1,721,085 research outputs found
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A retrospective analysis of patients with AF and HF undergoing treatment with Drug Therapy vs Catheter ablation: Which was better?
Get PDFBackground: Atrial fibrillation (AF) and heart failure (HF) are common cardiac disorders associated with substantial morbidity, mortality, and economic cost. AF can lead to HF, and HF can lead to AF. Hospital admissions for heart failure (HF) have been increasing over the past decade due to an aging population as well as longer survival of patients with chronic heart disease. Atrial fibrillation (AF) is present in up to 50% of patients with HF and both are associated with several common predisposing risk factors and a shared pathophysiology1Patients with these two diseases may encounter conflicting opinions from physicians based on guidelines on what is the most effective disease management and treatment strategy. Treating AF to restore sinus rhythm has been shown to positively affect long and short-term outcomes in patients suffering from HF. Prospective studies have compared catheter ablation with rate or rhythm control drugs for AF treatment among patients with HF and between the studies had found the former approach to be superior to the latter. One of the largest electrophysiology studies to date, is the Catheter Ablation versus Antiarrhythmic drug therapy for Atrial fibrillation (CABANA) trial. This study randomized more than 2,000 patients to either catheter ablation or drug therapy. It demonstrated catheter ablation as not having a clinical benefit in patients with heart failure. On the other hand, a second multicenter randomized controlled trial, showed that for patients suffering from heart failure, catheter ablation for treatment was associated with a significantly lower rate of death from any cause or hospitalization for worsening heart failure than drug therapy.2 This proposed study aims to provide real-world evidence (RWE) on the treatment options and examine whether or not catheter ablation emerges as superior to drug therapy in a real-world setting.Objectives: Compare the outcomes between two cohorts: ablation or drug therapy. Outcomes included inpatient admissions (all-cause, cardiovascular and AF), direct current cardioversions and treatment costs in the 12-month post-index period. Methods/Study design: A retrospective analysis was performed on all adults with a primary or secondary diagnosis of HF and AF in an inpatient or outpatient setting between January 1, 2011 and September 30th, 2016. These patients were identified from the Truven Health MarketScan® Commercial Claims and Encounters (CCAE) (IBM Truven Health Analytics, Ann Arbor, MI). The index episode was defined as their first database recording with HF, defined as the patient’s index date. A search strategy, using hospital charge codes, allowed for creation of two separate treatment cohorts: catheter ablation cohort or drug cohort. The catheter ablation cohort consisted of a) patients who were >18 years of age, b) patients with a primary procedure of ablation in an inpatient setting with a primary diagnosis of AF and a secondary diagnosis of HF in an inpatient setting OR c) primary diagnosis of HF and a secondary diagnosis of AF in an inpatient setting. For the ablation arm, those who had a previous catheter ablation in the 12 month pre- index date or did not have continuous insurance coverage 12- month post index date were removed. The drug therapy arm consisted of: a) patients >18 years of age, b) had a primary or secondary diagnosis of AF AND c) used a rhythm or rate control drug from 2011 to 2016 . Patients who had a catheter ablation procedure 12-month pre or post their index date were removed from the arm and considered for the ablation arm.Statistical analysis was performed to assess outcomes. A propensity score matching was run comparing catheter ablation versus drug therapy on all study outcomes: inpatient admissions (all-cause, cardiovascular and AF) direct current cardioversions and financial costs. Separate Logistic regression models were estimated for all-cause, CV-related, and AF-related admissions) and a generalized linear model was estimated for the cost outcome.Results A total of 1,225,988 patients were assessed for eligibility, including HF as a primary or secondary diagnosis. Of those, 169, 846 also had a primary or secondary diagnosis of AF. There were 9, 522 patients that qualified for the ablation cohort. Of this group 65% (6, 191) were retained after primary and secondary diagnosis exclusions were applied as well as all other exclusions regarding age, and previous surgeries. The drug cohort included 45, 748 patients. Following application of exclusion and inclusion criteria, there were 24, 265 remaining in this group.The propensity score matched (5,800 Ablation Group and 5,800 Drug Therapy) patients were included in the sub-analysis. The Ablation group had significantly lower odds of all-cause (odds ratio [OR] 0.393; 95% CI 0.206 - 0.747) and cardiovascular-related readmissions (OR 0.269; 95% CI 0.096- 0.754), and lower events of DCCV (OR 0.57; 95% CI 0.35–0.93) than those patients in the Drug therapy group. ConclusionIn conclusion, comparing catheter ablation with drug therapy in HF patients treated for atrial fibrillation, catheter ablation was associated with lower odds of all-cause inpatient readmission. Patients treated with catheter ablation showed at 12-months to have a reduction in burden of atrial fibrillation in forms of lower re-admission rates (All causes, AF/CV-related) and reduced number of direct current cardioversions. There was no significant difference in costs for either group
