Tolia V.N.,Baylor University |
Patrick S.W.,Vanderbilt University |
Bennett M.M.,Baylor Scott and White Health |
Murthy K.,Ann And Robert H Lurie Childrens Hospital Of Chicago |
And 5 more authors.
New England Journal of Medicine | Year: 2015
BACKGROUND: The incidence of the neonatal abstinence syndrome, a drug-withdrawal syndrome that most commonly occurs after in utero exposure to opioids, is known to have increased during the past decade. However, recent trends in the incidence of the syndrome and changes in demographic characteristics and hospital treatment of these infants have not been well characterized. METHODS: Using multiple cross-sectional analyses and a deidentified data set, we analyzed data from infants with the neonatal abstinence syndrome from 2004 through 2013 in 299 neonatal intensive care units (NICUs) across the United States. We evaluated trends in incidence and health care utilization and changes in infant and maternal clinical characteristics. RESULTS: Among 674,845 infants admitted to NICUs, we identified 10,327 with the neonatal abstinence syndrome. From 2004 through 2013, the rate of NICU admissions for the neonatal abstinence syndrome increased from 7 cases per 1000 admissions to 27 cases per 1000 admissions; the median length of stay increased from 13 days to 19 days (P<0.001 for both trends). The total percentage of NICU days nationwide that were attributed to the neonatal abstinence syndrome increased from 0.6% to 4.0% (P<0.001 for trend), with eight centers reporting that more than 20% of all NICU days were attributed to the care of these infants in 2013. Infants increasingly received pharmacotherapy (74% in 2004-2005 vs. 87% in 2012-2013, P<0.001 for trend), with morphine the most commonly used drug (49% in 2004 vs. 72% in 2013, P<0.001 for trend). CONCLUSIONS: From 2004 through 2013, the neonatal abstinence syndrome was responsible for a substantial and growing portion of resources dedicated to critically ill neonates in NICUs nationwide. Copyright © 2015 Massachusetts Medical Society.
Holmes D.R.,Mayo Medical School |
Brennan J.M.,Duke Clinical Research Institute |
Rumsfeld J.S.,Denver Medical Center |
Dai D.,Duke Clinical Research Institute |
And 10 more authors.
JAMA - Journal of the American Medical Association | Year: 2015
Importance: Introducing new medical devices into routine practice raises concerns because patients and outcomesmay differ from those in randomized trials. Objective: To update the previous report of 30-day outcomes and present 1-year outcomes following transcatheter aortic valve replacement (TAVR) in the United States. Design, Setting, and Participants: Data from the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapies Registry were linked with patient-specific Centers for Medicare & Medicaid Services (CMS) administrative claims data. At 299 US hospitals, 12 182 patients linked with CMS data underwent TAVR procedures performed from November 2011 through June 30, 2013, and the end of the follow-up period was June 30, 2014. Exposure: Transcatheter aortic valve replacement. Main Outcomes and Measures: One-year outcomes including mortality, stroke, and rehospitalization were evaluated using multivariate modeling. Results: The median age of patients was 84 years and 52%were women, with a median STS Predicted Risk of Operative Mortality (STS PROM) score of 7.1%. Following the TAVR procedure, 59.8%were discharged to home and the 30-day mortality was 7.0% (95%CI, 6.5%-7.4%) (n = 847 deaths). In the first year after TAVR, patients were alive and out of the hospital for a median of 353 days (interquartile range, 312-359 days); 24.4%(n = 2074) of survivors were rehospitalized once and 12.5%(n = 1525) were rehospitalized twice. By 1 year, the overall mortality rate was 23.7%(95%CI, 22.8%-24.5%) (n = 2450 deaths), the stroke rate was 4.1%(95%CI, 3.7%-4.5%) (n = 455 stroke events), and the rate of the composite outcome of mortality and stroke was 26.0%(25.1%-26.8%) (n = 2719 events). Characteristics significantly associated with 1-year mortality included advanced age (hazard ratio [HR] for ≥95 vs <75 years, 1.61 [95%CI, 1.24-2.09]; HR for 85-94 years vs <75 years, 1.35 [95%CI, 1.18-1.55]; and HR for 75-84 years vs <75 years, 1.23 [95%CI, 1.08-1.41]), male sex (HR, 1.21; 95%CI, 1.12-1.31), end-stage renal disease (HR, 1.66; 95%CI, 1.41-1.95), severe chronic obstructive pulmonary disease (HR, 1.39; 95%CI, 1.25-1.55), nontransfemoral access (HR, 1.37; 95%CI, 1.27-1.48), STS PROM score greater than 15%vs less than 8%(HR, 1.82; 95%CI, 1.60-2.06), and preoperative atrial fibrillation/flutter (HR, 1.37; 95%CI, 1.27-1.48). Compared with men, women had a higher risk of stroke (HR, 1.40; 95%CI, 1.15-1.71). Conclusions and Relevance: Among patients undergoing TAVR in US clinical practice, at 1-year follow-up, overall mortality was 23.7%, the stroke rate was 4.1%, and the rate of the composite outcome of death and stroke was 26.0%. These findings should be helpful in discussions with patients undergoing TAVR.
