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1.
J Am Geriatr Soc ; 2020 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-31958154

RESUMO

BACKGROUND: Accurate assessment of atherosclerotic cardiovascular disease (ASCVD) risk across heterogeneous populations is needed for effective primary prevention. Little is known about the performance of standard cardiovascular risk factors in older adults. OBJECTIVE: To evaluate the performance of the American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) risk model, as well as the underlying cardiovascular risk factors, among adults older than 65 years. DESIGN AND SETTING: Retrospective cohort derived from a regional referral system's electronic medical records. PARTICIPANTS: A total of 25 349 patients who were 65 years or older at study baseline (date of the first outpatient lipid panel taken between 2007 and 2010). MEASUREMENTS: Exposures of interest were traditional cardiovascular risk factors, as defined by inclusion in the PCE model. The primary outcome was major ASCVD events, defined as a composite of myocardial infarctions, stroke, and cardiovascular death. RESULTS: The PCE and internally estimated models produced similar risk distributions for white men aged 65 to 74 years. For all other groups, PCE predictions were generally lower than those of the internal models, particularly for African Americans. Discrimination of the PCE was poor for all age groups, with concordance index (95% confidence interval) estimates of 0.62 (0.60-0.64), 0.56 (0.54-0.57), and 0.52 (0.49-0.54) among patients aged 65 to 74, 75 to 84, and 85 years and older, respectively. Reestimating relationships within these age groups resulted in better calibration but negligible improvements in discrimination. Blood pressure, total cholesterol, and diabetes either were not associated at all or had inverse associations in the older age groups. CONCLUSION: Traditional clinical risk factors for cardiovascular disease failed to accurately characterize risk in a contemporary population of Medicare-aged patients. Among those aged 85 years and older, some traditional risk factors were not associated with ASCVD events. Better risk models are needed to appropriately inform treatment decision making for the growing population of older adults.

2.
JAMA Netw Open ; 2(12): e1916526, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31790569

RESUMO

Importance: Immune dysregulation can increase the risk of infection, malignant neoplasms, and cardiovascular disease, but improved methods are needed to identify and quantify immunologic hazard in the general population. Objective: To determine whether lymphopenia is associated with reduced survival in outpatients. Design, Setting, and Participants: This retrospective cohort study of the National Health and Nutrition Examination Survey (NHANES) included participants enrolled from January 1, 1999, to December 31, 2010, a large outpatient sample representative of the US adult population. Associations were evaluated between lymphopenia and other immunohematologic (IH) markers, clinical features, and survival during 12 years of follow-up, completed on December 31, 2011. Spearman correlations, Cox proportional hazards regression models, and Kaplan-Meier curves were used in univariable and multivariable models, allowing for nonlinear associations with bivariate cubic polynomials. Data were analyzed from September 1, 2018, through July 24, 2019. Exposures: Absolute lymphocyte counts (ALC), red blood cell distribution width (RDW), and C-reactive protein (CRP) level. Main Outcomes and Measures: All-cause survival. Results: Among the 31 178 participants, the median (interquartile range) age at baseline was 45 (30-63) years, 16 093 (51.6%) were women, 16 260 (52.2%) were nonwhite, and overall 12-year rate of survival was 82.8%. Relative lymphopenia (≤1500/µL) and severe lymphopenia (≤1000/µL) were observed in 20.1% and 3.0%, respectively, of this general population and were associated with increased risk of mortality (age- and sex-adjusted hazard ratios [HRs], 1.3 [95% CI, 1.2-1.4] and 1.8 [95% CI, 1.6-2.1], respectively) due to cardiovascular and noncardiovascular causes. Lymphopenia was also associated with worse survival in multivariable models, including traditional clinical risk factors, and this risk intensified when accompanied by bone marrow dysregulation (elevated RDW) and/or inflammation (elevated CRP level). Ten-year mortality ranged from 3.8% to 62.1% based on lymphopenia status, tertile of CRP level, and tertile of RDW. A high-risk IH profile was nearly twice as common as type 2 diabetes (19.3% and 10.0% of participants, respectively) and associated with a 3-fold risk of mortality (HR, 3.2; 95% CI, 2.6-4.0). Individuals aged 70 to 79 years with low IH risk had a better 10-year survival (74.1%) than those who were a decade younger with a high-risk IH profile (68.9%). Conclusions and Relevance: These findings suggest that lymphopenia is associated with reduced survival independently of and additive to traditional risk factors, especially when accompanied by altered erythropoiesis and/or heightened inflammation. Immune risk may be analyzed as a multidimensional entity derived from routine tests, facilitating precision medicine and population health interventions.

