, $50,869 [IQR, $41,051-$61,150] vs $52,522 [IQR, $41,356-$64,915]). On multivariable analysis, younger age (aged ≤40 years: odds ratio [OR], 5.41; 95% CI, 2.8-12.31; aged 41-64 years: OR, 2.65; 95% CI, 1.33-5.12; aged ≥65 years, reference category) and non-White race (non-White: OR, 2.43; 95% CI, 1.54-3.83; White, reference category) were associated with filing for bankruptcy after diagnosis CONCLUSIONS: Younger age and non-White race are associated with an increased risk of filing for bankruptcy after diagnosis among insured patients who undergo surgery for breast cancer. Additional steps should be taken to screen and address the financial vulnerability of these patients at treatment initiation.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Carla S Fisher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - David A Haggstrom
- Veterans Affairs Health Services Research and Development Center for Health Information and Communication, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana.,Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana
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14
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Ceppa DP, Ikonomidis JS, Timsina LR, Boden N, Kane LC, Donington JS. STS 2019 Workforce Report: Ad Hoc Analysis of Women in Cardiothoracic Surgery. Ann Thorac Surg 2021; 111:383-385. [DOI: 10.1016/j.athoracsur.2020.07.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 11/24/2022]
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Timsina LR, Zarzaur B, Haggstrom DA, Jenkins PC, Lustberg M, Obeng-Gyasi S. Dissemination of cancer survivorship care plans: who is being left out? Support Care Cancer 2021; 29:4295-4302. [PMID: 33415363 DOI: 10.1007/s00520-020-05915-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Institute of Medicine (IOM) and the American College of Surgeons Commission on Cancer (CoC) recommend a clear and effectively explained comprehensive survivorship care plan (SCP) be given to all cancer survivors. The objective of this study is to understand the relationship between social determinants of health (SDOH) and self-reported receipt of SCP by cancer survivors in the USA. METHODS We analyzed an adult population of cancer survivors in the 2016 Behavioral Risk Factor Surveillance System's (BRFSS) Survivorship modules. Weighted multivariable logistic regression was used to analyze the association of SDOH and reported receipt of SCP. RESULTS There were 7061 cancer patients eligible for an SCP. The probability of reporting receipt of SCP decreased with lower educational achievement (high school/some college: AOR = 0.82, 95% CI: 0.70-0.97, p = 0.02; < high school: AOR = 0.68, 95% CI: 0.47-0.97, p = 0.03) compared to those with at least one college degree. Additionally, being widowed/divorced/separated (widowed/divorced/separated: AOR = 0.72, 95% CI: 0.61-0.86, p < 0.01 vs. married/cohabiting) and uninsured (uninsured: AOR = 0.52, 95% CI: 0.0.34-0.80, p < 0.01 vs. insured) increased the odds of not receiving an SCP. Younger patients were more likely to receive an SCP than those over 65 (18-24 years: AOR = 6.62, 95% CI: 1.87-24.49, p < 0.01 vs. 65+ years). CONCLUSION Among cancer survivors, SDOH such as low educational achievement, widowed/divorced/separated marital status, and being uninsured were associated with a lower likelihood of receiving an SCP. Future studies should evaluate how omission of SCP in these patients influences the quality of care during the transition from oncologists to primary care.
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Affiliation(s)
- Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ben Zarzaur
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David A Haggstrom
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, IN, USA
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Peter C Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maryam Lustberg
- Department of Internal Medicine, Division of Medical Oncology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, N924 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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16
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Kapoor R, Timsina LR, Gupta N, Kaur H, Vidger AJ, Pollander AM, Jacobi J, Khare S, Rahman O. Maintaining Blood Glucose Levels in Range (70-150 mg/dL) is Difficult in COVID-19 Compared to Non-COVID-19 ICU Patients-A Retrospective Analysis. J Clin Med 2020; 9:jcm9113635. [PMID: 33198177 PMCID: PMC7697842 DOI: 10.3390/jcm9113635] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 01/08/2023] Open
Abstract
Beta cell dysfunction is suggested in patients with COVID-19 infections. Poor glycemic control in ICU is associated with poor patient outcomes. This is a single center, retrospective analysis of 562 patients in an intensive care unit from 1 March to 30 April 2020. We review the time in range (70–150 mg/dL) spent by critically ill COVID-19 patients and non-COVID-19 patients, along with the daily insulin use. Ninety-three in the COVID-19 cohort and 469 in the non-COVID-19 cohort were compared for percentage of blood glucose TIR (70–150 mg/dL) and average daily insulin use. The COVID-19 cohort spent significantly less TIR (70–150 mg/dL) compared to the non-COVID-19 cohort (44.4% vs. 68.5%). Daily average insulin use in the COVID-19 cohort was higher (8.37 units versus 6.17 units). ICU COVID-19 patients spent less time in range (70–150 mg/dL) and required higher daily insulin dose. A higher requirement for ventilator and days on ventilator was associated with a lower TIR. Mortality was lower for COVID-19 patients who achieved a higher TIR.
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Affiliation(s)
- Rajat Kapoor
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
- Correspondence: ; Tel.: +1-2172202058
| | - Lava R. Timsina
- Department of Surgery, Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Nupur Gupta
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Harleen Kaur
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Arianna J. Vidger
- Department of Pharmacy, Indiana University Health, Indianapolis, IN 46202, USA; (A.J.V.); (A.M.P.)
| | - Abby M. Pollander
- Department of Pharmacy, Indiana University Health, Indianapolis, IN 46202, USA; (A.J.V.); (A.M.P.)
