[show abstract][hide abstract] ABSTRACT: The magnitude and implication of variation in end-of-life decision-making among intensive care units (ICUs) in the United States is unknown.
We reviewed data on decisions to forgo life-sustaining therapy (DFLST) in 269,002 patients admitted to 153 ICUs in the United States between 2001 - 2009. We used fixed effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU.
Patient factors associated with an increased odds of DFLST included advanced age, female gender, white race, and poor baseline functional status (all p < 0.001). However, associations with several of these factors varied among ICUs (e.g., black race had an odds ratio for DFLST from 0.18 - 2.55 across ICUs). ICU staffing model was also found to be associated with DFLST, with open ICU staffing model associated with an increased odds of a DFLST (OR 1.19). The predicted probability of DFLST varied approximately 6-fold among ICUs after adjustment for the fixed patient and ICU effects, and was directly correlated with ICUs' standardized mortality ratios (r = 0.53, 0.41 - 0.68).
Although patient factors explain much of the variability in DFLST practices, there are significant effects of ICU culture and practice that influence end-of-life decision-making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.
[show abstract][hide abstract] ABSTRACT: Abstract Background: Women undergoing abortion do psychologically well long-term. Little data, however, describe how women fare in the immediate 1-3 day post-abortion period, when interventions may be most impactful for those who need them. Methods: We conducted a cohort study of patients undergoing first and second trimester surgical abortion and scored self-reported responses regarding psychological well-being before and after abortion, plus anticipated post-procedural psychological coping. Results: Sixty-two of 148 patients had complete questionnaires. Average predicted psychological scores were 9.7% better than pre-procedural psychological states. Actual psychological coping scores improved by 38% over women's predictions. Women who scored poorly on pre-procedural psychological assessments were more likely to have post-procedural psychosocial concerns (p=0.0376, r=0.2761). Conclusion: While most women approach their abortion with optimism, they actually fare even better psychologically than they predict they will during the 1-3 days following procedures. Poor scores on pre-procedural psychological assessments can identify women in need of additional support in the immediate post-abortion period.
Journal of Women s Health 11/2013; · 1.42 Impact Factor
[show abstract][hide abstract] ABSTRACT: Non-AIDS defining malignancies, particularly colorectal cancer (CRC), may be more prevalent among persons living with HIV (PLWH). Further, PLWH may be less likely to receive CRC screening (CRCS). We studied the epidemiology of CRC and CRCS patterns in PLWH and HIV-uninfected persons in a large US Medicaid population. We performed a matched cohort study examining CRC incidence in 2006 and CRCS between 1999 and 2007. Study participants were continuously enrolled in the Medicaid programs of California, Florida, New York, Ohio, and Pennsylvania. All PLWH enrollees were matched to five randomly sampled HIV-uninfected enrollees on 5-year age group, gender, and state. Adjusted odds ratios (AORs) for incident CRC (adjusted for comorbidity index) and the presence of CRCS (adjusted for comorbidity index and years in the data-set) among PLWH compared to HIV-uninfected enrollees were calculated. PLWH were not more likely to be diagnosed with CRC after adjusting for comorbidity index (unadjusted OR: 1.73, 95% confidence interval [CI]: 1.37-2.19; AOR 1.29; 95% CI: 0.98-1.70). While CRCS rates were low overall, PLWH were more likely to have received CRCS in unadjusted analyses (35.8% vs. 33.7%; OR 1.10, 95% CI: 1.07-1.13). This relationship was reversed after adjusting for comorbidity index and years in the data-set (AOR: 0.80, 95% CI: 0.77-0.83). Limitations of the study include a focus on the Medicaid population, an inability to detect fecal occult blood tests (FOBT), and having half of patients between 50 and 55 years of age. In conclusion, PLWH were not more likely to be diagnosed with CRC, but in adjusted analyses, were less likely to have received CRCS. As we showed a low rate of CRCS overall in this Medicaid population, researchers, clinicians, and policy-makers should improve access to and uptake of CRCS among all Medicaid patients, and particularly among PLWH.
[show abstract][hide abstract] ABSTRACT: Chinese translation BACKGROUND: Strains on the capacities of intensive care units (ICUs) may influence the quality of ICU-to-floor transitions.
To determine how 3 metrics of ICU capacity strain (ICU census, new admissions, and average acuity) measured on days of patient discharges influence ICU length of stay (LOS) and post-ICU discharge outcomes.
Retrospective cohort study from 2001 to 2008.
155 ICUs in the United States.
200 730 adults discharged from ICUs to hospital floors.
