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Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study.

Thu, 12/05/2019 - 19:40
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Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study.

Trauma Surg Acute Care Open. 2019;4(1):e000356

Authors: Cook A, Hu C, Ward J, Schultz S, Moore Iii FO, Funk G, Juern J, Turay D, Ahmad S, Pieri P, Allen S, Berne J, AAST Antibiotics in Tube Thoracostomy Study Group

Abstract
Background: Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement.
Methods: The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively.
Results: TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53).
Conclusion: There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship.
Level of evidence: II Prospective comparative study.

PMID: 31799417 [PubMed]

Role of Free Tissue Transfer in Facial Trauma.

Sat, 11/30/2019 - 06:46
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Role of Free Tissue Transfer in Facial Trauma.

Facial Plast Surg. 2019 Dec;35(6):584-589

Authors: Kim RY, Sokoya M, Williams FC, Shokri T, Ducic Y

Abstract
For large composite traumatic defects of the head and neck, free tissue transfer presents a reconstructive allowing for the reconstitution of both form and function. Furthermore, the ability to provide bulk, soft, and hard tissue, as well as immediate dental rehabilitation, makes free tissue transfer an efficient and attractive option for head and neck reconstruction. Herein, we discuss the utility of free tissue transfer in facial trauma, its problems, complications, and controversies.

PMID: 31783413 [PubMed - in process]

Adult Cancer Survivors' Engagement and Interest in Patient-Centered Research.

Wed, 11/20/2019 - 07:54
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Adult Cancer Survivors' Engagement and Interest in Patient-Centered Research.

Cancer Epidemiol Biomarkers Prev. 2019 Nov 18;:

Authors: Lubas MM, Lu Y, Gehr AW, Ghabach B, Tanna B, Narra K, Brinkman TM, Ojha RP

Abstract
BACKGROUND: Limited information is available about the representativeness of survivors engaging in patient-centered research, despite the potential for threats to generalizability. We thus aimed to assess the representativeness of survivors engaged or interested in research development.
METHODS: We used data from the Health Information National Trends Survey, nationally representative survey, to identify survivors of adult cancers. Our outcomes of interest were based on responses to questions about engagement or interest in developing patient-centered research. We estimated the ratio of relative frequencies (RRFs) and corresponding 95% confidence limits (CL) of sociodemographic and survivorship characteristics between survivors engaged or interested in patient-centered research and the overall survivor population.
RESULTS: Our study population comprised 934 survivors, of whom 5% reported being engaged in patient-centered research and 26% reported an interest in participating. Relative frequencies of characteristics were discordant for engaged survivors but largely similar for interested survivors compared with all survivors. In particular, engaged survivors had a higher relative frequency of individuals aged 50 - 64 years (RRF=1.7, 95% CL:1.1, 2.5), Hispanic (RRF=2.9, 95% CL:1.2, 6.9), non-Hispanic Black (RRF=2.9, 95% CL:1.1, 2.5), and unemployment (RRF=4.7, 95% CL: 1.4, 16).
CONCLUSIONS: We observed several meaningful differences in the characteristics of survivors engaged in patient-centered research compared with all survivors, which raises concerns about the generalizability of findings from such studies.
IMPACT: Patient-centered research may not benefit the broader survivor community if survivors engaging in research development are not representative of all survivors. Greater attention to recruiting mechanisms is necessary to avoid creating disparities.

PMID: 31740520 [PubMed - as supplied by publisher]

Different Cutpoints for Transient Elastography Lead to Different Associations With Cirrhosis.

Thu, 11/07/2019 - 14:47
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Different Cutpoints for Transient Elastography Lead to Different Associations With Cirrhosis.

Clin Gastroenterol Hepatol. 2018 08;16(8):1359-1360

Authors: Ojha RP, MacDonald BR, Chu TC, Greenland S

PMID: 29174788 [PubMed - indexed for MEDLINE]

Diffuse alveolar damage and e-cigarettes: Case report and review of literature.

