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Barlow SA, Price M, Jones CA, Pieper C, Galanos AN. Grief Training in Palliative Care Fellowships. J Pain Symptom Manage 2024; 67:e347-e354. [PMID: 38215895 DOI: 10.1016/j.jpainsymman.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
INTRODUCTION No prior study has assessed grief and bereavement curriculum in Hospice and Palliative Medicine (HPM) fellowship programs in the United States. METHODS A 14-item survey was created and distributed to Accreditation Council for Graduate Medical Education (ACGME)-accredited HPM fellowship Program Directors to assess program demographics, curriculum emphasis, grief and bereavement programming, and attitudes toward grief and bereavement training for HPM fellows. RESULTS The overall survey response rate was 63%. Most palliative care programs were academic (74%) and had four or fewer fellows (85%). 90% devoted a minority (0%-10%) of their curriculum to grief and bereavement training. Most programs reported at least some program-led grief and bereavement programming (69%); however, 53% endorsed that fellows are not very or not at all involved in this programming. Almost half of programs only have a small amount of programming related to supporting families after loss (49%). The majority endorsed having a great deal of programming for debriefing or supporting fellows through professional grief (55%), and the most common modalities were debriefing sessions (62%) and ensuring access to mental health resources (41%). The most common ways of teaching grief and bereavement were through bedside/anecdotal teaching and lectures/case conferences. Most program directors felt that palliative care fellowships should provide grief and bereavement training (81%) and consider it important or very important for fellows to learn how to process grief and bereavement (92%). DISCUSSION It was widely reported by program directors that grief and bereavement training are important curricular components for HPM fellows. Acknowledging professional grief remains an underrecognized need in palliative care training and practice. Our study suggests that for grief and bereavement curricula in HPM fellowships, the time dedicated, specific types, and amount of fellow involvement was highly variable. It will be critical for programs to disseminate best practices to help move toward a more uniform approach for ensuring basic competency in grief and bereavement training in HPM fellowship programs in the United States.
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Affiliation(s)
- Sara A Barlow
- Duke University Hospital (S.A.B., C.A.J., C.P., A.N.G.), Durham, North Carolina, USA.
| | - Meghan Price
- Johns Hopkins Hospital (M.P.), 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Christopher A Jones
- Duke University Hospital (S.A.B., C.A.J., C.P., A.N.G.), Durham, North Carolina, USA
| | - Carl Pieper
- Duke University Hospital (S.A.B., C.A.J., C.P., A.N.G.), Durham, North Carolina, USA
| | - Anthony N Galanos
- Duke University Hospital (S.A.B., C.A.J., C.P., A.N.G.), Durham, North Carolina, USA
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Dalton T, Darner G, McCray E, Price M, Baëta C, Erickson M, Karikari IO, Abd-El-Barr MM, Goodwin CR, Brown DA. Prophylactic Muscle Flaps Decrease Wound Complication Rates in Patients with Oncologic Spine Disease. Plast Reconstr Surg 2024; 153:221-231. [PMID: 37075264 DOI: 10.1097/prs.0000000000010568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
BACKGROUND Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established. METHODS A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data. RESULTS A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053). CONCLUSIONS Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | - Grant Darner
- Department of Surgery, Division of Plastic, Maxillofacial, and Oral Surgery
| | | | | | | | - Melissa Erickson
- Department of Orthopedic Surgery, Duke University Medical Center
| | | | | | | | - David A Brown
- Department of Surgery, Division of Plastic, Maxillofacial, and Oral Surgery
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Goodwin CR, Price M, Goodwin AN, Dalton T, Versteeg AL, Sahgal A, Rhines LD, Schuster JM, Weber MH, Lazary A, Boriani S, Bettegowda C, Fehlings MG, Arnold PM, Dea N, Charest-Morin R, Shin J, Laufer I, Chou D, Gokaslan ZL, Clarke MJ, Fisher CG, Sciubba DM. Gender and Sex Differences in Health-related Quality of Life, Clinical Outcomes and Survival after Treatment of Metastatic Spine Disease. Spine (Phila Pa 1976) 2023:00007632-990000000-00544. [PMID: 38149519 DOI: 10.1097/brs.0000000000004910] [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: 08/22/2023] [Accepted: 11/17/2023] [Indexed: 12/28/2023]
Abstract
STUDY DESIGN Retrospective review of prospective, multicenter and international cohort study. OBJECTIVE To describe the effect of gender on HRQoL, clinical outcomes and survival for patients with spinal metastases treated with either surgery and/or radiation. SUMMARY OF BACKGROUND DATA Gender differences in health-related outcomes are demonstrated in numerous studies, with women experiencing worse outcomes and receiving lower standards of care than men, however, the influence that gender has on low health-related quality of life (HRQoL) and clinical outcomes after spine surgery remains unclear. METHODS Patient demographic data, overall survival, treatment details, perioperative complications, and HRQoL measures including EQ-5D, pain NRS, the short form 36 version 2 (SF-36v2) and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) were reviewed. Patients were stratified by sex, and a separate sensitivity analysis that excluded gender-specific cancers (i.e., breast, prostate, etc.) was performed. RESULTS The study cohort included 207 female and 183 male patients, with age, smoking status, and site of primary cancer being significantly different between the two cohorts (P<0.001). Both males and females experienced significantly improved SOSGOQ2.0, EQ-5D, and pain NRS scores at all study time points from baseline (P<0.001). Upon sensitivity analysis, (gender-specific cancers removed from analysis), the significant improvement in SOSGOQ physical, mental, and social subdomains and on SF-36 domains disappeared for females. Males experienced higher rates of postoperative complications. Kaplan-Meier survival analysis of both the overall and sensitivity analysis cohorts showed females lived longer than males after treatment (P=0.001 and 0.043, respectively). CONCLUSION Both males and females experienced significantly improved HRQoL scores after treatment, but females demonstrated longer survival and a lower complication rate. This study suggests that gender may be a prognostic factor in survival and clinical outcomes for patients undergoing treatment for spine metastases and should be taken into consideration when counseling patients accordingly.
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Affiliation(s)
- C Rory Goodwin
- Department of Neurosurgery. Spine Division. Duke Center for Brain and Spine Metastasis. Duke University Medical Center, Durham, NC
| | - Meghan Price
- Department of Neurosurgery. Spine Division. Duke Center for Brain and Spine Metastasis. Duke University Medical Center, Durham, NC
| | - Andrea N Goodwin
- Department of Sociology, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tara Dalton
- Department of Neurosurgery. Spine Division. Duke Center for Brain and Spine Metastasis. Duke University Medical Center, Durham, NC
| | - Anne L Versteeg
- Department of Orthopaedic Surgery, Division of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Laurence D Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael H Weber
- Division of Surgery, McGill University and Montreal General Hospital, Montreal, Quebec, Canada
| | - Aron Lazary
- National Center for Spinal Disorders and Buda Health Center, Budapest, Hungary
| | | | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Paul M Arnold
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL
| | - Nicolas Dea
- Division of Spine, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Raphaele Charest-Morin
- Division of Spine, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - John Shin
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ilya Laufer
- Department of Neurosurgery, Division of Spinal Neurosurgery, NYU Langone Health, New York, NY
| | - Dean Chou
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | | | - Charles G Fisher
- Division of Spine, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
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Wang YF, Elliston C, Munbodh R, Savacool M, Tam J, Joseph J, Spina CS, Horowitz DP, Kachnic LA, Price M. Creation and Implementation of an Interdisciplinary Workflow for CBCT-Based Online Adaptive Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e736. [PMID: 37786139 DOI: 10.1016/j.ijrobp.2023.06.2262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) CBCT-based online adaptive radiotherapy (OART) is an emerging treatment strategy to replan based on the anatomy of the day while the patient remains on the couch. OART is not just an add-on to the current workflow; it necessitates a new approach across the patient's path of care, from CT simulation to treatment delivery. OART requires the addition of duties to clinical personnel, strategies to create auto-plan templates, and monitoring the "black box" adaptation process. Studies have shown that OART implementation is limited by its resource-intensive nature and the risks associated with the treatment approach. We hypothesized that the implementation of an interdisciplinary, streamlined workflow and checklists would enhance the OART treatment efficiency, prevent medical errors from the adaptation, and minimize the burden on clinicians. MATERIALS/METHODS An interdisciplinary OART working group comprising radiation oncologists, medical physicists, dosimetrists, and therapists was created to enable weekly knowledge sharing, workflow design, implementation, and continuous process improvement. 213 adaptive sessions from 5 treatment sites (pancreas, bladder, prostate, rectum, anus) were treated on a CBCT-based OART platform in a single institutional study. An evaluation of the treatment safety and workflow time was performed for each adaptive session. RESULTS The OART workflow was divided into four sub-workflows: 1) pre-treatment site-specific template preparation, 2) pre-treatment initial planning and verification, 3) on-treatment procedure, and 4) post-treatment evaluation. The sub-processes involved 4, 8, 13, and 4 separate, sequentially tasks, respectively, and a total of 11 task checklists. The template preparation is a new process developed for site-specific, standardized physician template directives, automated planning template development, and testing for its accuracy and robustness. The planning templates generated high-quality initial plans automatically within minutes once structures were segmented on the planning CT. This process was replicated during treatment using the CBCT. The median (interquartile range) online procedure time, defined as the time from initial CBCT to plan approval, of the five treatment sites (pancreas, bladder, prostate, rectum, anus) was 22.1 (19.2-24.8) min, 16.5 (15.3-17.5) min, 14.7 (13.9-17.4) min, 17 (15.3-19.7) min, and 24 (21.4-25.8) min, respectively. Safety assessment determined that no treatment deviations were observed. CONCLUSION Creating an interdisciplinary, standardized workflow and checklists allowed the safe delivery of OART with clinically feasible online procedure time and significantly reduced initial planning time compared with traditional EBRT. The unique workflow is essential to minimize the burden on the care team, increase patient safety, and access to OART.
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Affiliation(s)
- Y F Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C Elliston
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - R Munbodh
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Savacool
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Tam
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Joseph
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C S Spina
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - D P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - L A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
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Lee AW, Pasetsky J, Lavrova E, Wang YF, Sedor GJ, Li F, Gallitto M, Garrett MD, Elliston C, Price M, Kachnic LA, Horowitz DP. CT-Guided Online Adaptive Stereotactic Body Radiotherapy for Pancreas Ductal Adenocarcinoma: Dosimetric and Initial Clinical Experience. Int J Radiat Oncol Biol Phys 2023; 117:e312. [PMID: 37785126 DOI: 10.1016/j.ijrobp.2023.06.2340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Retrospective analysis suggests that dose escalation to a biologically effective dose of more than 70 Gy may improve overall survival in patients with pancreatic ductal adenocarcinoma (PDAC), but such treatments in practice are limited by proximity of organs at risk (OARs). We hypothesized that CT-guided online adaptive radiotherapy (OART) can account for interfraction movement of OARs, reduce dose to OARs, and improve coverage of targets. MATERIALS/METHODS This is a single institution retrospective analysis of patients with PDAC treated with OART on a CBCT-based OART platform. All patients were treated to 40 Gy in 5 fractions. PTV overlapping with a 5 mm planning risk volume expansion on the stomach, duodenum and bowel received 25 Gy. Initial treatment plans were created conventionally. For each fraction, PTV and OAR volumes were recontoured with AI assistance after initial cone beam CT (CBCT). The adapted plan was calculated, underwent QA, and then compared to the scheduled plan. A second CBCT was obtained prior to delivery of the selected plan. Total treatment time (first CBCT to end of radiation delivery) and active physician time (first to second CBCT) were recorded. PTV_4000 V95%, PTV_2500 V95%, and D0.03 cc to stomach, duodenum and bowel were reported for scheduled (S) and adapted (A) plans. CTCAEv5.0 toxicities were recorded. Statistical analysis was performed using a two-sided T test and α of 0.05. RESULTS Seven patients with unresectable or locally-recurrent PDAC were analyzed, with a total of 35 fractions. Average total time was 33:00 minutes (22:25-49:40) and average active time was 22:48 minutes (14:15-39:34). All fractions were treated with adapted plans. All adapted plans met PTV_4000 V95.0% > 95.0% coverage goal and OAR dose constraints. Dosimetric data for scheduled and adapted plans per fraction are in Table 1. Median follow up was 1.7 months. 5 (71%) patients experienced either Grade 1 or 2 toxicities. No patients experienced Grade 3+ toxicities. CONCLUSION Daily OART significantly reduced dose OARs while achieving superior PTV coverage. Treatment was generally well tolerated with no grade 3+ acute toxicity, and required only 22:48 minutes on average of active physician time. Our initial clinical experience demonstrates OART allows for safe dose escalation in the treatment of PDAC.
