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Cohen JB, Shults J, Goldberg DS, Abt PL, Sawinski DL, Reese PP. Kidney transplant outcomes: Position in the match-run does not seem to matter beyond other donor risk factors. Am J Transplant 2018; 18:1577-1578. [PMID: 29673067 DOI: 10.1111/ajt.14883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- J B Cohen
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - D S Goldberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - D L Sawinski
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P P Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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Hodges E, Marcus CL, Kim J, Xanthopoulos M, Shults J, Giordani B, Beebe DW, Rosen CL, Chervin RD, Mitchell RB, Katz ES, Gozal D, Redline S, Radcliffe J, Thomas NH. 0754 Depressive Symptomatology in School-Aged Children with Obstructive Sleep Apnea Syndrome: Incidence, Demographic Factors, and Changes Following a Randomized Controlled Trial of Adenotonsillectomy. Sleep 2018. [DOI: 10.1093/sleep/zsy061.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- E Hodges
- Department of Psychiatry and Psychology, University of Michigan, Ann Arbor, MI
| | - C L Marcus
- Sleep Center, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - J Kim
- Sleep Center Biostatistical and Informatics Core, Center for Human Phenomic Science, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - M Xanthopoulos
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - J Shults
- Biostatistical and Informatics Core, Center for Human Phenomic Science, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - B Giordani
- Department of Psychiatry and Psychology, University of Michigan, Ann Arbor, MI
| | - D W Beebe
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - C L Rosen
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Boston, MA
| | - R D Chervin
- Department of Neurology and Sleep Disorders Center, University of Michigan, Ann Arbor, MI
| | - R B Mitchell
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern and Children’s Medical Center Dallas, Dallas, TX
| | - E S Katz
- Division of Respiratory Diseases, Boston Children’s Hospital, Boston, MA
| | - D Gozal
- Department of Pediatrics, The University of Chicago, Chicago, IL
| | - S Redline
- Departments of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - J Radcliffe
- Department of Pediatrics, Children’s Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - N H Thomas
- Department of Child and Adolescent Psychiatry and Behavioral Sciences and Behavioral Neuroscience Core, Center for Human Phenomic Science, The Children’s Hospital of Philadelphia, Philadelphia, PA
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Cohen J, Shults J, Goldberg D, Abt P, Sawinski D, Reese P. Kidney allograft offers: Predictors of turndown and the impact of late organ acceptance on allograft survival. Am J Transplant 2018; 18:391-401. [PMID: 28758329 PMCID: PMC5790617 DOI: 10.1111/ajt.14449] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 07/19/2017] [Accepted: 07/23/2017] [Indexed: 01/25/2023]
Abstract
There is growing interest in understanding patterns of organ acceptance and reducing discard. Little is known about how donor factors, timing of procurement, and geographic location affect organ offer decisions. We performed a retrospective cohort study of 47 563 deceased donor kidney match-runs from 2007 to 2013. Several characteristics unrelated to allograft quality were independently associated with later acceptance in the match-run: Public Health Service increased-risk donor status (adjusted odds ratio [aOR] 2.49, 95% confidence interval [CI] 2.29-2.69), holiday or weekend procurement (aOR 1.11, 95% CI 1.07-1.16), shorter donor stature (aOR 1.53 for <150 cm vs reference >180 cm, 95% CI 1.28-1.94), and procurement in an area with higher intensity of market competition (aOR 1.71, 95% CI 1.62-1.78) and with the longest waiting times (aOR 1.41, 95% CI 1.34-1.49). Later acceptance in the match-run was associated with delayed graft function but not all-cause allograft failure (adjusted hazard ratio 1.01, 95% CI 0.96-1.07). Study limitations include a lack of match-run data for discarded organs and the possibility of sequence inaccuracies for some nonlocal matches. Interventions are needed to reduce turndowns of viable organs, especially when decisions are driven by infectious risk, weekend or holiday procurement, geography, or other donor characteristics unrelated to allograft quality.
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Affiliation(s)
- J.B. Cohen
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - J. Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - D.S. Goldberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - P.L. Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - D.L. Sawinski
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA
| | - P.P. Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
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Shults J. Discussion of “Generalized Estimating Equations: Notes on the Choice of the Working Correlation Matrix” – Continued. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1625346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Tapia IE, Spergel JM, Bradford RM, Cornaglia MA, Karamessinis L, Elden LM, Shults J, McDonough JM, Marcus CL. 0864 PREVALENCE OF ATOPY IN SCHOOL-AGE CHILDREN WITH THE OBSTRUCTIVE SLEEP APNEA SYNDROME. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.863] [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: 11/12/2022] Open
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Arevalo C, Kim J, Castro S, Shults J, Xanthopoulos M, Zemel B, Marcus C. 0502 RELATIONSHIP BETWEEN ANTHROPOMETRIC PARAMETERS AND OBSTRUCTIVE SLEEP APNEA IN SCHOOL AGE CHILDREN. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.501] [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: 11/12/2022] Open
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7