Associations between ICU capacity strain metrics and discharged patient ICU LOS, 72-hour ICU readmissions, subsequent in-hospital death, post-ICU discharge LOS, and hospital discharge destination.
Increases in the 3 strain variables on the days of ICU discharge were associated with shorter preceding ICU LOS (all P < 0.001) and increased odds of ICU readmissions (all P < 0.050). Going from the 5th to 95th percentiles of strain was associated with a 6.3-hour reduction in ICU LOS (95% CI, 5.3 to 7.3 hours) and a 1.0% increase in the odds of ICU readmission (CI, 0.6% to 1.5%). No strain variable was associated with increased odds of subsequent death, reduced odds of being discharged home from the hospital, or longer total hospital LOS.
Long-term outcomes could not be measured.
When ICUs are strained, triage decisions seem to be affected such that patients are discharged from the ICU more quickly and, perhaps consequentially, have slightly greater odds of being readmitted to the ICU. However, short-term patient outcomes are unaffected. These results suggest that bed availability pressures may encourage physicians to discharge patients from the ICU more efficiently and that ICU readmissions are unlikely to be causally related to patient outcomes.
Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute; and Society of Critical Care Medicine.
Annals of internal medicine 10/2013; 159(7):447-455. · 13.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: Rationale: The aging population may strain intensive care unit (ICU) capacity and adversely affect patient outcomes. Existing fluctuations in demand for ICU care offer an opportunity to explore such relationships. Objectives: To determine whether transient increases in ICU strain influence patient mortality, and identify characteristics of ICUs that are resilient to surges in capacity strain. Methods: Retrospective cohort study of 264,401 patients admitted to 155 U.S. ICUs from 2001-2008. We used logistic regression to examine relationships of measures of ICU strain (census, average acuity, and proportion of new admissions) near the time of ICU admission with mortality. Measurements and Main Results: 36,465 (14%) patients died in the hospital. ICU census on the day of a patient's admission was associated with increased mortality (OR: 1.02 per SD-unit increase (95% CI: 1.00, 1.03)). This effect was greater among ICUs employing closed (OR: 1.07 (95% CI: 1.02, 1.12)) versus open (OR: 1.01 (95% CI: 0.99, 1.03)) physician staffing models (interaction p-value=0.02). The relationship between census and mortality was stronger when the census was comprised of higher acuity patients (interaction p-value<0.01). Averaging strain over the first three days of patients' ICU stays yielded similar results except that the proportion of new admissions was now also associated with mortality (OR: 1.04 for each 10% increase (95% CI: 1.02, 1.06)). Conclusions: Several sources of ICU strain are associated with small but potentially important increases in patient mortality, particularly in ICUs employing closed staffing models. Although closed ICUs may promote favorable outcomes under static conditions, they are susceptible to being overwhelmed by patient influxes.
American Journal of Respiratory and Critical Care Medicine 08/2013; · 11.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine whether routine echocardiography increases diagnosis and treatment of patent ductus arteriosus (PDA) and whether randomized non-disclosure is a feasible strategy for studying PDA management.
2 center pilot randomized, controlled trial. 88 infants with birth weights <1250 grams and gestational ages <30 weeks were randomized to disclosure or non-disclosure of serial echocardiogram findings. Echocardiograms were performed at 3-5 and 7-10 days of life. The primary outcome was time to regain birth weight.
100% of echocardiograms in the disclosure group were disclosed; 16% (echocardiogram #1) and 29% (echocardiogram #2) were disclosed in the non-disclosure group. There was a statistically non-significant decrease in drug therapy for PDA in the non-disclosure group (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.24-1.34). There was no difference in time to regain birth weight or in other important neonatal outcomes. However, infants in the non-disclosure group were more likely to demonstrate appropriate weight loss and then regain birth weight within 7-14 days (AOR 2.64, 95% CI 1.08-6.44).
Randomized non-disclosure of echocardiograms is a feasible strategy for evaluation of approaches to PDA management in very preterm infants. Avoidance of routine echocardiography may reduce drug therapy for PDA without adverse clinical effects. This article is protected by copyright. All rights reserved.
[show abstract][hide abstract] ABSTRACT: Our objective was to determine tuberculin skin test conversion rate of health care workers traveling to Botswana. The rate of tuberculin skin test conversion was 4.2% for the entire group studied or 6.87 per 1000 person weeks (95% CI, 1.87-17.60).
International travel by health care workers traveling from low incidence countries to areas of the world where tuberculosis is highly endemic places the health care worker at an increased risk of acquiring tuberculosis.
To determine the tuberculin skin test conversion rate of health care workers living in the United States with previously negative tuberculin skin test results working for less than 1 year in a hospital in Botswana where tuberculosis is highly endemic.