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Affiliation(s)
- A W Lee
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Pasetsky
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - E Lavrova
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Y F Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - G J Sedor
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - F Li
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M D Garrett
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C Elliston
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - L A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - D P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
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Price M, Munoz L, McLoone P, Paludi D, Fox T, Mastwyk T. Clinical Evaluation of an Automated Iterative Optimization System for Radiation Oncology. Int J Radiat Oncol Biol Phys 2023; 117:e707-e708. [PMID: 37786071 DOI: 10.1016/j.ijrobp.2023.06.2201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Automation of radiotherapy treatment planning improves efficiency and consistency, while reducing planning time and errors. The objective of this study was to validate an Iterative Optimization Engine (IOE) within an existing automated IMRT/VMAT planning framework. The IOE was designed to reduce remaining manual intervention within the automation framework through measuring and codifying common user intervention within a commercial planning system. MATERIALS/METHODS The IOE was developed for external beam IMRT/VMAT treatment planning on the Monaco Treatment Planning System. The IOE was built on an existing automation framework, utilizing the Application Programming Interface (API) to create completely automated treatment plans. A network of 40 centers in Australia evaluated automated treatment plans for head and neck disease sites where users decided manual intervention was required post automated planning to achieve clinician approval. The modifications to automated plans were recorded, analyzed, and codified into the API to remove the requirement for manual intervention. A subset of the automated plans was then retrospectively processed by the IOE with resulting plans being scored in three categories of 1) superior, 2) equivalent and 3) inferior based on DVH assessment with the original clinician approved plan as the baseline. RESULTS The automation framework generated 546 head and neck plans from January 1 to February 1, 2023, of which 45% required manual intervention to achieve dosimetric criteria. After being processed by the IOE, 86% of plans showed equivalent or superior coverage and maximum dose, and 95% of plans demonstrated equivalent homogeneity or improved homogeneity. Multi-target plans showed equivalent or improved target dose for 67% of intermediate dose targets and 39% of low dose targets when multiple targets were treated simultaneously. Analysis of organs at risk showed 38% of plans with reduced Parotid mean dose, 92% improved Larynx mean dose, 43% reduced Spinal Cord maximum dose, 57% decreased Brainstem maximum dose, 85% reduced Oral Cavity mean dose and 56% reduced Pharynx mean dose. CONCLUSION The addition of an IOE achieved a clinical improvement to target and OAR metrics in the assessed clinical plans. The automation framework will incorporate this work into clinical production to improve the overall effectiveness of the automated planning framework.
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Affiliation(s)
- M Price
- GenesisCare, Sydney, NSW, Australia
| | - L Munoz
- GenesisCare, Sydney, NSW, Australia
| | | | - D Paludi
- GenesisCare, Sydney, NSW, Australia
| | - T Fox
- GenesisCare USA, Fort Myers, FL
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Gough LA, Newbury JW, Price M. The effects of sodium bicarbonate ingestion on swimming interval performance in trained competitive swimmers. Eur J Appl Physiol 2023; 123:1763-1771. [PMID: 37027014 PMCID: PMC10363041 DOI: 10.1007/s00421-023-05192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
The use of sodium bicarbonate (NaHCO3) supplementation to improve repeated high-intensity performance is recommended; however, most swimming performance studies examine time trial efforts rather than repeated swims with interspersed recovery that are more indicative of training sessions. The aim of this study, therefore, was to investigate the effects of 0.3 g.kg-1 BM NaHCO3 supplementation on sprint interval swimming (8 × 50 m) in regionally trained swimmers. Fourteen regionally competitive male swimmers (body mass (BM): 73 ± 8 kg) volunteered for this double-blind, randomised, crossover designed study. Each participant was asked to swim 8 × 50 m (front crawl) at a maximum intensity from a diving block, interspersed with 50 m active recovery swimming. After one familiarisation trial, this was repeated on two separate occasions whereby participants ingested either 0.3 g.kg-1 BM NaHCO3 or 0.05 g.kg-1 BM sodium chloride (placebo) in solution 60 min prior to exercise. Whilst there were no differences in time to complete between sprints 1-4 (p > 0.05), improvements were observed in sprint 5 (p = 0.011; ES = 0.26), 6 (p = 0.014; ES = 0.39), 7 (p = 0.005; ES = 0.60), and 8 (p = 0.004; ES = 0.79). Following NaHCO3 supplementation, pH was greater at 60 min (p < 0.001; ES = 3.09), whilst HCO3- was greater at 60 min (p < 0.001; ES = 3.23) and post-exercise (p = 0.016; ES = 0.53) compared to placebo. These findings suggest NaHCO3 supplementation can improve the latter stages of sprint interval swimming performance, which is likely due to the augmentation of pH and HCO3- prior to exercise and the subsequent increase in buffering capacity during exercise.
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Affiliation(s)
- L A Gough
- Human Performance and Health Research Group, Centre for Life and Sport Sciences (CLaSS), Birmingham City University, Birmingham, B15 3TN, UK.
| | - J W Newbury
- Human Performance and Health Research Group, Centre for Life and Sport Sciences (CLaSS), Birmingham City University, Birmingham, B15 3TN, UK
| | - M Price
- Centre for Sport, Exercise and Life Sciences, Coventry University, Coventry, CV1 2DS, UK
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Fairchild R, Price M, Craig A, Dotters-Katz SK. Reliability and comprehensiveness of YouTube videos about the COVID-19 vaccine in pregnancy. Am J Infect Control 2023:S0196-6553(23)00521-7. [PMID: 37487971 DOI: 10.1016/j.ajic.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023]
Abstract
Online information influences health care decisions and may contribute to vaccine hesitancy among pregnant individuals. We assessed the quality (reliability and comprehensiveness) of YouTube videos about COVID-19 vaccination in pregnancy. We systematically identified videos and recorded video information and quality. 137 videos were reviewed. Comments, likes, dislikes, duration, reliability, and content scores differed between sources. Videos were low quality overall, but videos produced by medical sources tended to be higher quality. Quality was positively correlated with duration, but not views.
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Affiliation(s)
| | - Meghan Price
- Johns Hopkins Department of Internal Medicine, Baltimore, MD, USA
| | - Amanda Craig
- Duke University Department of Obstetrics and Gynecology, Durham, NC, USA
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Clay AS, Andolsek KM, Niederhoffer K, Kandakatla A, Zhang G, Price M, Alagesan P, Jeffs S, DeLaura I, Nicholson CP, Chudgar SM, Narayan AP, Knudsen NW, Blazar M, Edwards P, Buckley EG. Creation of an asynchronous faculty development curriculum on well-written narrative assessments that avoid bias. BMC Med Educ 2023; 23:244. [PMID: 37060081 PMCID: PMC10103041 DOI: 10.1186/s12909-023-04237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/06/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The COVID-19 pandemic in parallel with concerns about bias in grading resulted in many medical schools adopting pass/fail clinical grading and relying solely on narrative assessments. However, narratives often contain bias and lack specificity. The purpose of this project was to develop asynchronous faculty development to rapidly educate/re-educate > 2000 clinical faculty spread across geographic sites and clinical disciplines on components of a well-written narrative and methods to minimize bias in the assessment of students. METHODS We describe creation, implementation, and pilot data outcomes for an asynchronous faculty development curriculum created by a committee of volunteer learners and faculty. After reviewing the literature on the presence and impact of bias in clinical rotations and ways to mitigate bias in written narrative assessments, the committee developed a web-based curriculum using multimedia learning theory and principles of adult learning. Just-in-time supplemental materials accompanied the curriculum. The Dean added completion of the module by 90% of clinical faculty to the department chairperson's annual education metric. Module completion was tracked in a learning management system, including time spent in the module and the answer to a single text entry question about intended changes in behavior. Thematic analysis of the text entry question with grounded theory and inductive processing was used to define themes of how faculty anticipate future teaching and assessment as a result of this curricula. OUTCOMES Between January 1, 2021, and December 1, 2021, 2166 individuals completed the online module; 1820 spent between 5 and 90 min on the module, with a median time of 17 min and an average time of 20.2 min. 15/16 clinical departments achieved completion by 90% or more faculty. Major themes included: changing the wording of future narratives, changing content in future narratives, and focusing on efforts to change how faculty teach and lead teams, including efforts to minimize bias. CONCLUSIONS We developed a faculty development curriculum on mitigating bias in written narratives with high rates of faculty participation. Inclusion of this module as part of the chair's education performance metric likely impacted participation. Nevertheless, time spent in the module suggests that faculty engaged with the material. Other institutions could easily adapt this curriculum with provided materials.
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Affiliation(s)
- Alison S Clay
- Department of Medical Education, School of Medicine, Duke University, 8 Searle Center Drive, TSCHE 1074, Durham, NC, 27710, USA.
| | - Kathryn M Andolsek
- Department of Family Medicine and Community Health, School of Medicine, Duke University, Durham, NC, USA
| | | | - Apoorva Kandakatla
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Gloria Zhang
- School of Medicine, Duke University, Durham, NC, USA
| | - Meghan Price
- Department of Internal Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Sydney Jeffs
- Medical Scientist Training Program, School of Medicine, Duke University, Durham, NC, USA
| | | | - C Phifer Nicholson
- School of Medicine, Duke University, Durham, NC, USA
- Divinity School, Duke University, Durham, NC, USA
| | - Saumil M Chudgar
- Department of Medicine, School of Medicine, Duke University, Durham, NC, USA
| | - Aditee P Narayan
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, USA
| | - Nancy W Knudsen
- Department of Anesthesiology, School of Medicine, Duke University, Durham, NC, USA
| | - Melinda Blazar
- Department of Family Medicine and Community Health, School of Medicine, Duke University, Durham, NC, USA
- Duke Physician Assistant Program, School of Medicine, Duke University, Durham, NC, USA
| | | | - Edward G Buckley
- Department of Ophthalmology, School of Medicine, Duke University, Durham, NC, USA
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Vashistha V, Katsoulakis E, Guo A, Price M, Ahmed S, Kelley MJ. Molecular-Guided Off-Label Targeted Therapy in a Large-Scale Precision Oncology Program. JCO Precis Oncol 2023; 7:e2200518. [PMID: 36787508 PMCID: PMC10309545 DOI: 10.1200/po.22.00518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/05/2022] [Accepted: 12/21/2022] [Indexed: 02/16/2023] Open
Abstract
PURPOSE Increasing utilization of comprehensive genomic profiling (CGP) and a growing number of targeted agents (TAs) have led to substantial improvements in outcomes among patients with cancer with actionable mutations. We sought to evaluate real-world experience with off-label TAs among Veterans who underwent CGP. METHODS The National Precision Oncology Program database and VA Corporate Data Warehouse were queried to identify patients who underwent CGP between February 2019 and December 2021 and were prescribed 1 of 73 TAs for malignancy. OncoKB annotations were used to select patients who received off-label TAs based upon CGP results. Chart abstraction was performed to review response, toxicities, and time to progression. RESULTS Of 18,686 patients who underwent CGP, 2,107 (11%) were prescribed a TA and 169 (0.9%) were prescribed a total of 183 regimens containing off-label TAs for variants in 31 genes. Median age was 68 years and 83% had prior systemic therapy, with 28% receiving three or more lines. Frequency of off-label TA prescriptions was highest for patients undergoing CGP for thyroid (8.6%) and breast (7.6%) cancers. Most patients harbored alterations in BRCA1/BRCA2/ATM (22.5%), ERBB2 (19.5%), and BRAF (19.5%). Among the 160 regimens prescribed > 4 weeks, 43 (27%) led to response. Median progression-free survival and overall survival were 5.3 (4.2-6.5) and 9.7 (7.5-11.9) months, respectively. Patients with OncoKB level 2/3A/3B annotations had longer median progression-free survival (5.8 [4.5-7] months v 3.7 [1.6-7.7] months; hazard ratio, 0.45; 95% CI, 0.24 to 0.82; P = .01) compared with those receiving level 4 treatments. CONCLUSION Although administration of off-label TAs is infrequent after CGP, more than one quarter of treatment regimens led to response. TAs associated with level 4 annotations lead to worse outcomes than TAs bearing higher levels of evidence.
