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Fishman CE, Sommers T, Bennett NL, Cohen ME. A peer-to-peer handoff tool to ease clerkship transitions. Med Teach 2024; 46:486-488. [PMID: 38104571 DOI: 10.1080/0142159x.2023.2292980] [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] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023]
Abstract
EDUCATIONAL CHALLENGE Frequent transitions between core clinical rotations in medical school increase anxiety and cognitive load. Few formalized programs exist to ease these transitions. Our institutional needs-assessment found that approximately 85% of students believed that additional rotation-specific information prior to starting a new rotation would reduce anxiety and increase success. PROPOSED SOLUTION AND IMPLEMENTATION OF SOLUTION We developed a novel web-based peer-to-peer handoff tool available to all clerkship students at a single, large academic institution. The tool contains the names and contact information of students who most recently completed rotations on each service for all clerkships. A handoff checklist was also created with suggested discussion points for handoffs. Students were encouraged to schedule a handoff 1-2 weeks before starting a new rotation. LESSONS LEARNED Overall, 83 students (66%) utilized the handoff tool, with use and efficacy decreasing with time during the clinical year. Of tool users, 65% expressed that having access to the tool prior to starting a new rotation helped to reduce anxiety, and 74% felt that the information gained helped to ease transitions. Our peer-to-peer handoff tool may help students feel more prepared to start a new rotation, decrease anxiety during clerkship year, and ease transitions. NEXT STEPS This low-resource intervention may be implemented at other institutions to provide students with equal opportunities to receive valuable information prior to starting new rotations, regardless of pre-existing peer connections. An automated update system, which we are implementing at our institution, could greatly decrease the time required to maintain a handoff tool and improve sustainability.
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Affiliation(s)
- Claire E Fishman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Sommers
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nadia L Bennett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Margot E Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Cohen ME, Linganna A, Kim J, Orr AR. A novel hospitalist peer observation program to improve educational and operational rounding practices. J Hosp Med 2024; 19:200-203. [PMID: 38268431 DOI: 10.1002/jhm.13285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/03/2024] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
Academic hospitalists must balance trainee education with operational demands to round efficiently and optimize hospital throughput. Peer observation has been shown to support educator development, however, few hospitalists have formal training to optimize both skill sets. We sought to extend and adapt peer observation programs to equally focus on education and operations-based outcomes. During the 2-year study period, 76 of 98 (78%) eligible faculty participated in a structured, real-time peer observation program. Immediately after observing a peer, 42% of respondents planned to adopt an operations-related rounding behavior. Following program completion, 77% of respondents endorsed the implementation of a new rounding behavior learned from a peer, with a third of these behaviors related to clinical operations. Ninety-five percent of respondents endorsed at least a moderate degree of program satisfaction. High levels of engagement and sustained behavior change following program participation suggest clinical operations are an important addition to peer observation programs and faculty development initiatives.
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Affiliation(s)
- Margot E Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashok Linganna
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew R Orr
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cohen ME, Kalotra A, Orr AR. Twelve tips for excelling as an introvert in academic medicine (at all levels). Med Teach 2023; 45:1118-1122. [PMID: 37262301 DOI: 10.1080/0142159x.2023.2216357] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Introverted individuals comprise up to half of the population, but are often overlooked in a culture that privileges extraversion. This misunderstanding of introversion has downstream effects for introverts in academic medicine, including lower grades on clinical rotations, increased stress, and under-representation in leadership positions. AIMS To increase support for and awareness of the unique strengths of introverted individuals at all stages of a career in academic medicine. DESCRIPTION This article offers twelve tips, based in the educational, business, and personality literature, to empower introverted students, residents, and faculty members for success in academic medicine. While many of the tips apply broadly, certain tips may be more relevant to those in a particular career stage. CONCLUSION Increased understanding of the natural tendencies and strengths of introversion will promote a more inclusive working environment for all personality types in medicine and allow introverts at all levels of training and practice to thrive.
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Affiliation(s)
- Margot E Cohen
- Assistant Professor of Clinical Medicine, Section of Hospital Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aditi Kalotra
- Instructor of Clinical Medicine, Section of Hospital Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew R Orr
- Assistant Professor of Clinical Medicine, Section of Hospital Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Herchline D, Cohen ME, Ambrose M, Hwang J, Kaminstein D, Kilberg M, Rosenblatt S, Ziemba J, Boyer D. Into the Unknown: Characterizing Fellow Uncertainty During the Transition to Unsupervised Practice. J Grad Med Educ 2023; 15:201-208. [PMID: 37139214 PMCID: PMC10150825 DOI: 10.4300/jgme-d-22-00221.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/22/2022] [Accepted: 12/14/2022] [Indexed: 05/05/2023] Open
Abstract
Background Helping fellows confront and manage uncertainty in the course of diagnosis and treatment of patients has been a growing focus of medical education. How these same fellows confront uncertainty as they make a transition in their professional development is less commonly a focus of training programs. Better understanding of how fellows experience these transitions will allow fellows, training programs, and hiring institutions to navigate transitions more easily. Objective This study aimed to explore how fellows in the United States experience uncertainty during the transition to unsupervised practice. Methods Using constructivist grounded theory, we invited participants to engage in semi-structured interviews exploring experiences with uncertainty as they navigate the transition to unsupervised practice. Between September 2020 and March 2021, we interviewed 18 physicians in their final year of fellowship training from 2 large academic institutions. Participants were recruited from adult and pediatric subspecialties. Data analysis was conducted using an inductive coding approach. Results Experiences with uncertainty during the transition process were individualized and dynamic. Primary sources of uncertainty identified included clinical competence, employment prospects, and career vision. Participants discussed multiple strategies for mitigating uncertainty, including structured graduated autonomy, leveraging professional networks locally and non-locally, and utilizing established program and institutional supports. Conclusions Fellows' experiences with uncertainty during their transitions to unsupervised practice are individualized, contextual, and dynamic with several shared overarching themes.
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Affiliation(s)
- Daniel Herchline
- Daniel Herchline, MD, MSEd, is an Assistant Professor, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
| | - Margot E. Cohen
- Margot E. Cohen, MD, MSEd, is an Assistant Professor, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Marietta Ambrose
- Marietta Ambrose, MD, MPH, MSEd, is an Associate Professor, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Jennifer Hwang
- Jennifer Hwang, MD, MHS, MSEd, is an Associate Professor, Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania
| | - Daniel Kaminstein
- Daniel Kaminstein, MD, DTM&H, FACEP, MSEd, is the Director of Global Health, Department of Emergency Medicine, Medical College of Georgia, Augusta University
| | - Marissa Kilberg
- Marissa Kilberg, MD, MSEd, is an Attending Physician, Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania
| | - Samuel Rosenblatt
- Samuel Rosenblatt, MD, MSEd, is an Assistant Professor, Department of Anesthesiology & Critical Care, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania
| | - Justin Ziemba
- Justin Ziemba, MD, MSEd, is an Assistant Professor, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Donald Boyer
- Donald Boyer, MD, MSEd, is an Assistant Professor, Department of Anesthesiology & Critical Care, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania
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Yin S, Arkes HR, McCoy JP, Cohen ME, Mellers BA. Conflicting Goals Influence Physicians' Expressed Beliefs to Patients and Colleagues. Med Decis Making 2021; 41:505-514. [PMID: 33764191 DOI: 10.1177/0272989x211001841] [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: 11/16/2022]
Abstract
BACKGROUND Physicians who communicate their prognostic beliefs to patients must balance candor against other competing goals, such as preserving hope, acknowledging the uncertainty of medicine, or motivating patients to follow their treatment regimes. OBJECTIVE To explore possible differences between the beliefs physicians report as their own and those they express to patients and colleagues. DESIGN An online panel of 398 specialists in internal medicine who completed their medical degrees and practiced in the United States provided their estimated diagnostic accuracy and prognostic assessments for a randomly assigned case. In addition, they reported the diagnostic and prognostic assessments they would report to patients and colleagues more generally. Physicians answered questions about how and why their own beliefs differed from their expressed beliefs to patients and colleagues in the specific case and more generally in their practice. RESULTS When discussing beliefs about prognoses to patients and colleagues, most physicians expressed beliefs that differed from their own beliefs. Physicians were more likely to express greater optimism when talking to patients about poor prognoses than good prognoses. Physicians were also more likely to express greater uncertainty to patients when prognoses were poor than when they were good. The most common reasons for the differences between physicians' own beliefs and their expressed beliefs were preserving hope and acknowledging the inherent uncertainty of medicine. CONCLUSION To balance candor against other communicative goals, physicians tended to express beliefs that were more optimistic and contained greater uncertainty than the beliefs they said were their own, especially in discussions with patients whose prognoses were poor.