| | - Judith Jacobi
- Sr. Consultant Visante, Inc., St. Paul, MN 55101, USA;
| | - Swapnil Khare
- Division of Endocrinology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Omar Rahman
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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17
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Motaganahalli RL, Kapoor R, Timsina LR, Gutwein AR, Ingram MD, Raman S, Roberts SD, Rahman O, Rollins D, Dalsing MC. Clinical and laboratory characteristics of patients with novel coronavirus disease-2019 infection and deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 9:605-614.e2. [PMID: 33190816 PMCID: PMC7581378 DOI: 10.1016/j.jvsv.2020.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Early reports suggest that patients with novel coronavirus disease-2019 (COVID-19) infection carry a significant risk of altered coagulation with an increased risk for venous thromboembolic events. This report investigates the relationship of significant COVID-19 infection and deep venous thrombosis (DVT) as reflected in the patient clinical and laboratory characteristics. METHODS We reviewed the demographics, clinical presentation, laboratory and radiologic evaluations, results of venous duplex imaging and mortality of COVID-19-positive patients (18-89 years) admitted to the Indiana University Academic Health Center. Using oxygen saturation, radiologic findings, and need for advanced respiratory therapies, patients were classified into mild, moderate, or severe categories of COVID-19 infection. A descriptive analysis was performed using univariate and bivariate Fisher's exact and Wilcoxon rank-sum tests to examine the distribution of patient characteristics and compare the DVT outcomes. A multivariable logistic regression model was used to estimate the adjusted odds ratio of experiencing DVT and a receiver operating curve analysis to identify the optimal cutoff for d-dimer to predict DVT in this COVID-19 cohort. Time to the diagnosis of DVT from admission was analyzed using log-rank test and Kaplan-Meier plots. RESULTS Our study included 71 unique COVID-19-positive patients (mean age, 61 years) categorized as having 3% mild, 14% moderate, and 83% severe infection and evaluated with 107 venous duplex studies. DVT was identified in 47.8% of patients (37% of examinations) at an average of 5.9 days after admission. Patients with DVT were predominantly male (67%; P = .032) with proximal venous involvement (29% upper and 39% in the lower extremities with 55% of the latter demonstrating bilateral involvement). Patients with DVT had a significantly higher mean d-dimer of 5447 ± 7032 ng/mL (P = .0101), and alkaline phosphatase of 110 IU/L (P = .0095) than those without DVT. On multivariable analysis, elevated d-dimer (P = .038) and alkaline phosphatase (P = .021) were associated with risk for DVT, whereas age, sex, elevated C-reactive protein, and ferritin levels were not. A receiver operating curve analysis suggests an optimal d-dimer value of 2450 ng/mL cutoff with 70% sensitivity, 59.5% specificity, and 61% positive predictive value, and 68.8% negative predictive value. CONCLUSIONS This study suggests that males with severe COVID-19 infection requiring hospitalization are at highest risk for developing DVT. Elevated d-dimers and alkaline phosphatase along with our multivariable model can alert the clinician to the increased risk of DVT requiring early evaluation and aggressive treatment.
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Affiliation(s)
- Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind.
| | - Rajat Kapoor
- Division of Pulmonary & Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - Lava R Timsina
- Department of Surgery, Center for Outcomes Research in Surgery, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael D Ingram
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Subha Raman
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - Scott D Roberts
- Division of Pulmonary & Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - Omar Rahman
- Division of Pulmonary & Critical Care, Department of Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - David Rollins
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
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Satava RM, Stefanidis D, Levy JS, Smith R, Martin JR, Monfared S, Timsina LR, Darzi AW, Moglia A, Brand TC, Dorin RP, Dumon KR, Francone TD, Georgiou E, Goh AC, Marcet JE, Martino MA, Sudan R, Vale J, Gallagher AG. Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial. Ann Surg 2020; 272:384-392. [PMID: 32675553 DOI: 10.1097/sla.0000000000003220] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To demonstrate the noninferiority of the fundamentals of robotic surgery (FRS) skills curriculum over current training paradigms and identify an ideal training platform. SUMMARY BACKGROUND DATA There is currently no validated, uniformly accepted curriculum for training in robotic surgery skills. METHODS Single-blinded parallel-group randomized trial at 12 international American College of Surgeons (ACS) Accredited Education Institutes (AEI). Thirty-three robotic surgery experts and 123 inexperienced surgical trainees were enrolled between April 2015 and November 2016. Benchmarks (proficiency levels) on the 7 FRS Dome tasks were established based on expert performance. Participants were then randomly assigned to 4 training groups: Dome (n = 29), dV-Trainer (n = 30), and DVSS (n = 32) that trained to benchmarks and control (n = 32) that trained using locally available robotic skills curricula. The primary outcome was participant performance after training based on task errors and duration on 5 basic robotic tasks (knot tying, continuous suturing, cutting, dissection, and vessel coagulation) using an avian tissue model (transfer-test). Secondary outcomes included cognitive test scores, GEARS ratings, and robot familiarity checklist scores. RESULTS All groups demonstrated significant performance improvement after skills training (P < 0.01). Participating residents and fellows performed tasks faster (DOME and DVSS groups) and with fewer errors than controls (DOME group; P < 0.01). Inter-rater reliability was high for the checklist scores (0.82-0.97) but moderate for GEARS ratings (0.40-0.67). CONCLUSIONS We provide evidence of effectiveness for the FRS curriculum by demonstrating better performance of those trained following FRS compared with controls on a transfer test. We therefore argue for its implementation across training programs before surgeons apply these skills clinically.
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Affiliation(s)
- Richard M Satava
- Department of Surgery, University of Washington Medical Center, Seattle, WA
| | | | - Jeffrey S Levy
- Department of Ob/Gyn, Drexel University College of Medicine, Institute of Surgical Excellence, Philadelphia, PA
| | - Roger Smith
- Florida Hospital Nicholson Center, University of Central Florida College of Medicine, Celebration, FL
| | - John R Martin
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Sara Monfared
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ara Wardkes Darzi
- Department of Surgery, St. Mary's Hospital, Imperial College, London, UK
| | - Andrea Moglia
- EndoCAS Simulation Center, University of Pisa, Pisa, Italy
| | - Timothy C Brand
- Andersen Simulation Center, Madigan Army Medical Center, Tacoma, WA
| | - Ryan P Dorin
- Center for Education, Simulation and Innovation, Hartford Hospital, Hartford, CT
| | | | - Todd D Francone
- Department of Colon and Rectal Surgery, Lahey Health and Medical Center, Burlington, MA
| | | | - Alvin C Goh
- Houston Methodist Hospital, Methodist Institute for Technology, Innovation, and Education, Houston, TX
| | - Jorge E Marcet
- USF Health Center for Advanced Medical Learning and Simulation, Tampa, FL
| | | | - Ranjan Sudan
- Department of Surgery, Surgical Education and Activities Lab, Duke University Medical Center, Durham, NC
| | - Justin Vale
- EndoCAS Simulation Center, University of Pisa, Pisa, Italy
| | - Anthony G Gallagher
- Technology Enhanced Learning, ASSERT Centre, College of Medicine and Health, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland
- Faculty of Life and Health Sciences, Ulster University, Magee Campus, Londonderry, United Kingdom
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Morone EJ, Barker SJ, Martinez Licha CR, Timsina LR, Namburi N, Milward JB, Everett JE, Corvera JS, Beckman DJ, Hess PJ, Lee LS. Impact of troponin I level on coronary artery bypass grafting outcomes. J Card Surg 2020; 35:2704-2709. [PMID: 32720357 DOI: 10.1111/jocs.14889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/17/2020] [Accepted: 07/14/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The effect of preoperative cardiac troponin level on outcomes after coronary artery bypass grafting (CABG) is unclear. We investigated the impact of preoperative cardiac troponin I (cTnI) level as well as the time interval between maximum cTnI and surgery on CABG outcomes. METHODS All patients who underwent isolated CABG at our institution between 2009 and 2016 and had preoperative cTnI level available were identified using our Society of Thoracic Surgeons registry. Receiver operating characteristic (ROC) analysis was performed to identify a cTnI threshold level. Subjects were divided into groups based on this value and outcomes compared. RESULTS A total of 608 patients were included. ROC analysis identified 5.74 µg/dL as the threshold value associated with worse postoperative outcomes. Patients with peak cTnI >5.74 µg/dL underwent CABG approximately 1 day later, had twice the risk of adverse postoperative events, and had 2.8 day longer postoperative length of stay than those with peak cTnI ≤5.74 µg/dL. cTnI level was not associated with mortality or 30-day readmission. Time interval between peak cTnI and surgery did not affect outcomes. CONCLUSION Elevated preoperative cTnI level beyond a certain threshold value is associated with adverse postoperative outcomes but is not a marker for increased mortality. Time from peak cTnI does not affect postoperative outcomes or mortality and may not need to be considered when deciding timing of CABG.
