Deepak J.A.,University of Maryland Baltimore County |
Deepak J.A.,Baltimore Veterans Administration Medical Center |
Ng X.,University of Maryland, Baltimore |
Feliciano J.,University of Maryland Baltimore County |
And 3 more authors.
Annals of the American Thoracic Society | Year: 2015
Rationale: Up to 80% of patients with lung cancer have comorbid chronic obstructive pulmonary disease (COPD). Many of them are poor candidates for stage-specific lung cancer treatment due to diminished lung function and poor functional status, and many forego treatment. The negative effect of COPD may be moderated by pulmonologist-guided management. Objectives: This study examined the association between pulmonologist management and the probability of receiving the recommended stage-specific treatment modality and overall survival among patients with non-small cell lung cancer (NSCLC) with preexisting COPD. Methods: Early- and advanced-stage NSCLC cases diagnosed between 2002 and 2005 with a prior COPD diagnosis (3-24 months before NSCLC diagnosis) were identified in Surveillance, Epidemiology, and End Results tumor registry data linked to Medicare claims. Study outcomes included receipt of recommended stage-specific treatment (surgical resection for early-stage NSCLC and chemotherapy for advanced-stage NSCLC [advNSCLC]) and overall survival. Pulmonologist management was considered present if one or more Evaluation and Management visit claims with pulmonologist specialty were observed within 6 months after NSCLC diagnosis. Stage-specific multivariate logistic regression tested association between pulmonologist management and treatment received. Cox proportional hazard models examined the independent association between pulmonologist care and mortality. Two-stage residual inclusion instrumental variable (2SRI-IV) analyses tested and adjusted for potential confounding based on unobserved factors or measurement error. Measurements and Main Results: The cohorts included 5,488 patients with early-stage NSCLC and 6,426 patients with advNSCLC disease with preexisting COPD. Pulmonologist management was recorded for 54.9% of patients with early stage NSCLC and 35.7% of patients with advNSCLC. Of those patients with pulmonologist involvement, 58.5% of patients with early NSCLC received surgical resection, and 43.6% of patients with advNSCLC received chemotherapy. Pulmonologist management post NSCLC diagnosis was associated with increased surgical resection rates (odds ratio, 1.26; 95% confidence interval, 1.11-1.45) for early NSCLC and increased chemotherapy rates (odds ratio, 1.88; 95% confidence interval, 1.67-2.10) for advNSCLC. Pulmonologist management was also associated with reduced mortality risk for patients with early-stage NSCLC but not AdvNSCLC. Conclusions: Pulmonologist management had a positive association with rates of stage-specific treatment in both groups and overall survival in early-stage NSCLC. These results provide preliminary support for the recently published guidelines emphasizing the role of pulmonologists in lung cancer management. Copyright © 2015 by the American Thoracic Society.
Blum K.,Inova Fairfax Heart and Vascular Institute |
Gottlieb S.S.,University of Maryland Baltimore County |
Gottlieb S.S.,Baltimore Veterans Administration Medical Center
Journal of Cardiac Failure | Year: 2014
Background Telemonitoring has been advocated as a way of decreasing costs and improving outcomes, but no study has looked at true Medicare payments and 30-day readmission rates in a randomized group of well treated patients. Objective The aim of this work was to analyze Medicare claims data to identify effects of home telemonitoring on medical costs, 30-day rehospitalization, mortality, and health-related quality of life. Methods A total of 204 subjects were randomized to usual-care and monitored groups and evaluated with the SF-36 and Minnesota Living With Heart Failure Questionnaire (MLHF). Hospitalizations, Medicare payments, and mortality were also assessed. Monitored subjects transmitted weight, blood pressure, and heart rate, which were monitored by an experienced heart failure nurse practitioner. Results Subjects were followed for 802 ± 430 days; 75 subjects in the usual-care group (316 hospitalizations) and 81 in the monitored group (327 hospitalizations) were hospitalized at least once (P =.51). There were no differences in Medicare payments for inpatient or emergency department visits, and length of stay was not different between groups. There was no difference in 30-day readmissions (P =.627) or mortality (P =.575). Scores for SF-36 and MLHF improved (P <.001) over time, but there were no differences between groups. The percentage of patients readmitted within 30 days was lower with telemonitoring for the 1st year, but this did not persist. Conclusions Telemonitoring did not result in lower total costs, decreased hospitalizations, improved symptoms, or improved mortality. A decrease in 30-day readmission rates for the 1st year did not result in decreased total cost or better outcomes. © 2014 Elsevier Inc. All rights reserved.