3.
PLoS One ; 14(7): e0219399, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31291339

RESUMO

In epidemiology, gerontology, human development and the social sciences, age-period-cohort (APC) models are used to study the variability in trajectories of change over time. A well-known issue exists in simultaneously identifying age, period and birth cohort effects, namely that the three characteristics comprise a perfectly collinear system. That is, since age = period-cohort, only two of these effects are estimable at a time. In this paper, we introduce an alternative framework for considering effects relating to age, period and birth cohort. In particular, instead of directly modeling age in the presence of period and cohort effects, we propose a risk modeling approach to characterize age-related risk (i.e., a hybrid of multiple biological and sociological influences to evaluate phenomena associated with growing older). The properties of this approach, termed risk-period-cohort (RPC), are described in this paper and studied by simulations. We show that, except for pathological circumstances where risk is uniquely determined by age, using such risk indices obviates the problem of collinearity. We also show that the size of the chronological age effect in the risk prediction model associates with the correlation between a risk index and chronological age and that the RPC approach can satisfactorily recover cohort and period effects in most cases. We illustrate the advantages of RPC compared to traditional APC analysis on 27496 individuals from NHANES survey data (2005-2016) to study the longitudinal variability in depression screening over time. Our RPC method has broad implications for examining processes of change over time in longitudinal studies.

4.
PLoS One ; 14(7): e0212390, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31356588

RESUMO

The contemporary scientific community places a growing emphasis on the reproducibility of research. The projects R package is a free, open-source package created in the interest of facilitating reproducible research workflows. It adds to existing software tools for reproducible research and introduces several practical features that are helpful for scientists and their collaborative research teams. For each individual project, it supplies a framework for storing raw and cleaned study data sets, and it provides script templates for protocol creation, data cleaning, data analysis and manuscript development. Internal databases of project and author information are generated and displayed, and manuscript title pages containing author lists and their affiliations are automatically generated from the internal database. File management tools allow teams to organize multiple projects. When used on a shared file system, multiple researchers can harmoniously contribute to the same project in a less punctuated manner, reducing the frequency of misunderstandings and the need for status updates.

5.
J Hypertens ; 36(11): 2251-2259, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30044311

RESUMO

BACKGROUND: The association between preinduction blood pressure (BP) and postoperative outcomes after noncardiac surgery is poorly understood. Whether this association depends on the presence of risk factors for poor cardiovascular outcomes remains unclear. Accordingly, we evaluated the association between preinduction BP and its different components; isolated systolic hypertension (ISH) and wide pulse pressure (WPP), and postoperative complications in patients with and without revised cardiac risk index (RCRI) components. METHODS: We analysed consecutive patients undergoing elective noncardiac surgery at Cleveland Clinic. Separate analyses were undertaken for patients with and without any RCRI components. Preinduction BP was assessed both continuously and according to hypertension stages. Logistic regression was used to assess the association between the BP values and composite of in-hospital mortality as well as cardiovascular, renal, and neurologic morbidity. We considered the following potential confounding factors in our analysis; year of surgery, age, sex, race, BMI, and American College of Cardiology/American Heart Association surgical procedure risk classification. RESULTS: Of 58 276 patients, 10 512 had one or more RCRI components. For those with no RCRI, no significant relationship was found between preinduction BP and outcome after adjustment for confounders. For patients with RCRI, the adjusted incidence was the greatest among those with normal preinduction SBP and DBP of less than 70 mmHg. Among patients with preinduction DBP greater than 75 mmHg, risk rose slightly with increasing SBP. However, we found no association between preinduction hypertension stages, ISH, or WPP and the composite outcome in patients with and without RCRI. CONCLUSION: Preinduction low DBP less than 70 mmHg or SBP greater than 160 mmHg and not ISH, nor WPP were associated with an increased risk of postoperative complications in noncardiac surgery patients with one or more RCRI components.