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Jemielita TO, Leonard MB, Baker J, Sayed S, Zemel BS, Shults J, Herskovitz R, Denburg MR. Association of 25-hydroxyvitamin D with areal and volumetric measures of bone mineral density and parathyroid hormone: impact of vitamin D-binding protein and its assays. Osteoporos Int 2016; 27:617-26. [PMID: 26359185 PMCID: PMC4924926 DOI: 10.1007/s00198-015-3296-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [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: 07/02/2015] [Accepted: 08/14/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED A comparison of the association of different forms of 25-hydroxyvitamin D [25(OH)D] with parathyroid hormone (PTH) and with areal and volumetric bone mineral density (BMD) demonstrated that bioavailable and free 25(OH)D do not provide a better index of vitamin D status in terms of bone health compared to total 25(OH)D. INTRODUCTION This study aims to compare measures of vitamin D-binding protein (DBP) using a monoclonal versus polyclonal ELISA and assess correlations of total versus estimated free and bioavailable 25(OH)D with BMD and PTH concentrations. METHODS DXA and peripheral quantitative CT (pQCT) scans were obtained in 304 adults (158 black, 146 white), ages 21-80 years. Free and bioavailable 25(OH)D were calculated from total 25(OH)D, DBP, and albumin concentrations. Multivariable linear regression with standardized beta coefficients was used to evaluate associations of bone measures and PTH with total, free, and bioavailable 25(OH)D. RESULTS Measures of DBP obtained using a monoclonal versus polyclonal ELISA were not correlated (r s = 0.02, p = 0.76). Free and bioavailable 25(OH)D based on the polyclonal assay were lower in black versus white participants (p < 0.0001); this race difference was not evident using the monoclonal assay. Adjusted for age, sex, calcium intake, and race, all forms of 25(OH)D were negatively associated with PTH, but the absolute coefficient was greatest for total 25(OH)D (-0.34, p < 0.001) versus free/bioavailable 25(OH)D (-0.18/-0.24 depending on DBP assay, p ≤ 0.003). In analyses stratified on race, none of the measures of 25(OH)D were associated with BMD across DXA and pQCT sites. CONCLUSIONS The monoclonal versus polyclonal ELISA yielded highly discrepant measures of DBP, particularly among black individuals, likely related to established race differences in DBP polymorphisms. Contrary to prior studies, our findings indicate that using DBP to estimate bioavailable and free 25(OH)D does not provide a better index of vitamin D status in terms of bone health.
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Affiliation(s)
- T O Jemielita
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - M B Leonard
- Stanford University School of Medicine, Stanford, CA, USA
| | - J Baker
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - S Sayed
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B S Zemel
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - J Shults
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - R Herskovitz
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M R Denburg
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Allen MB, Billig E, Reese PP, Shults J, Hasz R, West S, Abt PL. Donor Hemodynamics as a Predictor of Outcomes After Kidney Transplantation From Donors After Cardiac Death. Am J Transplant 2016; 16:181-93. [PMID: 26361242 DOI: 10.1111/ajt.13432] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 01/30/2015] [Revised: 05/22/2015] [Accepted: 06/22/2015] [Indexed: 01/25/2023]
Abstract
Donation after cardiac death is an important source of transplantable organs, but evidence suggests donor warm ischemia contributes to inferior outcomes. Attempts to predict recipient outcome using donor hemodynamic measurements have not yielded statistically significant results. We evaluated novel measures of donor hemodynamics as predictors of delayed graft function and graft failure in a cohort of 1050 kidneys from 566 donors. Hemodynamics were described using regression line slopes, areas under the curve, and time beyond thresholds for systolic blood pressure, oxygen saturation, and shock index (heart rate divided by systolic blood pressure). A logistic generalized estimation equation model showed that area under the curve for systolic blood pressure was predictive of delayed graft function (above median: odds ratio 1.42, 95% confidence interval [CI] 1.06-1.90). Multivariable Cox regression demonstrated that slope of oxygen saturation during the first 10 minutes after extubation was associated with graft failure (below median: hazard ratio 1.30, 95% CI 1.03-1.64), with 5-year graft survival of 70.0% (95%CI 64.5%-74.8%) for donors above the median versus 61.4% (95%CI 55.5%-66.7%) for those below the median. Among older donors, increased shock index slope was associated with increased hazard of graft failure. Validation of these findings is necessary to determine the utility of characterizing donor warm ischemia to predict recipient outcome.
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Affiliation(s)
- M B Allen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - E Billig
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - P P Reese
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA.,Renal Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - R Hasz
- Gift of Life Donor Program, Philadelphia, PA
| | - S West
- Gift of Life Donor Program, Philadelphia, PA
| | - P L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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Reese PP, Bloom RD, Feldman HI, Garg AX, Mussell A, Shults J, Silber JH. Selecting appropriate controls for kidney donors--reply. Am J Transplant 2015; 15:287-8. [PMID: 25363154 DOI: 10.1111/ajt.13015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 09/09/2014] [Accepted: 09/11/2014] [Indexed: 01/25/2023]
Affiliation(s)
- P P Reese
- Renal Electrolyte & Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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10
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Reese PP, Bloom RD, Feldman HI, Rosenbaum P, Wang W, Saynisch P, Tarsi NM, Mukherjee N, Garg AX, Mussell A, Shults J, Even-Shoshan O, Townsend RR, Silber JH. Mortality and cardiovascular disease among older live kidney donors. Am J Transplant 2014; 14:1853-61. [PMID: 25039276 PMCID: PMC4105987 DOI: 10.1111/ajt.12822] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 01/25/2023]
Abstract
Over the past two decades, live kidney donation by older individuals (≥55 years) has become more common. Given the strong associations of older age with cardiovascular disease (CVD), nephrectomy could make older donors vulnerable to death and cardiovascular events. We performed a cohort study among older live kidney donors who were matched to healthy older individuals in the Health and Retirement Study. The primary outcome was mortality ascertained through national death registries. Secondary outcomes ascertained among pairs with Medicare coverage included death or CVD ascertained through Medicare claims data. During the period from 1996 to 2006, there were 5717 older donors in the United States. We matched 3368 donors 1:1 to older healthy nondonors. Among donors and matched pairs, the mean age was 59 years; 41% were male and 7% were black race. In median follow-up of 7.8 years, mortality was not different between donors and matched pairs (p = 0.21). Among donors with Medicare, the combined outcome of death/CVD (p = 0.70) was also not different between donors and nondonors. In summary, carefully selected older kidney donors do not face a higher risk of death or CVD. These findings should be provided to older individuals considering live kidney donation.
