Jacobs Institute of Women's Health
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Adding hydroxyurea to chronic transfusion therapy for sickle cell anemia reduces transfusion burden
No full textBACKGROUND: Chronic red blood cell (RBC) transfusion is an established therapy to prevent stroke in patients with sickle cell anemia (SCA). It is unclear if adding daily hydroxyurea treatment to chronic transfusion is beneficial. STUDY DESIGN AND METHODS: We conducted a phase 2 clinical trial (NCT03644953) investigating the addition of dose-escalated hydroxyurea to chronic transfusion for patients with SCA receiving simple chronic transfusion for stroke prevention. Simple chronic transfusion therapy was administered as per the same protocol before and after hydroxyurea treatment in which the volume transfused was dependent on the pretransfusion hemoglobin (Hb). RESULTS: A total of 14 participants enrolled with nine completing one year of combination hydroxyurea and transfusion (HAT) therapy after reaching hydroxyurea target dose. No participant who discontinued the study prematurely had a serious adverse event attributed to HAT. Among the nine participants who completed the study, eight participants achieved a reduction in RBC transfusion volume with a median reduction of -19.4 mL/kg/year (interquartile range -31.8, -2.8 mL/kg/year), p = .02, when comparing pre- and post-HAT time periods. With the addition of hydroxyurea participants had a significant increase in pretransfusion Hb S% but this was balanced by an increased Hb F% and decreased lactate dehydrogenase. One participant developed a pretransfusion Hb \u3e11 g/dL and Hb S \u3e 45% that required holding hydroxyurea and changing to partial manual exchange transfusions. No patient had evidence of cerebrovascular disease progression. DISCUSSION: Hydroxyurea added to chronic transfusion therapy for patients with SCA is feasible and decreases RBC transfusion volume requirements
Skin Inflammation, Systemic Inflammation, and Cardiovascular Disease in Psoriasis
No full textIMPORTANCE: Psoriasis is associated with increased cardiovascular risk, but the underlying pathogenic mechanisms remain unclear. Elucidating these mechanisms can help develop treatment strategies and enhance understanding of the link between peripheral inflammation, such as psoriatic skin lesions, and cardiovascular disease (CVD). OBJECTIVE: To explore whether systemic inflammation is a mediator of the association between psoriasis skin disease severity and CVD. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from cross-sectional study (Psoriasis Atherosclerosis and Cardiometabolic Disease Initiative [PACI]), which enrolled patients from January 2013 to February 2022, and an inception cohort study (Stockholm Psoriasis Cohort [SPC]), which enrolled patients from January 2000 to December 2005. The PACI enrolled consecutive patients referred by dermatologists in Maryland, and the SPC enrolled consecutive patients referred from a wide range of practices in Sweden. Patients with prevalent psoriasis from the PACI and patients with incident psoriasis from the SPC were included. Data were analyzed from October 2023 to January 2024. EXPOSURES: Psoriasis skin disease severity was measured using the Psoriasis Area and Severity Index (PASI), and systemic inflammation was measured using glycan biomarker of N-acetyl side chains of acute-phase proteins (GlycA). Mediation analysis was performed by evaluating the associations between exposure, mediator, and outcome in patients with first-tertile and third-tertile PASI scores when GlycA level was set at the level observed in patients with first-tertile PASI. MAIN OUTCOMES AND MEASURES: Noncalcified coronary burden (NCB) measured using coronary computed tomography angiography in the PACI and hospitalization for CVD or cardiovascular death in the SPC. RESULTS: Of 260 eligible patients from the PACI, 162 (62.3%) were male, and the median (IQR) age was 51 (41-60) years; of 509 eligible patients from the SPC, 237 (46.6%) were male, and the median (IQR) age was 43 (30-57) years. In both studies, PASI was associated with GlycA level and CVD, and GlycA level was associated with CVD. The direct and indirect (through GlycA) effects of PASI on NCB were estimated at 0.94 (95% CI, 0.26-1.74) and 0.19 (95% CI, 0.02-0.47), respectively. The odds ratios for the direct and indirect effects of PASI on cardiovascular events were estimated at 1.23 (95% CI, 0.70-1.92) and 1.16 (95% CI, 1.04-1.42), respectively. CONCLUSIONS AND RELEVANCE: In this study, skin disease severity measured using PASI was associated with systemic inflammation, and both PASI and systemic inflammation, measured using GlycA levels, were associated with CVD. The association between PASI and CVD may be mediated by systemic inflammation