Assuntos
Pressão Arterial , Mortalidade Hospitalar , Hipertensão/fisiopatologia , Nefropatias/epidemiologia , Doenças do Sistema Nervoso/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Diástole , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Hipertensão/complicações , Incidência , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Fatores de Risco , Sístole
9.
Am J Health Behav ; 41(6): 810-821, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29025509

RESUMO

OBJECTIVES: We assessed characteristics that may predict outpatient appointment attendance in outpatient medical clinics among patients comorbid for serious mental illness (SMI) and type 2 diabetes (DM). METHODS: Baseline covariate data from 200 individuals with SMI-DM enrolled in a randomized controlled trial (RCT) were used to examine characteristics associated with electronic health record-identified clinic appointment attendance using a generalized estimating equations approach. The analyses evaluated the relationship between clinic attendance and potentially modifiable factors including disease knowledge, self-efficacy, social support, physical health, and mental health, as well as demographic information. RESULTS: Demographic and mental health characteristics were most associated with clinic attendance in adults with SMI-DM. Physical health was not associated with clinic attendance. CONCLUSIONS: Information on clinical and demographic characteristics and factors potentially modifiable by psychological interventions may be useful in improving adherence to treatment among SMI-DM patients. It is our hope that clinicians and researchers will use these results to help tailor adherence-facilitating interventions among people at particular risk for poor engagement in care.


Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/psicologia , Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Cooperação do Paciente/psicologia , Agendamento de Consultas , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Autoeficácia , Apoio Social
10.
Ann Intern Med ; 167(7): 456-464, 2017 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-28847012

RESUMO

Background: Inequality in health outcomes in relation to Americans' socioeconomic position is rising. Objective: First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)-related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates. Design: Observational cohort analysis of geocoded longitudinal electronic health records. Setting: A single academic health center and surrounding neighborhoods in northeastern Ohio. Patients: 109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline. Measurements: Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward). Results: The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract-level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM. Limitations: Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood. Conclusion: Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes. Primary Funding Source: The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health.


Assuntos
Doenças Cardiovasculares/epidemiologia , Disparidades em Assistência à Saúde , Características de Residência , Medição de Risco , Fatores Socioeconômicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Estudos Retrospectivos , Fatores de Risco
11.
Biomed Res Int ; 2017: 3718615, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28589139

RESUMO

BACKGROUND: Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. METHODS: We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. RESULTS: 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: 22 ± 6 days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, P = 0.77). The relationship did not differ for trauma and nontrauma patients (P = 0.75). Results were similar after adjusting for multiple potential confounders. CONCLUSIONS: Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage.


Assuntos
Preservação de Sangue , Bases de Dados Factuais , Transfusão de Eritrócitos , Eritrócitos , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo
12.
J Acquir Immune Defic Syndr ; 74(3): 298-302, 2017 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-27828877

RESUMO

Red cell distribution width (RDW) is linked to cardiovascular risk in the general population, an association that might be driven by inflammation. Whether this relationship holds for patients with HIV infection has not been previously studied. Using a large clinical registry, we show that elevated RDW (>14.5%) is independently associated with increased risk of coronary artery disease {odds ratio [OR] 1.39 [95% confidence interval (CI): 1.25 to 1.55]}, peripheral vascular disease [OR 1.41 (95% CI: 1.29 to 1.53)], myocardial infarction [1.43 (95% CI: 1.25 to 1.63)], heart failure [OR 2.23 (95% CI: 1.99 to 2.49)], and atrial fibrillation [OR 1.96 (95% CI: 1.64 to 2.33)]. In conclusion, in the context of the inflammatory milieu that accompanies HIV infection, RDW remains a powerful marker of cardiovascular disease.


Assuntos
Doenças Cardiovasculares/epidemiologia , Índices de Eritrócitos , Infecções por HIV/complicações , Infecções por HIV/patologia , Adolescente , Adulto , Idoso , Biomarcadores/análise , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Adulto Jovem
13.
Pain Physician ; 19(8): 603-615, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27906939