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Affiliation(s)
- Siyuan Yin
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Hal R Arkes
- Department of Psychology, Ohio State University, Columbus, OH, USA.,The Harding Center for Risk Literacy, Berlin, Germany
| | - John P McCoy
- Department of Marketing, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Margot E Cohen
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara A Mellers
- Department of Psychology and Department of Marketing, University of Pennsylvania, Philadelphia, PA, USA
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Al-Obaid LN, Bazarbashi AN, Cohen ME, Kim J, Lei Y, Axelrad JE, Fox A, Chandra S, Gordon FD. Enteric tube placement in patients with esophageal varices: Risks and predictors of postinsertion gastrointestinal bleeding. JGH Open 2019; 4:256-259. [PMID: 32280774 PMCID: PMC7144797 DOI: 10.1002/jgh3.12255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 07/28/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
Background and Aim Enteric tube (ET) placement is approached with caution in patients with esophageal varices (EV) due to concern of causing variceal bleeding. Data are limited on rates and predictors of gastrointestinal bleeding (GIB) in these patients. This study aims to assess the rate and predictors of bleeding from EV after ET placement. Methods We performed a retrospective chart review on patients requiring ET access with known EV. Inclusion criteria were age >18 with endoscopically proven EV who required ET placement. Patients who were admitted with, or developed a GIB prior to placement of ET were excluded, as were patients admitted for liver transplantation. Primary outcome was incidence of GIB within 48 h of tube placement. Secondary outcome was a >2 g/dL drop in hemoglobin within 48 h of placement without evidence of bleed. Statistical analysis was performed using Fischer's exact test, Mann-Whitney U test, and univariate logistic regression model. Results A total of 75 patients were included in the analysis. The most common etiology of cirrhosis was alcohol (44%). The most common location of EV was in the lower third of the esophagus (61%). The primary outcome was observed in 11 (14.6%) patients. The secondary outcome was found in eight (10.6%) patients. On univariate analysis, GIB was associated with higher MELD-Na (P = 0.026) and EV located in the lower third of the esophagus (P = 0.048). Conclusion ET placement in patients with EV is associated with low risk of bleeding. Elevated MELD-Na and lower EV location conferred a higher risk of bleeding after ET placement.
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Affiliation(s)
- Lolwa N Al-Obaid
- Department of Internal Medicine Lahey Hospital and Medical Center Burlington Massachusetts USA
| | - Ahmad Najdat Bazarbashi
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Margot E Cohen
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Judith Kim
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Yuxiu Lei
- Division of Pulmonary and Critical Care Medicine Lahey Hospital and Medical Center Burlington Massachusetts USA
| | - Jordan E Axelrad
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Alyson Fox
- Division of Gastroenterology and Hepatology New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Subani Chandra
- Division of Pulmonary and Critical Care Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Fredric D Gordon
- Division of Transplantation and Hepatobiliary Diseases Lahey Hospital and Medical Center Burlington Massachusetts USA
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Freedberg DE, Zhou MJ, Cohen ME, Annavajhala MK, Khan S, Moscoso DI, Brooks C, Whittier S, Chong DH, Uhlemann AC, Abrams JA. Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection. Intensive Care Med 2018; 44:1203-1211. [PMID: 29936583 DOI: 10.1007/s00134-018-5268-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/05/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. METHODS This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. RESULTS Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). CONCLUSIONS Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.
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Affiliation(s)
- Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.
| | - Margaret J Zhou
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - Margot E Cohen
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Medini K Annavajhala
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Sabrina Khan
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Dagmara I Moscoso
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Susan Whittier
- Division of Laboratory Medicine, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - David H Chong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Anne-Catrin Uhlemann
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.,Mailman School of Public Health, New York, USA
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Cohen ME, Salmasian H, Li J, Liu J, Zachariah P, Wright JD, Freedberg DE. Surgical Antibiotic Prophylaxis and Risk for Postoperative Antibiotic-Resistant Infections. J Am Coll Surg 2017; 225:631-638.e3. [PMID: 29030239 DOI: 10.1016/j.jamcollsurg.2017.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/10/2017] [Accepted: 08/10/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antibiotic-resistant infections have high rates of morbidity and mortality, and exposure to antibiotics is the crucial risk factor for development of antibiotic resistance. If surgical antibiotic prophylaxis (SAP) increases risk for antibiotic-resistant infections, prophylaxis may cause net harm, even if it decreases overall infection rates. STUDY DESIGN This retrospective cohort study included adults who underwent elective surgical procedures and developed infections within 30 postoperative days. Procedures from multiple disciplines were included if SAP was considered discretionary by current guidelines. Postoperative antibiotic-resistant infections were defined as positive culture results from any site within 30 postoperative days, showing intermediate or nonsusceptibility across 1 or more antibiotic classes. Surgical antibiotic prophylaxis included use of antibiotics within any class and at any dose from 1 hour before first incision until the end of the operation. RESULTS Among 689 adults with postoperative infections, 338 (49%) had postoperative resistant infections. Use of SAP was not associated with postoperative antibiotic-resistant infections (odds ratio [OR] 0.99; 95% CI 0.67 to 1.46). This result remained robust when the SAP definition was extended to antibiotics given within 4 hours before first incision (OR 0.94; 95% CI 0.63 to 1.40) and when the follow-up window was narrowed to 14 days (OR 0.82; 95% CI 0.50 to 1.34). Previous antibiotic-resistant infections were associated with risk for postoperative antibiotic-resistant infections (OR 1.81; 95% CI 1.16 to 2.83). CONCLUSIONS Use of SAP was not associated with risk for postoperative antibiotic-resistant infections in a large cohort of patients with postoperative infections. This provides important reassurance regarding use of surgical antibiotic prophylaxis.
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Affiliation(s)
- Margot E Cohen
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Hojjat Salmasian
- Biomedical Informatics, New York-Presbyterian Hospital, New York, NY
| | - Jianhua Li
- Biomedical Informatics, New York-Presbyterian Hospital, New York, NY
| | - Jianfang Liu
- School of Nursing, Columbia University, New York, NY
| | - Philip Zachariah
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY.
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Cohen ME, Hathway JM, Salmasian H, Liu J, Terry M, Abrams JA, Freedberg DE. Prophylaxis for Stress Ulcers With Proton Pump Inhibitors Is Not Associated With Increased Risk of Bloodstream Infections in the Intensive Care Unit. Clin Gastroenterol Hepatol 2017; 15:1030-1036.e1. [PMID: 28110095 PMCID: PMC5474142 DOI: 10.1016/j.cgh.2016.12.035] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/05/2016] [Accepted: 12/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Proton pump inhibitors (PPIs) have been associated with increased risk of infection, likely because of changes in intestinal epithelial permeability and the gastrointestinal microbiome. PPIs are frequently given to patients in the intensive care unit (ICU) to prevent stress ulcers. These patients are at risk for bloodstream infections (BSIs), so we investigated the relationship between PPI use and BSIs among patients in the ICU. METHODS We performed a retrospective cohort study of adults (≥18 years) admitted to 1 of 14 ICUs within a hospital network of 3 large hospitals from 2008 through 2014. The primary exposure was PPI use for stress ulcer prophylaxis in the ICU. The primary outcome was BSI, confirmed by culture analysis, arising 48 hours or more after admission to the ICU. Subjects were followed for 30 days after ICU admission or until death, discharge, or BSI. Multivariable Cox proportional hazards modeling was used to test the association between PPIs and BSI after controlling for patient comorbidities and other clinical factors. RESULTS We analyzed data from 24,774 patients in the ICU, including 756 patients (3.1%) who developed BSIs while in the ICU. The cumulative incidence of BSI was 3.7% in patients with PPI exposure compared with 2.2% in patients without PPI exposure (log-rank test, P < .01). After adjusting for potential confounders, PPI exposure was not associated with increased risk of BSI while in the ICU (adjusted hazard ratio, 1.08; 95% confidence interval, 0.91-1.29). Comorbidities, antibiotic use, and mechanical ventilation were all independently associated with increased risk for BSIs. CONCLUSIONS In a retrospective study of patients in the ICU, administration of PPIs to prevent bleeding was not associated with increased risk of BSI. These findings indicate that concern for BSI should not affect decisions regarding use of PPIs in the ICU.