Lead Longevity in Pediatric and Congenital Heart Disease Patients: The Impact of Patient Somatic Growth
No full textBACKGROUND: Pacemakers and implantable cardioverter-defibrillators in pediatric and congenital heart disease (CHD) patients may be required for decades. In this population, there are sparse data on long-term lead functionality. OBJECTIVES: The aims of this study were to assess pacemaker and defibrillator lead survival in pediatric and CHD patients beyond 10 years after implantation and to identify patient- and lead-related factors associated with earlier lead failure. METHODS: This was a retrospective study reviewing all patients with a pacemaker or defibrillator who received care at a single large children\u27s hospital during a 30-year timespan. The log-rank test and Cox proportional hazards model were used to identify risk factors associated with earlier lead failure. RESULTS: Data were collected from 952 leads in 396 patients. Overall lead survival was 87% at 10 years, 78% at 15 years, and 69% at 20 years. Male sex, younger patient age, greater somatic growth, left ventricular lead location, and epicardial implantation approach were associated with higher likelihood of lead failure (log-rank test P \u3c0.05). On multivariate analysis, the most significant predictor of lead failure was patient somatic growth ≥5 cm/year (HR 3.33; 95% CI: 1.78-6.25). The presence of CHD, lead insulation, and lead manufacturer had no impact on lead longevity. CONCLUSIONS: Greater patient somatic growth is an important predictor of lead failure. Greater somatic growth may account for the observation in this study (and prior studies) that leads in male patients, younger patients, and implanted via epicardial approach were more likely to fail
An Education Initiative to Increase the Use of Video Laryngoscopy and Improve Prehospital Patient Outcomes
Get PDFAssociation of Race and Ethnicity With Emergency Room Rate of Migraine Diagnosis, Testing, and Management in Children With Headache
No full textBACKGROUND AND OBJECTIVES: Headache evaluation and treatment are believed to be influenced by race and ethnicity. Specific headache diagnosis assigned in the pediatric emergency department (ED) may compound disparities. We sought to investigate racial and ethnic disparities in the diagnosis, testing, and treatment of pediatric patients with headache presenting to the ED. METHODS: We performed a cross-sectional analysis of ED visits from 49 children\u27s hospitals between 2016 and 2022 from the Pediatric Health Information System, an administrative database of ED and hospitalized encounters within children\u27s hospitals in the United States. Index encounters in the ED from patients (aged 5-21 years, median age 13 [10-15]) with a primary diagnosis of migraine, headache, new daily persistent headache, or tension-type headache were included. Encounters with trauma, infection, and malignancy where secondary headache was possible were excluded. The primary outcomes were the rates of migraine diagnosis, testing, and treatment. We used generalized estimating equations to estimate associations between race and ethnicity and outcomes after adjusting for demographic factors, medical complexity, visit timing, and final headache diagnosis. RESULTS: A total of 309,678 encounters were included while 61,677 repeat visits, 81,821 visits with diagnoses suggestive of secondary headache, and 5,714 visits from 3 hospitals with sparse data on patient race/ethnicity were excluded. Of 160,466 eligible visits (59.8% female), 41% were by non-Hispanic White (NHW) children, 24.8% non-Hispanic Black (NHB), and 26.0% Hispanic/Latino (HL). NHW children were more frequently diagnosed with migraine (45.5% vs NHB 28.2% and HL 28.3%, p \u3c 0.001). NHB and HL children compared with NHW children received less testing including brain MRI scans (adjusted odds ratio [aOR]: NHB 0.56 [95% CI 0.46-0.69] and HL 0.54 [0.36-0.82]). There was no difference in the proportion of visits without administration of headache-related medications (NHW 23.3% vs NHB 24.6% and HL 23.4%, p = 0.64). NHB and HL children were more likely to receive only oral medications (aOR: NHB 1.37 [1.2-1.56] and HL 1.54 [1.34-1.76]) and less likely to be admitted inpatient (aOR: NHB 0.8 [0.66-0.97] and HL 0.65 [0.44-0.94]). DISCUSSION: NHB and HL children in the pediatric ED with headache receive fewer migraine diagnoses, less testing, and less intensive treatment compared with NHW children. Beyond affecting headache management, this inequity in migraine diagnosis requires further consideration to include children from marginalized racial and ethnic groups in future migraine research
