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News Article | November 18, 2016
Site: www.eurekalert.org

DALLAS - November 18, 2016 - Proactive outreach to cirrhosis patients in a safety net health system successfully doubled their screening rates for liver cancer, UT Southwestern Medical Center researchers found. Cirrhosis (liver disease) patients are at high risk to develop liver cancer, which is increasing in frequency an average of 3 percent annually and has a five-year overall survival rate of just 17.5 percent. "Finding ways to reach patients at high risk of liver cancer is critical. Liver cancer has the fastest increasing mortality rate among solid tumors in the U.S.," said first author Dr. Amit G. Singal, Associate Professor of Internal Medicine and Clinical Sciences, and a member of the Harold C. Simmons Comprehensive Cancer Center. "This high mortality is primarily due to low rates of liver cancer screening and high rates of late-stage diagnosis." The study randomly divided 1,800 cirrhosis patients at Parkland Health & Hospital System in Dallas into three groups. The first group received mailed outreach invitations for screening ultrasound. The second group received similar outreach plus patient navigation, and the third received their usual care. Researchers learned that the group receiving mailed outreach invitations were most likely to schedule an ultrasound, which doubled the overall rate of screening. The study appears in the journal Gastroenterology. "Our study is one of the first interventions to improve liver cancer screening and early detection among at-risk patients. The vulnerable patient population we studied in our safety net health system are those who are at highest risk of dying from liver cancer, so this intervention helped those who might benefit the most," said Dr. Singal. Only one-fourth of patients with cirrhosis in routine care are currently screened every six months for liver cancer with an ultrasound as recommended by national guidelines. Symptoms are not usually present when the cancer is in its early stages. "Our research previously demonstrated that liver cancer screening is underused in clinical practice, with lower rates of screening among racial/ethnic minorities and socioeconomically disadvantaged patients," said senior author Dr. Ethan Halm, Director of the Center for Patient-Centered Outcomes Research, Chief of the William T. and Gay F. Solomon Division of General Internal Medicine, and Professor of Internal Medicine and Clinical Sciences. "Our new study presents a model of a proactive, population health outreach strategy that can improve liver cancer screening and early detection among those at highest risk of adverse outcomes." Dr. Halm holds the Walter Family Distinguished Chair in Internal Medicine in Honor of Albert D. Roberts, M.D. According to the National Cancer Institute, liver cancer is diagnosed in an estimated 39,230 people annually. In 2013, there were an estimated 54,954 people living with this cancer in the U.S. Risk factors include a diagnosis of fatty liver disease, hepatitis B, hepatitis C, cirrhosis, or a combination of these diseases. Additional UT Southwestern faculty who contributed to the study include: Dr. Jasmin A. Tiro, Associate Professor of Clinical Science and member of the Simmons Cancer Center; and Dr. Jorge A. Marrero, Medical Director of Liver Transplantation, Associate Vice President, Clinical Transformation Officer, and Professor of Internal Medicine. Dr. Tiro, Dr. Marrero, Dr. Halm, and Dr. Singal are all members of the Simmons Cancer Center. Dr. Noel O. Santini from Parkland Health & Hospital System also contributed to the study. This study was conducted as part of UT Southwestern's Center for Patient-Centered Outcomes Research with support from the Agency for Healthcare Research & Quality, the National Institutes of Health, and the National Cancer Institute. Dr. Singal reported being on the speaker bureau for Bayer Pharmaceutical and receiving grant funding from Gilead Pharmaceuticals. The Harold C. Simmons Comprehensive Cancer Center is the only NCI-designated Comprehensive Cancer Center in North Texas and one of just 47 NCI-designated Comprehensive Cancer Centers in the nation. Simmons Cancer Center includes 13 major cancer care programs. In addition, the Center's education and training programs support and develop the next generation of cancer researchers and clinicians. Simmons Cancer Center is among only 30 U.S. cancer research centers to be designated by the NCI as a National Clinical Trials Network Lead Academic Participating Site. Cancer that starts in the liver is called primary liver cancer. There are often no symptoms for early-stage liver cancer. Liver cancer can also develop in the bile ducts within the liver. UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution's faculty includes many distinguished members, including six who have been awarded Nobel Prizes since 1985. The faculty of almost 2,800 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in about 80 specialties to more than 100,000 hospitalized patients and oversee approximately 2.2 million outpatient visits a year. This news release is available on our website at http://www. . To automatically receive news releases from UT Southwestern via email, subscribe at http://www. .

