Showing papers by "Atlantic Health System published in 2015"

Right Ventricular Function in Preterm and Term Neonates: Reference Values for Right Ventricle Areas and Fractional Area of Change

Abstract: Background Right ventricular (RV) fractional area of change (FAC) is a quantitative two-dimensional echocardiographic measurement of RV function. RV FAC expresses the percentage change in the RV chamber area between end-diastole (RV end-diastolic area [RVEDA]) to end-systole (RV end-systolic area [RVESA]). The objectives of this study were to determine the maturational (age- and weight-related) changes in RV FAC and RV areas and to establish reference values in healthy preterm and term neonates. Methods A prospective longitudinal study was conducted in 115 preterm infants (23–28 weeks' gestational age at birth, 500–1,500 g). RV FAC was measured at 24 hours of age, 72 hours of age, and 32 and 36 weeks' postmenstrual age (PMA). The maturational patterns of RVEDA, RVESA, and RV FAC were compared with those in 60 healthy full-term infants in a cross-sectional study (≥37 weeks, 3.5 ± 1 kg), who underwent echocardiography at birth ( n = 25) and 1 month of age ( n = 35). RVEDA and RVESA were traced in the RV-focused apical four-chamber view, and FAC was calculated using the formula 100 × [(RVEDA − RVESA)/RVEDA)]. Premature infants who developed chronic lung disease or had clinically and hemodynamically significant patent ductus arteriosus were excluded ( n = 55) from the reference values. Intra- and interobserver reproducibility analysis was performed. Results RV FAC ranged from 26% at birth to 35% by 36 weeks' PMA in preterm infants ( n = 60) and increased almost 2 times faster in the first month of age compared with healthy term infants ( n = 60). Similarly, RVEDA and RVESA increased throughout maturation in both term and preterm infants. RV FAC and RV areas were correlated with weight ( r = 0.81, P r = 0.3, P = .45). RVEDA and RVESA were correlated with PMA in weeks ( r = 0.81, P P = .04) but was not correlated with size of patent ductus arteriosus ( P = .56). There was no difference in RV FAC based on gender or need for mechanical ventilation. Conclusions This study establishes reference values of RV areas (RVEDA and RVESA) and RV FAC in healthy term and preterm infants and tracks their maturational changes during postnatal development. These measures increase from birth to 36 weeks' PMA, and this is reflective of the postnatal cardiac growth as a contributor to the maturation of cardiac function These measures are also linearly associated with increasing weight throughout maturation. This study suggests that two-dimensional RV FAC can be used as a complementary modality to assess global RV systolic function in neonates and facilitates its incorporation into clinical pediatric and neonatal guidelines.

A multicenter, prospective trial to evaluate mesh-augmented sacrospinous hysteropexy for uterovaginal prolapse

Abstract: Introduction and hypothesis Hysterectomy is often part of pelvic organ prolapse repair. However, this may offer no benefit when compared to uterine preservation. We aimed to prospectively evaluate a minimally invasive bilateral sacrospinous hysteropexy using polypropylene mesh. We hypothesized that anatomic success and patient satisfaction can be achieved with this technique.

Prothrombin Time and Activated Partial Thromboplastin Time Testing: A Comparative Effectiveness Study in a Million-Patient Sample.

Abstract: Background A substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful. Methods and Findings We evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1, 053, 472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682, 049 patients (64.7%) had one or both tests done and history and physical (HPor aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing. Conclusions This study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.

Evaluation of the American-English Quality of Life in Short Stature Youth (QoLISSY) questionnaire in the United States

Abstract: The European Quality of Life in Short Stature Youth (QoLISSY) is a novel condition-specific instrument developed to assess health related quality of life (HrQoL) in children/adolescents with short stature from patient and parent perspectives. Study objective was to linguistically validate and psychometrically test the American-English version of the QoLISSY instrument. Upon conversion of the British-English version to American-English, content validity and acceptance of the questionnaire were examined through focus group discussions with cognitive debriefing in 28 children/adolescents with growth hormone deficiency (GHD) or idiopathic short stature (ISS) and their parents. In the subsequent field test with 51 families and a re-test with 25 families the psychometric performance of the American-English version was examined and compared with the original European dataset. Pilot test results supported the suitability of the American-English version. Good internal consistency with Cronbach’s Alpha ranging from 0.84 to 0.97 and high test-re-test reliabilities were observed in the field test. The QoLISSY was able to detect significant differences according to the degree of short stature with higher HrQoL for taller children. Correlations with a generic HrQoL tool support the QoLISSY’s concurrent validity. The scale’s operating characteristics were comparable to the original European data. Results support that the QoLISSY American-English version is a psychometrically sound short stature-specific instrument to assess the patient- and parent- perceived impact of short stature. The QoLISSY instrument is fit for use in clinical studies and health services research in the American-English speaking population.

