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Recent Research Articles from JPS Health Network
Defining Acute Traumatic Encephalopathy: Methods of the "HEAD Injury Serum Markers and Multi-Modalities for Assessing Response to Trauma" (HeadSMART II) Study
Front Neurol. 2021 Dec 8;12:733712. doi: 10.3389/fneur.2021.733712. eCollection 2021.
Despite an estimated 2.8 million annual ED visits, traumatic brain injury (TBI) is a syndromic diagnosis largely based on report of loss of consciousness, post-traumatic amnesia, and/or confusion, without readily available objective diagnostic tests at the time of presentation, nor an ability to identify a patient's prognosis at the time of injury. The recognition that "mild" forms of TBI and even sub-clinical impacts can result in persistent neuropsychiatric consequences, particularly when repetitive, highlights the need for objective assessments that can complement the clinical diagnosis and provide prognostic information about long-term outcomes. Biomarkers and neurocognitive testing can identify brain injured patients and those likely to have post-concussive symptoms, regardless of imaging testing results, thus providing a physiologic basis for a diagnosis of acute traumatic encephalopathy (ATE). The goal of the HeadSMART II (HEAD injury Serum markers and Multi-modalities for Assessing Response to Trauma) clinical study is to develop an in-vitro diagnostic test for ATE. The BRAINBox TBI Test will be developed in the current clinical study to serve as an aid in evaluation of patients with ATE by incorporating blood protein biomarkers, clinical assessments, and tools to measure, identify, and define associated pathologic evidence and neurocognitive impairments. This protocol proposes to collect data on TBI subjects by a multi-modality approach that includes serum biomarkers, clinical assessments, neurocognitive performance, and neuropsychological characteristics, to determine the accuracy of the BRAINBox TBI test as an aid to the diagnosis of ATE, defined herein, and to objectively determine a patient's risk of developing post-concussive symptoms.
Racial/Ethnic Distribution of Graduates from Doctorate and Masters Epidemiology Degree Programs in the United States, 2008 to 2018
Ann Epidemiol. 2021 Dec 21:S1047-2797(21)00346-X. doi: 10.1016/j.annepidem.2021.12.004. Online ahead of print.
PURPOSE: To identify trends in racial and ethnic diversity of epidemiology graduate degree recipients in the U.S. between academic years 2008 to 2018.
METHODS: National-level data from the National Center for Education Statistics was analyzed to assess the change in proportions of epidemiology degrees conferred to each racial/ethnic group - American Indian or Alaska Native; Asian, Native Hawaiian or Other Pacific Islander; Black or African American; Hispanic or Latino; White; and two or more races- over two time periods, Fall 2007- Spring 2012 (Period 1) and Fall 2012 - Spring 2018 (Period 2).
RESULTS: During Period 1, 3837 epidemiology graduate degrees were conferred, and 6960 in Period 2. Within race/ethnicity groups, there was a statistically significant increase in graduate epidemiology degrees awarded over the two time periods to students of Hispanic or Latino ethnicity, and to students reporting two or more races. The proportion of degrees awarded to non-White students in aggregate increased by 4.7 percentage points, from 33.5% to 38.2%, while awards to White students decreased by the same amount.
CONCLUSIONS: Overall, the racial/ethnic diversity of epidemiology graduates in the U.S. increased between 2008 and 2018, however, further efforts are needed to increase awards within some racial minority subgroups.
Multi-institutional intervention to improve patient perception of physician empathy in emergency care
Emerg Med J. 2021 Dec 21:emermed-2020-210757. doi: 10.1136/emermed-2020-210757. Online ahead of print.
BACKGROUND: Physician empathy has been linked to increased patient satisfaction, improved patient outcomes and reduced provider burnout. Our objective was to test the effectiveness of an educational intervention to improve physician empathy and trust in the ED setting.
METHODS: Physician participants from six emergency medicine residencies in the US were studied from 2018 to 2019 using a pre-post, quasi-experimental non-equivalent control group design with randomisation at the site level. Intervention participants at three hospitals received an educational intervention, guided by acognitivemap (the 'empathy circle'). This intervention was further emphasised by the use of motivational texts delivered to participants throughout the course of the study. The primary outcome was change in E patient perception of resident empathy (Jefferson scale of patient perception of physician empathy (JSPPPE) and Trust in Physicians Scale (Tips)) before (T1) and 3-6 months later (T2).