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Affiliation(s)
- P P Reese
- Renal Electrolyte & Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tsampalieros A, Berkenstock MK, Zemel BS, Griffin L, Shults J, Burnham JM, Baldassano RN, Leonard MB. Changes in trabecular bone density in incident pediatric Crohn's disease: a comparison of imaging methods. Osteoporos Int 2014; 25:1875-83. [PMID: 24760243 PMCID: PMC4532327 DOI: 10.1007/s00198-014-2701-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 05/31/2013] [Accepted: 03/21/2014] [Indexed: 12/30/2022]
Abstract
UNLABELLED This study of changes in dual energy x-ray absorptiometry (DXA) spine BMD following diagnosis and treatment for childhood Crohn's disease demonstrated that changes in conventional posteroanterior BMD results were confounded by impaired growth, and suggested that lateral spine measurements and strategies to estimate volumetric BMD were more sensitive to disease and treatment effects. INTRODUCTION We previously reported significant increases in peripheral quantitative CT (pQCT) measures of trabecular volumetric bone mineral density (vBMD) following diagnosis and treatment of pediatric Crohn's disease (CD). The objective of this study was to compare pQCT trabecular vBMD and three DXA measures of spine BMD in this cohort: (1) conventional posteroanterior BMD (PA-BMD), (2) PA-BMD adjusted for height Z (PA-BMDHtZ), and (3) width-adjusted volumetric BMD (WA-BMD) estimated from PA and lateral scans. METHODS Spine DXA [lumbar (L1-4) for posteroanterior and L3 for lateral] and tibia pQCT scans were obtained in 65 CD subjects (ages 7-18 years) at diagnosis and 12 months later. BMD results were converted to sex, race, and age-specific Z-scores based on reference data in >650 children (ages 5-21 years). Multivariable linear regression models identified factors associated with BMD Z-scores. RESULTS At CD diagnosis, all BMD Z-scores were lower compared with the reference children (all p values <0.01). The pQCT vBMD Z-scores (-1.46 ± 1.30) were lower compared with DXA PA-BMD (-0.75 ± 0.98), PA-BMDHtZ (-0.53 ± 0.87), and WA-BMD (-0.61 ± 1.10) among CD participants. Only PA-BMD Z-scores were correlated with height Z-scores at baseline (R = 0.47, p < 0.0001). pQCT and WA-BMD Z-scores increased significantly over 12 months to -1.04 ± 1.26 and -0.20 ± 1.14, respectively. Changes in all four BMD Z-scores were positively associated with changes in height Z-scores (p < 0.05). Glucocorticoid doses were inversely associated with changes in WA-BMD (p < 0.01) only. CONCLUSIONS Conventional and height Z-score-adjusted PA DXA methods did not demonstrate the significant increases in trabecular vBMD noted on pQCT and WA-BMD scans. WA-BMD captured glucocorticoid effects, potentially due to isolation of the vertebral body on the lateral projection. Future studies are needed to identify the BMD measure that provides greatest fracture discrimination in CD.
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Affiliation(s)
- A. Tsampalieros
- Department of Pediatrics, The Children’s Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, ON K1H 8 L1, Canada. Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - M. K. Berkenstock
- Department of Ophthalmology, Drexel University College of Medicine, 219 N. Broad St. 3rd Floor, Philadelphia, PA 19107, USA
| | - B. S. Zemel
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - L. Griffin
- Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - J. Shults
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J. M. Burnham
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - R. N. Baldassano
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - M. B. Leonard
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA. Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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13
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Shults J. Discussion of "generalized estimating equations: notes on the choice of the working correlation matrix" - continued. Methods Inf Med 2011; 50:96-99. [PMID: 21229188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Abstract
OBJECTIVE We examine the safety and efficacy of venlafaxine monotherapy in bipolar type II (BP II) patients with major depressive episode (MDE) who were unresponsive to prior lithium monotherapy. We hypothesized that venlafaxine would be superior to lithium with a low hypomanic conversion rate. METHOD Seventeen patients who were unresponsive to prior lithium monotherapy were crossed to venlafaxine monotherapy for 12 weeks. The primary outcome was within-subject change in total Hamilton Depression Rating (HAM-D) score over time. Secondary outcomes included the change in Young Mania Rating (YMRS) and clinical global impressions severity (CGI/S) and change (CGI/C) scores. RESULTS Venlafaxine produced significantly greater reductions in HAM-D (P < 0.0005), CGI/S (P < 0.0005), and CGI/C (P < 0.0005) scores vs. prior lithium. There was no difference in mean YMRS scores between treatment conditions (P = 0.179). CONCLUSION Venlafaxine monotherapy may be a safe and effective monotherapy of BP II MDE with a low hypomanic conversion rate in lithium non-responders.