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Affiliation(s)
- Emma J Morone
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shawn J Barker
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carlos R Martinez Licha
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lava R Timsina
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Niharika Namburi
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - James B Milward
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey E Everett
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joel S Corvera
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Daniel J Beckman
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip J Hess
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Liang TW, Wang SK, Dimusto PD, McAninch CM, Acher CW, Timsina LR, Dalsing MC, Motaganahalli RL. Association Between Body Mass Index and Perioperative Mortality After Repair of Ruptured Abdominal Aortic Aneurysms. Vasc Endovascular Surg 2020; 54:573-578. [PMID: 32643559 DOI: 10.1177/1538574420939356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The attempt to repair a ruptured abdominal aortic aneurysm carries a significant risk of perioperative mortality. The relationship between body mass index (BMI) and outcomes after repair of ruptured abdominal aortic aneurysms (AAAs) has not been well defined. We report the association of BMI with outcomes after ruptured AAA repair. METHODS Patients undergoing ruptured AAA repairs between 2008 and 2017 at 2 tertiary academic centers were included in this retrospective study. Demographics (including BMI), type of repair, length of stay, and admission mortality risk scores were gathered and analyzed using bivariate and multivariate logistic regressions. Adjusted odds ratio (AOR) was reported with 95% CIs and P values from the multivariate analysis. The primary outcome was 30-day mortality. Akaike information criterion (AIC) and c-statistics were used to assess the predictive power of models including physiologic score with or without BMI. RESULTS A total of 202 patients underwent repair of ruptured AAA. In bivariate relationship, increased BMI was significantly associated with 30-day mortality. With multivariate analysis, adjusting for demographics, type of procedure, and physiologic score, for each kg/m2 increase in BMI, an 8% increase in the likelihood of perioperative mortality (AOR = 1.08, 95% CI: 1.01-1.17; P = .04) was observed. CONCLUSION When adjusted for admission risk score, type of procedure, and demographics, obesity was associated with increased 30-day mortality. With BMI as an additional data point, the c-statistics and AIC comparisons indicated that we would have a greater ability to preoperatively estimate mortality after ruptured AAA repair. Consideration could be made to include BMI in future mortality risk scoring systems for ruptured AAA.
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Affiliation(s)
- Tiffany W Liang
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - S Keisin Wang
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Paul D Dimusto
- Division of Vascular Surgery, 5228University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher M McAninch
- Division of Vascular Surgery, 5228University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Charles W Acher
- Division of Vascular Surgery, 5228University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lava R Timsina
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael C Dalsing
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, 12250Indiana University School of Medicine, Indianapolis, IN, USA
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21
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Kutkut I, Rachwan RJ, Timsina LR, Ghabril MS, Lacerda MA, Kubal CA, Bourdillon PD, Mangus RS. Pre-Liver Transplant Cardiac Catheterization Is Associated With Low Rate of Myocardial Infarction and Cardiac Mortality. Hepatology 2020; 72:240-256. [PMID: 31696952 DOI: 10.1002/hep.31023] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A study at Indiana University demonstrated a reduction in myocardial infarction (MI) incidence with increased frequency of cardiac catheterization (CATH) in liver transplant (LT) candidates. A strict protocol for performing CATH based upon predefined risk factors, rather than noninvasive testing alone, was applied to a subgroup (2009-2010) from that study. CATH was followed by percutaneous coronary intervention (PCI) in cases of significant coronary artery disease (CAD; ≥50% stenosis). The current study applies this screening protocol to a larger cohort (2010-2016) to assess post-LT clinical outcomes. APPROACH AND RESULTS Among 811 LT patients, 766 underwent stress testing (94%) and 559 underwent CATH (69%), of whom 10% had CAD requiring PCI. The sensitivity of stress echocardiography in detecting significant CAD was 37%. Predictors of PCI included increasing age, male gender, and personal history of CAD (P < 0.05 for all). Compared to patients who had no CATH, patients who underwent CATH had higher mortality (P = 0.07), and the hazard rates (HR) for mortality increased with CAD severity (normal CATH, HR, 1.35; 95% confidence interval [CI], 0.79-2.33; P = 0.298; nonobstructive CAD, HR, 1.53; 95% CI, 0.84-2.77; P = 0.161; and significant CAD, HR, 1.96; 95% CI, 0.93-4.15; P = 0.080). Post-LT outcomes were compared to the 2009-2010 subgroup from the previous study and showed similar 1-year overall mortality (8% and 6%, P = 0.48), 1-year MI incidence (<1% and <1%, P = 0.8), and MI deaths as a portion of all deaths (3% and 9%, P = 0.35). CONCLUSIONS Stress echocardiography alone is not reliable in screening LT patients for CAD. Aggressive CAD screening with CATH is associated with low rate of MI and cardiac mortality and validates the previously published protocol when extrapolated over a larger sample and longer follow-up period.