RESULTS: Data were collected for 221 residents (postgraduate year 1-4.) In controls, the mean (SD) JSPPPE scores at T1 and T2 were 29 (3.8) and 29 (4.0), respectively (mean difference 0.8, 95% CI: -0.7 to 2.4, p=0.20, paired t-test). In the intervention group, the JSPPPE scores at T1 and T2 were 28 (4.4) and 30 (4.0), respectively (mean difference 1.4, 95% CI: 0.0 to 2.8, p=0.08). In controls, the TIPS at T1 was 65 (6.3) and T2 was 66 (5.8) (mean difference -0.1, 95% CI: -3.8 to 3.6, p=0.35). In the intervention group, the TIPS at T1 was 63 (6.9) and T2 was 66 (6.3) (mean difference 2.4, 95% CI: 0.2 to 4.5, p=0.007). Hierarchical regression revealed no effect of time×group interaction for JSPPPE (p=0.71) nor TIPS (p=0.16).
CONCLUSION: An educational intervention with the addition of text reminders designed to increase empathic behaviour was not associated with a change in patient-perceived empathy, but was associated with a modest improvement in trust in physicians.
High End-of-Life Health Care Utilization in a Contemporary Cohort of Head and Neck Cancer Patients Treated with Immune Checkpoint Inhibitors
J Palliat Med. 2021 Nov 30. doi: 10.1089/jpm.2021.0323. Online ahead of print.
Background/Objective: End-of-life health care utilization (EOLHCU) is largely uncharacterized among patients with recurrent/metastatic head and neck squamous cell carcinomas (RMHNSCC), particularly now that immune checkpoint inhibitors (ICI) have been introduced to the treatment landscape. We examined this in a single-institution, retrospective study. Design/Settings: We utilized a database of deceased, ICI-treated RMHNSCC patients to obtain demographic and EOLHCU data, the latter of which included advanced care plan documentation (ACPD) and systemic therapy or emergency room (ER)/hospital/intensive care unit (ICU) admission within 30 days of death (DOD). This was compared with a cohort of deceased thoracic malignancy (TM) patients in an exploratory analysis. Multivariate analysis was performed to examine for association between patient factors (such as age, Eastern Cooperative Oncology Group (ECOG) performance status, or smoking status) and overall survival (OS); associations between the said patient factors and EOLHCU were also evaluated. This study was conducted at an academic, tertiary center in the United States. Results: The RMHNSCC patients (n = 74) were more likely to have ACPD (p < 0.01), an emergency department visit (p < 0.01), and/or hospital admission (p < 0.01) within 30 DOD relative to the TM group. There was no difference in ICU admissions, ICU deaths, or systemic therapy at end of life (EOL). The OS declined in association with ECOG performance status (PS) and smoking. No association was observed between patient factors and any EOLHCU metric. Conclusions: At our center, patients with ICI-treated RMHNSCC have higher rates of both ACPD and EOLHCU, suggesting high symptom burden and representing opportunities for further study into supportive care augmentation.
J Clin Neurosci. 2021 Nov 25:S0967-5868(21)00556-7. doi: 10.1016/j.jocn.2021.11.008. Online ahead of print.
Percutaneous cryoablation (PCA) is a minimally invasive technique that has been recently used to treat spinal metastases with a paucity of data currently available in the literature. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective or retrospective studies concerning metastatic spinal neoplasms treated with current generation PCA systems and with available data on safety and clinical outcomes were included. In the 8 included studies (7 retrospective, 1 prospective), a total of 148 patients (females = 63%) underwent spinal PCA. Tumors were located in the cervical (3/109 [2.8%], thoracic (74/109 [68.8%], lumbar (37/109 [33.9%], and sacrococcygeal (17/109 [15.6%] regions. Overall, 187 metastatic spinal lesions were treated. Thermo-protective measures (e.g., carbo-/hydro-dissection, thermocouples) were used in 115/187 [61.5%] procedures. For metastatic spinal tumors, the pooled mean difference (MD) in pain scores from baseline on the 0-10 numeric rating scale was 5.03 (95% confidence interval [CI]: 4.24 to 5.82) at a 1-month follow-up and 4.61 (95% CI: 3.27 to 5.95) at the last reported follow-up (range 24-40 weeks in 3/4 studies). Local tumor control rates ranged widely from 60% to 100% at varying follow-ups. Grade I-II complications were reported in 9/148 [6.1%] patients and grade III-V complications were reported in 3/148 [2.0%]) patients. PCA, as a stand-alone or adjunct modality, may be a viable therapy in appropriately selected patients with painful spinal metastases who were traditionally managed with open surgery and/or radiation therapy.