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Affiliation(s)
- J D Amsterdam
- Depression Research Unit, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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15
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Reese PP, Feldman HI, Asch DA, Halpern SD, Blumberg EA, Thomasson A, Shults J, Bloom RD. Transplantation of kidneys from donors at increased risk for blood-borne viral infection: recipient outcomes and patterns of organ use. Am J Transplant 2009; 9:2338-45. [PMID: 19702645 PMCID: PMC3090728 DOI: 10.1111/j.1600-6143.2009.02782.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Kidney transplantation from deceased donors classified as increased risk for viral infection by the Centers for Disease Control (CDC) is controversial. Analyses of Organ Procurement and Transplantation Network (OPTN) data from 7/1/2004 to 7/1/2006 were performed. The primary cohort included 48 054 adults added to the kidney transplant wait list. Compared to receiving a standard criteria donor (SCD) kidney or remaining wait-listed, CDC recipients (HR 0.80, p = 0.18) had no significant difference in mortality. In a secondary cohort of 19 872 kidney recipients at 180 centers, SCD (reference) and CDC (HR 0.91, p = 0.16) recipients had no difference in the combined endpoint of allograft failure or death. Among centers performing >10 kidney transplants during the study period, the median proportion of CDC transplants/total transplants was 7.2% (range 1.1-35.6%). Higher volume transplant centers were more likely to use CDC kidneys compared to low and intermediate volume centers (p < 0.01). An analysis of procured kidneys revealed that 6.8% of SCD versus 7.8% of CDC (p = 0.13) kidneys were discarded. In summary, center use of CDC kidneys varied widely, and recipients had good short-term outcomes. OPTN should collect detailed data about long-term outcomes and recipient viral testing so the potential risks of CDC kidneys can be fully evaluated.
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Affiliation(s)
- P. P. Reese
- Department of Medicine, Renal Division, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Corresponding author: Peter P. Reese,
| | - H. I. Feldman
- Department of Medicine, Renal Division, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - D. A. Asch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA
| | - S. D. Halpern
- Department of Medicine, Renal Division, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - E. A. Blumberg
- Department of Medicine, Infectious Diseases Division, University of Pennsylvania, Philadelphia, PA
| | - A. Thomasson
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - J. Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - R. D. Bloom
- Department of Medicine, Renal Division, University of Pennsylvania, Philadelphia, PA
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Abstract
Liver retransplantation surgery has a high rate of allograft failure due to patient comorbidities and technical demands of the procedure. Success of liver retransplantation could depend on surgeon experience and processes of care that relate to center volume. We performed a retrospective cohort study of adult liver retransplantation procedures performed from January 1, 1996 through December 31, 2005 using registry data from the Organ Procurement Transplantation Network. The primary outcome was 1-year allograft failure. Liver transplant centers were categorized as small, intermediate or high volume by dividing overall liver transplants into three tertiles of approximately equal size. Mean annual volume of overall liver transplants was <50 for low-volume centers, 50-88 for intermediate-volume centers and >88 for high-volume centers. The primary analysis consisted of 3977 liver retransplantation patients. The unadjusted risk of 1-year allograft failure was 37.8%. In multivariable logistic regression, the risk of 1-year allograft failure was not significantly different between low- (reference), intermediate- (OR 0.86, CI 0.72-1.03, p = 0.11) and high-volume centers (OR 0.88, CI 0.74-1.04, p = 0.14). Results were similar when the analysis was limited to retransplantation performed >160 days after initial transplantation. Center volume is an imprecise surrogate measure for 1-year outcomes after liver retransplantation.
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Affiliation(s)
- P P Reese
- Renal, Hypertension and Electrolyte Division, University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
Existing methods for power analysis for longitudinal study designs are limited in that they do not adequately address random missing data patterns. Although the pattern of missing data can be assessed during data analysis, it is unknown during the design phase of a study. The random nature of the missing data pattern adds another layer of complexity in addressing missing data for power analysis. In this paper, we model the occurrence of missing data with a two-state, first-order Markov process and integrate the modelling information into the power function to account for random missing data patterns. The Markov model is easily specified to accommodate different anticipated missing data processes. We develop this approach for the two most popular longitudinal models: the generalized estimating equations (GEE) and the linear mixed-effects model under the missing completely at random (MCAR) assumption. For GEE, we also limit our consideration to the working independence correlation model. The proposed methodology is illustrated with numerous examples that are motivated by real study designs.
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Affiliation(s)
- X M Tu
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY 14642, USA.
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Baumann B, McCans K, Stahmer S, Leonard M, Shults J, Holmes W. Bladder Ultrasound Increases Catheterization Success in Pediatric Patients. Acad Emerg Med 2007. [DOI: 10.1197/j.aem.2007.03.1173] [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: 11/10/2022]
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Baumann B, McCans K, Stahmer S, Leonard M, Shults J, Holmes W. Caregiver and Healthcare Provider Satisfaction with Ultrasound-Guided Pediatric Bladder Catheterization. Acad Emerg Med 2007. [DOI: 10.1197/j.aem.2007.03.971] [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: 11/10/2022]
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Burnham JM, Shults J, Sembhi H, Zemel BS, Leonard MB. The dysfunctional muscle-bone unit in juvenile idiopathic arthritis. J Musculoskelet Neuronal Interact 2006; 6:351-2. [PMID: 17185819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- J M Burnham
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Burnham JM, Shults J, Weinstein R, Lewis JD, Leonard MB. Childhood onset arthritis is associated with an increased risk of fracture: a population based study using the General Practice Research Database. Ann Rheum Dis 2006; 65:1074-9. [PMID: 16627541 PMCID: PMC1798264 DOI: 10.1136/ard.2005.048835] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Childhood onset arthritis is associated with low bone mass and strength. OBJECTIVE To determine whether childhood onset arthritis is associated with greater fracture risk. METHODS In a retrospective cohort study all subjects with onset of arthritis between 1 and 19 years of age in the United Kingdom General Practice Research Database were identified. As controls, all sex and age matched subjects from a practice that included a subject with arthritis were included. Incidence rate ratios (IRRs) for first fracture were generated using Mantel-Haenszel methods and Poisson regression. RESULTS 1939 subjects with arthritis (51% female) and 207 072 controls (53% female) were identified. The median age at arthritis diagnosis was 10.9 years. A total of 129 (6.7%) first fractures were noted in subjects with arthritis compared with 6910 (3.3%) in controls over a median follow up of 3.90 and 3.95 years in the subjects with arthritis and controls, respectively. The IRR (95% confidence interval) for first fracture among subjects with arthritis, compared with controls, according to the age at the start of follow up were 1.49 (0.91 to 2.31) for age <10 years, 3.13 (2.21 to 4.33) at 10-15 years, 1.75 (1.18 to 2.51) at 15-20 years, 1.40 (0.91 to 2.08) at 20-45 years, and 3.97 (2.23 to 6.59) at >45 years. CONCLUSIONS Childhood onset arthritis is associated with a clinically significant increased risk of fracture in children, adolescents and, possibly, adults. Studies are urgently needed to characterise the determinants of structural bone abnormalities in childhood arthritis and devise prevention and treatment strategies.