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Affiliation(s)
- Issa Kutkut
- Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Rayan Jo Rachwan
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marco A Lacerda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Chandrashekhar A Kubal
- Department of Transplantation Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Patrick D Bourdillon
- Division of Cardiology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Mangus
- Department of Transplantation Surgery, Indiana University School of Medicine, Indianapolis, IN
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Dalsing MC, Gonzalez AA, Maijub JG, Rollins DM, Timsina LR. Prevalence and associations of incidental nonvenous duplex findings discovered during lower extremity venous imaging. J Vasc Surg Venous Lymphat Disord 2020; 9:200-208. [PMID: 32599309 DOI: 10.1016/j.jvsv.2020.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/01/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Venous duplex imaging defines venous pathology (VP). Unexpected clinically relevant findings are also found but rarely mentioned in the literature. This study aims to define the prevalence of ancillary findings (nonvenous duplex) by study type and venous outcome and subgroup associations with primary study indication and risk factors. METHODS Our vascular laboratory database was queried for lower extremity venous duplex studies with comments regarding ancillary findings and associated patient demographics, primary study indication, associated conditions, and venous study outcome. RESULTS There were 52,215 venous studies performed, 48,425 to evaluate for venous occlusion (acute/chronic) and 3790 for venous reflux. Of these studies, 15,810 found VP and 36,405 found no venous disease. There were 875 studies with venous disease that had ancillary duplex findings (5.5%) noted as 559 (3.5%) with prominent lymph node(s) (LN), 179 (1.1%) Baker's cyst (BC), 44 (0.3%) hematoma/mass (HM), 31 (0.2%) arterial aneurysm, and 16 (0.1%) arterial occlusion. There were 3130 studies free of VP with ancillary findings (8.6%) noted as 2258 (6.2%) prominent LN(s), 626 (1.7%) BC, 156 (0.4%) HM, 37 (0.1%) arterial aneurysm, and 22 (0.06%) arterial occlusion. The overall prevalence of ancillary findings was 8.62%. Analysis demonstrated statistically more ancillary findings in venous occlusion (odds ratio [OR], 1.25) studies, which was the largest group at 13 to 1. Studies free of venous disease had more ancillary findings (P < .001) with an OR of 1.88 and similar results were noted for LN(s), BC, and hematoma. Studies with VP favored a finding of aneurysm (OR, 0.52). Subgroup analyses demonstrated that those with prominent LN(s) were statistically older and male and BC statistically older in those with coexistent venous disease. BC subgroup analysis showed that studies free of venous disease were 2.5 times more likely to report pain as the primary study indication (P < .0001). In general, within ancillary subgroups, leg symptoms were statistically more prominent on the side with ancillary pathology and free of venous disease. CONCLUSIONS Ancillary findings are not uncommon and are more common in studies found free of VP. The most common are LNs, BC and HM and, within subgroups, significant leg symptoms favors the presence of ancillary findings without coexisting venous disease. Ancillary findings should be an integral part of a quality report.
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Affiliation(s)
- Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andrew A Gonzalez
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - John G Maijub
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - David M Rollins
- Diagnostic Vascular Laboratory, Indiana University Health, Indianapolis, Ind
| | - Lava R Timsina
- Department of Surgery, Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, Ind
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23
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Kesler KA, Stram AR, Timsina LR, Turrentine MW, Brown JW, Einhorn LH. Outcomes following surgery for primary mediastinal nonseminomatous germ cell tumors in the cisplatin era. J Thorac Cardiovasc Surg 2020; 161:1947-1959.e1. [PMID: 32446546 DOI: 10.1016/j.jtcvs.2020.01.118] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 01/16/2020] [Accepted: 01/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Treatment of primary mediastinal nonseminomatous germ cell tumors involves cisplatin-based chemotherapy followed by surgery to remove residual disease. We undertook a study to determine short and long-term outcomes. METHODS A retrospective analysis of patients with primary mediastinal nonseminomatous germ cell tumors who underwent surgery at our institution from 1982 to 2017 was performed. RESULTS A total of 255 patients (mean age, 29.2 years) were identified. Acute respiratory distress syndrome occurred postoperatively in 27 patients (10.9%), which was responsible for all 11 (4.3%) postoperative deaths. Of patients who developed acute respiratory distress syndrome, more patients received bleomycin-containing chemotherapy (25 out of 169; 14.8%) than non-bleomycin regimens (2 out of 77; 2.6%) (P = .004). With respect to variables independently predictive of long-term survival, evidence of choriocarcinoma before chemotherapy (n = 12) was determined to be an adverse factor (P = .006). In contrast, biopsy-proven elements of seminoma (n = 34) were predictive of improved survival (P = .04). The worst pathology identified in the residual mediastinal mass after chemotherapy was necrosis in 61 patients (25.0%), teratoma in 84 patients (34.4%), and malignant (persistent germ cell or non-germ cell cancer) in 97 patients (39.8%), which influenced overall survival (P < .001). Additionally, teratoma with stromal atypia (n = 18) demonstrated decreased survival compared with teratoma without atypia (n = 66; P = .031). Patients with malignancy involving >50% of the residual mass (n = 47) had a 2.3-fold increased risk of death compared with ≤50% malignancy (n = 45; P = .008). Finally, elevated postoperative serum tumor markers (n = 40) was significantly predictive of adverse survival (P < .001). CONCLUSIONS In the treatment of primary mediastinal nonseminomatous germ cell tumors, avoiding bleomycin-containing chemotherapy is important. Pre- and postchemotherapy pathology and postoperative serum tumor markers are independent predictors of long-term survival.
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Affiliation(s)
- Kenneth A Kesler
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind.
| | - Amanda R Stram
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Lava R Timsina
- Center for Outcomes Research, Department of Surgery, Indiana University, Indianapolis, Ind
| | - Mark W Turrentine
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - John W Brown
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Lawrence H Einhorn
- Division of Medical Oncology, Department of Medicine, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
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24
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Yee EJ, Wang SK, Timsina LR, Ruiz-Herrera S, Liao JL, Donde NN, Fajardo AC, Motaganahalli RL. Propensity-Matched Outcomes of Transcarotid Artery Revascularization Versus Carotid Endarterectomy. J Surg Res 2020; 252:22-29. [PMID: 32222590 DOI: 10.1016/j.jss.2019.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/31/2019] [Accepted: 12/03/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) with cerebral flow reversal is an emerging treatment option for carotid artery stenosis in patients with high risk for traditional endarterectomy. The purpose of this study was to compare real-world, procedure-related outcomes in similarly comorbid patients undergoing TCAR or carotid endarterectomy (CEA). METHODS A retrospective review of all patients receiving either TCAR or CEA outside of clinical trial regulations at our institution was performed. Participants were propensity-matched by age, gender, body mass index, smoking status, presence of restenosis, history of neck radiation, presence of contralateral carotid occlusion, history of previous neck dissection, and symptom status. Bivariate analysis was followed by a penalized Firth logistic regression to compare treatments. RESULTS Between January 2011 and July 2018, 342 CEAs and 109 TCARs were captured for analysis. After matching, 87 distinct treatment pairs were created without evidence of variation in any of the prespecified variables. On multivariate analysis using maximum and penalized likelihood ratios, we found that TCAR was associated with an increased incidence of intraoperative hypertension (adjusted coefficient, 1.41; 95% confidence interval [0.53, 2.29], P < 0.01). TCAR was also associated with decreased reverse flow/clamp time (mins; -36.80; [-45.47, -27.93], P < 0.01) and estimated blood loss (mLs; -63.66; [-85.91, -41.42], P < 0.01). In the perioperative period, there were no differences between TCAR and CEA with respect to myocardial infarction (-0.04; [-3.68, 3.60], P = 0.98), stroke (-0.74; [-2.68, 1.19], P = 0.45), and all-cause mortality (1.09; [-1.76, 3.94], P = 0.11). Similarly, a composite incidence of stroke/death was the same between cohorts (2.42; [-0.57, 5.41], P = 0.11). CONCLUSIONS This propensity-matched analysis of carotid artery revascularization modalities suggests that TCAR is equivalent to CEA in the perioperative period while incurring shorter operative time and less blood loss.