Outcomes of patients implanted with a left ventricular assist device at nontransplant mechanical circulatory support centers.

Abstract: The goal of this study was to assess outcomes of patients who underwent implantation of left ventricular assist devices (LVADs) at nontransplantation mechanical circulatory support centers. As the availability of LVADs for advanced heart failure has expanded to nontransplantation mechanical circulatory support centers, concerns have been expressed about maintaining good outcomes. Demographics and outcomes were evaluated in 276 patients with advanced heart failure who underwent implantation of LVADs as bridge to transplantation or destination therapy at 27 open-heart centers. Baseline characteristics, operative mortality, length of stay, readmission rate, adverse events, quality of life, and survival were analyzed. The overall 30-day mortality was 3% (8 of 276), and survival rates at 6, 12, and 24 months, respectively, were 92 ± 2%, 88 ± 3%, and 84 ± 4% for the bridge-to-transplantation group and 81 ± 3%, 70 ± 5%, and 63 ± 6% for the destination therapy group, comparable with results published by the national Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The median length of stay for all patients was 21 days. Bleeding was the most frequent adverse event. Stroke occurred in 4% (bridge to transplantation) and 6% (destination therapy) of patients. Quality-of-life measures and 6-minute walk distances showed sustained improvements throughout support. In conclusion, outcomes with LVAD support at open-heart centers are acceptable and comparable with results from the INTERMACS registry. With appropriate teams, training, center commitment, and certification, LVAD therapy is being disseminated in a responsible way to open-heart centers.

Traumatic brain injuries and computed tomography use in pediatric sports participants.

Abstract: Background Childhood sports-related head trauma is common, frequently leading to emergency department (ED) visits. We describe the spectrum of these injuries and trends in computed tomography (CT) use in the Pediatric Emergency Care Applied Research Network. Methods This was a secondary analysis of a large prospective cohort of children with head trauma in 25 Pediatric Emergency Care Applied Research Network EDs between 2004 and 2006. We described and compared children 5 to 18 years old by CT rate, traumatic brain injury (TBI) on CT, and clinically important TBI (ciTBI). We used multi-variable logistic regression to compare CT rates, adjusting for clinical severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by [ a ] death, [ b ] neurosurgery, [ c ] intubation >24 hours, or [ d ] hospitalization for ≥2 nights). Findings A total of 3289 (14%) of 23082 children had sports-related head trauma. Two percent had Glasgow Coma Scale scores less than 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had ciTBIs. Equestrians had increased adjusted odds (1.8; 95% confidence interval [CI], 1.0-3.0]) of CTs; the rate of TBI on CT was 4% (95% CI, 3%-5%). Compared with team sports, snow (adjusted odds ratio, 4.1; 95% CI 1.5-11.4) and nonmotorized wheeled (adjusted odds ratio, 12.8; 95% CI, 5.5-32.4) sports had increased adjusted odds of ciTBIs. Conclusions Children with sports-related head trauma commonly undergo CT. Only 4% of those imaged had TBIs on CT. Clinically important TBIs occurred in 1%, with significant variation by sport. There is an opportunity for injury prevention efforts in high-risk sports and opportunities to reduce CT use in general by use of evidence-based prediction rules. What is known about this subject: Pediatric sports-related head injuries are a common and increasingly frequent ED presentation, as is the use of CT in their evaluation. Little is known about TBIs resulting from different types of sports activities in children. What this study adds to existing knowledge: This study broadens the understanding of the epidemiology of Pediatric TBIs resulting from different sports activities through a prospective assessment of frequency and severity of ciTBIs and ED CT use in a large cohort of head-injured children in a network of pediatric EDs.