Fri, 11/01/2019 - 12:49
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Diffuse alveolar damage and e-cigarettes: Case report and review of literature.

Respir Med Case Rep. 2019;28:100935

Authors: Bakre SA, Al-Farra TS, Al-Farra S

Abstract
The prevalence of e-cigarette usage has increased in non-smokers and those who are planning to quit smoking since introduced in 2003. Although the potential long term adverse effects have not been studied in humans, there have been studies showing that e-cigarette vapor causes release of proinflammatory cytokines leading to cytotoxic damage to alveolar epithelial cells, increase in the release of fibroblast growth factor (FGF) in the alveolar epithelial cells which leads to fibroblastic proliferation, and increased risk of staphylococcus aureus and viral infections which are implicated in the pathogenesis of diffuse alveolar damage. We describe a case of a 47-year-old woman who was diagnosed with histologically confirmed diffuse alveolar damage (DAD). She had no significant medical history and she had been smoking e-cigarettes for 3 years prior to presentation. This case report describes the potential association between e-cigarettes and diffuse alveolar damage while making reference to relevant associated studies.

PMID: 31667071 [PubMed]

Diagnostic capability of dynamic ultrasound evaluation of supination-external rotation ankle injuries: a cadaveric study.

Fri, 11/01/2019 - 12:49
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Diagnostic capability of dynamic ultrasound evaluation of supination-external rotation ankle injuries: a cadaveric study.

BMC Musculoskelet Disord. 2019 Oct 30;20(1):502

Authors: Fisher CL, Rabbani T, Johnson K, Reeves R, Wood A

Abstract
BACKGROUND: Ankle syndesmosis injuries are common and range in severity from subclinical to grossly unstable. Definitive diagnosis of these injuries can be made with plain film radiographs, but are often missed when severity or image quality is low. Computed tomography (CT) and magnetic resonance imaging (MRI) can provide definitive diagnosis, but are costly and introduce the patient to radiation when CT is used. Ultrasonography may circumvent many of these disadvantages by being inexpensive, efficient, and able to detect injuries without radiation exposure. The purpose of this study was to evaluate the ability of ultrasonography to detect early stage supination-external rotation (SER) ankle syndesmosis injuries with a dynamic external rotational stress test.
METHODS: Nine, all male, fresh frozen specimens were secured to an ankle rig and stress tested to 10 Nm of external rotational torque with ultrasonography at the tibiofibular clear space. The ankles were subjected to syndesmosis ligament sectioning and repeat stress measurements of the tibiofibular clear space at peak torque. Stress tests and measurements were repeated three times and averaged and analyzed using a repeated one-way analysis of variance (ANOVA). There were six ankle injury states examined including: Intact State, 75% of AITFL Cut, 100% of AITFL Cut, Fibula FX - Cut 8 cm proximal, 75% PITFL Cut, and 100% PITFL Cut.
RESULTS: Dynamic external rotation stress evaluation using ultrasonography was able to detect a significant difference between the uninjured ankle with a tibiofibular clear space of 4.5 mm and the stage 1 complete injured ankle with a clear space of 6.0 mm (P < .02). Additionally, this method was able to detect significant differences between the uninjured ankle and the stage 2-4 injury states.
CONCLUSION: Dynamic external rotational stress evaluation using ultrasonography was able to detect stage 1 Lauge-Hansen SER injuries with statistical significance and corroborates criteria for diagnosing a syndesmosis injury at ≥6.0 mm of tibiofibular clear space widening.

PMID: 31666051 [PubMed - in process]

Mortality association between obesity and pneumonia using a dual restricted cohort model.

Wed, 10/23/2019 - 07:22
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Mortality association between obesity and pneumonia using a dual restricted cohort model.