Occupational Therapy Assessment Practice Patterns for Core Domains in Adult Populations
No full textPractitioners need to demonstrate the value of occupational therapy services in achieving effective patient outcomes. To intervene effectively, we must have adequate assessment practices. This study examines variation in occupational therapy assessment practices by facility type, areas addressed, and types of instruments. The study characterizes commonly and frequently used assessment practices in core occupational domains and identifies potential practice gaps related to assessment. A cross-sectional online survey across six domains central to adult occupational therapy practice (activities of daily living [ADL], instrumental activities of daily living [IADL], fear of falling, functional cognition, psychosocial, and vision) was administered to practitioners in various settings. Surveys were obtained from 1,198 respondent. Survey responses identified differences in domains being assessed and assessment methods used by occupational therapy practitioners across hospital inpatient post-acute care facilities and community settings. There is variability in the methods used to assess domains critical to occupational therapy practice and the degree to which occupational therapists evaluate domains in practice settings
Prediction of Hepatitis C Virus Perinatal Transmission in Pregnant Individuals With Hepatitis C Virus Infection
No full textOur objective was to develop a prediction model for hepatitis C virus (HCV) infection perinatal transmission to improve triage for neonatal follow-up. This was a secondary analysis of HCV antibody-positive participants who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network multicenter observational study of HCV infection in pregnancy. Among 432 participants, the perinatal transmission rate was 6.0% (95% CI, 4.0-8.7%). The prediction model was developed and included two factors: maternal HCV RNA titer greater than 106 international units/mL and having had any antepartum bleeding. Using this model, the area under the curve for perinatal transmission was 0.76 (95% CI, 0.67-0.86). Probabilities of perinatal transmission of HCV infection ranged from 1.5% (a pregnant individual with HCV RNA 106 international units/mL or less and no antepartum bleeding) to 28.5% (a pregnant individual with an HCV RNA titer greater than 106 international units/mL and antepartum bleeding). Our results provide data to aid in clinical counseling of pregnant individuals with positive HCV antibodies. Additional research is needed to externally validate this prediction model
Metabolic syndrome including both elevated blood pressure and elevated fasting plasma glucose is associated with higher mortality risk: a prospective study
No full textBACKGROUND: Metabolic syndrome (MetS) encompasses a collection of metabolic abnormalities. This study aims to determine which combination of MetS components has the highest mortality risk, and to investigate the causal relationships between MetS components and longevity. METHODS: Prospective analyses were conducted on 340,196 participants from the MJ cohort at baseline, and 121,936 participants had follow-up MetS information. We defined MetS according to the NCEP ATP III criteria. The study\u27s outcomes included mortality from cardiovascular disease (CVD), cancer, and all causes combined. We employed Cox proportional hazard models to calculate hazard ratios (HRs) and 95% confidence intervals. Multivariable Mendelian randomization (MVMR) was employed to infer causality using the genetic data of MetS components and longevity. RESULTS: Elevated blood pressure (BP) was the initial split for all-cause mortality, cancer mortality, and CVD mortality. Participants with MetS, especially those with elevated BP and elevated fasting plasma glucose (FPG), had higher mortality risks than those with other types of MetS. In the MJ cohort, participants with elevated BP and FPG (BG-type MetS) had a 44% (HR = 1.44, 95% CI = 1.37-1.51), 73% (HR = 1.73, 95% CI = 1.62-1.84), and 34% (HR = 1.34, 95% CI = 1.27-1.42) increased risk of all-cause mortality, cancer mortality, and CVD mortality, respectively, compared with non-BG-type MetS (12%, 24%, 5%). The highest mortality rate and mortality risk were observed in participants with BG-type MetS at baseline and follow-up (mortality rate/1000 person years = 9.73, 95% CI = 8.81-10.74; HR = 1.52, 95% CI = 1.35-1.72). SBP and FPG increases that were genetically proxied to a 1-standard deviation higher level decreased the probabilities of living to the 90th percentile age by 41% (OR = 0.59, 95% CI = 0.40-0.86) and 32% (OR = 0.68, 95% CI = 0.48-0.98) in MVMR, respectively. CONCLUSIONS: Individuals with BG-type MetS are at a higher risk of death than those with other types of MetS. Therefore, these individuals should be targeted to improve MetS outcomes
