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Gersie T, Bitter T, Wolfson D, Freeman R, Verdonschot N, Janssen D. Quantification of long-term nonlinear stress relaxation of bovine trabecular bone. J Mech Behav Biomed Mater 2024; 152:106434. [PMID: 38350383 DOI: 10.1016/j.jmbbm.2024.106434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/15/2024]
Abstract
The reliability of computational models in orthopedic biomechanics depends often on the accuracy of the bone material properties. It is widely recognized that the mechanical response of trabecular bone is time-dependent, yet it is often ignored for the sake of simplicity. Previous investigations into the viscoelastic properties of trabecular bone have not explored the relationship between nonlinear stress relaxation and bone mineral density. The inclusion of this behavior could enhance the accuracy of simulations of orthopedic interventions, such as of primary fixation of implants. Although methods to quantify the viscoelastic behavior are known, the time period during which the viscoelastic properties should be investigated to obtain reliable predictions is currently unclear. Therefore, this study aimed to: 1) Investigate the duration of stress relaxation in bovine trabecular bone; 2) construct a material model that describes the nonlinear viscoelastic behavior of uniaxial stress relaxation experiments on trabecular bone; and 3) implement bone density into this model. Uniaxial compressive stress relaxation experiments were performed with cylindrical bovine femoral trabecular bone samples (n = 16) with constant strain held for 24 h. Additionally, multiple stress relaxation experiments with four ascending strain levels with a holding time of 30 min, based on the results of the 24-h experiment, were executed on 18 bovine bone cores. The bone specimens used in this study had a mean diameter of 12.80 mm and a mean height of 28.70 mm. A Schapery and a Superposition model were used to capture the nonlinear stress relaxation behavior in terms of applied strain level and bone mineral density. While most stress relaxation happened in the first 10 min (up to 53 %) after initial compression, the stress relaxation continued even after 24 h. Up to 69 % of stress relaxation was observed at 24 h. Extrapolating the results of 30 min of experimental data to 24 h provided a good fit for accuracy with much improved experimental efficiency. The Schapery and Superposition model were both capable of fitting the repeated stress relaxation in a sample-by-sample approach. However, since bone mineral density did not influence the time-dependent behavior, only the Superposition model could be used for a group-based model fit. Although the sample-by-sample approach was more accurate for an individual specimen, the group based approach is considered a useful model for general application.
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Affiliation(s)
- Thomas Gersie
- Radboudumc, Orthopaedic Research Lab, PO Box 9101, 6500 HB, Nijmegen, Netherlands.
| | - Thom Bitter
- Radboudumc, Orthopaedic Research Lab, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - David Wolfson
- DePuy Synthes Joint Reconstruction, WW Research & Development, LS11 OBG, Leeds, UK
| | - Robert Freeman
- DePuy Synthes Joint Reconstruction, WW Research & Development, LS11 OBG, Leeds, UK
| | - Nico Verdonschot
- Radboudumc, Orthopaedic Research Lab, PO Box 9101, 6500 HB, Nijmegen, Netherlands; University of Twente, Faculty of Science and Technology, 7522LW, Enschede, Netherlands
| | - Dennis Janssen
- Radboudumc, Orthopaedic Research Lab, PO Box 9101, 6500 HB, Nijmegen, Netherlands
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Amin Z, El-Naggar AK, Offiah I, Dua A, Freeman R. Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction. Int Urogynecol J 2024:10.1007/s00192-024-05756-w. [PMID: 38523161 DOI: 10.1007/s00192-024-05756-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction. METHODS Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI. RESULTS The overall prevalence of LAA was 24% (95% CI: 18-30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA. CONCLUSION Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI.
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Affiliation(s)
- Zohra Amin
- The Royal Oldham Hospital NHS Trust, Oldham, UK.
| | | | | | - Anupreet Dua
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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Seyres M, Postans N, Freeman R, Pandyan A, Chadwick EK, Philp F. Children and adolescents with all forms of shoulder instability demonstrate differences in their movement and muscle activity patterns when compared to age- and sex-matched controls. J Shoulder Elbow Surg 2024:S1058-2746(24)00161-7. [PMID: 38467183 DOI: 10.1016/j.jse.2024.01.043] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/22/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Shoulder instability is a complex impairment and identifying biomarkers which differentiate subgroups is challenging. There is limited fundamental movement and muscle activity data for identifying different mechanisms for shoulder instability in children and adolescents which may inform subgrouping and treatment allocation. HYPOTHESIS Children and adolescents with shoulder instability (irrespective of etiology) have differences in their movement and muscle activity profiles compared to age- and sex-matched controls (two-tailed). METHODS Young people between eight to 18 years were recruited into two groups of shoulder instability (SI) or and age- and sex-matched controls (CG). All forms of SI were included and young people with co-existing neurological pathologies or deficits were excluded. Participants attended a single session and carried out four unweighted and three weighted tasks in which their movements and muscle activity was measured using 3D-movement analysis and surface electromyography. Statistical parametric mapping was used to identify between group differences. RESULTS Data was collected for 30 young people (15 SI (6M:9F) and 15 CG (8M:7F)). The mean (SD) age for all participants was 13.6 years (3.0). The SI group demonstrated consistently more protracted and elevated sternoclavicular joint positions during all movements. Normalized muscle activity in Latissimus dorsi was lower in the SI group and had the most statistically significant differences across all movements. Where differences were identified, the SI group also had increased normalized activity of their middle trapezius, posterior deltoid and biceps muscles whilst activity of their latissimus dorsi, triceps and anterior deltoid were decreased compared to the CG group. No statistically significant differences were found for pectoralis major across any movements. Weighted tasks produced fewer differences in muscle activity patterns compared to unweighted tasks. DISCUSSION Young people with SI may adapt their movements to minimize glenohumeral joint instability. This was demonstrated by reduced variability in acromioclavicular and sternoclavicular joint angles, adoption of different movement strategies across the same joints and increased activity of the scapular stabilizing muscles, despite achieving similar arm positions to the CG. CONCLUSION Young people with shoulder instability demonstrated consistent differences in their muscle activity and movement patterns. Consistently observed differences at the shoulder girdle included increased sternoclavicular protraction and elevation accompanied by increased normalized activity of the posterior scapula stabilizing muscles. Existing methods of measurement may be used to inform clinical decision making, however, further work is needed evaluate the prognostic and clinical utility of derived 3D and sEMG data for informing decision making within shoulder instability.
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Affiliation(s)
- Martin Seyres
- School of Pharmacy and Bioengineering, Keele University, Keele, UK; School of Engineering, University of Aberdeen, Aberdeen, UK
| | - Neil Postans
- ORLAU, Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
| | - Robert Freeman
- ORLAU, Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
| | - Anand Pandyan
- Faculty of Health and Social Sciences, Bournemouth University, Poole, UK
| | | | - Fraser Philp
- School of Health Sciences, University of Liverpool, Liverpool, UK.
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Levin MA, Kia A, Timsina P, Cheng FY, Nguyen KAN, Kohli-Seth R, Lin HM, Ouyang Y, Freeman R, Reich DL. Real-Time Machine Learning Alerts to Prevent Escalation of Care: A Nonrandomized Clustered Pragmatic Clinical Trial. Crit Care Med 2024:00003246-990000000-00296. [PMID: 38380992 DOI: 10.1097/ccm.0000000000006243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
OBJECTIVES Machine learning algorithms can outperform older methods in predicting clinical deterioration, but rigorous prospective data on their real-world efficacy are limited. We hypothesized that real-time machine learning generated alerts sent directly to front-line providers would reduce escalations. DESIGN Single-center prospective pragmatic nonrandomized clustered clinical trial. SETTING Academic tertiary care medical center. PATIENTS Adult patients admitted to four medical-surgical units. Assignment to intervention or control arms was determined by initial unit admission. INTERVENTIONS Real-time alerts stratified according to predicted likelihood of deterioration sent either to the primary team or directly to the rapid response team (RRT). Clinical care and interventions were at the providers' discretion. For the control units, alerts were generated but not sent, and standard RRT activation criteria were used. MEASUREMENTS AND MAIN RESULTS The primary outcome was the rate of escalation per 1000 patient bed days. Secondary outcomes included the frequency of orders for fluids, medications, and diagnostic tests, and combined in-hospital and 30-day mortality. Propensity score modeling with stabilized inverse probability of treatment weight (IPTW) was used to account for differences between groups. Data from 2740 patients enrolled between July 2019 and March 2020 were analyzed (1488 intervention, 1252 control). Average age was 66.3 years and 1428 participants (52%) were female. The rate of escalation was 12.3 vs. 11.3 per 1000 patient bed days (difference, 1.0; 95% CI, -2.8 to 4.7) and IPTW adjusted incidence rate ratio 1.43 (95% CI, 1.16-1.78; p < 0.001). Patients in the intervention group were more likely to receive cardiovascular medication orders (16.1% vs. 11.3%; 4.7%; 95% CI, 2.1-7.4%) and IPTW adjusted relative risk (RR) (1.74; 95% CI, 1.39-2.18; p < 0.001). Combined in-hospital and 30-day-mortality was lower in the intervention group (7% vs. 9.3%; -2.4%; 95% CI, -4.5% to -0.2%) and IPTW adjusted RR (0.76; 95% CI, 0.58-0.99; p = 0.045). CONCLUSIONS Real-time machine learning alerts do not reduce the rate of escalation but may reduce mortality.
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Affiliation(s)
- Matthew A Levin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Windreich Department of Artificial Intelligence and Human Health, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Anesthesiology and Yale Center for Analytical Sciences, Yale School of Medicine, New Haven, CT
| | - Arash Kia
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Prem Timsina
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Fu-Yuan Cheng
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kim-Anh-Nhi Nguyen
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hung-Mo Lin
- Department of Anesthesiology and Yale Center for Analytical Sciences, Yale School of Medicine, New Haven, CT
| | - Yuxia Ouyang
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Freeman
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David L Reich
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Dang YH, Shaeffer GK, Freeman R, Vasaitis TS. Pharmacy and Physician Assistant Dual Degree: An Analysis of Its Value and Implications on the Profession. J Pharm Pract 2024; 37:14-16. [PMID: 36281567 DOI: 10.1177/08971900221136636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The pharmacy and physician assistant dual degree is one of the newest programs offered and has been predicted to have a high likelihood of growth in the future. With only an additional year of education, the PharmD-PA dual degree holder will have prescriptive authority upon graduation to expand their clinical roles. Additionally, by combining both medical and pharmacotherapeutics education, these mid-level practitioners could potentially improve healthcare shortages and allow for improvements in patient care. While there are established PharmD-PA dual degree programs, there is low enrollment coupled by rigorous curriculums and financial burdens that students must endure. Despite its limitations, this novel dual degree program offers pharmacy students another method to provide clinical care apart from the post-graduate opportunities. Schools of Pharmacy should look into the development of PharmD-PA dual degree programs as a unique marketing opportunity for admissions and as a non-traditional method of career advancement.
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Affiliation(s)
- Yen H Dang
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD, USA
| | - Gregory K Shaeffer
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD, USA
| | - Robert Freeman
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD, USA
| | - T Sean Vasaitis
- School of Pharmacy and Health Professions, University of Maryland Eastern Shore, Princess Anne, MD, USA
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Swift S, Freeman R. Responsive or responsible use of QoL questionnaires in urogynecology. Int Urogynecol J 2024; 35:257-258. [PMID: 38386074 DOI: 10.1007/s00192-024-05752-0] [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] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Steven Swift
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, 29425, USA.
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Gulamali F, Jayaraman P, Sawant AS, Desman J, Fox B, Chang A, Soong BY, Arivazaghan N, Reynolds AS, Duong SQ, Vaid A, Kovatch P, Freeman R, Hofer IS, Sakhuja A, Dangayach NS, Reich DS, Charney AW, Nadkarni GN. Derivation, External Validation and Clinical Implications of a deep learning approach for intracranial pressure estimation using non-cranial waveform measurements. medRxiv 2024:2024.01.30.24301974. [PMID: 38352556 PMCID: PMC10863000 DOI: 10.1101/2024.01.30.24301974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Importance Increased intracranial pressure (ICP) is associated with adverse neurological outcomes, but needs invasive monitoring. Objective Development and validation of an AI approach for detecting increased ICP (aICP) using only non-invasive extracranial physiological waveform data. Design Retrospective diagnostic study of AI-assisted detection of increased ICP. We developed an AI model using exclusively extracranial waveforms, externally validated it and assessed associations with clinical outcomes. Setting MIMIC-III Waveform Database (2000-2013), a database derived from patients admitted to an ICU in an academic Boston hospital, was used for development of the aICP model, and to report association with neurologic outcomes. Data from Mount Sinai Hospital (2020-2022) in New York City was used for external validation. Participants Patients were included if they were older than 18 years, and were monitored with electrocardiograms, arterial blood pressure, respiratory impedance plethysmography and pulse oximetry. Patients who additionally had intracranial pressure monitoring were used for development (N=157) and external validation (N=56). Patients without intracranial monitors were used for association with outcomes (N=1694). Exposures Extracranial waveforms including electrocardiogram, arterial blood pressure, plethysmography and SpO2. Main Outcomes and Measures Intracranial pressure > 15 mmHg. Measures were Area under receiver operating characteristic curves (AUROCs), sensitivity, specificity, and accuracy at threshold of 0.5. We calculated odds ratios and p-values for phenotype association. Results The AUROC was 0.91 (95% CI, 0.90-0.91) on testing and 0.80 (95% CI, 0.80-0.80) on external validation. aICP had accuracy, sensitivity, and specificity of 73.8% (95% CI, 72.0%-75.6%), 99.5% (95% CI 99.3%-99.6%), and 76.9% (95% CI, 74.0-79.8%) on external validation. A ten-percentile increment was associated with stroke (OR=2.12; 95% CI, 1.27-3.13), brain malignancy (OR=1.68; 95% CI, 1.09-2.60), subdural hemorrhage (OR=1.66; 95% CI, 1.07-2.57), intracerebral hemorrhage (OR=1.18; 95% CI, 1.07-1.32), and procedures like percutaneous brain biopsy (OR=1.58; 95% CI, 1.15-2.18) and craniotomy (OR = 1.43; 95% CI, 1.12-1.84; P < 0.05 for all). Conclusions and Relevance aICP provides accurate, non-invasive estimation of increased ICP, and is associated with neurological outcomes and neurosurgical procedures in patients without intracranial monitoring.