Kapadia S.R.,Cleveland Clinic |
Leon M.B.,Columbia University |
Makkar R.R.,Cedars Sinai Medical Center |
Tuzcu E.M.,Cleveland Clinic |
And 15 more authors.
The Lancet | Year: 2015
Summary Background Based on the early results of the Placement of Aortic Transcatheter Valves (PARTNER) trial, transcatheter aortic valve replacement (TAVR) is an accepted treatment for patients with severe aortic stenosis who are not suitable for surgery. However, little information is available about the late clinical outcomes in such patients. Methods We did this randomised controlled trial at 21 experienced valve centres in Canada, Germany, and the USA. We enrolled patients with severe symptomatic inoperable aortic stenosis and randomly assigned (1:1) them to transfemoral TAVR or to standard treatment, which often included balloon aortic valvuloplasty. Patients and their treating physicians were not masked to treatment allocation. The randomisation was done centrally, and sites learned of the assignment only after a patient had been screened, consented, and entered into the database. The primary outcome of the trial was all-cause mortality at 1 year in the intention-to-treat population, here we present the prespecified findings after 5 years. This study is registered with ClinicalTrials.gov, number NCT00530894. Findings We screened 3015 patients, of whom 358 were enrolled (mean age 83 years, Society of Thoracic Surgeons Predicted Risk of Mortality 11·7%, 54% female). 179 were assigned to TAVR treatment and 179 were assigned to standard treatment. 20 patients crossed over from the standard treatment group and ten withdrew from study, leaving only six patients at 5 years, of whom five had aortic valve replacement treatment outside of the study. The risk of all-cause mortality at 5 years was 71·8% in the TAVR group versus 93·6% in the standard treatment group (hazard ratio 0·50, 95% CI 0·39-0·65; p<0·0001). At 5 years, 42 (86%) of 49 survivors in the TAVR group had New York Heart Association class 1 or 2 symptoms compared with three (60%) of five in the standard treatment group. Echocardiography after TAVR showed durable haemodynamic benefit (aortic valve area 1·52 cm2 at 5 years, mean gradient 10·6 mm Hg at 5 years), with no evidence of structural valve deterioration. Interpretation TAVR is more beneficial than standard treatment for treatment of inoperable aortic stenosis. TAVR should be strongly considered for patients who are not surgical candidates for aortic valve replacement to improve their survival and functional status. Appropriate selection of patients will help to maximise the benefit of TAVR and reduce mortality from severe comorbidities. Funding Edwards Lifesciences. © 2015 Elsevier Ltd.
Weir V.J.,Baylor Scott and White Health
Physics in Medicine and Biology | Year: 2016
In this paper the scatter component of computed tomography dose profiles is modeled using the solution to a nonlinear ordinary differential equation. This scatter function is summed with a modeled primary function of approximate trapezoidal shape. The primary dose profile is modeled to include the analytic continuation of the Heaviside step function. A mathematical theory is developed in a Banach space. The modeled function is used to accurately fit data from a 256-slice GE Revolution scanner. A 60 cm long body phantom is assembled and used for data collection with both a pencil chamber and a Farmer-type chamber. © 2016 Institute of Physics and Engineering in Medicine.
Chatterjee P.,Texas A&M University |
Chatterjee P.,Baylor Scott and White Health |
Chiasson V.L.,Texas A&M University |
Bounds K.R.,Texas A&M University |
And 2 more authors.
Frontiers in Immunology | Year: 2014
Inflammation mediated by both innate and adaptive immune cells is necessary for several important processes during pregnancy. Pro-inflammatory immune cell activation plays a critical role in embryo implantation, placentation, and parturition; however dysregulation of these cells can lead to detrimental pregnancy outcomes including spontaneous abortion, fetal growth restriction, maternal pathology including hypertensive disorders, or fetal and maternal death. The resolution of inflammation plays an important role throughout pregnancy and is largely mediated by immune cells that produce interleukin (IL)-4 and IL-10. The temporal and spatial aspects of reducing inflammation during pregnancy represent a complex process that if not functioning optimally can lead to persistent inflammation and pregnancy complications. In this review, we examine how immune cells that produce IL-4 and IL-10 are regulated throughout pregnancy as well as the effects that reduced IL-4 and IL-10 signaling has on fetal and maternal physiology. © 2014 Chatterjee, Chiasson, Bounds and Mitchell.
Schlein K.,Baylor Scott and White Health
Nutrition in Clinical Practice | Year: 2016
Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research. © 2016 The American Society for Parenteral and Enteral Nutrition.