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Affiliation(s)
- Margot E. Cohen
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Joanne M. Hathway
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Hojjat Salmasian
- Biomedical Informatics, New York-Presbyterian Hospital, New York, NY
| | - Jianfang Liu
- School of Nursing, Columbia University, New York, NY
| | - Melissa Terry
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Julian A. Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY
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Cohen ME, Chandra S. The Time to Grieve: A Difficult Question in Medical Training. Acad Med 2017; 92:580-581. [PMID: 28441207 DOI: 10.1097/acm.0000000000001649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Margot E Cohen
- Resident physician, Department of Medicine, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York; . Assistant professor of medicine, Department of Medicine, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
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Hudson DL, Cohen ME, Hudson SE. Development of health diagnostics based on personalized medical models. Annu Int Conf IEEE Eng Med Biol Soc 2015; 2015:1413-1416. [PMID: 26736534 DOI: 10.1109/embc.2015.7318634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Due to rapid evolution of new technologies the concept of personalized medicine has evolved. Components include molecular biology, proteomics, metabolomic analysis, genetic testing, and molecular medicine for diagnostics. In addition to diagnostics these methods can be used to determine individual susceptibility to diseases and conditions. In conjunction with new diagnostic methods, new therapies can be tailored to the individual. These new technologies present a challenge in terms of the expansion of the medical record as well as the development of new methods for creating disease profiles. This article focuses on a computer-aided support for personalized medicine. Specific approaches are explored that permit automated data analysis for prognosis and treatment based on analysis methods for numeric and pictorial data. Although personalized medicine based on the genome of the patient are occasionally performed, because of the large amount of data new methods are needed to form general disease models as well as specific profiles of the individual patient.
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Frouin F, Zhang Z, Cohen ME, Lefort M, de Cesare A, Pellot-Barakat C, Lucidarme O. Interest of reference region models to monitor cancer treatment using dynamic contrast enhanced studies. Cancer Imaging 2014. [PMCID: PMC4242642 DOI: 10.1186/1470-7330-14-s1-p28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
INTRODUCTION To facilitate diagnoses, this study determined the efficacy of commercial oral fluid collection devices for their ability to recover three human immunoglobulin isotypes; immunoglobulin A (IgA), IgG, and IgM. METHODS The sandwich enzyme-linked immunosorbent assay was used to determine antibody recovery from the following devices: (i) OraSure oral specimen collection device, (ii) saliva*sampler, (iii) ORALscreen collector, (iv) Dri-Angle, (v) no. 2 cotton roll, (vi) all-gauze sponges device, and (vii) DentaSwabs. For each isotype tested, the recovered eluate was compared with the concentration applied to the device. The performance of each device was determined at various antibody concentrations. RESULTS Recovery of IgA from the saliva*sampler, ORALscreen collector, Dri-Angle and cotton roll was comparable to that seeded onto the device. When compared with the seeded IgG concentration, the mean concentration of antibody recovered by each product differed by approximately +/- 9 ng/ml. The average amount of IgM recovered by the cotton roll and all-gauze sponges device was approximately 29 and 39 ng/ml, respectively, less (P < 0.0001) than that seeded on the device. For all isotypes tested, the amount of antibody recovered from the device was dependent on the initial seeding concentration. CONCLUSION Collectively, these data suggest that the product used for specimen collection can affect retrieval of antibodies and potentially confound patient diagnosis.
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Affiliation(s)
- C K Chang
- Naval Institute for Dental and Biomedical Research, Great Lakes, IL 60088-5259, USA
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Zacharia BE, Ducruet AF, Hickman ZL, Grobelny BT, Fernandez L, Schmidt JM, Narula R, Ko LN, Cohen ME, Mayer SA, Connolly ES. Renal dysfunction as an independent predictor of outcome after aneurysmal subarachnoid hemorrhage: a single-center cohort study. Stroke 2009; 40:2375-81. [PMID: 19461033 DOI: 10.1161/strokeaha.108.545210] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Acute kidney injury occurs in 1% to 25% of critically ill patients with small increases in creatinine adversely affecting outcome. We sought to determine the burden of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage and whether this dysfunction affects outcome. METHODS Between 1996 and 2008, 787 consecutive patients with aneurysmal subarachnoid hemorrhage were enrolled in our prospective database. Demographics, serum creatinine levels, and discharge modified Rankin scores were recorded, and changes in creatinine clearance were calculated. A multiple logistic regression was performed using known predictors for poor outcome after aneurysmal subarachnoid hemorrhage in addition to burden of contrast-enhanced imaging and change in creatinine clearance. RESULTS One hundred seventy-nine (23.1%) patients were at risk for renal failure during their hospitalization. In a multivariate model, those patients who developed risk for renal failure were twice as likely to have a poor 3-month outcome (OR, 2.01; P=0.021). Survival curves comparing those not at risk, those at risk (increasing severity classes Risk, Injury, and Failure, and the 2 outcome classes Loss and End-Stage Kidney Disease [RIFLE] R), and those with renal injury or failure (RIFLE I and F) demonstrated that risk of death increases significantly as one progresses through the RIFLE classes (log rank, P<0.0001). CONCLUSIONS In a large, consecutive series of prospectively enrolled patients with aneurysmal subarachnoid hemorrhage, we demonstrate, using the newly defined RIFLE classification for risk of renal failure, that even seemingly insignificant decreases in creatinine clearance are associated with significantly worse 3-month outcomes. This study highlights the importance of close surveillance of renal function and stresses the value of renal hygiene in the aneurysmal subarachnoid hemorrhage population.
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Affiliation(s)
- Brad E Zacharia
- Department of Neurological Surgery, Columbia University, College of Physicians & Surgeons, New York, NY 10032, USA.
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Chapman WP, Cohen ME, Cobb S. MEASUREMENTS RELATED TO PAIN IN NEUROCIRCULATORY ASTHENIA, ANXIETY NEUROSIS, OR EFFORT SYNDROME: LEVELS OF HEAT STIMULUS PERCEIVED AS PAINFUL AND PRODUCING WINCE AND WITHDRAWAL REACTIONS. J Clin Invest 2006; 25:890-6. [PMID: 16695387 PMCID: PMC435635 DOI: 10.1172/jci101777] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- W P Chapman
- Department of Medicine, Massachusetts General Hospital, the Massachusetts General Hospital Branch of the Hall-Mercer Hospital, Boston
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16
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Cohen ME, White PD. STUDIES OF BREATHING, PULMONARY VENTILATION AND SUBJECTIVE AWARENESS OF SHORTNESS OF BREATH (DYSPNEA) IN NEUROCIRCULATORY ASTHENIA, EFFORT SYNDROME, ANXIETY NEUROSIS. J Clin Invest 2006; 26:520-9. [PMID: 16695445 PMCID: PMC439184 DOI: 10.1172/jci101836] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- M E Cohen
- Medical and Psychiatric Clinics and the Cardiac Research Laboratory of the Massachusetts General Hospital
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Cohen ME, Consolazio F, Johnson RE. BLOOD LACTATE RESPONSE DURING MODERATE EXERCISE IN NEUROCIRCULATORY ASTHENIA, ANXIETY NEUROSIS, OR EFFORT SYNDROME. J Clin Invest 2006; 26:339-42. [PMID: 16695423 PMCID: PMC435675 DOI: 10.1172/jci101814] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- M E Cohen
- Medical and Psychiatric Clinics and Cardiac Research Laboratory of the Massachusetts General Hospital
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18
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Cohen ME, Thomson KJ. STUDIES ON THE CIRCULATION IN PREGNANCY. I. THE VELOCITY OF BLOOD FLOW AND RELATED ASPECTS OF THE CIRCULATION IN NORMAL PREGNANT WOMEN. J Clin Invest 2006; 15:607-25. [PMID: 16694434 PMCID: PMC424823 DOI: 10.1172/jci100813] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- M E Cohen
- Department of Obstetrics, Harvard University Medical School, Boston
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19
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Hudson DL, Cohen ME. Intelligent agent model for remote support of rural healthcare for the elderly. Conf Proc IEEE Eng Med Biol Soc 2006; 2006:6332-6335. [PMID: 17947188 DOI: 10.1109/iembs.2006.259376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
With the aging population, the number of individuals requiring long-term care is expected to dramatically increase in the next twenty years, placing an increasing burden on healthcare. Many patients are admitted to assisted living facilities at a fairly early stage due to their inability to perform normal daily living activities. The purpose of this study is to determine if the use of technology for both monitoring and intervention can permit elderly patients to remain in their homes for longer periods of time with the benefit of the comfort of familiar surroundings while at the same time reducing the burden on caregivers. In addition, remote access to healthcare can improve monitoring of the patient's physical and mental condition and involve the patient in his or her own care. The home monitoring and intervention system is based on intelligent agent methodology developed by the authors.
