Jim Y Wan

The University of Tennessee Health Science Center, Memphis, Tennessee, United States

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Publications (109)321.93 Total impact

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    ABSTRACT: To study the association of a multimodal pain protocol (MMPC) and reduced hospital stay after open abdominal hysterectomy.
    European Journal of Obstetrics & Gynecology and Reproductive Biology. 12/2014; 183.
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    ABSTRACT: Objectives: Determine whether the implementation of the Medicare Part D 2006 was associated with changes in differential racial and ethnic disparity patterns between the individuals ineligible for medication therapy management (MTM) services and MTM-eligible individuals. The urgency for modifying MTM eligibility criteria would be increased if the reduction of disparity not seen. Methods: Data from the Medicare Current Beneficiary Survey were analyzed. A difference-in-differences analyses, difference-in-differences-in-differences-in-differences (DDDD) model, was used to examine changes in difference in disparities between the MTM-ineligible and MTM-eligible individuals from 2004-2005 to 2007-2008 in relation to the changes from 2001-2002 to 2004-2005. Disparities were examined in health outcomes, health services utilizations/costs, and medication utilization. Both main and sensitivity analyses were conducted by various regression models. Findings: The main analysis found no significant DDDD values. For racial disparities, according to some sensitivity analyses, Part D implementation was associated with a reduction in greater racial disparities among the MTM-ineligible and MTM-eligible individuals in activities of daily living (DDDD=1.13; P=0.03 for one analysis) and instrumental activities of daily living (DDDD=0.95; P=0.03 for one analysis). For ethnic disparities, Part D implementation was associated with reduction in any greater disparities among the MTM-ineligible than MTM-eligible individuals in costs of physician visits (DDDD=-4613.71; P=0.04 for one analysis) and high risk medication utilization (DDDD=-0.10; P=0.03 for one analysis). Conclusions: Part D implementation is not consistently associated with reductions in the disparity implications of the Medicare MTM eligibility criteria. The MTM eligibility criteria need to be modified in order to eliminate their disparity implications.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
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    ABSTRACT: This study aimed to collect preliminary evidence on the efficacy of milnacipran in reducing pain in women with provoked vestibulodynia (PVD) and to identify which patient characteristics predict treatment success.
    Journal of Lower Genital Tract Disease 08/2014; · 1.21 Impact Factor
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    ABSTRACT: Objective Medication therapy management (MTM) has the potential to play an instrumental role in reducing racial and ethnic disparities in health care. However, previous research has found that blacks and Hispanics are less likely to be eligible for MTM. The purpose of the current study was to examine the potential effects of MTM eligibility criteria on racial and ethnic disparities in health outcomes.Methods The current study is a retrospective cross-sectional analysis of the Medicare Current Beneficiary Survey Cost and Use files for the years 2007 and 2008. A difference-in-differences model was used to compare disparities in outcomes between ineligible and eligible beneficiaries according to MTM eligibility criteria in 2010. This was achieved by including in regression models interaction terms between dummy variables for blacks/Hispanics and MTM eligibility criteria. Interaction terms were interpreted on both multiplicative and additive terms. Various regression models were used depending on the types of variables.Key findingsWhites were more likely to report self-perceived good health status than blacks and Hispanics among both MTM-eligible and MTM-ineligible populations. Disparities were greater among MTM-ineligible than MTM-eligible populations (e.g. on additive term, difference in odds = 1.94 and P < 0.01 for whites and blacks; difference in odds = 2.86 and P < 0.01 for whites and Hispanics). A few other measures also exhibited significant patterns.ConclusionsMTM eligibility criteria may exacerbate racial and ethnic disparities in health status and some measures of health services utilizations and costs and medication utilization. Future research should examine strategies to remediate the effects of MTM eligibility criteria on disparities.
    Journal of Pharmaceutical Health Services Research. 06/2014; 5(2).