DALLAS - March 1, 2017 - A large national study suggests that treating pregnant women for mildly low thyroid function does not improve the IQs of their babies or reduce preterm births or other negative outcomes. The 10-year study, conducted at UT Southwestern Medical Center and 14 other universities and medical centers in the National Institutes of Health's (NIH) Maternal Fetal Medicine Units Network, found no benefit in treating the women during their pregnancies. The results are published today in The New England Journal of Medicine (NEJM). Full-blown hypothyroidism during pregnancy, especially when untreated, has long been associated with lower mental functioning in offspring, as well as low birth weight, stillbirth, and preterm labor. It is commonly treated by giving expectant mothers a synthetic substitute to boost their low thyroid hormone, thyroxine. In 1999, another NEJM study raised concerns that the same problems might occur in women with even mild, or subclinical, hormone abnormalities. As a result, several physician groups called for routine testing of all pregnant women in the U.S. -- about 4 million women a year -- and treatment for these marginal hormone problems. The American College of Obstetricians and Gynecologists has recommended against universal screening for thyroid disease in pregnant women. "Our study found that treatment did not benefit children born to these women," said Dr. Brian Casey, Professor of Obstetrics and Gynecology at UT Southwestern Medical Center and first author of the new study. "There's no evidence that treatment improves either pregnancy outcomes or the children's neurodevelopmental or behavioral outcomes through 5 years of age." Dr. Casey is Division Director of Maternal-Fetal Medicine at UT Southwestern and holds the Gillette Professorship of Obstetrics and Gynecology. He is also Chief of Obstetrics at Parkland Health & Hospital System. The NIH study grew out of research begun in 2000 at UT Southwestern, when Dr. Casey and his colleagues performed a study on thyroid disease during pregnancy in over 25,000 women at Parkland Memorial Hospital. That study culminated in his proposal of a multicenter treatment study to the NIH in 2005. Dr. Casey now is principal investigator of the NIH study and chair of the protocol subcommittee. Starting in October 2006, researchers screened more than 97,000 pregnant women for the study and enrolled 1,203 who had either subclinical hypothyroidism or isolated hypothyroxinemia. Subclinical hypothyroidism is characterized by high levels of a pituitary gland hormone, TSH, which stimulates the thyroid to produce thyroxine. In isolated hypothyroxinemia, the pituitary hormone level is normal, but thyroxine, or free T4, is abnormally low. Half the study participants were given levothyroxine, a synthetic substitute for their thyroid hormone; the other half received a placebo. Researchers then analyzed pregnancy outcomes of both groups and followed the neurocognitive development of the women's babies for five years. IQ levels and other test scores were not significantly different between the children of women given levothyroxine and children whose mothers received a placebo, Dr. Casey said. Children of the women treated for subclinical hypothyroidism scored an average of 97 on the IQ test, compared with 94 for those born to women in the placebo group. In the hypothyroxinemia part of the study, the children of those treated averaged 94, while offspring of those given placebos averaged 91. These scores are considered normal and the three-point differences are not viewed as significant, Dr. Casey said. The results suggest there is no benefit to widespread testing and treatment for subclinical thyroid problems during pregnancy, he said. "If treatment doesn't improve outcomes, then it calls into question whether we should be screening every pregnant woman for this mild degree of thyroid deficiency." A 2012 study published in The Journal of Clinical Endocrinology & Metabolism estimated a cost of $25 (in 2009 dollars) for the TSH test and $13 to test the free T4 thyroid hormone level, in addition to the cost of the physician visits and consultation. Pregnant women diagnosed with a thyroid problem would then need continued testing, as well as potential treatment with levothyroxine at an estimated cost of $170 (again, in 2009 dollars) for a year's supply. The current study's findings followed those of a large British study, published in NEJM in 2012, which screened more than 20,000 pregnant women. That study concluded treatment for reduced thyroid function in pregnant women did not improve cognitive function in their children at age 3. The newly published study was funded by the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development, along with the National Institute of Neurological Disorders and Stroke. UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution's faculty includes many distinguished members, including six who have been awarded Nobel Prizes since 1985. The faculty of almost 2,800 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in about 80 specialties to more than 100,000 hospitalized patients and oversee approximately 2.2 million outpatient visits a year. This news release is available on our website at http://www. To automatically receive news releases from UT Southwestern via email, subscribe at http://www.