Obes Res Clin Pract. 2019 Oct 18;:

Authors: Wang H, Lee CC, Chou EH, Hsu WT, Robinson RD, Su KY, Kirby JJ, Hassani D

Abstract
BACKGROUND: An obesity survival paradox has been reported among obese patients with pneumonia.
AIMS: To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia.
METHODS: The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis.
RESULTS: A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07).
CONCLUSIONS: With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

PMID: 31635969 [PubMed - as supplied by publisher]

The effect of lifelong exercise frequency on arterial stiffness.

Wed, 10/23/2019 - 07:22
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The effect of lifelong exercise frequency on arterial stiffness.

J Physiol. 2018 07;596(14):2783-2795

Authors: Shibata S, Fujimoto N, Hastings JL, Carrick-Ranson G, Bhella PS, Hearon CM, Levine BD

Abstract
KEY POINTS: This study examined the effect of different 'doses' of lifelong (>25 years) exercise on arterial stiffening (a hallmark of vascular ageing) in older adults. There are clear dose-dependent effects of lifelong exercise training on human arterial stiffness that vary according to the site and size of the arteries. Similar to what we have observed previously with ventricular stiffening, 4-5 days week-1 of committed exercise over a lifetime are necessary to preserve 'youthful' vascular compliance, especially of the large central arteries. Casual exercise training of two to three times per week may be sufficient for middle-sized arteries like the carotid to minimize arterial stiffening with ageing. However, there is little effect of exercise training on the small-sized peripheral arteries at any dose.
ABSTRACT: Central arterial stiffness increases with sedentary ageing. While near-daily, vigorous lifelong (>25 years) endurance exercise training prevents arterial stiffening with ageing, this rigorous routine of exercise training over a lifetime is impractical for most individuals. The aim was to examine whether a less frequent 'dose' of lifelong exercise training (four to five sessions per week for > 30 min) that is consistent with current physical activity recommendations elicits similar benefits on central arterial stiffening with ageing. A cross-sectional examination of 102 seniors (>60 years old) who had a consistent lifelong exercise history was performed. Subjects were stratified into four groups based on exercise frequency as an index of exercise 'dose': sedentary: fewer than two sessions per week; casual exercisers: two to three sessions per week; committed exercisers: four to five sessions per week; and Masters athletes: six to seven sessions per week plus regular competitions. Detailed measurements of arterial stiffness and left ventricular afterload were collected. Biological aortic age and central pulse wave velocity were younger in committed exercisers and Masters athletes compared to sedentary seniors. Total arterial compliance index (TACi) was lower, while carotid β-stiffness index and effective arterial elastance were higher in sedentary seniors compared to the other groups. There appeared to be a dose-response threshold for carotid β-stiffness index and TACi. Peripheral arterial stiffness was not significantly different among the groups. These data suggest that four to five weekly exercise sessions over a lifetime is associated with reduced central arterial stiffness in the elderly. A less frequent dose of lifelong exercise (two to three sessions per week) is associated with decreased ventricular afterload and peripheral resistance, while peripheral arterial stiffness is unaffected by any dose of exercise.

PMID: 29781119 [PubMed - indexed for MEDLINE]

Effect of centrally acting angiotensin converting enzyme inhibitor on the exercise-induced increases in muscle sympathetic nerve activity.

Wed, 10/23/2019 - 07:22
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Effect of centrally acting angiotensin converting enzyme inhibitor on the exercise-induced increases in muscle sympathetic nerve activity.