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Affiliation(s)
- J M Burnham
- Children's Hospital of Philadelphia, Room 1579 CHOP North, 3535 Market Street, Philadelphia, PA 19104, USA.
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22
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Veronese ML, Sun W, Giantonio B, Berlin J, Shults J, Davis L, Haller DG, O'Dwyer PJ. A phase II trial of gefitinib with 5-fluorouracil, leucovorin, and irinotecan in patients with colorectal cancer. Br J Cancer 2005; 92:1846-9. [PMID: 15870719 PMCID: PMC2361767 DOI: 10.1038/sj.bjc.6602569] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 03/10/2005] [Accepted: 03/11/2005] [Indexed: 12/26/2022] Open
Abstract
Inhibition of epidermal growth factor receptor (EGFR) signalling contributes to the therapy of colorectal cancer. Gefitinib, an oral EGFR tyrosine kinase inhibitor, shows supra-additive growth inhibition with irinotecan and fluoropyrimidines in xenograft models. We designed a study to determine the tolerability and efficacy of gefitinib in combination with irinotecan, infusional 5-fluorouracil (5-FU) and leucovorin (LV), on a 2-week schedule. Among 13 patients with advanced colorectal cancer, 10 required dose reductions of irinotecan and 5-FU because of dehydration, diarrhoea, and neutropenia, seven of whom required hospitalisation, three with neutropenic fever. One patient achieved partial response and seven had disease stabilisation. The combination of this standard chemotherapy regimen with gefitinib is associated with excessive toxicity, suggesting an interaction at a pharmacokinetic or pharmacodynamic level.
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Affiliation(s)
- M L Veronese
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - W Sun
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - B Giantonio
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J Berlin
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J Shults
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - L Davis
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - D G Haller
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - P J O'Dwyer
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA 19104, USA
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Lipman TH, Hench KD, Benyi T, Delaune J, Gilluly KA, Johnson L, Johnson MG, McKnight-Menci H, Shorkey D, Shults J, Waite FL, Weber C. A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement. Arch Dis Child 2004; 89:342-6. [PMID: 15033843 PMCID: PMC1719855 DOI: 10.1136/adc.2003.030072] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To evaluate linear growth assessment and the effect of an intervention on measurement accuracy in primary care practices (PCP) within eight US geographical areas. METHODS In this multicentre randomised controlled intervention study, paediatric endocrine nurses as site coordinators (SC) visited 55 randomly assigned PCP to evaluate growth assessment of staff performing linear measurements. SC observed 127 measurers assessing a total of 878 children: 307 (baseline), 282 (3 months), and 289 (6 months). Accuracy was determined by SC re-measuring each child with correct technique and equipment. State of the art equipment and a standardised growth training session were provided to the intervention group (IG) following the baseline visit. SC repeated data collection at all PCP at 3 and 6 months. RESULTS There were no baseline differences between IG and CG equipment, technique, or accuracy; only 30% of measurements were accurate (< or =0.5 cm from SC). Post-intervention, significantly more IG measurements were accurate: IG = 55%, CG = 37% at 3 months; IG = 70%, CG = 34% at 6 months. Odds ratio of accuracy for IG versus CG was 2.1 at 3 months and 4.5 at 6 months. At 6 months, mean difference from the SC measurements was 0.5 cm in IG and 1.1 cm in CG. CONCLUSIONS In PCP, children are measured inaccurately. Our intervention significantly improved measurement accuracy. Improved accuracy could yield more rapid detection and diagnosis of paediatric growth disorders.
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Affiliation(s)
- T H Lipman
- Pediatric Endocrinology Nursing Society Multicenter Study, Gaithersburg, MD, USA.
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Velázquez FR, Matson DO, Guerrero ML, Shults J, Calva JJ, Morrow AL, Glass RI, Pickering LK, Ruiz-Palacios GM. Serum antibody as a marker of protection against natural rotavirus infection and disease. J Infect Dis 2000; 182:1602-9. [PMID: 11069230 DOI: 10.1086/317619] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2000] [Revised: 07/31/2000] [Indexed: 11/03/2022] Open
Abstract
To determine whether naturally acquired serum IgA and IgG antibodies were associated with protection against rotavirus infection and illness, a cohort of 200 Mexican infants was monitored weekly for rotavirus excretion and diarrhea from birth to age 2 years. Serum samples collected during the first week after birth and every 4 months were tested for anti-rotavirus IgA and IgG. Children with an IgA titer >1:800 had a lower risk of rotavirus infection (adjusted relative risk [aRR], 0.21; P<.001) and diarrhea (aRR, 0. 16; P=.01) and were protected completely against moderate-to-severe diarrhea. However, children with an IgG titer >1:6400 were protected against rotavirus infection (aRR, 0.51; P<.001) but not against rotavirus diarrhea. Protective antibody titers were achieved after 2 consecutive symptomatic or asymptomatic rotavirus infections. These findings indicate that serum anti-rotavirus antibody, especially IgA, was a marker of protection against rotavirus infection and moderate-to-severe diarrhea.
