[Show abstract][Hide abstract] ABSTRACT: Background:
The adoption of breast brachytherapy into clinical practice for early-stage breast cancer has increased over the last several years. Studies evaluating complication rates following treatment with brachytherapy have shown conflicting results. We compared local toxicity in patients treated with brachytherapy with those treated with whole-breast irradiation (WBI).
We identified 417 early-stage breast cancer patients treated with breast-conserving surgery and radiation between 2004 and 2010, and compared 271 women treated with intracavitary brachytherapy with 146 women treated with WBI. Long-term complications were assessed using Kaplan-Meier curves with the log-rank test.
Median follow-up was 4.6 years, and the 5-year incidence of infectious skin complications (9.7 vs. 11.0 %, p = 0.84), abscess (1.1 vs. 0 %, p = 0.15), telangiectasia (8.0 vs. 5.3 %, p = 0.35), and breast pain (14.2 vs. 9.4 %, p = 0.2) was similar between the brachytherapy and WBI cohorts. The brachytherapy cohort had a higher 5-year rate of seroma (46.5 vs. 18.5 %, p < 0.001), and fat necrosis (39.5 vs. 24.4 %, p < 0.001). Brachytherapy patients trended towards more frequent biopsies as a result of fat necrosis to rule out a recurrence (11.2 vs. 6.7 %, p = 0.13).
Patients treated with intracavitary brachytherapy had more local toxicity, particularly seroma and fat necrosis. Patients should be counseled on the possible increased rate of long-term complications associated with brachytherapy treatment.
[Show abstract][Hide abstract] ABSTRACT: Objective
To analyze satisfaction with health care among African American women living with HIV/AIDS.DesignSecondary analysis of baseline data of African American women who participated in Protect and Respect, a sexual risk reduction program for women living with HIV/AIDSSettingHIV Care Clinic in an urban city in the northeast United States.ParticipantsOne hundred fifty-seven (157) African American women living with HIV/AIDS.Methods
Regression analyses were used to examine the relationships between demographic variables, self-reported health characteristics, communication with health care providers, and satisfaction with health care provider.ResultsA majority of women reported satisfaction with medical services (88%, n = 140). Communication with health care providers, detectable viral load, education, income, self-reported health status, and sexual orientation were significantly bivariately associated with satisfaction with healthcare (all ps < .05). In the multivariate models, no variables significantly predicted satisfaction with healthcare.Conclusion
Because satisfaction with health care can influence the quality of care received, health outcomes, and adherence to provider recommendations among patients living with HIV/AIDS, health care providers’ ability to elicit satisfaction from their patients is just as important as the services they provide. This project is one of the first studies to find high rates of satisfaction with health care among African American women living with HIV/AIDS. Further examination of satisfaction with health care among African American women living HIV/AIDS may help in narrowing health care disparities and negative treatment outcomes.
[Show abstract][Hide abstract] ABSTRACT: The NoTouch BreastScan (NTBS) is a non-invasive infrared imaging device which measures thermal gradients in breasts using dual infrared cameras and computer analysis. We evaluated NTBS as a predictor of breast cancer in patients undergoing minimally invasive biopsy. In this IRB-approved prospective trial, 121 female patients underwent NTBS prior to scheduled tissue biopsy. Twenty-two patients were excluded due to uninterpretable scans (n = 18), diagnosis of a nonprimary breast malignancy (n = 1), or no biopsy performed (n = 3) for a total of 99 patients. Five patients had bilateral breast biopsies and one patient had two ipsilateral biopsies, resulting in 105 biopsies. Patients were prospectively scanned using a high specificity mode, termed NTBS1. All 99 patients were retrospectively re-evaluated in a high sensitivity mode, NTBS2. Of 105 biopsies performed in 99 women, 33 (31.4%) were malignant and 72 (68.6%) were benign. NTBS1 demonstrated a sensitivity of 45.5% and a specificity of 88.9%. Of 94 normal contralateral breasts, 9.6% had a positive NTBS1. In the retrospective evaluation, NTBS2 demonstrated a sensitivity of 78.8% and a specificity of 48.6%. Half (50%) of the normal contralateral breasts had a positive NTBS2. NTBS does not accurately predict malignancy in women with suspicious imaging abnormalities. The higher sensitivity mode results in an unacceptable number of false positives, precluding its use. Infrared imaging did not improve the sensitivity or specificity of mammography in this clinical setting.