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Affiliation(s)
- Faris Gulamali
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pushkala Jayaraman
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashwin S. Sawant
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jacob Desman
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Benjamin Fox
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annie Chang
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian Y. Soong
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Naveen Arivazaghan
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra S. Reynolds
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Son Q Duong
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Akhil Vaid
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patricia Kovatch
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Freeman
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ira S. Hofer
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ankit Sakhuja
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Neha S. Dangayach
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David S. Reich
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander W Charney
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Girish N. Nadkarni
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Higgins H, Freeman R, Doble A, Hood G, Islam J, Gerver S, Henderson KL, Demirjian A, Hopkins S, Ashiru-Oredope D. Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data. J Hosp Infect 2023; 142:115-129. [PMID: 37858806 DOI: 10.1016/j.jhin.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets. OBJECTIVES To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England. METHODS The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process. RESULTS Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration. CONCLUSIONS The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.
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Affiliation(s)
- H Higgins
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK.
| | - R Freeman
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK; IQVIA, London, UK
| | - A Doble
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK; Health Education England North West, Manchester, UK
| | - G Hood
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK; NHS England (Midlands), Birmingham, UK
| | - J Islam
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK
| | - S Gerver
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK
| | - K L Henderson
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK
| | - A Demirjian
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK; Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, London, UK; Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - S Hopkins
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK
| | - D Ashiru-Oredope
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, United Kingdom Health Security Agency (UKHSA, Previously Public Health England (PHE)), London, UK
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Doughty J, Macdonald ME, Muirhead V, Freeman R. Oral health-related stigma: Describing and defining a ubiquitous phenomenon. Community Dent Oral Epidemiol 2023; 51:1078-1083. [PMID: 37462247 DOI: 10.1111/cdoe.12893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 11/15/2023]
Abstract
This paper is the fourth of a series of narrative reviews to critically rethink underexplored concepts in oral health research. The series commenced with an initial commissioned framework of Inclusion Oral Health, which spawned further exploration into the social forces that undergird social exclusion and othering. The second review challenged unidimensional interpretations of the causes of inequality by bringing intersectionality theory to oral health. The third exposed how language, specifically labels, can perpetuate and (re)produce vulnerability by eclipsing the agency and power of vulnerabilised populations. In this fourth review, we revisit othering, depicted in the concept of stigma. We specifically define and conceptualize oral health-related stigma, bringing together prior work on stigma to advance the robustness and utility of this theory for oral health research.
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Affiliation(s)
- J Doughty
- NIHR Clinical Lecturer, School of Dentistry, University of Liverpool, Liverpool, UK
| | - M E Macdonald
- Clinical Reader and Honorary Consultant in Dental Public Health, Centre for Dental Public Health and Primary Care, Institute of Dentistry, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - V Muirhead
- J&W Murphy Foundation Endowed Chair in Palliative Care Research. Professor, Division of Palliative Medicine. Nova Scotia Health Affiliate Scientist (Research). Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - R Freeman
- Past co-director Dental Health Services Research Unit, School of Dentistry, University of Dundee, Dundee, UK
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Nguyen KAN, Tandon P, Ghanavati S, Cheetirala SN, Timsina P, Freeman R, Reich D, Levin MA, Mazumdar M, Fayad ZA, Kia A. A Hybrid Decision Tree and Deep Learning Approach Combining Medical Imaging and Electronic Medical Records to Predict Intubation Among Hospitalized Patients With COVID-19: Algorithm Development and Validation. JMIR Form Res 2023; 7:e46905. [PMID: 37883177 PMCID: PMC10636624 DOI: 10.2196/46905] [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: 03/01/2023] [Revised: 05/18/2023] [Accepted: 06/27/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Early prediction of the need for invasive mechanical ventilation (IMV) in patients hospitalized with COVID-19 symptoms can help in the allocation of resources appropriately and improve patient outcomes by appropriately monitoring and treating patients at the greatest risk of respiratory failure. To help with the complexity of deciding whether a patient needs IMV, machine learning algorithms may help bring more prognostic value in a timely and systematic manner. Chest radiographs (CXRs) and electronic medical records (EMRs), typically obtained early in patients admitted with COVID-19, are the keys to deciding whether they need IMV. OBJECTIVE We aimed to evaluate the use of a machine learning model to predict the need for intubation within 24 hours by using a combination of CXR and EMR data in an end-to-end automated pipeline. We included historical data from 2481 hospitalizations at The Mount Sinai Hospital in New York City. METHODS CXRs were first resized, rescaled, and normalized. Then lungs were segmented from the CXRs by using a U-Net algorithm. After splitting them into a training and a test set, the training set images were augmented. The augmented images were used to train an image classifier to predict the probability of intubation with a prediction window of 24 hours by retraining a pretrained DenseNet model by using transfer learning, 10-fold cross-validation, and grid search. Then, in the final fusion model, we trained a random forest algorithm via 10-fold cross-validation by combining the probability score from the image classifier with 41 longitudinal variables in the EMR. Variables in the EMR included clinical and laboratory data routinely collected in the inpatient setting. The final fusion model gave a prediction likelihood for the need of intubation within 24 hours as well. RESULTS At a prediction probability threshold of 0.5, the fusion model provided 78.9% (95% CI 59%-96%) sensitivity, 83% (95% CI 76%-89%) specificity, 0.509 (95% CI 0.34-0.67) F1-score, 0.874 (95% CI 0.80-0.94) area under the receiver operating characteristic curve (AUROC), and 0.497 (95% CI 0.32-0.65) area under the precision recall curve (AUPRC) on the holdout set. Compared to the image classifier alone, which had an AUROC of 0.577 (95% CI 0.44-0.73) and an AUPRC of 0.206 (95% CI 0.08-0.38), the fusion model showed significant improvement (P<.001). The most important predictor variables were respiratory rate, C-reactive protein, oxygen saturation, and lactate dehydrogenase. The imaging probability score ranked 15th in overall feature importance. CONCLUSIONS We show that, when linked with EMR data, an automated deep learning image classifier improved performance in identifying hospitalized patients with severe COVID-19 at risk for intubation. With additional prospective and external validation, such a model may assist risk assessment and optimize clinical decision-making in choosing the best care plan during the critical stages of COVID-19.
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Affiliation(s)
- Kim-Anh-Nhi Nguyen
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Pranai Tandon
- Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sahar Ghanavati
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Satya Narayana Cheetirala
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Prem Timsina
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Hospital Administration, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - David Reich
- Hospital Administration, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Windreich Department of Artificial Intelligence and Human Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Arash Kia
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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11
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Hong D, Freeman R, Huang Y, Grigsby PW, Markovina S. Adjuvant External Beam Radiotherapy and Histopathologic Prognostic Factors in Tall Cell Papillary Thyroid Carcinoma. Int J Radiat Oncol Biol Phys 2023; 117:e588. [PMID: 37785779 DOI: 10.1016/j.ijrobp.2023.06.1935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Differentiated thyroid cancer is a diverse disease, with histopathologic characteristics contributing to prognosis and treatment decisions. Tall cell variant of papillary thyroid cancer (TCV-PTC) carries a poor prognosis relative to other histologies, with first site of failure most often in the neck. Several small studies suggest there may be a disease control benefit to adjuvant external beam radiotherapy (EBRT) for certain high-risk DTC populations; however, data is limited. In this study we aim to shed light on both histopathologic prognostic factors and survival outcomes of patients with TCV-PTC carcinoma treated with surgery followed by EBRT and Radioactive Iodine (RAI) or RAI alone. We hypothesize that EBRT with RAI leads to better disease control than RAI alone. MATERIALS/METHODS Patients with TCV-PTC diagnosed between 1997-2020 at a single institution were included in the analysis. TNM staging was standardized to AJCC 8th edition. Demographics, staging, and histologic characteristics were compared between the two treatment groups using T-tests and Fisher's exact tests. Kaplan-Meier survival analyses were performed between patients receiving EBRT vs. RAI alone for disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS), along with Cox Proportional Hazards analysis. RESULTS A total of 93 patients were included. Of these patients, 22 received adjuvant RAI and EBRT, and 71 received RAI alone. There was no statistical difference in race, gender, tall cell percentage in the pathology specimen, TNM stage, AJCC group stage, or disease recurrence in patients receiving EBRT vs. RAI alone. However, those receiving EBRT were significantly older (RAI mean age (SD): 50.6 (18.7), EBRT mean age (SD): 59.7 (14.4), p = 0.02) and length of follow-up was shorter for the EBRT cohort (RAI mean (SD): 8.80 (5.81) years, EBRT mean (SD): 4.53 (2.14) years, p < 0.01). Multifocal disease (HR: 3.04, 95% CI: 1.30 - 7.08, p = 0.01) and soft tissue invasion (HR: 2.93, 95% CI: 1.28 - 6.75, p = 0.01) were associated with decreased DFS, whilst age (HR 1.08, 1.01 - 1.15: p = 0.03) was associated with decreased CSS; tall cell percentage in the pathology specimen, extra-thyroidal extension, vascular invasion, and positive surgical margin were not significant for either metric. There was no statistical difference in DFS (p = 0.5), CSS (p = 0.3), or OS (p = 0.6) between patients that received EBRT and RAI vs. RAI alone. CONCLUSION DFS, CSS, and OS were not different between patients who received EBRT compared to RAI only in this high-risk subgroup of patients. Short interval follow-up for the EBRT group and significant age differences between the EBRT and RAI cohorts may confound results. Given the significant association of advanced age with CSS, an expanded, age-matched cohort analysis is underway.
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Affiliation(s)
- D Hong
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - R Freeman
- Washington University, St. Louis, MO
| | - Y Huang
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - P W Grigsby
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - S Markovina
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
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12
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Vaid A, Sawant A, Suarez-Farinas M, Lee J, Kaul S, Kovatch P, Freeman R, Jiang J, Jayaraman P, Fayad Z, Argulian E, Lerakis S, Charney AW, Wang F, Levin M, Glicksberg B, Narula J, Hofer I, Singh K, Nadkarni GN. Implications of the Use of Artificial Intelligence Predictive Models in Health Care Settings : A Simulation Study. Ann Intern Med 2023; 176:1358-1369. [PMID: 37812781 DOI: 10.7326/m23-0949] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Substantial effort has been directed toward demonstrating uses of predictive models in health care. However, implementation of these models into clinical practice may influence patient outcomes, which in turn are captured in electronic health record data. As a result, deployed models may affect the predictive ability of current and future models. OBJECTIVE To estimate changes in predictive model performance with use through 3 common scenarios: model retraining, sequentially implementing 1 model after another, and intervening in response to a model when 2 are simultaneously implemented. DESIGN Simulation of model implementation and use in critical care settings at various levels of intervention effectiveness and clinician adherence. Models were either trained or retrained after simulated implementation. SETTING Admissions to the intensive care unit (ICU) at Mount Sinai Health System (New York, New York) and Beth Israel Deaconess Medical Center (Boston, Massachusetts). PATIENTS 130 000 critical care admissions across both health systems. INTERVENTION Across 3 scenarios, interventions were simulated at varying levels of clinician adherence and effectiveness. MEASUREMENTS Statistical measures of performance, including threshold-independent (area under the curve) and threshold-dependent measures. RESULTS At fixed 90% sensitivity, in scenario 1 a mortality prediction model lost 9% to 39% specificity after retraining once and in scenario 2 a mortality prediction model lost 8% to 15% specificity when created after the implementation of an acute kidney injury (AKI) prediction model; in scenario 3, models for AKI and mortality prediction implemented simultaneously, each led to reduced effective accuracy of the other by 1% to 28%. LIMITATIONS In real-world practice, the effectiveness of and adherence to model-based recommendations are rarely known in advance. Only binary classifiers for tabular ICU admissions data were simulated. CONCLUSION In simulated ICU settings, a universally effective model-updating approach for maintaining model performance does not seem to exist. Model use may have to be recorded to maintain viability of predictive modeling. PRIMARY FUNDING SOURCE National Center for Advancing Translational Sciences.
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Affiliation(s)
- Akhil Vaid
- Division of Data-Driven and Digital Medicine, Department of Medicine, and The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (A.V., P.J.)
| | - Ashwin Sawant
- Division of Data-Driven and Digital Medicine, Department of Medicine; The Charles Bronfman Institute of Personalized Medicine; and Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (A.S.)
| | - Mayte Suarez-Farinas
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York (M.S., J.L.)
| | - Juhee Lee
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York (M.S., J.L.)
| | - Sanjeev Kaul
- Department of Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey (S.K.)
| | - Patricia Kovatch
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York (P.K., B.G.)
| | - Robert Freeman
- Division of Data-Driven and Digital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (R.F.)
| | - Joy Jiang
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (J.J.)
| | - Pushkala Jayaraman
- Division of Data-Driven and Digital Medicine, Department of Medicine, and The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (A.V., P.J.)
| | - Zahi Fayad
- BioMedical Engineering and Imaging Institute and Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York (Z.F.)
| | - Edgar Argulian
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York (E.A., S.L., J.N.)
| | - Stamatios Lerakis
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York (E.A., S.L., J.N.)
| | - Alexander W Charney
- The Charles Bronfman Institute of Personalized Medicine and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, and Department of Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey (A.W.C.)
| | - Fei Wang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York (F.W.)
| | - Matthew Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (M.L.)
| | - Benjamin Glicksberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York (P.K., B.G.)
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York (E.A., S.L., J.N.)
| | - Ira Hofer
- Division of Data-Driven and Digital Medicine, Department of Medicine; The Charles Bronfman Institute of Personalized Medicine; and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York (I.H.)
| | - Karandeep Singh
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan (K.S.)
| | - Girish N Nadkarni
- Division of Data-Driven and Digital Medicine, Department of Medicine; The Charles Bronfman Institute of Personalized Medicine; and Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (G.N.N.)