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    ABSTRACT: Background: Whilst the incidence of type 2 diabetes (T2D) among persons with prediabetes is well-known (∼10%/year), the incidence of prediabetes among normoglycemic persons is unclear. Also, in the Diabetes Prevention Program, no racial/ethnic differences were seen in diabetes incidence, whereas marked racial/ethnic disparities are reported in the prevalence of T2D. We aimed to obtain estimates of incident prediabetes, and determine whether racial disparities manifest during transition to prediabetes. Design and Methods: We enrolled 376 (217 black, 159 white) non-diabetic offspring of parents with T2D (mean age 44.2 years), and followed them quarterly for 5.5 years. Assessments included anthropometry, body composition, OGTT, biochemistries, energy expenditure, insulin sensitivity, and insulin secretion. The primary outcome was progression to impaired fasting glucose and/or impaired glucose tolerance (or diabetes). Results: Of 343 participants with evaluable data, 101 subjects (49 white, 52 black) developed prediabetes and 10 (4 white, 6 black) developed diabetes during a mean follow-up of 2.62 years. There was no significant racial difference in the cumulative incidence of prediabetes (White 32.7%, Black 30%) or combined prediabetes/diabetes (White 35%, Black 30%). Significant predictors of prediabetes included age, gender, trunk fat, 2hr post-load glucose (2hrPG), insulin sensitivity, and insulin secretion. In a Cox proportional-hazards model, with adjustment for age and sex, the 2hrPG and abdominal obesity were independent predictors of incident prediabetes/diabetes (relative hazards [95% CI] for 90th vs. 10th percentile: trunk fat mass 2.90 [1.74-4.82], P<0.0001; 2hrPG 2.54 [1.46-4.40], P=0.0009. Having trunk fat mass and 2hrPG at the 90th percentile conferred a 7-fold hazard of prediabetes compared to persons at the 10th percentile for both measures. Conclusion: Black and white offspring of parents with type 2 diabetes develop prediabetes at a similar high rate of ∼11% per year. Therefore, close surveillance, with prompt intervention to prevent dysglycemia, is warranted in persons with parental diabetes.
    The Journal of Clinical Endocrinology and Metabolism 03/2014; · 6.31 Impact Factor
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    ABSTRACT: Objective To examine incidence of and risk factors for development of hyperlipidemia (HL) in patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for renal cortical neoplasms, as HL is a major source of morbidity in chronic kidney disease (CKD).Patients and Methods Two-center retrospective analysis of 905 patients (mean age 57.5 years, mean follow-up 78 months) who underwent RN (610) or PN (295) from 7/1987-6/2007. Demographics, preoperative and postoperative HL were recorded. De novo HL was defined ≥6 months after surgery with laboratory values meeting National Cholesterol Education Program ATP III definitions. Kaplan-Meier method was used to assess freedom from de novo HL. Multivariable analysis (MVA) was conducted to elucidate risk factors for de novo HL.ResultsThere were no significant differences with respect to demographics, preoperative GFR<60 (p=0.123) and HL (p=0.144). Tumor size (cm) was significantly larger for RN (7.0 vs. PN 3.7, p<0.001). Significantly greater postoperative GFR<60 was noted in RN (45.7% vs. PN 18%, p<0.001). Significantly more de novo HL developed in RN (23% vs. PN 6.4%, p<0.001). Mean time to development of HL was longer for PN (54 vs. RN 44 months, p=0.03). Five-year freedom from de novo HL probability was 76% RN vs. 96% PN (p<0.001). MVA demonstrated RN (OR 2.93, p=0.0107), preoperative (OR 1.98, p=0.037) and postoperative (OR 7.89, p<0.001) GFR<60 as factors associated with HL development.Conclusion Patients who underwent RN had significantly higher incidence and shorter time to development of de novo HL. RN, preoperative and postoperative eGFR<60 were associated with development of HL. Further follow-up and prospective investigation is necessary to confirm these findings.