J Physiol. 2018 06;596(12):2315-2332

Authors: Moralez G, Jouett NP, Tian J, Zimmerman MC, Bhella P, Raven PB

Abstract
KEY POINTS: The arterial baroreflex's operating point pressure is reset upwards and rightwards from rest in direct relation to the increases in dynamic exercise intensity. The intraneural pathways and signalling mechanisms that lead to upwards and rightwards resetting of the operating point pressure, and hence the increases in central sympathetic outflow during exercise, remain to be identified. We tested the hypothesis that the central production of angiotensin II during dynamic exercise mediates the increases in sympathetic outflow and, therefore, the arterial baroreflex operating point pressure resetting during acute and prolonged dynamic exercise. The results identify that perindopril, a centrally acting angiotensin converting enzyme inhibitor, markedly attenuates the central sympathetic outflow during acute and prolonged dynamic exercise.
ABSTRACT: We tested the hypothesis that the signalling mechanisms associated with the dynamic exercise intensity related increases in muscle sympathetic nerve activity (MSNA) and arterial baroreflex resetting during exercise are located within the central nervous system. Participants performed three randomly ordered trials of 70° upright back-supported dynamic leg cycling after ingestion of placebo and two different lipid soluble angiotensin converting enzyme inhibitors (ACEi): perindopril (high lipid solubility), captopril (low lipid solubility). Repeated measurements of whole venous blood (n = 8), MSNA (n = 7) and arterial blood pressures (n = 14) were obtained at rest and during an acute (SS1) and prolonged (SS2) bout of steady state dynamic exercise. Arterial baroreflex function curves were modelled at rest and during exercise. Peripheral venous superoxide concentrations measured by electron spin resonance spectroscopy were elevated during exercise and were not altered by ACEi at rest (P ≥ 0.4) or during exercise (P ≥ 0.3). Baseline MSNA and mean arterial pressure were unchanged at rest (P ≥ 0.1; P ≥ 0.8, respectively). However, during both SS1 and SS2, the centrally acting ACEi perindopril attenuated MSNA compared to captopril and the placebo (P < 0.05). Arterial pressures at the operating point and threshold pressures were decreased with perindopril from baseline to SS1 with no further changes in the operating point pressure during SS2 under all three conditions. These data suggest that centrally acting ACEi is significantly more effective at attenuating the increase in the acute and prolonged exercise-induced increases in MSNA.

PMID: 29635787 [PubMed - indexed for MEDLINE]

Validation of a Postextubation Dysphagia Screening Tool for Patients After Prolonged Endotracheal Intubation.

Wed, 10/23/2019 - 07:22
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Validation of a Postextubation Dysphagia Screening Tool for Patients After Prolonged Endotracheal Intubation.

Am J Crit Care. 2018 03;27(2):89-96

Authors: Johnson KL, Speirs L, Mitchell A, Przybyl H, Anderson D, Manos B, Schaenzer AT, Winchester K

Abstract
BACKGROUND: Patients who receive prolonged endotracheal intubation (> 48 hours) are at risk for dysphagia. Nurses should conduct swallowing assessments after extubation because of the high likelihood of aspiration pneumonia developing. No valid and reliable postextubation dysphagia screening tools are available.
OBJECTIVES: To establish content validity, analyze interrater reliability, and determine sensitivity and specificity of an evidence-based postextubation dysphagia screening tool developed by a multidisciplinary team.
METHODS: A prospective nonexperimental study was conducted in 4 medical-surgical intensive care units in 4 hospitals. The study was conducted in 3 phases: (1) establishing content validity with clinical experts who participated in a Delphi survey, (2) establishing inter-rater reliability by agreement with nurses who simultaneously and independently completed the tool, and (3) establishing sensitivity and specificity with speech language pathologists and nurses who independently and blindly completed the tool for eligible patients.
RESULTS: Individual item scores were > 0.82 and the overall content validity index was 0.93, indicating content validity. Interrater reliability was established (Cohen κ = 0.92). In 66 eligible patients, the prevalence of postextubation dysphagia was 56%, sensitivity of the postextubation dysphagia screening tool was 81%, and specificity was 69%.
CONCLUSION: The reliability and validity of a postextubation dysphagia screening tool that can help nurses determine an extubated patient's ability to swallow after prolonged endotracheal intubation were established.