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13
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Henderson KL, Saei A, Freeman R, Johnson AP, Ashiru-Oredope D, Gerver SM, Hopkins S. Intermittent point prevalence surveys on healthcare-associated infections, 2011 and 2016, in England: what are the surveillance and intervention priorities? J Hosp Infect 2023; 140:24-33. [PMID: 37532196 DOI: 10.1016/j.jhin.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Point prevalence surveys are an important surveillance method for determining the burden of healthcare-associated infections (HCAIs). AIM To outline the key results of two point prevalence surveys in England (2011 and 2016). METHODS All National Health Service and independent sector hospitals in England were eligible to participate. Data were collected between September and November in both 2011 and 2016 based on the protocol and codebook devised by the European Centre for Disease Prevention and Control. Analysis was performed using Stata Version 13 and SAS Version 9.3. A mixed-effects model was applied, which allowed estimation of organization-specific means and accounted for the heterogeneity in the responses from different organizations. FINDINGS A total of 100,755 case records were included (52,433 in 2011 and 48,312 in 2016). The estimated prevalence of HCAIs was slightly higher in 2016 [6.89%, 95% confidence interval (CI) 6.21-7.57%] than in 2011 (6.41%, 95% CI 5.75-7.06%). In both surveys, the prevalence of HCAIs was highest in adult intensive care units (23.1% in 2011, 21.2% in 2016), and pneumonia/lower respiratory tract infections was the most common cause of HCAIs (22.7% in 2011 vs 29.2% in 2016). Inpatients in acute hospitals were older and had higher risk of dying in 2016 compared with 2011; however, the proportion of inpatients with HCAIs or on antibiotics did not differ significantly. CONCLUSION The burden of HCAIs in English hospitals increased slightly between 2011 and 2016. However, the proportion of inpatients with HCAIs or on antibiotics did not differ significantly.
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Affiliation(s)
- K L Henderson
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK.
| | - A Saei
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
| | - R Freeman
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
| | - A P Johnson
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
| | - D Ashiru-Oredope
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
| | - S M Gerver
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
| | - S Hopkins
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK
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14
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van der Zande M, Exley C, Freeman R, Thetford C, Harris R. Is Dichotomization into Regular versus Irregular Dental Attenders Valid? A Qualitative Analysis. JDR Clin Trans Res 2023; 8:337-348. [PMID: 36032014 PMCID: PMC10504811 DOI: 10.1177/23800844221118515] [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] [Indexed: 11/15/2022] Open
Abstract
AIMS To discover whether dental visiting behavior can be understood as a dichotomy of planned versus problem based, or whether there were a range of different types of understanding and patient behavior, recognizable as patterns of dental visiting behavior. METHODS Secondary analysis drawing on 2 qualitative studies of patients' accounts of dental attendance and oral health, with 1) opportunistic interviews with people attending urgent dental care services (n = 43; including 19 with follow-up) and 2) home-based, in-depth interviews with people attending a dental practice with a mixture of improved or deteriorated/poor periodontal health (n = 25). RESULTS Four distinguishable patterns of dental visiting were identified in patients' accounts: Accepting and Active Monitoring, as well as Ambivalent and Active Problem-based dental visiting behavior. Individuals' patterns were relatively stable over time but could shift at turning points. Accepting Monitors were characterized as accepting dentists' recommendations and dental practice policies relating to oral health and visits, whereas Active Monitors were more independent in judging how often to attend for preventive appointments, while still valuing anticipatory care. Ambivalent Problem-based visitors placed a relatively low value on anticipatory care for oral health maintenance and drifted into lapsed attendance, in part because of service-related factors. This contrasted with Active Problem-based visitors, for whom using services only in an emergency was a conscious decision, with low value placed on anticipatory care. CONCLUSION This article demonstrates the dynamic nature of patterns of dental visiting where the dental system itself is partly instrumental in shaping patterns of utilization in an ecological way. Thus, service-related factors tend to combine with patients' behavior in expanding inequalities. This illuminates the reasons why risk-based recalls are challenging to implement as a dental policy. KNOWLEDGE TRANSFER STATEMENT The results of this analysis can be used by clinicians and policymakers to inform policy around supporting uptake of preventive health care visits, contributing in particular to understanding how risk-based preventive visiting policies may be better adapted to patients' understanding of the purpose of visits, taking into account that this is in part shaped by service-related factors in an ecological way, arising from patients' and dental teams' expectations.
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Affiliation(s)
- M.M. van der Zande
- Department of Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - C.E. Exley
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - R. Freeman
- School of Dentistry, University of Dundee, Dundee, UK
| | - C. Thetford
- School of Nursing, University of Central Lancashire, Preston, UK
| | - R.V. Harris
- Department of Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
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15
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Rahman MA, Pal RK, Islam N, Freeman R, Berthiaume F, Mazzeo A, Ashraf A. A Facile Graphene Conductive Polymer Paper Based Biosensor for Dopamine, TNF-α, and IL-6 Detection. Sensors (Basel) 2023; 23:8115. [PMID: 37836943 PMCID: PMC10575219 DOI: 10.3390/s23198115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023]
Abstract
Paper-based biosensors are a potential paradigm of sensitivity achieved via microporous spreading/microfluidics, simplicity, and affordability. In this paper, we develop decorated paper with graphene and conductive polymer (herein referred to as graphene conductive polymer paper-based sensor or GCPPS) for sensitive detection of biomolecules. Planetary mixing resulted in uniformly dispersed graphene and conductive polymer ink, which was applied to laser-cut Whatman filter paper substrates. Scanning electron microscopy and Raman spectroscopy showed strong attachment of conductive polymer-functionalized graphene to cellulose fibers. The GCPPS detected dopamine and cytokines, such as tumor necrosis factor-alpha (TNF-α), and interleukin 6 (IL-6) in the ranges of 12.5-400 µM, 0.005-50 ng/mL, and 2 pg/mL-2 µg/mL, respectively, using a minute sample volume of 2 µL. The electrodes showed lower detection limits (LODs) of 3.4 µM, 5.97 pg/mL, and 9.55 pg/mL for dopamine, TNF-α, and IL-6 respectively, which are promising for rapid and easy analysis for biomarkers detection. Additionally, these paper-based biosensors were highly selective (no serpin A1 detection with IL-6 antibody) and were able to detect IL-6 antigen in human serum with high sensitivity and hence, the portable, adaptable, point-of-care, quick, minute sample requirement offered by our fabricated biosensor is advantageous to healthcare applications.
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Affiliation(s)
- Md Ashiqur Rahman
- Department of Mechanical Engineering, Purdue University, West Lafayette, IN 47906, USA;
| | - Ramendra Kishor Pal
- Hyderabad Campus, Birla Institute of Technology and Science Pilani, Hyderabad 500078, Telangana, India;
| | - Nazmul Islam
- Department of Electrical and Computer Engineering, University of Texas Rio Grande Valley, Edinburg, TX 78539, USA;
| | - Robert Freeman
- Department of Mechanical Engineering, University of Texas Rio Grande Valley, Edinburg, TX 78539, USA;
| | - Francois Berthiaume
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ 08854, USA;
| | - Aaron Mazzeo
- Department of Mechanical & Aerospace Engineering, Rutgers University, Piscataway, NJ 08854, USA
| | - Ali Ashraf
- Department of Mechanical Engineering, University of Texas Rio Grande Valley, Edinburg, TX 78539, USA;
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16
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Patel D, Cheetirala SN, Raut G, Tamegue J, Kia A, Glicksberg B, Freeman R, Levin MA, Timsina P, Klang E. Predicting Adult Hospital Admission from Emergency Department Using Machine Learning: An Inclusive Gradient Boosting Model. J Clin Med 2022; 11:jcm11236888. [PMID: 36498463 PMCID: PMC9740100 DOI: 10.3390/jcm11236888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND AIM We analyzed an inclusive gradient boosting model to predict hospital admission from the emergency department (ED) at different time points. We compared its results to multiple models built exclusively at each time point. METHODS This retrospective multisite study utilized ED data from the Mount Sinai Health System, NY, during 2015-2019. Data included tabular clinical features and free-text triage notes represented using bag-of-words. A full gradient boosting model, trained on data available at different time points (30, 60, 90, 120, and 150 min), was compared to single models trained exclusively at data available at each time point. This was conducted by concatenating the rows of data available at each time point to one data matrix for the full model, where each row is considered a separate case. RESULTS The cohort included 1,043,345 ED visits. The full model showed comparable results to the single models at all time points (AUCs 0.84-0.88 for different time points for both the full and single models). CONCLUSION A full model trained on data concatenated from different time points showed similar results to single models trained at each time point. An ML-based prediction model can use used for identifying hospital admission.
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Affiliation(s)
- Dhavalkumar Patel
- Mount Sinai Health System, New York, NY 10017, USA
- Correspondence: (D.P.); (E.K.)
| | | | - Ganesh Raut
- Mount Sinai Health System, New York, NY 10017, USA
| | | | - Arash Kia
- Mount Sinai Health System, New York, NY 10017, USA
| | | | | | - Matthew A. Levin
- Mount Sinai Health System, New York, NY 10017, USA
- Department of Anesthesiology, Perioperative and Pain Management, Mount Sinai Hospital, New York, NY 10017, USA
| | - Prem Timsina
- Mount Sinai Health System, New York, NY 10017, USA
| | - Eyal Klang
- Mount Sinai Health System, New York, NY 10017, USA
- Correspondence: (D.P.); (E.K.)
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17
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Soffer S, Efros O, Levin MA, Freeman R, Zimlichman E, Reich DL, Klang E. Low Frequency of Folate and Vitamin B12 Deficiency in Patients with Marked Macrocytic Anemia. J Gen Intern Med 2022; 37:3504-3505. [PMID: 35194742 PMCID: PMC9551153 DOI: 10.1007/s11606-022-07451-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Shelly Soffer
- Internal Medicine B, Assuta Medical Center, Ashdod, Israel.
- Ben-Gurion University of the Negev, Be'er Sheva, Israel.
| | - Orly Efros
- Thrombosis & Hemostasis Unit, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Matthew A Levin
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eyal Zimlichman
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Hospital Management, Sheba Medical Center, Tel Hashomer, Israel
- Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel
| | - David L Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eyal Klang
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
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Besculides M, Mazumdar M, Phlegar S, Freeman R, Wilson S, Joshi H, Kia A, Gorbenko K. Implementing a Machine Learning Screening Tool for Malnutrition: Insights from Qualitative Research Applicable to Other ML-Based CDSS (Preprint). JMIR Form Res 2022. [PMID: 37440303 PMCID: PMC10375393 DOI: 10.2196/42262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Machine learning (ML)-based clinical decision support systems (CDSS) are popular in clinical practice settings but are often criticized for being limited in usability, interpretability, and effectiveness. Evaluating the implementation of ML-based CDSS is critical to ensure CDSS is acceptable and useful to clinicians and helps them deliver high-quality health care. Malnutrition is a common and underdiagnosed condition among hospital patients, which can have serious adverse impacts. Early identification and treatment of malnutrition are important. OBJECTIVE This study aims to evaluate the implementation of an ML tool, Malnutrition Universal Screening Tool (MUST)-Plus, that predicts hospital patients at high risk for malnutrition and identify best implementation practices applicable to this and other ML-based CDSS. METHODS We conducted a qualitative postimplementation evaluation using in-depth interviews with registered dietitians (RDs) who use MUST-Plus output in their everyday work. After coding the data, we mapped emergent themes onto select domains of the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework. RESULTS We interviewed 17 of the 24 RDs approached (71%), representing 37% of those who use MUST-Plus output. Several themes emerged: (1) enhancements to the tool were made to improve accuracy and usability; (2) MUST-Plus helped identify patients that would not otherwise be seen; perceived usefulness was highest in the original site; (3) perceived accuracy varied by respondent and site; (4) RDs valued autonomy in prioritizing patients; (5) depth of tool understanding varied by hospital and level; (6) MUST-Plus was integrated into workflows and electronic health records; and (7) RDs expressed a desire to eventually have 1 automated screener. CONCLUSIONS Our findings suggest that continuous involvement of stakeholders at new sites given staff turnover is vital to ensure buy-in. Qualitative research can help identify the potential bias of ML tools and should be widely used to ensure health equity. Ongoing collaboration among CDSS developers, data scientists, and clinical providers may help refine CDSS for optimal use and improve the acceptability of CDSS in the clinical context.
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19
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Gwadz M, Cluesman SR, Freeman R, Collins LM, Dorsen C, Hawkins RL, Cleland CM, Wilton L, Ritchie AS, Torbjornsen K, Leonard NR, Martinez BY, Silverman E, Israel K, Kutnick A. Advancing behavioral interventions for African American/Black and Latino persons living with HIV using a new conceptual model that integrates critical race theory, harm reduction, and self-determination theory: a qualitative exploratory study. Int J Equity Health 2022; 21:97. [PMID: 35840962 PMCID: PMC9286957 DOI: 10.1186/s12939-022-01699-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Rates of participation in HIV care, medication uptake, and viral suppression are improving among persons living with HIV (PLWH) in the United States. Yet, disparities among African American/Black and Latino PLWH are persistent, signaling the need for new conceptual approaches. To address gaps in services and research (e.g., insufficient attention to structural/systemic factors, inadequate harm reduction services and autonomy support) and improve behavioral interventions, we integrated critical race theory, harm reduction, and self-determination theory into a new conceptual model, then used the model to develop a set of six intervention components which were tested in a larger study. The present qualitative study explores participants' perspectives on the study's acceptability, feasibility, and impact, and the conceptual model's contribution to these experiences. METHODS Participants in the larger study were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City (N = 512). We randomly selected N = 46 for in-depth semi-structured interviews on their experiences with and perspectives on the study. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis. RESULTS On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). All had taken HIV medication previously. Challenging life contexts were the norm, including poverty, poor quality/unstable housing, trauma histories exacerbated by current trauma, health comorbidities, and substance use. Participants found the study highly acceptable. We organized results into four themes focused on participants' experiences of: 1) being understood as a whole person and in their structural/systemic context; 2) trustworthiness and trust; 3) opportunities for self-reflection; and 4) support of personal autonomy. The salience of nonjudgment was prominent in each theme. Themes reflected grounding in the conceptual model. Participants reported these characteristics were lacking in HIV care settings. CONCLUSIONS The new conceptual model emphasizes the salience of systemic/structural and social factors that drive health behavior and the resultant interventions foster trust, self-reflection, engagement, and behavior change. The model has potential to enhance intervention acceptability, feasibility, and effectiveness with African American/Black and Latino PLWH.