Causal Effect Analysis of Demographic Concordance of Physician Trust and Respect in an Emergency Care Setting
Open Access Emerg Med. 2021 Nov 19;13:503-509. doi: 10.2147/OAEM.S334495. eCollection 2021.
OBJECTIVE: Patient perceptions of physician trust and respect are important factors for patient satisfaction evaluations. However, perceptions are subjective by nature and can be affected by patient and physician demographic characteristics. We aim to determine the causal effect on patient-physician demographic concordance and patient perceptions of physician trust and respect in an emergency care setting.
METHODS: We performed a causal effect analysis in an observational study setting. A near-real-time patient satisfaction survey was sent via telephone to patients within 72 h of discharge from an emergency department (ED). Patient-trust-physician (PTP) and physician-show-respect (PSR) scores were measured. Patient and physician demographics (age, gender, race, and ethnicity) were matched. Causal effect was analyzed to determine the direct effect of patient-physician demographic concordance on PTP/PSR scores.
RESULTS: We enrolled 1815 patients. The treatment effect of patient-physician age concordance on PTP scores was -0.119 (p = 0.036). Other treatment effect of patient-physician demographic concordance on patient perception of physician trust and respect ranged from -0.02 to -0.2 (p > 0.05).
CONCLUSION: Patient-physician age concordance may cause a negative effect on patient perception of physician trust. Otherwise, patient-physician demographic concordance has no effect on patient perceptions of physician trust and respect.
Development and validation of a prediction model for estimating one-month mortality of adult COVID-19 patients presenting at emergency department with suspected pneumonia: a multicenter analysis
Intern Emerg Med. 2021 Nov 23. doi: 10.1007/s11739-021-02882-x. Online ahead of print.
There are only a few models developed for risk-stratifying COVID-19 patients with suspected pneumonia in the emergency department (ED). We aimed to develop and validate a model, the COVID-19 ED pneumonia mortality index (CoV-ED-PMI), for predicting mortality in this population. We retrospectively included adult COVID-19 patients who visited EDs of five study hospitals in Texas and who were diagnosed with suspected pneumonia between March and November 2020. The primary outcome was 1-month mortality after the index ED visit. In the derivation cohort, multivariable logistic regression was used to develop the CoV-ED-PMI model. In the chronologically split validation cohort, the discriminative performance of the CoV-ED-PMI was assessed by the area under the receiver operating characteristic curve (AUC) and compared with other existing models. A total of 1678 adult ED records were included for analysis. Of them, 180 patients sustained 1-month mortality. There were 1174 and 504 patients in the derivation and validation cohorts, respectively. Age, body mass index, chronic kidney disease, congestive heart failure, hepatitis, history of transplant, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, and national early warning score were included in the CoV-ED-PMI. The model was validated with good discriminative performance (AUC: 0.83, 95% confidence interval [CI]: 0.79-0.87), which was significantly better than the CURB-65 (AUC: 0.74, 95% CI: 0.69-0.79, p-value: < 0.001). The CoV-ED-PMI had a good predictive performance for 1-month mortality in COVID-19 patients with suspected pneumonia presenting at ED. This free tool is accessible online, and could be useful for clinical decision-making in the ED.
Premature cognitive decline in specific domains found in young veterans with mTBI coincide with elder normative scores and advanced-age subjects with early-stage Parkinson's disease
PLoS One. 2021 Nov 17;16(11):e0258851. doi: 10.1371/journal.pone.0258851. eCollection 2021.
IMPORTANCE: Epidemiologists report a 56% increased risk of veterans with (+) mild traumatic brain injury (mTBI) developing Parkinson's disease (PD) within 12-years post-injury. The most relevant contributors to this high risk of PD in veterans (+) mTBI is unknown. As cognitive problems often precede PD diagnosis, identifying specific domains most involved with mTBI-related PD onset is critical.
OBJECTIVES: To discern which cognitive domains underlie the mTBI-PD risk relationship proposed in epidemiology studies.
DESIGN AND SETTING: This exploratory match-controlled, cross-sectional study was conducted in a medical school laboratory from 2017-2020.