PMID: 29496764 [PubMed - indexed for MEDLINE]

Evidence that Swimming May be Protective of Knee Osteoarthritis: Data from the Osteoarthritis Initiative.

Sun, 10/20/2019 - 05:32

Evidence that Swimming May be Protective of Knee Osteoarthritis: Data from the Osteoarthritis Initiative.

PM R. 2019 Oct 19;:

Authors: Lo GH, Ikpeama UE, Driban JB, Kriska AM, McAlindon TE, Petersen NJ, Storti KL, Eaton CB, Hochberg MC, Jackson RD, Kwoh CK, Nevitt MC, Suarez-Almazor ME

Abstract
BACKGROUND: To date, there have not been any epidemiologic studies that have evaluated the association between swimming over a lifetime and knee health.
OBJECTIVE: We aimed to evaluate the relationship of a history of swimming with knee pain, radiographic knee OA (ROA), and symptomatic knee OA (SOA).
DESIGN: Cross-sectional retrospective study SETTING: 4 academic centers in the U.S.
PARTICIPANTS: Respondents to the historical physical activity survey within the Osteoarthritis Initiative with knee radiographs and symptom assessments METHODS: In this retrospective study nested within the Osteoarthritis Initiative (OAI), we performed logistic regression with the predictor being swimming over a lifetime and over particular age ranges.
MAIN OUTCOME MEASUREMENTS: Person-based definitions of frequent knee pain, ROA and SOA.
RESULTS: 2637 participants were included, with a mean age of 64.3 years (SD 8.9), BMI of 28.4 kg/m2 (SD 4.9), and 44.2% male. Over a lifetime, the adjusted prevalence measures for frequent knee pain, ROA, and SOA for any v. no history of swimming were 36.4% (33.4 - 39.5%) v. 39.9% (37.4 - 42.5%), 54.3% (51.0 - 57.6%) v. 61.1% (58.4 - 63.7%), and 21.9% (19.4 - 24.7%) v. 27.0% (24.7 - 29.4%) respectively.
CONCLUSIONS: This is the first epidemiologic study to indicate that swimming is potentially beneficial towards knee health, particularly when performed earlier in life (before age 35). Future prospective studies are needed to confirm these findings and to better scrutinize the associations in older age groups.
LEVEL OF EVIDENCE: III.

PMID: 31628825 [PubMed - as supplied by publisher]

A Comparison of Pavlik Harness Treatment Regimens for Dislocated But Reducible (Ortolani+) Hips in Infantile Developmental Dysplasia of the Hip.

Fri, 10/11/2019 - 05:19

A Comparison of Pavlik Harness Treatment Regimens for Dislocated But Reducible (Ortolani+) Hips in Infantile Developmental Dysplasia of the Hip.

J Pediatr Orthop. 2019 Nov/Dec;39(10):505-509

Authors: Hines AC, Neal DC, Beckwith T, Jo C, Kim HKW

Abstract
BACKGROUND: Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips.
METHODS: This study reviewed prospectively enrolled patients with DDH in a single center who presented at age <6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups.
RESULTS: Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P>0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P>0.99 for both).
CONCLUSIONS: The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting <6 months of age with Ortolani+ hips.
LEVEL OF EVIDENCE: Level III-therapeutic.

PMID: 31599859 [PubMed - in process]

Comparative Analysis of LASIK Flap Diameter and its Centration Using Two Different Femtosecond Lasers.

Fri, 10/11/2019 - 05:19
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Comparative Analysis of LASIK Flap Diameter and its Centration Using Two Different Femtosecond Lasers.