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Affiliation(s)
- Marya Gwadz
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA. .,Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA.
| | - Sabrina R Cluesman
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
| | | | - Linda M Collins
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA.,Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, USA
| | | | - Robert L Hawkins
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
| | - Charles M Cleland
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA.,Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Leo Wilton
- Department of Human Development, State University of New York at Binghamton, Binghamton, NY, USA.,Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| | - Amanda S Ritchie
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
| | - Karen Torbjornsen
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
| | - Noelle R Leonard
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA.,School of Global Public Health, New York University, New York, NY, USA
| | | | - Elizabeth Silverman
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
| | - Khadija Israel
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
| | - Alexandra Kutnick
- Intervention Innovations Team Lab (IIT-Lab), New York University Silver School of Social Work, New York, NY, USA
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20
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Philp F, Freeman R, Stewart C. An international survey mapping practice and barriers for upper-limb assessments in movement analysis. Gait Posture 2022; 96:93-101. [PMID: 35623317 DOI: 10.1016/j.gaitpost.2022.05.018] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Upper-limb movement analysis could improve our understanding of function, pathological mechanisms and inform rehabilitation and surgical decision-making. Despite the potential benefits, the use of clinical upper-limb motion analysis is not well established and it is not clear what the barriers to clinical motion analysis are. RESEARCH QUESTION What is current practice for assessment of the upper-limb and what are the barriers currently limiting upper-limb motion analysis being routinely used in clinical practice? METHODS A web-based questionnaire was used to collect responses through international professional movement analysis society coordinators over an 18 month-period. RESULTS A total of 55 responses were received and 75% of laboratories performed some form of upper-limb assessment. In total 44% of laboratories performed upper-limb assessments for clinical purposes and only 33% did 3D-movement analysis. The most commonly seen patient groups were those with neurological injury e.g. cerebral palsy (adults and children) and normal controls for comparative purposes. Barriers to upper-limb motion analysis were the availability of standard reference tasks, protocols, software, funding and clinical need. Practice was variable with no universally identified approaches to upper-limb movement analysis. Differences in practice were also identified between laboratories accredited by the Clinical Movement Analysis Society of the UK and Ireland and other international professional societies and affiliate laboratories. SIGNIFICANCE These findings may be used to inform the development of practice standards and progress the use of clinical motion analysis in the upper-limb. This study provides a summary and describes current practice, potentially providing access to peer support and experience for laboratories with an identified clinical need looking to conduct upper-limb assessment. A national picture (UK and Ireland) for practice regarding upper-limb assessment in this sub-population is presented. We have laid out further work which is needed to establish standards of practice or consensus initiatives for enhancing clinical upper-limb motion analysis.
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Affiliation(s)
- Fraser Philp
- School of Health Sciences, University of Liverpool, L69 3GB, UK.
| | - Robert Freeman
- ORLAU, RJAH Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK.
| | - Caroline Stewart
- ORLAU, RJAH Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK; School of Pharmacy and Bioengineering, Keele University, ST5 5BG, UK.
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21
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Jan I, De B, Kwon YS, Freeman R, Larkin K, Subramanian S, Pandu P, Song A, Young M, Sayan M, Ludmir EB, Haffty BG, Mattes MD. Race- and sex-based variation in industry research and general payments to medical oncologists in the United States. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.11050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11050 Background: Industry partnerships offer financial incentives, prestige, and can facilitate career advancement in oncology. However, not all physicians may have equal access to these opportunities. We hypothesized that physicians who are underrepresented in the medical oncology workforce based on race, ethnicity, and gender receive less industry funding. Methods: All US medical oncologists (MOs) who received ≥1 industry research payment between 2016 and 2020 according to the Open Payments database were included in this retrospective study. Information extracted from Open Payments included MO’s name, institution, research payments (i.e. funding for a research project where the physician is a Principle Investigator), and general payments (i.e. fees not associated with research, such as consulting and travel fees). Additional web searches were conducted using institutional websites, NPPES NPI registry, LinkedIn, Doximity, Scopus, and NIH RePORTER to determine each MO’s race, ethnicity, sex, academic rank, degrees, h-index, institutional NIH research funding rank, and individual receipt of NIH funding. Log-linear regression was performed to identify associations of both industry and general payment data. Results: Of 7,542 physicians meeting inclusion criteria, 69% were male, 65% White, 29% Asian, 2% Black, and 4% Hispanic, which is comparable to the American Medical Association Physician Masterfile figures for MO. The median sum research payment and general payment was $134,857 and $11,537 per physician respectively. Significantly higher mean research payments were associated with an MS (+72%; P = 0.003) or PhD degree (+30%; P = 0.009), h-index (+3%; P < 0.001), top 50 institution rank by NIH funding (+44%; P < 0.001), and associate professor rank (+95%; P < 0.001). Significantly lower mean research payment were observed for Black physicians (-36%; P = 0.022) and those with non-academic affiliation (-47%; P < 0.001). No significant association was observed between sex and research payment. Significantly higher mean general payments were associated with male sex (+46%; P < 0.001), MS degree (+171%; P < 0.001), h-index (+2%; P < 0.001), and Asian race (+72%; P < 0.001). Significantly lower mean general payments were associated with an affiliation with a non-academic practice (-31%; P = 0.012). Conclusions: Black physicians received smaller sums of industry research payments compared to White physicians. Female sex was associated with decreased general payments compared to male sex. Further exploring the underlying mechanisms determining access to industry payments may help facilitate greater equity and inclusivity in oncology.
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Affiliation(s)
- Imraan Jan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Young Suk Kwon
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert Freeman
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Kelsey Larkin
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | | | - Amy Song
- Rutgers New Jersey Medical School, Newark, NJ
| | | | - Mutlay Sayan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ethan B. Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce George Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Malcolm David Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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22
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Gorbenko K, Mohammed A, Ezenwafor E, Phlegar S, Healy P, Solly T, Nembhard I, Xenophon L, Smith C, Freeman R, Reich D, Mazumdar M. Innovating in a Crisis: A Qualitative Evaluation of a Hospital and Google Partnership to Implement a COVID-19 Inpatient Video Monitoring Program. J Am Med Inform Assoc 2022; 29:1618-1630. [PMID: 35595236 PMCID: PMC9129147 DOI: 10.1093/jamia/ocac081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/10/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To describe adaptations necessary for effective use of direct-to-consumer (DTC) cameras in an inpatient setting, from the perspective of health care workers. Methods Our qualitative study included semi-structured interviews and focus groups with clinicians, information technology (IT) personnel, and health system leaders affiliated with the Mount Sinai Health System. All participants either worked in a coronavirus disease 2019 (COVID-19) unit with DTC cameras or participated in the camera implementation. Three researchers coded the transcripts independently and met weekly to discuss and resolve discrepancies. Abiding by inductive thematic analysis, coders revised the codebook until they reached saturation. All transcripts were coded in Dedoose using the final codebook. Results Frontline clinical staff, IT personnel, and health system leaders (N = 39) participated in individual interviews and focus groups in November 2020–April 2021. Our analysis identified 5 areas for effective DTC camera use: technology, patient monitoring, workflows, interpersonal relationships, and infrastructure. Participants described adaptations created to optimize camera use and opportunities for improvement necessary for sustained use. Non-COVID-19 patients tended to decline participation. Discussion Deploying DTC cameras on inpatient units required adaptations in many routine processes. Addressing consent, 2-way communication issues, patient privacy, and messaging about video monitoring could help facilitate a nimble rollout. Implementation and dissemination of inpatient video monitoring using DTC cameras requires input from patients and frontline staff. Conclusions Given the resources and time it takes to implement a usable camera solution, other health systems might benefit from creating task forces to investigate their use before the next crisis.
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Affiliation(s)
- Ksenia Gorbenko
- Icahn School of Medicine at Mount Sinai, Population Health Science and Policy, Mount Sinai Health System, New York, USA.,Institute for Health Care Delivery Science, Mount Sinai Health System, New York, USA
| | - Afrah Mohammed
- Department of Clinical Innovation, Mount Sinai Health System, New York, NY, USA
| | - Edward Ezenwafor
- Institute for Health Care Delivery Science, Mount Sinai Health System, New York, USA
| | - Sydney Phlegar
- Institute for Health Care Delivery Science, Mount Sinai Health System, New York, USA
| | - Patrick Healy
- Department of Clinical Innovation, Mount Sinai Health System, New York, NY, USA
| | | | | | | | - Cardinale Smith
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Robert Freeman
- Department of Clinical Innovation, Mount Sinai Health System, New York, NY, USA
| | - David Reich
- The Mount Sinai Hospital, New York, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Madhu Mazumdar
- Icahn School of Medicine at Mount Sinai, Population Health Science and Policy, Mount Sinai Health System, New York, USA.,Institute for Health Care Delivery Science, Mount Sinai Health System, New York, USA
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23
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Soffer S, Zimlichman E, Levin MA, Zebrowski AM, Glicksberg BS, Freeman R, Reich DL, Klang E. Machine learning to predict in‐hospital mortality among patients with severe obesity: Proof of concept study. Obes Sci Pract 2022; 8:474-482. [PMID: 35949284 PMCID: PMC9358726 DOI: 10.1002/osp4.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/25/2021] [Accepted: 10/01/2021] [Indexed: 11/22/2022] Open
Abstract
Objectives Hospitalized patients with severe obesity require adapted hospital management. The aim of this study was to evaluate a machine learning model to predict in‐hospital mortality among this population. Methods Data of unselected consecutive emergency department admissions of hospitalized patients with severe obesity (BMI ≥ 40 kg/m2) was analyzed. Data was retrieved from five hospitals from the Mount Sinai health system, New York. The study time frame was between January 2011 and December 2019. Data was used to train a gradient‐boosting machine learning model to identify in‐hospital mortality. The model was trained and evaluated based on the data from four hospitals and externally validated on held‐out data from the fifth hospital. Results A total of 14,078 hospital admissions of inpatients with severe obesity were included. The in‐hospital mortality rate was 297/14,078 (2.1%). In univariate analysis, albumin (area under the curve [AUC] = 0.77), blood urea nitrogen (AUC = 0.76), acuity level (AUC = 0.73), lactate (AUC = 0.72), and chief complaint (AUC = 0.72) were the best single predictors. For Youden’s index, the model had a sensitivity of 0.77 (95% CI: 0.67–0.86) with a false positive rate of 1:9. Conclusion A machine learning model trained on clinical measures provides proof of concept performance in predicting mortality in patients with severe obesity. This implies that such models may help to adopt specific decision support tools for this population.
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Affiliation(s)
- Shelly Soffer
- Internal Medicine B Assuta Medical Center Ashdod Israel
- Ben‐Gurion University of the Negev Be’er Sheva Israel
| | - Eyal Zimlichman
- Hospital Management Sheba Medical Center Tel Hashomer Israel
- Sackler Medical School Tel Aviv University Tel Aviv Israel
- Sheba Talpiot Medical Leadership Program Tel Hashomer Israel
| | - Matthew A. Levin
- Department of Population Health Science and Policy Institute for Healthcare Delivery Science Icahn School of Medicine at Mount Sinai New York New York USA
- Department of Anesthesiology, Perioperative and Pain Medicine Icahn School of Medicine at Mount Sinai New York New York USA
| | - Alexis M. Zebrowski
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York New York USA
- Department of Population Health Science and Policy Institute for Translational Epidemiology Icahn School of Medicine at Mount Sinai New York New York USA
| | - Benjamin S. Glicksberg
- Hasso Plattner Institute for Digital Health at Mount Sinai Icahn School of Medicine at Mount Sinai New York New York USA
- Department of Genetics and Genomic Sciences Icahn School of Medicine at Mount Sinai New York New York USA
| | - Robert Freeman
- Department of Population Health Science and Policy Institute for Healthcare Delivery Science Icahn School of Medicine at Mount Sinai New York New York USA
| | - David L. Reich
- Department of Anesthesiology, Perioperative and Pain Medicine Icahn School of Medicine at Mount Sinai New York New York USA
| | - Eyal Klang
- Sackler Medical School Tel Aviv University Tel Aviv Israel
- Sheba Talpiot Medical Leadership Program Tel Hashomer Israel
- Department of Diagnostic Imaging Sheba Medical Center Tel Hashomer Israel
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24
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Soffer S, Zimlichman E, Glicksberg BS, Efros O, Levin MA, Freeman R, Reich DL, Klang E. Obesity as a mortality risk factor in the medical ward: a case control study. BMC Endocr Disord 2022; 22:13. [PMID: 34991575 PMCID: PMC8733434 DOI: 10.1186/s12902-021-00912-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 12/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Research regarding the association between severe obesity and in-hospital mortality is inconsistent. We evaluated the impact of body mass index (BMI) levels on mortality in the medical wards. The analysis was performed separately before and during the COVID-19 pandemic. METHODS We retrospectively retrieved data of adult patients admitted to the medical wards at the Mount Sinai Health System in New York City. The study was conducted between January 1, 2011, to March 23, 2021. Patients were divided into two sub-cohorts: pre-COVID-19 and during-COVID-19. Patients were then clustered into groups based on BMI ranges. A multivariate logistic regression analysis compared the mortality rate among the BMI groups, before and during the pandemic. RESULTS Overall, 179,288 patients were admitted to the medical wards and had a recorded BMI measurement. 149,098 were admitted before the COVID-19 pandemic and 30,190 during the pandemic. Pre-pandemic, multivariate analysis showed a "J curve" between BMI and mortality. Severe obesity (BMI > 40) had an aOR of 0.8 (95% CI:0.7-1.0, p = 0.018) compared to the normal BMI group. In contrast, during the pandemic, the analysis showed a "U curve" between BMI and mortality. Severe obesity had an aOR of 1.7 (95% CI:1.3-2.4, p < 0.001) compared to the normal BMI group. CONCLUSIONS Medical ward patients with severe obesity have a lower risk for mortality compared to patients with normal BMI. However, this does not apply during COVID-19, where obesity was a leading risk factor for mortality in the medical wards. It is important for the internal medicine physician to understand the intricacies of the association between obesity and medical ward mortality.
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Affiliation(s)
- Shelly Soffer
- Internal Medicine B, Assuta Medical Center, Ashdod, Israel.
