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Item Open Access 5-α reductase inhibitors and prostate cancer prevention: where do we turn now?(BMC Med, 2011-09-15) Hamilton, Robert J; Freedland, Stephen JWith the lifetime risk of being diagnosed with prostate cancer so great, an effective chemopreventive agent could have a profound impact on the lives of men. Despite decades of searching for such an agent, physicians still do not have an approved drug to offer their patients. In this article, we outline current strategies for preventing prostate cancer in general, with a focus on the 5-α-reductase inhibitors (5-ARIs) finasteride and dutasteride. We discuss the two landmark randomized, controlled trials of finasteride and dutasteride, highlighting the controversies stemming from the results, and address the issue of 5-ARI use, including reasons why providers may be hesitant to use these agents for chemoprevention. We further discuss the recent US Food and Drug Administration ruling against the proposed new indication for dutasteride and the change to the labeling of finasteride, both of which were intended to permit physicians to use the drugs for chemoprevention. Finally, we discuss future directions for 5-ARI research.Item Open Access A case-control study of airways obstruction among construction workers.(Am J Ind Med, 2015-10) Dement, John; Welch, Laura; Ringen, Knut; Quinn, Patricia; Chen, Anna; Haas, ScottBACKGROUND: While smoking is the major cause of chronic obstructive pulmonary disease (COPD), occupational exposures to vapors, gases, dusts, and fumes (VGDF) increase COPD risk. This case-control study estimated the risk of COPD attributable to occupational exposures among construction workers. METHODS: The study population included 834 cases and 1243 controls participating in a national medical screening program for older construction workers between 1997 and 2013. Qualitative exposure indices were developed based on lifetime work and exposure histories. RESULTS: Approximately 18% (95% CI = 2-24%) of COPD risk can be attributed to construction-related exposures, which are additive to the risk contributed by smoking. A measure of all VGDF exposures combined was a strong predictor of COPD risk. CONCLUSIONS: Construction workers are at increased risk of COPD as a result of broad and complex effects of many exposures acting independently or interactively. Control methods should be implemented to prevent worker exposures, and smoking cessation should be promoted.Item Open Access A clinician's guide to the ABCs of cardiovascular disease prevention: the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative.(Clinical cardiology, 2013-07) Hsu, Steven; Ton, Van-Khue; Dominique Ashen, M; Martin, Seth S; Gluckman, Ty J; Kohli, Payal; Sisson, Stephen D; Blumenthal, Roger S; Blaha, Michael JAtherosclerotic cardiovascular disease (CVD) is the leading cause of death in the United States and worldwide. Fortunately, it is often preventable with early adoption of lifestyle modification, prevention of risk factor onset, and aggressive treatment of existing risk factors. The Million Hearts Initiative is an effort by the Centers for Disease Control that aims to prevent 1 million myocardial infarctions and strokes over the next 5 years. As part of this initiative, we present a simply organized "ABCDE" approach for guiding a consistent comprehensive approach to managing cardiovascular risk in daily clinical practice. ABCDE stands for assessment of risk, antiplatelet therapy, blood pressure management, cholesterol management, cigarette/tobacco cessation, diet and weight management, diabetes prevention and treatment, and exercise, interventions regularly used to reduce cardiovascular (CV) risk. Throughout this article we summarize recommendations related to each topic and reference landmark trials and data that support our approach. We believe that the ABCDE approach will be the core framework for addressing CV risk in our effort to prevent CVD.Item Open Access A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial.(Annals of internal medicine, 2016-01) Allen, Kelli D; Yancy, William S; Bosworth, Hayden B; Coffman, Cynthia J; Jeffreys, Amy S; Datta, Santanu K; McDuffie, Jennifer; Strauss, Jennifer L; Oddone, Eugene ZBackground
Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused.Objective
To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes.Design
Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740).Setting
Department of Veterans Affairs Medical Center in Durham, North Carolina.Participants