Med Hypothesis Discov Innov Ophthalmol. 2019;8(3):241-249

Authors: Moshirfar M, Brown TW, Heiland MB, Rosen DB, Ronquillo YC, Hoopes PC

Abstract
The aim of this study was to compare the diameter, accuracy, variability, and centration with respect to the limbus of corneal flaps created by two femtosecond lasers, the VisuMax, and Wavelight FS200, for laser in situ keratomileusis (LASIK) and how these flaps affect visual outcomes. This is a retrospective chart review of flap morphology created during LASIK Surgery. Overall, 168 eyes underwent flap creation using the WaveLight FS200 laser, and on 189 eyes, the VisuMax laser was used. Of these total number, flap morphology was analyzed in a random sample of 158 eyes; 80 with the Visumax laser and 78 with the WaveLight FS200 laser. Intraoperative photos of the flaps taken by the Wavelight Allegretto EX500 were analyzed. Flap diameters and centration were measured using Adobe Acrobat Pro. All patients had visual acuity measurements including uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent refraction (SE) and refractive astigmatism recorded three months postoperatively. Greater than 90% of patients in both groups achieved a UDVA of 20/20 postoperatively. The mean difference between targeted and achieved flap diameter was 0.50 +/- 0.15 mm in the VisuMax group and 0.35 +/- 0.15 millimeters (mm) in the FS200 group (P<0.01). The flap diameters of the VisuMax group were more precise with a variance of 0.024 mm compared to a variance of 0.038 mm in the FS200 group (P<0.05). VisuMax flaps were more nasally displaced (log(NA/TA) = -0.21 +/- 0.10 mm) compared to the FS200 flaps (log(NA/TA) = 0.03 +/- 0.10 mm), (P< 0.01). We concluded that both the VisuMax and FS200 created flaps larger than the preoperative targeted diameter. VisuMax created corneal flaps that had a greater degree of deviation from the targeted diameter when compared to flaps from the FS200. However, there was less variance in the VisuMax flap diameter. In addition, VisuMax flaps were more nasally displaced. There were no statistically significant differences in visual outcomes when comparing the two femtosecond lasers.

PMID: 31598523 [PubMed]

Hospice care, cancer-directed therapy, and Medicare expenditures among older patients dying with malignant brain tumors.

Wed, 10/09/2019 - 12:59
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Hospice care, cancer-directed therapy, and Medicare expenditures among older patients dying with malignant brain tumors.

Neuro Oncol. 2018 06 18;20(7):986-993

Authors: Dover LL, Dulaney CR, Williams CP, Fiveash JB, Jackson BE, Warren PP, Kvale EA, Boggs DH, Rocque GB

Abstract
Background: End-of-life care for older adults with malignant brain tumors is poorly understood. The purpose of this study is to quantify end-of-life utilization of hospice care, cancer-directed therapy, and associated Medicare expenditures among older adults with malignant brain tumors.
Methods: This retrospective cohort study included deceased Medicare beneficiaries age ≥65 with primary malignant brain tumor (PMBT) or secondary MBT (SMBT) receiving care within a southeastern cancer community network including academic and community hospitals from 2012-2015. Utilization of hospice and cancer-directed therapy and total Medicare expenditures in the last 30 days of life were calculated using generalized linear and mixed effect models, respectively.
Results: Late (1-3 days prior to death) or no hospice care was received by 24% of PMBT (n = 383) and 32% of SMBT (n = 940) patients. SMBT patients received late hospice care more frequently than PMBT patients (10% vs 5%, P = 0.002). Cancer-directed therapy was administered to 18% of patients with PMBT versus 25% with SMBT (P = 0.003). Nonwhite race, male sex, and receipt of any hospital-based care in the final 30 days of life were associated with increased risk of late or no hospice care. The average decrease in Medicare expenditures associated with hospice utilization for patients with PMBT was $-12,138 (95% CI: $-18,065 to $-6210) and with SMBT was $-1,508 (95% CI: $-3,613 to $598).
Conclusions: Receiving late or no hospice care was common among older patients with malignant brain tumors and was significantly associated with increased total Medicare expenditures for patients with PMBT.

PMID: 29156054 [PubMed - indexed for MEDLINE]

Antihypertensive Drug Therapy for Mild to Moderate Hypertension During Pregnancy.