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Affiliation(s)
- D L Hudson
- California Univ., San Francisco, Fresno, CA 93701, USA
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20
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Cohen ME, Hudson DL. Non-linear analysis using continuous chaotic modeling. Cell Mol Biol (Noisy-le-grand) 2004; 50:291-5. [PMID: 15209350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Recent research in nanotechnology is opening exciting new avenues not only for understanding the human body but also for creating devices that can effectively interact with it to alleviate the effects of disease. These new developments present both challenges and opportunities for adaptation of existing methodologies to create new approaches for analysis and modeling of nanotechnology-based systems. The concept of continuous chaotic modeling presents an avenue for a paradigm shift away from traditional digital computing to take advantage of analog models that are more compatible with biological systems. The theoretical basis of continuous chaotic modeling is summarized, followed by illustrations of applications of this methodology.
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Affiliation(s)
- M E Cohen
- California State University, Fresno, CA 93740, USA.
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21
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Hudson DL, Cohen ME. The role of networks and artificial intelligence in nanotechnology design and analysis. Cell Mol Biol (Noisy-le-grand) 2004; 50:297-300. [PMID: 15209351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Techniques with their origins in artificial intelligence have had a great impact on many areas of biomedicine. Expert-based systems have been used to develop computer-assisted decision aids. Neural networks have been used extensively in disease classification and more recently in many bioinformatics applications including genomics and drug design. Network theory in general has proved useful in modeling all aspects of biomedicine from healthcare organizational structure to biochemical pathways. These methods show promise in applications involving nanotechnology both in the design phase and in interpretation of system functioning.
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Affiliation(s)
- D L Hudson
- University of California, San Francisco, Fresno, CA 93703, USA.
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22
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Hudson DL, Cohen ME, Meecham W, Kramer M. Inclusion of signal analysis in a hybrid medical decision support system. Methods Inf Med 2004; 43:79-82. [PMID: 15026843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Signal analysis has played an important role in cardiac diagnosis, both as a separate entity and in conjunction with clinical parameters. Hybrid systems are an effective method for developing higher-order decision models in which biomedical signal data can be incorporated. METHODS The hybrid system components include a knowledge-based system that utilizes approximate reasoning techniques, a neural network model based on a potential function approach to supervised learning that uses the general class of Cohen orthogonal functions as potential functions, and a signal analysis component that relies on continuous chaotic modeling to produce a degree of variability in the time series. The hybrid system is illustrated in an application for differentiation among different types of dementia. RESULTS Application of this method to cardiac diagnosis shows that chaotic parameters alone contribute significantly to correct classification while the addition of clinical parameters increases the sensitivity, specificity, and accuracy. Applications to electroencephalogram analysis indicate that the second-order difference plots display significant differences for the different types of EEG waves identifiable by frequency, both in shape and degree of dispersion. Hence the identification of these waves, and the duration of their occurrence, may provide suitable variables for chaotic analysis. CONCLUSIONS Results from studies in cardiology demonstrate that using chaotic measures for ECG analysis provide useful information for classification. Sensitivity, specificity, and accuracy are increased if these methods are combined with other clinical parameters in a hybrid system. This approach has been extended to new applications based on EEG analysis combined with other relevant information.
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Affiliation(s)
- D L Hudson
- University of California, San Francisco, Fresno, CA, USA.
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23
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Stone ME, Pederson ED, Cohen ME, Ragain JC, Karaway RS, Auxer RA, Saluta AR. Residual mercury content and leaching of mercury and silver from used amalgam capsules. Dent Mater 2002; 18:289-94. [PMID: 11992905 DOI: 10.1016/s0109-5641(01)00036-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of this investigation was to carry out residual mercury (Hg) determinations and toxicity characteristic leaching procedure (TCLP) analysis of used amalgam capsules. METHODS For residual Hg analysis, 25 capsules (20 capsules for one brand) from each of 10 different brands of amalgam were analyzed. Total residual Hg levels per capsule were determined using United States Environmental Protection Agency (USEPA) Method 7471. For TCLP analysis, 25 amalgam capsules for each of 10 brands were extracted using a modification of USEPA Method 1311. Hg analysis of the TCLP extracts was done with USEPA Method 7470A. Analysis of silver (Ag) concentrations in the TCLP extract was done with USEPA Method 6010B. RESULTS Analysis of the residual Hg data resulted in the segregation of brands into three groups: Dispersalloy capsules, Group A, retained the most Hg (1.225 mg/capsule). These capsules were the only ones to include a pestle. Group B capsules, Valliant PhD, Optaloy II, Megalloy and Valliant Snap Set, retained the next highest amount of Hg (0.534-0.770 mg/capsule), and were characterized by a groove in the inside of the capsule. Group C, Tytin regular set double-spill, Tytin FC, Contour, Sybraloy regular set, and Tytin regular set single-spill retained the least amount of Hg (0.125-0.266 mg/capsule). TCLP analysis of the triturated capsules showed Sybraloy and Contour leached Hg at greater than the 0.2 mg/l Resource Conservation and Recovery Act (RCRA) limit. SIGNIFICANCE This study demonstrated that residual mercury may be related to capsule design features and that TCLP extracts from these capsules could, in some brands, exceed RCRA Hg limits, making their disposal problematic. At current RCRA limits, the leaching of Ag is not a problem.
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Affiliation(s)
- M E Stone
- The Naval Dental Research Institute, Building 1H, 310A B Street, 60088-5259, Great Lakes, IL 60088-5259, USA.
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24
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Hudson DL, Cohen ME, Hudson SE. The use of consequential reasoning in cancer chemotherapy. Stud Health Technol Inform 2002; 84:1349-53. [PMID: 11604947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Knowledge-based decision support systems traditionally rely on condition-action rule structures, an adequate representation for simple decisions. In complex domains an important part of decision-making includes analysis of the consequences of a decision. Consequential reasoning is particularly important in medicine as potential risk and/or benefit can be included. In this paper, a knowledge structure and inference engine is described that permits the representation and analysis of consequential reasoning in a computer-assisted decision support system. The use of consequential reasoning is then illustrated in an application designed to assist in cancer chemotherapy decisions. The result is a method that is sensitive to individual patient reactions to chemotherapy agents, permitting an individualized approach to therapy. Individualized drug therapy is becoming increasingly feasible due to advances made in the field of genomics. The system is structured so that new information can be incorporated easily. Although the application shown here is to chemotherapy, the general methodology can be used in any area in which the consequences should significantly influence the decision.
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Affiliation(s)
- D L Hudson
- University of California, San Francisco, Fresno, California 93703, USA.
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25
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Abstract
OBJECTIVES We aimed to determine whether early trends in the serum pancreatic enzymes and liver tests of patients with gallstone pancreatitis predict persistent common bile duct (CBD) stones and complications. METHODS Medical records of patients with gallstone pancreatitis were reviewed retrospectively. Serial serum pancreatic enzymes and liver tests were recorded until the time of cholangiography. Laboratory trends were analyzed by comparing initial results obtained in the emergency department to subsequent results obtained 8-24 h, 24-48 h, and 48-72 h after presentation. RESULTS Of 154 patients with gallstone pancreatitis, 28 (18%) had persistent CBD stones at cholangiography. Complications and death were more frequent in patients with persistent CBD stones than in those without CBD stones (29% and 11% vs 12% and 1%, respectively; p < 0.05). Laboratory trends predicted both persistent CBD stones and complications of pancreatitis. When any laboratory value rose between admission and 24-48 h of hospitalization, persistent CBD stones were present in 31% of cases, versus 8% of those in whom all laboratory values remained constant or fell (p = 0.001). Likewise, complications occurred in 21% of those with any rising laboratory value, versus 8% of those in whom all values remained constant or fell (p < 0.05). CONCLUSIONS Patients with gallstone pancreatitis and rising serum chemistries had a 4-fold risk of persistent CBD stones and a nearly 3-fold risk of complications compared to patients in whom all chemistry values remained constant or fell. This simple prediction rule may identify patients with biliary pancreatitis who are most likely to benefit from early interventions to diagnose and remove persistent CBD stones.