30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis.Intervention
The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record.Measurements
The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes.Results
At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ.Limitation
The study was conducted in a single Veterans Affairs medical center.Conclusion
The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis.Primary funding source
Department of Veterans Affairs, Health Services Research and Development Service.Item Open Access A cost-effectiveness comparisons of adult spinal deformity surgery in the United States and Japan.(European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2018-03) Yagi, Mitsuru; Ames, Christopher P; Keefe, Malla; Hosogane, Naobumi; Smith, Justin S; Shaffrey, Christopher I; Schwab, Frank; Lafage, Virginie; Shay Bess, R; Matsumoto, Morio; Watanabe, Kota; International Spine Study Group (ISSG)Purpose
Information about the cost-effectiveness of surgical procedures for adult spinal deformity (ASD) is critical for providing appropriate treatments for these patients. The purposes of this study were to compare the direct cost and cost-effectiveness of surgery for ASD in the United States (US) and Japan (JP).Methods
Retrospective analysis of 76 US and 76 JP patients receiving surgery for ASD with ≥2-year follow-up was identified. Data analysis included preoperative and postoperative demographic, radiographic, health-related quality of life (HRQOL), and direct cost for surgery. An incremental cost-effectiveness ratio (ICER) was determined using cost/quality-adjusted life years (QALY). The cost/QALY was calculated from the 2-year cost and HRQOL data.Results
JP exhibited worse baseline spinopelvic alignment than the US (pelvic incidence and lumbar lordosis: 35.4° vs 22.7°, p < 0.01). The US had more three-column osteotomies (50 vs 16%), and shorter hospital stay (7.9 vs 22.7 days) (p < 0.05). The US demonstrated worse postoperative ODI (41.3 vs. 33.9%) and greater revision surgery rate (40 vs 10%) (p < 0.05). Due to the high initial cost and revision frequency, the US had greater total cost ($92,133 vs. $49,647) and cost/QALY ($511,840 vs. $225,668) at 2-year follow-up (p < 0.05).Conclusion
Retrospective analysis comparing the direct costs and cost-effectiveness of ASD surgery in the US vs JP demonstrated that the total direct costs and cost/QALY were substantially higher in the US than JP. Variations in patient cohort, healthcare costs, revision frequencies, and HRQOL improvement influenced the cost/QALY differential between these countries.Item Open Access A dimensional approach to understanding severity estimates and risk correlates of marijuana abuse and dependence in adults.(International journal of methods in psychiatric research, 2012-06) Wu, Li-Tzy; Woody, George E; Yang, Chongming; Pan, Jeng-Jong; Reeve, Bryce B; Blazer, Dan GWhile item response theory (IRT) research shows a latent severity trait underlying response patterns of substance abuse and dependence symptoms, little is known about IRT-based severity estimates in relation to clinically relevant measures. In response to increased prevalences of marijuana-related treatment admissions, an elevated level of marijuana potency, and the debate on medical marijuana use, we applied dimensional approaches to understand IRT-based severity estimates for marijuana use disorders (MUDs) and their correlates while simultaneously considering gender- and race/ethnicity-related differential item functioning (DIF). Using adult data from the 2008 National Survey on Drug Use and Health (N = 37,897), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for MUDs among past-year marijuana users were examined by IRT, logistic regression, and multiple indicators-multiple causes (MIMIC) approaches. Among 6917 marijuana users, 15% met criteria for a MUD; another 24% exhibited subthreshold dependence. Abuse criteria were highly correlated with dependence criteria (correlation = 0.90), indicating unidimensionality; item information curves revealed redundancy in multiple criteria. MIMIC analyses showed that MUD criteria were positively associated with weekly marijuana use, early marijuana use, other substance use disorders, substance abuse treatment, and serious psychological distress. African Americans and Hispanics showed higher levels of MUDs than Whites, even after adjusting for race/ethnicity-related DIF. The redundancy in multiple criteria suggests an opportunity to improve efficiency in measuring symptom-level manifestations by removing low-informative criteria. Elevated rates of MUDs among African Americans and Hispanics require research to elucidate risk factors and improve assessments of MUDs for different racial/ethnic groups.Item Open Access A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience.