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Streib CD, Rangaraju S, Campbell DT, Winger DG, Paolini SL, Zhang AJ, Jankowitz BT, Jadhav AP, Jovin TG. Infarct Volume Predicts Hospitalization Costs in Anterior Circulation Large-Vessel Occlusion Stroke. AJNR Am J Neuroradiol 2018; 40:51-58. [PMID: 30591512 DOI: 10.3174/ajnr.a5917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 10/21/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Anterior circulation large-vessel occlusion stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. We aimed to identify predictors of increased acute care hospitalization costs associated with anterior circulation large-vessel occlusion stroke. MATERIALS AND METHODS Comprehensive cost-tracking software was used to calculate acute care hospitalization costs for patients with anterior circulation large-vessel occlusion stroke admitted July 2012 to October 2014. Patient demographics and stroke characteristics were analyzed, including final infarct volume on follow-up neuroimaging. Predictors of hospitalization costs were determined using multivariable linear regression including subgroup cost analyses by treatment technique (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses incorporating patients initially excluded due to early withdrawal of care. RESULTS Three hundred forty-one patients (median age, 69 years; interquartile range, 57-80 years; median NIHSS score, 16; interquartile range, 13-21) were included in our primary analysis. Final infarct volume, parenchymal hematoma, baseline NIHSS score, ipsilateral carotid stenosis, age, and obstructive sleep apnea were significant predictors of acute care hospitalization costs. Final infarct volume alone accounted for 20.87% of the total cost variance. Additionally, final infarct volume was consistently the strongest predictor of increased cost in primary, subgroup, and sensitivity analyses. CONCLUSIONS Final infarct volume was the strongest predictor of increased hospitalization costs in anterior circulation large-vessel occlusion stroke. Acute stroke therapies that reduce final infarct volume may not only improve clinical outcomes but may also prove cost-effective.
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Affiliation(s)
- C D Streib
- From the Department of Neurology (C.D.S., A.J.Z.), University of Minnesota, Minneapolis, Minnesota.,Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - S Rangaraju
- Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania.,Department of Neurology (S.R.), Emory University, Atlanta, Georgia
| | - D T Campbell
- Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania.,Department of Neurology (D.T.C.), WellStar Kennestone Hospital, Marietta, Georgia
| | - D G Winger
- Clinical Translational Science Institute (D.G.W.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - S L Paolini
- Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - A J Zhang
- From the Department of Neurology (C.D.S., A.J.Z.), University of Minnesota, Minneapolis, Minnesota
| | - B T Jankowitz
- Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - A P Jadhav
- Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - T G Jovin
- Department of Neurology, Stroke Institute (C.D.S., S.L.P., B.T.J., A.P.J., T.G.J., S.R., D.T.C.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
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2
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Conroy MB, Shaffiey S, Jones S, Hackam DJ, Sowa G, Winger DG, Wang L, Boninger ML, Wagner AK, Levine AS. Scholarly Research Projects Benefit Medical Students' Research Productivity and Residency Choice: Outcomes From the University of Pittsburgh School of Medicine. Acad Med 2018; 93:1727-1731. [PMID: 29923890 DOI: 10.1097/acm.0000000000002328] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE Many medical schools require scholarly research projects. However, outcomes data from these initiatives are scarce. The authors studied the impact of the Scholarly Research Project (SRP), a four-year longitudinal requirement for all students at the University of Pittsburgh School of Medicine (UPSOM), on research productivity and residency match. METHOD The authors conducted a longitudinal study of non-dual-degree UPSOM graduates in 2006 (n = 121, non-SRP participants) versus 2008 (n = 118), 2010 (n = 106), and 2012 (n = 132), all SRP participants. The authors used PubMed for publication data, National Resident Matching Program for residency match results, and Blue Ridge Institute for Medical Research for National Institutes of Health funding rank for residency-affiliated academic institutions. RESULTS Research productivity of students increased for those completing the SRP, measured as a greater proportion of students with publications (27.3% in 2006 vs. 45.8% in 2008, 55.7% in 2010, and 54.5% in 2012; P < .001) and first-authorship (9.9% in 2006 vs. 26.3% in 2008, 33.0% in 2010, and 35.6% in 2012; P < .001). Across years, there was a significantly greater proportion of students with peer-reviewed publications matched in higher-ranked residency programs (57.0% with publications in the top 10%, 52.7% in the top 10%-25%, 32.4% in the top 25%-50%, 41.2% in the bottom 50%, and 45.2% in unranked programs; P = .018). CONCLUSIONS Longitudinal research experiences for medical students may be one effective tool in fostering student publications and interest in extending training in a research-focused medical center.
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Affiliation(s)
- Molly B Conroy
- M.B. Conroy is professor of medicine and chief, Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah. S. Shaffiey is a surgery resident, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. S. Jones is instructor of medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. D.J. Hackam is professor of pediatric surgery and surgeon-in-chief, Johns Hopkins Children's Center, Baltimore, Maryland. G. Sowa is professor and chair of physical medicine and rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. D.G. Winger is a statistician, University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, Pennsylvania. L. Wang is a statistician, University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, Pennsylvania. M.L. Boninger is professor of physical medicine and rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. A.K. Wagner is associate professor of physical medicine and rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. A.S. Levine is senior vice chancellor for health sciences and dean, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Forno E, Abraham N, Winger DG, Rosas-Salazar C, Kurland G, Weiner DJ. Perception of Pulmonary Function in Children with Asthma and Cystic Fibrosis. Pediatr Allergy Immunol Pulmonol 2018; 31:139-145. [PMID: 30283712 DOI: 10.1089/ped.2018.0906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/30/2018] [Indexed: 11/13/2022]
Abstract
Background: Under-perception of pulmonary dysfunction may delay appropriate treatment, while over-perception may result in unnecessary treatments. Objectives: To evaluate the ability of patients with asthma or cystic fibrosis and their subspecialty caregivers to assess changes in lung function based on their subjective clinical impressions. Methods: Patients were asked to qualitatively describe how they felt compared to their prior visit (same/better/worse) and to quantitatively estimate their forced expiratory volume in 1 s (FEV1) after being reminded of their FEV1 at the prior visit. Providers made similar estimates based on history and physical examination and knowledge of prior FEV1. After adjusting for relevant clinical covariates, lung function estimates were categorized as accurate (±5% of measured FEV1), overestimated (>5% above measured), and underestimated (>5% below measured). Results: One hundred nine patients estimated FEV1 on 179 occasions. Concordance between patient qualitative assessment and FEV1-based categories was low (κ = 0.08); 44% of patients reported feeling better than the FEV1-based category showed. Quantitatively, 56% of patient estimates were accurate, 18% were underestimated, and 26% overestimated; accuracy improved with age (odds ratio = 1.16, P = 0.01). Concordance between provider qualitative assessments and FEV1-based category was moderate (κ = 0.35); about 19% said their patient looked better than the FEV1-based category showed. Quantitatively, 65% of provider estimates were accurate, 16% were underestimated, and 19% were overestimated; accuracy improved with years of experience. Conclusions: Patients' and providers' perceptions of lung function were low to moderately accurate. Relying on subjective impression may place patients at risk for unnecessary treatments or increased morbidity. These findings highlight the importance of objective lung function assessment.