The Breast Journal 05/2014; 20(4). DOI:10.1111/tbj.12273 · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:
In America, children with disabilities and their families may receive early intervention (EI) services under the Individuals with Disabilities Education Improvement Act (IDEA). The IDEA mandates that decisions on service delivery are based on the needs of the child and family. It is unclear how decisions on intensity of services are made in EI. The purpose of this study was to determine whether parent participation and team support are determinants of the recommendation for intensity of service at the initial Individualized Family Service Planning (IFSP) meeting.
The participants were 63 parents of children 2-33 months of age and 74 professionals. The first author observed all IFSP meetings and completed the Parent Participation Measure. Following the meeting, parents completed a demographic form, the Ages and Stages Questionnaire, and the Family Needs Survey. The recommended intensity of service was recorded.
Results and conclusions:
Parent participation and team support were not significant determinants of intensity of EI service after controlling for child development and family needs (R2 = 0.145, p = .14). The recommended intensity of service was 240 min per month for 57% of the families suggesting that factors other than parent participation and team support influenced the decision on intensity of service.
[Show abstract][Hide abstract] ABSTRACT: Magnetic resonance imaging (MRI) use in the preoperative evaluation of newly diagnosed breast cancer (BC) patients is rising. We evaluated MRI as a function of surgical year with respect to mastectomy and contralateral prophylactic mastectomy (CPM) rates by a single surgeon. From January 2000 to December 2010, 1,279 patients with 1,296 breast cancers were identified. Our breast MRI was installed in April 2006. Mastectomy and CPM rates were evaluated by surgical year and stratified as "pre-MRI" or "MRI" depending on whether surgery occurred before or after April 2006. There was a significant increase in the percentage of patients undergoing MRI in the "pre-MRI" versus "MRI" era (17.2% versus 78.7%, p < 0.001). In contrast, mastectomy rates decreased with 29.9% undergoing mastectomy before 2006 versus 24.5% after 2006 (p = 0.038). Except for 2007, where CPM rates dropped to 7.1%, CPM rates increased from 16.7% in 2000 to 51.9% in 2010 (p = 0.033). The use of MRI, additional MRI findings and additional MRI biopsies were not associated with the decision for CPM. Age <50 was the only factor associated with CPM (RR = 2.12, p = 0.001). In our community hospital, mastectomy rates have decreased despite the increased use of preoperative MRI. MRI alone may not explain the increasing rates of mastectomy reported in other series. CPM rates have dramatically increased over time, seemingly independent of MRI use. Prospective studies are needed to assess the role of surgeon bias, along with other factors, in surgical decision making.
The Breast Journal 01/2014; 20(1):79-83. DOI:10.1111/tbj.12204 · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The American Society for Radiation Oncology (ASTRO) consensus statement (CS) provides guidelines for patient selection for accelerated partial breast irradiation (APBI) following breast conserving surgery. The purpose of this study was to evaluate recurrence rates based on ASTRO CS groupings. A single institution review of 238 early stage breast cancer patients treated with balloon-based APBI via balloon based brachytherapy demonstrated a 4-year actuarial ipsilateral breast tumor recurrence (IBTR) rate of 5.1%. There were no significant differences in the 4-year actuarial IBTR rates between the "suitable," "cautionary," and "unsuitable" ASTRO categories (0%, 7.2%, and 4.3%, resp., P = 0.28). ER negative tumors had higher rates of IBTR than ER positive tumors. The ASTRO groupings are poor predictors of patient outcomes. Further studies evaluating individual clinicopathologic features are needed to determine the safety of APBI in higher risk patients.