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Affiliation(s)
- F R Velázquez
- Department of Infectious Diseases, Instituto Nacional de la Nutrición, Mexico City, Mexico
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Abstract
PURPOSE To develop an improved model for the prediction of bacteremia in young febrile children. METHODS A retrospective review was performed on patients 3 to 36 months of age seen in a children's hospital emergency department between December 1995 and September 1997 who had a complete blood count and blood culture ordered as part of their regular care. Exclusion criteria included current use of antibiotics or any immunodeficient state. Clinical and laboratory parameters reviewed included age, gender, race, weight, temperature, presence of focal bacterial infection, white blood cell count (WBC), polymorphonuclear cell count (PMN), band count, and absolute neutrophil count (ANC). Logistic regression analyses were used to identify factors associated with bacteremia, defined as growth of a pathogen in a blood culture. The model that was developed was then validated on a second dataset consisting of febrile patients 3 to 36 months of age collected from a second children's hospital (validation set). RESULTS There were 633 patients in the derivation set (46 bacteremic) and 9465 patients in the validation set (149 bacteremic). The mean age of patients in the derivation and validation sets were 15.8 months (95% confidence interval [CI]: 15.2-16.5) and 16.6 months (95% CI: 16.5-16.8), respectively; the mean temperatures were 39.1 degrees C (95% CI: 39. 0-39.2) and 39.8 degrees C (95% CI: 39.7-39.8); 56% were male in the derivation set and 55% male in the validation set. Predictors of bacteremia identified by logistic regression included ANC, WBC, PMN, temperature, and gender. Receiver operator characteristic (ROC) analysis showed similar performance of ANC and WBC as predictors of bacteremia. When placed into a multivariate logistic regression model, band count was not significantly associated with bacteremia. Information regarding focal infection was available for 572 patients in the derivation set. The percentage of patients diagnosed with bacteremia with a focal bacterial infection was not significantly different from the percentage who had bacteremia without a focal bacterial infection (16/200 vs 30/372). Based on this dataset, a logistic regression formula was developed that could be used to develop a unique risk value for each patient based on temperature, gender, and ANC. When the final model was applied to the validation set, the area under the ROC curve (AUC) constructed from these data indicated that the model retained good predictive value (AUC for the derivation vs validation data =.8348 vs 0.8221, respectively). CONCLUSIONS Use of the formulas derived here allows the clinician to estimate a child's risk for bacteremia based on temperature, ANC, and gender. This approach offers a useful alternative to predictions based on fever and WBC alone.bacteremia, detection, white blood cell.
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Affiliation(s)
- D J Isaacman
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, Virginia 23507, USA.
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Karlowicz MG, Giannone PJ, Pestian J, Morrow AL, Shults J. Does candidemia predict threshold retinopathy of prematurity in extremely low birth weight (</=1000 g) neonates? Pediatrics 2000; 105:1036-40. [PMID: 10790459 DOI: 10.1542/peds.105.5.1036] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Extreme prematurity is a risk factor for both candidemia and threshold retinopathy of prematurity (ROP) and may confound the reported association between these conditions. OBJECTIVE To determine if candidemia is an independent risk factor for threshold ROP. METHODS A cohort study was conducted of infants weighing </=1000 g at birth using a prospectively maintained neonatal database. The study included infants admitted to the neonatal intensive care unit at </=3 days of age between January 1, 1993 and December 31, 1997. We excluded infants not screened for ROP because they died, were discharged, or transferred. Threshold ROP (ie, requiring ablative therapy within 72 hours of diagnosis) was defined by the criteria of the American Academy of Pediatrics Section on Ophthalmology ROP subcommittee. Candidemia was defined as Candida species growth from at least 1 blood culture. Cox proportional hazards regression was used to determine independent risk factors for threshold ROP. RESULTS Six hundred fourteen infants weighing </=1000 g at birth, of which 165 were excluded: 120 died before ROP screening, 40 were admitted >3 days of age, and 5 were discharged or transferred before ROP screening. A total of 449 infants were included in the study; 58 (13%) developed threshold ROP. Candidemia occurred in 58 (13%) infants before developing the worst stage of ROP. Candidemia occurred in 27 of 73 (37%) at 23 to 24 weeks' gestational age (GA), 25 of 197 (13%) at 25 to 26 weeks' GA, and 6 of 129 (5%) at 27 to 28 weeks' GA, 0 of 50 >28 weeks' GA. Similarly, threshold ROP occurred in 25 of 73 (34%) at 23 to 24 weeks' GA, 26 of 197 (13%) at 25 to 26 weeks' GA, and 6 of 129 (5%) at 27 to 28 weeks' GA, and 1 of 50 (2%) >28 weeks' GA. Threshold ROP developed in 19 of 58 (33%) infants with a history of candidemia and 39 of 391 (10%) without candidemia. Proportional hazards analysis indicated that GA in weeks (hazard ratio =.75; 95% confidence interval [CI]:. 61,.93) and non-black ethnicity (hazard ratio = 1.8; 95% CI: 1.05, 3. 08) were significantly associated with threshold ROP. After controlling for GA and other factors, candidemia did not remain significantly associated with threshold ROP (hazard ratio = 1.6; 95% CI:.89, 2.89). CONCLUSION Candidemia may not be an independent risk factor for threshold ROP in extremely low birth weight infants. The magnitude of the previously reported association between candidemia and threshold ROP (more than fivefold) is unlikely and much of the clinically observed association appears to be mediated by gestational age.
