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Maisel A.S.,Veterans Affairs San Diego Health Care System | Peacock W.F.,Cleveland Clinic | Shah K.S.,Research Service | Clopton P.,Research Service | And 7 more authors.
American Journal of Emergency Medicine | Year: 2011

Background: Dyspneic emergency department (ED) patients present a diagnostic dilemma. The S3, although highly specific for acute heart failure (AHF) and predicting death and readmission, is often difficult to auscultate. The HEart failure and Audicor technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational trial evaluated the S3 via acoustic cardiography (Audicor). Our goal in this secondary analysis was to determine if the strength of the S3 can provide diagnostic/prognostic information in problematic heart failure subgroups. Methods: Dyspneic ED patients older than 40 years and not on dialysis were prospectively enrolled. A gold standard AHF diagnosis was determined by 2 cardiologists blinded to acoustic cardiography results. The S3 strength parameter was delineated on a scale of 0 to 10. This secondary analysis of subgroups from the HEARD-IT database used univariate/multivariate regression to determine the diagnostic/prognostic ability of the S3 strength. Results: In the 995 patients enrolled, S3 strength was a significant prognosticator in univariate analysis for adverse events but not in a multivariable model. In patients with "gray zone" B-type natriuretic peptide (BNP) levels (100-499 pg/mL), acoustic cardiography increased diagnostic accuracy of AHF from 47% to 69%. Acoustic cardiography improved S3 detection sensitivity in obese patients when compared to auscultation. Conclusion: The strength of the S3 gallop provides rapid results that assist with identification of AHF in selected populations. S3 detection complements the use of BNP in the gray zone, and its diagnostic/prognostic ability is largely unaffected by body mass index and renal function. S3 strength shows promise as a diagnostic and prognostic tool in problematic HF subgroups. © 2011 Elsevier Inc. All rights reserved.

Arora G.,University of Texas Southwestern Medical Center | Rockey D.,Medical University of South Carolina | Gupta S.,Veterans Affairs San Diego Health Care System | Gupta S.,University of California at San Diego
Clinical Gastroenterology and Hepatology | Year: 2013

Background & Aims: It is important to carefully select patients who undergo endoscopic procedures, to optimize health care. Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive endoscopic procedure that has been associated with high short-term mortality. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among patients undergoing PEG. Methods: We conducted a nested, case-control, retrospective study using the US Nationwide Inpatient Sample (NIS) to analyze data from all hospitalizations in 2006 with an International Classification of Diseases, 9th revision, procedure code for PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality after the procedure. A separate analysis using a propensity score matching technique was conducted to compare mortality with a control cohort. Results were validated in an independent analysis of 2007 NIS data. Results: In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006 (95% confidence interval, 10.3%-11.3%). Odds of death increased with age (1%/y), congestive heart failure, renal failure, chronic pulmonary disease, coagulopathy, pulmonary circulation disorders, metastatic cancer, and liver disease. The indication for PEG was associated strongly with mortality. Women and patients with diabetes mellitus or paralysis had a lower risk of death. PEG was associated with slightly higher odds of in-hospital mortality compared with patients who did not undergo PEG. Qualitatively and quantitatively similar results were obtained when 2007 NIS data were analyzed. Conclusions: The mortality rate is almost 11% among hospital inpatients after PEG. We have identified factors that increase and decrease the risk of death after PEG; these factors could improve patient selection for those most likely to benefit from this procedure. © 2013 AGA Institute.

Nguyen L.,University of California at San Diego | Banks D.,University of California at San Diego | Manecke G.,University of California at San Diego | Shurter J.,University of California at San Diego | And 4 more authors.
Journal of Cardiothoracic and Vascular Anesthesia | Year: 2014