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Affiliation(s)
- Elliott J Yee
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lava R Timsina
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sebastian Ruiz-Herrera
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jane L Liao
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Nikunj N Donde
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andres C Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
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25
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Lee LS, Clark AJ, Namburi N, Naum CC, Timsina LR, Corvera JS, Beckman DJ, Everett JE, Hess PJ. The presence of a dedicated cardiac surgical intensive care service impacts clinical outcomes in adult cardiac surgery patients. J Card Surg 2020; 35:787-793. [PMID: 32048378 DOI: 10.1111/jocs.14457] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Postoperative critical care management is an integral part of cardiac surgery that contributes directly to clinical outcomes. In the United States there remains considerable variability in the critical care infrastructure for cardiac surgical programs. There is little published data investigating the impact of a dedicated cardiac surgical intensive care service. METHODS A retrospective study examining postoperative outcomes in cardiac surgical patients before and after the implementation of a dedicated cardiac surgical intensive care service at a single academic institution. An institutional Society of Thoracic Surgeons database was queried for study variables. Primary endpoints were the postoperative length of stay, intensive care unit length of stay, and mechanical ventilation time. Secondary endpoints included mortality, readmission rates, and postoperative complications. The effect on outcomes based on procedure type was also analyzed. RESULTS A total of 1703 patients were included in this study-914 in the control group (before dedicated intensive care service) and 789 in the study group (after dedicated intensive care service). Baseline demographics were similar between groups. Length of stay, mechanical ventilation hours, and renal failure rate were significantly reduced in the study group. Coronary artery bypass grafting patients observed the greatest improvement in outcomes. CONCLUSIONS Implementation of a dedicated cardiac surgical intensive care service leads to significant improvements in clinical outcomes. The greatest benefit is seen in patients undergoing coronary artery bypass, the most common cardiac surgical operation in the United States. Thus, developing a cardiac surgical intensive care service may be a worthwhile initiative for any cardiac surgical program.
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Affiliation(s)
- Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aaron J Clark
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Niharika Namburi
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chris C Naum
- Division of Pulmonary and Critical Care Medicine, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lava R Timsina
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joel S Corvera
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Daniel J Beckman
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey E Everett
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip J Hess
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
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Rachwan RJ, Kutkut I, Hathaway TJ, Timsina LR, Kubal CA, Lacerda MA, Ghabril MS, Bourdillon PD, Mangus RS. Postoperative Atrial Fibrillation and Flutter in Liver Transplantation: An Important Predictor of Early and Late Morbidity and Mortality. Liver Transpl 2020; 26:34-44. [PMID: 31454145 DOI: 10.1002/lt.25631] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022]
Abstract
Postoperative atrial fibrillation/flutter (POAF) is the most common perioperative arrhythmia and may be particularly problematic after liver transplantation (LT). This study is a single-center retrospective analysis of POAF to determine its incidence following LT, to identify risk factors, to assess its impact on clinical outcomes, and to summarize management strategies. The records of all patients who underwent LT between 2010 and 2018 were reviewed. Extracted data included pre-LT demographics and cardiac evaluation, in-hospital post-LT cardiac events, early and late complications, and survival. Among 1011 patients, the incidence of post-LT POAF was 10%. Using binary logistic regression, pre-LT history of atrial fibrillation was the strongest predictor of POAF (odds ratio [OR], 6.72; 95% confidence interval [CI], 2.00-22.57; P < 0.001), followed by history of coronary artery disease (CAD; OR, 2.52; 95% CI, 1.10-5.81; P = 0.03). Cardiac stress testing abnormality and CAD on cardiac catheterization were also associated with higher risk. Median time to POAF onset after LT was 3 days with 72% of cases resolving within 48 hours. POAF patients had greater hospital length of stay, death during the LT admission, and 90-day and 1-year mortality. POAF was an independent risk factor for post-LT mortality (OR, 2.0; 95% CI, 1.3-3.0; P < 0.01). Amiodarone was administered to 73% of POAF patients with no evidence of increased serum alanine aminotransferase levels. POAF occurred in 10% of post-LT patients with early onset and rapid resolution in most affected patients. POAF patients, however, had significant morbidity and mortality, suggesting that POAF is an important marker for worse early and late post-LT outcomes.
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Affiliation(s)
- Rayan Jo Rachwan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Issa Kutkut
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Taylor J Hathaway
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Lava R Timsina
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Chandrashekhar A Kubal
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Marco A Lacerda
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Patrick D Bourdillon
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Mangus
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Timsina LR, Qiao N, Mongalo AC, Vetor AN, Carroll AE, Bell TM. National Instant Criminal Background Check and Youth Gun Carrying. Pediatrics 2020; 145:peds.2019-1071. [PMID: 31792166 PMCID: PMC6939841 DOI: 10.1542/peds.2019-1071] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite being unable to purchase firearms directly, many adolescents have access to guns, leading to increased risk of injury and death. We sought to determine if the National Instant Criminal Background Check System (NICS) changed adolescents' gun-carrying behavior. METHODS We performed a repeated cross-sectional study using National Youth Risk Behavior Survey data from years 1993 to 2017. We used a survey-weighted multivariable logistic regression model to determine if the NICS had an effect on adolescent gun carrying, controlling for state respondent characteristics, state laws, state characteristics, the interaction between the NICS and state gun laws, and time. RESULTS On average, 5.8% of the cohort reported carrying a gun. Approximately 17% of respondents who carried guns were from states with a universal background check (U/BC) provision at the point of sale, whereas 83% were from states that did not have such laws (P < .001). The model indicated that the NICS together with U/BCs significantly reduced gun carrying by 25% (adjusted relative risk = 0.75 [95% confidence interval: 0.566-0.995]; P = .046), whereas the NICS independently did not (P = .516). CONCLUSIONS Adolescents in states that require U/BCs on all prospective gun buyers are less likely to carry guns compared with those in states that only require background checks on sales through federally licensed firearms dealers. The NICS was only effective in reducing adolescent gun carrying in the presence of state laws requiring U/BCs on all prospective gun buyers. However, state U/BC laws had no effect on adolescent gun carrying until after the NICS was implemented.