We performed a cross-sectional survey among health care workers affiliated with the University of Pennsylvania School of Medicine who participated in patient care in Botswana between July 1st 2004 and June 30th 2009. We recruited health care workers after returning from Botswana who had a documented negative tuberculin skin test in the year prior to travel, who spent at least 2 weeks but not more than 1 year and who had a documented tuberculin skin test 2-3 months post travel. The main study outcome was a positive tuberculin skin test 6-12 weeks after returning from Botswana, defined by an area of at least 10mm induration 48-72h after placement of the tuberculin skin test.
95 Subjects participated in the study and there were 4 tuberculin skin test conversions. The rate of tuberculin skin test conversion in our study population was 4.2% for the entire group studied or 6.87 per 1000 person weeks (95% CI, 1.87-17.60).
The tuberculin skin test conversion rate was higher than the reported conversion rates for those not working in a health care setting.
Travel Medicine and Infectious Disease 08/2013; · 1.78 Impact Factor
[show abstract][hide abstract] ABSTRACT: Human Adenovirus (AdHu)-based candidate AIDS vaccine can provide protection from SIV transmission and disease progression. However, their potential use may be limited by widespread preexisting immunity to the vector. In contrast, preexisting immunity to chimpanzee adenoviruses (AdC) is relatively rare. In this study, we utilized two regimes of prime-boost immunizations with AdC serotype SAd-V23, also called AdC6, and SAd-V24 also called AdC7, expressing SIV-gag/tat to test their immunogenicity and ability to protect Rhesus Macaques (RMs) from a repeated low dose SIVmac239 challenge. Both AdC6 followed by AdC7 (AdC6/7) and AdC7 followed by AdC6 (AdC7/6) induced robust SIVgag/tat-specific T cell responses as measured by tetramer staining and functional assays. However, no significant protection from SIV transmission was observed in either AdC7/6- or AdC7/6-vaccinated RMs. Interestingly, in the RMs showing breakthrough infections, AdC7/6-SIV immunization was associated with a transient but significant (p=0.035 at day 90 and p=0.033 at day 120 post infection) reduction in set-point viral load as compared to unvaccinated controls. None of the measured immunological markers (i.e., number or functionality of SIV-specific CD8(+) and CD4(+) T cell responses, level of activated and/or CCR5(+) CD4(+) target cells) at the time of challenge correlated with protection from SIV transmission in the AdC-SIV-vaccinated RMs. The robust immunogenicity observed in all AdC-immunized RMs and the transient signal of protection from SIV replication exhibited by AdC7/6-vaccinated RMs even in absence of any Envelope immunogen suggest that AdC-based vectors may represent a promising platform for candidate AIDS vaccines.
[show abstract][hide abstract] ABSTRACT: Evidence-based practice is a shift in the health care culture from basing decisions on consensus opinion, past practice, and precedent toward the use of rigorous analysis of scientific evidence using outcomes research and clinical evidence to guide clinical decision making. The development of evidence-based clinical practice guidelines (CPG) is critical to guide the assessment and management of children with diabetes. This article provides an overview of the infrastructure and processes that are crucial to providing evidence-based care in a large urban pediatric diabetes center. Development of a CPG to identify microalbuminuria in children with type 1 diabetes is discussed.
Nursing Clinics of North America 06/2013; 48(2):343-52. · 0.43 Impact Factor
[show abstract][hide abstract] ABSTRACT: Administrators play a major role in choosing and managing the use of the electronic health record (EHR). The documentation policies and EHR changes enacted or approved by administrators affect the ability to use clinical data for research. This article illustrates the challenges that can be avoided through awareness of the consequences of customization, variations in documentation policies and quality, and user interface features. Solutions are posed that assist administrators in avoiding these challenges and promoting data harmonization for research and quality improvement.
The Journal of nursing administration 06/2013; 43(6):355-360. · 1.15 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND:: Intensive care unit (ICU) readmission rates are commonly viewed as indicators of ICU quality. However, definitions of ICU readmissions vary, and it is unknown which, if any, readmissions are associated with ICU quality. OBJECTIVE:: Empirically derive the optimal interval between ICU discharge and readmission for purposes of considering ICU readmission as an ICU quality indicator. RESEARCH DESIGN:: Retrospective cohort study. SUBJECTS:: A total of 214,692 patients discharged from 157 US ICUs participating in the Project IMPACT database, 2001-2008. MEASURES:: We graphically examined how patient characteristics and ICU discharge circumstances (eg, ICU census) were related to the odds of ICU readmissions as the allowable interval between ICU discharge and readmission was lengthened. We defined the optimal interval by identifying inflection points where these relationships changed significantly and permanently. RESULTS:: A total of 2242 patients (1.0%) were readmitted to the ICU within 24 hours; 9062 (4.2%) within 7 days. Patient characteristics exhibited stronger associations with readmissions after intervals >48-60 hours. By contrast, ICU discharge circumstances and ICU interventions (eg, mechanical ventilation) exhibited weaker relationships as intervals lengthened, with inflection points at 30-48 hours. Because of the predominance of afternoon readmissions regardless of time of discharge, using intervals defined by full calendar days rather than fixed numbers of hours produced more valid results. DISCUSSION:: It remains uncertain whether ICU readmission is a valid quality indicator. However, having established 2 full calendar days (not 48 h) after ICU discharge as the optimal interval for measuring ICU readmissions, this study will facilitate future research designed to determine its validity.