Tai Chi in Parkinson’s Disease: A Preliminary Randomized, Controlled, and Rater-Blinded Study

Abstract: Background: Given the limited benefits of current treatments for Parkinson’s disease (PD), inter-ventions that might provide supplementary benefits would be of value. The traditional Chinese medicine practice of Tai Chi has been said to improve some aspects of PD, particularly imbalance. Methods: Preliminary randomized, controlled, and rater-blinded clinical trial of Tai Chi, focusing on its effects on global motor, daily function, mood and quality of life. Subjects continued their standard medical therapy and were randomly assigned to Tai Chi (16 weekly classes, expert trainer, practice at home between classes) or no Tai Chi (control group) in a 2:1 ratio. The primary outcome measure was the total motor score of the Unified Parkinson’s Disease Rating Scale (UPDRS) and this was scored by an experienced rater who was blinded to the treatment assignment. The same rater scored the Schwab and England Activities of Daily Living Scale. The patient-completed Geriatric Depression Scale, PD (quality of life) Questionnaire-39, and fall diary were also analyzed. Results: 44 subjects participated with 29 assigned to Tai Chi and 15 serving as controls. Tai Chi was well-tolerated. Seven subjects withdrew prior to completion (2 from Tai Chi, 5 from control). We found no significant difference between treatment groups in the change in scores from baseline to end of intervention for any of the scales. Trends toward a benefit of Tai Chi were observed for individual UPDRS items (depression, finger tapping, hand movements, posture). Conclusions: Tai Chi does not appear to improve global measures in patients with PD. The practice may have benefits for PD, but these appear to be largely restricted to specific motor tasks and perhaps mood rather than being a global functional response. More study is needed to clarify and establish efficacy.

Natural history of incidental pulmonary nodules in children

Abstract: SummaryRATIONALE As there are no evidence based guidelines for the diagnosis and/or management of pulmonary nodules in children, there is an over reliance on the adult based algorithms when dealing with pulmonary nodules in children. We present our experience of pediatric patients evaluated for incidentally found pulmonary nodules. METHODS Retrospective chart review of patients diagnosed with a pulmonary nodule and evaluated at Goryeb Children's Hospital between January 2000 and December 2012. Primary outcome: change in the size of the pulmonary nodule between the initial and follow-up imaging. RESULTS Thirty six patients with pulmonary nodule (21 male/15 female; Median [range] age 15 [5–20] years.) were included in the study. Chest CT was obtained for respiratory symptoms and/or abnormal chest radiograph in 19 (52%). Nine pulmonary nodules (25%) were identified on abdominal CT obtained for abdominal symptoms. A total of 46 nodules were identified in 36 patients. Nine of the pulmonary nodules (9 patients) were ≤4 mm in size, 37 of the pulmonary nodules (27 patients) were >4 mm in size. Twenty-two of the 27 (81%) patients with nodule size >4 mm had follow-up CT: 14 nodules (54%) remained unchanged in size, 5 nodules (19%) decreased in size, and 7 nodules (27%) were not detected. CONCLUSION Our review of 36 patients with pulmonary nodules shows no obvious growth of the nodules over the study period, suggesting low risk of malignancy. Routine follow-up chest computer tomography using ACCP/Fleischner Society guidelines may not apply in children without known malignancy. Pediatr Pulmonol. 2015; 50:456–459. © 2014 Wiley Periodicals, Inc.

Recent Advances in Understanding and Managing Autism Spectrum Disorders.

Abstract: Autism spectrum disorder in children is a group of neurodevelopmental disorders characterized by difficulties with social communication and behavior. Growing scientific evidence in addition to clinical practice has led the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to categorize several disorders into the broader category of autism spectrum disorder. As more is learned about how autism spectrum disorder manifests, progress has been made toward better clinical management including earlier diagnosis, care, and when specific interventions are required. The 2014 Neurobiology of Disease in Children symposium, held in conjunction with the 43rd annual meeting of the Child Neurology Society, aimed to (1) describe the clinical concerns involving diagnosis and treatment, (2) review the current status of understanding in the pathogenesis of autism spectrum disorder, (3) discuss clinical management and therapies for autism spectrum disorder, and (4) define future directions of research. The article summarizes the presentations and includes an edited transcript of question-and-answer sessions.