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Affiliation(s)
| | - Nan Qiao
- Department of Economics, School of Liberal Arts,
Indiana University, Indianapolis, Indiana
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Brown BP, Clark MT, Wise RL, Timsina LR, Reher TA, Vandewalle RJ, Brown JJ, Saenz ZM, Gray BW. A multifactorial severity score for left congenital diaphragmatic hernia in a high-risk population using fetal magnetic resonance imaging. Pediatr Radiol 2019; 49:1718-1725. [PMID: 31414145 DOI: 10.1007/s00247-019-04478-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/17/2019] [Accepted: 07/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adverse outcomes for infants born with left congenital diaphragmatic hernia (CDH) have been correlated with fetal imaging findings. OBJECTIVE We sought to corroborate these correlations in a high-risk cohort and describe a predictive mortality algorithm combining multiple imaging biomarkers for use in prenatal counseling. MATERIALS AND METHODS We reviewed fetal MRI examinations at our institution from 2004 to 2016 demonstrating left-side CDH. MRI findings, hospital course and outcomes were recorded and analyzed using bivariate and multivariable analysis. We generated a receiver operating curve (ROC) to determine a cut-off relation for mortality. Finally, we created a predictive mortality calculator. RESULTS Of 41 fetuses included in this high-risk cohort, 41% survived. Per bivariate analysis, observed-to-expected total fetal lung volume (P=0.007), intrathoracic position of the stomach (P=0.049), and extracorporeal membrane oxygenation (ECMO) requirement (P<0.001) were significantly associated with infant mortality. Youden J statistic optimized the ROC for mortality at 24% observed-to-expected total fetal lung volume (sensitivity 64%, specificity 82%, area under the curve 0.72). On multivariable analysis, observed-to-expected total fetal lung volume ± 24% was predictive of mortality (adjusted odds ratio, 95% confidence interval: 0.09 [0.02, 0.55]; P=0.008). We derived a novel mortality prediction calculator from this analysis. CONCLUSION In this high-risk cohort, decreased observed-to-expected total fetal lung volume and stomach herniation were significantly associated with mortality. The novel predictive mortality calculator utilizes information from fetal MR imaging and provides prognostic information for health care providers. Creation of similar predictive tools by other institutions, using their distinct populations, might prove useful in family counseling, especially where there are discordant imaging findings.
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Affiliation(s)
- Brandon P Brown
- The Fetal Center at Riley Children's Health, 705 Riley Hospital Drive, Indianapolis, IN, 54202, USA.
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Michael T Clark
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rachel L Wise
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lava R Timsina
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas A Reher
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert J Vandewalle
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joshua J Brown
- The Fetal Center at Riley Children's Health, 705 Riley Hospital Drive, Indianapolis, IN, 54202, USA
| | - Zoe M Saenz
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brian W Gray
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Murphy PB, Severance S, Savage S, Obeng-Gyasi S, Timsina LR, Zarzaur BL. Financial toxicity is associated with worse physical and emotional long-term outcomes after traumatic injury. J Trauma Acute Care Surg 2019; 87:1189-1196. [PMID: 31233442 PMCID: PMC6815224 DOI: 10.1097/ta.0000000000002409] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing health care costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health-related quality of life (HRQoL) outcomes. The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQoL. METHODS Adult patients with an Injury Severity Score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1 month, 2 months, 4 months, and 12 months. Screens for depression and posttraumatic stress syndrome were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. RESULTS Five hundred patients were enrolled, and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (odds ratio [OR], 0.96 [0.94-0.98]), lack of health insurance (OR, 0.28 [0.14-0.56]), and larger household size (OR, 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQoL, and more depression and posttraumatic stress syndrome in a stepwise fashion based on severity of financial toxicity. CONCLUSION Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified, and interventions to counteract the negative effects should be developed to improve long-term outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Affiliation(s)
- Patrick B Murphy
- From the Department of Surgery (P.T.M., S.Se., S.O.-G., L.R.T., B.L.Z.), Indiana University School of Medicine, Indianapolis, Indiana; and Department of Surgery (S.Sa.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Saad M, Gurjar H, Rodriguez M, Sharma P, Roy S, Timsina LR, Bhandari M, Vittorio T. The Role of Cardioselective versus Non-Cardioselective Beta-Adrenergic Blockade in the Acute Phase of Takotsubo Cardiomyopathy. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.077] [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: 10/26/2022]
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Roy S, Lacoste AG, Zaidi B, Hernandez N, Timsina LR, Saad M, Bhandari M, Bella JN, Vittorio TJ. SGLT-2 Inhibition Does Not Improve Left Ventricular Reverse Remodeling in Patients with Diabetes Mellitus Type 2. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nguyen R, Vater L, Timsina LR, Durm GA, Rupp K, Wright K, Spitznagle M, Paul B, Jalal SI, Carter-Harris L, Hudmon KS, Hanna NH, Loehrer PJ, Ceppa D. Impact of smoke-free ordinance strength on smoking prevalence and lung cancer incidence. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6578 Background: Smoke-free ordinances (SFO) have been shown to decrease the prevalence of cardiovascular and pulmonary disease, but there is limited data on the impact of such policies on lung cancer incidence. We investigated the relationship between strength of county-level SFO with smoking prevalence and lung cancer incidence in Indiana. Methods: Following IRB approval, we queried the Indiana State Cancer Registry and Indiana Tobacco Prevention and Cessation Commission’s policy database between 1995 and 2016. County-level characteristics included population, income, poverty, education, race/ethnicity, sex, and rurality. Lung cancer diagnosis and stage were also collected. Using generalized estimating equations (GEE) with robust standard errors and accounting for the clustering effect at county level, we performed multivariable analyses of smoking prevalence and age-adjusted lung cancer rates with respect to the strength of smoke-free ordinances at the county level over time. Results: Indiana consists of 92 counties, 24 of which had SFO by 2011. In 2012, Indiana enacted a law mandating at least a moderate state-wide SFO. From 1995 to 2016, 110,935 Indiana residents were diagnosed with lung cancer. Indiana also had an average age-adjusted yearly lung cancer incidence of 76.8 per 100,000 population and average yearly smoking prevalence of 25% during this time. Smoking prevalence was 1.2% (95% CI [-1.88, -0.52]) lower in counties with comprehensive or moderate SFO compared with those with weak or no SFO. Counties that had comprehensive or moderate SFO had an 8.36 (95% CI [-11.45, -5.27]) decrease in new lung cancer diagnosis per 100,000 population per year compared with counties that had weak or no SFO. Conclusions: Stronger municipal smoke-free air ordinances are associated with decreased smoking prevalence and fewer new lung cancer cases. Strengthening smoke-free ordinances is paramount to decreasing lung cancer incidence.