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Affiliation(s)
- Vishal Vashistha
- Section of Hematology/Oncology, Raymond G. Murphy New Mexico Veterans Affairs Medical Center, Albuquerque, NM
- University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A. Haley Veterans Affairs Medical Center, Tampa, FL
| | - Aixia Guo
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC
| | - Meghan Price
- Department of Medicine Baltimore, The Johns Hopkins Hospital, Baltimore, MD
| | - Sara Ahmed
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC
| | - Michael J. Kelley
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC
- Department of Medicine, Duke University Health System, Durham, NC
- Division of Hematology-Oncology, Durham Veterans Affairs Medical Center, Durham, NC
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Price M, Hofman PL, Hsiao K, Jones HF. The search for a unifying diagnosis involving neurological, endocrine and immune dysfunction: a case report of a novel presentation of DAVID syndrome. BMC Pediatr 2022; 22:706. [PMID: 36494638 PMCID: PMC9733238 DOI: 10.1186/s12887-022-03760-x] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/20/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We report a novel presentation of deficit in anterior pituitary function with variable immune deficiency (DAVID) syndrome in a healthy young girl presenting in Addisonian crisis with raised intracranial pressure. Nearly all cases of DAVID syndrome described in the literature have presented with recurrent infections and variable immunodeficiency. Pseudotumour cerebri has not been reported in DAVID syndrome to date. CASE PRESENTATION A four-year-old girl represented to hospital with vomiting, confusion and diplopia after ten days of tiredness, neck and abdominal pain, and headache. Her cranial nerve examination demonstrated a right abducens nerve palsy and papilloedema, and she was found to have ketotic hypoglycaemia and hypocortisolaemia secondary to adrenocorticotrophic hormone (ACTH) deficiency. Her neuroimaging was consistent with pseudotumour cerebri, and her lumbar puncture opening pressure confirmed raised intracranial pressure (30-40 cmH2O). Cerebrospinal fluid analysis was normal. The patient's symptoms improved with hydrocortisone replacement and acetazolamide, but the raised intracranial pressure recurred after acetazolamide was discontinued. She was subsequently found to have panhypogammaglobulinaemia, and DAVID syndrome was diagnosed. Genetic testing demonstrated a truncating mutation in the NFKB2 gene c.2557C > T, p.(Arg853*). CONCLUSIONS This case demonstrates pseudotumour cerebri as a novel neurological presentation of DAVID syndrome, highlights the rare association between adrenal insufficiency and intracranial hypertension, and shows the challenges in diagnosing isolated ACTH deficiency. We emphasise that cortisol should be checked in pre-pubertal children with pseudotumour cerebri and a diagnosis of DAVID syndrome considered in those presenting with low cortisol and neurological symptoms.
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Affiliation(s)
- M. Price
- Department of Immunology, Starship Child Health, Auckland, New Zealand
| | - P. L. Hofman
- Department of Endocrinology, Starship Child Health, Auckland, New Zealand ,grid.9654.e0000 0004 0372 3343Liggins Institute, University of Auckland, Auckland, New Zealand
| | - K. Hsiao
- Department of Immunology, Starship Child Health, Auckland, New Zealand ,grid.9654.e0000 0004 0372 3343Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - H. F. Jones
- Department of Neuroservices, Paediatric Neuroservices, Starship Child Health, Auckland, New Zealand ,grid.9654.e0000 0004 0372 3343Centre for Brain Research, University of Auckland, Auckland, New Zealand
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Imbimbo M, Ghisoni E, Mulvey A, Bouchaab H, Mederos Alfonso N, Karp D, Camidge D, Mansfield A, Yim C, Ames T, Price M, Baeck J, O'Donnell J, Peters S. 125P A phase IIa study of the novel immunogenic cell death (ICD) inducer PT-112 plus avelumab (“PAVE”) in advanced non-small cell lung cancer (NSCLC) patients (pts). Immuno-Oncology and Technology 2022. [DOI: 10.1016/j.iotech.2022.100237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Price M, McLoone P, Buman K, Sutter A, Fox T, Potrebko P. Clinical Evaluation of an Automated Treatment Planning Framework for Radiation Oncology. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Savacool M, Elliston C, Lozano IV, Tam J, Deutsch I, Kachnic L, Price M. Using Class-Solution Optimization and Knowledge-Based Planning, a Physician-Driven Treatment Planning Workflow Demonstrates Improved OAR-Sparing for EBRT of the Prostate. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.2262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Vashistha V, Guo A, Katsoulakis E, Price M, Ahmed S, Kelley MJ. Frequency and outcomes of molecularly guided off-label targeted agent prescriptions in the VA National Precision Oncology Program (NPOP). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18676 Background: The increasing availability of comprehensive genomic profiling (CGP) and a growing number of targeted agents (TAs) has led to substantial improvements in outcomes among cancer pts with actionable mutations. CGP has led to identification of both on-label (level 1) variants, for which TAs have known efficacy, and off-label variants with lesser strength of supporting data. We sought to evaluate real-world prescription patterns and outcomes of off-label TA prescriptions among pts who underwent CGP. Methods: The NPOP database and VA Corporate Data Warehouse were queried to identify pts who had underwent CGP between February 2019 and December 2021 and were prescribed at least 1 of 73 TAs before January 2022. TAs prescribed for FDA-approved indications not relying on CGP as a companion diagnostic were excluded. OncoKB was used to annotate gene variants and evaluated against prescriptions to select pts who received off-label TAs. The frequency of off-label TA use, and for those treated > 4 weeks, rate of pts treated for 6 months or longer, median treatment duration and overall survival (OS) were computed. Results: Of the 18686 patients who underwent CGP, 2107 (11%) were prescribed any TA, and 191 (1%) were prescribed off-label TAs, with 31 receiving multiple concurrent or sequential off-label TAs. Mean age was 65.5 years, and 88% were male. TAs were most often prescribed for cancers of unknown primary (CUP, 29), NSCLC (24), and colorectal cancer (22). Frequency of off-label prescriptions was highest for pts who completed CGP for thyroid cancer (9%), breast cancer (8%), and CUP (2%). Most common variants involved BRAF (21%), ERBB2 (18%), BRCA1/BRCA2/ATM (9%), and PIK3CA (6%). Among all 164 pts treated > 4 weeks, 40% received TAs for 6 months or longer, including 50%, 47%, and 46% of pts bearing BRAF-, ERBB2-, and PIK3CA-mutant disease, respectively. Median therapy duration and OS was 141 [78.5 – 317, IQR] days and 181 [96.5 – 304.5, IQR] days, respectively. Conclusions: Though overall use of off-label TAs following CGP is low, nearly 10% of advanced thyroid and breast cancer patients are prescribed TAs for off-label indications. Forty percent of all pts receiving off-label TAs continue for at least 6 months, with higher rates for pts bearing BRAF-, ERBB2-, and PIK3CA-mutant disease. CGP-guided off-label treatment approaches offer unique options for advanced stage cancer with amenable molecular profiles.
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Affiliation(s)
| | - Aixia Guo
- Department of Veterans Affairs, Durham, NC
| | | | | | - Sara Ahmed
- US Department of Veterans Affairs, Washington, DC
| | - Michael J. Kelley
- Duke Cancer Institute & Department of Medicine, Duke University, Durham, NC
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Magnocavallo M, Della Rocca D, Van Niekerk C, Gilhofer T, Ha G, D‘Ambrosio G, Galvin J, Urbanek L, Lavalle C, Schmidt B, Geller C, Lakkireddy D, Di Biase L, Price M, Mansour M, Saw J, Horton R, Gibson D, Natale A. P95 PERI–PROCEDURAL COMPLICATIONS AND LONG–TERM OUTCOMES IN ATRIAL FIBRILLATION PATIENTS STRATIFIED FOR CHRONIC KIDNEY DISEASE SEVERITY UNDERGOING LEFT ATRIAL APPENDAGE OCCLUSION: RESULTS FROM AN INTERNATIONAL, MULTICENTER REGISTRY. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartj/suac012.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thromboembolic events. CKD concomitantly contributes to several pathophysiological changes predisposing towards a pro–haemorrhagic state.
Objective
To evaluate the impact of kidney function on peri–procedural complications and clinical outcomes in AF patients undergoing left atrial appendage occlusion (LAAO) with a Watchman device.
Methods
2124 consecutive AF patients undergoing Watchman implantation at 8 different centers were categorized into CKD stage 1 + 2 (n = 1089), CKD stage 3 (n = 796), CKD stage 4 (n = 170), CKD stage 5 (n = 69) based on the estimated glomerular filtration rate at baseline. The primary efficacy endpoint included a composite of cardiovascular (CV) mortality, stroke, transient ischemic attack, peripheral thromboembolism (TE), and major bleeding.
Results
A non–significant higher incidence of major peri–procedural adverse events (1.7% vs. 2.3% vs. 4.1% vs. 4.3%) was observed with worsening baseline kidney function (p = 0.14). The mean follow–up period was 13 ± 7 months [2226 patient–years (PY)]. In comparison to CKD stage 1 + 2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log–rank p–value= 0.04), CKD stage 4 (log–rank p–value= 0.01), and CKD stage 5 (log–rank p–value= 0.001) (Fig. 1A). A non–significant increase in event rates for stroke/TIA and clinically relevant bleeding was observed among the four groups. LAAO led to a TE risk reduction of 72%, 66%, 62%, and 41% in each group (Fig. 1B). The relative risk reduction in the incidence of major bleeding was 58%, 44%, 51%, and 52%, respectively (Fig. 1C).
Conclusion
Patients with moderate–to–severe CKD had a higher incidence of the primary composite endpoint. The relative risk reduction in the incidence of TE and major bleeding was consistent across CKD groups, irrespective of the very different risk profiles at baseline.
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Affiliation(s)
- M Magnocavallo
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - D Della Rocca
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - C Van Niekerk
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - T Gilhofer
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - G Ha
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - G D‘Ambrosio
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - J Galvin
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - L Urbanek
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - C Lavalle
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - B Schmidt
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - C Geller
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - D Lakkireddy
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - L Di Biase
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - M Price
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - M Mansour
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - J Saw
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - R Horton
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - D Gibson
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
| | - A Natale
- POLICLINICO UMBERTO I, ROMA; TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN; SCRIPPS CLINIC, LA JOLLA; VANCOUVER GENERAL HOSPITAL, VANCOUVER; MASSACHUSETTS GENERAL HOSPITAL, BOSTON; ZENTRALKLINIK BAD BERKA, BAD BERKA; CARDIOANGIOLOGISCHES CENTRUM BETHANIEN, FRANKFURT; OTTO–VON–GUERICKE UNIVERSITY SCHOOL OF MEDICINE, MAGDEBURG; KANSAS CITY HEART RHYTHM INSTITUTE AND RESEARCH FOUNDATION, OVERLAND PARK
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Zhang H, Buell T, Baldwin E, Crutcher C, Dalton TE, Price M, Karikari IO, Abd-El-Barr MM, Goodwin CR, Erickson M. 104 Myelopathy and Increased Costs of Care After Hip Fracture. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Chand S, Wilcox I, McGrady M, Lal S, Hunyor I, O'Sullivan J, Fulthorp E, Price M, Mccoll A. Clinical and Echocardiographic Parameters in Community-Based Individuals Symptomatic Post Pfizer and AstraZeneca COVID-19 Vaccination. Heart Lung Circ 2022. [PMCID: PMC9345547 DOI: 10.1016/j.hlc.2022.06.234] [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: 11/25/2022]
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19
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Price M, Lavau C, Baeta C, Byemerwa J, Wardell S, Brueckner O, Mukherjee D, Haynes C, Nguyen A, Chang C, McDonnell D, Goodwin CR. Abstract P131: The role of UDP-6 glucose dehydrogenase (UGDH) in estrogen-mediated phenotypes in both estrogen receptor positive and estrogen receptor negative breast cancer. Mol Cancer Ther 2021. [DOI: 10.1158/1535-7163.targ-21-p131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
A better understanding of pathologic mechanisms underlying breast cancer progression and metastasis is critical to improve current treatment modalities. UDP-6- glucose dehydrogenase (UGDH) is an enzyme that has become a recent oncologic target of interest across various cancer subtypes for its role in increasing the aggressiveness and migratory capacity of tumor cells both in vitro and in vivo. UGDH is ubiquitously expressed and plays a critical role in forming the extracellular matrix (ECM), producing nucleotide sugars, and processing hormones through glucuronidation. For these reasons, investigating the effect of UGDH on breast cancer in the setting of hormonal stimulation is important. We found that knocking down UGDH in estrogen receptor positive (ER+) breast cancer cell lines (MCF7 marco and T47D) and an estrogen receptor negative (ER-) breast cancer cell line (MDA-MB-231) could abrogate estrogen induced migration-specific phenotypes in vitro. Furthermore, we found that knocking down UGDH mitigated estrogen stimulated primary tumor growth in vivo for both MCF7 macro and MDA-MB-231 mammary fat pad tumor models in mice. Thus, we found that UGDH regulates estrogen stimulated migratory phenotypes in both ER+ and ER- breast cancers in vitro and primary tumor growth in vivo. For this reason, UGDH and its associated pathways are promising targets for future drug development and small molecular targets in the treatment of both metastatic ER positive and ER negative breast cancers.