- Ben-Gurion University of the Negev, Be'er Sheva, Israel.
| | - Eyal Zimlichman
- Hospital Management, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel
| | - Benjamin S Glicksberg
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Orly Efros
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Thrombosis & Hemostasis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Matthew A Levin
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - David L Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Eyal Klang
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
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25
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Offiah I, Freeman R. Authors' reply re: Long-term efficacy and complications of a multicentre randomised controlled trial comparing retropubic and transobturator mid-urethral slings: a prospective observational study. BJOG 2021; 129:676-677. [PMID: 34878711 DOI: 10.1111/1471-0528.17024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Ifeoma Offiah
- University of Plymouth, Plymouth, UK.,University Hospital Plymouth NHS Trust, Plymouth, UK
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Maisto SA, Freeman R, Bryant K. Alcohol-related Behavioral Research and its Integration into Primary and Secondary HIV Preventive Interventions: Introduction. AIDS Behav 2021; 25:233-236. [PMID: 34390434 PMCID: PMC8616853 DOI: 10.1007/s10461-021-03420-8] [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] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
The purpose of this paper is to provide a brief introduction to and description of the contents of this special issue of AIDS and Behavior. The article begins with a description of the rationale for the special issue and the origin of its compilation. This background information is followed by a brief description of the main articles that are included in the special issue, which is structured by Gaist and Stirrat's [4] definitions of types of behavioral and social science research for HIV-AIDS research. The "bookend" article to this introduction is by Robert Freeman and identifies future directions for research and clinical practice that the special issue articles' content suggests.
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Affiliation(s)
- Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, NY, 13244, USA.
| | - Robert Freeman
- Division of Epidemiology and Prevention Research, NIAAA, Bethesda, MD, USA
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Humphris G, Freeman R. Editorial - The importance of studying communication processes in the dentist: patient interaction. Community Dent Health 2021; 38:222-223. [PMID: 34842367 DOI: 10.1922/cdh_dec21editorialhumphris02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
The delivery of dental services attracts continuing debate by health service management, public health specialists and public representatives. There is little argument, that communication among dental service providers and cli- ent groups is a vital component of exemplary services. However, the exact requirements of what constitutes good communication becomes problematic. Definitions can be applied to detailed observations of elements of dental staff behaviour. Such observational audits are rarely applied, due to the large resources required, and believing this approach is purely a research-only exercise. We acknowledge the demanding nature of any such endeavour in real-time by a trained observer. An alternative is to video-record clinical sessions. Although this has been possible for some decades, the widespread use of recording samples of clinical sessions, for example to assess staff engagement in prevention advice, is not realistic using current methodologies, even if the considerable ethical concerns could be assuaged. In addition, hitherto, there has been a wide ranging set of views of what would be considered poor, just good enough or excellent communication. Part of this difficulty is due to the complexity of the communication processes themselves. The variety of health service settings, staff experience and training received in the fi eld of communication and the sheer spectrum of patient types and problems that surface which require treatment, advice and instruction makes a universal framework of what constitutes acceptable communication skills difficult to specify. Furthermore, when no established standard can be agreed the status of rewarding good communication is therefore under-valued and simply ignored from service contracts.
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Somani SS, Honarvar H, Narula S, Landi I, Lee S, Khachatoorian Y, Rehmani A, Kim A, De Freitas JK, Teng S, Jaladanki S, Kumar A, Russak A, Zhao SP, Freeman R, Levin MA, Nadkarni GN, Kagen AC, Argulian E, Glicksberg BS. Development of a machine learning model using electrocardiogram signals to improve acute pulmonary embolism screening. Eur Heart J Digit Health 2021; 3:56-66. [PMID: 35355847 PMCID: PMC8946569 DOI: 10.1093/ehjdh/ztab101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/16/2021] [Accepted: 11/19/2021] [Indexed: 01/30/2023]
Abstract
Aims Clinical scoring systems for pulmonary embolism (PE) screening have low specificity and contribute to computed tomography pulmonary angiogram (CTPA) overuse. We assessed whether deep learning models using an existing and routinely collected data modality, electrocardiogram (ECG) waveforms, can increase specificity for PE detection. Methods and results We create a retrospective cohort of 21 183 patients at moderate- to high suspicion of PE and associate 23 793 CTPAs (10.0% PE-positive) with 320 746 ECGs and encounter-level clinical data (demographics, comorbidities, vital signs, and labs). We develop three machine learning models to predict PE likelihood: an ECG model using only ECG waveform data, an EHR model using tabular clinical data, and a Fusion model integrating clinical data and an embedded representation of the ECG waveform. We find that a Fusion model [area under the receiver-operating characteristic curve (AUROC) 0.81 ± 0.01] outperforms both the ECG model (AUROC 0.59 ± 0.01) and EHR model (AUROC 0.65 ± 0.01). On a sample of 100 patients from the test set, the Fusion model also achieves greater specificity (0.18) and performance (AUROC 0.84 ± 0.01) than four commonly evaluated clinical scores: Wells' Criteria, Revised Geneva Score, Pulmonary Embolism Rule-Out Criteria, and 4-Level Pulmonary Embolism Clinical Probability Score (AUROC 0.50-0.58, specificity 0.00-0.05). The model is superior to these scores on feature sensitivity analyses (AUROC 0.66-0.84) and achieves comparable performance across sex (AUROC 0.81) and racial/ethnic (AUROC 0.77-0.84) subgroups. Conclusion Synergistic deep learning of ECG waveforms with traditional clinical variables can increase the specificity of PE detection in patients at least at moderate suspicion for PE.
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Affiliation(s)
- Sulaiman S Somani
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA
| | - Hossein Honarvar
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Sukrit Narula
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, 20 Copeland Ave, Hamilton, ON L8L 2X2, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Isotta Landi
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Shawn Lee
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Yeraz Khachatoorian
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Arsalan Rehmani
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Andrew Kim
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Jessica K De Freitas
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Shelly Teng
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA
| | - Suraj Jaladanki
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA
| | - Arvind Kumar
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA
| | - Adam Russak
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA,Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Shan P Zhao
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA,Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Robert Freeman
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA,Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Girish N Nadkarni
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, 770 Lexington Ave, 15th Fl, New York, NY, 10065, USA,The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Alexander C Kagen
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Edgar Argulian
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA,Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
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Klang E, Soffer S, Zimlichman E, Zebrowski A, Glicksberg BS, Grossman E, Reich DL, Freeman R, Levin MA. Synergistic effect of hypoalbuminaemia and hypotension in predicting in-hospital mortality and intensive care admission: a retrospective cohort study. BMJ Open 2021; 11:e050216. [PMID: 34706952 PMCID: PMC8552132 DOI: 10.1136/bmjopen-2021-050216] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE Hypoalbuminaemia is an important prognostic factor. It may be associated with poor nutritional states, chronic heart and kidney disease, long-standing infection and cancer. Hypotension is a hallmark of circulatory failure. We evaluated hypoalbuminaemia and hypotension synergism as predictor of in-hospital mortality and intensive care unit (ICU) admission. DESIGN We retrospectively analysed emergency department (ED) visits from January 2011 to December 2019. SETTING Data were retrieved from five Mount Sinai health system hospitals, New York. PARTICIPANTS We included consecutive ED patients ≥18 years with albumin measurements. PRIMARY AND SECONDARY OUTCOME MEASURES Clinical outcomes were in-hospital mortality and ICU admission. The rates of these outcomes were stratified by systolic blood pressure (SBP) (<90 vs ≥90 mm Hg) and albumin levels. Variables included demographics, presenting vital signs, comorbidities (measured as ICD codes) and other common blood tests. Multivariable logistic regression models analysed the adjusted OR of different levels of albumin and SBP for predicting ICU admission and in-hospital mortality. The models were adjusted for demographics, vital signs, comorbidities and common laboratory results. Patients with albumin 3.5-4.5 g/dL and SBP ≥90 mm Hg were used as reference. RESULTS The cohort included 402 123 ED arrivals (27.9% of total adult ED visits). The rates of in-hospital mortality, ICU admission and overall admission were 1.7%, 8.4% and 47.1%, respectively. For SBP <90 mm Hg and albumin <2.5 g/dL, mortality and ICU admission rates were 34.0% and 40.6%, respectively; for SBP <90 mm Hg and albumin ≥2.5 g/dL 8.2% and 24.1%, respectively; for SBP ≥90 mm Hg and albumin <2.5 g/dL 11.4% and 18.6%, respectively; for SBP ≥90 mm Hg and albumin 3.5-4.5 g/dL 0.5% and 6.4%, respectively. Multivariable analysis showed that in patients with hypotension and albumin <2.5 g/dL the adjusted OR for in-hospital mortality was 37.1 (95% CI 32.3 to 42.6), and for ICU admission was 5.4 (95% CI 4.8 to 6.1). CONCLUSION Co-occurrence of hypotension and hypoalbuminaemia is associated with poor hospital outcomes.
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Affiliation(s)
- Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Shelly Soffer
- Internal Medicine B, Assuta Medical Center, Ashdod, Israel
- Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Eyal Zimlichman
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Hospital management, Sheba Medical Center, Tel Hashomer, Israel
| | - Alexis Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin S Glicksberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - E Grossman
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
- Internal medicine Wing, Sheba Medical Center, Tel Hashomer, Israel
| | - David L Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert Freeman
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew A Levin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Rodriguez A, Biazus Dalcin C, McGoldrick N, van Blerk L, Murray C, Freeman R. Co-designing a training package to promote health/oral health for people experiencing homelessness. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab164.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In Scotland, 31,333 households were assessed as experiencing homelessness in 2019/20. This population present high morbidity and mortality which is a public health issue. Their health needs have been identified within Scottish policy as part of the broad goal of reducing inequalities and poverty. Those experiencing homelessness face multiple exclusions that must be addressed by practitioners from all health and social care sectors. Frontline staff have identified they often do not have adequate information and/or training on wider health issues linked with their client's needs. The aim of this research is to co-produce training resources to support front-line staff to discuss and to promote health and oral health.
Methods
Community-based participatory research that used online workshops to listen to the views of people with lived experience, practitioners and students from health and third sector, and policy makers regarding accessibility of services and practitioner approach towards those experiencing homelessness. Content analysis will be used to identified recurrent themes.
Results
The preliminary findings shown that lack of empathy from practitioners, continuity of care and stigma are barriers to access services. This is informing a co-designed knowledge exchange training packaged to help practitioners to improve knowledge and ability to promote health/oral health and to engage with people experiencing homelessness or at risk of becoming homeless. Educational materials (e-book on health promotion, comics books on barriers to access services, and a guide to promote oral health) compose this training package.
Conclusions
The training package allows adaptations to different settings and contexts and will be an important resource to be used by practitioners from different fields to prevent and tackle homelessness. Participants are sharing important views related to the need of a human rights and social justice-based approach to health promotion.
Key messages
Development of a co-designed knowledge exchange training package to improve practitioners' knowledge and ability to communicate and to engage with people experiencing homelessness. To empower people experiencing homelessness regarding positive health/oral health behavior change.
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Affiliation(s)
- A Rodriguez
- School of Dentistry, University of Dundee, Dundee, UK
| | - C Biazus Dalcin
- School of Dentistry, University of Dundee, Dundee, UK
- School of Education and Social Work, University of Dundee, Dundee, UK
| | - N McGoldrick
- School of Dentistry, University of Dundee, Dundee, UK
| | - L van Blerk
- School of Social Sciences, University of Dundee, Dundee, UK
| | - C Murray
- School of Humanities, University of Dundee, Dundee, UK
| | - R Freeman
- School of Dentistry, University of Dundee, Dundee, UK
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31
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Freeman R, Gwadz M, Francis K, Hoffeld E. Forgetting to take HIV antiretroviral therapy: a qualitative exploration of medication adherence in the third decade of the HIV epidemic in the United States. SAHARA J 2021; 18:113-130. [PMID: 34654350 PMCID: PMC8525920 DOI: 10.1080/17290376.2021.1989021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Optimal adherence to HIV antiretroviral therapy (ART) is challenging, and racial/ethnic disparities in adherence rates are substantial. The most common reason persons living with HIV (PLWH) give for missed ART doses is forgetting. We took a qualitative exploratory approach to describe, from the perspectives of African American/Black and Hispanic/Latino PLWH, what it means to forget to take ART and factors that influence forgetting. Participants (N = 18) were purposively sampled for maximum variability and engaged in semi-structured/in-depth interviews on HIV/ART management. The analysis took a directed content analysis approach. Participants were mostly male (56%) and African American/Black (79%), between 50 and 69 years old, and had lived with HIV for an average of 21 years. Findings were organised into six inter-related themes: (1) forgetting to take ART was a shorthand description of a complex phenomenon, but rarely a simple lapse of memory; (2) ‘forgetting’ was means of managing negative emotions associated with HIV; (3) life events triggered mental health distress/substance use which disrupted adherence; (4) historical traumatic events (including AZT monotherapy) and recent trauma/loss contributed to forgetting; (5) patient-provider interactions could support or impede adherence; and (6) intrinsic motivation was fundamental. Implications for HIV social service and health care settings are described.