RESUMO

BACKGROUND: Low back pain may arise from disorders of the sacroiliac joint in up to 30% of patients. Radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint has been shown to be a safe and efficacious strategy. OBJECTIVES: We aimed to develop a new RFA technique to relieve low back pain secondary to sacroiliac joint disorders. STUDY DESIGN: Methodology development with validation through prospective observational non-randomized trial (PONRT). SETTING: Academic multidisciplinary health care system, Ohio, USA. METHODS: We devised a guide-block to facilitate accurate placement of multiple electrodes to simultaneously ablate the L5 dorsal ramus and lateral branches of the S1, S2, and S3 dorsal rami. This was achieved by bipolar radiofrequency ablation (b-RFA) to create a strip lesion from the lateral border of the base of the sacral superior articular process (L5-S1 facet joint) to the lateral border of the S3 sacral foramen. We applied this technique in 31 consecutive patients and compared the operating time, x-ray exposure time and dose, and clinical outcomes with patients (n = 62) who have been treated with the cooled radiofrequency technique. Patients' level of pain relief was reported as < 50%, 50 - 80%, and > 80% pain relief at one, 3, 6, and 12 months after the procedure. The relationship between RFA technique and duration of pain relief was evaluated using interval-censored multivariable Cox regression. RESULTS: The new technique allowed reduction of operating time by more than 50%, x-ray exposure time and dose by more than 80%, and cost by more than $1,000 per case. The percent of patients who achieved > 50% pain reduction was significantly higher in the b-RFA group at 3, 6, and 12 months follow-up, compared to the cooled radiofrequency group. No complications were observed in either group. LIMITATIONS: Although the major confounding factors were taken into account in the analysis, use of historical controls does not balance observed and unobserved potential confounding variables between groups so that the reported results are potentially confounded. CONCLUSION: Compared to the cooled radiofrequency ablation (c-RFA) technique, the new b-RFA technique reduced operating time by more than 50%, decreased x-ray exposure by more than 80%, and cut the cost by more than $1000 per case. The new method was associated with significantly improved clinical outcomes despite the limitations of the study design. Thus this new technique appeared to be safe, efficacious, and cost-effective. Key words: Sacroiliac joint pain, sacroiliac joint, low back pain, radiofrequency ablation (RFA), bipolar radiofrequency ablation (b-RFA), cooled radiofrequency ablation (c-RFA), cost-effectiveness.


Assuntos
Ablação por Cateter , Articulação Sacroilíaca , Artralgia , Humanos , Dor Lombar , Estudos Prospectivos
15.
Anesth Analg ; 123(4): 933-9, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27636576

RESUMO

BACKGROUND: Intraoperative hypotension may contribute to perioperative strokes. We therefore tested the hypothesis that intraoperative hypotension is associated with perioperative stroke. METHODS: After institutional review board approval for this case-control study, we identified patients who had nonneurological, noncardiac, and noncarotid surgery under general anesthesia at the Cleveland Clinic between 2005 and 2011 and experienced a postoperative stroke. Control patients not experiencing postoperative stroke were matched in a 4-to-1 ratio using propensity scores and restriction to the same procedure type as stroke patients. The association between intraoperative hypotension, measured as time-integrated area under a mean arterial pressure (MAP) of 70 mm Hg, and postoperative stroke was assessed using zero-inflated negative binomial regression. RESULTS: Among 106 337 patients meeting inclusion criteria, we identified 120 who had confirmed postoperative stroke events based on manual chart review. Four-to-one propensity matching yielded a final matched sample of 104 stroke cases and 398 controls. There was no association between stroke and intraoperative hypotension. Stroke patients were not more likely than controls to have been hypotensive (odds ratio, 0.49 [0.18-1.38]), and among patients with intraoperative hypotension, stroke patients did not experience a greater degree of hypotension than controls (ratio of geometric means, 1.07 [0.76-1.53]). CONCLUSIONS: In our propensity score-matched case-control study, we did not find an association between intraoperative hypotension, defined as MAP < 70 mm Hg, and postoperative stroke.


