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Pillai M, Posada J, Gardner RM, Hernandez-Boussard T, Bannett Y. Measuring quality-of-care in treatment of young children with attention-deficit/hyperactivity disorder using pre-trained language models. J Am Med Inform Assoc 2024; 31:949-957. [PMID: 38244997 PMCID: PMC10990536 DOI: 10.1093/jamia/ocae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/07/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVE To measure pediatrician adherence to evidence-based guidelines in the treatment of young children with attention-deficit/hyperactivity disorder (ADHD) in a diverse healthcare system using natural language processing (NLP) techniques. MATERIALS AND METHODS We extracted structured and free-text data from electronic health records (EHRs) of all office visits (2015-2019) of children aged 4-6 years in a community-based primary healthcare network in California, who had ≥1 visits with an ICD-10 diagnosis of ADHD. Two pediatricians annotated clinical notes of the first ADHD visit for 423 patients. Inter-annotator agreement (IAA) was assessed for the recommendation for the first-line behavioral treatment (F-measure = 0.89). Four pre-trained language models, including BioClinical Bidirectional Encoder Representations from Transformers (BioClinicalBERT), were used to identify behavioral treatment recommendations using a 70/30 train/test split. For temporal validation, we deployed BioClinicalBERT on 1,020 unannotated notes from other ADHD visits and well-care visits; all positively classified notes (n = 53) and 5% of negatively classified notes (n = 50) were manually reviewed. RESULTS Of 423 patients, 313 (74%) were male; 298 (70%) were privately insured; 138 (33%) were White; 61 (14%) were Hispanic. The BioClinicalBERT model trained on the first ADHD visits achieved F1 = 0.76, precision = 0.81, recall = 0.72, and AUC = 0.81 [0.72-0.89]. Temporal validation achieved F1 = 0.77, precision = 0.68, and recall = 0.88. Fairness analysis revealed low model performance in publicly insured patients (F1 = 0.53). CONCLUSION Deploying pre-trained language models on a variable set of clinical notes accurately captured pediatrician adherence to guidelines in the treatment of children with ADHD. Validating this approach in other patient populations is needed to achieve equitable measurement of quality of care at scale and improve clinical care for mental health conditions.
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Affiliation(s)
- Malvika Pillai
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Jose Posada
- Computer Science Department, University of the North, Barranquilla 080020, Colombia
| | - Rebecca M Gardner
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Tina Hernandez-Boussard
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Yair Bannett
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, United States
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Beshar I, Milki AA, Gardner RM, Zhang WY, Johal JK, Bavan B. Elevated body mass index in modified natural cycle frozen euploid embryo transfers is not associated with live birth rate. J Assist Reprod Genet 2023; 40:1055-1062. [PMID: 37000344 PMCID: PMC10239415 DOI: 10.1007/s10815-023-02787-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 03/21/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE To assess the impact of elevated BMI on the success of modified natural cycle frozen embryo transfers (mNC-FET) of euploid embryos. METHODS This retrospective cohort study at a single academic institution reviewed mNC-FET involving single euploid blastocysts from 2016 to 2020. Comparison groups were divided by pre-pregnancy BMI (kg/m2) category: normal weight (18.5-24.9), overweight (25-29.9) or obese (≥ 30). Underweight BMI (< 18.5) was excluded from the analysis. The primary outcome was live birth rate (LBR) and secondary outcome was clinical pregnancy rate (CPR), defined as presence of fetal cardiac activity on ultrasound. Absolute standardized differences (ASD) were calculated to compare descriptive variables and p-values and multivariable logistic regressions with generalized estimating equations (GEE) were used to compare pregnancy outcomes. RESULTS 562 mNC-FET cycles were completed in 425 patients over the study period. Overall, there were 316 transfers performed in normal weight patients, 165 in overweight patients, and 81 in obese weight patients. There was no statistically significant difference in LBR across all BMI categories (55.4% normal weight, 61.2% overweight, and 64.2% obese). There was also no difference for the secondary outcome, CPR, across all categories (58.5%, 65.5%, and 66.7%, respectively). This was confirmed in GEE analysis when adjusting for confounders. CONCLUSION While increased weight has commonly been implicated in poor pregnancy outcomes, the effect of BMI on the success of mNC-FET remains debated. Across five years of data from a single institution using euploid embryos in mNC-FET cycles, elevated BMI was not associated with reduced LBR or CPR.
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Affiliation(s)
- Isabel Beshar
- Department of Obstetrics & Gynecology, Stanford Hospital, Center for Academic Medicine, MC 5317, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - Amin A. Milki
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, Stanford University, 1195 W Fremont Avenue, Sunnyvale, CA 94087 USA
| | - Rebecca M. Gardner
- Department of Epidemiology & Population Health, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305 USA
| | - Wendy Y. Zhang
- Department of Obstetrics & Gynecology, Stanford Hospital, Center for Academic Medicine, MC 5317, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - Jasmyn K. Johal
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, 1305 York Avenue, 6th Floor, New York, NY 10021 USA
| | - Brindha Bavan
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, Stanford University, 1195 W Fremont Avenue, Sunnyvale, CA 94087 USA
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Lester TR, Herrmann JE, Bannett Y, Gardner RM, Feldman HM, Huffman LC. Anxiety and Depression Treatment in Primary Care Pediatrics. Pediatrics 2023; 151:e2022058846. [PMID: 37066669 PMCID: PMC10691450 DOI: 10.1542/peds.2022-058846] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review. METHODS We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices. RESULTS At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects. CONCLUSIONS When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.
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Affiliation(s)
- Talia R. Lester
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| | | | - Yair Bannett
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| | - Rebecca M. Gardner
- Stanford School of Medicine, Palo Alto, California
- Quantitative Science Unit, Department of Medicine
| | - Heidi M. Feldman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| | - Lynne C. Huffman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
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Frelinger C, Gardner RM, Huffman LC, Whitgob EE, Feldman HM, Bannett Y. Detection of Speech-Language Delay in the Primary Care Setting: An Electronic Health Record Investigation. J Dev Behav Pediatr 2023; 44:e196-e203. [PMID: 36978234 PMCID: PMC10065357 DOI: 10.1097/dbp.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 12/14/2022] [Indexed: 03/30/2023]
Abstract
OBJECTIVE The purpose of this study is to determine the rate and age at first identification of speech-language delay in relation to child sociodemographic variables among a pediatric primary care network. METHODS We analyzed a deidentified data set of electronic health records of children aged 1- to 5-years-old seen between 2015 and 2019 at 10 practices of a community-based pediatric primary health care network. Primary outcomes were numbers (proportions) of patients with relevant ICD-10 visit-diagnosis codes and patient age (months) at first documentation of speech-language delay. Regression models estimated associations between outcomes and patient characteristics, adjusting for practice affiliation. RESULTS Of 14,559 included patients, 2063 (14.1%) had speech-language delay: 68.4% males, 74.4% with private insurance, and 96.1% with English as a primary household language. Most patients (60%) were first identified at the 18- or 24-month well-child visit. The mean age at first documentation was 25.4 months (SD = 9.3), which did not differ between practices reporting the use of standardized developmental screener and those using surveillance questionnaires. Regression models showed that males were more than twice as likely than females to be identified with speech-language delay (adjusted odds ratio [aOR] = 2.05, 95% CI: [1.86-2.25]); publicly insured were more likely than privately insured patients to be identified with speech-language delay (aOR = 1.48, 95% CI: [1.30-1.68]). Females were older than males at first identification (+1.2 months, 95% CI: [0.3-2.1]); privately insured were older than military insured patients (private +3.3 months, 95% CI: [2.2-4.4]). CONCLUSION Pediatricians in this network identified speech-language delays at similar rates to national prevalence. Further investigation is needed to understand differences in speech-language delay detection across patient subgroups in practices that use developmental screening and/or surveillance.
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Affiliation(s)
- Catherine Frelinger
- Stanford University School of Medicine, Division of Developmental and Behavioral Pediatrics, Stanford, California
| | - Rebecca M. Gardner
- Stanford University School of Medicine, Quantitative Sciences Unit, Stanford, California
| | - Lynne C. Huffman
- Stanford University School of Medicine, Division of Developmental and Behavioral Pediatrics, Stanford, California
| | - Emily E. Whitgob
- Santa Clara Valley Medical Center, Department of Developmental and Behavioral Pediatrics, San Jose, California
| | - Heidi M. Feldman
- Stanford University School of Medicine, Division of Developmental and Behavioral Pediatrics, Stanford, California
| | - Yair Bannett
- Stanford University School of Medicine, Division of Developmental and Behavioral Pediatrics, Stanford, California
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5
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Zhang WY, Gardner RM, Johal JK, Beshar IE, Bavan B, Milki AA, Lathi RB, Aghajanova L. Pregnancy and neonatal outcomes of letrozole versus natural cycle frozen embryo transfer of autologous euploid blastocyst. J Assist Reprod Genet 2023; 40:873-881. [PMID: 36849755 PMCID: PMC10224882 DOI: 10.1007/s10815-023-02759-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
PURPOSE To investigate the pregnancy and neonatal outcomes of letrozole-stimulated frozen embryo transfer (LTZ-FET) cycles compared with natural FET cycles (NC-FET). METHODS Our retrospective cohort included all LTZ-FET (n = 161) and NC-FET (n = 575) cycles that transferred a single euploid autologous blastocyst from 2016 to 2020 at Stanford Fertility Center. The LTZ-FET protocol entailed 5 mg of daily letrozole for 5 days starting on cycle day 2 or 3. Outcomes were compared using absolute standardized differences (ASD), in which a larger ASD signifies a larger difference. Multivariable regression models adjusted for confounders: maternal age, BMI, nulliparity, embryo grade, race, infertility diagnosis, and endometrial thickness. RESULTS The demographic and clinical characteristics were overall similar. A greater proportion of the letrozole cohort was multiparous, transferred high-graded embryos, and had ovulatory dysfunction. The cohorts had similar pregnancy rates (67.1% LTZ vs 62.1% NC; aOR 1.31, P = 0.21) and live birth rates (60.9% LTZ vs 58.6% NC; aOR 1.17, P = 0.46). LTZ-FET neonates on average were born 5.7 days earlier (P < 0.001) and had higher prevalence of prematurity (18.6% vs. 8.0%NC, ASD = 0.32) and low birth weight (10.4% vs. 5.0%, ASD = 0.20). Both cohorts' median gestational ages (38 weeks and 1 day for LTZ; 39 weeks and 0 day for NC) were full term. CONCLUSION There were similar rates of pregnancy and live birth between LTZ-FET and NC-FET cycles. However, there was a higher prevalence of prematurity and low birth weight among LTZ-FET neonates. Reassuringly, the median gestational age in both cohorts was full term, and while the difference in gestational length of almost 6 days does not appear to be clinically significant, this warrants larger studies.