[show abstract][hide abstract] ABSTRACT: Of 1112 children with type 1 diabetes, dilated eye exams were performed in 717 (64%). Children were less likely to be screened for diabetic retinopathy (DR) if they were black (OR=1.6; p=0.005) or had poorer diabetes control (p=0.002). Those at greatest risk for DR were least likely to be screened.
Diabetes research and clinical practice 05/2013; · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: To assess whether women with polycystic ovary syndrome (PCOS) follow the same age-related decline in IVF outcomes as women with tubal factor infertility over the reproductive life span. PCOS is characterized by increased ovarian reserve as assessed by antral follicle counts and anti-Müllerian hormone levels. It is unclear whether these surrogate markers of ovarian reserve reflect a true lengthening of the reproductive window. DESIGN: Retrospective cohort. SETTING: Not applicable. PATIENT(S): Women with PCOS and tubal factor infertility (42,286 cycles). INTERVENTION(S): IVF. MAIN OUTCOME MEASURE(S): Pregnancy and live-birth rates. RESULT(S): The mean number of oocytes retrieved was higher in women with PCOS compared with in women with tubal factor (16.4 vs. 12.8; odds ratio [OR], 1.27; 95% confidence interval [CI], 1.25-1.29). The clinical pregnancy (42.5% vs. 35.8%; OR, 1.32; 95% CI, 1.27-1.38) and live-birth rates were also increased in women with PCOS (34.8% vs. 29.1%; OR, 1.30; 95% CI, 1.24-1.35). A similar rate of decline in clinical pregnancy and live-birth rates was noted in both groups (20-44 years). The implantation, clinical pregnancy, miscarriage, and live-birth rates were not significantly different for each year after age 40 in the two groups. CONCLUSION(S): Despite a higher oocyte yield in all age groups, women with PCOS over age 40 had similar clinical pregnancy and live-birth rates compared with women with tubal factor infertility. These findings suggest that the reproductive window may not be extended in PCOS and that patients with infertility should be treated in a timely manner despite indicators of high ovarian reserve.
Fertility and sterility 04/2013; · 3.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Population-based (PB) registries of type 1 diabetes (T1D) in children have been essential in determining the geographic, racial and temporal patterns of the disease. There is a paucity of PB data on the prevalence of type 1 and type 2 diabetes (T2D) in youth. METHODS: Prevalence of diabetes in children was determined using a PB survey of the 628 schools in Philadelphia. Data obtained included type of diabetes, DOB, race, gender, date of diagnosis, diabetes treatment, and most recent height and weight. RESULTS: The survey was completed by nurses at 510 schools (81% of schools) representing 252,896 children (70% of children in Philadelphia). Prevalence (per 1000) was computed assuming data were missing at random. The survey identified 492 school children with diabetes (355 T1D, 88 T2D, 49 type unknown). Overall prevalence of T1D was 1.58 (0.73 W, 0.56 AA, 0.50 H) and T2D was 0.35 (0.03 W, 0.28 AA, 0.05 H). Mean age of diagnosis was T1D= 8.6 yr, T2D= 11.9 yr. T1D was greater in males, T2D in females. Of children with T2D, 25% were treated with insulin. BMI was >95th % in 20% of children weighed; 10% of T1D, 57% of T2D. CONCLUSIONS: Although the Philadelphia Pediatric Diabetes Registry is the longest ongoing US incidence registry of its kind, these are the first PB prevalence data of children with diabetes in Philadelphia, PB studies in schools are able to capture children with diabetes who are diagnosed and treated in a variety of settings. THE SIGNIFICANT FINDING (S) OF THE STUDY: The Philadelphia data demonstrate that T1DM is 4.5 times more prevalent than T2DM in children. Although there has been a marked increase of T2DM, it is critical to recognize that T1DM continues to be a much greater risk for children. THIS STUDY ADDS: Few studies have examined the prevalence of diabetes in youth because of inherent difficulties in case ascertainment. These data are among the few derived from a population based prevalence study of type 1 and type 2 diabetes in youth.