PARTICIPANTS: Age- and IQ-matched veterans with (+) and without mTBI, non-veteran healthy controls, and IQ-matched non-demented early-stage PD were compared. Chronic neurological, unremitted/debilitating diseases, disorders, dementia, and substance use among others were excluded.
EXPOSURE: Veterans were or were not exposed to non-penetrating combat-related mTBI occurring within the past 7-years. No other groups had recent military service or mTBI.
MAIN OUTCOMES / MEASURES: Cognitive flexibility, attention, memory, visuospatial ability, and verbal fluency were examined with well-known standardized neuropsychological assessments.
RESULTS: Out of 200 volunteers, 114 provided evaluable data. Groups significantly differed on cognitive tests [F (21,299) = 3.09, p<0.0001]. Post hoc tests showed veterans (+) mTBI performed significantly worse than matched-control groups on four out of eight cognitive tests (range: p = .009 to .049), and more often than not performed comparably to early-stage PD (range: p = .749 to .140).
CONCLUSIONS AND RELEVANCE: We found subtle, premature cognitive decline occurring in very specific cognitive domains in veterans (+) mTBI that would typically be overlooked in a clinic setting, This result potentially puts them at-risk for continual cognitive decline that may portend to the eventual onset of PD or some other neurodegenerative disease.
Dermatol Surg. 2021 Nov 8. doi: 10.1097/DSS.0000000000003273. Online ahead of print.
BACKGROUND: The infraorbital cheek is a common location for cutaneous malignancy and thus surgical defects. Reconstruction in this region must maintain nearby free margins to ensure optimal cosmetic and functional outcomes. Large defects may require a flap using lateral or inferior tissue reservoirs.
OBJECTIVE: To examine outcomes of inferiorly based rotation flaps in the repair of infraorbital cheek defects and highlight pearls for optimal long-term results.
METHODS: Chart review of patients with a defect of the infraorbital cheek repaired with an inferiorly based rotation flap between February 2010 and December 2018 at a single academic institution. The Visual Analog Scale (VAS) was used for scar assessment.
RESULTS: Sixty-five patients underwent extirpation of a cutaneous malignancy resulting in defects ranging from 1.0 × 1.0 to 4.5 × 5.5 cm (mean area = 4.8 cm2). Most of the patients did not experience complications. Ectropion occurred in 7 patients. The mean VAS score was 11.6.
CONCLUSION: An inferiorly based rotation flap yields acceptable outcomes for infraorbital cheek defects and can be considered for defects as large as 5.5 cm. Using pearls for surgical execution presented in this article may allow reconstructive surgeons to include this flap in their repertoire.
Factors That Affect Patient Attrition in Buprenorphine Treatment for Opioid Use Disorder: A Retrospective Real-World Study Using Electronic Health Records
Neuropsychiatr Dis Treat. 2021 Oct 28;17:3229-3244. doi: 10.2147/NDT.S331442. eCollection 2021.
PURPOSE: To describe attrition patterns of opioid use disorder (OUD) patients treated with buprenorphine (BUP) and to assess how clinical, sociodemographic, or BUP medication dosing features are associated with attrition.
PATIENTS AND METHODS: Electronic health records of adults (16+ year-olds) with OUD treated with BUP from 23 different substance use or mental health care programs across 11 US states were examined for one year following BUP initiation in inpatient (IP), intensive outpatient (IOP), or outpatient (OP) settings. Treatment attrition was declared at >37 days following the last recorded visit. Survival analyses and predictive modelling were used.
RESULTS: Retention was consistently 2-3 times higher following BUP initiation in OP (n = 2409) than in IP/IOP (n = 2749) settings after 2 (50% vs 25%), 6 (27% vs 9%) and 12 months (14% vs 4%). Retention was higher for females, whites (vs blacks), and those with less severe OUD, better global function, or not using non-psychotropic medications. Comorbid substance use, other psychiatric disorders, and the number of psychotropic medications were variously related to retention depending on the setting in which BUP was initiated. Predictive modelling revealed that a higher global assessment of functioning and a smaller OUD severity based on the Clinical Global Impression - Severity led to longer retentions, a higher initial BUP dose led to higher retention in a few cases, an OP setting of BUP initiation led to longer retentions, and a lower total number of psychotropic and non-psychotropic medications led to longer retentions. These were the most important parameters in the model, which identified 75.2% of patients who left BUP treatment within three months post-initiation, with a precision of 90.5%.
CONCLUSION: Of all the OUD patients who began BUP, 50-75% left treatment within three months, and most could be accurately identified. This could facilitate patient-centered management to better retain OUD patients in BUP treatment.