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Affiliation(s)
- Erick Forno
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Neethu Abraham
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniel G Winger
- Department of Statistics, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Rosas-Salazar
- Division of Pediatric Allergy, Immunology and Pulmonology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Geoffrey Kurland
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniel J Weiner
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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4
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Ross MS, Burriss ME, Winger DG, Edwards RP, Courtney-Brooks M, Boisen MM. Unplanned postoperative intensive care unit admission for ovarian cancer cytoreduction is associated with significant decrease in overall survival. Gynecol Oncol 2018; 150:306-310. [PMID: 29929924 DOI: 10.1016/j.ygyno.2018.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous studies have identified age, nutritional status, and hematocrit as risk factors for unplanned ICU admission in gynecologic oncology patients. We sought to identify additional perioperative factors that can be predictive of unplanned ICU admission and its impact on outcomes in women with ovarian cancer undergoing ovarian cancer cytoreductive procedures. METHODS This was a case-control study of patients with unplanned ICU admission after primary surgery for ovarian cancer from January 2007 to December 2013. Controls were selected in a 2:1 ratio matching for primary surgeon and date of surgery. Clinical data was abstracted and compared between cases and controls using conditional logistic regression. RESULTS The dataset consisted of 324 patients (108 ICU admissions, 216 controls). On multivariable analysis, failure to optimally cytoreduce (p = 0.001, OR 3.76) and higher EBL (p < 0.001, OR 1.20 per 100 cm3) remained significant predictors of unplanned ICU admission. On multivariable analysis of outcomes, ICU admission was independently associated with increased length of stay (12 days vs. 6 days, p < 0.001), increased number of postop complications (2 vs. 0, p < 0.001), and increased risk of readmission within 30 days (p = 0.041, OR 2.46). Even controlling for debulking status, ICU admission remained associated with a worse median OS (27.3 vs 57.9 months, p < 0.001). CONCLUSIONS ICU admission for women undergoing cytoreductive surgery for ovarian cancer is associated with a significant decrease in OS and increase in number of postoperative complications. For this inherently high-risk population, this information is critical when counseling patients about peri-operative risks in primary cytoreductive surgery.
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Affiliation(s)
- Malcolm S Ross
- Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Mary E Burriss
- Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel G Winger
- University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, PA, USA
| | - Robert P Edwards
- Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Madeleine Courtney-Brooks
- Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michelle M Boisen
- Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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5
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Bhama JK, Bansal U, Winger DG, Teuteberg JJ, Bermudez C, Kormos RL, Bansal A. Clinical experience with temporary right ventricular mechanical circulatory support. J Thorac Cardiovasc Surg 2018; 156:1885-1891. [PMID: 29861112 DOI: 10.1016/j.jtcvs.2018.04.094] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to determine if indication for support affects the outcomes after temporary right ventricular mechanical circulatory support after postcardiotomy cardiogenic shock, cardiac transplant, or left ventricular assist device placement. METHODS A retrospective review was performed on 80 patients receiving a right ventricular assist device. Data were collected from a prospectively maintained database. Kaplan-Meier survival analysis was performed to compare survival between groups. Multivariate regression analysis was performed to identify risk factors for failure to wean from support. RESULTS The indication for support was postcardiotomy cardiogenic shock in 13 patients (16%), cardiac transplant in 25 patients (31%), and left ventricular assist device in 42 patients (53%). Median support time was 6 days. Device was successfully weaned in 6 postcardiotomy cardiogenic shock cases (46%), 21 cardiac transplant cases (84%), and 35 left ventricular assist device cases (83%). Survival was worse for patients with postcardiotomy cardiogenic shock compared with patients with a left ventricular assist device. Survival up to 3 months was better for patients who received immediate (n = 43) versus delayed (n = 37) support (79% vs 46%, P = .003). Weaning and survival remained static across implant era. Risk factor analysis identified postcardiotomy cardiogenic shock indication (odds ratio, 0.161; P = .007; confidence interval, 0.043-0.600) as an independent negative predictor of weaning from mechanical support. CONCLUSIONS Temporary right ventricular mechanical support remains an effective treatment strategy after left ventricular assist device placement with immediate support resulting in superior short-term survival. Caution should be applied in postcardiotomy cardiogenic shock when weaning and survival are poor. Overall survival outcomes have remained relatively static over time.
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Affiliation(s)
- Jay K Bhama
- Division of Cardiothoracic Surgery, University of Iowa Health Care, Iowa City, Iowa.
| | - Utsav Bansal
- University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Jeffrey J Teuteberg
- Heart and Vascular Institute, Artificial Heart Program, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Christian Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Robert L Kormos
- Heart and Vascular Institute, Artificial Heart Program, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Aditya Bansal
- Division of Cardiothoracic Surgery, Ochsner Clinic, New Orleans, La
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6
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Shah PR, Boisen ML, Winger DG, Marquez J, Bermudez CA, Bhama JK, Shigemura N, D'Cunha J, Subramaniam K. Corrigendum to 'Extracorporeal Support During Bilateral Sequential Lung Transplantation in Patients with Pulmonary Hypertension: Risk factors and Outcomes' [Journal of Cardiothoracic and Vascular Anesthesia volume 31/2 (2017) 418-425]. J Cardiothorac Vasc Anesth 2018; 32:2034. [PMID: 29567039 DOI: 10.1053/j.jvca.2018.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pranav R Shah
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Jose Marquez
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jay K Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA.