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Comparison of Primary Compliance in Electronic versus Paper Prescriptions Prescribed from the Emergency Department
Get PDFThe Medicare Improvements for Patients and Providers Act passed by Congress in 2008 has changed prescribing practices in the United States. Electronic prescriptions (e-prescriptions) have now become the most widely used form of prescriptions. The government in fact financially discourages the use of the older more traditional paper prescriptions. Many emergency medicine physicians fear that this blanket policy is not in the best interests of their unique patient population. It is the belief of many of these physicians that emergency patients are more likely to fill paper prescriptions than e-prescriptions. This theory is predicated on the knowledge that many emergency patients are less established in the system and their visits are frequently rushed, chaotic, and unplanned. For these reasons, the e-prescription system is not ideal for them and the theorized consequence is that many e-prescriptions go unfilled, leaving patients to go untreated. A retrospective analysis was conducted at the emergency department of the University of California, Irvine Medical Center to identify insured adult patients who were given a non-controlled substance prescription in either the paper or electronic form. Pharmacy claim data to insurances was used to determine whether these prescriptions were filled. 405 encounters were included, 218 of which included e-prescriptions and 187 of which included paper prescriptions. Our findings showed that paper prescriptions are filled at the same rate as electronic prescriptions (58.3% versus 57.8% p=1). These results were surprising as they contradicted what many physicians believe is the situation. More studies are needed in order to be able to broaden these results to the entire emergency medicine patient population, but these results may begin to alter prescription practices in emergency medicine
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p53 Restoration in Ovarian Carcinoma Harnessing a Genetic Aberration
Get PDFOvarian cancer is the most fatal gynecologic malignancy. The majority of deaths are in advance staged patients with high-grade serous histology. Most patients respond to primary surgery and chemotherapy yet experience recurrent disease. Chemotherapy remains central to recurrent treatment and is rarely curative. There is an unmet clinical need for additional treatment options. Advancements in tumor biology, particularly the genetic landscape of ovarian cancer, shape current researched therapeutic targets. The genotypic characterization of this malignancy is generalized by chromosomal disarray and p53 mutations. Mutations of p53 are ubiquitous across cancer. These mutations are a rational target for therapeutic exploration due to the frequency in ovarian carcinoma and its dominant role in tumor suppression. Small molecule compounds, including 38RNW, have been developed that bind to mutated p53 and partially restore wild-type tumor suppressor function. This translational approach leads to the hypothesis that 38RNW would synergistically combine with other drugs to induce apoptosis in an in-vitro model. Herein, a high throughput robotic nano-technology platform was implored to identify synergistic combinations with 38RNW in TOV-112D ovarian cancer cells. A Luciferase-base cell proliferation assay was implored to determine inhibitor effects in a high-throughput approach. Z-scores were calculated comparing plate averages of luciferase values to individual compounds or change in half-inhibitor concentration. 38RNW demonstrated strong synergistic activity with mammalian target of rapamycin/phosphatidylinositol 3-kinase (mTOR/PI3K) and polo-like kinase 1(Plk-1) inhibitors. The lead candidates warrant further investigation. Our long-term objective is to develop p53 restoration drug combinations for ovarian cancer treatment
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Risk Factors for Prostate Cancer Recurrence in African American Patients: VA versus Non-VA Healthcare Recipients