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Affiliation(s)
- M E Cohen
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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26
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Thaisetthawatkul P, Weinstock A, Kerr SL, Cohen ME. Muromonab-CD3-induced neurotoxicity: report of two siblings, one of whom had subsequent cyclosporin-induced neurotoxicity. J Child Neurol 2001; 16:825-31. [PMID: 11732768 DOI: 10.1177/08830738010160110801] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Muromonab-CD3 is widely used for immunosuppression in patients undergoing solid organ transplant. We report two siblings with oligomeganephronia and end-stage renal disease who developed encephalopathy and seizures from muromonab-CD3 following renal transplant. The first case is a 13-year-old girl who developed encephalopathy, seizure, and triparesis following renal transplant while muromonab-CD3 was used for immunosuppression. The second case was the 6-year-old sister of the first case, who also developed recurrent focal seizures while she was on muromonab-CD3 for renal transplant immunosuppression. In both cases, a sequential brain magnetic resonance image (MRI) showed progression of abnormalities from the cerebral cortex to the white matter. In the first case, the MRI normalized after muromonab-CD3 was discontinued. In the second case, the patient developed a leukoencephalopathy following cyclosporin administration. The pathophysiology of muromonab-CD3 encephalopathy is believed to be a disturbance to the blood-brain barrier mediated by cytokine release from lymphocyte stimulation by muromonab-CD3. Because the major histocompatibility complex genes are known to regulate cytokine responses, it is possible that the excessive production of cytokines that causes encephalopathy may occur in patients who share close major histocompatibility complex genes. Muromonab-CD3 in a patient whose sibling has developed cerebral complications from its use should be administered with caution. The second case suggests that muromonab-CD3 encephalopathy predisposes patients to develop cyclosporin neurotoxicity. Because the pathogenesis of muromonab-CD3 encephalopathy and cyclosporin-related cerebral complications are both potentially mediated through a disturbance of the blood-brain barrier, it is possible that one agent may predispose a patient to the complication of the other.
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Affiliation(s)
- P Thaisetthawatkul
- Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, USA
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27
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Mercandetti M, Putterman AM, Cohen ME, Mirante JP, Cohen AJ. Internal levator advancement by Müller's muscle-conjunctival resection: technique and review. ACTA ACUST UNITED AC 2001; 3:104-10. [PMID: 11368662 DOI: 10.1001/archfaci.3.2.104] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Müller's muscle-conjunctival resection surgery presumably works by advancing the levator aponeurosis of the upper eyelid. The amount of blepharoptosis and the lid's response to the instillation of phenylephrine hydrochloride onto the superior ocular fornix are used to determine the extent of surgery needed. OBJECTIVES To demonstrate the procedure developed and popularized by Allen M. Putterman, MD, performed by Michael Mercandetti, MD, MBA, and to describe the relationship between the amount of Müller's muscle-conjunctival resection performed and the amount of elevation achieved. METHODS Data were retrospectively analyzed based on surgical cases done over a 5-year period by one surgeon (A.M.P.). RESULTS A linear regression model was developed. From this regression a simple table correlating the amount of resection with the amount of elevation desired was derived. CONCLUSION The surgeon will need to modify the table based on his or her clinical experience and postoperative results.
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Affiliation(s)
- M Mercandetti
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, and Michael Reese Hospital, USA.
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28
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Abstract
BACKGROUND The purpose of this study was to examine the prevalence, distribution, and features of alveolar dehiscences and fenestrations in modern American skulls and correlate their presence with occlusal attrition, root prominence, and alveolar bone thickness. METHODS A representative sample of 146 dentate modern American skulls from a collection at the National Museum of Natural History were examined. RESULTS The skulls were from subjects ranging in age from 17 to 87 years old (mean 49.1 years). The mean number of teeth per skull was 22.7 and the mean number of either dehiscence or fenestration defects per skull was 3.0. Of the 3,315 individual teeth examined, 4.1% (135) had dehiscences and 9.0% (298) had fenestrations. A dehiscence was present in 40.4% of the skulls, and a fenestration was present in 61.6% of skulls. Mandibular canines were most often affected by dehiscences (12.9%), while maxillary first molars were most often affected by fenestrations (37.0%). Sixty-seven percent of dehiscences were found in the mandible, and 58% of fenestrations were found in the maxilla. CONCLUSIONS The presence of dehiscences and fenestrations were positively correlated with thin alveolar bone and negatively correlated with occlusal attrition. African-American males and Caucasian females were significantly more likely to have dehiscences, while African-American females were significantly more likely to have fenestrations.
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Affiliation(s)
- R D Rupprecht
- Periodontics Department, Naval Dental Center Far East, Yokosuka, Japan
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Abstract
Although recommendations for the appropriate analysis of non-normal and ordinal-scaled data have appeared in the dental research literature for many years, there is no consensus. When one is conducting statistical tests for differences between groups, the central concern is whether it is safe to use parametric tests (e.g., analysis of variance), or if only non-parametric ranking tests should be considered. Relevant statistical and scientific issues associated with non-normality and measurement scale are reviewed, and three conclusions are reached regarding the analysis of dental data: (1) Parametric tests are sufficiently robust relative to typical violations of normality; (2) presumed statistical prohibitions against the application of parametric methods to ordinal data do not actually exist; and (3) 'ordinal' dental indices have sufficient quantitative meaning to be considered quasi-interval. For these reasons, parametric tests should not be avoided; they will be valid and usually more powerful and more easily applied to complex designs than non-parametric alternatives.
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Affiliation(s)
- M E Cohen
- Naval Dental Research Institute, Great Lakes, IL 60088-5259, USA.
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Grys EL, Schade SZ, Cohen ME, Geivelis M, Robinson PJ, Simonson LG. Measurement of proteases in human subgingival dental plaque by fluorescence polarization. Arch Oral Biol 2000; 45:1101-6. [PMID: 11084150 DOI: 10.1016/s0003-9969(00)00073-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fluorescence polarization (FP) was examined as a rapid quantitative method to assay the proteases in subgingival plaque. Protease activity was measured by a decrease in FP at 0.5-min intervals over 5 min, using BODIPY-alpha-casein, a protein substrate. To quantitate activity, the least absolute deviation (LAD) slope for each assay was determined. Protease activity increased with the quantity of plaque (r=0.416, P<0.001). Of the 208 subgingival plaque samples, 87 contained detectable protease activity, with a mean of about 4 microg trypsin equivalents above a general background of 1 microg per site. The mean plaque protease activity of 89 paired samples from 15 individuals had decreased by 1.1 microg trypsin equivalents per site when measured at 8 months after tooth scaling and root planing (P<0.01). Most isolates of Porphyromonas gingivalis, Treponema denticola, Prevotella nigrescens, and Prevotella intermedia implicated in the pathogenesis of adult periodontitis exhibited high activity in the FP assay. The assay is rapid, quantitative and requires only one-tenth of the plaque sampled using a single pass with a Gracey curette at a single tooth site.
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Affiliation(s)
- E L Grys
- Department of Periodontics, Northwestern University Dental School, 240 East Huron Street, Chicago, IL, 60611, USA
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Abstract
OBJECTIVE To review the major functional status measures currently used in rehabilitation research, including the domains and scope of functional status measures, as well as the psychometric properties of selected functional status measures and their use in adult rehabilitation populations. DATA SOURCES Measures of physical functioning widely used in rehabilitation research. STUDY SELECTION Major generic measures included the following activities of daily living and instrumental activities of daily living: the FIM instrument, the Katz Activities of Daily Living Scale, the Level of Rehabilitation Scale, the Barthel index, and the Patient Evaluation and Conference System. Measures were evaluated based on published evidence of validity, reliability, and sensitivity. DATA EXTRACTION Measures were chosen on the basis of the amount and quality of published research on the functional measures widely used in rehabilitation medicine. Independent research of computer databases and reviews of functional measures were conducted to determine suitability for inclusion. The quality and validity of the measures were assessed using standard psychometric guidelines. DATA SYNTHESIS Measures were evaluated based on published evidence of validity, reliability, sensitivity response and administrative burdens and instrument bias. Each criterion was graded on a 3-point scale reflecting the level of evidence. CONCLUSION Researchers in the field of disabilities research need to consider carefully study objectives when measuring physical functioning in people with disabilities.