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Affiliation(s)
- M G Karlowicz
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA.
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Kelly CS, Morrow AL, Shults J, Nakas N, Strope GL, Adelman RD. Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in medicaid. Pediatrics 2000; 105:1029-35. [PMID: 10790458 DOI: 10.1542/peds.105.5.1029] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate health care and financial outcomes in a population of Medicaid-insured asthmatic children after a comprehensive asthma intervention program. DESIGN Controlled clinical trial. SETTING Pediatric allergy clinic in an urban, tertiary care children's hospital. SUBJECTS Eighty children, 2 to 16 years old, with a history of frequent use of emergent health care services for asthma. Intervention. Children in the intervention group received asthma education and medical treatment in the setting of a tertiary care pediatric allergy clinic. An asthma outreach nurse maintained monthly contact with the families enrolled in the intervention group. OUTCOME MEASURES Emergency department (ED) visits, hospitalizations, and health care charges per patient in the year after enrollment. RESULTS Baseline demographics did not differ significantly between the 2 groups. In the year before the study, there were no significant differences between intervention and control children in ED visits (mean, 3.5 per patient), hospitalizations (mean,.6 per patient) or health care charges ($2969 per patient). During the study year, ED visits decreased to a mean of 1.7 per patient in the intervention group and 2.4 in controls, while hospitalizations decreased to a mean of.2 per patient in the intervention group and.5 in the controls. Average asthma health care charges decreased by $721/child/year in the intervention group and by $178/patient/year in the control group. CONCLUSIONS A comprehensive asthma intervention program for Medicaid-insured asthmatic children can significantly improve health outcomes while reducing health care costs.asthma education, health care outcomes, Medicaid, asthma outreach, utilization.
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Affiliation(s)
- C S Kelly
- Division of Pulmonary, Allergy and Immunology, Eastern Virginia MedicalSchool, Norfolk, VA, USA.
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Morrow AL, Guerrero ML, Shults J, Calva JJ, Lutter C, Bravo J, Ruiz-Palacios G, Morrow RC, Butterfoss FD. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet 1999; 353:1226-31. [PMID: 10217083 DOI: 10.1016/s0140-6736(98)08037-4] [Citation(s) in RCA: 281] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Exclusive breastfeeding is recommended worldwide but not commonly practised. We undertook a randomised controlled study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers and infants residing in periurban Mexico City. METHODS Two intervention groups with different counselling frequencies, six visits (44) and three visits (52), were compared with a control group (34) that had no intervention. From March, 1995, to September, 1996, 170 pregnant women were identified by census and invited to participate in the study. Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League. Data were collected by independent interview. Exclusive breastfeeding was defined by WHO criteria. FINDINGS 130 women participated in the study. Only 12 women refused participation. Study groups did not differ in baseline factors. At 3 months post partum, exclusive breastfeeding was practised by 67% of six-visit, 50% of three-visit, and 12% of control mothers (intervention groups vs controls, p<0.001; six-visit vs three-visit, p=0.02). Duration of breastfeeding was significantly (p=0.02) longer in intervention groups than in controls, and fewer intervention than control infants had an episode of diarrhoea (12% vs 26%, p=0.03). INTERPRETATION This is the first reported community-based randomised trial of breastfeeding promotion. Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration. The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health.
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Affiliation(s)
- A L Morrow
- Centre for Pediatric Research, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk 23510-1001, USA.
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Newburg DS, Peterson JA, Ruiz-Palacios GM, Matson DO, Morrow AL, Shults J, Guerrero ML, Chaturvedi P, Newburg SO, Scallan CD, Taylor MR, Ceriani RL, Pickering LK. Role of human-milk lactadherin in protection against symptomatic rotavirus infection. Lancet 1998; 351:1160-4. [PMID: 9643686 DOI: 10.1016/s0140-6736(97)10322-1] [Citation(s) in RCA: 209] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Human milk contains a 46 kDa mucin-associated glycoprotein, lactadherin, which binds specifically to rotavirus and inhibits its replication. This study tested the hypothesis that lactadherin protects against symptoms of rotavirus infection. METHODS 200 infants in Mexico City were recruited at birth and monitored by regular stool EIA for rotavirus, serology, and recording of feeding and stool patterns. Milk samples were obtained from the mothers weekly until 4 weeks post partum then monthly. The sample taken immediately before an infant's episode of rotavirus infection was assayed for lactadherin, butyrophilin, mucin, and secretory IgA. An infection was defined as symptomatic if diarrhoea occurred in the 5 days before or after detection of the virus. FINDINGS 31 infants developed rotavirus infection; 15 were symptomatic and 16 had no symptoms. The median concentration of lactadherin in the milk samples (obtained 4-41 days [median 13] before the infection) was 48.4 (range 5.6-180) microg/mL in the asymptomatic group and 29-2 (6.2-103-4) microg/mL in the symptomatic group. Although these medians did not differ significantly, in logistic regression analysis adjusted for age at infection and secretory IgA concentration there was a significant difference between the groups (p=0O01). No association between symptom status and concentrations of butyrophilin, mucin, or secretory IgA was found. INTERPRETATION Protection against rotavirus by human milk is associated with the glycoprotein lactadherin. This association is independent of products of the secretory immune system.
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Affiliation(s)
- D S Newburg
- Shriver Center for Mental Retardation, Waltham, MA 02254, USA.