International Journal of Surgical Oncology 12/2013; 2013(5):829050. DOI:10.1155/2013/829050
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to identify determinants of self-determined behaviors of young children with cerebral palsy. The participants were 429 children (56% boys, 18-60 months) and their parents. Structural equation modeling was used to test two models of self-determined behaviors, one for children with walking mobility (Gross Motor Function Classification System, GMFCS levels I-II) and the other for children with limited self-mobility (GMFCS levels III-V). Cognitive-behavioral problems and the extent family supports their child's self-determined behaviors explained 60% of the variance in self-determined behaviors of children with walking mobility. Cognitive-behavioral problems, playfulness, and the extent family supports their child's self-determined behaviors explained 68% of the variance in self-determined behaviors of children with limited self-mobility. The less the child's cognitive-behavioral problems affect daily activities (p<.05) and the more the extent family supports their child's self-determined behaviors (p<.05), the more effective the child's self-determined behaviors. Playfulness only had an effect on self-determined behaviors of children with limited self-mobility (p<.05). Service providers are encouraged to assess and support children's daily functioning in cognition, communication, and emotional/behavioral regulation, playfulness, and family strategies in providing opportunity for children to practice self-determined behaviors.
Research in developmental disabilities 11/2013; 35(1):99-109. DOI:10.1016/j.ridd.2013.10.004 · 4.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although oral topical anesthesia is used routinely before rigid laryngeal endoscopy, no study has determined whether oral topical anesthesia changes voice quality. Our goal was to determine the effects of topical anesthesia on voice.
Prospective cohort study.
Adult patients presenting to a laryngology practice who required rigid laryngeal endoscopy as part of the routine clinical visit were eligible for the study. Voices were recorded before and after oral topical benzocaine (14%)/butamben (2%)/tetracaine (2%) (ie, cetacaine) spray. Consensus auditory perceptual evaluation of voice (CAPE-V) protocol was used for the voice recordings and was the primary outcome measure. Recordings were presented randomly to two blinded speech-language pathologists specialized in voice. Secondary outcome measures were fundamental frequency (F0), jitter, shimmer, and noise-to-harmonics ratio (N/H) on sustained /i/ and speaking F0.
One hundred two patients participated in the study. There was no significant difference in CAPE-V measurements before and after topical anesthesia for all six attributes: overall severity (P = 0.145), roughness (P = 0.214), breathiness (P = 0.761), strain (P = 0.053), pitch (P = 0.301), and loudness (P = 0.320). There was no significant difference in jitter (P = 0.315), shimmer (P = 0.942), N/H (P = 0.128), and speaking F0 (P = 0.320). F0 /i/ decreased by a mean of 4.8Hz, which was statistically significant (P = 0.003), but probably not clinically significant.
There was no clinically significant voice change after oral topical anesthesia.
[Show abstract][Hide abstract] ABSTRACT: Objective:
To assess the effectiveness of a muscle protocol to treat patients diagnosed with neuraxial low back pain (LBP) before and after invasive treatments.
Patients with chronic (>6 months) LBP-postinvasive treatment and pre-spine surgery-were assessed and treated. An electrical device rather than palpation was used to determine muscle(s) as possible sources of pain. Patients testing positive for muscle pain were treated with a comprehensive protocol and were followed for >3 months to determine the effect of treatment on pain severity and interference in function.
Study 1: In 56 (postinvasive treatment) patients who had failed back surgery, epidural steroid injections, facet blocks, and/or trigger point injections, mean Brief Pain Inventory (BPI) pain severity dropped from 5.54 at baseline to 3.96 (P < 0.001) at a median follow-up of 77 weeks; mean BPI interference dropped from 6.09 to 3.4 (P < 0.001). Fifty-two percent of respondents reported over 50% relief. Study 2: Three of seven patients originally scheduled for spine surgery completed a substantial part of the muscle protocol, canceled their surgeries, and obtained significant relief at the 16-19 month follow-up point.