(Educ Health (Abingdon), 2014-09) Freistadt, Fernanda; Branigan, Erin; Pupp, Chris; Stefanutto, Marzio; Bambo, Carlos; Alexandre, Maria; Pinheiro, Sandro O; Ballweg, Ruth; Dgedge, Martinho; O'Malley, Gabrielle; de Oliveira, Justine StrandMozambique, with approximately 0.4 physicians and 4.1 nurses per 10,000 people, has one of the lowest ratios of health care providers to population in the world. To rapidly scale up health care coverage, the Mozambique Ministry of Health has pushed for greater investment in training nonphysician clinicians, Tιcnicos de Medicina (TM). Based on identified gaps in TM clinical performance, the Ministry of Health requested technical assistance from the International Training and Education Center for Health (I-TECH) to revise the two-and-a-half-year preservice curriculum. A six-step process was used to revise the curriculum: (i) Conducting a task analysis, (ii) defining a new curriculum approach and selecting an integrated model of subject and competency-based education, (iii) revising and restructuring the 30-month course schedule to emphasize clinical skills, (iv) developing a detailed syllabus for each course, (v) developing content for each lesson, and (vi) evaluating implementation and integrating feedback for ongoing improvement. In May 2010, the Mozambique Minister of Health approved the revised curriculum, which is currently being implemented in 10 training institutions around the country. Key lessons learned: (i) Detailed assessment of training institutions' strengths and weaknesses should inform curriculum revision. (ii) Establishing a Technical Working Group with respected and motivated clinicians is key to promoting local buy-in and ownership. (iii) Providing ready-to-use didactic material helps to address some challenges commonly found in resource-limited settings. (iv) Comprehensive curriculum revision is an important first step toward improving the quality of training provided to health care providers in developing countries. Other aspects of implementation at training institutions and health care facilities must also be addressed to ensure that providers are adequately trained and equipped to provide quality health care services. This approach to curriculum revision and implementation teaches several key lessons, which may be applicable to preservice training programs in other less developed countries.Item Open Access A health literacy pilot intervention to improve medication adherence using Meducation® technology.(Patient education and counseling, 2014-05) Zullig, Leah L; McCant, Felicia; Melnyk, S Dee; Danus, Susanne; Bosworth, Hayden BObjective
To determine whether antihypertensive medication adherence could improve using a Meducation® technology health literacy intervention.Methods
We conducted a six-month feasibility study among patients with cardiovascular disease (CVD) risk factors receiving care from hospital-based primary care clinics. All patients received a personalized Meducation® calendar listing CVD-related medications. We evaluated changes in medication adherence and clinical outcomes at six months.Results
There was a 42% enrollment rate (n=23). Forty percent had low health literacy, defined as less than 9th grade reading level. At three months, self-reported medication adherence improved. At six months, medication possession ratio improved 3.2%. Also, at six months there were decreases in patients' average systolic blood pressure (0.5 mmHg), diastolic blood pressure (1.5 mmHg), and body weight (3.6 pounds) (p>0.05).Conclusions
A health literacy intervention may be a feasible mechanism to improve cardiovascular-related medication adherence and outcomes.Practice implications
