Objective Positive associations of body mass index (BMI) and clinical outcomes have been found, called "the obesity paradox". Whether obesity has protective effects or this is due to confounding ...remains unclear. Herein, we analyzed the effects of weight on long-term mortality in a large cohort of patients with community-acquired pneumonia (CAP) and investigated whether differential effects of obesity on inflammation pathways account for mortality differences. Methods For this secondary analysis, we prospectively followed CAP patients over 6 years previously included in a multicenter trial (“ProHOSP”). To assess associations of BMI with mortality, and with several inflammatory biomarker levels, respectively, we calculated three regression models adjusted for severity (Pneumonia severity index PSI), fully-adjusted for PSI, age, gender, metabolic factors, cardiovascular diseases and other comorbidities and fully-adjusted including biomarker levels. Results Within the 763 patients, all-cause 6-year mortality was significantly lower in obese patients (BMI>30kg/m2 ) compared to normal weight patients (BMI18.5-25kg/m2 ) with a severity-adjusted hazard ratio (HR) of 0.641 (95% CI 0.462- to 0.889) and robust results in fully-adjusted and a fully-adjusted plus biomarker models. No associations of increased BMI and C-reactive protein, procalcitonin and white blood cell count were found, but BMI>30Kg/m2 was associated with higher proadrenomedullin levels. Conclusions Over a 6-year long-term follow up we found obesity to be associated with lower all-cause mortality in CAP patients confirming the "obesity paradox" in this population. Yet, differences in inflammatory pathways did not explain these findings.
Objective Endovascular aneurysm repair (EVAR) is associated with significant direct device costs. Such costs place EVAR at odds with efforts to constrain healthcare expenditures. This study examines ...the procedure-associated costs and operating margins associated with EVAR at a tertiary care academic medical center. Methods All infrarenal EVARs performed from April 2011 to March 2012 were identified (n = 127). Among this cohort, 49 patients met standard commercial instruction for use guidelines, were treated using a single manufacturer device, and billed to Medicare diagnosis-related group (DRG) 238. Of these 49 patients, net technical operating margins (technical revenue minus technical cost) were calculated in conjunction with the hospital finance department. EVAR implant costs were determined for each procedure. DRG 238-associated costs and length of stay were benchmarked against other academic medical centers using University Health System Consortium 2012 data. Results Among the studied EVAR cohort (age 75, 82% male, mean length of stay, 1.7 days), mean technical costs totaled $31,672. Graft implants accounted for 52% of the allocated technical costs. Institutional overhead was 17% ($5495) of total technical costs. Net mean total technical EVAR-associated operating margins were −$4015 per procedure. Our institutional costs and length of stay, when benchmarked against comparable centers, remained in the lowest quartile nationally using University Health System Consortium costs for DRG 238. Stent graft price did not correlate with total EVAR market share. Conclusions EVAR is currently associated with significant negative operating margins among Medicare beneficiaries. Currently, device costs account for over 50% of EVAR-associated technical costs and did not impact EVAR market share, reflecting an unawareness of cost differential among surgeons. These data indicate that EVAR must undergo dramatic care delivery redesign for this practice to remain sustainable.
Objective To examine the association between treatment for patent ductus arteriosus (PDA) and neonatal outcomes in preterm infants, after adjustment for treatment selection bias. Study design ...Secondary analyses were conducted using data collected by the Canadian Neonatal Network for neonates born at a gestational age ≤32 weeks and admitted to neonatal intensive care units in Canada between 2004 and 2008. Infants who had PDA and survived beyond 72 hours were included in multivariable logistic regression analyses that compared mortality or any severe neonatal morbidity (intraventricular hemorrhage grades ≥3, retinopathy of prematurity stages ≥3, bronchopulmonary dysplasia, or necrotizing enterocolitis stages ≥2) between treatment groups (conservative management, indomethacin only, surgical ligation only, or both indomethacin and ligation). Propensity scores (PS) were estimated for each pair of treatment comparisons, and used in PS-adjusted and PS-matched analyses. Results Among 3556 eligible infants with a diagnosis of PDA, 577 (16%) were conservatively managed, 2026 (57%) received indomethacin only, 327 (9%) underwent ligation only, and 626 (18%) were treated with both indomethacin and ligation. All multivariable and PS-based analyses detected significantly higher mortality/morbidities for surgically ligated infants, irrespective of prior indomethacin treatment (OR ranged from 1.25-2.35) compared with infants managed conservatively or those who received only indomethacin. No significant differences were detected between infants treated with only indomethacin and those managed conservatively. Conclusions Surgical ligation of PDA in preterm neonates was associated with increased neonatal mortality/morbidity in all analyses adjusted for measured confounders that attempt to account for treatment selection bias.