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Affiliation(s)
- R Freeman
- Independent Consultant, Brooklyn, NY, USA
| | - M Gwadz
- New York University Silver School of Social Work, New York, NY, USA.,Centre for Drug Use and HIV Research (CDUHR), New York University School of Global Public Health, New York, NY, USA
| | - K Francis
- New York University Silver School of Social Work, New York, NY, USA
| | - E Hoffeld
- New York University Silver School of Social Work, New York, NY, USA
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Thakar R, Bidwell P, Freeman R, Gurol-Urganci I, Jurczuk M, Martinez D, Percy E, Sevdalis N, Silverton L, van der Meulen J. Authors' reply re: OASI Care Bundle. BJOG 2021; 129:175-176. [PMID: 34590412 DOI: 10.1111/1471-0528.16901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/12/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ranee Thakar
- Croydon University Hospital, Croydon Health Services NHS Trust, London, UK.,Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Posy Bidwell
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Robert Freeman
- Department of Women's Health, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ipek Gurol-Urganci
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Magdalena Jurczuk
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Dorian Martinez
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Elizabeth Percy
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK.,Department of Women's Health, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | | | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
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Hemming C, Constable L, Goulao B, Kilonzo M, Boyers D, Elders A, Cooper K, Smith A, Freeman R, Breeman S, McDonald A, Hagen S, Montgomery I, Norrie J, Glazener C. Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs. Health Technol Assess 2021; 24:1-220. [PMID: 32138809 DOI: 10.3310/hta24130] [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] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND New surgical approaches for apical prolapse have gradually been introduced, with few prospective randomised controlled trial data to evaluate their safety and efficacy compared with traditional methods. OBJECTIVE To compare surgical uterine preservation with vaginal hysterectomy in women with uterine prolapse and abdominal procedures with vaginal procedures in women with vault prolapse in terms of clinical effectiveness, adverse events, quality of life and cost-effectiveness. DESIGN Two parallel randomised controlled trials (i.e. Uterine and Vault). Allocation was by remote web-based randomisation (1 : 1 ratio), minimised on the need for concomitant anterior and/or posterior procedure, concomitant incontinence procedure, age and surgeon. SETTING UK hospitals. PARTICIPANTS Uterine trial - 563 out of 565 randomised women had uterine prolapse surgery. Vault trial - 208 out of 209 randomised women had vault prolapse surgery. INTERVENTIONS Uterine trial - uterine preservation or vaginal hysterectomy. Vault trial - abdominal or vaginal vault suspension. MAIN OUTCOME MEASURES The primary outcome measures were women's prolapse symptoms (as measured using the Pelvic Organ Prolapse Symptom Score), prolapse-specific quality of life and cost-effectiveness (as assessed by incremental cost per quality-adjusted life-year). RESULTS Uterine trial - adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for uterine preservation was 4.2 (standard deviation 4.9) versus vaginal hysterectomy with a Pelvic Organ Prolapse Symptom Score of 4.2 (standard deviation 5.3) (mean difference -0.05, 95% confidence interval -0.91 to 0.81). Serious adverse event rates were similar between the groups (uterine preservation 5.4% vs. vaginal hysterectomy 5.9%; risk ratio 0.82, 95% confidence interval 0.38 to 1.75). There was no difference in overall prolapse stage. Significantly more women would recommend vaginal hysterectomy to a friend (odds ratio 0.39, 95% confidence interval 0.18 to 0.83). Uterine preservation was £235 (95% confidence interval £6 to £464) more expensive than vaginal hysterectomy and generated non-significantly fewer quality-adjusted life-years (mean difference -0.004, 95% confidence interval -0.026 to 0.019). Vault trial - adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for an abdominal procedure was 5.6 (standard deviation 5.4) versus vaginal procedure with a Pelvic Organ Prolapse Symptom Score of 5.9 (standard deviation 5.4) (mean difference -0.61, 95% confidence interval -2.08 to 0.86). The serious adverse event rates were similar between the groups (abdominal 5.9% vs. vaginal 6.0%; risk ratio 0.97, 95% confidence interval 0.27 to 3.44). The objective anterior prolapse stage 2b or more was higher in the vaginal group than in the abdominal group (odds ratio 0.38, 95% confidence interval 0.18 to 0.79). There was no difference in the overall prolapse stage. An abdominal procedure was £570 (95% confidence interval £459 to £682) more expensive than a vaginal procedure and generated non-significantly more quality-adjusted life-years (mean difference 0.004, 95% confidence interval -0.031 to 0.041). CONCLUSIONS Uterine trial - in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between uterine preservation and vaginal hysterectomy. Vault trial - in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between an abdominal and a vaginal approach. FUTURE WORK Long-term follow-up for at least 6 years is ongoing to identify recurrence rates, need for further prolapse surgery, adverse events and cost-effectiveness. TRIAL REGISTRATION Current Controlled Trials ISRCTN86784244. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 13. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
| | - Lynda Constable
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professionals Research Unit (NMAHP RU), Glasgow Caledonian University, Glasgow, UK
| | - Kevin Cooper
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Anthony Smith
- St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison McDonald
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professionals Research Unit (NMAHP RU), Glasgow Caledonian University, Glasgow, UK
| | - Isobel Montgomery
- Independent patient representative, c/o Health Services Research Unit, Aberdeen, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, Edinburgh BioQuarter, University of Edinburgh, Edinburgh, UK
| | - Cathryn Glazener
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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34
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Offiah I, Freeman R. Long-term efficacy and complications of a multicentre randomised controlled trial comparing retropubic and transobturator mid-urethral slings: a prospective observational study. BJOG 2021; 128:2191-2199. [PMID: 34478604 DOI: 10.1111/1471-0528.16899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There are concerns regarding the risks of mid-urethral slings (MUS) for stress urinary incontinence (SUI), particularly because of the lack of long-term data. We compare patient-reported outcomes of a multicentre randomised controlled trial of retropubic (TVT, GYNECARE™) versus transobturator (TOT, MONARC™) tape surgery at 12 years. DESIGN AND SETTING A multicentre study was performed in 11 tertiary referral centres. POPULATION A cohort of 180 participants from the original trial, the majority of whom had mixed urinary incontinence. METHODS Postal questionnaire survey of patient-reported outcome measures using the International Consultation on Incontinence Questionnaire, Patient Global Impression of Improvement questionnaire (PGI-I) and a numeric rating scale pain questionnaire. MAIN OUTCOME MEASURES Comparison of the efficacy and complications between the TVT and TOT procedures in the long term. RESULTS A total of 110/180 responses were received: 55 for TVT and 55 for TOT. The mean follow-up was 12.8 ± 0.29 years (SD). TVT was significantly superior to TOT: 41.8% TVT with no SUI, versus 21.8% TOT (P = 0.04). Urgency urinary incontinence (UUI) was the most bothersome urinary symptom: 14.5% of respondents reported UUI after TVT and TOT. This was an improvement from the baseline levels: 61.8% TVT and 76.4% TOT. Seventeen patients (9 TVT and 8 TOT) out of 121 reported moderate or severe pain with severe pain in 3 with TVT and 2 with TOT. Overall, 80% TVT and 77% TOT participants reported their symptoms as improved on the PGI-I. CONCLUSIONS TVT is superior to TOT for SUI cure. Efficacy is reduced by 12 years. There is low incidence of severe vaginal or groin pain. Careful patient counselling on long-term outcomes is required. The Retropubic tape appears to be an effective treatment for the majority of women with SUI. TWEETABLE ABSTRACT Retropubic tape has superior efficacy to transobturator tape. Complications are comparable with low rates.
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Affiliation(s)
- I Offiah
- University of Plymouth, Plymouth, UK.,University Hospital Plymouth NHS Trust, Plymouth, UK
| | - R Freeman
- University Hospital Plymouth NHS Trust, Plymouth, UK
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Soffer S, Glicksberg BS, Zimlichman E, Efros O, Levin MA, Freeman R, Reich DL, Klang E. The association between obesity and peak antibody titer response in COVID-19 infection. Obesity (Silver Spring) 2021; 29:1547-1553. [PMID: 33945220 PMCID: PMC8242567 DOI: 10.1002/oby.23208] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/16/2021] [Accepted: 04/29/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Obesity is associated with severe coronavirus disease 2019 (COVID-19) infection. Disease severity is associated with a higher COVID-19 antibody titer. The COVID-19 antibody titer response of patients with obesity versus patients without obesity was compared. METHODS The data of individuals tested for COVID-19 serology at the Mount Sinai Health System in New York City between March 1, 2020, and December 14, 2021, were retrospectively retrieved. The primary outcome was peak antibody titer, assessed as a binary variable (1:2,880, which was the highest detected titer, versus lower than 1:2,880). In patients with a positive serology test, peak titer rates were compared between BMI groups (<18.5, 18.5 to 25, 25 to 30, 30 to 40, and ≥40 kg/m2 ). A multivariable logistic regression model was used to analyze the independent association between different BMI groups and peak titer. RESULTS Overall, 39,342 individuals underwent serology testing and had BMI measurements. A positive serology test was present in 12,314 patients. Peak titer rates were associated with obesity (BMI < 18.5 [34.5%], 18.5 to 25 [29.2%], 25 to 30 [37.7%], 30 to 40 [44.7%], ≥40 [52.0%]; p < 0.001). In a multivariable analysis, severe obesity had the highest adjusted odds ratio for peak titer (95% CI: 2.1-3.0). CONCLUSION COVID-19 neutralizing antibody titer is associated with obesity. This has implications on the understanding of the role of obesity in COVID-19 severity.
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Affiliation(s)
- Shelly Soffer
- Internal Medicine BAssuta Medical CenterAshdodIsrael
- Goldman Medical SchoolBen‐Gurion University of the NegevBe'er ShevaIsrael
| | - Benjamin S. Glicksberg
- Hasso Plattner Institute for Digital Health at Mount SinaiIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Eyal Zimlichman
- Hospital managementSheba Medical CenterTel HashomerIsrael
- Sackler Medical SchoolTel Aviv UniversityTel AvivIsrael
- Sheba Talpiot Medical Leadership ProgramTel HashomerIsrael
| | - Orly Efros
- Sackler Medical SchoolTel Aviv UniversityTel AvivIsrael
- Thrombosis & Hemostasis UnitSheba Medical CenterTel HashomerIsrael
| | - Matthew A. Levin
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Institute for Healthcare Delivery ScienceDepartment of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Department of AnesthesiologyPerioperative and Pain MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Robert Freeman
- Institute for Healthcare Delivery ScienceDepartment of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - David L. Reich
- Department of AnesthesiologyPerioperative and Pain MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Eyal Klang
- Sackler Medical SchoolTel Aviv UniversityTel AvivIsrael
- Sheba Talpiot Medical Leadership ProgramTel HashomerIsrael
- Department of Diagnostic ImagingSheba Medical CenterTel HashomerIsrael
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Hirten RP, Danieletto M, Tomalin L, Choi KH, Zweig M, Golden E, Kaur S, Helmus D, Biello A, Pyzik R, Calcogna C, Freeman R, Sands BE, Charney D, Bottinger EP, Murrough JW, Keefer L, Suarez-Farinas M, Nadkarni GN, Fayad ZA. Factors Associated with Longitudinal Psychological and Physiological Stress in Health Care Workers During the COVID-19 Pandemic: Observational Study Using Apple Watch Data. J Med Internet Res 2021; 23:e31295. [PMID: 34379602 PMCID: PMC8439178 DOI: 10.2196/31295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/19/2021] [Accepted: 08/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background The COVID-19 pandemic has resulted in a high degree of psychological distress among health care workers (HCWs). There is a need to characterize which HCWs are at an increased risk of developing psychological effects from the pandemic. Given the differences in the response of individuals to stress, an analysis of both the perceived and physiological consequences of stressors can provide a comprehensive evaluation of its impact. Objective This study aimed to determine characteristics associated with longitudinal perceived stress in HCWs and to assess whether changes in heart rate variability (HRV), a marker of autonomic nervous system function, are associated with features protective against longitudinal stress. Methods HCWs across 7 hospitals in New York City, NY, were prospectively followed in an ongoing observational digital study using the custom Warrior Watch Study app. Participants wore an Apple Watch for the duration of the study to measure HRV throughout the follow-up period. Surveys measuring perceived stress, resilience, emotional support, quality of life, and optimism were collected at baseline and longitudinally. Results A total of 361 participants (mean age 36.8, SD 10.1 years; female: n=246, 69.3%) were enrolled. Multivariate analysis found New York City’s COVID-19 case count to be associated with increased longitudinal stress (P=.008). Baseline emotional support, quality of life, and resilience were associated with decreased longitudinal stress (P<.001). A significant reduction in stress during the 4-week period after COVID-19 diagnosis was observed in the highest tertial of emotional support (P=.03) and resilience (P=.006). Participants in the highest tertial of baseline emotional support and resilience had a significantly different circadian pattern of longitudinally collected HRV compared to subjects in the low or medium tertial. Conclusions High resilience, emotional support, and quality of life place HCWs at reduced risk of longitudinal perceived stress and have a distinct physiological stress profile. Our findings support the use of these characteristics to identify HCWs at risk of the psychological and physiological stress effects of the pandemic.
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Affiliation(s)
- Robert P Hirten
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | | | - Lewis Tomalin
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | | | - Micol Zweig
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Eddye Golden
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Sparshdeep Kaur
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Drew Helmus
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Anthony Biello
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Renata Pyzik
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | | | - Robert Freeman
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Bruce E Sands
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | - Dennis Charney
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | | | | | - Laurie Keefer
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
| | | | | | - Zahi A Fayad
- Icahn School of Medicine, 1 Gustave L Levy Place, New York, US
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Bidwell P, Sevdalis N, Silverton L, Harris J, Gurol-Urganci I, Hellyer A, Freeman R, van der Meulen J, Thakar R. Women's experiences of the OASI Care Bundle; a package of care to reduce severe perineal trauma. Int Urogynecol J 2021; 32:1807-1816. [PMID: 33475817 PMCID: PMC8295065 DOI: 10.1007/s00192-020-04653-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/10/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injury (OASI) is a severe form of perineal trauma that can occur during vaginal birth. Long-term morbidities include anal incontinence and psychosocial disorders. To reduce these injuries within England, Scotland and Wales, the OASI Care Bundle was introduced to 16 maternity units (January 2017-March 2018). The OASI Care Bundle comprises four elements: (1) antenatal information, (2) manual perineal protection, (3) medio-lateral episiotomy (when indicated) and 4) recognition and diagnosis of tears. As part of the project evaluation, a qualitative study was conducted to explore women's experiences of the OASI Care Bundle. METHODS Semi-structured interviews were conducted with women (n = 19) who received the OASI Care Bundle as part of their maternity care. This was to explore their experience of each element. A thematic analysis of the interview data was performed. RESULTS Three themes were identified: (1) memories of touch, whereby women reported that a 'hands-on' approach to perineal protection was a positive experience; (2) midwife as a supportive guide, where women reported that good communication facilitated a calm birth and post-birth diagnosis; (3) education: women need more information about perineal trauma. CONCLUSION This study contributes to the literature through its exploration of women's experiences of perineal protection techniques and diagnosis of perineal trauma. Interviewed women indicated that they did not experience any of the care bundle elements as an intrusion of their physical integrity. Additionally, an urgent need was identified for more information about perineal trauma in terms of risk, prevention and recovery.