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7
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Lavelle ES, Giugale LE, Winger DG, Wang L, Carter-Brooks CM, Shepherd JP. Prolapse recurrence following sacrocolpopexy vs uterosacral ligament suspension: a comparison stratified by Pelvic Organ Prolapse Quantification stage. Am J Obstet Gynecol 2018; 218:116.e1-116.e5. [PMID: 28951262 DOI: 10.1016/j.ajog.2017.09.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/07/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Insufficient evidence evaluates which pelvic organ prolapse surgery is best suited to an individual woman based on the stage of her prolapse. OBJECTIVE We sought to compare prolapse recurrence rates following sacrocolpopexy and uterosacral ligament suspension after stratifying by preoperative Pelvic Organ Prolapse Quantification stage. STUDY DESIGN We compared all women who underwent minimally invasive sacrocolpopexy or vaginal or minimally invasive uterosacral ligament suspension from 2009 through 2015 at a large academic center. All women with preoperative and postoperative Pelvic Organ Prolapse Quantification data were included. Patients were grouped by preoperative Pelvic Organ Prolapse Quantification stage for analysis. Recurrence rates following sacrocolpopexy and uterosacral ligament suspension were compared for patients presenting with stage II, III, and IV prolapse, adjusting for potential confounders in regression models. Prolapse recurrence was defined as any retreatment for prolapse or any Pelvic Organ Prolapse Quantification point beyond the hymen. RESULTS Of 756 women, 633 underwent sacrocolpopexy (83.7%) and 123 (16.3%) underwent uterosacral ligament suspension. In all, 189 (25%) had preoperative Pelvic Organ Prolapse Quantification stage II prolapse, 527 (69.7%) stage III, and 40 (5.3%) stage IV. Patients were predominantly Caucasian (97.3%) with mean age 59.8 ± 9.5 years. Compared to uterosacral ligament suspension patients, more sacrocolpopexy patients had undergone prior prolapse repair (20.9% vs 5.7%, P < .001) and fewer had known diabetes mellitus (7.9% vs 13.8%, P = .034). Characteristics of the groups were otherwise similar. Median follow-up was 41.0 (interquartile range 13.0-88.8) weeks. Stage II prolapse patients had similar recurrence rates following sacrocolpopexy or uterosacral ligament suspension (6.0% vs 5.0, P = 1.00). However, stage III prolapse patients were more likely to experience recurrence following uterosacral ligament suspension (25.7% vs 7.8%, P < .001). This difference persisted after controlling for age, body mass index, smoking, diabetes, and prior prolapse repair (odds ratio, 4.3; 95% confidence interval, 2.2-8.2). There was no discernable difference in recurrence rates for women with stage IV prolapse, although sample size was limited. CONCLUSION Sacrocolpopexy resulted in a lower prolapse recurrence rate than uterosacral ligament suspension for stage III prolapse. However, there was no difference in recurrence rate among women with preoperative stage II prolapse, suggesting mesh augmentation may not be indicated for these patients. Larger prospective trials are necessary for confirmation.
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8
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Shah PR, Boisen ML, Winger DG, Marquez J, Bermudez CA, Bhama JK, Shigemura N, D’Cunha J, Subramaniam K. Extracorporeal Support During Bilateral Sequential Lung Transplantation in Patients With Pulmonary Hypertension: Risk Factors and Outcomes. J Cardiothorac Vasc Anesth 2017; 31:418-425. [DOI: 10.1053/j.jvca.2016.08.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Indexed: 11/11/2022]
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9
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Heisel RW, Sutton RR, Mascara GP, Winger DG, Weber DR, Lim SH, Oleksiuk LM. Vancomycin-resistant enterococci in acute myeloid leukemia and myelodysplastic syndrome patients undergoing induction chemotherapy with idarubicin and cytarabine. Leuk Lymphoma 2017; 58:2565-2572. [PMID: 28351179 DOI: 10.1080/10428194.2017.1306645] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We conducted a retrospective study to determine the risk factors associated with vancomycin-resistant enterococci (VRE) acquisition/infection in newly diagnosed acute myeloid leukemia and myelodysplastic syndrome patients undergoing chemotherapy with the 7 + 3 regimen of cytarabine and idarubicin. Although only 2.5% (6/235) patients were colonized with VRE on admission, 59% (134/229) of patients acquired VRE during their hospitalization. Multivariable analysis identified the use of intravenous vancomycin (p = .024; HR: 1.548) and cephalosporin (p = .009; HR: 1.596) as the risk factors for VRE acquisition. VRE infection developed in 14% (33/229) of patients, with bloodstream infections accounting for 82% (27/33) of cases. VRE infection occurred in 25/126 (20%) of the VRE-colonized patients, but only 8/103 (8%) of those who were not (p = .01). Our study provides the evidence for the role of intravenous cephalosporin and vancomycin in VRE acquisition and highlights the clinical significance of VRE colonization in these patients.
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Affiliation(s)
- Ronald W Heisel
- a Department of Pharmacy , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Robert R Sutton
- b University of Pittsburgh School of Pharmacy , Pittsburgh , PA , USA
| | - Gerard P Mascara
- a Department of Pharmacy , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Daniel G Winger
- c Clinical and Translational Science Institute, University of Pittsburgh , Pittsburgh , PA , USA
| | - David R Weber
- d Division of Infectious Diseases , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Seah H Lim
- e Division of Hematology/Oncology , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Louise-Marie Oleksiuk
- a Department of Pharmacy , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
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Arakali SR, Winger DG, Wang L, Green TD. Oral Food Challenge Outcomes in Nut and Seed Allergy. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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11
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Sommerfeld CG, Winger DG, Green TD. Predictors of Oral Food Challenge Outcomes in Children with a Diagnosis of Food Allergy. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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West LJ, Baloh C, Chong H, Larkin AS, Nash DR, Broyles J, Winger DG, Wang L, Green TD. Infant and Young Child Peanut Challenges, a Clinical Application of the Learning Early About Peanut Allergy Study. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Streib C, Rangaraju S, Winger DG, Campbell DT, Paolini S, Jankowitz B, Jadhav A, Jovin T. Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies.
Methods:
We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses.