Health literacy interventions may improve adherence while requiring relatively few resources to implement.Item Open Access A housing mobility program's impacts on teen and young adult parenting.(SSM - population health, 2019-12) Fuller, Taleria R; Sciandra, Matt; Koumans, Emilia H; Boulet, Sheree L; Warner, Lee; Cox, Shanna; Gennetian, Lisa AObjective:To assess the impact of Moving to Opportunity for Fair Housing Demonstration Program (MTO) implemented in 1994 in five U.S. cities (Baltimore, Boston, Chicago, Los Angeles, and New York City) on teen births. Methods:We analyzed baseline and long-term evaluation data for youth (ages 13-20) and young adults (ages 21-30) (N = 7861) who were children or teens at baseline. We used regression analyses to estimate the impact of housing vouchers on having a teen birth. Results:Overall, MTO had no significant effect on teen births. However, among young adults whose parent had a child before age 20, the proportion with a teen birth themselves was 21% lower among those offered housing vouchers to low-poverty neighborhoods with no restrictions compared to those not offered housing vouchers (p < 0.05). Conclusion:MTO appeared to decrease intergenerational teen births among young adults. Further exploration of housing relocation may help untangle risks and protective factors for reducing intergenerational teen births. Public health implications:Reducing intergenerational teen births is important, especially among those facing economic, environmental, and health risks. Comprehensive programs addressing multiple social determinants of health are vital to reducing teen births.Item Open Access A minimal monitoring approach for the treatment of hepatitis C virus infection (ACTG A5360 [MINMON]): a phase 4, open-label, single-arm trial.(The lancet. Gastroenterology & hepatology, 2022-04) Solomon, Sunil S; Wagner-Cardoso, Sandra; Smeaton, Laura; Sowah, Leonard A; Wimbish, Chanelle; Robbins, Gregory; Brates, Irena; Scello, Christine; Son, Annie; Avihingsanon, Anchalee; Linas, Benjamin; Anthony, Donald; Nunes, Estevão Portela; Kliemann, Dimas A; Supparatpinyo, Khuanchai; Kityo, Cissy; Tebas, Pablo; Bennet, Jaclyn Ann; Santana-Bagur, Jorge; Benson, Constance A; Van Schalkwyk, Marije; Cheinquer, Nelson; Naggie, Susanna; Wyles, David; Sulkowski, MarkBackground
Despite widespread availability of direct-acting antivirals including generic formulations, limited progress has been made in the global adoption of hepatitis C virus (HCV) treatment. Barriers to treatment scale-up include availability and access to diagnostic and monitoring tests, health-care infrastructure, and requirement for frequent visits during treatment.Methods
ACTG A5360 was a phase 4, open-label, single-arm trial across 38 sites in Brazil, South Africa, Thailand, Uganda, and the USA. Key inclusion criteria were age of 18 years or older, evidence of active HCV infection (HCV RNA >1000 IU/mL) and HCV treatment-naive; patients with compensated cirrhosis and HIV/HCV co-infection were included but their enrolment was capped. All participants received a fixed dose combination of oral sofosbuvir (400 mg) and velpatasvir (100 mg) once daily for 12 weeks. The minimal monitoring (MINMON) approach consisted of four components: (1) there was no pre-treatment genotyping; (2) the entire treatment course (84 tablets) was dispensed at entry; (3) there were no scheduled visits or laboratory monitoring; and (4) there were two points of remote contact, at week 4 for adherence and week 22, to schedule outcome assessment at week 24 (-2 weeks to +4 weeks). Participants who missed the week 24 window could return for a visit to assess treatment response any time before week 72. Unplanned visits for any reason were permissible before the week 24 visit. The primary efficacy outcome was sustained virological response (SVR), defined as HCV RNA less than the lower limit of quantification measured at least 22 weeks post-treatment initiation; the primary safety outcome was serious adverse events. The primary efficacy analysis included all participants who initiated treatment, using a missing=failure approach. The primary safety analysis included all participants who initiated treatment and had at least one post-treatment assessment. This trial is registered at ClinicalTrials.gov, NCT03512210.Findings
Between Oct 22, 2018, and July 19, 2019, 400 participants were enrolled across all 38 sites; 399 initiated treatment. At the SVR assessment visit, 355 (89%) of 397 participants reported taking 100% of the trial medication during the 12-week treatment period; two patients did not have any follow-up visits after the entry visit and were excluded from the safety analyses. Overall, 379 of the 399 who initiated treatment had an SVR (95·0%, 95% CI 92·4-96·7). 14 (4%) of 397 participants reported serious adverse events between treatment initiation and week 28; none were treatment related or led to treatment discontinuation or death. 15 (4%) of 399 participants had unplanned visits; none were related to treatment.Interpretation