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Affiliation(s)
- Posy Bidwell
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK.
| | - Nick Sevdalis
- Health Service and Population Research Department, King's College London, De Crespingy Park, London, SE5 8AF, UK
| | - Louise Silverton
- Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK
| | - James Harris
- Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Ipek Gurol-Urganci
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Alexandra Hellyer
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - Robert Freeman
- University Hospitals Plymouth NHS Trust, Derriford Road, Devon, PL6 8DH, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Ranee Thakar
- Croydon Health Services NHS Trust, 530 London Road, Croydon, CR7 7YE, UK
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Alharbi A, Freeman R, Humphris G. Dental anxiety, child-oral health related quality of life and self- esteem in children and adolescents: a systematic review and meta-analysis. Community Dent Health 2021; 38:119-126. [PMID: 34029016 DOI: 10.1922/cdh_00295alharbi08] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To identify the directions, strength and associations between dental anxiety, COHRQoL and self-esteem in children and adolescents. BASIC RESEARCH DESIGN PRISMA guidelines were followed and the review registered (PROSPERO CRD42019140037). MEDLINE, Cochrane Library, Scopus, Science Direct, CINAHL, Joanna Briggs Institute (JBI), Grey Literature Report, and British Library EThOS using MeSH terms and keywords were searched. Three reviewers examined the abstracts of all articles, excluded duplicates and those not meeting inclusion criteria. All full-text papers were read by all reviewers. Meta-analysis association data including Pearson's or Spearman's correlation coefficient were extracted and effect sizes estimated. RESULTS Twelve papers met the inclusion criteria, 7 assessed the relationship between child dental anxiety and COHRQoL; four between COHRQoL and self-esteem and one between child dental anxiety and self-esteem. Significant relationships were found between COHRQoL and the other child-related outcomes measures. An inverse relationship was shown for dental anxiety and COHRQoL. The meta-analysis found small associations between child dental anxiety and COHRQoL and moderate associations between COHRQoL and self-esteem. High heterogeneity between COHRQoL and self-esteem was noted. The association between child dental anxiety and self-esteem was limited. No source reported associations between all three variables. CONCLUSION The studies were of varying quality and the degree of heterogeneity meant that only limited conclusions were possible. There is a need for high-quality evidence to underpin intervention designs to promote COHRQoL and self-esteem to reduce child dental anxiety.
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Affiliation(s)
- A Alharbi
- School of Dentistry, University of Dundee, UK
| | - R Freeman
- Dental Health Services Research Unit School of Dentistry, University of Dundee, UK
| | - G Humphris
- School of Medicine, University of St Andrews, UK
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Gwadz M, Campos S, Freeman R, Cleland CM, Wilton L, Sherpa D, Ritchie AS, Hawkins RL, Allen JY, Martinez BY, Dorsen C, Collins LM, Hroncich T, Cluesman SR, Leonard NR. Black and Latino Persons Living with HIV Evidence Risk and Resilience in the Context of COVID-19: A Mixed-Methods Study of the Early Phase of the Pandemic. AIDS Behav 2021; 25:1340-1360. [PMID: 33566212 PMCID: PMC7873114 DOI: 10.1007/s10461-021-03177-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 01/24/2023]
Abstract
The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., “hustling” for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.
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Affiliation(s)
- Marya Gwadz
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA.
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA.
| | | | | | - Charles M Cleland
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Leo Wilton
- Department of Human Development, State University of New York at Binghamton, Binghamton, NY, USA
- Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| | - Dawa Sherpa
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
| | - Amanda S Ritchie
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
| | - Robert L Hawkins
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
| | - J Yvette Allen
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
| | - Belkis Y Martinez
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
| | | | - Linda M Collins
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, USA
| | - Theresa Hroncich
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Sabrina R Cluesman
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
| | - Noelle R Leonard
- NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, USA
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Waterfield A, Waterfield M, Campbell J, Freeman R. Can effective supervised pelvic floor muscle training be provided by primary care nurses? A randomized controlled trial. Int Urogynecol J 2021; 32:2717-2725. [PMID: 33624122 DOI: 10.1007/s00192-021-04692-3] [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: 10/27/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To determine whether primary care nurses with no prior experience can, after training, provide effective supervised pelvic floor muscle training (PFMT) by a three-group parallel randomized controlled trial (RCT): primary care nurse, urogynaecology nurse specialist and controls undertaken in 11 primary care/general practices, covering urban and rural settings in SW England. The sample consisted of 337 women with weak pelvic floor muscles (Modified Oxford Score 2 or less) in a randomly sampled survey. METHODS Following detailed instruction and training, primary care nurses recruited patients who were randomized to PFMT provided by them, a urogynaecology nurse specialist or a 'no training' control group. The primary outcome measure to assess the effectiveness of training was pelvic floor muscle strength as measured by perineometry. RESULTS Two hundred forty women aged 19 to 76 (median 49) years were recruited. After 3 months there was an increase in strength in both intervention groups compared with controls: median differences (95% CI) were 3.0 (0.3, 6.0) cmH2O higher for the primary care nurse group (n = 50) compared to the control group (n = 56; p = 0.02) and 4.3 (1.0, 7.3) cmH2O for the urogynaecology nurse specialist group (n = 53) compared to control (p < 0.01); there was no difference between the primary care nurse and urogynaecology nurse specialist groups [1.3 (-2.0,4.7; p = 0.70]. CONCLUSIONS PFMT provided by trained primary care nurses achieved improvements in pelvic floor muscle strength compared with controls (and comparable to that of a urogynaecology nurse specialist). This could have implications for the provision of PFMT for all women and potentially help in the prevention of pelvic floor dysfunction. TRIAL REGISTRATION Registered with ClinicalTrials.gov; Identifier NCT01635894. This was done retrospectively to conform to current registration requirements. When the trial commenced (2003), there was no requirement to register; this was introduced in 2005. The International Committee of Medical Journal Editors (ICMJE) decided that from July 1, 2005, no trials would be considered for publication unless they are included on a clinical trials registry, hence the retrospective registration.
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Affiliation(s)
- Ann Waterfield
- Urogynaecology Unit, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK
| | - Malcolm Waterfield
- Urogynaecology Unit, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK
| | - John Campbell
- Department of General Practice and Primary Care, University of Exeter Medical School, Exeter, EX1 2LU, UK
| | - Robert Freeman
- Urogynaecology Unit, University Hospitals Plymouth NHS Trust, Plymouth, PL6 8DH, UK. .,Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
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O'Leary JG, Philippe A, Freeman R, Heidecke H, Jennings LW, Catar R, Klintmalm GB, Dragun D. Non-HLA Autoantibodies at 1 Year Negatively Affect 5-Year Native Renal Function in Liver Transplant Recipients. Transplant Proc 2021; 53:1019-1024. [PMID: 33579550 DOI: 10.1016/j.transproceed.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Angiotensin II type-1 receptor (AT1R) and endothelin-1 type A receptor (ETAR) autoantibodies, in addition to allograft injury, can bind native endothelial cells and cause vascular vasoconstriction and fibrosis progression in nontransplanted organs. Therefore, we investigated long-term native renal function in liver transplant (LT) recipients with and without anti-AT1R-Abs and/or anti-ETAR-Abs present in serum. METHODS Primary LT recipients at our single center from January 2000 to April 2009 had their prospectively collected pre-LT (1269 patients) and year 1 post-LT (795 patients) serum tested retrospectively for anti-AT1R-Abs and/or anti-ETAR-Abs. Anti-AT1R-Abs and anti-ETAR-Abs testing was accomplished with a standardized solid phase assay in which >10 U was considered positive. RESULTS Pretransplant anti-AT1R-Abs and/or anti-ETAR-Abs did not change the median delta creatinine from pretransplant to 1 year post-transplant. In multivariable analysis controlling for diabetes (DM) and calcineurin inhibitor (CNI) use, anti-AT1R-Abs and/or anti-ETAR-Abs at 1-year remained statistically significantly associated with a decline in GFR (measured by Modification of Diet in Renal Disease-6) from years 1-5 post-LT (P = .04). In diabetic patients the association with a decline in renal function was more pronounced with (-9.29 mL/min) vs without (-2.28 mL/min) anti-AT1R-Abs and/or anti-ETAR-Abs at year 1, respectively (P = .004). CONCLUSION At 1-year post-LT, the autoantibodies anti-AT1R-Abs and/or anti-ETAR-Abs are associated in multivariable analysis with an increased risk of native renal function decline especially in diabetic patients.
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Affiliation(s)
| | - Aurélie Philippe
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany
| | - Robert Freeman
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Harald Heidecke
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany
| | - Linda W Jennings
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rusan Catar
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany
| | - Goran B Klintmalm
- Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Duska Dragun
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Nephrology and Intensive Care Medicine, Campus Virchow Klinikum, Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany
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Vij M, Dua A, Davies A, Freeman R. Do patients with central sensitivity syndromes have poor subjective outcomes despite anatomical cure from pelvic organ prolapse surgery? Int Urogynecol J 2021; 32:1461-1467. [PMID: 33459804 DOI: 10.1007/s00192-020-04655-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/10/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pelvic organ prolapse(POP) has an adverse impact on quality of life with lifetime risk of surgery varying from 11 to 20%. Conditions such as fibromyalgia (FMS), chronic fatigue syndrome (CFS/ME) and irritable bowel syndrome (IBS), collectively known as central sensitivity syndromes (CSS), may affect the outcome of POP surgery. The aim of this article is to compare the outcomes of vaginal POP surgery between women with and without CSS. METHOD This was a prospective cohort study. The validated Central Sensitisation Inventory (CSI) was used to identify women with CSS. Subjective and objective outcomes were compared between the two groups using POP-SS, Expectation and satisfaction/"EGGS", pain scores and the POP quantification system (POP-Q). A non-parametric test was used for analysis. RESULT Seventy-eight women were recruited. Complete data were available in 62 patients; 23 patients had evidence of CSS and 39 did not. Women with CSS had significantly higher pre- and post-operative POP-SS scores than those without (p < 0.0005, p = 0.004). Seventeen (73.9%) women with CSS compared to 38 (97.4%) women without CSS demonstrated improvement of a minimum 6 points on the POP-SS scale; however, this was not stastically significant. McGill's pain scores were higher in women with CSS both pre- and post-surgery. Ninety-five per cent of women without CSS achieved their goals and were satisfied with the surgery compared to 69.5% of women with CSS (p < 005). CONCLUSION There is a less favourable outcome of POP surgery in women with CSS compared to those without in terms of persistence of symptoms, pain and overall satisfaction.
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Affiliation(s)
| | - Anu Dua
- Singleton Hospital, Swansea, Wales, UK
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Chan L, Chaudhary K, Saha A, Chauhan K, Vaid A, Zhao S, Paranjpe I, Somani S, Richter F, Miotto R, Lala A, Kia A, Timsina P, Li L, Freeman R, Chen R, Narula J, Just AC, Horowitz C, Fayad Z, Cordon-Cardo C, Schadt E, Levin MA, Reich DL, Fuster V, Murphy B, He JC, Charney AW, Böttinger EP, Glicksberg BS, Coca SG, Nadkarni GN. AKI in Hospitalized Patients with COVID-19. J Am Soc Nephrol 2021; 32:151-160. [PMID: 32883700 PMCID: PMC7894657 DOI: 10.1681/asn.2020050615] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/03/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Early reports indicate that AKI is common among patients with coronavirus disease 2019 (COVID-19) and associated with worse outcomes. However, AKI among hospitalized patients with COVID-19 in the United States is not well described. METHODS This retrospective, observational study involved a review of data from electronic health records of patients aged ≥18 years with laboratory-confirmed COVID-19 admitted to the Mount Sinai Health System from February 27 to May 30, 2020. We describe the frequency of AKI and dialysis requirement, AKI recovery, and adjusted odds ratios (aORs) with mortality. RESULTS Of 3993 hospitalized patients with COVID-19, AKI occurred in 1835 (46%) patients; 347 (19%) of the patients with AKI required dialysis. The proportions with stages 1, 2, or 3 AKI were 39%, 19%, and 42%, respectively. A total of 976 (24%) patients were admitted to intensive care, and 745 (76%) experienced AKI. Of the 435 patients with AKI and urine studies, 84% had proteinuria, 81% had hematuria, and 60% had leukocyturia. Independent predictors of severe AKI were CKD, men, and higher serum potassium at admission. In-hospital mortality was 50% among patients with AKI versus 8% among those without AKI (aOR, 9.2; 95% confidence interval, 7.5 to 11.3). Of survivors with AKI who were discharged, 35% had not recovered to baseline kidney function by the time of discharge. An additional 28 of 77 (36%) patients who had not recovered kidney function at discharge did so on posthospital follow-up. CONCLUSIONS AKI is common among patients hospitalized with COVID-19 and is associated with high mortality. Of all patients with AKI, only 30% survived with recovery of kidney function by the time of discharge.
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Affiliation(s)
- Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kumardeep Chaudhary
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aparna Saha
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kinsuk Chauhan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Akhil Vaid
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - Shan Zhao
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ishan Paranjpe
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - Sulaiman Somani
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - Felix Richter
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - Riccardo Miotto
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - Anuradha Lala
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Arash Kia
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Prem Timsina
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Li Li
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert Freeman
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rong Chen
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Allan C. Just
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carol Horowitz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zahi Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carlos Cordon-Cardo
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eric Schadt
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew A. Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L. Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Barbara Murphy
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John C. He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander W. Charney
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- The Pamela Sklar Division of Psychiatric Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erwin P. Böttinger
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
| | - Benjamin S. Glicksberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - Steven G. Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Girish N. Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, New York
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
| | - on behalf of the Mount Sinai COVID Informatics Center (MSCIC)*
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
- The Pamela Sklar Division of Psychiatric Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
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Bennett AS, Freeman R, Des Jarlais DC, Aronson ID. Reasons People Who Use Opioids Do Not Accept or Carry No-Cost Naloxone: Qualitative Interview Study. JMIR Form Res 2020; 4:e22411. [PMID: 33355094 PMCID: PMC7787889 DOI: 10.2196/22411] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many people use opioids and are at risk of overdose. Naloxone is an opioid antagonist used to counter the effects of opioid overdose. There is an increased availability of naloxone in New York City; however, many who use opioids decline no-cost naloxone even when offered. Others may have the medication but opt not to carry it and report that they would be reluctant to administer it if they were to witness an overdose. OBJECTIVE We aim to better understand why people who use opioids may be reluctant to accept, carry, and administer naloxone, and to inform the development of messaging content that addresses barriers to its acceptance and use. METHODS We conducted formative qualitative interviews with 20 people who use opioids who are 18 years and older in New York City. Participants were recruited via key informants and chain referral. RESULTS Participants cited 4 main barriers that may impede rates of naloxone acceptance, possession, and use: (1) stigma related to substance use, (2) indifference toward overdose, (3) fear of negative consequences of carrying naloxone, and (4) fear of misrecognizing the need for naloxone. Participants also offered suggestions about messaging content to tackle the identified barriers, including messages designed to normalize naloxone possession and use, encourage shared responsibility for community health, and elicit empathy for people who use drugs. Taken together, participants' narratives hold implications for the following potential messaging content: (1) naloxone is short-acting, and withdrawal sickness does not have to be long-lasting; (2) it is critical to accurately identify an opioid-involved overdose; (3) anyone can overdose; (4) naloxone cannot do harm; and (5) the prompt administration of the medication can help ensure that someone can enjoy another day. Finally, participants suggested that messaging should also debunk myths and stereotypes about people who use drugs more generally; people who use opioids who reverse overdoses should be framed as lay public health advocates and not just "others" to be managed with stigmatizing practices and language. CONCLUSIONS It must be made a public health priority to get naloxone to people who use opioids who are best positioned to reverse an overdose, and to increase the likelihood that they will carry naloxone and use it when needed. Developing, tailoring, and deploying messages to address stigma, indifference toward overdose, fear and trepidation about reversing an overdose, and fear of police involvement may help alleviate fears among some people who are reluctant to obtain naloxone and use the medication on someone in an overdose situation.