    BJU International 03/2014; · 3.05 Impact Factor
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    ABSTRACT: Objective A hemoglobin (Hb) A1c range of 5.7%-6.4% has been recommended for the diagnosis of prediabetes. To determine the significance of such “prediabetic” HbA1c levels, we compared glucoregulatory function in persons with HbA1c levels of 5.7%-6.4% and those with HbA1c < 5.7%. Methods We studied 280 nondiabetic adults (142 black, 138 white; mean (± SD) age 44.2 ± 10.6 y). Each subject underwent clinical assessment, blood sampling for HbA1c measurement, and a 75-g oral glucose tolerance test at baseline. Additional assessments during subsequent outpatient visits included insulin sensitivity, using homeostasis model assessment (HOMA)-IR and the hyperinsulinemic euglycemic clamp; insulin secretion, using HOMA-B and frequently samples intravenous glucose tolerance test (FSIVGTT) and disposition index (DI); and measurement of fat mass, using DXA. Results Compared to subjects with HbA1c < 5.7%, persons with HbA1c levels of 5.7%- 6.4% were older, and had higher body mass index (BMI) and insulin secretion but similar insulin sensitivity. When the two groups were matched in age and BMI, persons with HbA1c 5.7-6.4% were indistinguishable from those with HbA1c < 5.7% with regard to all measures of glycemia glucoregulatory function. Conclusions: Unlike glucose-defined prediabetes status, an HbA1c range of 5.7%- 6.4% does not reliably identify individuals with impaired insulin action or secretion, the classical defects underlying the pathophysiology of prediabetes. Thus, HbA1c cannot validly replace blood glucose measurement in the diagnosis of prediabetes. If utilized as a screening test due to convenience, aberrant HbA1c values should be corroborated with blood glucose measurement before therapeutic intervention.
    Metabolism: clinical and experimental 01/2014; · 3.10 Impact Factor
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    ABSTRACT: Intradermally injected capsaicin has been used extensively both as a human pain model and to assess analgesic efficacy. Factors such as dose, formulation, route, and site are known to affect its sensitivity. We determined whether potency and stability of capsaicin solutions were further sources of variability when following strict manufacturing guidelines. Capsaicin solution (1.0 mg/mL) was prepared according to Current Good Manufacturing Practice (cGMP) guidelines and aseptically filled into sterile amber borosilicate vials and stored at 5°C, 25°C, and 30°C. All samples were analyzed at one, three, six, and twelve months. Chemical stability was determined using HPLC and physical stability was evaluated by visual inspection of color changes, clarity, particulate matter, and product/ container closure abnormalities during each sampling time. Capsaicin intradermal injection was found to be sterile and retained 95% of the initial concentration for at least one year, regardless of studied storage temperatures (P<0.0001). Visual inspection indicated no changes in color, clarity, particulate matter, and product/ container closure abnormalities in all samples. These data show that capsaicin solutions (1.0 mg/mL) maintain their potency and stability over one year when manufactured according to cGMP guidelines. These results suggest that in clinical trials manufacturing of capsaicin solutions is recommended over extemporaneous compounding.
    Clinical & experimental pharmacology. 01/2014; 4(1):142.
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    ABSTRACT: Motor slowing and forebrain white matter loss have been reported in premanifest Huntington's disease (HD) prior to substantial striatal neuron loss. These findings raise the possibility that early motor defects in HD may be related to loss of excitatory input to striatum. In a prior study, we showed that in the heterozygous Q140 knock-in mouse model of HD that loss of thalamostriatal axospinous terminals is evident by 4 months, and loss of corticostriatal axospinous terminals is evident at 12 months, before striatal projection neuron pathology. In the present study, we specifically characterized the loss of thalamostriatal and corticostriatal terminals on direct (dSPN) and indirect (iSPN) pathway striatal projection neurons, using immunolabeling to identify thalamostriatal (VGLUT2+) and corticostriatal (VGLUT1+) axospinous terminals, and D1 receptor immunolabeling to distinguish dSPN (D1+) and iSPN (D1-) synaptic targets. We found that the loss of corticostriatal terminals at 12 months of age was preferential for D1+ spines, and especially involved smaller terminals, presumptively of the intratelencephalically projecting (IT) type. By contrast, indirect pathway D1- spines showed little loss of axospinous terminals at the same age. Thalamostriatal terminal loss was comparable for D1+ and D1- spines at both 4 and 12 months. Regression analysis showed that the loss of VGLUT1+ terminals on D1+ spines was correlated with a slight decline in open field motor parameters at 12 months. Our overall results raise the possibility that differential thalamic and cortical input loss to SPNs is an early event in human HD, with cortical loss to dSPNs in particular contributing to premanifest motor slowing.