Citation Format: Meghan Price, Catherine Lavau, Cesar Baeta, Jovita Byemerwa, Suzanne Wardell, Olivia Brueckner, Debarati Mukherjee, Corinne Haynes, Annee Nguyen, Chingyi Chang, Donald McDonnell, C. Rory Goodwin. The role of UDP-6 glucose dehydrogenase (UGDH) in estrogen-mediated phenotypes in both estrogen receptor positive and estrogen receptor negative breast cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P131.
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Affiliation(s)
- Meghan Price
- 1Duke University School of Medicine, Durham, NC,
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Ding G, Osmundson E, Shinohara E, Newman N, Price M, Kirschner A. Skin Dose Distributions from Total Skin Electron Irradiation Therapy (TSET). Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rayn K, Lemus OD, Li F, Gallitto M, Padilla O, Price M, Savacool M, Kachnic L, Horowitz D. Trigger-Based Adaptive Planning to Reduce Bowel Dose in Patients Receiving Radiotherapy for Anal Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kang JH, Price M, Dalton T, Ramirez L, Fecci PE, Kamal AH, Johnson MO, Peters KB, Goodwin CR. Palliative Care Use for Critically Ill Patients With Brain Metastases. J Pain Symptom Manage 2021; 62:927-935. [PMID: 33992757 DOI: 10.1016/j.jpainsymman.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Critically ill patients with brain metastases (BM) face significant uncertainty regarding prognosis and survival and can benefit from Palliative care (PC). However, research regarding the role of PC in this population is lacking. OBJECTIVES We sought to compare BM patients admitted to an intensive care unit who received an inpatient PC consult (PC cohort) to those who did not (Usual Care, UC cohort). METHODS We performed a single-institution retrospective cohort analysis. Our outcome variables were mortality, time from intensive care unit admission to death, disposition, and change in code status. We also evaluated PC's role in complex medical decision making, symptom management and hospice education. RESULTS PC consult was placed in 31 of 118 (28%) of patients. The overall mortality rates were not statistically different (78.8% vs. 90.3%, P= 0.15, UC vs. PC cohort). Patients in the PC cohort had a shorter time to death, higher rate of death within 30 days of admission, increased rate of discharge to hospice, and increase percentage of code status change to "do not attempt resuscitation" during the admission. The primary services provided by PC were symptom management (n = 21, 67.7%) and assistance in complex medical decision making (n = 20, 64.5%). CONCLUSION In our patient cohort, PC is an underutilized service that can assist in complex medical decision making and symptom management of critically ill BM patients. Further prospective studies surveying patient, family and provider experiences could better inform the qualitative impact of PC in this unique patient population.
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Affiliation(s)
- Jennifer H Kang
- Department of Neurology, Duke University Medical Center, Durham, (J.H.K.) NC, USA.
| | - Meghan Price
- Duke University School of Medicine, Durham, (M.P., T.D.) NC, USA
| | - Tara Dalton
- Duke University School of Medicine, Durham, (M.P., T.D.) NC, USA
| | - Luis Ramirez
- Department of Neurosurgery, Duke University Medical Center, Durham, (L.R., P.E.F., M.O.J., K.B.P., C.R.G.) NC, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, (L.R., P.E.F., M.O.J., K.B.P., C.R.G.) NC, USA
| | - Arif H Kamal
- Department of Medicine, Duke University Medical Center, Durham, (A.H.K.) NC, USA
| | - Margaret O Johnson
- Department of Neurosurgery, Duke University Medical Center, Durham, (L.R., P.E.F., M.O.J., K.B.P., C.R.G.) NC, USA
| | - Katherine B Peters
- Department of Neurosurgery, Duke University Medical Center, Durham, (L.R., P.E.F., M.O.J., K.B.P., C.R.G.) NC, USA
| | - Courtney R Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, (L.R., P.E.F., M.O.J., K.B.P., C.R.G.) NC, USA
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Morgan R, Clamp A, Ryder W, Wheeler C, Buckley E, Truelove J, Murphy A, Hasan J, Mitchell C, Burghel G, White D, Price M, Bhaskar S, Shaw J, Dive C, Wallace A, O'Connor J, Rothwell D, Edmondson R, Jayson G. 731P Multi-maintenance olaparib in relapsed, platinum-sensitive BRCA-mutant high-grade serous ovarian carcinoma (MOLTO): A phase II feasibility study. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.1174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Foster N, Price M, Bettger JP, Goodwin CR, Erickson M. Objective Test Scores Throughout Orthopedic Surgery Residency Suggest Disparities in Training Experience. J Surg Educ 2021; 78:1400-1405. [PMID: 33454284 DOI: 10.1016/j.jsurg.2021.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Diversifying clinical residencies, particularly in fields that are historically dominated by majority male (M/M) cohorts, is critical to improve both the training experiences of residents and the overall physician workforce. Orthopedic surgery in particular has low numbers of females and under-represented minorities (F/URM) at all levels of training and practice. Despite efforts to increase its diversity, this field has become more homogeneous in recent years. To highlight potential barriers and disparate training environments that may contribute to this dynamic, we present 25 years' worth of institutional data on standardized exam performance throughout residency. We report that despite starting residency with standardized exam scores that were comparable to their M/M peers, F/URM orthopedic surgery residents performed progressively worse on Orthopaedic In-service Training Exams throughout residency and had lower first pass rates on the American Board of Orthopedic Surgery Part 1. Given these findings, we propose that disparate performance on standardized test scores throughout residency could identify trainees that may have different experiences that negatively impact their exam performance. Shedding light on these underlying disparities provides opportunities to find meaningful and sustained ways to develop a culture of diversity and inclusion. It may also allow for other programs to identify similar patterns within their training programs. Overall, we propose monitoring test performance on standardized exams throughout orthopedic surgery residency to identify potential disparities in training experience; further, we acknowledge that interventions to mitigate these disparities require a broad, systems wide approach and a firm institutional commitment to reducing bias and working toward sustainable change.
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Affiliation(s)
| | - Meghan Price
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, North Carolina
| | - Janet Prvu Bettger
- Department of Orthopedic Surgery, Division of Spine, Duke University Medical Center, Durham, North Carolina
| | - C Rory Goodwin
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, North Carolina
| | - Melissa Erickson
- Department of Orthopedic Surgery, Division of Spine, Duke University Medical Center, Durham, North Carolina.
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Cabell GH, Anjorin A, Price M, Biswas S, Doty JP. How the COVID-19 Pandemic Has Demonstrated a Need for Increased Leadership Education in Medicine. J Healthc Leadersh 2021; 13:137-138. [PMID: 34177282 PMCID: PMC8219661 DOI: 10.2147/jhl.s317847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/02/2021] [Indexed: 11/23/2022] Open
Abstract
The healthcare system in the United States has been taxed in various ways throughout the COVID-19 pandemic, stressing healthcare facilities to their breaking point. This has forced decision-makers in healthcare to make difficult choices, highlighting the need for effective leadership. However, there are little intentional leadership development curricula in medical education. Leadership skills can be taught and acquired similar to other skills in medical school, and we believe medical education institutions should cultivate these skills in their trainees. We hope that this will help inspire change in medical education curricula to intentionally teach and develop leadership skills in their students.
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Affiliation(s)
- Grant H Cabell
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Aderike Anjorin
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Meghan Price
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Sonali Biswas
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Joseph P Doty
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
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Sheriff I, Lima A, Tseng O, Aviña A, Dawes M, Barber CEH, Esdaile J, Shojania K, Koehn CL, Hoens A, Mcquitty S, Singh S, Yap J, Page D, Kur J, Hobson B, Price M, Lacaille D. POS0303 PREVENTION OF CHRONIC DISEASES DUE TO INFLAMMATION IN INFLAMMATORY ARTHRITIS: RESULTS OF A DELPHI PROCESS TO SELECT CARE RECOMMENDATIONS FOR AN ELECTRONIC MEDICAL RECORD (EMR) INTERVENTION. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Inflammatory arthritis (IA) predisposes patients to several chronic conditions including cardiovascular diseases (CVD), diabetes (DM), osteoporosis (OP) and infections, likely due to systemic effects of inflammation. Studies have found that patients with IA often receive suboptimal care for screening and managing these conditions.Objectives:This is the first phase of a study which will develop and pilot test automated EMR reminders for family physicians. The reminders will prompt family physicians to screen for and address risk factors for these conditions. We conducted a Delphi process to select care recommendations to be addressed by the EMR reminders.Methods:We conducted a review of current BC, Canadian and international guidelines for screening and addressing risk factors for CVD, DM, OP and infection. A list of 22 care recommendations, including their level of evidence and risks/benefits of implementation, was reviewed by a panel of six family physicians, three rheumatologists and three IA patients, in a three-round online modified Delphi process. Panelists rated each care recommendation, using 9-point scales, on 1) their clinical importance, 2) their likelihood of improving outcomes, and 3) implementation feasibility. Results were discussed in an online forum. Panelists then rated slightly revised care recommendations, modified based on feedback from the discussion. Care recommendations were retained if the median rating was ≥7 with no disagreement as defined by the RAND/UCLA Method handbook.Results:A list of 15 care recommendations was selected by the Delphi process for EMR integration, including recommendations that address CVD risk assessment (1), hypertension screening (1), DM screening (2), fracture risk assessment (1), BMD testing (1), osteoporosis prevention (1) and treatment (1) with bisphosphonates, preventing infections through immunization (2), minimizing steroids (1) and hepatitis screening (1), screening for hydroxychloroquine retinal toxicity (1), and counselling for lifestyle modifications (2). We excluded 7 recommendations which addressed lipid testing (1), BMD testing in steroid users (1), immunizations (2), weight management (1), and DMARD laboratory test monitoring (2). Recommendations were excluded on the basis of importance (1) or feasibility (6).Conclusion:The results of the Delphi process will inform the development of reminders, integrated in EMRs, that will support family physicians in their efforts to engage IA patients in addressing risk factors for chronic diseases related to inflammation. We hope to improve the prevention of these diseases, which represent an important cause of morbidity and mortality for people with inflammatory arthritis.Acknowledgements:Iman Sheriff’s work on this project was funded by the CRA summer studentship programme. Dr. Lacaille is supported by the Mary Pack Chair in Arthritis Research from UBC and The Arthritis Society of Canada. Thank you to all who participated in the Delphi survey.Disclosure of Interests:None declared
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Öngür D, Price M, Malekani M, Heinrich H, Prete S, Singer DE, Lewis E, Hsu J. Creatine kinase levels among asymptomatic patients with severe mental illnesses: A complex baseline for an important clinical biomarker. Schizophr Res 2021; 232:85-86. [PMID: 34023581 DOI: 10.1016/j.schres.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Affiliation(s)
- D Öngür
- Harvard Medical School, Boston, MA, United States of America; McLean Hospital, Belmont, MA, United States of America.