Insurance and In-hospital Outcomes of Type A Aortic Dissection Repair: A Population Study of National Inpatient Sample from 2015-2020
No full textBACKGROUND: Although insurance status has been linked to surgical outcomes in thoracic aortic operations, its specific association with the outcomes of Type A Aortic Dissection (TAAD) repair remains underexplored. This study aimed to conduct a comprehensive, population-based analysis to assess the association between insurance status and in-hospital outcomes after TAAD repair using a national registry. METHODS: Patients who underwent TAAD repair were identified in National Inpatient Sample from the last quarter of 2015 to 2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients using public and private insurance while adjusting for demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status. RESULTS: There were 2,380 (55.58%) and 1,468 (34.28%) patients under public and private insurance, respectively. Patients under public and private insurance had comparable time from admission to operation (p = 0.08) and adjusted in-hospital mortality rates (aOR = 1.172, 95 CI = 0.925-1.484, p = 0.19). However, patients under public insurance had higher mechanical ventilation (aOR = 1.185, 95 CI = 1.024-1.373, p = 0.02), acute kidney injury (aOR = 1.213, 95 CI = 1.052-1.399, p = 0.01), and infection (aOR = 1.428, 95 CI = 1.087-1.876, p = 0.01). Moreover, patients under public insurance had higher transfer-out rate (p \u3c 0.01), longer length of stay (p \u3c 0.01), and higher total hospital charge (p \u3c 0.01). CONCLUSION: Although patients with public insurance had comparable adjusted mortality outcomes to those of privately insured patients, they experienced higher rates of postoperative complications and resource utilization. Future studies should investigate the underlying systemic reasons for these disparities and explore strategies for improving surgical outcomes and ensuring equitable healthcare delivery for these vulnerable populations
Coffee drinking timing and mortality in US adults
No full textBACKGROUND AND AIMS: To identify the patterns of coffee drinking timing in the US population and evaluate their associations with all-cause and cause-specific mortality. METHODS: This study included 40 725 adults from the National Health and Nutrition Examination Survey 1999-2018 who had complete information on dietary data and 1463 adults from the Women\u27s and Men\u27s Lifestyle Validation Study who had complete data on 7-day dietary record. Clustering analysis was used to identify patterns of coffee drinking timing. RESULTS: In this observational study, two distinct patterns of coffee drinking timing [morning type (36% of participants) and all-day-type patterns (14% of participants)] were identified in the National Health and Nutrition Examination Survey and were validated in the Women\u27s and Men\u27s Lifestyle Validation Study. During a median (interquartile range) follow-up of 9.8 (9.1) years, a total of 4295 all-cause deaths, 1268 cardiovascular disease deaths, and 934 cancer deaths were recorded. After adjustment for caffeinated and decaffeinated coffee intake amounts, sleep hours, and other confounders, the morning-type pattern, rather than the all-day-type pattern, was significantly associated with lower risks of all-cause (hazard ratio: .84; 95% confidential interval: .74-.95) and cardiovascular disease-specific (hazard ratio: .69; 95% confidential interval: .55-.87) mortality as compared with non-coffee drinking. Coffee drinking timing significantly modified the association between coffee intake amounts and all-cause mortality (P-interaction = .031); higher coffee intake amounts were significantly associated with a lower risk of all-cause mortality in participants with morning-type pattern but not in those with all-day-type pattern. CONCLUSIONS: Drinking coffee in the morning may be more strongly associated with a lower risk of mortality than drinking coffee later in the day