In patients thought to have neuraxial pain, identification and treatment of painful muscles had statistically significant long-lasting and clinically meaningful reductions in pain and improvement in function. Muscle and tendon attachments may be an important and treatable source of pain in patients diagnosed with pre and postsurgical neuraxial pain.
Pain Medicine 05/2013; 14(8). DOI:10.1111/pme.12144 · 2.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Philadelphia Lead Court (PLC) was created as an innovative law enforcement strategy to compel property owners to comply with city health codes to remediate their properties of lead hazards, which had led to elevated blood lead levels and lead poisoning in resident children. This study presents a detailed account of and analyzes the opinions of fifteen key informants drawn from the Philadelphia health and law departments and judicial system that staff and run the PLC in response to a fifteen-question structured survey. Main themes reviewed include the effectiveness of the PLC as compared with precourt law enforcement strategies and within the context of a specialized court, the use of fines, the impact of grant funding for remediation work, the major advantages and disadvantages of the PLC, and suggested changes to improve court function, followed by key recommendations. The article concludes that our informants found that the PLC has been very effective and successful. This model could be replicated by other cities with similar health code enforcement challenges.
Journal of Health Politics Policy and Law 05/2013; 38(4). DOI:10.1215/03616878-2208585 · 1.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Folate and vitamin B-12 are important for nervous system functioning at all ages, with important roles in functions such as neurotransmitter synthesis. Although studies suggest a relation between folate and vitamin B-12 and cognitive function in the elderly population, there is relatively less evidence regarding these vitamins and children's cognitive function. The purpose of the study was to examine the associations of serum folate and vitamin B-12 with cognitive performance in children 6-16 y old in the NHANES III, conducted from 1988 to 1994, prior to the implementation of folic acid fortification. A cross-sectional analysis was conducted using data on 5365 children 6-16 y old from NHANES III. Serum folate and vitamin B-12 concentrations were measured, along with performance, on the Wide Range Achievement Test-Revised and the Wechsler Intelligence Scale for Children-Revised. Associations of B vitamins with cognitive performance were assessed using linear regression models adjusted for various covariates. Higher serum concentrations of folate were associated with higher reading and block design scores after adjusting for various covariates. For example, compared with the lowest quartile of folate, children in the highest quartile scored 3.28 points or 0.19 SD units higher on the reading test (P < 0.05). Vitamin B-12 was not associated with any of the test scores. In the largest study to date, higher folate concentrations were associated with better reading and block design scores. These associations appear to be biologically plausible and merit further study.
Journal of Nutrition 02/2013; 143(4). DOI:10.3945/jn.112.166165 · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Medical educators assume clinical observation skills improve as practitioner level of experience increases, but no studies to date assess whether such improvements occur. This study compares observational skills of medical students, residents, fellows, and attending physicians in a simulated inpatient environment.
Approval from the Institutional Review Board was obtained. From October to December 2011, 59 participants, ranging from medical students through attendings, completed a seven minute session in the simulation laboratory at a pediatric hospital.
A simulated inpatient room included a high fidelity mannequin,a real-time cardiac monitor, a documented history and physical, and vitals flow sheet. Actors role-played the bedside nurse and infant's parent. After reading a brief HPI (a four month old infant with Hirschsprung's disease presenting with diarrhea), participants were instructed to write down their visual observations only. They were not expected to communicate with the actors, intervene, or assess the patient. Participants listed any observations they deemed important to the clinical scenario by free text during the allotted time period.