Results:
341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35.
Conclusion:
FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.
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Affiliation(s)
| | | | - Daniel G Winger
- Univ of Pittsburgh Clinical Translational Science Institute, Pittsburgh, PA
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14
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Tam V, Luketich JD, Winger DG, Sarkaria IS, Levy RM, Christie NA, Awais O, Shende MR, Nason KS. Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis. J Gastrointest Surg 2017; 21:137-145. [PMID: 27492355 PMCID: PMC5209749 DOI: 10.1007/s11605-016-3231-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 06/07/2016] [Accepted: 07/26/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. METHODS We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. RESULTS Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair. CONCLUSIONS Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.
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Affiliation(s)
- Vernissia Tam
- University of Pittsburgh Department of General Surgery, Pittsburgh, PA
| | | | - Daniel G. Winger
- University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, PA
| | | | - Ryan M. Levy
- Department of Cardiothoracic Surgery, Pittsburgh, PA
| | | | - Omar Awais
- Department of Cardiothoracic Surgery, Pittsburgh, PA
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15
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Oluwole OB, Noll RB, Winger DG, Akinyanju O, Novelli EM. Cognitive functioning in children from Nigeria with sickle cell anemia. Pediatr Blood Cancer 2016; 63:1990-7. [PMID: 27393914 PMCID: PMC7134368 DOI: 10.1002/pbc.26126] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 10/21/2015] [Revised: 05/31/2016] [Accepted: 06/10/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cognitive impairment is a major neurological complication of sickle cell anemia (SCA) in the United States, but there are limited studies of cognitive impairment in Nigeria, the country with the highest SCA burden. We hypothesized that children from Nigeria with SCA have worse cognitive functioning than comparison children and explored the association between lower cognitive functioning and key laboratory demographic and socioeconomic variables among children with SCA. PROCEDURE We conducted a cross-sectional survey, supplemented by anthropomorphic and laboratory data, among a convenience sample of children from Nigeria with and without SCA. We administered the Wechsler Intelligence Scale for Children, Version IV. Our primary outcome measures included (1) estimated IQ (Est. IQ), (2) working memory (WM), and (3) processing speed (PS). RESULTS The sample included 56 children with SCA (mean age 9.20 [SD 2.75], 46.43% girls) and 44 comparison children (mean age 9.41 [SD 2.49], 40.91% girls). Children with SCA performed worse on Est. IQ (84.58 vs. 96.10, P = 0.006) and PS (86.69 vs 96.91, P = 0.009) than comparison children. There was no significant difference in WM between both groups. Factors associated with lower Est. IQ and PS among children with SCA included age, maternal education, weight-for-age Z scores, and height-for age Z scores. CONCLUSION In this small sample of children from Nigeria, we found worse cognitive functioning in children with SCA than in comparison children, and that sociodemographic and anthropomorphic factors were correlated with cognitive functioning.
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Affiliation(s)
| | - Robert B. Noll
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel G. Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Enrico M. Novelli
- Division of Hematology/Oncology, Department of Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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16
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Attaar A, Winger DG, Luketich JD, Schuchert MJ, Sarkaria IS, Christie NA, Nason KS. A clinical prediction model for prolonged air leak after pulmonary resection. J Thorac Cardiovasc Surg 2016; 153:690-699.e2. [PMID: 27912898 DOI: 10.1016/j.jtcvs.2016.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/15/2016] [Accepted: 10/05/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables. METHODS Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed. RESULTS A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk. CONCLUSIONS Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management.
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Affiliation(s)
- Adam Attaar
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - James D Luketich
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Inderpal S Sarkaria
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Neil A Christie
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Katie S Nason
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
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17
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Horner KB, Jones A, Wang L, Winger DG, Marin JR. Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED. Am J Emerg Med 2016; 34:2320-2325. [PMID: 27613363 DOI: 10.1016/j.ajem.2016.08.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging (ultrasound ±computed tomography [CT]) and factors associated with isolated CT use. METHODS This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007 to 2013. Primary outcome was ultrasound or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging. RESULTS Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.4-0.5) and Medicaid (OR, 0.6; 95% CI, 0.5-0.7) had lower odds of advanced imaging compared with white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR, 0.6; 95% CI, 0.5-0.7) compared with the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared with 76% of those to general EDs included an isolated CT (P<.001). Low pediatric volume (OR, 1.8; 95% CI, 1.5-2.2) and rural (OR,1.8; 95% CI, 1.3-2.5) EDs had higher odds of isolated CT use, compared with higher pediatric volumes and nonrural EDs, respectively. CONCLUSION There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of "ultrasound first."
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Affiliation(s)
- Kimberly B Horner
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Amy Jones
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer R Marin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg 2016; 155:501-7. [DOI: 10.1177/0194599816644410] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/23/2016] [Indexed: 11/17/2022]
Abstract
Objectives To examine the sensitivity and specificity of history, physical examination, and radiologic studies as predictors of foreign body aspiration in children. Study Design Case series with chart review. Setting Tertiary care children’s hospital. Subjects and Methods Medical records were reviewed for 102 children who presented to our institution from 2006 to 2013 with suspected foreign body aspiration and who underwent endoscopy. Data included symptoms, physical examination, radiologic, and endoscopy findings. Descriptive statistics, sensitivity and specificity, and univariate and multivariable analyses were performed. Results A total of 102 patients were included (62% male). The mean age was 3.3 years (SD, 3.7). A foreign body was identified on endoscopy in 69 cases (68%). The most common presenting symptoms were cough (88%), choking/gagging (67%), and wheezing (57%). Decreased breath sounds and wheezing on examination were independently associated with increased odds of foreign body. The most common abnormal radiographic finding was air trapping (33%). The most frequent items retrieved were fragments of seeds and nuts (49%). There were no serious complications related to endoscopy. The sensitivity and specificity of any finding on history, physical examination, and imaging were 100% and 3%, 90% and 33%, 61% and 77%, respectively. Having a positive history, examination, and chest radiograph combined was 46% sensitive and 79% specific. Conclusions Patients with airway foreign bodies have varied presentations. The presence of any radiologic finding suggests that endoscopy should be performed, as a foreign body is probable. The absence of any history or physical examination finding was associated with a low likelihood of a foreign body.