    Frontiers in Systems Neuroscience 01/2014; 8:198.
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    ABSTRACT: Objective: Initial assessment of metabolic acidosis in subjects with diabetic ketoacidosis (DKA) is performed using arterial blood gas analysis. This process is expensive, painful and technically difficult. Furthermore, blood gas analysis may not be available in some facilities especially in developing countries where the morbidity and mortality from DKA remain high. Therefore we investigated the utility of venous bicarbonate concentration obtained from basic metabolic panel in predicting arterial pH in adults with DKA.Methods: We performed a retrospective analysis of clinical and biochemical data of 396 adults admitted with DKA in two community teaching hospitals. We determined the correlation between arterial pH and venous serum parameters. Using multiple logistic regression module we obtained a predictive formula for arterial pH from serum venous bicarbonate level.Results: The patient population was composed of 59.0% males and had mean age of 36.7 ± 13.3 years. We derived that arterial pH = 6.97 + (0.0163 x bicarbonate); applying this equation, we determined that serum venous bicarbonate concentration of ≤ 20.6 mEq/L predicted arterial pH of ≤ 7.3 with over 95% sensitivity and 92% accuracy.Conclusion: Venous serum bicarbonate obtained from the basic metabolic panel proved to be an affordable and reliable way of estimating arterial pH in adults with DKA. Validation of this formula in a prospective study would offer a more accessible means of estimating metabolic acidosis in adults with DKA especially in developing countries where the incidence and mortality of DKA remain high.
    Endocrine Practice 09/2013; · 2.49 Impact Factor
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    ABSTRACT: We wish to develop a CT scan-based scoring system which estimates the probability of adnexal mass malignancy. Patients (324) undergoing adnexal mass surgery were recruited into the study from June 1, 2002, to January 1, 2009. All study patients had a preoperative CT scan and serum CA-125 test. CT scan abnormalities included any solid tumor components, ascites, and pelvic or abdominal lymphadenopathy and omental caking. There were 225 (70 %) benign and 99 (30 %) malignant ovarian masses. Using logistic regression with the area under the curve of the receiver operating curve of 82 %, the cancer probability was determined by the equation.[Formula: see text]where A = age, B = CA-125, C = solid adnexal mass is 1 and cystic is 0, D = ascites is 1, E = omental caking is 1 and absence is 0, F = node size ≥1 cm is 1 and <1 cm is 0 value. The natural logarithm e is a constant [2.718281828]. For example, for a woman of age 60, CA-125 = 50 U/mL, with solid adnexal mass, ascites, omental caking, and lymphadenopathy, the probability is 0.994. Hence, this woman has a 99.4 % probability of having cancer. The computed tomography adnexal mass score combines CT scan findings, CA-125, and patient age into an equation to predict the malignant probability of an adnexal mass.