Get PDFBiochemical recurrence (BCR) has been a cause of concern for patients and medical professionals. Although several studies have reported that only half of the patients with BCR eventually progress to metastatic disease at 10 years, there is a substantial need for developing a predictive pattern or algorithm to efficiently identify and categorize prostate cancer patients based on their risk of recurrence. Currently non-Hispanic African American adults experience the highest incidence and mortality rates for cancers, with prostate cancer being one of the most prevalent. These statistics could be significantly reduced by introducing an appropriate predictive mechanism by which patients with higher risk of recurrence and tumor progression could be identified and recommended for more aggressive treatments during initial diagnosis, preventing possible progression to metastasis. Recurrence and oncologic outcomes may be dependent on sociodemographic factors and certain other factors contributing to comorbidities. We selected the patients from Veterans Affairs medical facilities for a comparison group, primarily due to reports suggesting that VA patients provide a diverse group of individuals with different socioeconomic, educational, and medical backgrounds. VA patients are generally expected to present with clinically worse comorbidities. Ultimately, the aim was to demonstrate a significant association between higher SES and lowered risk of BCR in African American prostate cancer patients, adjusted for the site of care. We used ‘complexity’, Gleason, and Decipher scores to compare the differences in African American and White patients adjusting for site of care. Our results suggest that African American patients have higher complexity scores, which we defined as a dynamic state in which the personal, social, and clinical aspects of the patient's experience operate as complicating factors. African American patients also had higher Decipher scores regardless of site of care, suggesting a higher risk of BCR. Our findings indicate that complexity scores and Decipher scores can be simultaneously employed to assist in identifying patients with high risk of BCR, allowing for recommendations for intensive treatments
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Assessing Risk Factors for Pediatric Medical Injuries Using Nationwide Malpractice Data
Get PDFPediatrics is considered a low-liability medical specialty with respect to the odds of facing a malpractice claim, yet indemnity payments made by pediatricians are among the most expensive of all physicians. Little is known about pediatric malpractice risks from a patient-perspective; especially non-obstetric risks in the infant population, and whether certain pediatric age groups are higher-risk for malpractice injuries. This study uses ten years of malpractice reports from the National Practitioner Data Bank (n = 70,441) to compare pediatric (infant, child, and teenage groups) to adult malpractice events. We compare the severity of injuries and the type of medical errors that were reported, and calculate rates for malpractice reports on a per capita (per 100K population) level for each age group. We found that the pediatric population is a heterogeneous patient population with unique age-specific risk factors. On a per-capita basis, non-obstetric infant malpractice claims were much more common than adult claims, whereas non-infant pediatric claims were less common than in adults. Devastating non-fatal permanent injuries such as brain damage and paralysis were exponentially more common in the infant population across most non-obstetric medical error types. Overall, diagnostic and treatment-related errors were more common among pediatric claims than in adults, whereas surgical and medication-related errors were less common. While previous research has identified the significance of obstetric injuries in the infant population, future safety and training efforts should also focus on reducing the potential for negligence that can lead to non-obstetric paralysis or brain damage injuries in the infant population, particularly in the realms of diagnosis and treatment
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Pregnancy Outcomes of Pre-viable Preterm Premature Rupture of Membranes: A Systematic Review
Get PDFOBJECTIVE: The aim of my study was: to assess the maternal and neonatal outcomes of pre-viable PPROM pregnancies and to describe the predictors for better outcomes of these pregnancies.METHODS: I performed a systematic review of the literature published on the pregnancy outcomes of pre-viable PPROM following expectant management. I collected 17 high-quality studies through PubMed database search and reviewed them to obtain data on neonatal survival; maternal and neonatal morbidity; predictors for better neonatal survival and proportion of women opting for termination of pregnancies. RESULTS: The overall survival to hospital discharge was 41.1%. Of these, 49.2% neonates survived without a major morbidity. Respiratory morbidity was the most common morbidity among surviving neonates. 37% neonates suffered from respiratory distress syndrome, 28% from bronchopulmonary dysplasia, and 9.8% from pulmonary hypoplasia. Sepsis occurred in 22.7% neonates. 