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Affiliation(s)
- M E Cohen
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Mahoney DH, Cohen ME, Friedman HS, Kepner JL, Gemer L, Langston JW, James HE, Duffner PK, Kun LE. Carboplatin is effective therapy for young children with progressive optic pathway tumors: a Pediatric Oncology Group phase II study. Neuro Oncol 2000; 2:213-20. [PMID: 11265230 PMCID: PMC1920597 DOI: 10.1093/neuonc/2.4.213] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Pediatric Oncology Group conducted a phase II study to evaluate the activity of carboplatin in children 5 years or younger with progressive optic pathway tumors (OPTs). Of the 51 patients accrued to this study, 1 was not eligible because the child was older than 6 years. Fifty patients were eligible and had either neuro-imaging or symptomatic evidence of progressive OPTs. Twenty-one of 50 had evidence of neurofibromatosis type I (NF-1). Therapy consisted of carboplatin 560 mg/m2 at 4-week intervals. Patients with stable disease or better after two courses were continued on therapy for 18 months or until progressive disease. Of the 50 eligible children, 39 had stable disease or better, and 34 completed the 18-month therapy. Our data are sufficient to conclude that the proportion of objective responses (complete, partial, or minor response or stable disease) exceeded 30% (P < 0.00001), and the approximate 95% confidence interval estimate of the objective response rate was 0.665 to 0.895. Twenty-one patients went off protocol because of progressive disease. Fifteen patients progressed during the 18-month therapy, and 6 patients progressed after completing therapy. Six children died with progressive disease. Major toxicities were neutropenia and thrombocytopenia, and 3 children experienced allergic reactions. Carboplatin is active and safe for the treatment of young children with progressive OPTs. The addition of other potentially active drugs may further increase the event-free survival for these children.
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Affiliation(s)
- D H Mahoney
- Baylor College of Medicine, 6621 Fannin St., Houston, TX 77030, USA
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33
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Abstract
Moyamoya disease is a chronic occlusive cerebrovascular disorder. It can occur as a primary disease or as a syndrome associated with a variety of conditions. Usually it takes 1 to 2 years to develop a classic moyamoya pattern. We report a 20-month-old girl with Down syndrome and moyamoya syndrome who presented with seizure and hemiparesis. To our knowledge, this is the youngest case reported with moyamoya syndrome and Down syndrome. The prognosis and current treatment of moyamoya syndrome and its relation to Down syndrome are reviewed. There is some reason to speculate that the abnormalities associated with Down syndrome might create a vulnerability for the development of moyamoya syndrome.
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Affiliation(s)
- A I Dai
- Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, 14222, USA
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Abstract
BACKGROUND Buttressing bone formation has been described as the development of thickened or exostotic buccal alveolar bone in response to heavy occlusal forces. Little supporting evidence for this model has been found in previous literature, however, and there is little seen on the prevalence or characteristics of buccal alveolar exostoses. METHODS A sample of 416 selected teeth and investing bone in 52 modern skeletal specimens at the National Museum of Natural History were examined. Two measures of heavy occlusal function--periodontal ligament (PDL) width and occlusal attrition--were analyzed for their relationship to three parameters of buccal alveolar bone (exostoses, lipping, and overall thickness). RESULTS Buccal alveolar bone enlargements were found in 25% of all teeth examined: 18% were expressed as marginal bony lippings and 7% as buccal exostoses. Exostoses were mainly seen around maxillary molars and bicuspids, especially in males, while lippings were seen in molars, bicuspids, and mandibular incisors, with even gender distribution. When findings were controlled for arch and tooth type, no significant correlations were found between wider PDL spaces or occlusal attrition and exostotic, lipped, or thicker alveolar bone. CONCLUSIONS These results indicate a lack of anatomic evidence for the theory of buttressing bone formation and suggest that other factors may be of greater importance in the etiology of buccal bone enlargements. Incidentally, no correlation was found between widened PDL spaces or severe occlusal attrition and the presence of cervical loss of tooth structure, which casts doubt on the currently popular concept of abfraction.
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Affiliation(s)
- G M Horning
- Periodontics Department, Little Creek Branch Dental Clinic, Norfolk, VA, USA
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Ditunno JF, Cohen ME, Hauck WW, Jackson AB, Sipski ML. Recovery of upper-extremity strength in complete and incomplete tetraplegia: a multicenter study. Arch Phys Med Rehabil 2000; 81:389-93. [PMID: 10768525 DOI: 10.1053/mr.2000.3779] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine upper-extremity motor recovery of subjects with tetraplegia with both complete and incomplete injuries, to predict which patients and at what time they would recover a motor level. DESIGN Prospective, multicenter clinical study of upper-extremity motor recovery in subjects with acute traumatic spinal cord injury. SETTING Three regional spinal cord injury centers. SUBJECTS One hundred sixty-seven individuals with acute traumatic tetraplegia (144 males [86%], and 23 females [14%]) between the ages of 15 and 75 years (mean age, 35.5 yrs). METHODS Subjects were examined and classified using sequential manual muscle tests performed on admission, 72 hours, 1, 2, and 3 weeks, and 1, 2, 3, 6, 12, 18, and 24 months postinjury. C5 biceps, C6 extensor carpi radialis, C7 triceps, and C8 flexor digitorum profundus were evaluated using a 0-5 scale. Analyses of the right motor levels used a series of logistic regression models, and for multiple measurements on each subject, models were estimated using generalized estimating equations. RESULTS The analysis for recovery of the biceps for the C4 group showed 70% of complete compared with 90% of incomplete injuries recovered (p < .001); of the extensor carpi radialis in the C5 group, 75% complete and 90% incomplete recovered (p < .002); and of the triceps in the C6 group, 85% of complete and 90% of incomplete injuries recovered (p < .16). CONCLUSION Predicting future potential for upper-extremity motor recovery and for independence in self-care in groups of patients at a specific motor level is possible within the first week of injury.
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Affiliation(s)
- J F Ditunno
- Department of Rehabilitation Medicine, Regional Spinal Cord Injury Center of Delaware Valley, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Kelly EW, Jonson SR, Cohen ME, Shaffer R. Stress fractures of the pelvis in female navy recruits: an analysis of possible mechanisms of injury. Mil Med 2000; 165:142-6. [PMID: 10709377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
The purpose of our study was to investigate possible risk factors and mechanisms for the development of pelvic stress fractures in female Navy recruits. We used a case-control retrospective study of female Navy recruits undergoing basic military training. We compared anthropometric and activity data between recruits with pelvic stress fractures (N = 25) and female recruits who completed training without injury (N = 61). Recruits developing pelvic stress fractures were significantly (p < 0.05) shorter and lighter and were more frequently Asian or Hispanic than recruits without stress fractures. In addition, recruits with pelvic stress fractures reported marching in the back of their training division, were road guards, and felt that their stride was too long during training activities more often than recruits without injury. Self-reported fitness, activities before recruit training, or a history of amenorrhea was not found to be associated with the development of a pelvic stress fracture in our population.
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Affiliation(s)
- E W Kelly
- Mayo Clinic, Rochester, MN 55905, USA
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Cohen ME. Wisconsin law banning 'partial-birth' abortion in flux. WMJ 1999; 98:56, 58. [PMID: 10639898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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Abstract
OBJECTIVES The characteristics of the Functional Independence Measure (FIM) were examined for spinal cord injury (SCI) in regard to norms over time by level and completeness of injury, differential benefit of motor and cognition subscales, and "ceiling effect" after rehabilitation discharge. DESIGN Descriptive study of raw FIM data collected prospectively at admission and discharge from acute inpatient rehabilitation, and at 1, 2, and 5 years after injury. SETTING National Database of the 18 Spinal Cord Injury Model Systems. SUBJECTS Persons with SCI, age 16 and over, with functionally complete injuries at inpatient rehabilitation admission (ASIA grades A, B, or C), admitted to Model System an average of 8 days after injury (standard deviation = 13, median = 1 day). Maximum sample sizes for which data were available were: at rehabilitation admission, 3,971 cases; at discharge, 4,033; at year 1 postinjury, 903; 2 years, 712; and 5 years, 570. OUTCOME MEASURES The FIM motor and cognition subscales. RESULTS There is a substantial ceiling effect of the FIM cognition items even by inpatient rehabilitation discharge, ie, 80% to 90% of the cases average 6 to 7 (independent or modified independence) across the 5 FIM cognition items. At 1 year 89% to 97% of cases were rated independent. FIM motor items were consistent with level of injury and neurologic status. Motor items (excluding locomotion items) were highly intercorrelated (correlations range from .58 to .92 for self care, sphincter control, and mobility items). Trends over years 1, 2, and 5 were stable for both motor and cognition subscales. FIM motor gains were greatest between admission and discharge and gains continued through 1 year after injury, but at a much-decreased rate. CONCLUSIONS The cognition items are not informative for detecting changes over time in SCI; at best, these items could serve as a crude cognition screening assessment. Motor items, in contrast, appear to reflect well the functional status of individuals. High correlations among several of the motor items suggest item redundancy. FIM motor scores illustrated the improvements in neurologic and ASIA scores in appropriate cases. Individuals with ASIA impairment grades of B or C at admission make the most gains in FIM motor scores.