Each participant sheet was scored by three raters according to a predetermined scoring sheet. One point was given for each observation that matched these data points up to a maximum score of twenty. Participants were grouped by their level of training: third year medical students, third year pediatric residents, pediatric subspecialty fellows, and pediatric attendings.
A tukey post hoc test with ANOVA was used to determine which group means were significantly different from one another. Inter-rater reliability was assessed with intraclass correlation coefficients, calculated using mixed and random-effects models.
Residents scored significantly higher than medical students on their matched observations (p<0.05) (Figure 1). The other comparisons between individual groups were not statistically significant.
The raters were assessed using intraclass correlation coefficients. A two-way random effects model was used to allow for different raters in each subject, taking mean differences into account. The three raters were quite reliable with the lowest intraclass correlation of 0.851 for the attending physicians.
There was a significant difference in the clinical observational skills between the medical student and the resident levels. However, an increase in observed data did not continue beyond the resident level of training. We speculate this lack of progression is multifactorial. The absence of formalized training in teaching the art of medicine may be one reason. Another explanation may be the integration of electronic health records and advancing medical technology which allow for the assimilation of patient data without the need to be at the bedside.
The simulated environment is a novel and useful tool to evaluate clinical observational skills. Future research directions may include an intervention to teach observational skills in a training program or continuing medical education curriculum.
2012 American Academy of Pediatrics National Conference and Exhibition; 10/2012
[Show abstract][Hide abstract] ABSTRACT: We examined the burden of cardiovascular disease (CVD) and its associated risk factors using statewide representative data from the Pennsylvania Behavior Risk Factors Surveillance System. The data from 35,576 subjects aged ≥18 years participating in the Pennsylvania Behavior Risk Factors Surveillance System in 2005, 2007, and 2009 were analyzed. The age-adjusted prevalence rates of CVD were computed. Logistic regression analysis was applied to examine associations between the risk factors and CVD prevalence, with adjustment for confounding variables. The results showed that no significant changes in the prevalence of CVD, coronary heart disease, and stroke were observed in either European Americans or African Americans from 2005 to 2009 (p >0.05). African Americans had significantly greater CVD rates than European Americans. Although smoking rates significantly decreased, several other CVD risk factors (i.e., obesity, hypertension, and hypercholesterolemia) significantly increased from 2005 to 2009 in European Americans. Similar changes were observed in African Americans, although these changes did not reach statistical significance. Logistic regression analysis indicated that African Americans had a 35% greater risk of CVD. Education level less than high school, smoking, obesity, hypertension, and diabetes were significantly and positively associated with CVD. In conclusion, no significant achievements in CVD control and risk factor reduction were observed from 2005 to 2009 in Pennsylvania. Additional aggressive control of hypertension, obesity, and diabetes for both European and African Americans must be made to reduce the burden of CVD.
The American journal of cardiology 10/2012; 111(1). DOI:10.1016/j.amjcard.2012.08.045 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The 2000 Institute of Medicine report, 'To Err is Human: Building a Safer Health System', focused the medical community on medical error. This focus led to educational initiatives and legislation designed to minimise errors and increase their disclosure.
This study aimed to investigate whether increased general awareness about medical error has affected interns' attitudes toward medical error and disclosure by comparing responses to surveys of interns carried out at either end of the last decade.
Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure.
We collected 510 surveys (100% response rate). For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999-2001 to 2008-2009 ('no permanent harm': 38% and 71%, respectively [p < 0.001]; 'adverse outcome': 29% and 55%, respectively [p < 0.001]). About two thirds of fully disclosing interns in both scenarios believed 'the patient's right to full information' to be the primary reason for their disclosure. Fear of litigation in response to error disclosure decreased (70% and 52%, respectively), the percentage of interns who felt that 'medical mistakes are preventable if doctors know enough' decreased (49% and 31%, respectively), belief that competent doctors keep emotions and uncertainties to themselves decreased (51% and 14%, respectively), and agreement with leaving medicine if one (as an intern) caused harm or death decreased (50% and 3%, respectively). Prior training about medical mistakes increased more than four-fold between the cohorts.