    Archives of Gynecology 08/2013; · 0.91 Impact Factor
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    ABSTRACT: Objectives- To evaluate whether picture archiving and communication systems (PACS) adequately satisfy radiologists' needs in ultrasound (US) imaging and which PACS functions may be inadequately implemented for handling US diagnosis. Methods- An electronic survey was sent to the membership of the Society of Radiologists in Ultrasound asking them to rate their PACS experience for different modalities, judge the quality of various PACS functions having an impact on US practice and diagnosis, indicate if they felt a need for US-related PACS functions to be implemented or improved, and rate PACS-related improvements for different components of their US practice. Results- Of the 161 respondents, 112 (70%) used a general radiology PACS. Of these respondents, only 53.2% gave a high rating to the US experience in PACS, significantly lower (P < .0001) than for computed tomography (85.2%), magnetic resonance imaging (84.4%), and radiography (83.2%). The functionality of US-specific display, image-processing, and data management PACS processes were graded significantly lower than basic PACS display functions. Only 0.9% of respondents highly rated PACS handling of 3-dimensional US volume data, whereas 92% highly rated the quality of the black-and-white US image display (P < .0001). Most respondents would like most of these US-specific functions implemented or improved, and most respondents stated that PACS has improved their US practice in different ways, although the contribution in more complex image analysis is lagging. Conclusions- Radiologists with a special interest in US believe that the PACS experience for US is lacking. This research helps identify those specific tasks that may further improve work efficiency and diagnostic confidence.
    Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 08/2013; 32(8):1377-84. · 1.40 Impact Factor
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    ABSTRACT: BACKGROUND: Previous studies have found that racial and ethnic minorities would be less likely to meet the Medicare eligibility criteria for medication therapy management (MTM) services than their non-Hispanic White counterparts. OBJECTIVES: To examine whether racial and ethnic disparities in health status, health services utilization and costs, and medication utilization patterns among MTM-ineligible individuals differed from MTM-eligible individuals. METHODS: This study analyzed Medicare beneficiaries in 2004-2005 Medicare Current Beneficiary Survey. Various multivariate regressions were employed depending on the nature of dependent variables. Interaction terms between the dummy variables for Blacks (and Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals. Main and sensitivity analyses were conducted for MTM eligibility thresholds for 2006 and 2010. RESULTS: Based on the main analysis for 2006 MTM eligibility criteria, the proportions for self-reported good health status for Whites and Blacks were 82.82% vs. 70.75%, respectively (difference = 12.07%; P < 0.001), among MTM-ineligible population; and 56.98% vs. 52.14%, respectively (difference = 4.84%; P = 0.31), among MTM-eligible population. The difference between these differences was 7.23% (P < 0.001). In the adjusted logistic regression, the interaction effect for Blacks and MTM eligibility had an OR of 1.57 (95% Confidence Interval, or CI = 0.98-2.52) on multiplicative term and difference in odds of 2.38 (95% CI = 1.54-3.22) on additive term. Analyses for disparities between Whites and Hispanics found similar disparity patterns. All analyses for 2006 and 2010 eligibility criteria generally reported similar patterns. Analyses of other measures did not find greater racial or ethnic disparities among the MTM-ineligible than MTM-eligible individuals. CONCLUSIONS: Disparities in MTM eligibility may aggravate existing racial and ethnic disparities in health outcomes. However, disparities in MTM eligibility may not aggravate existing disparities in health services utilization and costs and medication utilization patterns. Future studies should examine the effects of Medicare Part D on these disparities.
    Research in Social and Administrative Pharmacy 06/2013; · 2.35 Impact Factor
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    ABSTRACT: OBJECTIVE: We wished to investigate the prevalence of missing lymph nodes (MLN), factors contributing to MLN, and the effect of MLN on progression free survival (PFS). METHODS: Patients with uterine cancer undergoing abdominal hysterectomy and lymphadenectomy were recruited. All surgeries adhered to the Gynecologic Oncology Group protocol in collecting all the lymph node tissues in paraaortic, common iliac, obturator fossa, and external and internal iliac bilaterally. Data regarding race, age, body mass index (BMI), lymph node counts, staging, location of missing lymph nodes, length of surgery, and estimated blood loss were collected and analysed in reference to missing lymph nodes. The definition of missing lymph node was an incomplete nodal specimen obtained without actual lymph node tissue. RESULTS: Between April 2003 and January 2010, 235 consecutive patients were enrolled prospectively; 108 patients had missing lymph nodes post-operatively (46%), and 127 patients had complete lymph nodes. We found no correlation between MLN relative to race (P=0.97), age (P=0.25), BMI (P=0.09), Estimated blood loss (P=0.38), American Society of Anaesthesiologist physical status classification system (P=0.18), surgery time (P=0.22), hospital stay (P=0.05), nodes without cancer (P=0.12), nodes with cancer (P=0.99), stage (P=0.90), grade (P=0.17), or PFS (P=0.29). CONCLUSION: In our study, although prevalence of missing lymph nodes seems relatively high, none of the perioperative variables studied appeared to contribute to missing lymph nodes. Finally, missing lymph nodes did not affect progression free survival.