Objectives Patients with left-sided heart dysfunction and volume overload often have associated elevations in vasopressin from neuroendocrine activation. The authors investigated perioperative levels of vasopressin in patients with isolated right-sided heart dysfunction from chronic thromboembolic pulmonary hypertension. Design Prospective, observational study. Setting Single center, tertiary hospital. Participants Patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy. Interventions Vasopressin levels were measured in 22 patients during the perioperative period. Measurements and Main Results Vasopressin was undetectable in 8/22 patients at baseline. As a group, vasopressin levels at baseline and after induction of anesthesia were 0.8 pg/mL (median; 0.5-1.5, interquartile range of 25% and 75%) and 0.7 pg/mL (median; 0.5-1.4, interquartile range of 25% and 75%), respectively. During cardiopulmonary bypass (CPB), vasopressin increased to 13.9 pg/mL (median; 6.7-19.9, interquartile range of 25% and 75%). Vasopressin remained elevated after deep hypothermic circulatory arrest (DHCA) at 10.5 pg/mL (median; 6.5-19.9 interquartile range of 25% and 75%) and after CPB at 19.9 pg/mL (median; 11.1-19.9 interquartile range of 25% and 75%). Conclusions Vasopressin levels in PTE patients are in the low-to-normal range at baseline and may be a clinically relevant issue in the hemodynamic management of PTE. © 2014 Elsevier Inc.

Worley M.J.,University of California at Los Angeles | Trim R.S.,Veterans Affairs San Diego Health Care System | Trim R.S.,University of California at San Diego | Tate S.R.,Veterans Affairs San Diego Health Care System | And 5 more authors.
Psychology of Addictive Behaviors | Year: 2014

Proximal personal and environmental factors typically predict outcomes of treatment for alcohol or drug dependence (AODD), but longitudinal treatment studies have rarely examined these factors in adults with co-occurring psychiatric disorders. In adults with AODD and major depression, the aims of this study were to: (a) disaggregate person-and time-level components of network substance use and self-efficacy, (b) examine their prospective effects on posttreatment alcohol/drug use, and (c) examine whether residential environment moderated relations between these proximal factors and substance use outcomes. Veterans (N=201) enrolled in a trial of group psychotherapy for AODD and independent MDD completed assessments every 3 months during 1 year of posttreatment follow-up. Outcome variables were percent days drinking (PDD) and using drugs (PDDRG). Proximal variables included abstinence self-efficacy and social network drinking and drug use. Self-efficacy and network substance use at the person-level prospectively predicted PDD (ps <.05) and PDDRG (ps <.05). Within-person, time-level effects of social networks predicted future PDD (ps <.05) but not PDDRG. Controlled environments moderated person-level social network effects (ps <.05), such that greater time in controlled settings attenuated the association between a heavier drinking/using network and posttreatment drinking and drug use. Both individual differences and time-specific fluctuations in proximal targets of psychosocial interventions are related to posttreatment substance use in adults with co-occurring AODD and MDD. More structured environmental settings appear to alleviate risk associated with social network substance use, and may be especially advised for those who have greater difficulty altering social networks during outpatient treatment. © 2014 American Psychological Association.

Worley M.J.,San Diego State University | Tate S.R.,Veterans Affairs San Diego Health Care System | Tate S.R.,University of California at San Diego | Granholm E.,Veterans Affairs San Diego Health Care System | And 2 more authors.
Journal of Consulting and Clinical Psychology | Year: 2014

Objective: Neurocognitive impairment has not consistently predicted substance use treatment outcomes but has been linked to proximal mediators of outcome. These indirect effects have not been examined in adults with substance dependence and co-occurring psychiatric disorders. We examined mediators and moderators of the effects of neurocognitive impairment on substance use among adults in treatment for alcohol or drug dependence and major depression (MDD). Method: Participants were veterans (N = 197, mean age = 49.3 years, 90% male, 75% Caucasian) in a trial of 2 group interventions for alcohol/drug dependence and MDD. Measures examined here included intake neurocognitive assessments and percent days drinking (PDD), percent days using drugs (PDDRG), self-efficacy, 12-step affiliation, and depressive symptoms measured every 3 months from intake to the 18-month follow-up. Results: Greater intake neurocognitive impairment predicted lower self-efficacy, lower 12-step affiliation, and greater depression severity, and these time-varying variables mediated the effects of impairment on future PDD and PDDRG. The prospective effects of 12-step affiliation on future PDD were greater for those with greater neurocognitive impairment. Impairment also interacted with depression to moderate the effects of 12-step affiliation and self-efficacy on PDD. Adults with greater impairment and currently severe depression had the strongest associations between 12-step affiliation/self-efficacy and future drinking. Conclusions: Greater neurocognitive impairment may lead to poorer outcomes from group therapy for alcohol/drug dependence and MDD due to compromised change in therapeutic processes. Distal factors such as neurocognitive impairment can interact with dynamic risk factors to modulate the association between therapeutic processes and future drinking outcomes. © 2014 American Psychological Association.

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