| | - M Price
- Harvard Medical School, Boston, MA, United States of America; Massachusetts General Hospital, Boston, MA, United States of America
| | - M Malekani
- McLean Hospital, Belmont, MA, United States of America
| | - H Heinrich
- McLean Hospital, Belmont, MA, United States of America
| | - S Prete
- McLean Hospital, Belmont, MA, United States of America
| | - D E Singer
- Harvard Medical School, Boston, MA, United States of America; Massachusetts General Hospital, Boston, MA, United States of America
| | - E Lewis
- Harvard Medical School, Boston, MA, United States of America; Brigham and Women's Hospital, Boston, MA, United States of America
| | - J Hsu
- Harvard Medical School, Boston, MA, United States of America; Massachusetts General Hospital, Boston, MA, United States of America
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Price M, Doshi P, Kim JY. Caring Outside the Clinic. Acad Med 2021; 96:782-783. [PMID: 33538476 PMCID: PMC8140619 DOI: 10.1097/acm.0000000000003963] [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: 06/12/2023]
Affiliation(s)
- Meghan Price
- Fourth-year medical student, Duke University School of Medicine, Durham, North Carolina; ; ORCID: https://orcid.org/0000-0002-2683-9758
| | - Pratik Doshi
- Fourth-year medical student, Duke University School of Medicine, Durham, North Carolina; ORCID: https://orcid.org/0000-0002-3282-9687
| | - Ju Young Kim
- Fourth-year medical student, Duke University School of Medicine, Durham, North Carolina; ORCID: https://orcid.org/0000-0003-3936-3733
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Price M, Vashistha V, Winski D, Kelley M, Bitting R, Montgomery RB. Real-world outcomes among prostate cancer patients with BRCA2 gene variants compared to variants in other homologous DNA repair genes. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e17033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17033 Background: PARP inhibitors (PARPis) were approved by the FDA for the treatment of advanced prostate cancer (PC) among patients (pts) harboring mutations in genes responsible for homologous DNA repair. Increasing evidence has suggested that pts with BRCA2 gene alterations may derive the most benefit from these drugs. Study objectives were to evaluate real-world treatment outcomes among Veterans prescribed PARPis for PC and to compare outcomes between pts with BRCA2 gene variants and those with variants in other homologous DNA repair genes. Methods: The U.S. Department of Veterans Affairs (VA) National Precision Oncology Program database was reviewed to identify PC pts who successfully underwent tumor DNA sequencing and were prescribed olaparib, rucaparib, niraparib or talazaporib prior to FDA approval for PARPi use in PC (May 15, 2020). Only pts who received a PARPi for > 4 weeks were included in outcome assessments The VA’s Corporate Data Warehouse was reviewed to obtain clinical and disease characteristics, laboratory and imaging reports, and treatments administered. Assessed outcomes included PSA30, defined as the percentage of pts achieving 30% reduction in prostate-specific antigen (PSA) level, and composite progression-free survival (PFS), which included time to radiographic progression per RECIST criteria, discontinuation of therapy, and/or death. Pts who discontinued therapy due to toxicity were censored for PFS analyses. PSA30 and PFS were compared between pts bearing BRCA2 gene variants and those with variants in other homologous DNA repair genes using t-testing and log-rank testing, respectively. Results: 48 pts were prescribed a PARPi for PC; 43 (89.6%) received therapy for > 4 weeks. BRCA2 gene variants (43.8%) were most commonly observed followed by ATM (23.0%) and BRCA1 (16.7%). Forty-two pts (87.5%) received prior systemic therapy beyond androgen deprivation. Forty (83.3%) pts received olaparib, 6 (12.5%) received rucaparib, and 2 (4.2%) received both. Eleven (22.9%) discontinued therapy due to toxicity, with anemia being most common toxicity. Of the 43 pts treated for > 4 weeks, pts with BRCA2 variants had a higher rate of PSA30 than those without (47.9% vs. 4.5%; p = 0.004). The median PFS for all pts was 4.0 months. Pts with BRCA2 gene variants had longer PFS than those without BRCA2 gene variants (7.2 vs 3.3 months; p = 0.037). Pts with BRCA2 gene variants also had longer PFS than those with BRCA1 variants (7.2 vs 3.3, p = 0.031). No difference was observed in PFS between those with BRCA2 variants and those with ATM variants ( p = 0.51). Conclusions: Approximately one-quarter of PC pts with variants in homologous DNA repair genes treated with PARPis achieve a 30% reduction in PSA, and the median PFS is 4 months. Pts harboring BRCA2 gene variants have a significantly higher rate of PSA30 and a longer PFS than those with variants in other homologous DNA repair genes.
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De la Garza Ramos R, Park C, McCray E, Price M, Wang TY, Dalton T, Baëta C, Erickson MM, Foster N, Pennington Z, Shin JH, Sciubba DM, Than KD, Karikari IO, Shaffrey CI, Abd-El-Barr MM, Yassari R, Goodwin CR. Interhospital transfer status for spinal metastasis patients in the United States is associated with more severe clinical presentations and higher rates of inpatient complications. Neurosurg Focus 2021; 50:E4. [PMID: 33932934 DOI: 10.3171/2021.2.focus201085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD. METHODS The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes. RESULTS Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18-1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16-1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46-1.98, p < 0.001), with no significant difference in inpatient mortality rates. CONCLUSIONS Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.
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Affiliation(s)
| | | | | | | | | | | | | | - Melissa M Erickson
- 3Orthopedic Surgery, Spine Division, Duke University Medical Center, Durham, North Carolina
| | | | - Zach Pennington
- 5Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - John H Shin
- 6Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel M Sciubba
- 5Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | | | | | | | | | - Reza Yassari
- 2Department of Neurosurgery, Montefiore Medical Center, New York, New York
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Vashistha V, Armstrong J, Winski D, Poonnen PJ, Hintze B, Price M, Snowdon JL, Weeraratne D, Brotman D, Jackson GP, Kelley MJ. Barriers to Prescribing Targeted Therapies for Patients With NSCLC With Highly Actionable Gene Variants in the Veterans Affairs National Precision Oncology Program. JCO Oncol Pract 2021; 17:e1012-e1020. [PMID: 33780286 DOI: 10.1200/op.20.00703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Next-generation sequencing (NGS) gene panels are frequently completed for patients with advanced non-small-cell lung cancer (NSCLC). Patients with highly actionable gene variants have improved outcomes and reduced toxicities with the use of corresponding targeted agents. We sought to identify barriers to targeted agent use within the Veterans Health Affairs' National Precision Oncology Program (NPOP). METHODS A retrospective evaluation of patients with NSCLC who underwent NGS multigene panels through NPOP between July 2015 and February 2019 was conducted. Patients who were assigned level 1 or 2A evidence for oncogenic gene variants by an artificial intelligence offering (IBM Watson for Genomics [WfG]) and NPOP staff were selected. Antineoplastic drug prescriptions and provider notes were reviewed. Reasons for withholding targeted treatments were categorized. RESULTS Of 1,749 patients with NSCLC who successfully underwent NGS gene panel testing, 112 (6.4%) patients were assigned level 1 and/or 2A evidence for available targeted treatments by WfG and NPOP staff. All highly actionable gene variants were within ALK, BRAF, EGFR, ERBB2, MET, RET, and ROS1. Of these, 36 (32.1%) patients were not prescribed targeted agents. The three most common reasons were (1) patient did not carry a diagnosis of metastatic disease (33.3%), (2) treating provider did not comment on the NGS results (25.0%), and (3) provider felt that patient could not tolerate therapy (19.4%). No patients were denied access to level 1 or 2A targeted drugs because of rejection of a nonformulary drug request. CONCLUSION A substantial minority of patients with NSCLC bearing highly actionable gene variants are not prescribed targeted agents. Further provider- and pathologist-directed educational efforts and implementation of health informatics systems to provide real-time decision support for test ordering and interpretation are needed.
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Affiliation(s)
- Vishal Vashistha
- Raymond G. Murphy New Mexico Veterans Affairs Medical Center, Section of Hematology/Oncology, Albuquerque, NM.,Durham Veterans Affairs Medical Center, Division of Hematology and Oncology, Durham, NC
| | - Jenna Armstrong
- National Oncology Program Office, Department of Veterans Affairs, Durham, NC.,Duke University School of Medicine, Durham, NC
| | - David Winski
- Veterans Affairs Boston Healthcare System, Jamaica Plan Campus, Boston, MA
| | - Pradeep J Poonnen
- Durham Veterans Affairs Medical Center, Division of Hematology and Oncology, Durham, NC.,National Oncology Program Office, Department of Veterans Affairs, Durham, NC.,Duke University School of Medicine, Durham, NC.,Duke University Health System, Divisions of Medical Oncology, Hematology, Hematologic Malignancies and Cell Therapeutics, Durham, NC
| | | | - Meghan Price
- Durham Veterans Affairs Medical Center, Division of Hematology and Oncology, Durham, NC.,Duke University School of Medicine, Durham, NC
| | | | | | | | - Gretchen P Jackson
- IBM Watson Health, Cambridge, MA.,Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN
| | - Michael J Kelley
- Durham Veterans Affairs Medical Center, Division of Hematology and Oncology, Durham, NC.,National Oncology Program Office, Department of Veterans Affairs, Durham, NC.,Duke University School of Medicine, Durham, NC.,Duke University Health System, Divisions of Medical Oncology, Hematology, Hematologic Malignancies and Cell Therapeutics, Durham, NC
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Price M, Howell EP, Dalton T, Ramirez L, Howell C, Williamson T, Fecci PE, Anders CK, Check DK, Kamal AH, Goodwin CR. Inpatient palliative care utilization for patients with brain metastases. Neurooncol Pract 2021; 8:441-450. [PMID: 34277022 DOI: 10.1093/nop/npab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. Methods We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. Results We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001). Conclusions In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.
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Affiliation(s)
- Meghan Price
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth P Howell
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ramirez
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Claire Howell
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Kye J, Bagsic S, Kuo R, Cohoon T, Bhavnani S, Almeida S, Price M, Robinson A, Gonzalez J, Wesbey G. Gender interaction effect on coronary lumen volume to mass ratio after administration of sublingual GTN powder compared to tablet in coronary computed tomography angiography (CCTA). Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.238] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Nitroglycerin (GTN) results in improved CCTA image quality and diagnostic accuracy due to vasodilation and improved contrast density. Although studies have shown that sublingual (SL) GTN spray has greater vasodilation and faster onset and duration of action compared to SL tablet, it is not commonly used due to cost. The comparative efficacy of SL GTN powder in CCTA is unknown.
Purpose
The purpose of this study is to determine whether SL GTN powder can increase the coronary lumen volume (V) and the coronary lumen volume to left myocardial mass ratio (V/M) compared to SL GTN tablet.
Methods
34 patients (17 females) with 0.8 mg SL GTN powder and 34 patients (17 females) with 0.8 mg SL GTN tablet administration were included in this retrospective case-control study. GTN was given 5 minutes pre-CCTA on a 256 slice single-heartbeat CT. Inclusion criteria: CAD-RADS 0 or 1, precontrast LM + LAD AJ-130 CAC < 100, heart rate less than 75, phase of the cardiac cycle diastole, successful motion correction, Likert score 4 or 5, right- or co-dominance. The primary outcome assessed was left main plus left anterior descending (LM + LAD) V between GTN powder vs tablet. The secondary outcomes were LM + LAD V divided by 1) length of LM + LAD (derived mean area, A), and 2) M (V/M). The outcomes were measured by blinded PI with 17 yrs CCTA experience on GE workstation, 2020 version. Categorical variables were compared by Chi-Squared tests and continuous variables were compared between powder and tablet groups by unpaired t-tests if normally distributed, and Mann-Whitney U tests otherwise. Exploratory outcome analyses tested route of administration by sex interactions and main effects by Two-Way ANOVA’s. Further covariate-adjusted analyses were conducted using multiple linear regression models.
Results
Baseline characteristics were similar between powder and tablet administration. No statistically significant difference in median V, LM + LAD derived A , or median V/M was observed. A sex main effect demonstrated that females had significantly smaller V (630.6 mm3 vs 951.7 mm3, p< 0.0001) and A (4.2 mm2 vs 6.4 mm2, p< 0.0001) compared to males. These V and A sex differences were also observed when BMI or weight were included as covariates. When V and A were normalized by M, both revealed sex interactions depending on formulation. While males had higher normalized V and A in powder vs tablet (p < 0.04), females had the opposite with higher normalized V and A with tablet compared to powder (p < 0.04).