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Affiliation(s)
- Alex S Bennett
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, United States
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, United States
| | - Robert Freeman
- School of Social Work, New York University, New York, NY, United States
| | - Don C Des Jarlais
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, United States
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, United States
- Department of Epidemiology, School of Global Public Health, New York University, New York City, NY, United States
| | - Ian David Aronson
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, United States
- Center for Drug Use and HIV Research, School of Global Public Health, New York University, New York, NY, United States
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Clifford CT, Pour TR, Freeman R, Reich DL, Glicksberg BS, Levin MA, Klang E. Association between COVID-19 diagnosis and presenting chief complaint from New York City triage data. Am J Emerg Med 2020; 46:520-524. [PMID: 33191048 PMCID: PMC7648523 DOI: 10.1016/j.ajem.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIM New York City (NYC) is an epicenter of the COVID-19 pandemic in the United States. Proper triage of patients with possible COVID-19 via chief complaint is critical but not fully optimized. This study aimed to investigate the association between presentation by chief complaints and COVID-19 status. METHODS We retrospectively analyzed adult emergency department (ED) patient visits from five different NYC hospital campuses from March 1, 2020 to May 13, 2020 of patients who underwent nasopharyngeal COVID-19 RT-PCR testing. The positive and negative COVID-19 cohorts were then assessed for different chief complaints obtained from structured triage data. Sub-analysis was performed for patients older than 65 and within chief complaints with high mortality. RESULTS Of 11,992 ED patient visits who received COVID-19 testing, 6524/11992 (54.4%) were COVID-19 positive. 73.5% of fever, 67.7% of shortness of breath, and 65% of cough had COVID-19, but others included 57.5% of weakness/fall/altered mental status, 55.5% of glycemic control, and 51.4% of gastrointestinal symptoms. In patients over 65, 76.7% of diarrhea, 73.7% of fatigue, and 69.3% of weakness had COVID-19. 45.5% of dehydration, 40.5% of altered mental status, 27% of fall, and 24.6% of hyperglycemia patients experienced mortality. CONCLUSION A novel high risk COVID-19 patient population was identified from chief complaint data, which is different from current suggested CDC guidelines, and may help triage systems to better isolate COVID-19 patients. Older patients with COVID-19 infection presented with more atypical complaints warranting special consideration. COVID-19 was associated with higher mortality in a unique group of complaints also warranting special consideration.
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Affiliation(s)
- Christopher T Clifford
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Trevor R Pour
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - David L Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Benjamin S Glicksberg
- The Hasso Plattner Institute of Digital Health at Mount Sinai, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Eyal Klang
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.
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46
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Friedman JI, Li L, Kirpalani S, Zhong X, Freeman R, Cheng YT, Alfonso FL, McAlpine G, Vakil A, Macon B, Francaviglia P, Cassara M, LoPachin V, Reina K, Davis K, Reich D, Craven CK, Mazumdar M, Siu AL. A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons. J Am Geriatr Soc 2020; 69:216-224. [PMID: 33150615 DOI: 10.1111/jgs.16897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/22/2020] [Accepted: 09/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium. DESIGN Hypothesis testing was carried out using a pretest-posttest design on program administrative data. SETTING Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium. INTERVENTION A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system. MEASUREMENTS Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units. RESULTS There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units. CONCLUSION Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.
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Affiliation(s)
- Joseph I Friedman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lihua Li
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | | | - Xiaobo Zhong
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Robert Freeman
- Clinical Operations, Mount Sinai Hospital, New York, New York
| | - Yim Tan Cheng
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Francis L Alfonso
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - George McAlpine
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Aditi Vakil
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Bernard Macon
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Paul Francaviglia
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Margherita Cassara
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Vicki LoPachin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Katherine Reina
- Department of Nursing, Mount Sinai Hospital, New York, New York
| | - Kenneth Davis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,President's Office, Mount Sinai Health System, New York, New York
| | - David Reich
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine K Craven
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Albert L Siu
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Aronson ID, Bennett AS, Freeman R. Toward a human-centered use of technology: a stakeholder analysis of harm reduction and CBO staff. Harm Reduct J 2020; 17:77. [PMID: 33076911 PMCID: PMC7570409 DOI: 10.1186/s12954-020-00422-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022] Open
Abstract
Background Technology can enable syringe service programs (SSPs) and other community-based organizations (CBOs) operating under a harm reduction framework to work with an increased number of clients and can also enable organizations to offer services more effectively (e.g., offering HIV testing in ways participants may be more likely to accept). In the current time of COVID-19 social distancing, technology can also help organizations more safely provide services to people with compromised immune systems and to clients who might otherwise not be reached. However, technology projects implemented in harm reduction settings are frequently conceptualized and developed by researchers or technology specialists rather than by SSP staff or clients. Methods To more effectively meet the needs of SSPs and other CBOs across the USA, our team conducted qualitative interviews with 16 individuals who have extensive backgrounds working in the field of harm reduction. Interviews were digitally recorded and professionally transcribed, and the transcripts were checked for accuracy by the interviewers. The resulting transcripts were coded and analyzed to determine emerging themes. Results Interviewees mentioned the ability of technology to deliver consistent quality messaging to multiple clients at the same time and the potential to customize or tailor technology-based messaging to specific client populations as positive benefits. Clear barriers to technology use also emerged, in particular regarding privacy, data security, and the need to maintain client trust when discussing sensitive issues (e.g., illicit drug use). Conclusions Technology offers the potential to deliver consistently high-quality health communication and maintain contact with clients who may have no other access to care. If designed and managed effectively, technology can also address issues related to providing services during times when physical contact is limited due to COVID-19 social distancing measures.
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Affiliation(s)
- Ian David Aronson
- Digital Health Empowerment, Brooklyn, USA. .,New York University, School of Global Public Health, New York, USA.
| | - Alex S Bennett
- Digital Health Empowerment, Brooklyn, USA.,New York University, School of Global Public Health, New York, USA
| | - Robert Freeman
- New York University, School of Global Public Health, New York, USA
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Parchure P, Joshi H, Dharmarajan K, Freeman R, Reich DL, Mazumdar M, Timsina P, Kia A. Development and validation of a machine learning-based prediction model for near-term in-hospital mortality among patients with COVID-19. BMJ Support Palliat Care 2020; 12:bmjspcare-2020-002602. [PMID: 32963059 PMCID: PMC8049537 DOI: 10.1136/bmjspcare-2020-002602] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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] [Received: 07/28/2020] [Revised: 08/09/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To develop and validate a model for prediction of near-term in-hospital mortality among patients with COVID-19 by application of a machine learning (ML) algorithm on time-series inpatient data from electronic health records. METHODS A cohort comprised of 567 patients with COVID-19 at a large acute care healthcare system between 10 February 2020 and 7 April 2020 observed until either death or discharge. Random forest (RF) model was developed on randomly drawn 70% of the cohort (training set) and its performance was evaluated on the rest of 30% (the test set). The outcome variable was in-hospital mortality within 20-84 hours from the time of prediction. Input features included patients' vital signs, laboratory data and ECG results. RESULTS Patients had a median age of 60.2 years (IQR 26.2 years); 54.1% were men. In-hospital mortality rate was 17.0% and overall median time to death was 6.5 days (range 1.3-23.0 days). In the test set, the RF classifier yielded a sensitivity of 87.8% (95% CI: 78.2% to 94.3%), specificity of 60.6% (95% CI: 55.2% to 65.8%), accuracy of 65.5% (95% CI: 60.7% to 70.0%), area under the receiver operating characteristic curve of 85.5% (95% CI: 80.8% to 90.2%) and area under the precision recall curve of 64.4% (95% CI: 53.5% to 75.3%). CONCLUSIONS Our ML-based approach can be used to analyse electronic health record data and reliably predict near-term mortality prediction. Using such a model in hospitals could help improve care, thereby better aligning clinical decisions with prognosis in critically ill patients with COVID-19.
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Affiliation(s)
- Prathamesh Parchure
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Himanshu Joshi
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Kavita Dharmarajan
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hospital Administration, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - David L Reich
- Hospital Administration, Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Prem Timsina
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arash Kia
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Morgenthau AS, Levin MA, Freeman R, Reich DL, Klang E. Moderate or Severe Impairment in Pulmonary Function is Associated with Mortality in Sarcoidosis Patients Infected with SARS‑CoV‑2. Lung 2020; 198:771-775. [PMID: 32915271 PMCID: PMC7484928 DOI: 10.1007/s00408-020-00392-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/27/2020] [Indexed: 12/22/2022]
Abstract
Purpose To investigate whether sarcoidosis patients infected with SARS-CoV-2 are at risk for adverse disease outcomes. Study Design and Methods This retrospective study was conducted in five hospitals within the Mount Sinai Health System during March 1, 2020 to July 29, 2020. All patients diagnosed with COVID-19 were included in the study. We identified sarcoidosis patients who met diagnostic criteria for sarcoidosis according to accepted guidelines. An adverse disease outcome was defined as the presence of intubation and mechanical ventilation or in-hospital mortality. In sarcoidosis patients, we reported (when available) the results of pulmonary function testing measured within 3 years prior to the time of SARS‑CoV‑2 infection. A multivariable logistic regression model was used to generate an adjusted odds ratio (aOR) to evaluate sarcoidosis as a risk factor for an adverse outcome. The same model was used to analyze sarcoidosis patients with moderate and/or severe impairment in pulmonary function. Results The study included 7337 patients, 37 of whom (0.5%) had sarcoidosis. The crude rate of developing an adverse outcome was significantly higher in patients with moderately and/or severely impaired pulmonary function (9/14 vs. 3/23, p = 0.003). While the diagnosis of sarcoidosis was not independently associated with risk of an adverse event, (aOR 1.8, 95% CI 0.9–3.6), the diagnosis of sarcoidosis in patients with moderately and/or severely impaired pulmonary function was associated with an adverse outcome (aOR 7.8, 95% CI 2.4–25.8). Conclusion Moderate or severe impairment in pulmonary function is associated with mortality in sarcoidosis patients infected with SARS‑CoV‑2. Electronic supplementary material The online version of this article (10.1007/s00408-020-00392-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adam S Morgenthau
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Freeman
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David L Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eyal Klang
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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50
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Bidwell P, Thakar R, Gurol-Urganci I, Harris JM, Silverton L, Hellyer A, Freeman R, Morris E, Novis V, Sevdalis N. Exploring clinicians' perspectives on the 'Obstetric Anal Sphincter Injury Care Bundle' national quality improvement programme: a qualitative study. BMJ Open 2020; 10:e035674. [PMID: 32907894 PMCID: PMC7482496 DOI: 10.1136/bmjopen-2019-035674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/07/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASI) can have severe debilitating consequences to women and health systems. The OASI Care Bundle quality improvement programme was introduced in 16 maternity units across England, Scotland and Wales (January 2017 to March 2018) to address increasing OASI rates. OBJECTIVES To explore clinicians' (midwives' and obstetricians') perspectives of the OASI Care Bundle with respect to (1) acceptability, (2) feasibility, and (3) sustainability. DESIGN A qualitative exploratory study using focus groups methodology. SETTING A total of 16 focus groups were conducted in 16 maternity units in England, Scotland and Wales where the OASI Care Bundle was implemented. Focus groups took place approximately 3 months following initial implementation of the care bundle in each unit. PARTICIPANTS A total of 101 clinicians participated, with an average of six per focus group. Participants volunteered to take part and compromised of 37 obstetricians and 64 midwives (including eight students). The majority were female and the mean age was 36.5 years. RESULTS Four main themes emerged: 'Implementation strategies', 'Opportunities to use the OASI Care Bundle', 'Does current practice need to change?' and 'Perceptions of what women want'. Midwives were more likely than obstetricians to report themes alluding to 'what women want' and variations in intrapartum perineal protection techniques. Both professional groups reported similar views of other themes, in particular regarding the supporting clinical evidence. Gaps were identified in clinicians' knowledge and experience of intrapartum perineal management. CONCLUSIONS Adoption of the OASI Care Bundle was associated with a number of cognitive and interpersonal factors, such as personal values, interprofessional working and how the intervention was launched; which both facilitated and impeded adoption. The 'what women want' theme has implications for maternal autonomy and needs further exploration. Our findings can be used by similar initiatives to reduce perineal trauma both nationally and internationally. TRIAL REGISTRATION NUMBER ISCTRN 12143325; https://doi.org/10.1186/ISRCTN12143325.
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Affiliation(s)
- Posy Bidwell
- Royal College of Obstetricians and Gynaecologists, London, UK
| | | | - Ipek Gurol-Urganci
- Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - James M Harris
- Centre for Nursing, Midwifery and Allied Health Professional Research, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Edward Morris
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Vivienne Novis
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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