Assuntos
Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Procedimentos Cirúrgicos Operatórios/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Hipotensão/complicações , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos
16.
J Clin Anesth ; 31: 106-10, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27185687

RESUMO

STUDY OBJECTIVE: To determine the number of difficult airway (DA) carts required based on the number of anesthetising locations and patients risk of DA. DESIGN: Binomial distributions. SETTING AND PATIENTS: Various hypothetical settings and patient cohorts. INTERVENTIONS AND MEASUREMENTS: Binomial distributions were used to calculate the number of distinct combinations of DAs by number of anesthetising locations assuming an average risk of 10%. The 'at least' number of DAs was calculated using cumulative probabilities of having exactly two plus more than 2 DAs up to the total number of simultaneously started anesthetising locations or until the cumulative probability exceeds the 50% threshold, therefore being more likely than not. MAIN RESULTS: The probability of encountering concurrent DAs increases as the number of simultaneously started anesthetising locations increases. For at least 2 concurrent DAs, the probability first exceeds 50% at 17 locations. The corresponding thresholds for at least 3 and 4 concurrent DAs, are 27 and 37 locations respectively. The probability of at least 2 concurrent DAs will exceed 50% when approximately 17 anesthetising sites are started simultaneously and a 10% worst case risk is assumed. CONCLUSIONS: With continuing resource constraints, proper planning of human and capital resources for DAs needs to be addressed without compromising patient safety. It is recommended that every block of 15-20 sites be equipped with a DA cart, that anaesthesia groups develop and rehearse DA algorithms with available equipment, and that preoperative anaesthesia clinics be used to identify DA therefore providing logistical leverage.


Assuntos
Manuseio das Vias Aéreas/instrumentação , Anestesiologia/estatística & dados numéricos , Salas Cirúrgicas , Alocação de Recursos/estatística & dados numéricos , Manuseio das Vias Aéreas/métodos , Humanos , Segurança do Paciente
17.
Med Care ; 54(6): 623-31, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27050445

RESUMO

BACKGROUND: While substantial practice variation in coronary revascularization has been described and deviation from clinical practice guidelines has been associated with worse outcomes, the degree to which this is driven by flawed decision making and/or appropriate deviation associated with comorbid conditions is unknown. We evaluated heterogeneity in procedure use, and the extent to which hospital-level practice variation is related to surgical mortality. METHODS: We analyzed data on 554,563 inpatients undergoing either percutaneous coronary intervention or coronary artery bypass grafting at 391 centers in 6 states. Procedure-specific risk models were developed based on demographics and comorbidities, allowing for differential effects of comorbidities for each sex. For each patient, the revascularization procedure that minimized predicted probability of inhospital mortality was designated as the model-preferred procedure.Hospital-level discordance rates-the proportion of cases in each hospital for which the opposite from the model-preferred procedure was performed-were calculated. Hierarchical linear models were used to analyze the relationship between HDRs and hospital-level risk-standardized mortality ratios (RSMRs). RESULTS: Comorbidities and demographics alone explained between 68% and 86% of overall variation in inhospital mortality (corresponding C-statistics of 0.84-0.93). The mean (SD) HDR was 26.3% (9.6%). There was a positive independent association between HDRs and inhospital mortality, with a 10% increase in HDR associated with an 11% increase in RSMR (P<0.001). CONCLUSIONS: Variance in procedure use according to model preference was strongly associated with worse outcomes. A systematic approach to incorporating comorbidity as part of the decision-making process for coronary revascularization is needed.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Idoso , Ponte de Artéria Coronária/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Modelos Estatísticos , Intervenção Coronária Percutânea/mortalidade , Fatores de Risco , Estados Unidos/epidemiologia
18.
J Anaesthesiol Clin Pharmacol ; 32(1): 84-8, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27006548

RESUMO

BACKGROUND AND AIMS: Diabetes affects peripheral and central neurons causing paresthesia, allodynia, hyperalgesia, and spontaneous pain. However, the effect of diabetes on response to epidural steroid injection (ESI) remains unknown. We hypothesized that diabetic patients receiving ESI will have different pain scores compared to nondiabetic patients. We tested a secondary hypothesis that pain reduction differs at different levels of hemoglobin A1c (HbA1c) for patients with diabetes. MATERIAL AND METHODS: Data from 284 consecutive patients given ESIs for radiculopathy were obtained via a manual review of electronic medical records. We initially compared diabetic and nondiabetic groups with respect to balance on baseline demographic and morphometric characteristics. Next, a linear regression model was developed to evaluate the association between existing diabetes and postinjection reduction in pain scores. And finally, we univariably characterized the association between HbA1c and pain reduction. RESULTS: After exclusion of nine patients, 275 patients were analysed, including 55 (20%) who were diabetic. Pain reduction after ESI was comparable in diabetic and nondiabetic patients (Wald test P = 0.61). The degree of pain reduction generally decreased with the level of HbA1c until reaching HbA1c levels of approximately 7.5%, after which point it stayed fairly constant. CONCLUSION: There was no difference in pain reduction after ESIs comparing diabetic with nondiabetic patients; however, for diabetic patients, pain reduction may decrease with uncontrolled diabetes determined by high HbA1c values, thus suggesting pain physicians to take an active role in guiding their patients to have their blood glucose levels better regulated to improve outcomes of their ESIs.