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Affiliation(s)
- Wendy Y Zhang
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Rebecca M Gardner
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Jasmyn K Johal
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Isabel E Beshar
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Brindha Bavan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Amin A Milki
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ruth B Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Dunham TB, Gardner RM, Lippner EA, Fasani DE, Moir E, Halpern-Felsher B, Sundaram V, Liu AY. Digital Antibiotic Allergy Decision Support Tool Improves Management of β-Lactam Allergies. J Allergy Clin Immunol Pract 2023; 11:1243-1252.e6. [PMID: 36736957 PMCID: PMC10085826 DOI: 10.1016/j.jaip.2023.01.026] [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] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Frontline providers frequently make time-sensitive antibiotic choices, but many feel poorly equipped to handle antibiotic allergies. OBJECTIVE We hypothesized that a digital decision support tool could improve antibiotic selection and confidence when managing β-lactam allergies. METHODS A digital decision support tool was designed to guide non-allergist providers in managing patients with β-lactam allergy labels. Non-allergists were asked to make decisions in clinical test cases without the tool, and then with it. These decisions were compared using paired t tests. Users also completed surveys assessing their confidence in managing antibiotic allergies. RESULTS The tool's algorithm was validated by confirming its recommendations aligned with that of five allergists. Non-allergist providers (n = 102) made antibiotic management decisions in test cases, both with and without the tool. Use of the tool increased the proportion of correct decisions from 0.41 to 0.67, a difference of 0.26 (95% CI, 0.22-0.30; P < .001). Users were more likely to give full-dose antibiotics in low-risk situations, give challenge doses in medium-risk situations, and avoid the antibiotic and/or consult allergy departments in high-risk situations. A total of 98 users (96%) said the tool would increase their confidence when choosing antibiotics for patients with allergies. CONCLUSIONS A point-of-care clinical decision tool provides allergist-designed guidance for non-allergists and is a scalable system for addressing antibiotic allergies, irrespective of allergist availability. This tool encouraged appropriate antibiotic use in low- and medium-risk situations and increased caution in high-risk situations. A digital support tool should be considered in quality improvement and antibiotic stewardship efforts.
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Affiliation(s)
- Theresa B Dunham
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif.
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Elizabeth A Lippner
- Division of Allergy and Immunology, Department of Pediatrics, Anne and Robert H. Lurie Children's Hospital and Northwestern Feinberg School of Medicine, Chicago, Ill
| | | | - Elwyn Moir
- Clinical Observation and Medical Transcription Program, Stanford, Calif
| | - Bonnie Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, Calif
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Anne Y Liu
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
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7
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Bannett Y, Gardner RM, Huffman LC, Feldman HM, Sanders LM. Continuity of Care in Primary Care for Young Children With Chronic Conditions. Acad Pediatr 2023; 23:314-321. [PMID: 35858663 DOI: 10.1016/j.acap.2022.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/19/2022] [Accepted: 07/02/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES 1) To assess continuity of care (CoC) within primary-care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC. METHODS Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits. RESULTS Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69). CONCLUSION After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.
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Affiliation(s)
- Yair Bannett
- Division of Developmental-Behavioral Pediatrics (Y Bannett, LC Huffman and HM Feldman), Stanford University School of Medicine, Stanford, Calif.
| | | | - Lynne C Huffman
- Division of Developmental-Behavioral Pediatrics (Y Bannett, LC Huffman and HM Feldman), Stanford University School of Medicine, Stanford, Calif
| | - Heidi M Feldman
- Division of Developmental-Behavioral Pediatrics (Y Bannett, LC Huffman and HM Feldman), Stanford University School of Medicine, Stanford, Calif
| | - Lee M Sanders
- Division of General Pediatrics (LM Sanders), Stanford University School of Medicine, Stanford, Calif
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Bavan B, Gardner RM, Zhang WY, Aghajanova L. The Effect of Human Growth Hormone on Endometrial Growth in Controlled Ovarian Hyperstimulation Cycles. J Pers Med 2022; 12:jpm12121991. [PMID: 36556212 PMCID: PMC9788117 DOI: 10.3390/jpm12121991] [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: 08/15/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 12/04/2022] Open
Abstract
This study aims to compare endometrial growth before and after the addition of human growth hormone (hGH) in controlled ovarian hyperstimulation (COH) cycles. A 5-year retrospective cohort study of patients treated with hGH to improve oocyte development during COH cycles was conducted. Each patient’s cycle without hGH immediately preceding cycle(s) with hGH was used for patients to serve as their own controls. Primary outcome was absolute growth in endometrial thickness from pre-stimulation start to day of hCG trigger. Mixed-model regression analysis controlled for patient correlation over repeat cycles and potential confounders. 80 patients were included. Mean age was 39.7 years; mean BMI was 23.8 kg/m2. Majority of patients were nulliparous, non-smoking, and White or Asian. Most common diagnosis was diminished ovarian reserve. Endometrial growth was compared between 159 COH cycles with hGH and 80 COH control cycles; mean increase was 4.5 mm and 3.9 mm, respectively-an unadjusted difference of 0.6 mm (95% CI: 0.2−1.1, p = 0.01). After adjusting for demographic/clinical factors, hGH was associated with 0.9 mm greater endometrial growth (0.4−1.4, p < 0.01). Absolute increase in endometrial thickness was higher in COH cycles that included hGH. Further prospective studies in embryo transfer cycles are needed.
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Affiliation(s)
- Brindha Bavan
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility, Stanford University, Sunnyvale, CA 94087, USA
- Correspondence:
| | - Rebecca M. Gardner
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Wendy Y. Zhang
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility, Stanford University, Sunnyvale, CA 94087, USA
| | - Lusine Aghajanova
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility, Stanford University, Sunnyvale, CA 94087, USA
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Culbertson CJ, Perino AC, Gardner RM, Balasubramanian V, Vora N. Trends in Utilization of Magnetic Resonance Imaging for Stroke Patients With Cardiac Rhythm Devices. Neurohospitalist 2022; 12:624-631. [PMID: 36147760 PMCID: PMC9485690 DOI: 10.1177/19418744221115004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose Magnetic resonance imaging (MRI) is safe for most patients with cardiovascular implantable electronic devices (CIEDs). However, patients presenting with acute ischemic stroke or transient ischemic attack (AIS/TIA) who have CIEDs may undergo MRI less frequently than patients without devices. We assessed contemporary use of MRI for patients with AIS/TIA and the effect of a recent coverage revision by the Center for Medicare and Medicaid Services (CMS) on MRI utilization. Methods Using Optum® claims data from January 2012 to June 2019, we performed an interrupted time series analysis of MRI utilization during AIS/TIA hospitalizations with the April 2018 CMS coverage revision serving as the intervention. For patients treated after the coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA. Results We identified 417,899 patient hospitalizations for AIS/TIA, of which 30,425 (7%) had a CIED present (CIED vs non-CIED patients: age 77.6 ± 9.8 vs 72.7 ± 12.3 years; 45.5% vs 54.3% female). From 2012 to 2019, annual MRI utilization increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute additional increase in MRI utilization for CIED patients. Non-CIED patients treated after the CMS coverage revision were substantially more likely than CIED patients to undergo MRI (adjusted OR 6.7, 95% CI: 6.3-7.1, P<.001). Conclusions MRI utilization has increased for stroke patients with CIEDs but remains far lower than in similar patients without devices.