In this diverse global population of people with HCV, the MINMON approach with sofosbuvir-velpatasvir treatment was safe and achieved SVR comparable to standard monitoring observed in real-world data. Coupled with innovative case finding strategies, this strategy could be crucial to the global HCV elimination agenda.Funding
US National Institutes of Health and Gilead Sciences.Item Open Access A Multi-Center International Analysis of Lung Transplantation Outcomes in Patients With COVID-19.(Clinical transplantation, 2024-09) Kashem, Mohammed Abul; Loor, Gabriel; Emtiazjoo, Amir; Hartwig, Matthew; Van Raemdonck, Dirk; Calvelli, Hannah; Leon Pena, Andres; Salan-Gomez, Marcelo; Zhao, Huaqing; Warnick, Michael; Villavicencio, Mauricio; Ius, Fabio; Ghadimi, Kamrouz; Salman, Jawad; Chandrashekaran, Satish; Machuca, Tiago; Sanchez, Pablo G; Subramaniam, Kathirvel; Neyrinck, Arne; Huddleston, Stephen; Ceulemans, Laurens; Osho, Asishana; D'Silva, Ethan; Ramamurthy, Uma; Shaffer, Andrew; Langer, Nathaniel; Toyoda, YoshiyaIntroduction
Lung transplantation has become increasingly utilized in patients with COVID-19. While several single-center and UNOS database studies have been published on lung transplants (LTs) for end-stage lung disease (ESLD) from Coronavirus disease 2019 (COVID-19), there is a lack of multi-center and international data.Methods
This is a multicenter analysis from 11 high-volume lung transplant centers in the United States and Europe. Data were collected through the Multi-Institutional ECLS Registry and stratified by ESLD due to COVID-19 versus other etiologies. Demographics and clinical variables were compared using Chi-square test and Fisher's exact test. Survival was assessed by Kaplan-Meier curves and compared by log-rank test with propensity score matching.Results
Of 1606 lung transplant recipients, 46 (2.9%) were transplanted for ESLD from COVID-19 compared to 1560 (97.1%) without a history of COVID-19. Among COVID-19 patients, 30 (65.2%) had COVID-19-associated ARDS and 16 (34.8%) had post-COVID-19 fibrosis. COVID-19 patients had higher lung allocation scores (78.0 vs. 44.4, p < 0.0001), had severely limited functional status (37.0% vs. 2.9%, p < 0.0001), had higher preoperative ECMO usage (65.2% vs. 5.4%, p < 0.0001), and spent less time on the waitlist (32 vs. 137 days, p < 0.0001). A 30-day survival was comparable between COVID-19 and non-COVID-19 patients before (100% vs. 98.7%, p = 0.39) and after propensity matching (p = 0.15).Conclusions
Patients who received LTs due to COVID-19 had short-term survival comparable to that of patients without COVID-19. Our findings support the idea that lung transplantation should be considered for select patients with ESLD due to COVID-19.Item Open Access A Pharmacology-Based Enrichment Program for Undergraduates Promotes Interest in Science.(CBE Life Sci Educ, 2015) Godin, Elizabeth A; Wormington, Stephanie V; Perez, Tony; Barger, Michael M; Snyder, Kate E; Richman, Laura Smart; Schwartz-Bloom, Rochelle; Linnenbrink-Garcia, LisaThere is a strong need to increase the number of undergraduate students who pursue careers in science to provide the "fuel" that will power a science and technology-driven U.S. economy. Prior research suggests that both evidence-based teaching methods and early undergraduate research experiences may help to increase retention rates in the sciences. In this study, we examined the effect of a program that included 1) a Summer enrichment 2-wk minicourse and 2) an authentic Fall research course, both of which were designed specifically to support students' science motivation. Undergraduates who participated in the pharmacology-based enrichment program significantly improved their knowledge of basic biology and chemistry concepts; reported high levels of science motivation; and were likely to major in a biological, chemical, or biomedical field. Additionally, program participants who decided to major in biology or chemistry were significantly more likely to choose a pharmacology concentration than those majoring in biology or chemistry who did not participate in the enrichment program. Thus, by supporting students' science motivation, we can increase the number of students who are interested in science and science careers.Item Open Access A protocol to evaluate the efficacy, perceptions, and cost of a cholesterol packaging approach to improve medication adherence.(Contemporary clinical trials, 2014-09) Zullig, Leah L; Pathman, Joshua; Melnyk, S Dee; Brown, Jamie N; Sanders, Linda L; Koropchak, Celine; Howard, Teresa; Danus, Susanne; McCant, Felicia; Bosworth, Hayden BPurpose