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Bhisitkul DM, Vinik AI, Morrow AL, She JX, Shults J, Powers AC, Maclaren NK. Prediabetic markers in children with stress hyperglycemia. Arch Pediatr Adolesc Med 1996; 150:936-41. [PMID: 8790124 DOI: 10.1001/archpedi.1996.02170340050010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Previous studies have shown that children with stress hyperglycemia have an increased risk for development of type I or insulin-dependent diabetes mellitus. OBJECTIVE To determine whether stress hyperglycemia in prospectively screened pediatric patients represents a prediabetic state. DESIGN Prospective, cohort analytic study. SETTING The Children's Hospital of the King's Daughters is an urban pediatric emergency department at a tertiary care, university-based children's hospital in Norfolk, Va. PATIENT POPULATION All patients who required a venipuncture for evaluation of an acute illness or injury from October 1992 through March 1993 were screened prospectively for hyperglycemia (blood glucose level > or = 8.3 mmol/L [> or = 150 mg/dL]). Each hyperglycemic patient was age matched to a stress control subject (defined as a nonhyperglycemic but acutely ill child) from the emergency department and a healthy control subject from a well-child clinic. INTERVENTION Blood samples were obtained at the time of initial evaluation in the emergency department from 30 hyperglycemic patients (age range, 4 weeks to 12.4 years; median, 2 years), 30 stress control subjects, and 30 healthy control subjects. All samples were tested for islet cell antibodies, insulin autoantibodies, glutamic acid decarboxylase (GAD) antibodies, and HLA typing, specifically the genotypes at the DQB1 gene. MAIN OUTCOME MEASURES The presence of immunologic or genetic markers for insulin-dependent diabetes mellitus and/or the clinical development of insulin-dependent diabetes mellitus. RESULTS No patients or control subjects were positive for islet cell antibodies. One hyperglycemic patient and 3 stress control subjects were positive for insulin autoantibodies; all 4 of these subjects had sickle-cell disease and fever. Four of the 8 patients with sickle-cell disease had insulin autoantibodies, compared with none of the 52 patients and stress control subjects without sickle-cell disease (P < .001). One healthy control subject had antibodies to GAD65. The patient group did not show increased genotypes at the DQB1 gene that were indicative of an enhanced risk for insulin-dependent diabetes mellitus. Of the 32 hyperglycemic patients, 27 healthy control subjects, and 25 stress control subjects contacted for follow-up at 31 to 36 months, none has developed insulin-dependent diabetes mellitus. CONCLUSIONS Children with stress hyperglycemia do not have an increased prevalence of immunologic or genetic markers of insulin-dependent diabetes mellitus and thus do not appear to be at an increased risk for development of insulin-dependent diabetes mellitus. Our data suggest that insulin autoantibodies develop in children subject to sickle cell crises.
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Affiliation(s)
- D M Bhisitkul
- Division of Pediatric Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, VA 23507, USA
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Abstract
OBJECTIVE To determine the prevalence and clinical characteristics associated with stress hyperglycemia among children and adolescents attending a pediatric emergency department. DESIGN Patients who required a venipuncture for evaluation of an acute illness or injury from October 1992 to March 1993 in an urban pediatric emergency department were enrolled and screened prospectively for hyperglycemia (glucose level > or = 8.3 mmol/L; > or = 150 mg/dl). Data were collected regarding demographic characteristics, history, clinical findings, and admission status. RESULTS A total of 926 patients ranging in age from 3 days to 21 years were enrolled. Blood glucose values ranged from 1.94 mmol/L (35 mg/L) to 14.65 mmol/L (264 mg/dl); 35 patients (3.8%) had hyperglycemia. The prevalence of stress hyperglycemia was significantly increased among patients if they (1) had temperatures greater than 39.5 degrees C (9.3%) versus normal temperatures (2.8%) (p < 0.001), (2) had been admitted to a critical care unit of the hospital (24.1%) or to any hospital unit (4.4%) versus not having been admitted (2.6%) (p < 0.001), and (3) had received fluids intravenously (6.0%) versus having received no fluids intravenously (2.7%) (p = 0.014). CONCLUSIONS Stress hyperglycemia is a frequent clinical occurrence in a pediatric emergency department. It does not appear to be associated with a particular diagnostic category but is significantly associated with severity of illness as measured by elevated temperature, hospital admission, and hydration status.
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Affiliation(s)
- D M Bhisitkul
- Division of Pediatric Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, VA 23507
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Abstract
OBJECTIVE Von Willebrand disease (vWD) was thought to be a rare disorder until a recent survey reported a prevalence of 0.8% in an ethnically homogenous community in northern Italy. The purpose of this study was to determine the prevalence of vWD in an ethnically heterogenous population. METHODS Von Willebrand factor (vWF) was measured by the ristocetin cofactor method in 600 healthy children, aged 2 to 18 years, seen for routine school physical examinations in a three-state region. Personal and family bleeding symptoms were determined by questionnaire. The diagnosis of vWD required a personal history of bleeding symptoms, an abnormal vWF activity concentration, and a family history of at least one immediate family member with bleeding symptoms. RESULTS A total of 315 subjects were white, 212 were black, 16 were Hispanic, 10 were from other groups, and 47 were biracial. Eight subjects (four black, four white) met the criteria for vWD, for a prevalence of 1.3%. Seven subjects with vWD had blood group O (mean vWF = 32 U/dl; range, 10 to 42 U/dl), and one had blood group A (vWF = 41 U/dl). Children who had blood group O had significantly (p < 0.001) lower vWF activities (median, 83 U/dl, range, 43 to 162 U/dl) than those from non-O blood groups (median, 98 U/dl; range, 51 to 190 U/dl). There were no significant differences in vWF activity by ethnicity. The vWF activity was significantly (p < 0.02) greater for boys than girls in both blood groups. CONCLUSION Von Willebrand disease is the most common congenital hemostatic disorder; its high prevalence is not limited to one ethnic group.
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Affiliation(s)
- E J Werner
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
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