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Affiliation(s)
- Jacquelyn R. Sink
- UPMC Medical Education Preliminary Year Residency Program, UPMC Montefiore Hospital, Pittsburgh, Pennsylvania, USA
| | - Dennis J. Kitsko
- Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew W. Georg
- Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel G. Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P. Simons
- Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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19
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Winger DG, Nason KS. Propensity-score analysis in thoracic surgery: When, why, and an introduction to how. J Thorac Cardiovasc Surg 2016; 151:1484-7. [DOI: 10.1016/j.jtcvs.2016.02.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/04/2016] [Accepted: 02/16/2016] [Indexed: 11/28/2022]
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20
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Johnson TJ, Hickey RW, Switzer GE, Miller E, Winger DG, Nguyen M, Saladino RA, Hausmann LRM. The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias. Acad Emerg Med 2016; 23:297-305. [PMID: 26763939 DOI: 10.1111/acem.12901] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/09/2015] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias. METHODS This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores. RESULTS Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21). CONCLUSIONS While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.
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Affiliation(s)
- Tiffani J. Johnson
- Division of Pediatric Emergency Medicine; PolicyLab, and Center for Perinatal and Pediatric Health Disparities Research; Children's Hospital of Philadelphia, and the Department of Pediatrics; University of Pennsylvania School of Medicine; Philadelphia PA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Galen E. Switzer
- Division of General Internal Medicine; Department of Medicine; University of Pittsburgh; Pittsburgh PA
- Veterans Affairs Pittsburgh Healthcare System; Center for Health Equity Research and Promotion; Pittsburgh PA
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Daniel G. Winger
- Clinical and Translational Science Institute; University of Pittsburgh; Pittsburgh PA
| | - Margaret Nguyen
- Department of Emergency Medicine; Rady Children's Hospital San Diego; San Diego CA
| | - Richard A. Saladino
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Leslie R. M. Hausmann
- Division of General Internal Medicine; Department of Medicine; University of Pittsburgh; Pittsburgh PA
- Veterans Affairs Pittsburgh Healthcare System; Center for Health Equity Research and Promotion; Pittsburgh PA
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21
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Ferris LK, Harkes JA, Gilbert B, Winger DG, Golubets K, Akilov O, Satyanarayanan M. Computer-aided classification of melanocytic lesions using dermoscopic images. J Am Acad Dermatol 2015; 73:769-76. [DOI: 10.1016/j.jaad.2015.07.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/21/2015] [Accepted: 07/26/2015] [Indexed: 10/23/2022]
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22
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Zahoor H, Luketich JD, Weksler B, Winger DG, Christie NA, Levy RM, Gibson MK, Davison JM, Nason KS. The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma. Am J Surg 2015; 210:610-7. [PMID: 26188709 PMCID: PMC4575853 DOI: 10.1016/j.amjsurg.2015.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/22/2015] [Accepted: 05/26/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Staging for esophagogastric adenocarcinoma lacked sufficient prognostic accuracy and was revised. We compared survival prognostication between American Joint Committee on Cancer (AJCC) 6th and 7th editions. METHODS We abstracted data for 836 patients who underwent minimally invasive esophagectomy for esophagogastric adenocarcinoma (n = 256 neoadjuvant). Monotonicity and strength of survival trends, by stage, were assessed (log-rank test of trend chi-square statistic) and compared using permutation testing. Overall survival (Cox regression) and model fit (Akaike Information Criterion) were determined. RESULTS A greater log-rank test of trend statistic indicated stronger survival trends by stage in AJCC 7th (152.872 vs 167.623; permutation test P < .001) edition. Greater Cox likelihood chi-square value (162.957 vs 173.951) and lower Akaike Information Criterion (4,831.011 vs 4,820.016) indicated better model fit. Superior performance was also shown after neoadjuvant therapy. CONCLUSION AJCC 7th edition staging for esophagogastric adenocarcinoma provides superior prognostic stratification after minimally invasive esophagectomy, overall and after neoadjuvant therapy compared with AJCC 6th edition.
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Affiliation(s)
- Haris Zahoor
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA 15232, USA
| | - Benny Weksler
- Division of Cardiothoracic Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Neil A Christie
- Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA 15232, USA
| | - Ryan M Levy
- Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA 15232, USA
| | - Michael K Gibson
- Division of Hematology and Oncology, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jon M Davison
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katie S Nason
- Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA 15232, USA.
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23
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Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr 2015; 167:897-904.e3. [PMID: 26233603 PMCID: PMC4881390 DOI: 10.1016/j.jpeds.2015.06.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/25/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. STUDY DESIGN This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use. RESULTS Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs. CONCLUSION There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.
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Affiliation(s)
- Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Rebekah C Mannix
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg 2015; 211:226-38. [PMID: 26520872 DOI: 10.1016/j.amjsurg.2015.07.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [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: 02/17/2015] [Revised: 05/22/2015] [Accepted: 07/17/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair. DATA SOURCE Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis. CONCLUSIONS The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.
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Affiliation(s)
- Vernissia Tam
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA, USA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katie S Nason
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA, USA.
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25
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Kiguchi M, Bath J, Winger DG, Makaroun MS, Chaer R. The Effect of Stress on Task Acquisition in a Simulated Open Aortic Aneurysm Model. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Hilmi IA, Damian D, Al-Khafaji A, Sakai T, Donaldson J, Winger DG, Kellum JA. Acute kidney injury after orthotopic liver transplantation using living donor versus deceased donor grafts: A propensity score-matched analysis. Liver Transpl 2015; 21:1179-85. [PMID: 25980614 PMCID: PMC4550550 DOI: 10.1002/lt.24166] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/02/2015] [Indexed: 12/15/2022]
Abstract
Acute kidney injury (AKI) is a common complication after liver transplantation (LT). Few studies investigating the incidence and risk factors for AKI after living donor liver transplantation (LDLT) have been published. LDLT recipients have a lower risk for post-LT AKI than deceased donor liver transplantation (DDLT) recipients because of higher quality liver grafts. We retrospectively reviewed LDLTs and DDLTs performed at the University of Pittsburgh Medical Center between January 2006 and December 2011. AKI was defined as a 50% increase in serum creatinine (SCr) from baseline (preoperative) values within 48 hours. One hundred LDLT and 424 DDLT recipients were included in the propensity score matching logistic model on the basis of age, sex, Model for End-Stage Liver Disease score, Child-Pugh score, pretransplant SCr, and preexisting diabetes mellitus. Eighty-six pairs were created after 1-to-1 propensity matching. The binary outcome of AKI was analyzed using mixed effects logistic regression, incorporating the main exposure of interest (LDLT versus DDLT) with the aforementioned matching criteria and postreperfusion syndrome, number of units of packed red blood cells, and donor age as fixed effects. In the corresponding matched data set, the incidence of AKI at 72 hours was 23.3% in the LDLT group, significantly lower than the 44.2% in the DDLT group (P = 0.004). Multivariate mixed effects logistic regression showed that living donor liver allografts were significantly associated with reduced odds of AKI at 72 hours after LT (P = 0.047; odds ratio, 0.31; 95% confidence interval, 0.096-0.984). The matched patients had lower body weights, better preserved liver functions, and more stable intraoperative hemodynamic parameters. The donors were also younger for the matched patients than for the unmatched patients. In conclusion, receiving a graft from a living donor has a protective effect against early post-LT AKI.