Elevated low-density lipoprotein cholesterol (LDL-C) is a major modifiable risk factor for cardiovascular disease (CVD), a leading cause of death in the United States. Despite clinical practice guidelines aimed at facilitating LDL-C control, many Veterans do not achieve guideline-recommended LDL-C levels.Methods
We describe a study focused on VA healthcare system users at risk for CVD (i.e., LDL-C level >130 mg/dl and/or <80% cholesterol pill refill adherence in the last 12 months). We are conducting a two and a half year randomized controlled trial (i.e., intervention administered over 12 months) among Veterans with uncontrolled cholesterol receiving care at select VA-affiliated primary care clinics in North Carolina. We anticipate enrolling 250 diverse patients (10% women; 40% African American). Patients are randomized to an educational control group or intervention group. Intervention group participants' medication is provided in special blister packaging labeled for daily use that includes reminders; MeadWestvaco Corporation's pre-filled DosePak® contains standard doses of statins in accordance with the existing prescriptions.Conclusions
Pre-filled blister packaging may provide an inexpensive solution to improve medication adherence. Our study enrolls a diverse sample and provides information about whether an adherence packaging intervention can: 1) improve medication adherence; 2) improve patients' LDL-C levels; 3) be well received by patients and providers; and 4) provide a cost effective solution to improve medication adherence.Item Open Access A putatively functional polymorphism in the HTR2C gene is associated with depressive symptoms in white females reporting significant life stress.(PloS one, 2014-01) Brummett, Beverly H; Babyak, Michael A; Williams, Redford B; Harris, Kathleen Mullan; Jiang, Rong; Kraus, William E; Singh, Abanish; Costa, Paul T; Georgiades, Anastasia; Siegler, Ilene CPsychosocial stress is well known to be positively associated with subsequent depressive symptoms. Cortisol response to stress may be one of a number of biological mechanisms that links psychological stress to depressive symptoms, although the precise causal pathway remains unclear. Activity of the x-linked serotonin 5-HTR2C receptor has also been shown to be associated with depression and with clinical response to antidepressant medications. We recently demonstrated that variation in a single nucleotide polymorphism on the HTR2C gene, rs6318 (Ser23Cys), is associated with different cortisol release and short-term changes in affect in response to a series of stress tasks in the laboratory. Based on this observation, we decided to examine whether rs6318 might moderate the association between psychosocial stress and subsequent depressive symptoms. In the present study we use cross-sectional data from a large population-based sample of young adult White men (N = 2,366) and White women (N = 2,712) in the United States to test this moderation hypothesis. Specifically, we hypothesized that the association between self-reported stressful life events and depressive symptoms would be stronger among homozygous Ser23 C females and hemizygous Ser23 C males than among Cys23 G carriers. In separate within-sex analyses a genotype-by-life stress interaction was observed for women (p = .022) but not for men (p = .471). Homozygous Ser23 C women who reported high levels of life stress had depressive symptom scores that were about 0.3 standard deviations higher than female Cys23 G carriers with similarly high stress levels. In contrast, no appreciable difference in depressive symptoms was observed between genotypes at lower levels of stress. Our findings support prior work that suggests a functional SNP on the HTR2C gene may confer an increased risk for depressive symptoms in White women with a history of significant life stress.Item Open Access A qualitative analysis of the Three Good Things intervention in healthcare workers.