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Affiliation(s)
- Collin J. Culbertson
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
- Department of Neurology, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Alexander C. Perino
- Department of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rebecca M. Gardner
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Nirali Vora
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
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10
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Peinado Fabregat MI, Gardner RM, Hassan MA, Kapphahn K, Yeh AM. Small Intestinal Bacterial Overgrowth in Children: Clinical Features and Treatment Response. JPGN Rep 2022; 3:e185. [PMID: 37168915 PMCID: PMC10158461 DOI: 10.1097/pg9.0000000000000185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 12/21/2021] [Indexed: 05/13/2023]
Abstract
To characterize the population of children diagnosed with small intestinal bacterial overgrowth (SIBO) based on breath test (BT), correlate symptomatology, and describe SIBO treatments and treatment efficacy. Methods A retrospective cohort study of pediatric patients seen at Stanford Children's Health Gastroenterology Clinics from 2012 to 2018 who had a positive BT, defined by a rise in hydrogen by ≥20 ppm, a baseline hydrogen level ≥20 ppm, or a methane value ≥10 ppm. The main outcome was symptom resolution, defined as complete or partial improvement after a course of treatment. Absolute standardized differences and Chi-square tests were used to assess associations. Results From 98 children, 54 met inclusion and did not meet exclusion criteria (53.7% female). Lactulose substrate was used for 41 (75.9%) patients, whereas glucose was used for 13 (24.1%). Complete or partial resolution of symptoms was achieved in 13 of 16 (81.2%) patients who received probiotics with or without antibiotics versus 21 of 31 (67.7%) patients treated with antibiotics alone (P = 0.524). Metronidazole versus rifaximin versus other antibiotics showed no significant difference in symptom resolution (12 (63.2%), 13 (76.5%), 7 (77.8%), respectively, P = 0.601). Conclusion Seventy-two percent of patients experienced at least partial symptom relief after treatment. We did not find a strong correlation between specific symptoms and analyte elevation. There was no difference in effectiveness between metronidazole and rifaximin to treat SIBO symptoms. Further research needs to be done to determine effective treatments for SIBO in pediatrics.
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Affiliation(s)
| | | | - Maheen A. Hassan
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition at Stanford University, Stanford, CA
| | | | - Ann Ming Yeh
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition at Stanford University, Stanford, CA
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11
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Lester TR, Bannett Y, Gardner RM, Feldman HM, Huffman LC. Medication Management of Anxiety and Depression by Primary Care Pediatrics Providers: A Retrospective Electronic Health Record Study. Front Pediatr 2022; 10:794722. [PMID: 35372169 PMCID: PMC8970594 DOI: 10.3389/fped.2022.794722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe medication management of children diagnosed with anxiety and/or depression by primary care providers within a primary care network. STUDY DESIGN/METHODS We performed a retrospective cross-sectional analysis of electronic health record (EHR) structured data from all children seen at least twice in a 4-year observation period within a network of primary care clinics in Northern California. For children who had visit diagnoses of anxiety, depression, anxiety+depression or symptoms characteristic of these conditions, we analyzed the rates and types of medications prescribed. A logistic regression model considered patient variables for the combined sample. RESULTS Of all patients 6-18 years old (N = 59,484), 4.4% (n = 2,635) had a diagnosis of anxiety only, 2.4% (n = 1,433) depression only, and 1.2% (n = 737) both anxiety and depression (anxiety + depression); 18% of children with anxiety and/or depression had comorbid ADHD. A total of 15.0% with anxiety only (n = 357), 20.5% with depression only (n = 285), and 47.4% with anxiety+depression (n=343) were prescribed a psychoactive non-stimulant medication. For anxiety and depression only, the top three medications prescribed were sertraline, fluoxetine, and citalopram. For anxiety + depression, the top three medications prescribed were citalopram, sertraline, and escitalopram. Frequently prescribed medications also included benzodiazepines. Logistic regression modeling showed that the depression only and anxety + depression categories had increased likelihood of medication prescription. Older age and mental health comorbidities were independently associated with increased likelihood of medication prescription. CONCLUSIONS In this network, ~8% of children carried a diagnosis of anxiety and/or depression. Medication choices generally aligned with current recommendations with the exception of use of benzodiazepines.
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Affiliation(s)
- Talia R Lester
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Yair Bannett
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Rebecca M Gardner
- Quantitative Science Unit, Department of Medicine, Stanford School of Medicine, Palo Alto, CA, United States
| | - Heidi M Feldman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lynne C Huffman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
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12
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Bannett Y, Gardner RM, Posada J, Huffman LC, Feldman HM. Rate of Pediatrician Recommendations for Behavioral Treatment for Preschoolers With Attention-Deficit/Hyperactivity Disorder Diagnosis or Related Symptoms. JAMA Pediatr 2022; 176:92-94. [PMID: 34661611 PMCID: PMC8524350 DOI: 10.1001/jamapediatrics.2021.4093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study investigates the rate of pediatrician recommendations for behavioral treatment for preschoolers with an attention-deficit/hyperactivity disorder diagnosis or symptoms.
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Affiliation(s)
- Yair Bannett
- Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, California
| | | | - Jose Posada
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lynne C. Huffman
- Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Heidi M. Feldman
- Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, California
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13
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White MN, Piper-Vallillo AJ, Gardner RM, Cunanan K, Neal JW, Das M, Padda SK, Ramchandran K, Chen TT, Sequist LV, Piotrowska Z, Wakelee HA. Chemotherapy Plus Immunotherapy Versus Chemotherapy Plus Bevacizumab Versus Chemotherapy Alone in EGFR-Mutant NSCLC After Progression on Osimertinib. Clin Lung Cancer 2021; 23:e210-e221. [PMID: 34887193 DOI: 10.1016/j.cllc.2021.11.001] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Patients with EGFR-mutant lung cancer who have had disease progression on osimertinib commonly receive platinum doublet chemotherapy, but whether adding immunotherapy or bevacizumab provides additional benefit is unknown. MATERIALS AND METHODS This was a retrospective analysis at 2 university-affiliated institutions. Patients with EGFR-mutant lung cancer who had progression on osimertinib and received next-line therapy with platinum doublet chemotherapy (chemo), platinum doublet chemotherapy plus immunotherapy (chemo-IO), or platinum doublet chemotherapy plus bevacizumab (chemo-bev), were identified; patients who continued osimertinib with these regimens were included. Efficacy outcomes including duration on treatment (DOT) and overall survival (OS) from the start of chemotherapy were assessed. Associations of treatment regimen with outcomes were evaluated using adjusted Cox regression models, using pairwise comparisons between groups. RESULTS 104 patients were included: 57 received chemo, 12 received chemo-IO, and 35 received chemo-bev. In adjusted models, patients who received chemo-IO had worse OS than did those who received chemo (hazard ratio (HR) 2.66, 95% CI 1.25-5.65; P= .011) or those who received chemo-bev (HR 2.37, 95% CI 1.09-5.65; P= .030). A statistically significant difference in OS could not be detected in patients who received chemo-bev versus those who received chemo (HR 1.50, 95% CI 0.84-2.69; P= .17). CONCLUSION In this retrospective study, giving immunotherapy with platinum doublet chemotherapy after progression on osimertinib was associated with a worse OS compared with platinum doublet chemotherapy alone. Platinum doublet chemotherapy without immunotherapy (with consideration of continuation of osimertinib, in selected cases) is a reasonable choice in this setting, while we await results of clinical trials examining optimal next-line chemotherapy-based regimens in EGFR-mutant lung cancer.
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Affiliation(s)
- Maya N White
- Department of Medicine, Division of Oncology, Stanford University, Stanford CA
| | - Andrew J Piper-Vallillo
- Department of Medicine, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA
| | - Kristen Cunanan
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA
| | - Joel W Neal
- Department of Medicine, Division of Oncology, Stanford University, Stanford CA
| | - Millie Das
- Department of Medicine, Division of Oncology, Stanford University, Stanford CA; Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Sukhmani K Padda
- Department of Medicine, Division of Oncology, Stanford University, Stanford CA
| | - Kavitha Ramchandran
- Department of Medicine, Division of Oncology, Stanford University, Stanford CA
| | | | - Lecia V Sequist
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Zofia Piotrowska
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Heather A Wakelee
- Department of Medicine, Division of Oncology, Stanford University, Stanford CA.
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14
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Hellyer JA, White MN, Gardner RM, Cunanan K, Padda SK, Das M, Ramchandran K, Neal JW, Wakelee HA. Impact of Tumor Suppressor Gene Co-Mutations on Differential Response to EGFR TKI Therapy in EGFR L858R and Exon 19 Deletion Lung Cancer. Clin Lung Cancer 2021; 23:264-272. [PMID: 34838441 DOI: 10.1016/j.cllc.2021.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 06/26/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND In most studies, patients with EGFR L858R mutant non-small cell lung cancer (NSCLC) have a shorter duration of response to EGFR tyrosine kinase inhibitor (TKI) therapy than do patients with EGFR exon 19 deletion NSCLC. The role that co-mutations play in this observation is unknown. METHODS We performed a single-institution retrospective analysis of patients with EGFR-mutant NSCLC (exon 19 deletion or L858R mutation) who received frontline EGFR TKI for metastatic disease between 2014 and 2019, and who had STAMP next-generation sequencing (NGS), a 130-gene platform. Time to treatment failure (TTF) and overall survival were calculated using Cox models adjusted for age, race, and brain metastases. Co-mutations in key tumor suppressor genes (TP53, RB1, KEAP1, CDKN2A, or CTNNB1) were identified and their effects on outcomes were evaluated. Analyses were stratified according to receipt of osimertinib versus nonosimertinib as frontline EGFR TKI. RESULTS Of 137 patients, 72 (57%) had EGFR exon 19 deletions and 65 (43%) had EGFR L858R mutations. Median TTF and OS on frontline TKI was shorter for the L858R cohort versus the exon 19 deletion cohort in univariate analysis. In adjusted models, this difference persisted for TTF but was no longer significant for OS. The difference in TTF in L858R mutant tumors was driven by the presence of co-mutations in key tumor suppressor genes. CONCLUSION Patients with metastatic NSCLC with mutations in EGFR L858R had shorter TTF on frontline TKI compared to patients with EGFR exon 19 deletions. Co-mutations in tumor suppressor genes may play an important role in the differential response to TKI therapy.