Wed, 10/02/2019 - 08:32

Antihypertensive Drug Therapy for Mild to Moderate Hypertension During Pregnancy.

Am Fam Physician. 2019 Oct 01;100(7):403-405

Authors: LeFevre N, Krumm E

PMID: 31573163 [PubMed - in process]

Sex differences in prescription opioid use patterns assessed through a community engagement program in Florida.

Tue, 10/01/2019 - 06:49

Sex differences in prescription opioid use patterns assessed through a community engagement program in Florida.

Drug Alcohol Depend. 2019 Sep 20;204:107568

Authors: Serdarevic M, Striley CW, Gurka KK, Leeman RF, Cottler LB

Abstract
BACKGROUND: Morbidity and mortality attributed to prescription opioids are a crisis in the US and spreading globally. Sex differences related to these conditions have not been adequately assessed.
METHODS: Through our community engagement program, data on demographics, health status, and substance use, including prescription opioids (e.g., Vicodin®, Oxycodone), were collected from community members in Florida (primarily North Central Florida) during a health needs assessment. Participants over 18 years of age were classified by opioid use: past 30-day, lifetime but not past 30-day, or no lifetime prescription opioid use. Descriptive statistics and chi-square tests were calculated, and multinomial logistic regression was used to calculate adjusted odds ratios (aOR; CI). Analyses were conducted for men and women separately to examine sex specific effects.
RESULTS: Among 9221 community members assessed, the mean age was 45 years, 60% were female, and 58% were black. Respondents who endorsed past 30-day use and lifetime use were more likely to be female. Prescription sedative use was the strongest risk factor for past 30-day (aOR = 3.96; 95% CI, 3.35-4.68) and lifetime (aOR = 2.67; 95% CI, 2.34-3.04) prescription opioid use, regardless of sex. Other factors including marijuana use and history of cancer were significantly associated with prescription opioid use; they varied by sex.
CONCLUSIONS: The risk factors identified in this community sample provide additional information not accounted for by national studies. Future examinations of the consequences of concomitant opioid and sedative use, especially among women, are needed.

PMID: 31568932 [PubMed - as supplied by publisher]

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.

Mon, 09/30/2019 - 05:33

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.

Ann Emerg Med. 2019 Sep 26;:

Authors: Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S

Abstract
Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

PMID: 31563402 [PubMed - as supplied by publisher]

Injustice Appraisal but not Pain Catastrophizing Mediates the Relationship Between Perceived Ethnic Discrimination and Depression and Disability in Low Back Pain.

Sun, 09/29/2019 - 07:37
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Injustice Appraisal but not Pain Catastrophizing Mediates the Relationship Between Perceived Ethnic Discrimination and Depression and Disability in Low Back Pain.

J Pain. 2019 Sep 25;:

Authors: Ziadni MS, Sturgeon JA, Bissell D, Guck A, Martin KJ, Scott W, Trost Z

Abstract
Despite growing evidence of significant racial disparities in the experience and treatment of chronic pain, the mechanisms by which these disparities manifest have remained relatively understudied. The current study examined the relationship between past experiences of racial discrimination and pain-related outcomes (self-rated disability and depressive symptomatology), and tested the potential mediating roles of pain catastrophizing and perceived injustice related to pain. Analyses consisted of cross-sectional path modeling in a multiracial sample of 137 individuals with chronic low back pain (Hispanics N=43; Blacks N=43; Whites N=51). Results indicated a positive relationship between prior discriminatory experiences and severity of disability and depressive symptoms. In mediation analyses, pain-related appraisals of injustice, but not pain catastrophizing, were found to mediate these relationships. Notably, the association between discrimination history and perceived injustice was significantly stronger in Black and Hispanic participants and was not statistically significant in White participants. The findings suggest that race-based discriminatory experiences may contribute to racial disparities in pain outcomes and highlight the specificity of pain-related, injustice-related appraisals as a mechanism by which these experiences may impair physical and psychosocial function. Future research is needed to investigate temporal and causal mechanisms suggested by the model through longitudinal and clinical intervention studies. PERSPECTIVE: More frequent prior experiences of racial discrimination are associated with greater depressive symptomatology and pain-related disability in individuals with chronic low back pain. These associations are explained by the degree of injustice perception related to pain, but not pain catastrophizing, and were stronger among Black and Hispanic participants.