    Gynecologic Oncology 04/2013; · 3.93 Impact Factor
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    ABSTRACT: The emphasis on eliminating racial and ethnic disparities in healthcare has received national attention, with various policy initiatives addressing this problem and proposing solutions. However, in the current economic era requiring tight monetary constraints, emphasis is increasingly being placed on economic efficiency, which often conflicts with the equality doctrine upon which many policies have been framed. The authors' review aims to highlight the disparity implications of one such policy provision - the predominantly utilization-based eligibility criteria for medication therapy management services under Medicare Part D - by identifying studies that have documented racial and ethnic disparities in health status and the use of and spending on prescription medications. Future design and evaluation of various regulations and legislations employing utilization-based eligibility criteria must use caution in order to strike an equity-efficiency balance.
    Expert Review of Pharmacoeconomics & Outcomes Research 04/2013; 13(2):201-16. · 1.67 Impact Factor
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    ABSTRACT: STUDY OBJECTIVE: This study seeks to determine whether health information exchange reduces repeated diagnostic imaging and related costs in emergency back pain evaluation. METHODS: This was a longitudinal data analysis of health information exchange patient-visit data. All repeated emergency department (ED) patient visits for back pain with previous ED diagnostic imaging to a Memphis metropolitan area ED between August 1, 2007, and July 31, 2009, were included. Use of a regional health information exchange by ED personnel to access the patient's record during the emergency visit was the primary independent variable. Main outcomes included repeated lumbar or thoracic diagnostic imaging (radiograph, computed tomography [CT], or magnetic resonance imaging [MRI]) and total patient-visit estimated cost. RESULTS: One hundred seventy-nine (22.4%) of the 800 qualifying repeated back pain visits resulted in repeated diagnostic imaging (radiograph 84.9%, CT 6.1%, and MRI 9.5%). Health information exchange use in the study population was low, at 12.5%, and health care providers as opposed to administrative/nursing staff accounted for 80% of the total health information exchange use. Health information exchange use by any ED personnel was associated with reduced repeated diagnostic imaging (odds ratio 0.36; 95% confidence interval 0.18 to 0.71), as was physician or nurse practitioner health information exchange use (odds ratio 0.47; 95% confidence interval 0.23 to 0.96). No cost savings were associated with health information exchange use because of increased CT imaging when health care providers used health information exchange. CONCLUSION: Health information exchange use is associated with 64% lower odds of repeated diagnostic imaging in the emergency evaluation of back pain. Health information exchange effect on estimated costs was negligible. More studies are needed to evaluate specific strategies to increase health information exchange use and further decrease potentially unnecessary diagnostic imaging and associated costs of care.