PubMed | Parkland Health & Hospital System, Parkland Health and Hospital System, Rutgers University and University of Texas Southwestern Medical Center
Type: Journal Article | Journal: BMC infectious diseases | Year: 2016

Tuberculosis (TB) disproportionately affects immigrants, HIV-infected individuals, and those living in crowded settings such as homeless shelters and correctional facilities. Although the majority of jails and prisons use a tuberculin skin test (TST) for latent tuberculosis infection (LTBI) screening, limited data exist on the clinical performance and costs of the TST compared to interferon gamma release assays (IGRAs) in this setting.A prospective pilot study comparing cost between TST and an IGRA (QuantiFERON Gold In-tube, QFT-GIT) for the detection of LTBI in a convenience sample of inmates entering the Dallas County Jail (DCJ) was conducted June-October 2014. Participants completed a risk questionnaire, TST placement, QFT-GIT testing, and were offered opt-out HIV-Ab testing. LTBI prevalence based on TST and QFT-GIT results, an evaluation of discordant results and a cost analysis are presented.A total of 529 subjects were enrolled. The majority were male (75%), and 46% were Black, 29% White, and 24% Hispanic. Most (85%) had been previously incarcerated. Over 28% of participants were released prior to TST reading, with paired QFT-GIT and TST results available for 351 subjects. Of these, nine (2.6%) tested positive by TST and 47 (13.4%) tested positive by QFT-GIT. It costs $23.27 more per inmate per year to screen with QFT-GIT than TST in this population, though the cost per LTBI case detected was nearly three times higher for TST than QFT-GIT ($1247 v $460).We found a substantially higher rate of QFT-GIT positivity compared to TST in this sample of individuals entering the Dallas County Jail. Although no gold standard exists, this finding may indicate under-recognized LTBI in this setting. QFT-GIT as an initial screening tool was more time-efficient, had four-fold fewer labor costs and provided results on more individuals when compared with the TST. The overall cost of QFT-GIT was $23.27 more per inmate per year, though the cost per LTBI case detected was nearly three times higher for TST than QFT-GIT. Further research is needed to determine the long-term performance of IGRA testing in the correctional setting and the public health implications of pairing QFT-GIT screening with other tests for communicable diseases.

Singal A.G.,Parkland Health Hospital System | Singal A.G.,Southwestern University | Yopp A.C.,Southwestern University | Gupta S.,Parkland Health Hospital System | And 9 more authors.
Cancer Prevention Research | Year: 2012

Hepatocellular carcinoma (HCC) surveillance is underutilized among patients with cirrhosis. Understanding which steps in the surveillance process are not being conducted is essential for designing effective interventions to improve surveillance rates. The aim of our study was to characterize reasons for failure in the HCC surveillance process among a cohort of cirrhotic patients with HCC. We conducted a retrospective cohort study of cirrhotic patients diagnosed withHCCat a large urban safety-net hospital between 2005 and 2011. Patients were characterized by receipt of HCC surveillance over a two-year period before HCC diagnosis. Among patients without HCC surveillance, we classified reasons for failure into four categories: failure to recognize liver disease, failure to recognize cirrhosis, failure to order surveillance, and failure to complete surveillance despite orders. Univariate and multivariate analyses were conducted to identify predictors of failures. We identified 178 patients with HCC, of whom 20% had undergone surveillance. There were multiple points of failure - 20% had unrecognized liver disease, 19% had unrecognized cirrhosis, 38% lacked surveillance orders, and 3% failed to complete surveillance despite orders. Surveillance was more likely among patients seen by hepatologists [OR, 6.11; 95% confidence interval (CI), 2.5-14.8] and less likely in those with alcohol abuse (OR, 0.14; 95% CI, 0.03-0.65). Although a retrospective analysis in a safety-net hospital, our data suggest that only one in five patients received surveillance before HCCdiagnosis. There are multiple points of failure in the surveillance process, with the mostcommonbeing failure to order surveillance in patients with known cirrhosis. Future interventions must target multiple failure points in the surveillance process to be highly effective. ©2012 AACR.