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Affiliation(s)
- Ryan Nguyen
- Indiana University School of Medicine, Indianapolis, IN
| | | | | | - Greg Andrew Durm
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
| | - Katelin Rupp
- Indiana State Department of Health, Indianapolis, IN
| | - Keylee Wright
- Indiana State Department of Health, Indianapolis, IN
| | | | - Brandy Paul
- Indiana State Department of Health, Indianapolis, IN
| | | | | | | | - Nasser H. Hanna
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
| | - Patrick J. Loehrer
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN
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Anton NE, Mizota T, Timsina LR, Whiteside JA, Myers EM, Stefanidis D. Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment. Am J Surg 2018; 217:266-271. [PMID: 30538032 DOI: 10.1016/j.amjsurg.2018.11.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Several studies demonstrated that simulator-acquired skill transfer to the operating room is incomplete. Our objective was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room. METHODS Trainees completed baseline assessments including intracorporeal suturing (IS) performance, attentional selectivity, self-reported use of mental skills, and self-reported prior clinical and simulated laparoscopic experience and confidence. Residents then followed proficiency-based laparoscopic skills training, and their skill transfer was assessed on a live-anesthetized porcine model. Predictive characteristics for transfer test performance were assessed using multiple linear regression. RESULTS Thirty-eight residents completed the study. Automaticity, attentional selectivity, resident perceived ability with laparoscopy and simulators, and post-training IS performance were predictive of IS performance during the transfer test. CONCLUSIONS Promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. Mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal.
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Affiliation(s)
- Nicholas E Anton
- Department of Surgery, Indiana University School of Medicine, USA
| | - Tomoko Mizota
- Department of Surgery, Indiana University School of Medicine, USA
| | - Lava R Timsina
- Department of Surgery, Indiana University School of Medicine, USA
| | - Jake A Whiteside
- Department of Surgery, Indiana University School of Medicine, USA
| | - Erinn M Myers
- Carolinas Simulation Center, Carolinas Healthcare System, USA
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Anton NE, Sawyer JM, Korndorffer JR, DuCoin CG, McRary G, Timsina LR, Stefanidis D. Developing a robust suturing assessment: validity evidence for the intracorporeal suturing assessment tool. Surgery 2018; 163:560-564. [DOI: 10.1016/j.surg.2017.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/10/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
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Timsina LR, Willetts JL, Brennan MJ, Marucci-Wellman H, Lombardi DA, Courtney TK, Verma SK. Circumstances of fall-related injuries by age and gender among community-dwelling adults in the United States. PLoS One 2017; 12:e0176561. [PMID: 28472065 PMCID: PMC5417511 DOI: 10.1371/journal.pone.0176561] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 04/12/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Falls are the leading cause of injury in almost all age-strata in the U.S. However, fall-related injuries (FI) and their circumstances are under-studied at the population level, particularly among young and middle-aged adults. This study examined the circumstances of FI among community-dwelling U.S. adults, by age and gender. METHODS Narrative texts of FI from the National Health Interview Survey (1997-2010) were coded using a customized taxonomy to assess place, activity, initiating event, hazards, contributing factors, fall height, and work-relatedness of FI. Weighted proportions and incidence rates of FI were calculated across six age-gender groups (18-44, 45-64, 65+ years; women, men). RESULTS The proportion of FI occurring indoors increased with age in both genders (22%, 30%, and 48% among men, and 40%, 49% and 62% among women for 18-44, 45-64, 65+ age-groups, respectively). In each age group the proportion of indoor FI was higher among women as compared to men. Among women, using the stairs was the second leading activity (after walking) at the time of FI (19%, 14% and 10% for women in 18-44, 45-64, 65+ age groups, respectively). FI associated with tripping increased with age among both genders, and women were more likely to trip than men in every age group. Of all age-gender groups, the rate of FI while using ladders was the highest among middle-aged men (3.3 per 1000 person-year, 95% CI 2.0, 4.5). Large objects, stairs and steps, and surface contamination were the three most common hazards noted for 15%, 14% and 13% of fall-related injuries, respectively. CONCLUSIONS The rate and the circumstances of FI differ by age and gender. Understanding these differences and obtaining information about circumstances could be vital for developing effective interventions to prevent falls and FI.
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Affiliation(s)
- Lava R. Timsina
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- College of Public Health, University of Kentucky, Lexington, Kentucky, United States of America
| | - Joanna L. Willetts
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
| | - Melanye J. Brennan
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
| | - Helen Marucci-Wellman
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
| | - David A. Lombardi
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- Environmental and Occupational Medicine and Epidemiology Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Theodore K. Courtney
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- Environmental and Occupational Medicine and Epidemiology Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Santosh K. Verma
- Center for Injury Epidemiology, Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts, United States of America
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
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Mays GP, Mamaril CB, Timsina LR. Preventable Death Rates Fell Where Communities Expanded Population Health Activities Through Multisector Networks. Health Aff (Millwood) 2016; 35:2005-2013. [DOI: 10.1377/hlthaff.2016.0848] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Glen P. Mays
- Glen P. Mays ( ) is the F. Douglas Scutchfield Endowed Professor in Health Services and Systems Research, College of Public Health, at the University of Kentucky, in Lexington
| | - Cezar B. Mamaril
- Cezar B. Mamaril is an assistant professor in the Department of Health Management and Policy, College of Public Health, University of Kentucky
| | - Lava R. Timsina
- Lava R. Timsina is a graduate research assistant in the Department of Health Management and Policy, College of Public Health, University of Kentucky
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Carman AL, Timsina LR, Scutchfield FD. Quality improvement activities of local health departments during the 2008-2010 economic recession. Am J Prev Med 2014; 46:171-4. [PMID: 24439351 DOI: 10.1016/j.amepre.2013.10.005] [Citation(s) in RCA: 8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 07/18/2013] [Accepted: 10/04/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND A review of the work of researchers in the field of quality reveals a connection between the use of quality improvement (QI) concepts and improved financial performance. The disconnect between the expanding role of public health and the levels of per capita spending to support this role suggests that local health departments with a change in funding might benefit by employing QI to increase service delivery efficiency. PURPOSE To examine the relationship between changes in local health department (LHD) total revenue during the 2008-2010 economic recession and changes in LHD quality improvement activities during the same period. METHODS A matched-pairs study assessed change in revenue and associated change in QI activities at two points of time, 2008 and 2010. The study was completed in 2013. A proportional odds regression model estimated the adjusted ORs, measuring the association between change in QI activities and total revenue change, controlling for demographics, leadership QI training, and accreditation intention. RESULTS Neither changes in revenue nor changes in expenses predicted change in QI activities in LHDs. Enhanced QI activities were found in LHDs led by a director with a master's degree, led by directors trained in QI, or those serving medium-sized (50,000-499,000) jurisdictions. CONCLUSIONS This study revealed that neither changes in revenue nor changes in LHD expenses predict enhanced QI activities. Rather, improvements appear to be more related to characteristics of local health department leaders, which suggests areas to focus on for future efforts in public health services improvement.