Conclusions
SL administration of the GTN powder 5 minutes before CCTA did not result in greater vasodilatory effect compared to the GTN tablet. However, gender interaction effects were observed, with greater V/M and A/M ratio in males with powder and greater V/M and A/M in women with tablet. These results suggest a potential differential gender effect based on the formulation of GTN. Prospective studies are warranted to evaluate these findings.
Abstract Figure. LM + LAD Lumen Volume to LV Mass by Sex
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Affiliation(s)
- J Kye
- Scripps Prebys Cardiovascular Institute, Pharmacy, La Jolla, United States of America
| | - S Bagsic
- Scripps Hub Academic Research Core , Scripps Whittier Diabetes Institute, La Jolla, United States of America
| | - R Kuo
- Scripps Prebys Cardiovascular Institute, Pharmacy, La Jolla, United States of America
| | - T Cohoon
- Scripps Prebys Cardiovascular Institute, Department of Medicine, La Jolla, United States of America
| | - S Bhavnani
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases, La Jolla, United States of America
| | - S Almeida
- HCA Midwest Heart and Vascular Specialists, Cardiology, Kansas City, United States of America
| | - M Price
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases, La Jolla, United States of America
| | - A Robinson
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases, La Jolla, United States of America
| | - J Gonzalez
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases and Radiology, La Jolla, United States of America
| | - G Wesbey
- Scripps Prebys Cardiovascular Institute, Scripps Clinic Medical Group, Division of Cardiovascular Diseases and Radiology, La Jolla, United States of America
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Price M, Goodwin JC, De la Garza Ramos R, Baëta C, Dalton T, McCray E, Yassari R, Karikari I, Abd-El-Barr M, Goodwin AN, Rory Goodwin C. Gender disparities in clinical presentation, treatment, and outcomes in metastatic spine disease. Cancer Epidemiol 2021; 70:101856. [PMID: 33348243 DOI: 10.1016/j.canep.2020.101856] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/10/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence of metastatic spine disease (MSD) is increasing among cancer patients. Given the poor outcomes and high rates of morbidity associated with MSD, it is important to determine demographic factors that could impact interventions and outcomes for this patient population. The objectives of this study were to compare in-hospital mortality and complication rates, clinical presentation, and interventions between female and male patients diagnosed with MSD. METHODS Patient data were collected from the United States National Inpatient Sample (NIS) database from the years 2012-2014. Descriptive statistics were used to compare data from 51,800 cases; subsequently, multivariable logistic regression analyses were conducted to assess the effect of gender on outcomes. RESULTS Males had significantly higher rates of in-hospital mortality (OR 1.30; 95 % CI 1.09-1.56, p = 0.004) and were more likely to have received surgical intervention than females (OR 1.34; 95 % CI 1.16-1.55, p < 0.001). Additionally, female patients were more likely to present with vertebral compression fracture (p < 0.001), while metastatic spinal cord compression (MSCC) and paralysis were more common in male patients (p < 0.001). There was no significant difference in rates of in-hospital complications between female and male patients. CONCLUSION Given the significant differences in mortality, disease course, treatment, and in-hospital complications between female and male patients diagnosed with MSD, additional prospective studies are necessary to understand how to meaningfully incorporate these differences into clinical care and prognostication going forward.
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Affiliation(s)
- Meghan Price
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Jessica C Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Rafael De la Garza Ramos
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - César Baëta
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Tara Dalton
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Edwin McCray
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Reza Yassari
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Isaac Karikari
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Andrea N Goodwin
- Department of Sociology, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States.
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Wang TY, Price M, Mehta VA, Bergin SM, Sankey EW, Foster N, Erickson M, Gupta DK, Gottfried ON, Karikari IO, Than KD, Goodwin CR, Shaffrey CI, Abd-El-Barr MM. Preoperative optimization for patients undergoing elective spine surgery. Clin Neurol Neurosurg 2021; 202:106445. [PMID: 33454498 DOI: 10.1016/j.clineuro.2020.106445] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/21/2020] [Accepted: 12/17/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Timothy Y Wang
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Meghan Price
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Vikram A Mehta
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Stephen M Bergin
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Eric W Sankey
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Norah Foster
- Department of Orthopedic Surgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Melissa Erickson
- Department of Orthopedic Surgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Dhanesh K Gupta
- Department of Anesthesiology, Division of Neuroanesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Oren N Gottfried
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Isaac O Karikari
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Khoi D Than
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA
| | - Muhammad M Abd-El-Barr
- Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA.
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Price M, Howell EP, Dalton T, Ramirez L, Williamson T, Painter B, Check D, Kamal A, Goodwin CR. The Impact of Sociodemographic Factors on Inpatient Palliative Care Consultation for Patients with Brain and Spine Metastases. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Noiman A, Macalino G, Won SH, Byrne M, Deiss R, Haw NJ, Ganesan A, Okulicz JF, Schofield C, Lalani T, Maves RC, Wang X, Agan BK, Achatz E, Bradley W, Merritt S, Merritt T, Olsen C, Rhodes C, Sjoberg T, Baker C, Chambers S, Colombo R, Ferguson T, Kunz A, Powers J, Tramont E, Banks S, Illinik L, Kronmann K, Tant R, Cammarata S, Curry J, Kirkland N, Utz G, Price M, Aronson N, Burgess T, Chu X, Estupigan C, Hsieh, Parmelee E, Tribble D, Won S, Ake J, Crowell T, Peel S, Barahona I, Blaylock J, Decker C, Ressner R. Sexual Risk Behaviors Associated with Sexually Transmitted Infections in a US Military Population Living with HIV After the Repeal of "Don't Ask, Don't Tell". AIDS Patient Care STDS 2020; 34:523-533. [PMID: 33296270 DOI: 10.1089/apc.2020.0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Risk behaviors associated with sexually transmitted infections (STIs) among people living with HIV (PLWH) have not been well characterized in the US military. We identified risk behaviors associated with a new STI in this population after the repeal of "Don't Ask, Don't Tell." US Military HIV Natural History Study participants who completed the risk behavior questionnaire (RBQ) between 2014 and 2017 and had at least 1 year of follow-up were included (n = 1589). Logistic regression identified behaviors associated with incident STI in the year following RBQ completion. Overall, 18.9% acquired an STI and 52.7% reported condom use at last sexual encounter. Compared with those with no new sex partners, participants with between one and four or five or more new partners were 1.71 [1.25-2.35] and 6.12 [3.47-10.79] times more likely to get an STI, respectively. Individuals reporting low or medium/high perceived risk of STI were 1.83 [1.23-2.72] and 2.65 [1.70-4.15] times more likely to acquire a new STI than those reporting no perceived risk, respectively. Participants who preferred not to answer about sexual preference, number of new partners, or perceived STI risk were also more likely to acquire a new STI. Our study illustrates that despite regular access to health care and accurate perceptions of risk, rates of STI among PLWH remain high in the US military setting, as in others. Given the potential individual and public health consequences of STI coinfection after HIV, more work is needed to assess interventions aimed at sexual behavior change for PLWH.
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Affiliation(s)
- Adi Noiman
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | | | - Seung Hyun Won
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Morgan Byrne
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Robert Deiss
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | | | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- Division of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jason F. Okulicz
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Infectious Disease Service, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Christina Schofield
- Division of Infectious Diseases, Madigan Army Medical Center, Joint Base Lewis McChord, Washington, District of Columbia, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Ryan C. Maves
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center San Diego, San Diego, California, USA
| | - Xun Wang
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Brian K. Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
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Yock A, Ahmed M, Newman N, Ayala-Peacock D, Chakravarthy A, Price M. Dosimetric Impact and Required Clinician Time of Online Adaptive Radiotherapy Using a Newly Commercially-Available, CBCT-Based Adaptive Treatment System. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mehta VA, Van Belleghem F, Price M, Jaykel M, Ramirez L, Goodwin J, Wang TY, Erickson MM, Than KD, Gupta DK, Abd-El-Barr MM, Karikari IO, Shaffrey CI, Rory Goodwin C. Hematocrit as a predictor of preoperative transfusion-associated complications in spine surgery: A NSQIP study. Clin Neurol Neurosurg 2020; 200:106322. [PMID: 33127163 DOI: 10.1016/j.clineuro.2020.106322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND CONTEXT Preoperative optimization of medical comorbidities prior to spinal surgery is becoming an increasingly important intervention in decreasing postoperative complications and ensuring a satisfactory postoperative course. The treatment of preoperative anemia is based on guidelines made by the American College of Cardiology (ACC), which recommends packed red blood cell transfusion when hematocrit is less than 21% in patients without cardiovascular disease and 24% in patients with cardiovascular disease. The literature has yet to quantify the risk profile associated with preoperative pRBC transfusion. PURPOSE To determine the incidence of complications following preoperative pRBC transfusion in a cohort of patients undergoing spine surgery. STUDY DESIGN Retrospective review of a national surgical database. PATIENT SAMPLE The national surgical quality improvement program database OUTCOME NEASURES: Postoperative physiologic complications after a preoperative transfusion. Complications were defined as the occurrence of any DVT, PE, stroke, cardiac arrest, myocardial infarction, longer length of stay, need for mechanical ventilation greater than 48 h, surgical site infections, sepsis, urinary tract infections, pneumonia, or higher 30-day mortality. METHODS The national surgical quality improvement program database was queried, and patients were included if they had any type of spine surgery and had a preoperative transfusion. RESULTS Preoperative pRBC transfusion was found to be protective against complications when the hematocrit was less than 20% and associated with more complications when the hematocrit was higher than 20%. In patients with a hematocrit higher than 20%, pRBC transfusion was associated with longer lengths of stay, and higher rates of ventilator dependency greater than 48 h, pneumonia, and 30-day mortality. CONCLUSION This is the first study to identify an inflection point in determining when a preoperative pRBC transfusion may be protective or may contribute to complications. Further studies are needed to be conducted to stratify by the prevalence of cardiovascular disease.
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Affiliation(s)
- Vikram A Mehta
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
| | | | - Meghan Price
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew Jaykel
- Division of Spine, Department of Orthopedics, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ramirez
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jessica Goodwin
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Timothy Y Wang
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Melissa M Erickson
- Division of Spine, Department of Orthopedics, Duke University Medical Center, Durham, North Carolina, USA
| | - Khoi D Than
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Dhanesh K Gupta
- Division of Neuroanesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Muhammad M Abd-El-Barr
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Isaac O Karikari
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher I Shaffrey
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - C Rory Goodwin
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Wong ST, Katz A, Williamson T, Singer A, Peterson S, Taylor C, Price M, McCracken R, Thandi M. Can Linked Electronic Medical Record and Administrative Data Help Us Identify Those Living with Frailty? Int J Popul Data Sci 2020; 5:1343. [PMID: 33644409 PMCID: PMC7893852 DOI: 10.23889/ijpds.v5i1.1343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction Frailty is a complex condition that affects many aspects of patients’ wellbeing and health outcomes. Objectives We used available Electronic Medical Record (EMR) and administrative data to determine definitions of frailty. We also examined whether there were differences in demographics or health conditions among those identified as frail in either the EMR or administrative data. Methods EMR and administrative data were linked in British Columbia (BC) and Manitoba (MB) to identify those aged 65 years and older who were frail. The EMR data were obtained from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and the administrative data (e.g. billing, hospitalizations) was obtained from Population Data BC and the Manitoba Population Research Data Repository. Sociodemographic characteristics, risk factors, prescribed medications, use and costs of healthcare are described for those identified as frail. Results Sociodemographic and utilization differences were found among those identified as frail from the EMR compared to those in the administrative data. Among those who were >65 years, who had a record in both EMR and administrative data, 5%-8% (n=191 of 3,553, BC; n=2,396 of 29,382, MB) were identified as frail. There was a higher likelihood of being frail with increasing age and being a woman. In BC and MB, those identified as frail in both data sources have approximately twice the number of contacts with primary care (n=20 vs. n=10) and more days in hospital (n=7.2 vs. n=1.9 in BC; n=9.8 vs. n=2.8 in MB) compared to those who are not frail; 27% (BC) and 14% (MB) of those identified as frail in 2014 died in 2015. Conclusions Identifying frailty using EMR data is particularly challenging because many functional deficits are not routinely recorded in structured data fields. Our results suggest frailty can be captured along a continuum using both EMR and administrative data.