(BMJ open, 2017-06-13) Rippstein-Leuenberger, Karin; Mauthner, Oliver; Bryan Sexton, J; Schwendimann, ReneBACKGROUND:Intensive care unit (ICU) personnel have an elevated prevalence of job-related burn-out and post-traumatic stress disorder, which can ultimately impact patient care. To strengthen healthcare workers' skills to deal with stressful events, it is important to focus not only on minimising suffering but also on increasing happiness, as this entails many more benefits than simply feeling good. Thus, the purpose of this study was to explore the content of the 'good things' reported by healthcare workers participating in the 'Three Good Things' intervention. METHODS:In a tertiary care medical centre, a sample of 89 neonatal ICU (NICU) healthcare professionals registered for the online intervention. Of these, 32 individuals eventually participated fully in the 14-day online Three Good Things intervention survey. Daily emails reminded participants to reflect on and respond to the questions: "What are the three things that went well today?" and "What was your role in bringing them about?" To analyse their responses, we applied a thematic analysis, which was guided by our theoretical understanding of resilience. RESULTS:Involving more than 1300 statements, the Three Good Things responses of the 32 study participants, including registered nurses, physicians and neonatal nurse practitioners, led to the identification of three main themes: (1) having a good day at work; (2) having supportive relationships and (3) making meaningful use of self-determined time. CONCLUSIONS:The findings show the personal and professional relevance of supportive relationships strengthened by clear communication and common activities that foster positive emotions. The Three Good Things exercise acknowledges the importance of self-care in healthcare workers and appears to promote well-being, which might ultimately strengthen resilience.Item Open Access A risk score for in-hospital death in patients admitted with ischemic or hemorrhagic stroke.(J Am Heart Assoc, 2013-01-28) Smith, Eric E; Shobha, Nandavar; Dai, David; Olson, DaiWai M; Reeves, Mathew J; Saver, Jeffrey L; Hernandez, Adrian F; Peterson, Eric D; Fonarow, Gregg C; Schwamm, Lee HBACKGROUND: We aimed to derive and validate a single risk score for predicting death from ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). METHODS AND RESULTS: Data from 333 865 stroke patients (IS, 82.4%; ICH, 11.2%; SAH, 2.6%; uncertain type, 3.8%) in the Get With The Guidelines-Stroke database were used. In-hospital mortality varied greatly according to stroke type (IS, 5.5%; ICH, 27.2%; SAH, 25.1%; unknown type, 6.0%; P<0.001). The patients were randomly divided into derivation (60%) and validation (40%) samples. Logistic regression was used to determine the independent predictors of mortality and to assign point scores for a prediction model in the overall population and in the subset with the National Institutes of Health Stroke Scale (NIHSS) recorded (37.1%). The c statistic, a measure of how well the models discriminate the risk of death, was 0.78 in the overall validation sample and 0.86 in the model including NIHSS. The model with NIHSS performed nearly as well in each stroke type as in the overall model including all types (c statistics for IS alone, 0.85; for ICH alone, 0.83; for SAH alone, 0.83; uncertain type alone, 0.86). The calibration of the model was excellent, as demonstrated by plots of observed versus predicted mortality. CONCLUSIONS: A single prediction score for all stroke types can be used to predict risk of in-hospital death following stroke admission. Incorporation of NIHSS information substantially improves this predictive accuracy.Item Open Access A Structured Approach to Detecting and Treating Depression in Primary Care: VitalSign6 Project.(Annals of family medicine, 2019-07) Jha, Manish K; Grannemann, Bruce D; Trombello, Joseph M; Clark, E Will; Eidelman, Sara Levinson; Lawson, Tiffany; Greer, Tracy L; Rush, A John; Trivedi, Madhukar HPurpose
This report describes outcomes of an ongoing quality-improvement project (VitalSign6) in a large US metropolitan area to improve recognition, treatment, and outcomes of depressed patients in 16 primary care clinics (6 charity clinics, 6 federally qualified health care centers, 2 private clinics serving low-income populations, and 2 private clinics serving patients with either Medicare or private insurance).Methods
Inclusion in this retrospective analysis was restricted to the first 25,000 patients (aged ≥12 years) screened with the 2-item Patient Health Questionnaire (PHQ-2) in the aforementioned quality-improvement project. Further evaluations with self-reports and clinician assessments were recorded for those with positive screen (PHQ-2 >2). Data collected from August 2014 though November 2016 were available at 3 levels: (1) initial PHQ-2 (n = 25,000), (2) positive screen (n = 4,325), and (3) clinician-diagnosed depressive disorder with 18 or more weeks of enrollment (n = 2,160).Results
