Background Comparing effectiveness of biologics in real-world settings will help inform treatment decisions. Objectives We sought to compare therapeutic responses among patients initiating ...infliximab, adalimumab, or etanercept versus ustekinumab during the Psoriasis Longitudinal Assessment and Registry (PSOLAR). Methods Proportions of patients achieving a Physician Global Assessment score of clear (0)/minimal (1) and mean decrease in percentage of body surface area with psoriasis were evaluated at 6 and 12 months. Adjusted logistic regression (Physician Global Assessment score 0/1) and analysis of covariance (percentage of body surface area with psoriasis) were performed to determine treatment factors associated with effectiveness. Results Of 2541 new users on registry, 2076 had efficacy data: ustekinumab (n = 1041), infliximab (n = 116), adalimumab (n = 662), and etanercept (n = 257). Patients receiving tumor necrosis factor-alpha(-α) inhibitors were significantly less likely to achieve Physician Global Assessment score 0/1 versus ustekinumab (infliximab odds ratio {OR} 0.396, P < .0001, adalimumab OR 0.686, P = .0012, etanercept OR 0.554, P = .0003 at 6 months and infliximab OR 0.449, P = .0040 at 12 months). Mean decrease in percentage of body surface area with psoriasis was significantly greater for ustekinumab versus adalimumab (point estimate 1.833, P = .0020) and etanercept (point estimate 3.419, P < .0001) at 6 months and versus infliximab (point estimate 3.945, P = .0005) and etanercept (point estimate 2.778, P = .0007) at 12 months. Limitations Treatment selection bias and limited data for doing adjustments are limitations. Conclusions In PSOLAR, effectiveness of ustekinumab was significantly better versus all 3 tumor necrosis factor-α inhibitors studied for the majority of comparisons at 6 and 12 months.
Background In an era of increasing demands to provide high-quality health care, surgeons need an accurate preoperative risk assessment tool to facilitate informed decision-making for themselves and ...their patients. Emergency laparotomy procedures have a high risk profile, but the currently available risk-assessment models for emergency laparotomy are either unreliable (eg, small sample size or single center study), difficult to calculate preoperatively, or are specific to the geriatric population. Study Design The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2009) was used to develop logistic regression models for 30-day mortality after emergency laparotomy. Two models were created, one with the knowledge of the postoperative diagnosis and one without. Models' calibration and discrimination were judged using the receiver operating characteristics curves and the Hosmer-Lemeshow test. Results There were 37,553 patients who had undergone emergency laparotomy, with a 14% mortality rate. The American Society of Anesthesiologists classification system, functional status, sepsis, and age were the variables most significantly associated with mortality. Patients older than 90 years of age, with an American Society of Anesthesiologists class V, septic shock, dependent functional status, and abnormal white blood cell count have a <10% probability of survival. Conclusions The models developed in this study have a high discriminative ability to stratify the operative risk in a broad range of acute abdominal emergencies. These data will assist surgeons, patients, and their families in making end-of-life decisions in the face of medical futility with greater certainty when emergency surgery is being contemplated.
Background Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases ...do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak. Methods The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010–2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks. Results Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001). Conclusion Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.
Background Biologics are widely used in the treatment of psoriasis and psoriatic arthritis. Objective Our aim was to arrive at a consensus on the kind of monitoring and the vaccinations that should ...be performed before and during biologic therapy. Methods Medical literature and data presented at meetings were reviewed and a consensus conference was held by members of the Medical Board of the National Psoriasis Foundation. Results Consensus was established on monitoring and vaccination practices that included discussion and recognition of variations in those practices. History, physical examination, chemistry screen with liver function tests, complete blood cell count, and platelet count and tuberculosis testing are widely obtained at baseline and with variable frequencies thereafter. Patients treated with efalizumab have platelet counts checked more often; liver function tests are repeated more frequently in patients treated with infliximab; patients taking tumor necrosis factor blockers undergo tuberculosis testing more often; and patients treated with alefacept have CD4 counts checked approximately every 2 weeks. Avoidance of live vaccines during biologic therapy and administration of essential vaccines before biologic therapy were discussed, although vaccination is performed only to a variable degree. There was no consistency in the measurement of antinuclear antibodies among the experts. Limitations There are few evidence-based studies on monitoring practices for patients with psoriasis taking biologic therapies. Conclusions In patients taking biologic therapies for psoriasis, monitoring of blood chemistries, blood counts, CD4 counts, antinuclear antibodies, tuberculin skin tests, history, and physical examination may be warranted depending on the particular therapy and the particular patient. Vaccination practices are also addressed.