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Affiliation(s)
- K M Hall
- Santa Clara Valley Medical Center, San Jose, CA, USA
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Kadota RP, Kun LE, Langston JW, Burger PC, Cohen ME, Mahoney DH, Walter AW, Rodman JH, Parent A, Buckley E, Kepner JL, Friedman HS. Cyclophosphamide for the treatment of progressive low-grade astrocytoma: a Pediatric Oncology Group phase II Study. J Pediatr Hematol Oncol 1999; 21:198-202. [PMID: 10363852 DOI: 10.1097/00043426-199905000-00007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Results of a phase II trial of cyclophosphamide (CPM) for children with progressive low-grade astrocytoma are reported. PATIENTS AND METHODS Fifteen patients with a median age of 39 months (range, 2 to 71) were included in this study. The tumors of 11 children were located in the optic pathway, hypothalamus, or thalamus. Four courses of intravenous CPM 1.2 g/m2 were administered every 3 weeks during the upfront window portion of this protocol. Subsequently, chemotherapy was to continue with CPM, vincristine, and carboplatin for 2 years. RESULTS By study design, the first 14 patients were centrally reviewed after completion of the initial 4 CPM courses. Toxicity was primarily hematologic. One patients had a complete response, 8 had stable disease, and 5 had progressive disease (PD). The excessive number of children with PD prompted study closure. CONCLUSION CPM as used in this protocol showed insufficient activity against astrocytoma to justify further patient accrual.
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Affiliation(s)
- R P Kadota
- Pediatric Oncology Group, Chicago, Illinois, USA
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Duffner PK, Horowitz ME, Krischer JP, Burger PC, Cohen ME, Sanford RA, Friedman HS, Kun LE. The treatment of malignant brain tumors in infants and very young children: an update of the Pediatric Oncology Group experience. Neuro Oncol 1999; 1:152-61. [PMID: 11554387 PMCID: PMC1920752 DOI: 10.1093/neuonc/1.2.152] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- P K Duffner
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Roswell Park Center Institute, Buffalo, NY, USA
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Mandell LR, Kadota R, Freeman C, Douglass EC, Fontanesi J, Cohen ME, Kovnar E, Burger P, Sanford RA, Kepner J, Friedman H, Kun LE. There is no role for hyperfractionated radiotherapy in the management of children with newly diagnosed diffuse intrinsic brainstem tumors: results of a Pediatric Oncology Group phase III trial comparing conventional vs. hyperfractionated radiotherapy. Int J Radiat Oncol Biol Phys 1999; 43:959-64. [PMID: 10192340 DOI: 10.1016/s0360-3016(98)00501-x] [Citation(s) in RCA: 193] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE In June 1992, POG began accrual to a phase III study, POG-9239, designed to compare the time to disease progression, overall survival, and toxicities observed in children with newly diagnosed brainstem tumor treated with 100 mg/m2 of infusional cisplatin and randomized to either conventional vs. hyperfractionated radiotherapy. METHODS AND MATERIALS Patients eligible for study were those between 3 and 21 years of age with previously untreated tumors arising in the pons. Histologic confirmation of diagnosis was not mandatory, provided that the clinical and MRI scan findings were typical for a diffusely infiltrating pontine lesion. Treatment consisted of a six-week course of local field radiotherapy with either once a day treatment of 180 cGy per fraction to a total dose of 5400 cGy (arm 1) or a twice a day regimen of 117 cGy per fraction to a total dose of 7020 cGy (the second of the three hyperfractionated dose escalation levels of POG-8495) (arm 2). Because of previously reported poor results with conventional radiotherapy alone, cisplatin was included as a potential radiosensitizer in an attempt to improve progression-free and ultimate survival rates. Based on results of the phase I cisplatin dose escalation trial, POG-9139, 100 mg/m2 was chosen for this trial and was delivered by continuous infusion over a 120-hour period, beginning on the first day of radiotherapy and repeated during weeks 3 and 5. One hundred thirty eligible patients were treated on protocol, 66 on arm 1 and 64 on arm 2. RESULTS The results we report are from time of diagnosis through October 1997. For patients treated on arm 1, the median time to disease progression (defined as time to off study) was 6 months (range 2-15 months) and the median time to death 8.5 months (range 3-24 months); survival at 1 year was 30.9% and at 2 years, 7.1%. For patients treated on arm 2, the corresponding values were 5 months (range 1-12 months) and 8 months (range 1-23 months), with 1- and 2-year survival rates at 27.0% and 6.7%, respectively. Evaluation of response by MRI at 4 or 8 wks post treatment was available in 108 patients and revealed a complete response in 1 patient of each Rx arm, a partial response (> 50% decrease in size) in 18 patients of arm 1 and 15 patients of arm 2, minimal to no response (stable) in 25 patients of arm 1 and 23 patients of arm 2, and progressive disease in 13 patients of arm 1 and 12 patients of arm 2. The pattern of failure was local in all patients. Morbidity of treatment was similar in both Rx arms, with no significant toxicity (including hearing loss) reported. Autopsy was performed in 6 patients, and confirmed the presence of extensive residual tumor in these cases. CONCLUSION The major conclusion from this trial is that the hyperfractionated method of Rx 2 did not improve event-free survival (p = 0.96) nor did it improve survival (p = 0.65) over that of the conventional fractionation regimen of Rx 1, and that both treatments are associated with a poor disease-free and survival outcome.
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Affiliation(s)
- L R Mandell
- Department of Radiation Oncology, Mount Sinai Medical Center, New York, NY 10029-6574, USA.
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Abstract
The prevalence and features of 3 types of exostoses commonly encountered during periodontal surgery were studied in a sample of 328 modern American skulls drawn from the collection at the American Museum of Natural History. Measurements were made of the height, width, and breadth of exostoses. The relationship to teeth or other skeletal structures was also recorded. Palatal tubercles were observed in 56% of all skulls (69% of all dentate skulls), with higher prevalences among males and African-Americans. Palatal tubercles were commonly associated with second and third molars, and were usually directly lateral to and a mean of 11.4 mm from the greater palatine foramen. Mandibular tori were observed in 27% of all skulls (42% of dentate skulls), with higher prevalences seen among African-Americans and males. The importance of these findings relates to the frequent need for exostosis removal to permit proper flap adaptation, especially in the posterior maxilla, and to the potential use of the mandibular and palatal tori as sources of autogenous cortical bone.
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Abstract
This paper describes the results obtained in the optimization of the composition of dental sealants in relation to the nature and proportions of monomer mixtures and photoinitiating system employed. The quantification and variation of certain parameters which determine the quality of a dental sealant (such as viscosity and penetrating power, residual double bonds, solubility and absorption, volume shrinkage and certain specific mechanical properties) have resulted in the development of new formulations. The composition which has achieved the best results of all the above properties was that corresponding to the monomer mixture bis-GMA/tri(ethylene glycol) dimethacrylate (TEGDMA) 40/60 wt%, and the photoinitiating system camphorquinone (CQ) with co-initiators N,N,3,5-tetramethyaniline (TMA) or N,N-dimethyl-p-toluidine (DMPT) in the ratio 1:1. The final properties and characteristics of the obtained formulations are superior to those of commercial dental sealants currently in use.