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Affiliation(s)
- Jessica A Hellyer
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Maya N White
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Stanford School of Medicine, Stanford, CA
| | - Kristen Cunanan
- Quantitative Sciences Unit, Stanford School of Medicine, Stanford, CA
| | - Sukhmani K Padda
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Millie Das
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Kavitha Ramchandran
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Joel W Neal
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
| | - Heather A Wakelee
- Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA.
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15
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Chamberlain LJ, Bruce J, De La Cruz M, Huffman L, Steinberg JR, Bruguera R, Peterson JW, Gardner RM, He Z, Ordaz Y, Connelly E, Loeb S. A Text-Based Intervention to Promote Literacy: An RCT. Pediatrics 2021; 148:peds.2020-049648. [PMID: 34544847 DOI: 10.1542/peds.2020-049648] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children entering kindergarten ready to learn are more likely to thrive. Inequitable access to high-quality, early educational settings creates early educational disparities. TipsByText, a text-message-based program for caregivers of young children, improves literacy of children in preschool, but efficacy for families without access to early childhood education was unknown. METHODS We conducted a randomized controlled trial with caregivers of 3- and 4-year-olds in 2 public pediatric clinics. Intervention caregivers received TipsByText 3 times a week for 7 months. At pre- and postintervention, we measured child literacy using the Phonological Awareness Literacy Screening Tool (PALS-PreK) and caregiver involvement using the Parent Child Interactivity Scale (PCI). We estimated effects on PALS-PreK and PCI using multivariable linear regression. RESULTS We enrolled 644 families, excluding 263 because of preschool participation. Compared with excluded children, those included in the study had parents with lower income and educational attainment and who were more likely to be Spanish speaking. Three-quarters of enrollees completed pre- and postintervention assessments. Postintervention PALS-PreK scores revealed an unadjusted treatment effect of 0.260 (P = .040); adjusting for preintervention score, child age, and caregiver language, treatment effect was 0.209 (P = .016), equating to ∼3 months of literacy gains. Effects were greater for firstborn children (0.282 vs 0.178), children in 2-parent families (0.262 vs 0.063), and 4-year-olds (0.436 vs 0.107). The overall effect on PCI was not significant (1.221, P = .124). CONCLUSIONS The health sector has unique access to difficult-to-reach young children. With this clinic-based texting intervention, we reached underresourced families and increased child literacy levels.
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Affiliation(s)
- Lisa J Chamberlain
- Division of General Pediatrics .,Center for Policy, Outcomes, and Prevention
| | | | | | | | | | | | | | | | | | | | | | - Susanna Loeb
- Education, Stanford University, Stanford, California
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16
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Perino AC, Gummidipundi SE, Lee J, Hedlin H, Garcia A, Ferris T, Balasubramanian V, Gardner RM, Cheung L, Hung G, Granger CB, Kowey P, Rumsfeld JS, Russo AM, True Hills M, Talati N, Nag D, Tsay D, Desai S, Desai M, Mahaffey KW, Turakhia MP, Perez MV. Arrhythmias Other Than Atrial Fibrillation in Those With an Irregular Pulse Detected With a Smartwatch: Findings From the Apple Heart Study. Circ Arrhythm Electrophysiol 2021; 14:e010063. [PMID: 34565178 DOI: 10.1161/circep.121.010063] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Alexander C Perino
- Department of Medicine (A.C.P., M.P.T., M.V.P.), Stanford University School of Medicine, CA.,Center for Digital Health (A.C.P., M.P.T.), Stanford University School of Medicine, CA
| | - Santosh E Gummidipundi
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | - Justin Lee
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | - Haley Hedlin
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | - Ariadna Garcia
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | - Todd Ferris
- Information Resources and Technology (T.F., G.H.), Stanford University School of Medicine, CA
| | - Vidhya Balasubramanian
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | - Rebecca M Gardner
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | | | - Grace Hung
- Information Resources and Technology (T.F., G.H.), Stanford University School of Medicine, CA
| | | | - Peter Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA (P.K.)
| | - John S Rumsfeld
- Department of Medicine, University of Colorado School of Medicine, Aurora (J.S.R.)
| | - Andrea M Russo
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | | | - Nisha Talati
- Stanford Center for Clinical Research (N.T., K.W.M.), Stanford University School of Medicine, CA
| | - Divya Nag
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., D.N.)
| | - David Tsay
- Apple, Inc, Cupertino, CA (L.C., D.T., S.D.)
| | | | - Manisha Desai
- Quantitative Sciences Unit (S.E.G., J.L., H.H., A.G., V.B., R.M.G., M.D.), Stanford University School of Medicine, CA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (N.T., K.W.M.), Stanford University School of Medicine, CA
| | - Mintu P Turakhia
- Department of Medicine (A.C.P., M.P.T., M.V.P.), Stanford University School of Medicine, CA.,Center for Digital Health (A.C.P., M.P.T.), Stanford University School of Medicine, CA
| | - Marco V Perez
- Department of Medicine (A.C.P., M.P.T., M.V.P.), Stanford University School of Medicine, CA
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17
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Johal JK, Gardner RM, Vaughn SJ, Jaswa EG, Hedlin H, Aghajanova L. Pregnancy success rates for lesbian women undergoing intrauterine insemination. F S Rep 2021; 2:275-281. [PMID: 34553151 PMCID: PMC8441558 DOI: 10.1016/j.xfre.2021.04.007] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/15/2021] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the pregnancy outcomes of lesbian women undergoing donor sperm intrauterine insemination (IUI) with that of heterosexual women undergoing IUI using partner or donor sperm. Design Retrospective cohort analysis. Setting Two academic fertility practices. Patient(s) All IUI cycles between 2007 and 2016. Intervention(s) None. Main outcome measure(s) Primary outcomes included clinical pregnancy (CP) rates and live birth/ongoing pregnancy (LB) rates. The baseline characteristics and cycle characteristics were compared between the two groups using absolute standardized differences (ASDs). To account for the correlation between cycles per patient, a generalized estimating equation method for multivariable logistic regression was used. Results A total of 11,870 IUI cycles were included, of which 393 were in lesbian women using donor sperm and 11,477 were in heterosexual women with infertility using either partner or donor sperm. The CP rates were similar between the lesbian and heterosexual groups (13.2% vs. 11.1%, respectively, ASD = 0.06). In addition, the LB rates were similar between the two groups (10.4% vs. 8.3%, respectively, ASD = 0.10). After implementing the generalized estimating equation in a multivariable logistic regression, the lesbian group had an overall higher odds of CP (adjusted odds ratio 1.40, 95% confidence interval: [1.04–1.88]) and LB (adjusted odds ratio 1.59, 95% confidence interval [1.15–2.20]) compared with the heterosexual group. The clinical miscarriage rate was higher in the heterosexual group compared with that in the lesbian group (23.8% vs. 15.4%, respectively, ASD = 0.21). Conclusion Although the unadjusted rates were similar between the two groups, the adjusted CP and LB odds were significantly higher for lesbian women undergoing IUI for procreative management than those for heterosexual women undergoing IUI for infertility.
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Affiliation(s)
- Jasmyn K Johal
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, California
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Sara J Vaughn
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, California
| | - Eleni G Jaswa
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Franciso, California
| | - Haley Hedlin
- Quantitative Sciences Unit, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, California
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18
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Zhang WY, Gardner RM, Kapphahn KI, Ramachandran MK, Murugappan G, Aghajanova L, Lathi RB. The impact of estradiol on pregnancy outcomes in letrozole-stimulated frozen embryo transfer cycles. F S Rep 2021; 2:320-326. [PMID: 34553158 PMCID: PMC8441577 DOI: 10.1016/j.xfre.2021.05.007] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 10/25/2022] Open
Abstract
Objective To assess the impact of low estradiol (E2) levels in letrozole-stimulated frozen embryo transfer (FET) cycles on pregnancy and neonatal outcomes. Design Retrospective cohort. Setting University-affiliated fertility center. Patients All patients who underwent letrozole-stimulated FET cycles from January 2017 to April 2020 (n = 217). The "Low E2" group was defined as those with E2 serum levels on the day of trigger <10th percentile level (E2 <91.16 pg/mL, n = 22) and the "Normal E2" group was defined as those with E2 serum levels ≥10th percentile level (E2 ≥91.16 pg/mL, n = 195). Interventions None. Main Outcome Measures Pregnancy outcomes including rates of clinical pregnancy, clinical miscarriage, and live birth. Neonatal outcomes including gestational age at delivery, birth weight, and Apgar score. Results The mean ± SD estradiol level was 66.8 ± 14.8 pg/mL for the "Low E2" group compared with 366.3 ± 322.1 pg/mL for the "Normal E2" group. There were otherwise no substantial differences in cycle characteristics such as endometrial thickness on the day of ovulation trigger and progesterone levels in early pregnancy. The "Low E2" group had a significantly higher clinical miscarriage rate (36.4% vs. 8.8%, adjusted odds ratio 8.06) and lower live birth rate (31.8% vs. 57.9%, adjusted odds ratio 0.28). Neonatal outcomes such as gestational age at delivery, mean birth weight, Apgar scores, and incidence of newborn complications were not clinically different between the groups. Conclusion Low E2 levels were associated with a significantly higher miscarriage rate and lower live birth rate, suggesting that E2 levels in the follicular phase may have an effect on cycle outcomes. Given the rise in use of FET, further studies are needed to confirm our findings and understand the mechanisms.