PMID: 31562992 [PubMed - as supplied by publisher]

Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use.

Thu, 09/26/2019 - 07:29
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Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use.

Community Ment Health J. 2019 Sep 24;:

Authors: Petrovich JC, Hunt JJ, North CS, Pollio DE, Roark Murphy E

Abstract
Secondary data obtained through the 2015 point-in-time homelessness count and an administrative health care utilization database was used to identify differences in demographic characteristics, health service use, and predictors of health service use among people experiencing unsheltered and sheltered homelessness. Compared to sheltered participants, unsheltered participants had higher proportions of males and Caucasians, were younger, were more likely to use any type of health service and ED services, and used significantly more of any health service and ED and outpatient services. Results also confirm that health services utilization is a complex phenomenon predicted by a variety of predisposing, enabling, and need-related factors, including mental health problems. Together, these findings demonstrate important differences between people living unsheltered and those residing in shelters and they inform local health policy and program initiatives tailored towards these homeless populations.

PMID: 31552539 [PubMed - as supplied by publisher]

Comparative effectiveness of 8- and 12-week ledipasvir/sofosbuvir regimens for HCV infection.

Thu, 09/26/2019 - 07:29
Related Articles

Comparative effectiveness of 8- and 12-week ledipasvir/sofosbuvir regimens for HCV infection.

Antivir Ther. 2018;23(7):585-592

Authors: Ojha RP, MacDonald BR, Chu TC, Fasanmi EO, Moore JD, Stewart RA

Abstract
BACKGROUND: Real-world studies have aimed to compare the effects of 8- and 12-week ledipasvir/sofosbuvir regimens on sustained virological response (SVR) among HCV infection genotype-1 (HCV-1) treatment-naive patients. Nevertheless, real-world comparative effectiveness studies pose unique challenges, such as confounding by indication, that were not adequately addressed in prior studies. We thus aimed to address limitations in prior studies and compare overall- and subgroup-specific effectiveness of 8- and 12-week ledipasvir/sofosbuvir regimens among HCV-1 treatment-naive patients.
METHODS: Patients eligible for our study were aged ≥18 years and initiated 8- or 12-week ledipasvir/sofosbuvir regimens for treatment-naive HCV-1 at an urban public hospital network. We excluded patients with HIV or cirrhosis. We used marginal structural models to estimate overall and subgroup-specific risk ratios (RRs) and 95% confidence limits (CL) comparing the effect of 8- and 12-week ledipasvir/sofosbuvir regimens on 12-week SVR.
RESULTS: Our study population comprised 191 patients. Among both regimens, the majority were aged >50 years, non-Hispanic White and uninsured. The overall risk of SVR was comparable between the 8- and 12-week regimens (RR=1.01, 95% CL: 0.92, 1.11). The risk of SVR did not vary by race/ethnicity (non-Hispanic Black: RR=1.01, 95% CL: 0.84, 1.21; non-Hispanic White: RR=1.01, 95% CL: 0.89, 1.04).
CONCLUSIONS: Our real-world results suggest that 8- and 12-week ledipasvir/sofosbuvir have comparable effects on SVR among HCV-1 patients without cirrhosis or HIV. In addition, the comparable effectiveness of 8- and 12-week regimens among non-Hispanic Black individuals adds to the growing body of evidence that supports the removal of race-based treatment guidelines.

PMID: 29969099 [PubMed - indexed for MEDLINE]

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