PubMed | Parkland Health & Hospital System, Southwestern Medical Center, Texas Health Resources and PCCI, Inc.
Type: Journal Article | Journal: Journal of general internal medicine | Year: 2016

Vital sign instability on discharge could be a clinically objective means of assessing readiness and safety for discharge; however, the association between vital sign instability on discharge and post-hospital outcomes is unclear.To assess the association between vital sign instability at hospital discharge and post-discharge adverse outcomes.Multi-center observational cohort study using electronic health record data. Abnormalities in temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation were assessed within 24hours of discharge. We used logistic regression adjusted for predictors of 30-day death and readmission.Adults (18years) with a hospitalization to any medicine service in 2009-2010 at six hospitals (safety-net, community, teaching, and non-teaching) in north Texas.Death or non-elective readmission within 30days after discharge.Of 32,835 individuals, 18.7% were discharged with one or more vital sign instabilities. Overall, 12.8% of individuals with no instabilities on discharge died or were readmitted, compared to 16.9% with one instability, 21.2% with two instabilities, and 26.0% with three or more instabilities (p<0.001). The presence of any (1) instability was associated with higher risk-adjusted odds of either death or readmission (AOR 1.36, 95% CI 1.26-1.48), and was more strongly associated with death (AOR 2.31, 95% CI 1.91-2.79). Individuals with three or more instabilities had nearly fourfold increased odds of death (AOR 3.91, 95% CI 1.69-9.06) and increased odds of 30-day readmission (AOR 1.36, 95% 0.81-2.30) compared to individuals with no instabilities. Having two or more vital sign instabilities at discharge had a positive predictive value of 22% and positive likelihood ratio of 1.8 for 30-day death or readmission.Vital sign instability on discharge is associated with increased risk-adjusted rates of 30-day mortality and readmission. These simple vital sign criteria could be used to assess safety for discharge, and to reduce 30-day mortality and readmissions.

Dalton-Fitzgerald E.,University of Texas Southwestern Medical Center | Dalton-Fitzgerald E.,Parkland Health Hospital System | Tiro J.,University of Texas Southwestern Medical Center | Kandunoori P.,University of Texas Southwestern Medical Center | And 6 more authors.
Clinical Gastroenterology and Hepatology | Year: 2015

Background & Aims: Fewer than 20% of patients with cirrhosis undergo surveillance for hepatocellular carcinoma (HCC), therefore these tumors often are detected at late stages. Although primary care providers (PCPs) care for 60% of patients with cirrhosis in the United States, little is known about their practice patterns for HCC surveillance. We investigated factors associated with adherence to guidelines for HCC surveillance by PCPs. Methods: We conducted a web-based survey of all 131 PCPs at a large urban hospital. The survey was derived from validated surveys and pretested among providers; it included questions about provider and practice characteristics, self-reported rates of surveillance, surveillance test and frequency preference, and attitudes and barriers to HCC surveillance. Results: We obtained a clinic-level response rate of 100% and a provider-level response rate of 60%. Only 65% of respondents reported annual surveillance and 15% reported biannual surveillance of patients for HCC. Barriers to HCC surveillance included not being up-to-date with HCC guidelines (68% of PCPs), difficulties in communicating effectively with patients about HCC surveillance (56%), and more important issues to manage in the clinic (52%). Approximately half of PCPs (52%) reported using ultrasound or measurements of α-fetoprotein in surveillance; 96% said that this combination was effective in reducing HCC-related mortality. However, many providers incorrectly believed that clinical examination (45%) or levels of liver enzymes (59%) or α-fetoprotein alone (89%) were effective surveillance tools. Conclusions: PCPs have misconceptions about tests to detect HCC that contribute to ineffective surveillance. Reported barriers to surveillance include suboptimal knowledge about guidelines, indicating a need for interventions, including provider education, to increase HCC surveillance effectiveness. © 2015 AGA Institute.

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