Abstract Background context A paucity of data exists studying outcomes of patients with syringomyelia undergoing spinal deformity correction. The literature does not stratify patients by syrinx size, ...which is likely a major contributor to outcomes. Purpose To compare differences in outcomes between patients with large (≥ 4mm) and small syrinxes (< 4mm) undergoing spinal deformity correction. Design Retrospective review Patient sample 28 patients (11 with large syrinx LS, ≥ 4mm and 17 with small syrinx SS, < 4mm). Outcome measures Radiographic, operative and neurophysiologic measures Methods We retrospectively reviewed 28 patients with syringomyelia who underwent spine deformity surgery with 2 year follow-up. Demographic, surgical, and radiographic data were collected and compared preoperatively and at 2 years. Results The LS group (11 patients) trended toward more left sided thoracic curves (36% vs. 18%, p=0.38) and was more likely to have had a Chiari decompression (45% vs. 12%, p=0.08). LS patients had larger preoperative major curves (LS=66° vs. SS=57°, p=0.05), more thoracic kyphosis (LS=42°, SS=24°, p<0.01) and greater rib prominences (LS=16°, SS=13°, p=0.04). LS patients had more levels fused (LS=12.2, SS=11.2, p=0.05), higher EBL (LS=1068cc, SS=832cc, p=0.04), and a trend toward less percent correction of the major curve (LS=57%, SS=65%, p=0.18). 4/11 LS patients (36%) did not have SSEPS, and one of these also did not have MEPS. Neuromonitoring changes occurred in 3/11 (27%) of the LS patients and in none of the SS, with no postoperative deficits. Conclusions Outcomes of patients with syringomyelia undergoing spine deformity surgery are dependent on the size of the syrinx. Those with large syringomyelia are fused longer with more EBL and less correction. Spine surgeons should be aware that these patients are more likely to have less reliable neuromonitoring, with a higher chance of experiencing a change.
Survey research has been used to investigate a wide range of issues in dermatology. The proper use of survey design and analysis is critical for achieving reliable, accurate data and high impact in ...the medical literature. Here we describe the use of surveys from both a theoretical and practical standpoint. We provide recommendations for limiting error and producing interpretable results, followed by an outline for achieving publication. We conclude with a discussion of previous successful uses of survey studies in dermatologic literature.
This paper reports measures of preference parameters relating to risk tolerance, time preference, and intertemporal substitution. These measures are based on survey responses to hypothetical ...situations constructed using an economic theorist's concept of the underlying parameters. The individual measures of preference parameters display heterogeneity. Estimated risk tolerance and the elasticity of intertemporal substitution are essentially uncorrelated across individuals. Measured risk tolerance is positively related to risky behaviors, including smoking, drinking, failing to have insurance, and holding stocks rather than Treasury bills. These relationships are both statistically and quantitatively significant, although measured risk tolerance explains only a small fraction of the variation of the studied behaviors.
Tumor necrosis factor (TNF) is believed to have a role in the pathogenesis of psoriasis. In this 24-week randomized trial involving patients with moderate-to-severe plaque psoriasis, treatment with ...etanercept, a TNF antagonist, resulted in significant improvement in the psoriasis area-and-severity index. Rates of adverse events were similar in the etanercept and placebo groups.
A TNF antagonist leads to improvement.
Psoriasis is a chronic inflammatory skin disorder that affects approximately 2 percent of the world's population.
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Patients report substantial disease-related inability to work
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and may face discrimination, financial distress, or depression.
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Rapp et al.
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showed that psoriasis causes more physical and mental disability than many major diseases. Current therapies for psoriasis are not satisfactory.
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Many therapies are associated with cumulative toxicity that may limit their usefulness in this chronic disease.
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Psoriasis is characterized by the infiltration of the skin by activated T cells and an abnormal proliferation of keratinocytes. As a result of overproduction by T cells, keratinocytes, dendritic . . .
Diaphragmatic function is believed to be inhibited after thoracic surgery and may be improved by thoracic epidural anesthesia.
Diaphragmatic function after a thoracotomy was monitored by implanting ...one pair of sonomicrometry crystals and two electromyogram (EMG) electrodes on the costal diaphragm of six patients undergoing an elective pulmonary resection. Crystals and EMG electrodes remained in place for 12-24 h.
During mechanical ventilation, costal diaphragmatic length (as a percent of rest length; %LFRC) decreased passively as tidal volume (VT) increased (%LFRC = 2.81 + 1.12 x 10(-2) VT (ml), r = 0.99). During spontaneous ventilation, the costal shortening (2.1 +/- 2.3 %LFRC) was less than during mechanical ventilation (7.9 +/- 3.0 %LFRC, P < 0.05) at the same VT. Comparing spontaneous ventilation before and 30 min after thoracic epidural anesthesia, there were increases of VT (390 +/- 78 to 555 +/- 75 ml), vital capacity (1.37 +/- 0.16 to 1.68 +/- 0.21 l), and esophageal (-8.5 +/- 1.5 to -10.6 +/- 1.7 cmH2O), gastric (-0.7 +/- 0.8 to +0.8 +/- 0.8 cmH2O), and transdiaphragmatic (7.7 +/- 1.5 to 11.5 +/- 1.9 cmH2O) pressures, but diaphragmatic EMG and shortening fraction remained constant. In three of six patients, epidural anesthesia produced paradoxical segment lengthening upon inspiration.
Thoracotomy and pulmonary resection produce a marked reduction of active diaphragmatic shortening, which is not reversed by thoracic epidural anesthesia despite improvement of other indices of respiratory function.
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