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Affiliation(s)
- Ibtesam A. Hilmi
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Daniela Damian
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Ali Al-Khafaji
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Tetsuro Sakai
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Joseph Donaldson
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Daniel G. Winger
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
| | - John A. Kellum
- Department of Anesthesiology; Presbyterian Hospital; University of Pittsburgh Medical Center; Pittsburgh PA
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Rivera-Vega MY, Flint A, Winger DG, Libman I, Arslanian S. Obesity and youth diabetes: distinguishing characteristics between islet cell antibody positive vs. negative patients over time. Pediatr Diabetes 2015; 16:375-81. [PMID: 25482141 PMCID: PMC4457715 DOI: 10.1111/pedi.12249] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 11/10/2014] [Accepted: 11/10/2014] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Obese youth clinically diagnosed with type 2 diabetes mellitus (T2DM) frequently have evidence of islet cell autoimmunity. We investigated the clinical and biochemical differences, and therapeutic modalities among autoantibody positive (Ab+) vs. autoantibody negative (Ab-) youth at the time of diagnosis and over time in a multi-provider clinical setting. STUDY DESIGN Chart review of 145 obese youth diagnosed with T2DM from January 2003 to July 2012. Of these, 70 patients were Ab+ and 75 Ab-. The two groups were compared with respect to clinical presentation, physical characteristics, laboratory data, and therapeutic modalities at diagnosis and during follow up to assess the changes in these parameters associated with disease progression. RESULTS At presentation, Ab+ youth with a clinical diagnosis of T2DM were younger, had higher rates of ketosis, higher hemoglobin A1c (HbA1c) and glucose levels, and lower insulin and c-peptide concentrations compared with the Ab- group. The Ab- group had a higher body mass index (BMI) z-score and cardiometabolic risk factors at diagnosis and such difference remained over time. Univariate analysis revealed that treatment modality had no effect on BMI in either group. Generalized estimating equations for longitudinal data analysis revealed that (i) BMI z-score and diastolic blood pressure (DBP) were significantly affected by duration of diabetes; (ii) systolic blood pressure (SBP) and ALT were affected by changes in BMI z-score; and (iii) changes in HbA1c had an effect on lipid profile and cardiometabolic risk factors regardless of antibody status. CONCLUSIONS Irrespective of antibody status and treatment modality, youth who present with obesity and diabetes, show no improvement in obesity status over time, with the deterioration in BMI z-score affecting blood pressure (BP) and ALT, but the lipid profile being mostly impacted by HbA1c and glycemic control. Effective control of BMI and glycemia are needed to lessen the future macrovascular complications irrespective of antibody status.
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Affiliation(s)
- Michelle Y. Rivera-Vega
- Division of Weight Management and Wellness, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Amanda Flint
- Division of Weight Management and Wellness, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Daniel G. Winger
- Department of Biostatistics, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Ingrid Libman
- Division of Weight Management and Wellness, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Silva Arslanian
- Division of Weight Management and Wellness, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
- Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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Wolf JA, Moreau JF, Patton TJ, Winger DG, Ferris LK. Prevalence and impact of health-related internet and smartphone use among dermatology patients. Cutis 2015; 95:323-328. [PMID: 26125208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Health information is increasingly accessible via the Internet and smartphone applications (apps), and patients may perceive these resources as tools for self-education and/or self-diagnosis. The objective of this study was to assess the characteristics of dermatology patients who use the Internet and/or smartphone apps to access health information and to evaluate the impact that these resources have on patients' health care-seeking behavior and interactions with physicians. Online resources offer both opportunities and challenges for dermatologists. Because patients often consult online resources for information about dermatologic conditions and may rely on these resources instead of seeking the care of a dermatologist, it is important for dermatologists to be involved in the development of high-quality online content that educates the public while also emphasizing the need to seek in-person medical care.
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Olafiranye O, Hostler D, Winger DG, Wang L, Reis SE. Effect of aspirin on acute changes in peripheral arterial stiffness and endothelial function following exertional heat stress in firefighters: The factorial group results of the Enhanced Firefighter Rehab Trial. Vasc Med 2015; 20:230-6. [PMID: 25939657 DOI: 10.1177/1358863x15571447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peripheral arterial stiffness and endothelial function, which are independent predictors of cardiac events, are abnormal in firefighters. We examined the effects of aspirin on peripheral arterial stiffness and endothelial function in firefighters. Fifty-two firefighters were randomized to receive daily 81 mg aspirin or placebo for 14 days before treadmill exercise in thermal protection clothing, and a single dose of 325 mg aspirin or placebo immediately following exertion. Peripheral arterial augmentation index adjusted for a heart rate of 75 (AI75) and reactive hyperemia index (RHI) were determined immediately before, and 30, 60, and 90 minutes after exertion. Low-dose aspirin was associated with lower AI75 (-15.25±9.25 vs -8.08±10.70, p=0.014) but not RHI. On repeated measures analysis, treatment with low-dose aspirin before, but not single-dose aspirin after exertion, was associated with lower AI75 following exertional heat stress (p=0.018). Low-dose aspirin improved peripheral arterial stiffness and wave reflection but not endothelial function in firefighters.