Proc (Bayl Univ Med Cent). 2021 Jun 15;34(6):736-738. doi: 10.1080/08998280.2021.1935140. eCollection 2021.
Tissue adhesives are commonly used for skin closure in both surgical and nonsurgical specialties. Although they are very well tolerated, tissue adhesives can induce a localized allergic response in 0.5% to 14% of patients. Allergic response can result in wound dehiscence, patient discomfort, increased healing time, and suboptimal esthetic results. We present two cases of allergic reaction to anterior neck incisions following topical application of tissue adhesives. The patients were managed with local wound care, steroid administration, and one with subsequent revision surgery. Clinicians who routinely use tissue adhesives should understand the incidence, risk factors, and management of allergic reaction to these products.
Real-world performance of blood-based proteomic profiling in first-line immunotherapy treatment in advanced stage non-small cell lung cancer
J Immunother Cancer. 2021 Oct;9(10):e002989. doi: 10.1136/jitc-2021-002989.
PURPOSE: Immune checkpoint inhibition (ICI) therapy has improved patient outcomes in advanced non-small cell lung cancer (NSCLC), but better biomarkers are needed. A clinically validated, blood-based proteomic test, or host immune classifier (HIC), was assessed for its ability to predict ICI therapy outcomes in this real-world, prospectively designed, observational study.
MATERIALS AND METHODS: The prospectively designed, observational registry study INSIGHT (Clinical Effectiveness Assessment of VeriStrat® Testing and Validation of Immunotherapy Tests in NSCLC Subjects) (NCT03289780) includes 35 US sites having enrolled over 3570 NSCLC patients at any stage and line of therapy. After enrolment and prior to therapy initiation, all patients are tested and designated HIC-Hot (HIC-H) or HIC-Cold (HIC-C). A prespecified interim analysis was performed after 1-year follow-up with the first 2000 enrolled patients. We report the overall survival (OS) of patients with advanced stage (IIIB and IV) NSCLC treated in the first-line (ICI-containing therapies n=284; all first-line therapies n=877), by treatment type and in HIC-defined subgroups.
RESULTS: OS for HIC-H patients was longer than OS for HIC-C patients across treatment regimens, including ICI. For patients treated with all ICI regimens, median OS was not reached (95% CI 15.4 to undefined months) for HIC-H (n=196) vs 5.0 months (95% CI 2.9 to 6.4) for HIC-C patients (n=88); HR=0.38 (95% CI 0.27 to 0.53), p<0.0001. For ICI monotherapy, OS was 16.8 vs 2.8 months (HR=0.36 (95% CI 0.22 to 0.58), p<0.0001) and for ICI with chemotherapy OS was unreached vs 6.4 months (HR=0.41 (95% CI 0.26 to 0.67), p=0.0003). HIC results were independent of programmed death ligand 1 (PD-L1). In a subgroup with PD-L1 ≥50% and performance status 0-1, HIC stratified survival significantly for ICI monotherapy but not ICI with chemotherapy.
CONCLUSION: Blood-based HIC proteomic testing provides clinically meaningful information for immunotherapy treatment decision in NSCLC independent of PD-L1. The data suggest that HIC-C patients should not be treated with ICI alone regardless of their PD-L1 expression.
J Am Coll Emerg Physicians Open. 2021 Oct 12;2(5):e12558. doi: 10.1002/emp2.12558. eCollection 2021 Oct.
OBJECTIVE: Patients with labor and sex trafficking experiences seek healthcare while and after being trafficked. Their trafficking experiences are often unrecognized by clinicians who lack a validated tool to systematically screen for trafficking. We aimed to derive and validate a brief, comprehensive trafficking screening tool for use in healthcare settings.
METHODS: Patients were randomly selected to participate in this prospective study based on time of arrival. Data collectors administered 5 dichotomous index questions and a reference standard trafficking assessment tool that requires 30 to 60 minutes to administer. Data collection was from June 2016 to January 2021. Data from patients in 5 New York City (NYC) emergency departments (EDs) were used for tool psychometric derivation, and data from patients in a Fort Worth ED were used for external validation. Clinically stable ED adults (aged ≥18 years) were eligible to participate. Candidate questions were selected from the Trafficking Victim Identification Tool (TVIT). The study outcome measurement was a determination of a participant having a lifetime experience of labor and/or sex trafficking based on the interpretation of the reference standard interview, the TVIT.