Background Accurate assessment of glenoid inclination is of interest for a variety of conditions and procedures. The purpose of this study was to develop an accurate and reproducible measurement for ...glenoid inclination on standardized anterior-posterior (AP) radiographs and on computed tomography (CT) images. Materials and methods Three consistently identifiable angles were defined: Angle α by line AB connecting the superior and inferior glenoid tubercle (glenoid fossa) and the line identifying the scapular spine; angle β by line AB and the floor of the supraspinatus fossa; angle γ by line AB and the lateral margin of the scapula. Experimental study: these 3 angles were measured in function of the scapular position to test their resistance to rotation. Conventional AP radiographs and CT scans were acquired in extension/flexion and internal/external rotation in a range up to ±40°. Clinical study: the inter-rater reliability of all angles was assessed on AP radiographs and CT scans of 60 patients (30 with proximal humeral fractures, 30 with osteoarthritis) by 2 independent observers. Results The experimental study showed that angle α and β have a resistance to rotation of up to ±20°. The deviation from neutral position was not more than ±10°. The results for the inter-rater reliability analyzed by Bland-Altman plots for the angle β fracture group were (mean ± standard deviation) −0.1 ± 4.2 for radiographs and −0.3 ± 3.3 for CT scans; and for the osteoarthritis group were −1.2 ± 3.8 for radiographs and −3.0 ± 3.6 for CT scans. Conclusion Angle β is the most reproducible measurement for glenoid inclination on conventional AP radiographs, providing a resistance to positional variability of the scapula and a good inter-rater reliability.
Summary Background Mycobacterium tuberculosis strains that cause untreatable drug-resistant disease are a threat worldwide. We describe the treatment, management, and outcomes of patients with ...extensively drug-resistant tuberculosis in Tomsk, Russia. Methods We undertook a retrospective cohort study of 608 patients with multidrug resistant tuberculosis who had treatment in civilian or prison services, between Sept 10, 2000, and Nov 1, 2004, according to the treatment strategy recommended by WHO. Clinical characteristics, management practices, and treatment outcomes of patients with extensively drug-resistant (XDR) tuberculosis and non-extensively drug-resistant (non-XDR) tuberculosis are described. The main outcome was the frequency of poor and favourable outcomes at the end of treatment. Findings Of 608 patients with multidrug resistant tuberculosis, 29 (4·8%) patients had baseline XDR tuberculosis. Treatment failure was more common in patients with XDR tuberculosis than in those with non-XDR tuberculosis (31% vs 8·5%, p=0·0008). 48·3% of patients with XDR tuberculosis and 66·7% of patients with non-XDR tuberculosis had treatment cure or completion (p=0·04). The frequency and management of adverse events did not differ between patients with XDR and non-XDR tuberculosis. Interpretation The chronic features of tuberculosis in these patients suggest that extensively drug-resistant tuberculosis may be acquired through previous treatments that include second-line drugs. Aggressive management of this infectious disease is feasible and can prevent high mortality rates and further transmission of drug-resistant strains of Mycobacterium tuberculosis. Funding Bill & Melinda Gates Foundation, Eli Lilly Foundation, The Open Society Institute, Frank Hatch Fellowships in Global Health Equity at the Brigham & Women's Hospital, Infectious Disease Society of America, the Heiser Foundation, the United States National Institutes of Health, and the John D and Catherine T MacArthur Foundation.