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Affiliation(s)
- Oladipupo Olafiranye
- The Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David Hostler
- Department of Exercise and Nutrition Sciences, SUNY University at Buffalo, Buffalo, NY, USA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven E Reis
- The Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Leake AE, Winger DG, Leers SA, Gupta N, Dillavou ED. Management and outcomes of dialysis access-associated steal syndrome. J Vasc Surg 2015; 61:754-60. [DOI: 10.1016/j.jvs.2014.10.038] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/16/2014] [Indexed: 10/24/2022]
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31
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Bykowski MR, Naran S, Winger DG, Losee JE. The Rate of Oronasal Fistula Following Primary Cleft Palate Surgery: A Meta-Analysis. Cleft Palate Craniofac J 2014; 52:e81-7. [PMID: 25322441 DOI: 10.1597/14-127] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite decades of craniofacial surgeons repairing cleft palates, there is no consensus for the rate of fistula formation following surgery. The authors present a meta-analysis of studies that reported on primary cleft palate to determine the rate of oronasal fistula and to identify risk factors for their development. METHODS A literature search for the period between 2000 and 2012 was performed. Articles were queried and strict inclusion and exclusion criteria were applied to focus on primary cleft palate repair. A meta-analysis of these data was conducted. RESULTS The meta-analysis included 11 studies, comprising 2505 children. The rate of oronasal fistula development was 4.9% (95% confidence interval, 3.8% to 6.1%). When analyzing a larger cohort, there was a significant relationship between Veau classification and the occurrence of a fistula (P < .001), with fistulae most prevalent in patients with a Veau IV cleft. The most common location for a fistula was at the soft palate-hard palate junction. One study used decellularized dermis in cleft repair with a fistula rate of 3.2%. CONCLUSIONS Using 11 studies comprising 2505 children, we find the rate of reported fistula occurrence to be 4.9%. Furthermore, patients with a Veau IV cleft are significantly more likely to develop an oronasal fistula. When fistulae do occur, they do so most often at the soft palate-hard palate junction. A deeper understanding of fistula formation will help cleft palate surgeons improve their outcomes in the operating room and will allow them to effectively communicate expectations with patients' families in the clinic.
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Zahoor H, Luketich JD, Levy RM, Awais O, Winger DG, Gibson MK, Nason KS. A propensity-matched analysis comparing survival after primary minimally invasive esophagectomy followed by adjuvant therapy to neoadjuvant therapy for esophagogastric adenocarcinoma. J Thorac Cardiovasc Surg 2014; 149:538-47. [PMID: 25454907 DOI: 10.1016/j.jtcvs.2014.10.044] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 09/22/2014] [Accepted: 10/06/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Prognosis for patients with locally advanced esophagogastric adenocarcinoma (EAC) is poor with surgery alone, and adjuvant therapy after open esophagectomy is frequently not tolerated. After minimally invasive esophagectomy (MIE); however, earlier return to normal function may render patients better able to receive adjuvant therapy. We examined whether primary MIE followed by adjuvant chemotherapy influenced survival compared with propensity-matched patients treated with neoadjuvant therapy. METHODS Patients with stage II or higher EAC treated with MIE (N = 375) were identified. Using 30 pretreatment covariates, propensity for assignment to either neoadjuvant followed by MIE (n = 183; 54%) or MIE as primary therapy (n = 156; 46%) was calculated, generating 97 closely matched pairs. Hazard ratios were adjusted for age, sex, body mass index, smoking, comorbidity, and final pathologic stage. RESULTS In propensity-matched pairs, adjusted hazard ratio for death did not differ significantly for primary MIE compared with neoadjuvant (hazard ratio, 0.83; 95% confidence interval, 0.60-1.16). Recurrence patterns were similar between groups and 65% of patients with IIb or greater pathologic stage received adjuvant therapy. Clinical staging was inaccurate in 37 out of 105 patients (35%) who underwent primary MIE (n = 18 upstaged and n = 19 downstaged). CONCLUSIONS Primary MIE followed by adjuvant chemotherapy guided by pathologic findings did not negatively influence survival and allowed for accurate staging compared with clinical staging. Our data suggest that primary MIE in patients with resectable EAC may be a reasonable approach, improving stage-based prognostication and potentially minimizing overtreatment in patients with early stage disease through accurate stage assignments. A randomized controlled trial testing this hypothesis is needed.
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Affiliation(s)
- Haris Zahoor
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ryan M Levy
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Omar Awais
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Michael K Gibson
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Katie S Nason
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
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Rosas-Salazar C, Walczak SA, Winger DG, Kurland G, Spahr JE. Comparison of two aspiration techniques of bronchoalveolar lavage in children. Pediatr Pulmonol 2014; 49:978-84. [PMID: 24155175 PMCID: PMC3999312 DOI: 10.1002/ppul.22916] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 06/11/2013] [Revised: 08/29/2013] [Accepted: 09/25/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although bronchoalveolar lavage (BAL) via flexible bronchoscopy is an essential diagnostic tool, its technique is not standardized in children. Our objective was to compare two different aspiration techniques of BAL in children (continuous wall suction vs. handheld syringe suction) in regards to the percentage of fluid recovered and the odds of performing a technically acceptable procedure (i.e., >40% of volume return). METHODS We conducted a review of all pediatric flexible bronchoscopies with BAL conducted at our institution over a 2-year period. To minimize the differences between groups at baseline and reduce the possibility of bias, we used one-to-one propensity score (PS) caliper matching with no replacement for statistical analyses. RESULTS We identified 539 procedures that met pre-specified criteria. There were considerable covariate imbalances between procedures in the handheld syringe group (n = 147) and those in the continuous wall group (n = 392); however, these imbalances were substantially reduced after the PS matching. In the matched sample (n = 236), children in the handheld syringe group had ∼7% higher volume return (95% CI = 3.4-11.0, P < 0.001) from BAL and threefold higher odds (95% CI = 1.5-8.6, P = 0.002) of performing a technically acceptable procedure. CONCLUSIONS Our results suggest that handheld syringe suction offers a higher percentage of volume return from BAL and increases the odds of performing a technically acceptable procedure in children when compared to continuous wall suction.