Human Papilloma Virus (HPV) Infection and Non-Cervical Oncogenic DiseaseStates

Abstract: Human papillomavirus (HPV) infection is causative for cervical cancer and has been implicated in cancers at other sites. We review the English language literature in regard to the epidemiology of HPV infection as a risk for non-cervical cancer with a focus on the molecular evidence to support HPV having an etiologic role at each anatomic site. HPV DNA is detected in and/or serology provides evidence that HPV is associated with 35-50% of penile cancers, 80-95% of anal cancers, and ~35% of oropharyngeal cancers. HPV has also been implicated for cancer of the larynx, esophagus, lung, and urinary bladder with varying levels of linkage. Molecular studies at the respective anatomic sites provide evidence of HPV integration, E6 and E7 oncogene expression coupled with tumor suppressor down-regulation consistent with a role in the pathogenesis of tumor formation. HPV-associated cancer may represent a distinct disease entity relative to non HPV-associated cancers based upon natural history and outcome studies. Thus, the disease burden of HPV associated non-cervical cancers may be significant and justifies a comprehensive investigation of the utility of global prophylactic vaccination strategies.

Autism Spectrum Disorders Current Understanding and Future Directions

Abstract: Autism spectrum disorders was chosen as the topic for the 14th Neurobiology of Disease in Children Symposium, held on October 22-23, 2014, in Columbus, Ohio. Program codirectors Drs Stewart Mostofsky, Manny DiCicco-Bloom, and Deborah Hirtz prepared an engaging agenda that included individual presentations as well as a panel discussion from leaders working to advance the autism field. The symposium covered a variety of topics, such as clinical features, recent advances in understanding the pathogenesis of autism spectrum disorder, and new investigations of characteristic symptoms and behaviors categorized under the broad ‘‘spectrum’’ of autism. This was followed by a session on controversial topics and unanswered questions. The symposium concluded with a panel discussion led by scientific leaders in the field of autism spectrum disorders. Dr Sarah Spence opened the symposium with an introduction to autism, including changes to and advances in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Dr Spence explained how the DSM-5 criteria may provide clinicians with better diagnostic tools to properly diagnose certain symptoms, behaviors, and disabilities associated with autism spectrum disorder. Dr Craig Newschaffer then discussed the epidemiology of the disorder, addressing its rising prevalence in addition to genetic and environmental risk factors. Dr Lonnie Zwaigenbaum’s discussion stressed the importance of identifying early behavioral and neurological characteristics of autism spectrum disorder. In addition, he focused on the significance of early diagnosis and recent advances in early intervention. To conclude the first session, Dr Roberto Tuchman discussed the relationship between autism spectrum disorder and epilepsy, concentrating on the impact and shared mechanisms of both disorders. The next session of the symposium focused on recent progress in understanding the molecular mechanisms underlying different types of autism spectrum disorder. Dr Jonathan Sebat discussed the genetics of autism, summarizing studies of rare genetic variation, copy number variants, and exome sequencing, and new discoveries from comprehensive analysis of de novo mutations in autism. Dr Sebat described his work to identify copy number variation in the human genome as an important contributor to human disease. He also emphasized the genetic and hereditary factors contributing to various types of autism. Recently, Dr Sebat and his colleagues attempted to sequence the entire human genome in an effort to characterize patterns of mutation in both coding and noncoding regions of the genome. Dr Tim Roberts addressed the significance of biomarkers in autism, which can be used for diagnostic and prognostic purposes, in order to understand experimental models and to monitor response to therapy. Dr Roberts reviewed the application of magnetoencephalography for children with epilepsy or autism, discussing event-related potentials-type responses in auditory sensation and gamma-band activity. Dr Roberts also discussed his study of the motor cortex and concluded that g-aminobutyric (GABA) concentration predicted gamma band oscillation, in addition to GABA level variations observed in children with autism. To conclude the second session, Dr Cyndi Schumann focused on the current understanding of neuropathology and neurobiology of autism. Dr Schumann emphasized the importance of having brain tissue for autism research in order to make progress in the field. The third session of the symposium focused on translational and therapeutic targets in autism research. Dr Mustafa Sahin reviewed current translational work involving mice and human models with tuberous sclerosis complex. It is reported that about half of the patients who have tuberous sclerosis also might be affected by autism spectrum disorder. Therefore, his discussion was focused on the relationship between the mammalian target of rapamycin pathway and tuberous sclerosis complex, to test the role of tuberous sclerosis complex in autism. He also discussed studies in which the loss of 1 or both TSC1 and TSC2 genes resulted in disease. Dr Sahin and his colleagues conducted a study that focused on the non-tuber pathology of the brain in mice with tuberous sclerosis complex. His team demonstrated that miswiring the neural connectivity within the central nervous system had contributed to the pathogenesis of tuberous sclerosis. Last, Dr Sahin addressed the circuitry and localization of brain lesions and how these lesions might contribute to clinical abnormalities observed in patients.