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Affiliation(s)
- Wendy Y Zhang
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kristopher I Kapphahn
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Maya K Ramachandran
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Gayathree Murugappan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Ruth B Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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19
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Choi E, Sanyal N, Ding VY, Gardner RM, Aredo JV, Lee J, Wu JT, Hickey TP, Barrett B, Riley TL, Wilkens LR, Leung AN, Le Marchand L, Tammemägi MC, Hung RJ, Amos CI, Freedman ND, Cheng I, Wakelee HA, Han SS. Development and Validation of a Risk Prediction Tool for Second Primary Lung Cancer. J Natl Cancer Inst 2021; 114:87-96. [PMID: 34255071 PMCID: PMC8755509 DOI: 10.1093/jnci/djab138] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/04/2021] [Accepted: 07/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background With advancing therapeutics, lung cancer (LC) survivors are rapidly increasing in
number. Although mounting evidence suggests LC survivors have high risk of second
primary lung cancer (SPLC), there is no validated prediction model available for
clinical use to identify high-risk LC survivors for SPLC. Methods Using data from 6325 ever-smokers in the Multiethnic Cohort (MEC) study diagnosed with
initial primary lung cancer (IPLC) in 1993-2017, we developed a prediction model for
10-year SPLC risk after IPLC diagnosis using cause-specific Cox regression. We evaluated
the model’s clinical utility using decision curve analysis and externally validated it
using 2 population-based data—Prostate, Lung, Colorectal, and Ovarian Cancer Screening
Trial (PLCO) and National Lung Screening Trial (NLST)—that included 2963 and 2844 IPLC
(101 and 93 SPLC cases), respectively. Results Over 14 063 person-years, 145 (2.3%) ever-smoking IPLC patients developed SPLC in MEC.
Our prediction model demonstrated a high predictive accuracy (Brier score = 2.9, 95%
confidence interval [CI] = 2.4 to 3.3) and discrimination (area under the receiver
operating characteristics [AUC] = 81.9%, 95% CI = 78.2% to 85.5%) based on bootstrap
validation in MEC. Stratification by the estimated risk quartiles showed that the
observed SPLC incidence was statistically significantly higher in the 4th vs 1st
quartile (9.5% vs 0.2%; P < .001). Decision curve
analysis indicated that in a wide range of 10-year risk thresholds from 1% to 20%, the
model yielded a larger net-benefit vs hypothetical all-screening or no-screening
scenarios. External validation using PLCO and NLST showed an AUC of 78.8% (95% CI =
74.6% to 82.9%) and 72.7% (95% CI = 67.7% to 77.7%), respectively. Conclusions We developed and validated a SPLC prediction model based on large population-based
cohorts. The proposed prediction model can help identify high-risk LC patients for SPLC
and can be incorporated into clinical decision making for SPLC surveillance and
screening.
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Affiliation(s)
- Eunji Choi
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Nilotpal Sanyal
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Victoria Y Ding
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Justin Lee
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Julie T Wu
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Lynne R Wilkens
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Ann N Leung
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Loïc Le Marchand
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Martin C Tammemägi
- Department of Health Sciences, Brock University, St Catharines, Ontario, Canada
| | - Rayjean J Hung
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | | | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Iona Cheng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Heather A Wakelee
- Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Summer S Han
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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Aredo JV, Luo SJ, Gardner RM, Sanyal N, Choi E, Hickey TP, Riley TL, Huang WY, Kurian AW, Leung AN, Wilkens LR, Robbins HA, Riboli E, Kaaks R, Tjønneland A, Vermeulen RCH, Panico S, Le Marchand L, Amos CI, Hung RJ, Freedman ND, Johansson M, Cheng I, Wakelee HA, Han SS. Tobacco Smoking and Risk of Second Primary Lung Cancer. J Thorac Oncol 2021; 16:968-979. [PMID: 33722709 PMCID: PMC8159872 DOI: 10.1016/j.jtho.2021.02.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Lung cancer survivors are at high risk of developing a second primary lung cancer (SPLC). However, SPLC risk factors have not been established and the impact of tobacco smoking remains controversial. We examined the risk factors for SPLC across multiple epidemiologic cohorts and evaluated the impact of smoking cessation on reducing SPLC risk. METHODS We analyzed data from 7059 participants in the Multiethnic Cohort (MEC) diagnosed with an initial primary lung cancer (IPLC) between 1993 and 2017. Cause-specific proportional hazards models estimated SPLC risk. We conducted validation studies using the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (N = 3423 IPLC cases) and European Prospective Investigation into Cancer and Nutrition (N = 4731 IPLC cases) cohorts and pooled the SPLC risk estimates using random effects meta-analysis. RESULTS Overall, 163 MEC cases (2.3%) developed SPLC. Smoking pack-years (hazard ratio [HR] = 1.18 per 10 pack-years, p < 0.001) and smoking intensity (HR = 1.30 per 10 cigarettes per day, p < 0.001) were significantly associated with increased SPLC risk. Individuals who met the 2013 U.S. Preventive Services Task Force's screening criteria at IPLC diagnosis also had an increased SPLC risk (HR = 1.92; p < 0.001). Validation studies with the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and European Prospective Investigation into Cancer and Nutrition revealed consistent results. Meta-analysis yielded pooled HRs of 1.16 per 10 pack-years (pmeta < 0.001), 1.25 per 10 cigarettes per day (pmeta < 0.001), and 1.99 (pmeta < 0.001) for meeting the U.S. Preventive Services Task Force's criteria. In MEC, smoking cessation after IPLC diagnosis was associated with an 83% reduction in SPLC risk (HR = 0.17; p < 0.001). CONCLUSIONS Tobacco smoking is a risk factor for SPLC. Smoking cessation may reduce the risk of SPLC. Additional strategies for SPLC surveillance and screening are warranted.
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Affiliation(s)
| | - Sophia J Luo
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Nilotpal Sanyal
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Eunji Choi
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | | | - Wen-Yi Huang
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, Maryland
| | - Allison W Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California; Department of Medicine, Stanford University School of Medicine, Stanford, California; Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Ann N Leung
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Lynne R Wilkens
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, Hawaii
| | | | - Elio Riboli
- Epidemiology and Prevention, School of Public Health, Imperial College London, London, United Kingdom
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Center for Lung Research, Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany
| | - Anne Tjønneland
- Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Roel C H Vermeulen
- Division Environmental Epidemiology, Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Salvatore Panico
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Loïc Le Marchand
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, Hawaii
| | | | - Rayjean J Hung
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Neal D Freedman
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, Maryland
| | | | - Iona Cheng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Heather A Wakelee
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Summer S Han
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California; Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
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Johal JK, Bavan B, Zhang W, Gardner RM, Lathi RB, Milki AA. The impact of timing modified natural cycle frozen embryo transfer based on spontaneous luteinizing hormone surge. J Assist Reprod Genet 2020; 38:219-225. [PMID: 33230616 DOI: 10.1007/s10815-020-01994-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate whether adjusting timing of modified natural cycle frozen embryo transfer (mNC-FET) 1 day earlier in the setting of a spontaneous LH surge has an impact on pregnancy outcomes. METHODS This retrospective cohort study evaluated all mNC-FET with euploid blastocysts from May 1, 2016 to March 30, 2019, at a single academic institution. Standard protocol for mNC-FET included ultrasound monitoring and hCG trigger when the dominant follicle and endometrial lining were appropriately developed. Patients had serum LH, estradiol, and progesterone checked on day of trigger. If LH was ≥ 20 mIU/mL, trigger was given that day and FET was performed 6 days after surge (LH/HCG+6), with the intent of transferring 5 days after ovulation. If LH was < 20 mIU/mL, FET was performed 7 days after trigger (hCG+7). Primary outcomes included clinical pregnancy and live birth rates. To account for correlation between cycles, a generalized estimating equation (GEE) method for multivariable logistic regression was used. RESULTS Four hundred fifty-three mNC-FET cycles met inclusion criteria, of which 205 were in the LH/HCG+6 group and 248 were in the HCG+7 group. The overall clinical pregnancy rate was 64% and clinical miscarriage rate was 4.8%, with similar rates between the two groups. The overall live birth rate was 60.9% (61.0% in LH/HCG+6 group and 60.9% in HCG+7 group). After implementing GEE, the odds of CP (aOR 0.97, 95% CI [0.65-1.45], p = 0.88) and LB (aOR 0.98, 95% CI [0.67-1.45], p = 0.93) were similar in both groups. CONCLUSIONS In our study cohort, mNC-FET based on LH/HCG+6 versus HCG+7 had similar pregnancy outcomes.
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Affiliation(s)
- J K Johal
- Department of Obstetrics & Gynecology, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304, USA.
| | - B Bavan
- Division of Reproductive Endocrinology & Infertility Department of Obstetrics & Gynecology, Stanford University, 1195 West Fremont Avenue, MC 7717, Sunnyvale, CA, 94087, USA
| | - W Zhang
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - R M Gardner
- Quantitative Sciences Unit, Stanford University School of Medicine, 1701 Page Mill Road, Palo Alto, CA, 94304, USA
| | - R B Lathi
- Division of Reproductive Endocrinology & Infertility Department of Obstetrics & Gynecology, Stanford University, 1195 West Fremont Avenue, MC 7717, Sunnyvale, CA, 94087, USA
| | - A A Milki
- Division of Reproductive Endocrinology & Infertility Department of Obstetrics & Gynecology, Stanford University, 1195 West Fremont Avenue, MC 7717, Sunnyvale, CA, 94087, USA
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Abstract
OBJECTIVES To review the history of clinical information systems over the past twenty-five years and project anticipated changes to those systems over the next twenty-five years. METHODS Over 250 Medline references about clinical information systems, quality of patient care, and patient safety were reviewed. Books, Web resources, and the author's personal experience with developing the HELP system were also used. RESULTS There have been dramatic improvements in the use and acceptance of clinical computing systems and Electronic Health Records (EHRs), especially in the United States. Although there are still challenges with the implementation of such systems, the rate of progress has been remarkable. Over the next twenty-five years, there will remain many important opportunities and challenges. These opportunities include understanding complex clinical computing issues that must be studied, understood and optimized. Dramatic improvements in quality of care and patient safety must be anticipated as a result of the use of clinical information systems. These improvements will result from a closer involvement of clinical informaticians in the optimization of patient care processes. CONCLUSIONS Clinical information systems and computerized clinical decision support have made contributions to medicine in the past. Therefore, by using better medical knowledge, optimized clinical information systems, and computerized clinical decision, we will enable dramatic improvements in both the quality and safety of patient care in the next twenty-five years.