[show abstract][hide abstract] ABSTRACT: Antibody and B cell responses to influenza A viruses were measured over a period of 2 months in 30 aged and 15 middle-aged individuals following vaccination with the 2011/12 trivalent inactivated influenza vaccine by micro-neutralization assays, ELISAs, ELISpot assays and cell surface staining with lineage-defining antibodies followed by multicolor flow cytometry. Both cohorts developed comparable antibody responses to the H3N2 virus of the vaccine while responses to the H1N1 virus were compromised in the aged. ELISpot assays of peripheral blood mononuclear cells (PBMCs) gave comparable results for the two cohorts. Analysis by flow cytometry upon staining of CD19+IgD-CD20- PBMCs with antibodies to CD27 and CD38 showed markedly reduced increases of such cells following vaccination in the aged. Additional analysis of cells from a subset of 10 younger and 10 aged individuals indicated that in the aged a portion of IgG producing cells lose expression of CD27 and reduce expression of CD38.
[show abstract][hide abstract] ABSTRACT: Of 151 youth with type 1 diabetes who were screened for peripheral neuropathy, and received nerve conduction studies, 11% were diagnosed with Diabetic Peripheral Neuropathy (DPN). DPN can occur in young children, with short diabetes duration, and good diabetes control. National guidelines for screening children for DPN should be developed.
Diabetes research and clinical practice 02/2013; · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE
The purpose of this study was to describe the incidence of type 1 diabetes in children in Philadelphia from 2000-2004, compare the epidemiology to the previous three cohorts in the Philadelphia Pediatric Diabetes Registry, and, for the first time, describe the incidence of type 2 diabetes.RESEARCH DESIGN AND METHODS
Diabetes cases were obtained through a retrospective population-based registry. Hospital inpatient and outpatient records were reviewed for cases of type 1 and type 2 diabetes diagnosed from 1 January 2000 to 31 December 2004. The secondary source of validation was the School District of Philadelphia. Time series analysis was used to evaluate the changing pattern of incidence over the 20-year period.RESULTSThe overall age-adjusted incidence rate in 2000-2004 of 17.0 per 100,000 per year was significantly higher than that of previous cohorts, with an average yearly increase of 1.5% and an average 5-year cohort increase of 7.8% (P = 0.025). The incidence in white children (19.2 per 100,000 per year) was 48% higher than in the previous cohort. Children aged 0-4 years had a 70% higher incidence (12.2 per 100,000 per year) than the original cohort; this increase was most marked in young black children. The overall age-adjusted incidence of type 2 diabetes was 5.8 per 100,000 per year and was significantly higher in black children.CONCLUSIONS
The incidence of type 1 diabetes is rising among children in Philadelphia. The incidence rate has increased by 29% since the 1985-1989 cohort. The most marked increases were among white children ages 10-14 years and black children ages 0-4 years. The incidence of type 1 diabetes is 18 times higher than that of type 2 in white children but only 1.6 times higher in black children.
[show abstract][hide abstract] ABSTRACT: In this study, we compared the immunogenicity and protection from repeated low-dose intrarectal SIVmac251 challenge in two groups of vaccinated RMs. Animals were immunized with live SIVmac239, which had been attenuated by a deletion of the nef sequence, or they were vaccinated twice with an E1-deleted AdHu5, expressing AdHu5gag. The vaccinated animals and a cohort of unvaccinated control animals were then challenged 10 times in weekly intervals with low doses of SIVmac251 given rectally. Our results confirm previous studies showing that whereas SIVΔnef provides some degree of protection against viral acquisition after repeated low-dose rectal SIVmac251 challenges, vaccination with an AdHu5gag vaccine designed to induce only antiviral T cell responses is ineffective. As immunological analyses of prechallenge, vaccine-induced T and B cell responses failed to reveal correlates of protection that distinguished the more susceptible from the more resistant vaccinated animals, we carried out RNA-Seq studies of paired pre- and postvaccination samples to identify transcriptional patterns that correlated with the differences in response. We show that gene expression signatures associated with the delayed SIV infection seen in some AdHu5gag recipients were largely present in prevaccination samples of those animals. In contrast, the responding SIVΔnef-immunized animals showed a predominance of vaccine-induced changes, thus enabling us to define inherited and vaccine-induced gene expression signatures and their associated pathways that may play a role in preventing SIV acquisition.
Journal of leukocyte biology 12/2012; · 4.99 Impact Factor