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Affiliation(s)
- S T Wong
- University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5
| | - A Katz
- University of Manitoba, 408-727 McDermot Ave, Winnipeg, Mb, R3E 3P5
| | - T Williamson
- University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1
| | - A Singer
- University of Manitoba, 408-727 McDermot Ave, Winnipeg, Mb, R3E 3P5
| | - S Peterson
- University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5
| | - C Taylor
- University of Manitoba, 408-727 McDermot Ave, Winnipeg, Mb, R3E 3P5
| | - M Price
- University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5
| | - R McCracken
- University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5
| | - M Thandi
- University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5
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Dass D, Fung V, Price M. The Impact of the ACA Medicaid Fee Bump on Pediatricians’ Participation in Medicaid: Evidence from Massachusetts. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- D. Dass
- Massachusetts General Hospital Boston MA United States
| | - V. Fung
- Harvard Medical School Boston MA United States
| | - M. Price
- Massachusetts General Hospital Boston MA United States
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Yuan Y, Price M, Thomas K, Van Houtven C, Garrido M. Veteran‐Directed Care Recipients Living in Rural Areas Have Fewer Incidents of Potentially Avoidable Health care Use Compared to Recipients of Other Purchased Care Services. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Y. Yuan
- PEPReC, Boston VA Healthcare System Boston MA United States
- Boston University School of Public Health Boston MA United States
| | - M. Price
- PEPReC, Boston VA Healthcare System Boston MA United States
| | - K. Thomas
- Brown University School of Public Health Providence RI United States
- Providence VA Medical Center Providence RI United States
| | - C. Van Houtven
- Durham Veterans Affairs Health Care System Durham NC United States
- Duke University Durham NC United States
| | - M. Garrido
- PEPReC, Boston VA Healthcare System Boston MA United States
- Boston University School of Public Health Boston MA United States
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Hill M, Puddiford M, Talbot C, Price M. The validity and reproducibility of perceptually regulated exercise responses during combined arm + leg cycling. Eur J Appl Physiol 2020; 120:2203-2212. [PMID: 32710290 DOI: 10.1007/s00421-020-04444-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Rating of perceived exertion (RPE) is a reliable method of assessing exercise intensity during isolated arm and leg cycling. The aim of this study was to assess the validity and reproducibility of perceptually regulated exercise responses during combined arm + leg cycling. METHODS Twelve males (age; 24.6 ± 5.3 years, height; 1.81 ± 0.7 m, mass; 83.1 ± 8.4 kg) initially undertook incremental exercise tests to volitional exhaustion for arm cycling (133 ± 14 W) and leg cycling (253 ± 32 W). On three subsequent occasions, participants undertook combined arm + leg cycling trials using two modified Monark ergometers involving three bouts of exercise at RPE 9, 13 and 17, in that order. Heart rate (HR), oxygen uptake ([Formula: see text]) and pulmonary ventilation ([Formula: see text]) were recorded continuously. RESULTS No significant differences were observed for HR (P = 0.086), [Formula: see text] (P = 0.525) and [Formula: see text] (P = 0.899) between trials, whilst significant differences were observed between each level of RPE (all P < 0.001). For % peak [Formula: see text], the ICC increased with successive trials for all RPE levels. For % maximal HR the ICC generally decreased with successive trials. CONCLUSION RPE can be used as a reliable frame of reference for the production of exercise intensity during combined arm + leg cycling without any formal familiarisation. Since combined arm + leg cycling elicits a greater energy expenditure than arm or leg work alone, this novel mode of non-weight bearing exercise might prove effective for aerobic conditioning and weight control.
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Affiliation(s)
- M Hill
- Centre for Sport, Exercise and Life Sciences, School of Life Sciences, Coventry University, Whitefriars Street, Coventry, CV1 2DS, UK.
| | - M Puddiford
- Sport, Exercise and Life Sciences, Faculty of Health and Society, University of Northampton, Northamptonshire, UK
| | - C Talbot
- Sport, Exercise and Life Sciences, Faculty of Health and Society, University of Northampton, Northamptonshire, UK
| | - M Price
- Centre for Sport, Exercise and Life Sciences, School of Life Sciences, Coventry University, Whitefriars Street, Coventry, CV1 2DS, UK
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Riordan PA, Price M, Robbins-Welty GA, Leff V, Jones CA, Prigerson HG, Galanos A. Top Ten Tips Palliative Care Clinicians Should Know About Bereavement and Grief. J Palliat Med 2020; 23:1098-1103. [PMID: 32614632 DOI: 10.1089/jpm.2020.0341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Palliative care (PC) focuses on caring for the whole person, from birth to death, while managing symptoms and helping to navigate medical complexities. Care does not stop at the time of death, however, as assisting patients, families, and fellow clinicians through grief and bereavement is within PC's purview. Unfortunately, many clinicians feel unprepared to deal with these topics. In this article, PC and hospice clinicians define and explain bereavement, distinguish normative grief from pathological grief, offer psychometrically sound scales to screen and follow those suffering from grief, and discuss the interaction between grief and bereavement and the physical and mental health of those who are left behind after the death of a loved one.
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Affiliation(s)
- Paul A Riordan
- Division of Psychiatry, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Meghan Price
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg A Robbins-Welty
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Victoria Leff
- Duke HomeCare and Hospice, Durham, North Carolina, USA
| | - Christopher A Jones
- Department of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly G Prigerson
- Department of Medicine and Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA
| | - Anthony Galanos
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Palliative Care, Duke University School of Medicine, Durham, North Carolina, USA
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Das E, Epstein J, Gentry R, Mills D, Poolovadoo Y, Ward N, Bull K, Cole A, Hack J, Khawari S, Lake C, Mandishona T, Perry R, Sleight S, Sultan S, Thornton T, Williams S, Arif T, Castle A, Chauhan P, Chesner R, Eilon T, Kamarajah S, Kambasha C, Lock L, Loka T, Mohammad F, Motahariasl S, Roper L, Sadhra SS, Sheikh A, Toma T, Wadood Q, Yip J, Ainger E, Busti S, Cunliffe L, Flamini T, Gaffing S, Moorcroft C, Peter M, Simpson L, Stokes E, Stott G, Wilson J, York J, Yousaf A, Borakati A, Brown M, Goaman A, Hodgson B, Ijeomah A, Iroegbu U, Kaur G, Lowe C, Mahmood S, Sattar Z, Sen P, Szuman A, Abbas N, Al-Ausi M, Anto N, Bhome R, Eccles L, Elliott J, Hughes EJ, Jones A, Karunatilleke AS, Knight JS, Manson CCF, Mekhail I, Michaels L, Noton TM, Okenyi E, Reeves T, Yasin IH, Banfield DA, Harris R, Lim D, Mason-Apps C, Roe T, Sandhu J, Shafiq N, Stickler E, Tam JP, Williams LM, Ainsworth P, Boualbanat Y, Doull C, Egan E, Evans L, Hassanin K, Ninkovic-Hall G, Odunlami W, Shergill M, Traish M, Cummings D, Kershaw S, Ong J, Reid F, Toellner H, Alwandi A, Amer M, George D, Haynes K, Hughes K, Peakall L, Premakumar Y, Punjabi N, Ramwell A, Sawkins H, Ashwood J, Baker A, Baron C, Bhide I, Blake E, De Cates C, Esmail R, Hosamuddin H, Kapp J, Nguru N, Raja M, Thomson F, Ahmed H, Aishwarya G, Al-Huneidi R, Ali S, Aziz R, Burke D, Clarke B, Kausar A, Maskill D, Mecia L, Myers L, Smith ACD, Walker G, Wroe N, Donohoe C, Gibbons D, Jordan P, Keogh C, Kiely A, Lalor P, McCrohan M, Powell C, Foley MP, Reynolds J, Silke E, Thorpe O, Kong JTH, White C, Ali Q, Dalrymple J, Ge Y, Khan H, Luo RS, Paine H, Paraskeva B, Parker L, Pillai K, Salciccioli J, Selvadurai S, Sonagara V, Springford LR, Tan L, Appleton S, Leadholm N, Zhang Y, Ahern D, Cotter M, Cremen S, Durrigan T, Flack V, Hrvacic N, Jones H, Jong B, Keane K, O'Connell PR, O'sullivan J, Pek G, Shirazi S, Barker C, Brown A, Carr W, Chen Y, Guillotte C, Harte J, Kokayi A, Lau K, McFarlane S, Morrison S, Broad J, Kenefick N, Makanji D, Printz V, Saito R, Thomas O, Breen H, Kirk S, Kong CH, O'Kane A, Eddama M, Engledow A, Freeman SK, Frost A, Goh C, Lee G, Poonawala R, Suri A, Taribagil P, Brown H, Christie S, Dean S, Gravell R, Haywood E, Holt F, Pilsworth E, Rabiu R, Roscoe HW, Shergill S, Sriram A, Sureshkumar A, Tan LC, Tanna A, Vakharia A, Bhullar S, Brannick S, Dunne E, Frere M, Kerin M, Kumar KM, Pratumsuwan T, Quek R, Salman M, Van Den Berg N, Wong C, Ahluwalia J, Bagga R, Borg CM, Calabria C, Draper A, Farwana M, Joyce H, Khan A, Mazza M, Pankin G, Sait MS, Sandhu N, Virani N, Wong J, Woodhams K, Croghan N, Ghag S, Hogg G, Ismail O, John N, Nadeem K, Naqi M, Noe SM, Sharma A, Tan S, Begum F, Best R, Collishaw A, Glasbey J, Golding D, Gwilym B, Harrison P, Jackman T, Lewis N, Luk YL, Porter T, Potluri S, Stechman M, Tate S, Thomas D, Walford B, Auld F, Bleakley A, Johnston S, Jones C, Khaw J, Milne S, O'Neill S, Singh KKR, Smith R, Swan A, Thorley N, Yalamarthi S, Yin ZD, Ali A, Balian V, Bana R, Clark K, Livesey C, McLachlan G, Mohammad M, Pranesh N, Richards C, Ross F, Sajid M, Brooke M, Francombe J, Gresly J, Hutchinson S, Kerrigan K, Matthews E, Nur S, Parsons L, Sandhu A, Vyas M, White F, Zulkifli A, Zuzarte L, Al-Mousawi A, Arya J, Azam S, Yahaya AA, Gill K, Hallan R, Hathaway C, Leptidis I, McDonagh L, Mitrasinovic S, Mushtaq N, Pang N, Peiris GB, Rinkoff S, Chan L, Christopher E, Farhan-Alanie MMH, Gonzalez-Ciscar A, Graham CJ, Lim H, McLean KA, Paterson HM, Rogers A, Roy C, Rutherford D, Smith F, Zubikarai G, Al-Khudairi R, Bamford M, Chang M, Cheng J, Hedley C, Joseph R, Mitchell B, Perera S, Rothwell L, Siddiqui A, Smith J, Taylor K, Wright OW, Baryan HK, Boyd G, Conchie H, Cox L, Davies J, Gardner S, Hill N, Krishna K, Lakin F, Scotcher S, Alberts J, Asad M, Barraclough J, Campbell A, Marshall D, Wakeford W, Cronbach P, D'Souza F, Gammeri E, Houlton J, Hall M, Kethees A, Patel R, Perera M, Prowle J, Shaid M, Webb E, Beattie S, Chadwick M, El-Taji O, Haddad S, Mann M, Patel M, Popat K, Rimmer L, Riyat H, Smith H, Anandarajah C, Cipparrone M, Desai K, Gao C, Goh ET, Howlader M, Jeffreys N, Karmarkar A, Mathew G, Mukhtar H, Ozcan E, Renukanthan A, Sarens N, Sinha C, Woolley A, Bogle R, Komolafe O, Loo F, Waugh D, Zeng R, Crewe A, Mathias J, Mills A, Owen A, Prior A, Saunders I, Baker A, Crilly L, McKeon J, Ubhi HK, Adeogun A, Carr R, Davison C, Devalia S, Hayat A, Karsan RB, Osborne C, Scott K, Weegenaar C, Wijeyaratne M, Babatunde F, Barnor-Ahiaku E, Beattie G, Chitsabesan P, Dixon O, Hall N, Ilenkovan N, Mackrell T, Nithianandasivam N, Orr J, Palazzo F, Saad M, Sandland-Taylor L, Sherlock J, Ashdown T, Chandler S, Garsaa T, Lloyd J, Loh SY, Ng S, Perkins C, Powell-Chandler A, Smith F, Underhill R. Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study. Br J Surg 2020; 107:1023-1032. [PMID: 32026470 DOI: 10.1002/bjs.11453] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/21/2019] [Accepted: 11/08/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. METHODS This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. RESULTS A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498). CONCLUSION There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.