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Affiliation(s)
| | - Lava R Timsina
- National Coordinating Center for Public Health Services and Systems Research (Timsina)
| | - F Douglas Scutchfield
- College of Public Health (Carman, Scutchfield); College of Medicine (Scutchfield), University of Kentucky, Lexington, Kentucky
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Singh GK, Siahpush M, Hiatt RA, Timsina LR. Dramatic increases in obesity and overweight prevalence and body mass index among ethnic-immigrant and social class groups in the United States, 1976-2008. J Community Health 2011; 36:94-110. [PMID: 20549318 PMCID: PMC3020302 DOI: 10.1007/s10900-010-9287-9] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [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] [Indexed: 11/29/2022]
Abstract
This study examined trends in US obesity and overweight prevalence and body mass index (BMI) among 30 immigrant groups, stratified by race/ethnicity and length of immigration, and among detailed education, occupation, and income/poverty groups from 1976 to 2008. Using 1976–2008 National Health Interview Surveys, differentials in obesity, overweight, and BMI, based on self-reported height and weight, were analyzed by using disparity indices, logistic, and linear regression. The obesity prevalence for the US population aged ≥18 tripled from 8.7% in 1976 to 27.4% in 2008. Overweight prevalence increased from 36.9% in 1976 to 62.0% in 2008. During 1991–2008, obesity prevalence for US-born adults increased from 13.9 to 28.7%, while prevalence for immigrants increased from 9.5 to 20.7%. While immigrants in each ethnic group and time period had lower obesity and overweight prevalence and BMI than the US-born, immigrants’ risk of obesity and overweight increased with increasing duration of residence. In 2003–2008, obesity prevalence ranged from 2.3% for recent Chinese immigrants to 31–39% for American Indians, US-born blacks, Mexicans, and Puerto Ricans, and long-term Mexican and Puerto Rican immigrants. Between 1976 and 2008, the obesity prevalence more than quadrupled for those with a college education or sales occupation. Although higher prevalence was observed for lower education, income, and occupation levels in each period, socioeconomic gradients in obesity and overweight decreased over time because of more rapid increases in prevalence among higher socioeconomic groups. Continued immigrant and socioeconomic disparities in prevalence will likely have substantial impacts on future obesity trends in the US.
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Affiliation(s)
- Gopal K Singh
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 5600 Fishers Lane, Room 18-41, Rockville, MD 20857, USA.
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Siahpush M, Jones PR, Singh GK, Timsina LR, Martin J. Association of availability of tobacco products with socio-economic and racial/ethnic characteristics of neighbourhoods. Public Health 2010; 124:525-9. [PMID: 20723950 DOI: 10.1016/j.puhe.2010.04.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Revised: 03/24/2010] [Accepted: 04/28/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the association of neighbourhood median income and racial/ethnic composition with the availability of tobacco products in Omaha Metropolitan Area, Nebraska, USA. METHODS A total of 94 census tracts were selected at random. The outcome measures were the percentage of stores that sold tobacco and the number of stores that sold tobacco per square mile in each census tract. RESULTS Median household income was negatively associated (P<0.001), and percentage African American population (P<0.001) and percentage Hispanic population (P=0.049) were positively associated with the percentage of stores that sold tobacco. Median household income was negatively associated (P<0.001) and percentage Hispanic population (P=0.012) was positively associated with the number of stores that sold tobacco per square mile. CONCLUSION Policies that reduce the number of tobacco outlets might reduce social disparities in tobacco use.
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Affiliation(s)
- M Siahpush
- Department of Health Promotion, Social and Behavioral Health Sciences, College of Public Health, University of Nebraska Medical Center, 986075 Nebraska Medical Center, Omaha, NE 68198-6075, USA.
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Siahpush M, Singh GK, Jones PR, Timsina LR. Racial/ethnic and socioeconomic variations in duration of smoking: results from 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey. J Public Health (Oxf) 2009; 32:210-8. [PMID: 19892784 DOI: 10.1093/pubmed/fdp104] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Little is known about racial/ethnic and socioeconomic variations in the duration of smoking. The goal of this research was to examine these variations. METHODS Data came from the 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey. The analysis was limited to ever-smokers (n = 117,168). The outcome was number of years of daily smoking. Survival analysis was employed to predict smoking duration. RESULTS American Indians with 32 years had the highest median duration of smoking, followed by Blacks and 'other' races with 30 years, Whites with 28 years and Hispanics with 24 years. The difference in the duration of smoking between Blacks and Whites disappeared after adjusting for poverty. Individuals in poverty had a median duration of smoking of 40 years, while those with a family income of at least three times that of the poverty threshold had a median duration of 22 years. Median duration of smoking was 40 years among individuals without a high-school diploma and 18 years among those with a bachelors or higher degree. CONCLUSION This research revealed large variations in smoking duration between racial/ethnic and socioeconomic groups. Longer exposure to tobacco among groups that are already disadvantaged is likely to exacerbate existing health disparities.
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Affiliation(s)
- M Siahpush
- Department of Health Promotion, Social and Behavioral Health Sciences, College of Public Health, University of Nebraska Medical Center, 986075 Nebraska Medical Center, Omaha, NE 68198-6075, USA.
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