    Annals of emergency medicine 02/2013; · 4.33 Impact Factor
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    ABSTRACT: OBJECTIVE To study the effects of high-protein versus high-carbohydrate diets on various metabolic end points (glucoregulation, oxidative stress [dichlorofluorescein], lipid peroxidation [malondialdehyde], proinflammatory cytokines [tumor necrosis factor-α and interleukin-6], adipokines, and resting energy expenditure [REE]) with high protein-low carbohydrate (HP) and high carbohydrate-low protein (HC) diets at baseline and after 6 months of dietary intervention.RESEARCH DESIGN AND METHODS We recruited obese, premenopausal women ages 20-50 years with no diabetes or prediabetes who were randomized to HC (55% carbohydrates, 30% fat, and 15% protein) or HP (40% carbohydrates, 30% fat, and 30% protein) diets for 6 months. The diets were provided in prepackaged food, which provided 500 kcal restrictions per day. The above metabolic end points were measured with HP and HC diet at baseline and after 6 months of dietary intervention.RESULTSAfter 6 months of the HP versus HC diet (12 in each group), the following changes were significantly different by Wilcoxon rank sum test for the following parameters: dichlorofluorescein (-0.8 vs. -0.3 µmol/L, P < 0.0001), malondialdehyde (-0.4 vs. -0.2 μmol/L, P = 0.0004), C-reactive protein (-2.1 vs. -0.8 mg/L, P = 0.0003), E-selectin (-8.6 vs. -3.7 ng/mL, P = 0.0007), adiponectin (1,284 vs. 504 ng/mL, P = 0.0011), tumor necrosis factor-α (-1.8 vs. -0.9 pg/mL, P < 0.0001), IL-6 (-1.3 vs. -0.4 pg/mL, P < 0.0001), free fatty acid (-0.12 vs. 0.16 mmol/L, P = 0.0002), REE (259 vs. 26 kcal, P < 0.0001), insulin sensitivity (4 vs. 0.9, P < 0.0001), and β-cell function (7.4 vs. 2.1, P < 0.0001).CONCLUSIONS To our knowledge, this is the first report on the significant advantages of a 6-month hypocaloric HP diet versus hypocaloric HC diet on markers of β-cell function, oxidative stress, lipid peroxidation, proinflammatory cytokines, and adipokines in normal, obese females without diabetes.
    Diabetes care 02/2013; · 7.74 Impact Factor
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    ABSTRACT: OBJECTIVES: Persistent human papillomavirus (HPV) infections can cause intraepithelial neoplasia of the lower genital tract. Immune-compromised women have higher rates for all lower genital tract intraepithelial neoplasia. We wish to study the distribution of genital intraepithelial neoplasia in women with and without an immune system. METHODS: The study consisted of 343 women with an abnormal genital lesion or cervical cytology who were referred to a gynecologic oncologist. All patients underwent vulva, vaginal, cervical and anal colposcopy. Any lesion detected was biopsied. Demographic and medical data were collected. The Chi-square test was used to determine the relationship between immunosuppression status and various variables, including sites of intraepithelial neoplasia. RESULTS: Immune-compromised women (N = 33) are more likely than immune-competent women (N = 310) to have intraepithelial neoplasia of the vulva (p < 0.05) and vagina (p < 0.05), but not more likely to have intraepithelial neoplasia of the anus or cervix. Immune-compromised women are more likely than immune-competent women to have multifocal intraepithelial neoplasia (p < 0.001). In addition, immune-compromised women are more likely to have higher grade disease of the vulva and vagina (p < 0.05), and no more likely to have higher grade disease on the cervix or anus than immune-competent women. CONCLUSION: Women with conditions suppressing the immune system are at higher risk for HPV-related disease outside of the cervix and for worse HPV-related diseases than immune-competent women. This study highlights the need for vigilant evaluation of the complete lower genital tract in women with immune-compromised systems.
    Archives of Gynecology 11/2012; · 0.91 Impact Factor
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    ABSTRACT: BACKGROUND:: This study seeks to determine the most important patient factors and health care exposures available through administrative databases associated with antihypertensive nonadherence. METHODS:: This is a cross-sectional analysis of Medicaid hypertensive patients of Tennessee enrolled for 3 to 7 years from 1994 to 2000. Demographic characteristics, comorbidity and health care utilization were assessed during a 2-year period. The primary outcome was antihypertensive medication refill nonadherence. Subjects were categorized as adherent or nonadherent using an 80% cutoff criteria. Associations with nonadherence were assessed using logistic regression modeling. RESULTS:: Of 49,479 subjects, 60.6% (n = 29,970) were classified as nonadherent and 39.4% (n = 19,509) as adherent. Significant predictors of nonadherence in multivariate analysis (P < 0.05) included male sex (odds ratio [OR] 1.12), black race (OR 1.67), urban residence (OR 1.12), obesity (OR 1.10), mental illness (OR 1.08) and substance abuse (OR 1.43). Significant protective factors included age (OR 0.97), disability (OR 0.62), diabetes (OR 0.76), hypercholesterolemia (OR 0.72) and Charlson index (OR 0.97). When health care utilization was considered, increased outpatient visits were associated with decreased nonadherence. Emergency department visits (OR 1.07) and hospital visits (OR 1.12) were associated with increased nonadherence. CONCLUSIONS:: This cross-sectional study suggests that substance abuse, black race, emergency department visits and hospitalizations are risk factors associated with nonadherence. Outpatient visits are associated with a small decrease in nonadherence. Further studies are needed to determine the characteristics of outpatient visits that most improve adherence.