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Mills WR, Sender S, Lichtefeld J, Romano N, Reynolds K, Price M, Phipps J, White L, Howard S, Poltavski D, Barnes R. Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA. J Intellect Disabil Res 2020; 64:489-496. [PMID: 32490559 PMCID: PMC7300850 DOI: 10.1111/jir.12740] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 05/28/2023]
Abstract
BACKGROUND It is unknown how the novel Coronavirus SARS-CoV-2, the cause of the current acute respiratory illness COVID-19 pandemic that has infected millions of people, affects people with intellectual and developmental disability (IDD). The aim of this study is to describe how individuals with IDD have been affected in the first 100 days of the COVID-19 pandemic. METHODS Shortly after the first COVID-19 case was reported in the USA, our organisation, which provides continuous support for over 11 000 individuals with IDD, assembled an outbreak committee composed of senior leaders from across the health care organisation. The committee led the development and deployment of a comprehensive COVID-19 prevention and suppression strategy, utilising current evidence-based practice, while surveilling the global and local situation daily. We implemented enhanced infection control procedures across 2400 homes, which were communicated to our employees using multi-faceted channels including an electronic resource library, mobile and web applications, paper postings in locations, live webinars and direct mail. Using custom-built software applications enabling us to track patient, client and employee cases and exposures, we leveraged current public health recommendations to identify cases and to suppress transmission, which included the use of personal protective equipment. A COVID-19 case was defined as a positive nucleic acid test for SARS-CoV-2 RNA. RESULTS In the 100-day period between 20 January 2020 and 30 April 2020, we provided continuous support for 11 540 individuals with IDD. Sixty-four per cent of the individuals were in residential, community settings, and 36% were in intermediate care facilities. The average age of the cohort was 46 ± 12 years, and 60% were male. One hundred twenty-two individuals with IDD were placed in quarantine for exhibiting symptoms and signs of acute infection such as fever or cough. Sixty-six individuals tested positive for SARS-CoV-2, and their average age was 50. The positive individuals were located in 30 different homes (1.3% of total) across 14 states. Fifteen homes have had single cases, and 15 have had more than one case. Fifteen COVID-19-positive individuals were hospitalised. As of 30 April, seven of the individuals hospitalised have been discharged back to home and are recovering. Five remain hospitalised, with three improving and two remaining in intensive care and on mechanical ventilation. There have been three deaths. We found that among COVID-19-positive individuals with IDD, a higher number of chronic medical conditions and male sex were characteristics associated with a greater likelihood of hospitalisation. CONCLUSIONS In the first 100 days of the COVID-19 outbreak in the USA, we observed that people with IDD living in congregate care settings can benefit from a coordinated approach to infection control, case identification and cohorting, as evidenced by the low relative case rate reported. Male individuals with higher numbers of chronic medical conditions were more likely to be hospitalised, while most younger, less chronically ill individuals recovered spontaneously at home.
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Affiliation(s)
| | - S. Sender
- BrightSpring Health ServicesLouisvilleKYUSA
| | | | - N. Romano
- BrightSpring Health ServicesLouisvilleKYUSA
| | | | - M. Price
- BrightSpring Health ServicesLouisvilleKYUSA
| | - J. Phipps
- BrightSpring Health ServicesLouisvilleKYUSA
| | - L. White
- BrightSpring Health ServicesLouisvilleKYUSA
| | - S. Howard
- BrightSpring Health ServicesLouisvilleKYUSA
| | - D. Poltavski
- BrightSpring Health ServicesLouisvilleKYUSA
- University of North DakotaGrand ForksNDUSA
| | - R. Barnes
- BrightSpring Health ServicesLouisvilleKYUSA
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Howell E, Price M, Dalton T, Williamson T, Kamal A, Goodwin R. Patterns of inpatient palliative care consultation for patients with brain and spine metastases. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e24117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24117 Background: Patients diagnosed with brain and/or spine metastases (BSM) face high symptom burden and complex clinical decision-making. Through expertise in pain and symptom management, facilitation of end-of-life planning, and caregiver support, specialty Palliative Care (PC) can provide a crucial component of the care for these patients. No prior study has formally evaluated the rates of inpatient PC referral in BSM patients, nor the patient-specific factors that may affect consultation rates within this context. Methods: Analysis was performed of the rates of PC consults in a cohort of BSM inpatients admitted to three tertiary medical centers: one major academic center and two smaller affiliate centers. Patients were identified using a combination of ICD-9 and -10 codes and surgical provider lists to aggregate brain and spine metastases patient cohorts at each institution. Patient demographics, surgical status, and readmission data were collected. PC utilization was assessed by flagging encounters within which an inpatient consult to PC was placed. Results: 2608 total discharges were analyzed, with 2397 brain metastasis and 301 spine metastasis discharges. Average rate of inpatient PC consultation over the 3.5 year study period was 13.6% for brain metastasis patients and 11.0% for spine metastases patients. Rates of PC utilization differed significantly by patient race (11.6% in white vs. 17.0% in non-white patients, p = 0.02). Patients who received surgery had significantly lower rates of PC consultation in both brain (3.5% vs 15.6%, p < 0.001) and spine (5.5% vs 14.1% p < 0.001) cohorts. The large academic center had the lowest utilization as compared to two smaller affiliate centers, with 6.4% of brain and 7.6% of spine metastasis patients receiving PC consults. For both cohorts, Neurology was the discharging service with the highest rates of PC utilization, consulting PC for 37.7% of brain and 42.9% of spine metastasis patients respectively. Over time, PC utilization increased for brain, but not spine, metastasis patients. Conclusions: Despite their high symptom burden and low overall survival, BSM patients have low rates of inpatient PC consultation. Utilization appears to vary by patient demographics and surgical status, as well as discharging service and practice setting. These single-institution patterns may ultimately provide a microcosm for national patterns and trends at similar institutions, and further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.
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Affiliation(s)
| | | | - Tara Dalton
- Duke University School of Medicine, Durham, NC
| | | | | | - Rory Goodwin
- Duke University Department of Neurosurgery, Durham, NC
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Vashistha V, Armstrong J, Winski D, Price M, Hintze BJ, Poonnen P, Snowdon J, Jackson GP, Weeraratne D, Brotman D, Spector NL, Kelley MJ. Barriers to prescribing targeted therapies for NSCLC patients with highly actionable gene variants in the VA National Precision Oncology Program. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2005 Background: Next-Generation Sequencing (NGS) gene panels are often completed to guide therapeutic decisions for patients with advanced stage non-small cell lung cancer (NSCLC). Patients with highly-actionable gene variants may experience improved therapeutic treatments and reduced toxicities with use of targeted agents. Ensuring appropriate prescription of targeted therapies is therefore of high importance. We sought to identify barriers to targeted agent use within the Veterans Health Affairs’ (VHA) National Precision Oncology Program (NPOP). Methods: A retrospective evaluation examined the cohort of NSCLC patients who underwent NGS multi-gene panels through NPOP between July 2015 and February 2019. A level of evidence for drug actionability was assigned to each observed oncogenic gene variant using an artificial intelligence offering (IBM Watson for Genomics: WfG). WfG level 1 and 2A evidence was reviewed by NPOP staff to exclude gene variants that did not conform to NPOP level 1 and 2A definitions. Anti-neoplastic drug prescriptions and oncology provider notes were obtained for all included patients from the VHA Corporate Data Warehouse. Review of clinical notes of patients who did not receive targeted agents was performed to categorize the reason(s). Results: Of 1764 NSCLC patients who successfully underwent NGS gene panel testing, 156 (8.9%) received therapeutic level 1 (7.3%) or 2A (1.6%) options for targeted agents based on WfG evidence analysis. In total, 117 (6.6%) patients had NPOP level 1 and 2A gene variants, all within ALK, BRAF, EGFR, ERBB2, MET, and RET. Of these, 49 (41.2%) patients were not prescribed available targeted agents. The three most common reasons were: (1) treating provider did not comment on NGS results (30.7%), (2) patient did not carry a diagnosis of advanced stage disease (18.4%), and (3) patient had begun an alternative systemic therapy prior to completion of sequencing (16.3%). No patient was denied access to a level 1 or 2A targeted drug due to utilization-management review. Conclusions: A substantial minority of patients with advanced NSCLC bearing highly-actionable gene variants are not prescribed available targeted agents. Further provider- and pathologist-directed educational effort are needed, as well as implementation of health informatics systems to provide near real-time decision support for test ordering and interpretation.
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Affiliation(s)
- Vishal Vashistha
- Duke University Health System/Durham VA Health Care System, Durham, NC
| | | | | | | | | | - Pradeep Poonnen
- Duke University Health System/Durham VA Medical Center, Durham, NC
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HABER Z, Lee E, Price M, Wainberg Z, Hecht J, Sayre J, Padia S. 3:00 PM Abstract No. 237 Additive benefit of yttrium-90 radioembolization to systemic therapy in patients with hepatic metastases from colorectal cancer in the salvage setting: results of a propensity-score matched study. J Vasc Interv Radiol 2020. [DOI: 10.1016/j.jvir.2019.12.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Striegel AK, Price M, Frandsen V, Gernert S, Arens A, Wiesenäcker D, Lange L. Der Stand der allergologischen Weiterbildung von Kinderärzten. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00850-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Zusammenfassung
Hintergrund
Ein deutlicher Rückgang abgelegter Prüfungen im Fach Allergologie und gleichzeitig eine Zunahme allergologischer Erkrankungen haben die Nachwuchsgruppe der Gesellschaft für Pädiatrische Allergologie und Umweltmedizin (GPAU) dazu bewogen, die Qualität und die Bedingungen der allergologischen Ausbildung in der Pädiatrie zu untersuchen. Zeitgleich wurde beim Deutschen Ärztetag ein neues Format der Zusatzweiterbildung Allergologie (Musterweiterbildungsordnung [MWBO]) verabschiedet.
Ziel der Arbeit
Ziel dieser Umfrage war es, die Rahmenbedingungen der allergologischen Ausbildung von Kinderärzten in Deutschland genauer zu untersuchen.
Material und Methoden
Es wurde eine Umfrage mithilfe eines Fragebogens sowohl bei den Weiterbildungsermächtigten (insgesamt 169) als auch bei deren Weiterbildungsassistent*innen durchgeführt.
Ergebnisse und Diskussion
Von insgesamt 56 Weiterbildungsermächtigten und 32 Weiterbildungsassistent*innen wurde der Fragebogen ausgewertet. Es zeigt sich in der Auswertung, dass der Prozentsatz an Frauen bei den Weiterbildungsermächtigten deutlich geringer ist im Vergleich zu den Weiterbildungsassistent*innen (20 vs. 66 %), jedoch sind mittlerweile mehr als zwei Drittel der Medizinstudierenden weiblich. In der Umfrage stellt sich heraus, dass die allergologische Weiterbildung bei fast 20 % der Weiterbildungsassistent*innen weniger als 10 % der Gesamtarbeitszeit ausmacht und oft außerhalb der Regelarbeitszeit stattfindet. Es sind in Zukunft sowohl flexiblere Arbeitszeitmodelle als auch kombinierte Ausbildungsmodelle zwischen Klinik und Praxis und feste Strukturen für eine fundierte Ausbildung im klinischen Alltag notwendig, um der wachsenden Anzahl allergologischer Fragestellungen v. a. bei Kindern flächendeckend gerecht werden zu können. In der neuen MWBO darf nicht nur der Nachweis von Untersuchungstechniken eine Rolle spielen, sondern sie muss auch die Betreuung von komplexen allergologischen Fällen abbilden, die gerade in der Pädiatrie vorzufinden sind, z. B. im Rahmen von Hospitationen.
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