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Affiliation(s)
- N Davidenko
- Centro de Biomateriales, Universidad de la Habana, Cuba
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Duffner PK, Krischer JP, Horowitz ME, Cohen ME, Burger PC, Friedman HS, Kun LE. Second malignancies in young children with primary brain tumors following treatment with prolonged postoperative chemotherapy and delayed irradiation: a Pediatric Oncology Group study. Ann Neurol 1998; 44:313-6. [PMID: 9749596 DOI: 10.1002/ana.410440305] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.5] [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: 11/09/2022]
Abstract
Between 1986 and 1990, the Pediatric Oncology Group conducted a study in which 198 children younger than 3 years of age with malignant brain tumors were treated with prolonged postoperative chemotherapy in an effort to delay irradiation and reduce long-term neurotoxicity. Children younger than 2 years of age received 24 months of chemotherapy followed by irradiation, and those between 2 and 3 years of age received 12 months of chemotherapy plus irradiation. Chemotherapy was given in 28-day cycles (AAB, AAB), with cycle A = vincristine (0.065 mg/kg) intravenously on days 1 and 8 and cyclophosphamide (65 mg/kg) intravenously on day 1, and cycle B = cisplatinum (4 mg/kg) intravenously on day 1 and etoposide (6.5 mg/kg) intravenously on days 3 and 4. Five of the 198 children developed second malignancies, with a cumulative risk at 8 years of 11.3% (95% confidence interval [CI], 0-39%). Four of the five second malignancies occurred in children younger than 2 years of age at diagnosis, with a cumulative risk at 8 years of 18.9% (CI, 0-70%). Initial diagnoses were choroid plexus carcinoma (2 children), ependymoma (1 child), desmoplastic infantile ganglioglioma (2 children), and medulloblastoma (1 child). Duration from diagnosis of initial tumor to second malignancy was 33, 35, 57, 66, and 92 months. Three children younger than 2 years of age developed lymphoproliferative disease, that is, myelodysplastic syndrome (2 children), both with monosomy 7 deletions, and acute myelogenous leukemia (1 child), after 24 to 26 cycles of chemotherapy, including 8 cycles of etoposide. Two of 3 received craniospinal irradiation (2,560/3,840 cGy) and (3,520/5,320 cGy). Time to second malignancy was 7 years 8 months, 4 years 9 months, and 2 years 9 months. Two children developed solid tumors, at 5 years 6 months and 2 years 11 months, respectively, after initiation of treatment. A sarcoma developed after 26 cycles of chemotherapy and no irradiation, and a meningioma developed after 12 cycles of chemotherapy and local craniospinal irradiation. Potential causative factors for this high rate of secondary malignancies include prolonged use of alkylating agents and etoposide with or without irradiation.
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Abstract
SLUG is a member of the snail family of zinc finger proteins. It is involved in epithelial to mesenchyme cell transition during neurulation and plays a role in limb bud development. We have isolated and described the human SLUG gene by sequencing a region spanning 4034 bp. The human SLUG gene contains three exons. The SLUG transcript is 2.2 kb and is found in placenta and adult heart, pancreas, liver, kidney, and skeletal muscle, and it codes for a protein of 268 amino acids and 29.989 kDa. This protein contains five zinc finger regions. The human SLUG protein is 95, 93, and 88% homologous to mouse, chicken, and Xenopus slug, respectively, but shows only 47% homology to mouse Snail. The zinc finger region is 100% identical between human and mouse Slug. Slug maps to the long arm of chromosome 8, closely linked to D8S2090 between D8S519 and D8S1098.
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Affiliation(s)
- M E Cohen
- Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland, 21287-3914, USA
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Cohen ME, Ditunno JF, Donovan WH, Maynard FM. A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. Spinal Cord 1998; 36:554-60. [PMID: 9713924 DOI: 10.1038/sj.sc.3100602] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study was designed to test the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. One hundred and six professionals in the field of spinal cord injury attending an instructional course at the 1994 ASIA Meeting participated in the test. Participants completed a pretest and posttest in which they classified two patients who had a spinal cord injury (one with complete tetraplegia and one with incomplete paraplegia) by sensory and motor levels, zone of partial preservation (ZPP), ASIA Impairment Scale and completeness of injury. Between tests, three members of the ASIA Standards Executive Committee gave presentations on the neurological assessment, scoring, scaling and classification of spinal cord injury and a video of the actual examinations of the two cases was viewed. Percent 'correct' (as defined by the ASIA Standards Committee) was calculated for sensory and motor levels, ZPP, ASIA Impairment and completeness. Overall, the analyses showed that participants had very little difficulty in correctly classifying the patient with complete tetraplegia. Pretests scores ranged from 72% (left motor level) to 96% (complete injury), posttest scores from 73% (left motor level) to 100% correct (complete injury). For the patient with incomplete paraplegia (Case 2), scores were considerably lower. Pretest scores ranged from 16% (right motor level) to 95% correct (incomplete injury); posttest scores from 21% (right motor level) to 97% correct (incomplete injury). The results showed that further revisions of the 1992 Standards and more training is needed to ensure accurate classification of spinal cord injury.
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Affiliation(s)
- M E Cohen
- Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Cohen ME, Horning GM. A quantile plot for simultaneous representation of clinical and statistical attributes of probing change: application to early identification of the downhill patient. J Periodontal Res 1998; 33:187-95. [PMID: 9689614 DOI: 10.1111/j.1600-0765.1998.tb02190.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
When multiple periodontal sites are observed in patients over time there is an intention to identify those sites where there is important change, typically loss of attachment or increase in probing depth. A change may be declared if it: (a) exceeds a threshold level, and/or (b) is determined to be statistically significant (e.g. regression slope different from zero), perhaps after (c) that significance level has been corrected for multiple testing. These criteria are not often considered when clinical or research decisions are made and there is no universal protocol for their evaluation. A quantile (uniform probability) plot, modified to incorporate additional information, is proposed as a graphical method for the display of changes at multiple sites within a mouth. This plot identifies, for each site, clinical changes beyond a threshold, site-wise statistical significance and statistical significance adjusted for multiple testing. These alternative criteria for attachment change are, thereby, made explicit, providing a detailed evaluative context. In addition, this methodology permits incorporation of an estimation procedure for the number of sites for which the null hypothesis of no change is false. This statistic can provide evidence of progressive disease even when no site has significant clinical or statistical change and even if the average change is zero. Use of the quantile plot was elucidated by application to simulated data, and to a clinical dataset using a BASIC program to automate the computational process. In the clinical example presented, the approach appeared more effective in detecting periodontal change than traditional clinical and statistical criteria. Pending technical refinement, this graphical approach may represent a new tool for the early identification of the downhill patient.
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Affiliation(s)
- M E Cohen
- Naval Dental Research Institute, Great Lakes, Illinois 60088-5259, USA
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Wormmeester L, Sanchez de Medina F, Kokke F, Tse CM, Khurana S, Bowser J, Cohen ME, Donowitz M. Quantitative contribution of NHE2 and NHE3 to rabbit ileal brush-border Na+/H+ exchange. Am J Physiol 1998; 274:C1261-72. [PMID: 9612213 DOI: 10.1152/ajpcell.1998.274.5.c1261] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intestinal neutral NaCl absorption, which is made up of brush-border (BB) Na+/H+ exchange linked to BB Cl-/HCO3- exchange, is up- and downregulated as part of digestion and diarrheal diseases. Glucocorticoids stimulate ileal NaCl absorption and BB Na+/H+ exchange. Intestinal BB contains two Na+/H+ exchanger isoforms, NHE2 and NHE3, but their relative roles in rabbit ileal BB Na+/H+ exchange has not been determined. A technique to separate the contribution of NHE2 and NHE3 to ileal BB Na+/H+ exchange activity was standardized by using an amiloride-related compound, HOE-694. Under basal conditions, both NHE2 and NHE3 contribute approximately 50% to ileal Na+/H+ exchange. Glucocorticoids (methylprednisolone) increase BB Na+/H+ exchange (2.5 times) but increase only ileal NHE3 activity (4.1 times), without an effect on NHE2 activity. Thus ileal BB Na+/H+ exchange in animals treated with glucocorticoids is 69% via NHE3. A quantitative Western analysis for NHE3 was developed, using as an internal standard a fusion protein of the COOH-terminal 85 amino acids of NHE3 and maltose binding protein. Glucocorticoid treatment increased the amount of BB NHE3. The quantitative Western analysis showed that NHE3 makes up 0.018% of ileal BB protein in control rabbits and 0.042% (2.3 times as much) in methylprednisolone-treated rabbits. Methylprednisolone treatment did not alter the amount of ileal BB NHE2 protein. NHE3 turnover number was estimated to be 458 cycles/s under basal conditions and 708 cycles/s in glucocorticoid-treated ileum. Thus methylprednisolone stimulates ileal BB Na+/H+ exchange activity only by an effect on NHE3 and not on NHE2; it does so primarily by increasing the amount of BB NHE3, although it also increases the NHE3 turnover number.
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Affiliation(s)
- L Wormmeester
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205-2195, USA
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