19.
Anesth Analg ; 122(6): 1887-93, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26910492

RESUMO

BACKGROUND: Patients with rheumatoid arthritis have a high overall incidence of mortality, primarily because of cardiovascular complications. Thus, we tested the primary hypothesis that rheumatoid arthritis is independently associated with increased postoperative cardiovascular complications. Second, we determined whether rheumatoid arthritis is associated with increased thromboembolic complications, microcirculatory complications, and mortality. METHODS: We obtained censuses of 2009 to 2010 inpatient hospital discharge data across 7 states (Arizona, California, Florida, Iowa, Maryland, Michigan, and New Jersey). Rheumatoid arthritis was identified using the present-on-admission diagnosis code 714.0. Each rheumatoid arthritis discharge that had surgery was propensity matched to a control discharge. Multivariable logistic regression was used to compare matched rheumatoid arthritis and control patients on risk of in-hospital cardiovascular complications. RESULTS: Among 5.5 million qualifying discharges, the matching procedure yielded successful 66,886 matched pairs. One thousand ninety-five (1.64%) of the matched rheumatoid arthritis discharges and 1006 (1.50%) of the matched controls had in-hospital cardiovascular complications. The adjusted odds ratio (99% confidence interval) was estimated at 1.08 (0.96-1.21; P = 0.08). There were no significant differences in the odds of in-hospital thromboembolic complications (1.03 [0.93-1.15]; P = 0.42), in-hospital microcirculatory complications (0.94 [0.86-1.01]; P = 0.03), or in-hospital mortality (1.11 [0.98-1.25]; P = 0.04). CONCLUSIONS: Rheumatoid arthritis was not associated with an increased risk for postoperative cardiovascular complications.


Assuntos
Artrite Reumatoide/complicações , Doenças Cardiovasculares/etiologia , Complicações Pós-Operatórias/etiologia , Idoso , Artrite Reumatoide/diagnóstico , Artrite Reumatoide/mortalidade , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/fisiopatologia , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Microcirculação , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Alta do Paciente , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tromboembolia/etiologia , Tromboembolia/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
20.
Med Decis Making ; 36(1): 101-14, 2016 01.
Artigo em Inglês | MEDLINE | ID: mdl-25852080

RESUMO

Randomized trials provide strong evidence regarding efficacy of interventions but are limited in their capacity to address potential heterogeneity in effectiveness within broad clinical populations. For example, a treatment that on average is superior may be distinctly worse in certain patients. We propose a technique for using large electronic health registries to develop and validate decision models that measure-for distinct combinations of covariate values-the difference in predicted outcomes among 2 alternative treatments. We demonstrate the methodology in a prototype analysis of in-hospital mortality under alternative revascularization treatments. First, we developed prediction models for a binary outcome of interest for each treatment. Decision criteria were then defined based on the treatment-specific model predictions. Patients were then classified as receiving concordant or discordant care (in relation to the model recommendation), and the association between discordance and outcomes was evaluated. We then present alternative decision criteria and validation methodologies, as well as sensitivity analyses that investigate 1) the imbalance between treatments on observed covariates and 2) the aggregate impact of unobserved covariates. Our methodology supplements population-average clinical trial results by modeling heterogeneity in outcomes according to specific covariate values. It thus allows for assessment of current practice, from which cogent hypotheses for improved care can be derived. Newly emerging large population registries will allow for accurate predictions of outcome risk under competing treatments, as complex functions of predictor variables. Whether or not the models might be used to inform decision making depends on the extent to which important predictors are available. Further work is needed to understand the strengths and limitations of this approach, particularly in relation to those based on randomized trials.


Assuntos
Tomada de Decisão Clínica/métodos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Análise Custo-Benefício , Mortalidade Hospitalar , Humanos , Modelos Estatísticos , Revascularização Miocárdica/métodos , Revascularização Miocárdica/mortalidade , Razão de Chances
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