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Affiliation(s)
- R M Gardner
- Reed M. Gardner, PhD, Professor Emeritus, Department of Biomedical Informatics, University of Utah, 1745 Cornell Circle (Home Address), Salt Lake City, UT 84108, Tel: +1 801 581 1164, Cell: +1 801 455 8207, E-mail:
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Blomström Å, Gardner RM, Dalman C, Yolken RH, Karlsson H. Influence of maternal infections on neonatal acute phase proteins and their interaction in the development of non-affective psychosis. Transl Psychiatry 2015; 5:e502. [PMID: 25646591 PMCID: PMC4445745 DOI: 10.1038/tp.2014.142] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/24/2014] [Indexed: 11/24/2022] Open
Abstract
Although primary infections with Toxoplasma gondii or herpes viruses during pregnancy are established teratogens, chronic maternal infections with these pathogens are considered far less serious. However, such chronic infections have been associated with neuropsychiatric disorders in the offspring. The risks of non-affective psychoses, including schizophrenia, in offspring associated with these exposures during pregnancy have not been completely defined. We used data from neonatal dried blood samples from 199 cases of non-affective psychosis and 525 matched controls (born 1975-1985). We measure immunoglobulin G antibodies directed at T. gondii, cytomegalovirus and herpes simplex virus type-1 and -2, as well as levels of nine acute phase proteins (APPs). We assessed the interaction between maternal antibodies and neonatal APP in terms of risk of non-affective psychosis. Among controls, maternal exposure to T. gondii or cytomegalovirus, but not to the other herpes viruses, was associated with significantly higher levels of neonatal APPs. Among cases, none of the maternal exposures were associated with any significant change in APPs. We observed increased RR for non-affective psychosis associated with maternal infection with T. gondii (odds ratio 2.1, 95% confidence interval 1.1-4.0) or cytomegalovirus (1.7, 0.9-3.3) only among neonates with low APP levels. These findings suggest that chronic maternal infection with T. gondii or cytomegalovirus affect neonatal markers of innate immunity. Deficient fetal immune responses in combination with maternal chronic infections may contribute to subsequent risk for psychosis. A greater understanding of the maternal-fetal immunological interplay may ultimately lead to preventive strategies toward neuropsychiatric disorders.
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Affiliation(s)
- Å Blomström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden,Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Stockholm 171 76, Sweden. E-mail:
| | - R M Gardner
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - C Dalman
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - R H Yolken
- Stanley Division of Developmental Neurovirology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - H Karlsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Gardner RM, Dalman C, Wicks S, Lee BK, Karlsson H. Neonatal levels of acute phase proteins and later risk of non-affective psychosis. Transl Psychiatry 2013; 3:e228. [PMID: 23423137 PMCID: PMC3591005 DOI: 10.1038/tp.2013.5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 01/03/2013] [Indexed: 12/26/2022] Open
Abstract
Mounting evidence suggests that immune disturbances in early life may be implicated in the etiology of non-affective psychoses. Our aim was to assess the levels of neonatal acute phase proteins (APPs), central to innate immune function as well as central nervous system development, in neonatal dried blood spots and their association with later risk of non-affective psychoses. This case-control study included 196 individuals with a verified register-based diagnosis of non-affective psychosis and 502 controls matched on age, sex and hospital of birth. Concentrations of nine different APPs were measured in eluates from dried blood spots using a bead-based multiplex assay. Odds ratios (OR) for non-affective psychoses were calculated for log(2)-transformed (continuous) as well as tertiles of APP concentrations. In continuous analysis, higher concentrations of two APPs, tissue plasminogen activator (tPA; OR: 0.90, 95% confidence interval (CI): 0.85-0.96) and serum amyloid P (SAP; OR: 0.88, 95% CI: 0.78-0.99) were protective in terms of risk of non-affective psychosis. These relationships were not affected by the addition of covariates relevant to maternal health, pregnancy and delivery to the model. Tertile analysis confirmed a protective relationship for higher levels of tPA and SAP, as well as for procalcitonin (highest tertile OR: 0.54, 95% CI:0.32-0.91). Our results suggest that persons who develop non-affective psychoses have lower levels of certain APPs at the time of birth. These differences may render individuals more susceptible to infectious diseases or cause deficiencies in pathways critical for neurodevelopment.
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Affiliation(s)
- R M Gardner
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - C Dalman
- Department of Public Health Sciences, Division of Public Health Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - S Wicks
- Department of Public Health Sciences, Division of Public Health Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - B K Lee
- Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, PA, USA
| | - H Karlsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Petratos GN, Kim Y, Evans RS, Williams SD, Gardner RM. Comparing the effectiveness of computerized adverse drug event monitoring systems to enhance clinical decision support for hospitalized patients. Appl Clin Inform 2010; 1:293-303. [PMID: 23616843 DOI: 10.4338/aci-2009-11-ra-0009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 07/30/2010] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Performance of computerized adverse drug event (ADE) monitoring of electronic health records through a prospective ADE Monitor and ICD9-coded clinical text review operating independently and simultaneously on the same patient population for a 10-year period are compared. Requirements are compiled for clinical decision support in pharmacy systems to enhance ADE detection. METHODS A large tertiary care facility in Utah, with a history of quality improvement using its advanced hospital information system, was leveraged in this study. ICD9-based review of clinical charts (ICD9 System) was compared quantitatively and qualitatively to computer-assisted pharmacist-verified ADEs (ADE Monitor). The capture-recapture statistical method was applied to the data to determine an estimated prevalence of ADEs. RESULTS A total estimated ADE prevalence of 5.53% (13,420/242,599) was calculated, with the ICD9 system identifying 2,604 or 19.4%, and the ADE monitor 3,386 or 25.2% of all estimated ADEs. Both methods commonly identified 4.9% of all estimated ADEs and matched 62.0% of the time, each having its strength in detecting a slightly different domain of ADEs. 70% of the ADE documentation in the clinical notes was found in the discharge summaries. CONCLUSION Coupled with spontaneous reporting, computerized methods account for approximately half of all ADEs that can currently be detected. To enhance ADE monitoring and patient safety in a hospitalized setting, pharmacy information systems should incorporate prospective structuring and coding of the text in clinical charts and using that data alongside computer-generated alerts of laboratory results and drug orders. Natural language processing can aid computerized detection by automating the coding, in real-time, of physician text from clinical charts so that decision support rules can be created and applied. New detection strategies and enhancements to existing systems should be researched to enhance the detection of ADEs since approximately half are not currently detected.
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Gardner RM. Clinical decision support systems: the fascination with closed-loop control. Yearb Med Inform 2009:17-21. [PMID: 19855866] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Affiliation(s)
- R M Gardner
- Department of Medical Informatics, University of Utah, Salt Lake City, Utah, USA.
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Jaspers MWM, Gardner RM, Gatewood LC, Haux R, Evans RS. An international summer school on health informatics: a collaborative effort of the Amsterdam Medical Informatics Program and IPhiE--the International Partnership for Health Informatics Education. Int J Med Inform 2006; 76:538-46. [PMID: 16542869 DOI: 10.1016/j.ijmedinf.2006.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Revised: 02/17/2006] [Accepted: 02/19/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE Today, the need for health informatics training for health care professionals is acknowledged and educational opportunities for these professionals are increasing. To contribute to these efforts, a new initiative was undertaken by the Medical Informatics Program of the University of Amsterdam-Academic Medical Center and IPHIE (IPhiE)-the International Partnership for Health Informatics Education. In the year 2004, a summer school on health informatics was organized for advanced medical students from all over the world. METHODS We elaborate on the goals and the program for this summer school. In developing the course, we followed the international guidelines of the International Medical Informatics Association-IMIA. Students provided feedback for the course through both summative and formative evaluations. As a result of these evaluations, we outline the lessons we have learned and what consequences these results have had in revising the course. RESULTS Overall the results of both the summative and formative evaluation of the summer school showed that we succeeded in the goals we set at the beginning of the course. Students highly appreciated the course content and indicated that the course fulfilled their educational needs. The decision support and image processing computer practicums however proved too high level. We therefore will redesign these practicums to competence requirements of medical doctors as defined by IMIA. All participants recommended the summer school event to other students. CONCLUSIONS Our experiences demonstrated a true need for health informatics education among medical students and that even a 2 weeks course can fulfill health informatics educational needs of these future physicians. Further establishment of health informatics courses for other health professions is recommended.
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Affiliation(s)
- M W M Jaspers
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1000 DE Amsterdam, The Netherlands.