Overall, 17.3% (4,325/25,000) of patients screened positive for depression. Of positive screens, 56.1% (2,426/4,325) had clinician-diagnosed depressive disorder. Of those enrolled for 18 or more weeks, 64.8% were started on measurement-based pharmacotherapy and 8.9% referred externally. Of the 1,400 patients started on pharmacotherapy, 45.5%, 30.2%, 12.6%, and 11.6% had 0, 1, 2, and 3 or more follow-up visits, respectively. Remission rates were 20.3% (86/423), 31.6% (56/177), and 41.7% (68/163) for those with 1, 2, and 3 or more follow-up visits, respectively. Baseline characteristics associated with higher attrition were: non-white, positive drug-abuse screen, lower depression/anxiety symptom severity, and younger age.Conclusion
Although remission rates are high in those with 3 or more follow-up visits after routine screening and treatment of depression, attrition from care is a significant issue adversely affecting outcomes.Item Open Access A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors.(World neurosurgery, 2013-03) Groff, Michael W; Heller, Joshua E; Potts, Eric A; Mummaneni, Praveen V; Shaffrey, Christopher I; Smith, Justin SObjective
To understand better the scope of wrong-level lumbar spine surgery and current practices in place to help avoid such errors.Methods
The Joint Section on Disorders of the Spine and Peripheral Nerves (Spine Section) developed a survey on single-level lumbar spine decompression surgery. Invitations to complete the Web-based survey were sent to all Spine Section members. Respondents were assured of confidentiality.Results
There were 569 responses from 1045 requests (54%). Most surgeons either routinely (74%) or sometimes (11%) obtain preoperative imaging for incision planning. Most surgeons indicated that they obtained imaging after the incision was performed for localization either routinely before bone removal (73%) or most frequently before bone removal but occasionally after (16%). Almost 50% of reporting surgeons have performed wrong-level lumbar spine surgery at least once, and >10% have performed wrong-side lumbar spine surgery at least once. Nearly 20% of responding surgeons have been the subject of at least one malpractice case relating to these errors. Only 40% of respondents believed that the site marking/"time out" protocol of The Joint Commission on the Accreditation of Healthcare Organizations has led to a reduction in these errors.Conclusions
There is substantial heterogeneity in approaches used to localize operative levels in the lumbar spine. Existing safety protocols may not be mitigating wrong-level surgery to the extent previously thought.Item Open Access A tale of two callings.(J Clin Invest, 2011-10) Lefkowitz, Robert JItem Open Access Absence of July Phenomenon in Acute Ischemic Stroke Care Quality and Outcomes.(Journal of the American Heart Association, 2018-01-31) Gonzalez-Castellon, Marco; Ju, Christine; Xian, Ying; Hernandez, Adrian; Fonarow, Gregg C; Schwamm, Lee; Smith, Eric E; Bhatt, Deepak L; Reeves, Matthew; Willey, Joshua ZBACKGROUND:Lower care quality and an increase in adverse outcomes as a result of new medical trainees is a concept well rooted in popular belief, termed the "July phenomenon." Whether this phenomenon occurs in acute ischemic stroke has not been well studied. METHODS AND RESULTS:We analyzed data from patients admitted with ischemic stroke in 1625 hospitals participating in the Get With The Guidelines-Stroke program for the 5-year period between January 2009 and December 2013. We compared acute stroke treatment processes and in-hospitals outcomes among the 4 quarters (first quarter: July-September, last quarter: April-June) of the academic year. Multivariable logistic regression models were used to evaluate the relationship between academic year transition and processes measures. A total of 967 891 patients were included in the study. There was a statistically significant, but modest (<4 minutes or 5 percentage points) difference in distribution of or quality and clinical metrics including door-to-computerized tomography time, door-to-needle time, the proportion of patients with symptomatic intracranial hemorrhage within 36 hours of admission, and the proportion of patients who received defect-free care in stroke performance measures among academic year quarters (P<0.0001). In multivariable analyses, there was no evidence that quarter 1 of the academic year was associated with lower quality of care or worse in-hospital outcomes in teaching and nonteaching hospitals. CONCLUSIONS:We found no evidence of the "July phenomenon" in patients with acute ischemic stroke among hospitals participating in the Get With The Guidelines-Stroke program.