This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns' intended disclosure practices and attitudes toward medical error.
Medical Education 07/2012; 46(7):668-77. DOI:10.1111/j.1365-2923.2012.04269.x · 3.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Philadelphia Lead Safe Homes (LSH) Study was designed to evaluate whether educational and environmental interventions in the first year of life for families of newborns increased knowledge of lead exposure prevention and were associated with less elevation of blood lead levels (BLLs) for these children, when compared to children receiving standard care.
The current study performed descriptive statistics on the second-year BLL data for both groups and compared these using chi-square tests for proportions and unpaired t-tests for means.
A BLL result was found for 159 (50.6%) of the 314 LSH cohort children and 331 (52.7%) of the 628 control children (p = 0.1). Mean and standard deviation for age at draw was 23.8 (3.4) months versus 23.6 (3.1) months (P = 0.6). Geometric mean BLLs were 3.7 versus 3.5 µg/dL (P = 0.4). The percentages of the cohort group with a BLL of ≥ 20, ≥ 10 and ≥ 5 μg/dL, respectively, were 0.6%, 5% and 30%; for the controls 1.2%, 6.6%, and 25%. These percentages were not significantly different between groups.
A comparison of geometric mean BLLs and percentages above several BLL cut points drawn at age two years in a group of urban newborns benefitting from study interventions versus a group of similar urban children did not yield statistically significant differences. Both groups had relatively lower lead levels when compared to historical cohort groups, which may reflect a continuing downward trend in BLLs in U.S. children. The interventions did result in benefits to the families such as an increase in parental knowledge about lead exposure prevention and in-home wet cleaning activity, and a decrease in lead dust levels in study homes.
International Journal of Environmental Research and Public Health 04/2012; 9(4):1216-26. DOI:10.3390/ijerph9041216 · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cross-sectional studies demonstrate an association between metabolic syndrome and impaired lung function.
To define if metabolic syndrome biomarkers are risk factors for loss of lung function after irritant exposure.
A nested case-control study of Fire Department of New York personnel with normal pre-September 11th FEV(1) and who presented for subspecialty pulmonary evaluation before March 10, 2008. We correlated metabolic syndrome biomarkers obtained within 6 months of World Trade Center dust exposure with subsequent FEV(1). FEV(1) at subspecialty pulmonary evaluation within 6.5 years defined disease status; cases had FEV(1) less than lower limit of normal, whereas control subjects had FEV(1) greater than or equal to lower limit of normal.
Clinical data and serum sampled at the first monitoring examination within 6 months of September 11, 2001, assessed body mass index, heart rate, serum glucose, triglycerides and high-density lipoprotein (HDL), leptin, pancreatic polypeptide, and amylin. Cases and control subjects had significant differences in HDL less than 40 mg/dl with triglycerides greater than or equal to 150 mg/dl, heart rate greater than or equal to 66 bpm, and leptin greater than or equal to 10,300 pg/ml. Each increased the odds of abnormal FEV(1) at pulmonary evaluation by more than twofold, whereas amylin greater than or equal to 116 pg/ml decreased the odds by 84%, in a multibiomarker model adjusting for age, race, body mass index, and World Trade Center arrival time. This model had a sensitivity of 41%, a specificity of 86%, and a receiver operating characteristic area under the curve of 0.77.
Abnormal triglycerides and HDL and elevated heart rate and leptin are independent risk factors of greater susceptibility to lung function impairment after September 11, 2001, whereas elevated amylin is protective. Metabolic biomarkers are predictors of lung disease, and may be useful for assessing risk of impaired lung function in response to particulate inhalation.
American Journal of Respiratory and Critical Care Medicine 11/2011; 185(4):392-9. DOI:10.1164/rccm.201109-1672OC · 13.00 Impact Factor