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Affiliation(s)
- Christian Rosas-Salazar
- Division of Pediatric Pulmonary Medicine, Allergy, and Immunology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. Int Urogynecol J 2014; 26:207-12. [PMID: 25182150 DOI: 10.1007/s00192-014-2474-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/26/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. METHODS Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. RESULTS A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1%) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8% vs 9.4%, p < 0.001), but less likely to have rectocele (3.4% vs 12.2%, p < 0.001) or combined cystocele/rectocele repair (16.4% vs 25.6%, p < 0.001). Of those without apical procedures, 95.7% were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1% and 88.8% vs 23.6%, p < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95% CI 3.127-8.304). Surgeons practicing for 10-14 years and >20 years were less likely to perform apical procedures than those practicing <5 years (p < 0.001 vs. p = 0.01). CONCLUSIONS At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.
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Affiliation(s)
- Kelly L Kantartzis
- Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Hospital, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA,
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35
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Leake AE, Winger DG, Leers SA, Gupta N, Makaroun MS, Dillavou ED. SS21 Dialysis Access-Associated Steal Syndrome Management and Outcomes: A 10-Year Experience. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.03.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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36
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Lott MP, Storti K, Kriska AM, Kinzel L, Barinas-Mitchell E, Winger DG, Wang L, Conroy MB. Use Of Lifestyle Strategies Following Intervention And Impact On Longer-term Leisure Physical Activity Levels. Med Sci Sports Exerc 2014. [DOI: 10.1249/01.mss.0000494016.77961.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Moreau JF, Weinstock MA, Geller AC, Winger DG, Ferris LK. Individual and ecological factors associated with early detection of nodular melanoma in the United States. Melanoma Res 2014; 24:165-71. [PMID: 24500502 DOI: 10.1097/cmr.0000000000000049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the study was to identify individual and ecological factors associated with early diagnosis of nodular melanoma (NM). Using cross-sectional, prospective data from 18 Surveillance, Epidemiology, and End Results registries, we performed multiple logistic regression to generate odds of thick (>4 mm) versus thin (≤2 mm) NM using patient-level demographics and tumor characteristics as well as county-level socioeconomic status, healthcare access, and preventive service use as predictors. We identified 10 475 patients with NM. Divorced, separated, and widowed individuals had increased odds of thick versus thin NM compared with married individuals [odds ratio (OR): 1.47, P<0.001], as did never married individuals (OR: 1.63, P<0.001). Individuals who lived in areas with high (≥4/100 000) dermatologist density had decreased odds of thick versus thin NM (OR: 0.75, P=0.02). Women aged 18-65 years who lived in areas with high Papanicolaou test use and women aged 40 years and older who lived in areas with high mammography use had decreased odds of thick versus thin NM (OR: 0.60, P<0.001 and OR: 0.68, P<0.001, respectively). High school completion, median income, insurance status, family medicine physician density, and internist density in one's area of residence were not associated with odds of thick versus thin NM. In contrast to other types of melanoma, NM thickness at diagnosis is not associated with the socioeconomic environment in one's area of residence. Instead, it is related to factors associated with incidental or formal detection. This information should be used to better target melanoma education and early detection programs.
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Affiliation(s)
- Jacqueline F Moreau
- aUniversity of Pittsburgh School of Medicine bDepartment of Dermatology, University of Pittsburgh School of Medicine cClinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania dDermatoepidemiology Unit, Veterans Affairs Medical Center eDepartment of Dermatology, Rhode Island Hospital and Brown University fDepartments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island gDepartment of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts, USA
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Kiguchi MM, Marone LK, Chaer RA, Winger DG, Shi ZY, Celis RI, Makaroun MS, Rhee RY. Patterns of femoropopliteal recurrence after routine and selective stenting endoluminal therapy. J Vasc Surg 2012; 57:37-43. [PMID: 22975333 DOI: 10.1016/j.jvs.2012.06.097] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 06/08/2012] [Accepted: 06/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study determined the incidence and characteristics of recurrent disease after femoropopliteal angioplasty, following either selective or routine stenting of diseased site(s). METHODS Retrospective analysis of a prospectively maintained database for femoropopliteal interventions from June 2003 to July 2010 was performed. Interventions during this period were from a single institution, followed up at 1, 3, and 6 months after initial intervention and on a semiannual basis thereafter with clinical examinations and duplex ultrasound imaging. Two groups were identified: those with routine stenting (RS; routine stenting for all diseased areas) and those with selective stenting (SS; selective stenting for only segments which exhibited compromised flow from residual stenosis or significant dissection). Patients who developed recurrent symptoms (claudication, rest pain), a decrease in ankle-brachial index (ABI) (>0.2), or duplex documentation of a significant (>80%) recurrent stenosis underwent reintervention. Patient demographics, comorbidities, Trans-Atlantic Inter-Society Consensus (TASC) II classification, runoff, and degree of calcification (none, mild, moderate, severe) at initial intervention were recorded. The time to reintervention and recurrence pattern were recorded for both groups. RESULTS During the study period, 746 endovascular interventions in 477 patients were performed. Total reintervention rate, including bypass, amputation, and asymptomatic occlusion after initial intervention, was 36.48% (group SS, 42.9%; group RS, 33.1%; P=.04). Of all initial interventions, 182 endovascular reinterventions in 165 patients for recurrent femoropopliteal disease were identified (group SS, 70; group RS, 95). No differences were noted among the groups in gender, comorbidities, initial TASC II classification, run off, calcification scores, or statin or clopidogrel use, or both. Time to recurrence was similar in the RS and SS groups. TASC II classification, runoff score, and degree of calcification were similar between the two groups. Although not statistically significant, analysis of recurrence pattern demonstrated de novo stenosis was more common in the SS group (50.0% vs 34.7%; P=.06). CONCLUSIONS This single-center retrospective study found a significant difference in the incidence of recurrence requiring reintervention between patients treated with selective and routine stenting for femoropopliteal disease. Analysis of endovascular reinterventions, however, reveals no significant difference in recurrence time or recurrence pattern between the two groups. No significant differences were identified in time to recurrence, TASC II classification, runoff, and calcification of endovascular reinterventions between the two groups' end points. Additional prospective studies to evaluate the roles of routine and selective stenting in symptomatic femoropopliteal peripheral arterial disease and to investigate recurrence lesion characteristics and the patency of multiple endovascular interventions between these two groups are needed.
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Affiliation(s)
- Misaki M Kiguchi
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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