Kalaria C.,University of Maryland Baltimore County |
Kittner S.,University of Maryland Baltimore County |
Kittner S.,Baltimore Veterans Administration Medical Center
Neurologic Clinics | Year: 2015
Although screening for hypercoagulable states is commonly performed as part of the evaluation of first arterial ischemic stroke in young adults, available evidence does not support this as a routine practice, even in patients with cryptogenic stroke and a positive family history of early thrombotic events or in patients with a patent foramen ovale. Testing for antiphospholipid antibodies is a possible exception because persistent antibodies are associated with an increased risk of recurrent stroke. Despite the lack of supporting data, screening for hypercoagulable states in recurrent early-onset cryptogenic cerebral ischemia could be considered. © 2015.
Dipietro L.,Massachusetts Institute of Technology |
Krebs H.I.,Massachusetts Institute of Technology |
Krebs H.I.,University of Maryland, Baltimore |
Volpe B.T.,Feinstein Institute for Medical Research |
And 7 more authors.
IEEE Transactions on Neural Systems and Rehabilitation Engineering | Year: 2012
Both the American Heart Association and the VA/DoD endorse upper-extremity robot-mediated rehabilitation therapy for stroke care. However, we do not know yet how to optimize therapy for a particular patient's needs. Here, we explore whether we must train patients for each functional task that they must perform during their activities of daily living or alternatively capacitate patients to perform a class of tasks and have therapists assist them later in translating the observed gains into activities of daily living. The former implies that motor adaptation is a better model for motor recovery. The latter implies that motor learning (which allows for generalization) is a better model for motor recovery. We quantified trained and untrained movements performed by 158 recovering stroke patients via 13 metrics, including movement smoothness and submovements. Improvements were observed both in trained and untrained movements suggesting that generalization occurred. Our findings suggest that, as motor recovery progresses, an internal representation of the task is rebuilt by the brain in a process that better resembles motor learning than motor adaptation. Our findings highlight possible improvements for therapeutic algorithms design, suggesting sparse-activity-set training should suffice over exhaustive sets of task specific training. © 2006 IEEE.
Ma X.,University of Maryland, Baltimore |
Holt D.,University of Maryland, Baltimore |
Kundu N.,University of Maryland, Baltimore |
Reader J.,University of Maryland, Baltimore |
And 4 more authors.
OncoImmunology | Year: 2013
Cyclooxygenase-2 is frequently upregulated in epithelial tumors and contributes to poor outcomes in multiple malignancies. The COX-2 product prostaglandin E2 (PGE2) promotes tumor growth and metastasis by acting on a family of four G protein-coupled receptors (EP 1-4). Using a novel small molecule EP 4 antagonist (RQ-15986) and a syngeneic murine model of metastatic breast cancer, we determined the effect of EP 4 blockade on innate immunity and tumor biology. Natural killer (NK)-cell functions are markedly depressed in mice bearing murine mammary tumor 66.1 or 410.4 cells owing to the actions of PGE2 on NK cell EP 4 receptors. The EP 4 agonist PGE1-OH inhibits NK functions in vitro, and this negative regulation is blocked by RQ-15986. Likewise, the treatment of tumor-bearing mice with RQ-15986 completely protected NK cells from the immunosuppressive effects of the tumor microenvironment in vivo. RQ-15986 also has direct effects on EP 4 expressed by tumor cells, inhibiting the PGE2-mediated activation of adenylate cyclase and blocking PGE2-induced tumor cell migration. The pretreatment of tumor cells with a non-cytotoxic concentration of RQ-15986 inhibited lung colonization, a beneficial effect that was lost in mice depleted of NK cells. The oral administration of RQ-15986 inhibited the growth of tumor cells implanted into mammary glands and their spontaneous metastatic colonization to the lungs, resulting in improved survival. Our findings reveal that EP 4 antagonism prevents tumor-mediated NKcell immunosuppression and demonstrates the anti-metastatic activity of a novel EP 4 antagonist. These observations support the investigation of EP 4 antagonists in clinical trials. © 2013 Landes Bioscience.