    The American Journal of the Medical Sciences 08/2012; · 1.33 Impact Factor
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    ABSTRACT: Study Type - Therapy (prospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). We hypothesized that partial nephrectomy (PN) would limit development of ED compared with radical nephrectomy (RN), primarily due to renal function preservation, and found that patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN; in addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. To our knowledge, this is the first study demonstrating an increased risk of ED after RN compared with PN. OBJECTIVES: •  To evaluate prevalence and risk factors for development of erectile dysfunction (ED) in patients who underwent radical nephrectomy (RN) and partial nephrectomy (PN). •  ED is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). PN confers superior renal functional preservation compared with RN; however, the impact on ED is unclear. METHODS: •  This was a retrospective study of 432 patients (264 RN/168 PN, mean age 58 years, mean follow-up 5.8 years) who underwent surgery for renal tumours between January 1998 and December 2007. •  The primary outcome was rate of de novo ED postoperatively. Secondary outcomes included development of CKD (estimated GFR < 60 mL/min/1.73 m(2) ) and response to phosphodiesterase-5 inhibitors. •  Multivariate analysis was performed to determine risk factors for de novo ED postoperatively. RESULTS: •  RN and PN groups had similar demographics and comorbidities. •  Tumour size (cm) was larger for RN (RN 7.0 vs PN 3.7, P < 0.001) and more preoperative ED existed in PN vs RN (P= 0.042). No differences were observed for preoperative CKD, hyperlipidaemia and diabetes mellitus. •  Postoperatively, higher rates of de novo ED (29.5% vs 9.5%, P < 0.001) and CKD (33.0% vs 9.8%, P < 0.001) developed in RN vs PN cohorts, respectively. •  Of men with ED, 63% responded to phosphodiesterase inhibitors, without significant difference between the two groups (P= 0.896). •  Multivariate analysis demonstrated de novo ED to be associated with RN (odds ratio [OR] 3.56, P < 0.001), hypertension (OR 2.32, P= 0.014), preoperative (OR 8.77, P < 0.001) and postoperative (OR 2.64, P= 0.001) CKD, and postoperative diabetes mellitus (OR 2.93, P < 0.001). CONCLUSIONS: •  Patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN. In addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. •  Further investigation on effects of surgically induced nephron loss on ED is requisite.
    BJU International 07/2012; · 3.05 Impact Factor

Publication Stats

1k Citations
321.93 Total Impact Points

Institutions

  • 2003–2014
    • The University of Tennessee Health Science Center
      • • Division of Endocrinology, Diabetes and Metabolism
      • • Department of Urology
      • • Department of Obstetrics and Gynecology
      • • Department of Preventive Medicine
      Memphis, Tennessee, United States
    • Louisiana State University Health Sciences Center Shreveport
      Shreveport, Louisiana, United States
  • 2009–2013
    • West Georgia Obstetrics and Gynecology
      Georgetown, Georgia, United States
  • 2011
    • University of California, San Diego
      • Moores Cancer Center/Oncology
      San Diego, CA, United States
  • 2004–2011
    • University of Tennessee
      • • Department of Obstetrics and Gynecology
      • • Department of Preventive Medicine
      Knoxville, TN, United States
  • 1998
    • The University of Memphis
      Memphis, Tennessee, United States