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Ammenwerth E, Talmon J, Ash JS, Bates DW, Beuscart-Zéphir MC, Duhamel A, Elkin PL, Gardner RM, Geissbuhler A. Impact of CPOE on mortality rates--contradictory findings, important messages. Methods Inf Med 2006; 45:586-93. [PMID: 17149499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To analyze the seemingly contradictory results of the Han study (Pediatrics 2005) and the Del Beccaro study (Pediatrics 2006), both analyzing the effect of CPOE systems on mortality rates in pediatric intensive care settings. METHODS Seven CPOE system experts from the United States and Europe comment on these papers. RESULTS The two studies are not contradictory, but almost non-comparable due to differences in design and implementation. They demonstrate the range of outcomes that can be obtained from introducing informatics applications in complex health care settings. Implementing informatics applications is a sociotechnical activity, which often depends more on the organizational context than on a specific technology. As health informaticians, we must not only learn from failures, but also avoid both uncritical scepticism that may arise from drawing overly general conclusions from one negative trial, as much as uncritical optimism from limited successful ones. CONCLUSION The commentaries emphasize the need to promote systematic studies for assessing the socio-technical factors that influence the introduction of increasingly sophisticated informatics applications within complex organizations. The emergence of evidence-based health informatics will be based both on evaluation guidelines and implementation guidelines, both of which increase the chances of successful implementation. In addition, well-educated health informaticians are needed to manage and guide the implementation processes.
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Affiliation(s)
- E Ammenwerth
- University for Health Sciences, Medical Informatics and Technology, Institute for Health Information Systems, Eduard-Wallnöfer-Zentrum I, 6060 Hall, Tyrol, Austria.
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Jaspers MWM, Gardner RM, Gatewood LC, Haux R, Schmidt D, Wetter T. Achievements after Six Years of The International Partnership for Health Informatics Education. Yearb Med Inform 2005:173-182. [PMID: 27706301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Affiliation(s)
- M W M Jaspers
- Monique W. M. Jaspers, PhD, University of Amsterdam, Academic Medical Center, Department of Medical Informatics, J2-259, P.O. Box 22700, 1000 DE Amsterdam, The Netherlands, Tel: +31 20 5665178, Fax: +31 20 6919840, E-mail:
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Jaspers MWM, Gardner RM, Gatewood LC, Haux R, Schmidt D, Wetter T. The International Partnership for Health Informatics Education: lessons learned from six years of experience. Methods Inf Med 2005; 44:25-31. [PMID: 15778791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVES To inform the medical and health informatics community on the rational, goals, and the achievements of the International Partnership for Health Informatics Education--IPHIE, (I phi E), that was established at six universities in 1999. METHODS We elaborate on the overall goals of I phi E and describe the current state of affairs: the activities undertaken and faculty and student experience related to these activities. In addition we outline the lessons we have learned over these past six years and our plans for the future. RESULTS I phi E members first started to collaborate by supporting and encouraging the exchange of talented students and faculty and by establishing joint master classes for honors students. Following the success of these activities, new initiatives were undertaken such as the organization of student workshops at medical informatics conferences and a joint course on strategic information management in hospitals in Europe. CONCLUSIONS International partnerships such as I phi E take time to establish, and, if they are to be successful, maintaining leadership continuity is critically important. We are convinced that I phi E promotes professionalism of future medical informatics specialists. There will be a continuing growth of globalization in higher education. It will therefore become increasingly important to offer educational programs with international components.
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Affiliation(s)
- M W M Jaspers
- Department of Medical Informatics, American Medical College, University of Amsterdam, J2-259, P.O. Box 22700, 1000 DE Amsterdam, The Netherlands.
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Jaspers MWM, Gardner RM, Gatewood LC, Haux R, Schmidt D, Wetter T. The International Partnership in Health Informatics Education. Stud Health Technol Inform 2004; 107:884-8. [PMID: 15360939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
The International Partnership for Health Informatics Education (IPHIE) seeks to promote education through international collaboration of graduate and undergraduate training programs in Medical and Health Informatics. In 1998 an International Partnership of Health Informatics Education was established at six universities: The University of Amsterdam, the Universities of Heidelberg and Heilbronn, the University of Health Informatics and Technology Tyrol at Innsbruck, the University of Minnesota and the University of Utah. The overall goal of this cooperation was to form a network for training and educating medical informatics faculty and students in order to prepare them for leading international positions in medical information and communication technology. In this paper we describe the current state of affairs of IPhiE: the activities undertaken, our experiences, the lessons we have learned over these past five years. In addition we outline our plans for the future.
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Affiliation(s)
- M W M Jaspers
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, The Netherlands
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Abstract
Body size perception was measured in 41 children aged 6-10 who had been either sexually or physically abused, or had no history of abuse. Two psychophysical methods were used, including the staircase method and a signal detection method. In the staircase methodology, children adjusted the direction of distortion of their continuously changing body size. In the signal detection method, children made judgments about the presence or absence of size distortion in presented images. Results using the staircase method indicated children overestimated their body sizes, with no differences between abuse conditions, gender, or age. For the signal detection methodology, no difference in ability to detect the presence/absence of size distortion (d') was found between abuse conditions, although females were less accurate than males. All groups were better able to detect distortion when the image was distorted too wide. Measures of response bias (Ln beta) indicated that sexually abused children had a greater bias to report size distortion as present, as compared with the physically abused children.
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Affiliation(s)
- R M Gardner
- Department of Psychology, University of Southern Colorado, Pueblo 81001
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Jaspers MW, Gardner RM, Gatewood LC, Haux R, Leven FJ, Limburg M, Ravesloot JH, Schmidt D, Wetter T. IPHIE: an International Partnership in Health Informatics Education. Stud Health Technol Inform 2001; 77:549-53. [PMID: 11187613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Medical informatics contributes significantly to high quality and efficient health care and medical research. The need for well educated professionals in the field of medical informatics therefore is now worldwide recognized. Students of medicine, computer science/informatics are educated in the field of medical informatics and dedicated curricula on medical informatics have emerged. To advance and further develop the beneficial role of medical informatics in the medical field, an international orientation of health and medical informatics students seems an indispensable part of their training. An international orientation and education of medical informatics students may help to accelerate the dissemination of acquired knowledge and skills in the field and the promotion of medical informatics research results on a more global level. Some years ago, the departments of medical informatics of the university of Heidelberg/university of applied sciences Heilbronn and the university of Amsterdam decided to co-operate in the field of medical informatics. Now, this co-operation has grown out to an International Partnership of Health Informatics Education (IPHIE) of 5 universities, i.e. the university of Heidelberg, the university of Heilbronn, the university of Minnesota, the university of Utah and the university of Amsterdam. This paper presents the rationale behind this international partnership, the state of the art of the co-operation and our future plans for expanding this international co-operation.
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Affiliation(s)
- M W Jaspers
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam
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Abstract
The immature rat uterus has been extensively used as an in vivo model system to study the molecular mechanisms of steroid hormone actions. In this study, we demonstrated the regulated expression of syndecan-3 in the rat uterus by the steroid hormone 17 beta-estradiol. Administration of a single physiological dose of 17 beta-estradiol (40 microg/kg) to ovariectomized immature animals induced a rapid and transient increase in uterine syndecan-3 mRNA. Transcript levels reached a peak elevation of 3-fold above saline control tissues 4 h after hormone administration. Inhibition of message up-regulation by actinomycin D but not cycloheximide indicated a hormone response dependent on RNA transcription but not new protein synthesis. The estrogenic ligands estriol and tamoxifen were also effective at raising syndecan-3 mRNA levels; however, nonestrogenic ligands, including progesterone, 5 alpha-dihydrotestosterone, and dexamethasone, failed to stimulate a change in mRNA levels. Hormone-induced changes in mRNA led to transient changes in syndecan-3 protein content and significant alteration in the temporal and spatial expression in endometrial epithelial cells. Collectively, these data show that the steroid hormone 17 beta-estradiol, regulates transcription of the syndecan-3 gene in the uterus via an estrogen receptor-dependent mechanism. This estrogen-regulated expression of syndecan-3 may play an important role in changes in tissue ultrastructure crucial for proper uterine growth.
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Affiliation(s)
- L A Russo
- Department of Biology, Villanova University, Villanova, Pennsylvania 19085, USA.
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Gardner RM. University of Utah Medical Informatics Research and Training Program. Yearb Med Inform 2001:103-111. [PMID: 27701603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Affiliation(s)
- R M Gardner
- Reed M. Gardner, PhD, Professor and Chairman, Department of Medical Informatics, University of Utah, Co-Director of Medical Informatics, LDS Hospital, University of Utah, School of Medicine, Room AB193, 50 North Medical Drive, Salt Lake City, Utah, USA, E-mail:
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Abstract
OBJECTIVE To analyze whether computer-generated reminders about infections could influence clinicians' practice patterns and consequently improve the detection and management of nosocomial infections. DESIGN The conclusions produced by an expert system developed to detect and manage infections were presented to the attending clinicians in a pediatric hospital to determine whether this information could improve detection and management. Clinician interventions were compared before and after the implementation of the system. MEASUREMENTS The responses of the clinicians (staff physicians, physician assistants, and nurse practitioners) to the reminders were determined by review of paper medical charts. Main outcome measures were the number of suggestions to treat and manage infections that were followed before and after the implementation of COMPISS (Computerized Pediatric Infection Surveillance System). The clinicians' opinions about the system were assessed by means of a paper questionnaire distributed following the experiment. RESULTS The results failed to show a statistical difference between the clinicians' treatment strategies before and after implementation of the system (P: > 0.33 for clinicians working in the emergency room and P: > 0.45 for clinicians working in the pediatric intensive care unit). The questionnaire results showed that the respondents appreciated the information presented by the system. CONCLUSION The computer-generated reminders about infections were unable to influence the practice patterns of clinicians. The methodologic problems that may have contributed to this negative result are discussed.