49.3% pre-viable PPROM women developed chorioamnionitis. Other common maternal morbidities included cesarean delivery (33%) and placental abruption (30%). The predictors of better neonatal survival to discharge included later gestational age at PPROM, an absence of oligohydramnios, iatrogenic etiology of PPROM, and the C-reactive protein (CRP) level <1mg/dl on the first day of the presentation. Later gestational age at birth was associated with less neonatal morbidity. Overall, 21.1% of pre-viable PPROM women opted for the termination of pregnancy instead of expectant management.CONCLUSION: The survival rate of pre-viable PPROM is poor, but it is not zero. 4 of every 10 affected neonates do survive and half of them are without any major morbidity. Maternal morbidity is still high, but serious maternal morbidities are rare
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Association of race and socioeconomic status with prostate cancer genomic risk classifier: Implications for precision medicine in prostate cancer
Get PDFBackground: Africans Americans, low socioeconomic status (SES) and other minority patients have been observed to have higher rates of metastasis and prostate cancer specific mortality. There are several known genetic differences in prostate cancer between Whites and other minority patients which may adversely impact interpretations of validated genetic tests like the Decipher. Methods: We conducted a cross-sectional analytical study of men with early stage prostate cancer. Mean Decipher scores, Decipher risk categories and gene expression signatures related to molecular pathways and treatment response were analyzed by race/ ethnicity and SES using one way of analysis of variance, linear and logistic regression. Results: African Americans and other minority patients had non-significantly higher mean Decipher scores (p=0.227). There were non-significant differences in the distribution of Decipher risk categories by race/ethnicity (p=0.167). African American men had slightly lower ETS-related gene (ERG), lower E26 transformation-specific (ETS), higher serine protease inhibitor Kazal-type 1 (SPINK1) and higher Triple Negative molecular subtypes compared to Whites. African American men had slightly higher post-op radiation response (p=0.207), higher dasatinib sensitivity (p=0.002), but lower docetaxel sensitivity (p=0.007) and lower androgen receptor signaling (p=0.133) compared to Whites. Conclusions: There were non-significant associations of Decipher scores with race or SES. However, African Americans and other minorities differed in the molecular subtypes and pharmacogenomics of docetaxel and dasatinib compared to Whites. Future efforts to create a precision medicine model for predicting outcomes and personalizing treatments to reduce prostate cancer disparities should include genetic differences in tumor by race/ ethnicity and treatment response
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Significance of Decipher genomic classifier risk scores for Prostate Cancer: A Systematic Review
Get PDFProstate Cancer (PCa) is a non-cutaneous malignancy in men. Considering the severity of the disease, it is essential to consider the early detection and screening of prostate-specific antigen for decreasing the incidence of death due to this disease. Decipher is a genomic test that has gained increasing attention in estimating the risk of developing a recurrence or metastatic PCa disease in patients. Therefore, this study is focused on evaluating the association of Decipher score risk with recurrence of prostate cancer patients based on their medical, genetic predictors, and demographics (e.g., races) by conducting a systematic review. Moreover, the study would also assess whether Decipher score risk can be a good predictor for prostate patients’ metastasis and prostate cancer-specific mortality in men and clinical decision-making regarding Treatment Recommendations for patients. The research study reviewed 120 research articles, and the results of the systematic review have been presented in the form of themes. The studies' review indicated that Decipher acts as a genomic metastasis signature to predict metastatic disease among patients and make better decisions about treating the disease. Moreover, this genomic test can also be used in conjunction with MRI for identifying the lesions that may carry the biological potential for early metastases. Furthermore, the studies also identified that treatment options for PCa might range from ART and SRT to RP; however, the selection of treatment methodology depends upon the GC score and risk stratification. The results further suggested that the occurrence of PCa is two folds greater among AA men than non-AA men. The increasing incidence of PCa among AA and discrimination within AA's health and socio-economic conditions plays a significant role in treating AA. In this scenario, the Decipher score plays an essential role in making treatment decisions. Hence, this research has reviewed the evidence of benefits of the Decipher