Facilitating Interoperability1351 Overview1351 Historical Context1352 Integration Profile Development Cycle1352 Benefits of Interoperability/IHE1352 Cardiology Profiles1354 Overview of the ...Profiles1354 Cardiac Catheterization Workflow1354 Echocardiography Workflow1354 Retrieve Electrocardiogram for Display Content Profile1354 Resting Electrocardiogram Workflow Profile1354 Evidence Documents1355 Stress Testing Workflow1355 Displayable Reports Profile1355 Cardiac Imaging Report Content1355 Image-Enabled Office Workflow1355 Electrophysiology Laboratory Report Content-Implant/Explant1355 Implantable Device Cardiac Observations1356 Cardiac Cath Report Content1356 Registry Content Submission1356 Nuclear Medicine Image1356 Profiles in Development1356 Clinical Research and Quality Metrics1356 Promoting the IHE Interoperability Framework1356 Request for Proposals1357 Advantages to Vendors/Users1357 Office of the National Coordinator1358 Measuring Success1358 The Patient's Perspective on Interoperability and Quality1358 Conclusions1359 Appendix 1 Author Listing of Relevant Relationships With Industry and Other Entities--2016 ACC/ASE/ASNC/HRS/SCAI Health Policy Statement on Integrating the Healthcare Enterprise1361 Appendix 2 Peer Reviewer Listing of Relevant Relationships With Industry and Other Entities (Relevant)--2016 ACC/ASE/ASNC/HRS/SCAI Health Policy Statement on Integrating the Healthcare Enterprise1362 Appendix 3 Abbreviations1364 Preamble This document has been developed as a health policy statement by the American College of Cardiology (ACC), in conjunction with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, and Society for Cardiovascular Angiography and Interventions. By capturing and reporting high-quality data, the NCDR serves as a tool to measure, benchmark, and improve cardiovascular care (5).\n Jude Medical None None John S. Rumsfeld Official Reviewer--ACC Board of Trustees U.S. Veterans Health Administration--National Director of Cardiology None None None None None None Joyce Sensmeier Organizational Reviewer--HIMSS HIMSS North America--Vice President Informatics None None None None None None H. Vernon Anderson Content Reviewer--NCDR Management Board University of Texas Health Science Center, McGovern Medical School, Houston, Texas--Professor of Medicine None None None MedPace Medical Devices (DSMB) None None Shyam Bhakta Content Reviewer--Advocacy Steering Committee Northeast Ohio Medical University College of Medicine--Assistant Professor of Internal Medicine; Cleveland Clinic Akron General None None None None None None Gilead I. Lancaster Content Reviewer--Advocacy Steering Committee Bridgeport Hospital/Yale New Haven Health System--Director, Non-Invasive Cardiology None None None None None None William A. Van Decker Content Reviewer--Advocacy Steering Committee Temple University Hospital--Assistant Professor of Medicine None None None None None None Paul G. Varghese Content Reviewer--Data Standards Task Force Harvard Medical School--National Library of Medicine Informatics Fellow None None ChartWise Medicallow * None None None Siqin Kye Ye Content Reviewer--Informatics and Health Information Technology Task Force Columbia University Medical Center--Assistant Professor of Medicine, Division of Cardiology, Department of Medicine None None None None None None * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document.
Background: Anti-Program-Death-1 (PD-1) is a standard adjuvant therapy for patients with resected melanoma. We hypothesized that there are discrepancies in survival, recurrence pattern and toxicity ...to adjuvant PD-1 between different ethnicities and melanoma subtypes. Objective: We performed a multicenter cohort study incorporating 6 independent institutions in Australia, China, Japan, and the United States. The primary outcomes were recurrence free survival (RFS) and overall survival (OS). Secondary outcomes were disease recurrence patterns and toxicities. Results: In total 534 patients were included. East-Asian/Hispanic/African reported significantly poorer RFS/OS. Nonacral cutaneous or melanoma of unknown primary reported the best RFS/OS, followed by acral, and mucosal was the poorest. Within the nonacral cutaneous or melanoma of unknown primary subtypes, East-Asian/Hispanic/African reported significantly poorer RFS/OS than Caucasian. In the multivariate analysis incorporating ethnicity/melanoma-subtype/age/sex/stage/lactate dehydrogenase/BRAF (v-Raf murine sarcoma viral oncogene homolog B)-mutation/adjuvant radiotherapy, East-Asian/Hispanic/African had independently significantly poorer outcomes (RFS: HR, 1.71; 95% CI, 1.19-2.44 and OS: HR, 2.34; 95% CI, 1.39-3.95), as was mucosal subtype (RFS: HR, 3.25; 95% CI, 2.04-5.17 and OS: HR, 3.20; 95% CI, 1.68-6.08). Mucosal melanoma was an independent risk factor for distant metastasis, especially liver metastasis. East-Asian/Hispanic/African had significantly lower incidence of gastrointestinal/musculoskeletal/respiratory/other-rare-type-toxicities; but higher incidences of liver toxicities. Limitations: A retrospective study. Conclusions: Ethnicity and melanoma subtype are associated with survival and recurrence pattern in melanoma patients treated with adjuvant anti-PD-1. Toxicity profile differs by ethnicity and may require a precision toxicity surveillance strategy.
PDF