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Affiliation(s)
- B H Rocha
- University of Utah, Salt Lake City, Utah.
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Abstract
Avoidance of shortcomings of older scales of body image and use of additional measurements in newer scales are stated.
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Affiliation(s)
- R M Gardner
- Department of Psychology, University of Colorado at Denver, 80217, USA.
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Abstract
The objective of this study was to identify variables that predict higher eating disorder scores in non-clinical boys and girls ages 6 through 14. Two hundred sixteen children participated and were tested annually for 3 years. A TV-video procedure was used to measure the accuracy of body size judgments. Variables examined included demographic, familial, sociocultural, social, esteem, and clinical variables. Predictors of higher eating disorder scores for both sexes included height and weight, children's perceptions of parental concerns about their body size, low body esteem, and depression. For girls only, a larger perceived body size and smaller idealized body size were also predictors. Teasing was a predictor for boys only. An analysis of longitudinal changes suggests that low body esteem becomes a significant factor around age 9, depression emerges as a predictor at age 10, and body size judgments in perceived and ideal sizes at ages 11 and 12. Changes over 2 years in individuals' weight and height, teasing, body dissatisfaction, and eating disorder scores were also found to predict higher eating disorder scores.
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Affiliation(s)
- R M Gardner
- Department of Psychology, University of Colorado at Denver, Campus Box 173, P.O. Box 173364, Denver, CO 80217-3364, USA.
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Gardner RM. Interaction between clinical research and patient data. Stud Health Technol Inform 2000; 76:35-47. [PMID: 10947500] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- R M Gardner
- Department of Medical Informatics, University of Utah, Salt Lake City, USA
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Abstract
This study reports the development and validation of two new and improved tools for assessment of body-image. Two schematic contour scales were created using a frontal view photograph of an adult male and female with height and weight of the median American. A 2-figure analogue scale was created by distorting this drawing by +/- 30%. A 13-card scale was created by generating 13 drawings distorted between +/- 30% by increments of 5%. Evidence is presented for the reliability and validity of both scales. The advantages of these new scales over existing figural and silhouette scales are discussed.
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Affiliation(s)
- R M Gardner
- Department of Psychology, University of Colorado at Denver 80217-3364, USA.
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Gardner RM. Y2K: need for health care professionals to be responsible and prepared. Heart Lung 1999; 28:377-9. [PMID: 10580211 DOI: 10.1016/s0147-9563(99)70026-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- R M Gardner
- Department of Medical Informatics, University of Utah and LDS Hospital, Salt Lake City, UT 84143, USA
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Abstract
The HELP hospital information system has been operational at LDS Hospital since 1967. The system initially supported a heart catheterization laboratory and a post open heart Intensive Care Unit. Since the initial installation the system has been expanded to become an integrated hospital information system providing services with sophisticated clinical decision-support capabilities to a wide variety of clinical areas such as laboratory, nurse charting, radiology, pharmacy, etc. The HELP system is currently operational in multiple hospitals of LDS Hospital's parent health care enterprise--Intermountain Health Care (IHC). The HELP system has also been integrated into the daily operations of several other hospitals in addition to those at IHC. Evaluations of the system have shown: (1) it to be widely accepted by clinical staff; (2) computerized clinical decision-support is feasible; (3) the system provides improvements in patient care; and (4) the system has aided in providing more cost-effective patient care. Plans for making the transition from the 'function rich' HELP system to more modern hardware and software platforms are also discussed.
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Affiliation(s)
- R M Gardner
- LDS Hospital, Salt Lake City, UT 84143, USA.
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Gardner RM. Medical informatics at the University of Utah: applying research to real-life issues. MD Comput 1999; 16:29-32. [PMID: 10439597] [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] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- R M Gardner
- Department of Medical Informatics, University of Utah, USA.
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Abstract
Estimates of perceived and ideal body size were collected in 216 boys and girls ages 6 through 14 years. Video methodology was used to adjust the width of a life-size frontal image of the children. Longitudinal data were collected annually for three years, beginning at ages 6, 9, and 12. Three psychological methods were used, including the method of adjustment, staircase method, and adaptive probit estimation technique which permitted separate measures of the children's point of subjective equality and just noticeable difference values. The point of subjective equality is the body size which is subjectively equal to the child's perception of self. The just noticeable difference is the amount of change in body size necessary to detect the difference 50% of the time. Acceptable size boundaries were also measured, using the method of adjustment. Over-all, children were accurate in estimating their body width, with average overestimation of less than 2%. Overestimation decreased within each age group during the three years of the study. There were no differences between ages or sexes. Both point of subjective equality and just noticeable difference values decreased significantly during the three years of the study. The latter values significantly decreased as children became older. Body dissatisfaction (the discrepancy between perceived and ideal size) remained low for boys in all age groups. Girls' body dissatisfaction significantly increased across ages, beginning at age 9. Test-retest consistency of both perceived and ideal size judgments at intervals of one and two years were low. Acceptable boundaries in body width were similar between sexes and across age cohorts.
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Affiliation(s)
- R M Gardner
- Department of Psychology, University of Colorado at Denver 80217-3364, USA.
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Abstract
The University of Utah has been educating health professionals in medical informatics since 1964. Over the 35 years since the program's inception, 272 graduate students have studied in the department. Most students have been male (80 percent) and have come from the United States (75 percent). Students entering the program have had diverse educational backgrounds, most commonly in medicine, engineering, computer science, or biology (59 percent of all informatics students). A total of 209 graduate degrees have been awarded, with an overall graduation rate of 87 percent since the program's start. Alumni are located in the United States (91 percent) and abroad (9 percent); half (51 percent) have remained in Utah. Former students are employed in a wide variety of jobs, primarily concerned with the application of medical informatics in sizable health care delivery organizations. Trends toward increasing managerial responsibility for medical informatics graduates and the emergence of the chief information officer role are noted.
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Affiliation(s)
- G A Patton
- University of Utah, Salt Lake City 84132, USA
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Abstract
This paper discusses methodological concerns of using silhouette figures to measure body images. These include concerns related to scale coarseness (limiting response options to one of a finite number of drawings), restriction of range, method of presentation, and scale of measurement. Recommendations are made to address these limitations, and an alternative silhouette scale using continuous scale measurements is proposed.
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Affiliation(s)
- R M Gardner
- Department of Psychology, University of Colorado at Denver 80217-3364, USA.
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Miller RA, Gardner RM. Summary recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, The Computer-based Patient Record Institute, The Medical Library Association, The Association of Academic Health Science Libraries, The American Health Information Management Association, and The American Nurses Association. Ann Intern Med 1997; 127:842-5. [PMID: 9382409 DOI: 10.7326/0003-4819-127-9-199711010-00014] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Clinical software systems are becoming ubiquitous. A growing literature documents how these systems can improve health care delivery, but concerns about patient safety must now be formally addressed. In 1996, the U.S. Food and Drug Administration (FDA) called for discussions on regulation of software programs as medical devices. In response, a consortium of organizations dedicated to improving health care through information technology developed recommendations for the responsible regulation and monitoring of clinical software systems by users, vendors, and regulatory agencies. These recommendations were revised and approved by the American Medical informatics Association Public Policy Committee and Board. Other organizations reviewed, modified, and approved the recommendations, and the Boards of Directors of most of the organizations in the consortium endorsed the guidelines. The consortium proposes four categories of clinical system risk and four classes of monitoring and regulatory action that can be applied on the basis of the risk level. The consortium recommends that most clinical software systems be supervised locally and that developers of health care information systems adopt a code of good business practices. Budgetary and other constraints limit the type and number of systems that the FDA can regulate effectively; therefore, the FDA should exempt most clinical software systems and focus on systems that pose high clinical risk and provide limited opportunity for competent human intervention.
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Miller RA, Gardner RM. Recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, Computer-based Patient Record Institute, Medical Library Association, Association of Academic Health Science Libraries, American Health Information Management Association, American Nurses Association. J Am Med Inform Assoc 1997; 4:442-57. [PMID: 9391932 PMCID: PMC61262 DOI: 10.1136/jamia.1997.0040442] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/1997] [Accepted: 07/17/1997] [Indexed: 02/05/2023] Open
Abstract
In mid-1996, the FDA called for discussions on regulation of clinical software programs as medical devices. In response, a consortium of organizations dedicated to improving health care through information technology has developed recommendations for the responsible regulation and monitoring of clinical software systems by users, vendors, and regulatory agencies. Organizations assisting in development of recommendations, or endorsing the consortium position include the American Medical Informatics Association, the Computer-based Patient Record Institute, the Medical Library Association, the Association of Academic Health Sciences Libraries, the American Health Information Management Association, the American Nurses Association, the Center for Healthcare Information Management, and the American College of Physicians. The consortium proposes four categories of clinical system risks and four classes of measured monitoring and regulatory actions that can be applied strategically based on the level of risk in a given setting. The consortium recommends local oversight of clinical software systems, and adoption by healthcare information system developers of a code of good business practices. Budgetary and other constraints limit the type and number of systems that the FDA can regulate effectively. FDA regulation should exempt most clinical software systems and focus on those systems posing highest clinical risk, with limited opportunities for competent human intervention.
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Affiliation(s)
- R A Miller
- American Medical Informatics Association, Bethesda, MD, USA.
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