RESULTS: Overall, 4127 ED patients were enrolled. In the derivation group, the reference standard identified 36 (1.1%) as positive for a labor and/or sex trafficking experience. In the validation group, 12 (1.4%) were positive by the reference standard. Rapid Appraisal for Trafficking (RAFT) is a new 4-item trafficking screening tool: in the derivation group, RAFT was 89% sensitive (95% confidence interval [CI], 79%-99%) and 74% specific (95% CI, 73%-76%) and in the external validation group, RAFT was 100% sensitive (95% CI, 100%-100%) and 61% specific (95% CI, 56%-65%).
CONCLUSIONS: The rapid, 4-item RAFT screening tool demonstrated good sensitivity compared with the existing, resource-intensive reference standard tool. RAFT may enhance the detection of human trafficking in EDs. Additional multicenter studies and research on RAFT's implementation are needed.
Cureus. 2021 Sep 8;13(9):e17820. doi: 10.7759/cureus.17820. eCollection 2021 Sep.
Killian-Jamieson diverticulum (KJD) is a rare presentation of esophageal diverticulum. It is located beneath the cricopharyngeal muscle and arises laterally from the Killian-Jamieson space. The pathogenesis is postulated to be from increased intraluminal pressure. Most patients with KJD are typically asymptomatic; however, a common clinical presentation is dysphagia. Demographics of patients with KJD are typically elderly, in which the majority are female and over 50 years old. Due to less frequent diagnosis of KJD, there are a limited number of case studies compared to Zenker's diverticulum, the more common presentation of esophageal diverticulum. In this case study, we discuss an atypical case presentation in a young, African-American female.
J Oral Maxillofac Surg. 2021 Sep 30:S0278-2391(21)01126-5. doi: 10.1016/j.joms.2021.09.016. Online ahead of print.
PURPOSE: The SARS-CoV-2 global pandemic has resulted in widespread changes to healthcare practices across the United States. The purpose of this study is to examine the incidence of COVID-19 patients in the oral-maxillofacial surgery setting in order to help guide perioperative protocols during the pandemic.
METHODS: In this retrospective cohort study, predictor variables (presence of preoperative symptoms on presentation, patient age, patient gender, patient race, hospital location, and presence of statewide stay-at-home orders) were examined with outcome variables (SARS-CoV-2 test results) over 10 months between March 2020 and December 2020 for patients undergoing surgical procedures in the operating room by the following Oral-Maxillofacial Surgery Departments: - Louisiana State University Health Sciences Center (Baton Rouge, LA) - University of Illinois at Chicago (Chicago, IL) - University of Texas Health Science Center at Houston (Houston, TX) Data analysis included Fisher exact tests to compare categorical variables across COVID test groups and Wilcoxon rank sum tests to compare continuous covariates. Two-sample tests of proportions were used to compare observed COVID-19 positivity rates to other study results.
RESULTS: Out of 684 patients in 3 institutions, 17 patients (2.5%, 95% CI = 1.5 to 4.0%) tested positive for COVID-19 over a 10 month interval (March 1, 2020- December 31, 2020). The majority of patients that tested positive were asymptomatic in the preoperative setting (P-value = .09). They were significantly more likely to be African-American (P-value = .015) and less likely to have a stay-at-home order present at the time of surgery (P-value = .033). Age, gender, and hospital location did not play a statistically significant role.
CONCLUSION: Our results demonstrate a 2.5% incidence of COVID-19 infection in the total population of patients undergoing scheduled oral-maxillofacial surgeries in 3 major healthcare systems across the United States. This data may help inform perioperative protocols and infection control measures during the COVID-19 pandemic.
The Association of Mobile Health Applications with Self-Management Behaviors among Adults with Chronic Conditions in the United States
Int J Environ Res Public Health. 2021 Sep 30;18(19):10351. doi: 10.3390/ijerph181910351.
BACKGROUND: Mobile applications related to health and wellness (mHealth apps) are widely used to self-manage chronic conditions. However, research on whether mHealth apps facilitate self-management behaviors of individuals with chronic conditions is sparse. We aimed to evaluate the association of mHealth apps with different types of self-management behaviors among patients with chronic diseases in the United States.