Robotic sacrocolpopexy. A review.

Abstract: The aim of this article was to provide a contemporary reference source for robotic sacrocolpopexy. This article will discuss robotic sacrocolpopexy, in terms of its history, acceptance in modern medicine, indications, materials used, technique, outcomes, and complications. Research from our institution and others was summarized to provide a comprehensive review of robotic sacrocolpopexy. In conclusion, we found out that robotic sacrocolpopexy provides a minimally invasive approach to treatment of pelvic organ prolapse with excellent outcomes and low complication rates.

Serum and CSF Cytokines in Patients with Active CNS Lyme Disease, other Inflammatory CNS Diseases, Encephalopathy Following Treated Lyme Disease, other Encephalopathies, and Normal Controls (S37.007)

Abstract: Objective: To investigate the hypothesis that neurobehavioral symptoms occurring in some Lyme disease patients after treatment are not due to CNS infection/inflammation, but possibly to systemic inflammation. Background: The etiology of post-treatment symptoms in Lyme disease patients is unknown and neurobehavioral symptoms are often inaccurately attributed to CNS infection. Despite a lack of supporting evidence, symptomatic patients often receive repeated courses of antibiotics, which are ineffective. In the absence of ongoing infection, such symptoms could result from an abnormal immune response. Design/Methods: Using multiplex assays, we characterized the inflammatory profile in serum from patients with post-treatment symptoms ranging from headache to encephalopathy (n=64). Results were compared to those from patients with similar symptoms unrelated to Lyme disease (n=47), patients with active CNS infection (n=15), and healthy controls (n=50). Similar assays were conducted on CSF from a subset of these patients, and additional patients with non-Lyme neuroinflammation. Results: CSF pleocytosis and elevations in multiple cytokines and chemokines, including CXCL13, were found in patients with active CNS Lyme infection and other neuroinflammatory conditions, but not in patients with post-treatment symptoms. In serum, IL-7 levels were significantly elevated in patients with neurobehavioral symptoms following treatment for Lyme disease (4.24±0.83 pg/ml compared to 0.70±0.07 pg/ml in controls). IL-7 was similarly elevated in symptomatic patients with no history of Lyme disease. Compared to controls, symptomatic patients also had higher levels of IL-17A, IL-17F, and MIP-1alpha. Conclusions: Patients with neurobehavioral symptoms following treatment for Lyme disease do not show any evidence of nervous system infection or inflammation. Elevations in serum IL-7 and IL-17 in these patients may reflect T-cell dysregulation. Interestingly, such elevations were seen in symptomatic patients regardless of prior Lyme disease exposure. These results warrant further investigation, as IL-7 may represent a useful biomarker, and could lead to the identification of novel therapeutic targets. Disclosure: Dr. Halperin has received personal compensation in an editorial capacity for The Neurologist. Dr. Halperin holds stock and/or stock options in Abbott Labs, Bristol Myers Squib, Johnson & Johnson. Dr. Pacheco-Quinto has nothing to disclose. Dr. Herdt has nothing to disclose. Dr. Eckman has nothing to disclose.

Lighted polyhedral retractor

Abstract: The present invention provides a surgical retractor that provides improved access to a surgical space, devised in the shape of a partial polyhedron, and also provides improved visualization of the surgical space with light emitting elements placed within the polyhedron structure.

Aligning Community Hospitals with Local Public Health Departments: Collaborative Emergency Management

Abstract: This chapter reviews the current organizational relationships between public health departments, local community hospitals, and medical centers as they relate to emergency preparedness and management. To examine their collaborative role, an analysis of legislative statutes, Joint Commission compliance mandates, professional accreditation standards, NIMS task force recommendations, and eligibility criteria for federal grants was completed. The information gleaned from this process was then synthesized to offer suggestions for developing positive collaboration outcomes. Reports from the three example stakeholder organizations suggest that positive changes in the level of community relationships have occurred. Continued maturation of emergency preparedness advisory boards, task forces, and coalitions also appear to have strengthened collaboration between the public and private agencies. To further encourage a systems model of collaboration, two strategies based on coalition capacity building are recommended. Leveraging gains made in community relationships over the past few years will continue to strengthen and improve emergency preparedness and management collaborations.