test, placed the usage into clinical context, made recommendations to help providers and patients know which treatment might be more appropriate based on the GC score, and when they should consider using the Decipher score based on the works of literature. To conclude, further trials are still required for validating the Decipher biomarkers. All treatment options should be managed based on the individual risk profile and sensitivity to particular medical treatment. As a future direction, scientists could enhance decipher score ability to be run on blood samples of a patient instead of tumor tissue, which will help patients to use decipher test as a screening test at the asymptomatic level. In this way, this test can be routinely done for patients with a family history of prostate cancer, and the biopsy will not be required during the screening stage
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Patients with Alzheimer’s Disease Die More Frequently Than Other Patients During Emergency Department Visit and Subsequent Hospital Stay
Get PDFBackground: Patients with dementia have an average 2 to 8 additional comorbidities which may accelerate progression of cognitive and functional impairments in the under-diagnosed and under-treated conditions. Patients with dementia who visit the emergency departments (ED) more frequently are hospitalized more often than patients without dementia and have higher mortality after an ED visit than patients without dementia.Methods: The Nationwide Emergency Department Sample (NEDS) for the years 2006-2010 was used for the present study. All samples with a diagnosis of Alzheimer’s disease (AD) or any of 18 comorbidities in the listed (n=15) ICD-9 diagnoses, and patients aged 55 years and above (35,429,235 samples) were included. The frequencies of 18 comorbidities being listed with the AD diagnoses in the died-in-visit AD sample and their impacts on the likelihood of AD patients died-in-visit were investigated.Results: In the whole sample, the mean age was 71.33 years, 57.2% were female. The number of patients with AD is 754011 (2.1%). Hypertension is the most frequent diagnosis in total samples (14343260, 40.5%) and in AD samples (379507, 50.3%). The number of total patients died-in- visit is 672722 (1.8%). The number of total AD patients died-in-visit is 26603 (4.0%). Hypertension is the most frequent diagnosis in total samples (40.5%) and in AD samples (50.3%); As for died-in-visit AD samples, dysrhythmias (52.5%) is the most frequent diagnosis followed by hypertension (30.3%), atherosclerosis (23.1%), chronic heart disease (12.7%) hypotension (8.6%), COPD (8.3%), brain hemorrhage (4.2%), and asthma (3.9%). AD patients have increased likelihood of dying with brain hemorrhage (OR = 7.06; 95% CI, 6.51 – 7.65, p < 0.001), hypotension (OR = 2.49; 95% CI, 2.36 – 2.63, p < 0.001), dysrhythmias (OR = 2.48; 95% CI, 2.40 – 2.55, p < 0.001), gastrointestinal ulcer (OR = 1.26; 95% CI, 1.02 - 1.55, p=0.032), diabetes mellitus (OR = 1.21; 95% CI, 1.16 - 1.27, p < 0.001), and atherosclerosis (OR = 1.08; 95% CI, 1.04 - 1.13, p < 0.001).Conclusions: cardiovascular comorbidities are overwhelmingly common in AD patients died-in-visit after being admitted to ED. Screening newly admitted AD patients in ED for these comorbidities may help address them early and reduce the likelihood of dying-in-visit
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Systematic Review of Veteran Suicide Literature
Get PDFOBJECTIVE: This systematic review was conducted to assess published literature that estimated the suicide risk of military veterans relative to nonveterans, to identify differences in suicide risk and, if indicated, to identify causes of such differences to orient preventative measures.METHODS: I performed a systematic review of literature regarding suicide risk of U.S. military veterans relative to U.S. nonveterans. Studies were not excluded based on method of suicide. Studies counting suicides were preferred to studies of ideation or attempts. Intervention studies were excluded.RESULTS: Studies that met inclusion criteria were scrutinized in terms of methods, comorbidities, demographics, potential causes, general conclusions, and posited theory. I identified 115 unique studies from PubMed, Scopus, PsycInfo, and CINAHL, and secondary references. Of these, 13 studies offered direct and original comparisons of veteran and non-veteran suicide risk.CONCLUSION: Increased risk of suicide among Vietnam veterans was best demonstrated by Hearst et al. (1986). The cause(s) of that increased risk are unknown but are unlikely unique to the Vietnam era. Suicide risk is not distributed evenly among veterans. Individuals who volunteer for military service are more likely to have had a pre-military trauma, but lower military suicide rates suggest a social structure protective against suicide. Suicide risk peaks in veterans immediately after discharge. The causes of these increases are unknown. Several theories are discussed
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