Regner J.L.,Baylor Scott and White Health |
Mrdutt M.M.,Baylor Scott and White Health |
Munoz-Maldonado Y.,Baylor Scott and White Health
American Journal of Surgery | Year: 2015
Background Obesity's influence on postoperative complications in either laparoscopic ventral hernia repair (LVHR) or open ventral hernia repair (OVHR) has yet to be defined. Although 30-day postoperative complications increase with higher body mass index (BMI), we propose LVHR minimizes surgical site infections (SSIs) and surgical site occurrences (SSOs) for given BMI categories. Methods Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2009 to 2012) for patients aged 18 years or more undergoing elective ventral hernia repair. Exclusion criteria included immunosuppression, disseminated malignancy, advanced liver disease, or pregnancy. Patients were stratified by BMI (20 to 25, 25 to 30, 30 to 35, 35 to 40, and >40 kg/m2), and 30-day SSOs evaluated across BMI groups for LVHR vs OVHR. Results A total of 106,968 patients met inclusion criteria, with 60% patients obese. LVHR decreased SSO for all patients (odds ratio,.4; confidence interval,.19 to.60). Obesity classes I/II/III have increased odds of superficial SSI, deep SSI, and dehiscence for OVHR compared with LVHR. Only obesity class III has increased odds of organ space SSI and reoperation for OVHR vs LVHR (P <.05). Conclusions Obese patients are over-represented in VHRs. Thirty-day postoperative wound complications increase with higher BMI. LVHR minimizes both SSIs and SSOs, especially in higher obesity classes. © 2015 Elsevier Inc.
Butlar M.,Baylor Scott and White Health
Journal for Nurses in Professional Development | Year: 2015
Although atypical, there are urgent situations in which education must be developed and deployed quickly to a large number of people. This article describes a strategy to guide rapid deployment of staff education based on lessons learned by educators who were recently faced with such a situation. Copyright © 2015 Lippincott Williams & Wilkins.
Ho T.Q.,Baylor Scott and White Health
Annals of Plastic Surgery | Year: 2016
BACKGROUND: Prompt identification of significant ocular injuries in patients who sustain an orbital fracture is important to prevent any potential long-term visual sequelae. The true incidence of these injuries has not been determined, however. As a consequence, most surgeons choose to have all patients evaluated by an ophthalmologist. The objective of this study was to conclusively identify the incidence of significant ocular injuries in patients with isolated orbital fractures and to determine their predictors to guide more efficient patient care. METHODS: A prospective cohort study powered to detect a 15% incidence of ocular injuries was designed. All patients presenting to our center with computed tomography findings of an isolated orbital fracture were included and evaluated by plastic surgery and ophthalmology services. Patients were followed up for a minimum of 1 week to identify any delayed injuries. RESULTS: Eighty patients were enrolled from 2012 to 2014. There were 46 men and 34 women with a mean age of 42.8 years. Assault was the most common mechanism of injury. There were 8 ocular injuries (10%): ruptured globe (1), uveal prolapse (1), retrobulbar hemorrhage (2), hyphema (2), hemorrhagic glaucoma with hyphema (1), and scleral tear (1). Predictors for significant ocular injuries were grossly abnormal visual acuity and abnormal pupillary reactivity of the affected eye. CONCLUSIONS: The incidence of significant ocular injuries in isolated orbital fractures is lower than previously reported. Patients presenting with grossly abnormal visual acuity or abnormal pupillary reactivity are at high risk and should receive prompt ophthalmology service evaluation. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
McNeal C.J.,Baylor Scott and White Health
Journal of Clinical Lipidology | Year: 2015
Lipoprotein(a) (Lp(a)) is a highly atherogenic and heterogeneous lipoprotein that is inherited in an autosomal codominant trait. A unique aspect of this lipoprotein is that it is fully expressed by the first or second year of life in children, a pattern that is distinctly different from other lipoproteins, which typically only reach adult levels after adolescence. Despite decades of research, Lp(a) metabolism is still poorly understood but what is abundantly clear is that it is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD). The Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents does not recommend measuring Lp(a) levels as part of routine screening except in youth with an ischemic or hemorrhagic stroke or youth with a parental history of ASCVD not explained by classical risk factors. One of the reasons that both the pediatric and adult guidelines fail to include this lipoprotein as part of routine lipid screening is the absence of data to show that lowering Lp(a) will reduce current or future ASCVD risk independently of low-density lipoprotein cholesterol (LDL-C) lowering. The cholesterol carried by Lp(a) is included in the low-density lipoprotein cholesterol measurement, but a separate test is used to measure the lipoprotein mass and/or cholesterol carried only by Lp(a). Because levels seem to be largely under genetic control, studies of lifestyle modification have been inconclusive although one study in obese children showed a decrease in the Lp(a) level comparable with the favorable effect on other lipids. The most compelling data regarding the importance of Lp(a) in the pediatric population are the increased risk associated with arterial ischemic stroke, a risk that is comparable with that associated with antiphospholipid antibodies or protein C deficiency. Although no specific pharmaceutical treatments are recommended to lower Lp(a) levels in youth, it is vitally important to educate youth and their parents about the excessive risk associated with this lipoprotein and the need to avoid the acquisition of other lifestyle-related risk factors such as smoking, excess weight, and physical inactivity to preserve more ideal cardiovascular health in adulthood. © 2015 National Lipid Association.