METHODS: This is a cross-sectional observational study. We used data from adult participants (unweighted n = 2340) of the Health Information National Trends Survey in 2018 and 2019. We identified three self-management behaviors: (1) resource utilization using electronic personal health records; (2) treatment discussions with healthcare providers; and (3) making healthcare decisions. We analyzed the association of mHealth apps to self-management behaviors with multivariable logistic and ordinal regressions.
RESULTS: Overall, 59.8% of adults (unweighted number = 1327) used mHealth apps. Adults using mHealth apps were more likely to use personal health records (AOR = 3.11, 95% CI 2.26-4.28), contact healthcare providers using technology (AOR = 2.70, 95% CI 1.93-3.78), and make decisions on chronic disease management (AOR = 2.59, 95% CI 1.93-3.49). The mHealth apps were associated with higher levels of self-management involvement (AOR = 3.53, 95% CI 2.63-4.72).
CONCLUSION: Among individuals with chronic conditions, having mHealth apps was associated with positive self-management behaviors.
J Am Coll Emerg Physicians Open. 2021 Oct 1;2(5):e12569. doi: 10.1002/emp2.12569. eCollection 2021 Oct.
Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.
Impact of prognostic factor distributions on mortality disparities for socioeconomically disadvantaged cancer patients
Ann Epidemiol. 2021 Sep 30:S1047-2797(21)00306-9. doi: 10.1016/j.annepidem.2021.09.014. Online ahead of print.
PURPOSE: We aimed to assess whether differences in the distributions of prognostic factors explain reported mortality disparities between urban safety-net and SEER cancer populations.
METHODS: We used data from SEER and a safety-net cancer center in Texas. Eligible patients were adults aged ≤64 years and diagnosed with first primary female breast, colorectal, or lung cancer between 2008 and 2016. We estimated crude and adjusted risk differences (RD) in 3- and 5-year all-cause mortality (1- and 3-year for lung cancer), where adjustment was based on entropy balancing weights that standardized the distribution of sociodemographic and tumor characteristics between the two populations.
RESULTS: Our study populations comprised 1,914 safety-net patients and 389,709 SEER patients. For breast cancer, the crude 3- and 5-year mortality RDs between safety-net and SEER populations were 7.7% (95% CL: 4.3%, 11%) and 11% (95% CL: 6.7%, 16%). Adjustment for measured prognostic factors reduced the mortality RDs (3-year adjusted RD=0.049%, 95% CL: -2.6%, 2.6%; 5-year adjusted RD=5.6%, 95% CL: -0.83%, 12%). We observed similar patterns for colorectal and lung cancer albeit less magnitude.
CONCLUSIONS: Sociodemographic and tumor characteristics may largely explain early mortality disparities between safety-net and SEER populations, but not late mortality disparities.
Evaluating the Cost-effectiveness of Prehospital Plasma Transfusion in Unstable Trauma Patients: A Secondary Analysis of the PAMPer Trial
JAMA Surg. 2021 Sep 22. doi: 10.1001/jamasurg.2021.4529. Online ahead of print.
IMPORTANCE: Prehospital plasma transfusion is lifesaving for trauma patients in hemorrhagic shock but is not commonly used owing to cost and feasibility concerns.
OBJECTIVE: To evaluate the cost-effectiveness of prehospital thawed plasma transfusion in trauma patients with hemorrhagic shock during air medical transport.
DESIGN, SETTING, AND PARTICIPANTS: A decision tree and Markov model were created to compare standard care and prehospital thawed plasma transfusion using published and unpublished patient-level data from the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial conducted from May 2014 to October 2017, health care and trauma-specific databases, and the published literature. Prehospital transfusion, short-term inpatient care, and lifetime health care costs and quality of life outcomes were included. One-way, 2-way, and Monte Carlo probabilistic sensitivity analyses were performed across clinically plausible ranges. Data were analyzed in December 2019.
MAIN OUTCOMES AND MEASURES: Relative costs and health-related quality of life were evaluated by an incremental cost-effectiveness ratio at a standard willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY).
RESULTS: The trial included 501 patients in the modified intention-to-treat cohort. Median (interquartile range) age for patients in the thawed plasma and standard care cohorts were 44 (31-59) and 46 (28-60) years, respectively. Overall, 364 patients (72.7%) were male. Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care. The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37 735.19 per QALY. Thawed plasma was preferred in 8140 of 10 000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma.
CONCLUSIONS AND RELEVANCE: In this study, prehospital thawed plasma transfusion during air medical transport for trauma patients in hemorrhagic shock was lifesaving and cost-effective compared with standard care and should become commonplace.