Alan C. Elliott

Gender differences in outcomes of patients with cystic fibrosis.

BACKGROUNDnCystic fibrosis (CF) is a common life-shortening genetic disease in which women have been described to have worse outcomes than males, particularly in response to respiratory infections with Pseudomonas aeruginosa. However, as advancements in therapies have improved life expectancy, this gender disparity has been challenged. The objective of this study is to examine whether a gender-based survival difference still exists in this population and determine the impact of common CF respiratory infections on outcomes in males versus females with CF.nnnMETHODSnWe conducted a retrospective cohort analysis of 32,766 patients from the United States Cystic Fibrosis Foundation Patient Registry over a 13-year period. Kaplan-Meier and Cox proportional hazards models were used to compare overall mortality and pathogen based survival rates in males and females.nnnRESULTSnFemales demonstrated a decreased median life expectancy (36.0 years; 95% confidence interval [CI] 35.0-37.3) compared with men (38.7 years; 95% CI 37.8-39.6; p<0.001). Female gender proved to be a significant risk factor for death (hazard ratio 2.22, 95% CI 1.79-2.77), despite accounting for variables known to influence CF mortality. Women were also found to become colonized earlier with several bacteria and to have worse outcomes with common CF pathogens.nnnCONCLUSIONSnCF women continue to have a shortened life expectancy relative to men despite accounting for key CF-related comorbidities. Women also become colonized with certain common CF pathogens earlier than men and show a decreased life expectancy in the setting of respiratory infections. Explanations for this gender disparity are only beginning to be unraveled and further investigation into mechanisms is needed to help develop therapies that may narrow this gender gap.

Cognitive gains from gist reasoning training in adolescents with chronic-stage traumatic brain injury.

Adolescents with traumatic brain injury (TBI) typically demonstrate good recovery of previously acquired skills. However, higher-order and later emergent cognitive functions are often impaired and linked to poor outcomes in academic and social/behavioral domains. Few control trials exist that test cognitive treatment effectiveness at chronic recovery stages. The current pilot study compared the effects of two forms of cognitive training, gist reasoning (top-down) versus rote memory learning (bottom-up), on ability to abstract meanings, recall facts, and utilize core executive functions (i.e., working memory, inhibition) in 20 adolescents (ages 12–20) who were 6u2009months or longer post-TBI. Participants completed eight 45-min sessions over 1u2009month. After training, the gist reasoning group (nu2009=u200910) exhibited significant improvement in ability to abstract meanings and increased fact recall. This group also showed significant generalizations to untrained executive functions of working memory and inhibition. The memory training group (nu2009=u200910) failed to show significant gains in ability to abstract meaning or on other untrained specialized executive functions, although improved fact recall approached significance. These preliminary results suggest that relatively short-term training (6u2009h) utilizing a top-down reasoning approach is more effective than a bottom-up rote learning approach in achieving gains in higher-order cognitive abilities in adolescents at chronic stages of TBI. These findings need to be replicated in a larger study; nonetheless, the preliminary data suggest that traditional cognitive intervention schedules need to extend to later-stage training opportunities. Chronic-stage, higher-order cognitive trainings may serve to elevate levels of cognitive performance in adolescents with TBI.

Injury severity and comorbidities alone do not predict futility of care after geriatric trauma.

BACKGROUNDnWhen counseling surrogates of massively injured elderly trauma patients, the prognostic information they desire is rarely evidence based.nnnOBJECTIVEnWe sought to objectively predict futility of care in the massively injured elderly trauma patient using easily available parameters: age, Injury Severity Score (ISS), and preinjury comorbidities.nnnMETHODSnTwo cohorts (70-79 years and ≥80 years) were constructed from The National Trauma Data Bank (NTDB) for years 2007-2011. Comorbidities were tabulated for each patient. Mortality rates at every ISS score were tabulated for subjects with 0, 1, or ≥2 comorbidities. Futility was defined a priori as an in-hospital mortality rate of ≥95% in a cell with ≥5 subjects.nnnRESULTSnA total of 570,442 subjects were identified (age 70-79 years, n=217,384; age ≥80 years, n=352,608). Overall mortality was 5.3% for ages 70-79 and 6.6% for ≥80 years. No individual ISS score was found to have a mortality rate of ≥95% for any number of comorbidities in either age cohort. The highest mortality rate seen in any cell was for an ISS of 66 in the ≥80 year-old cohort with no listed comorbidities (93.3%). When upper extremes of ISS were aggregated into deciles, mortality for both cohorts across all number of comorbidities was 45.5%-60.9% for ISS 40-49, 56.6%-81.4% for ISS 50-59, and 73.9%-93.3% for ISS ≥60.nnnCONCLUSIONSnISS and preinjury comorbidities alone cannot be used to predict futility in massively injured elderly trauma patients. Future attempts to predict futility in these age groups may benefit from incorporating measures of physiologic distress.

Prediction of esophageal varices and variceal hemorrhage in patients with acute upper gastrointestinal bleeding

In patients with upper gastrointestinal bleeding (UGIB), identifying those with esophageal variceal hemorrhage prior to endoscopy would be clinically useful. This retrospective study of a large cohort of patients with UGIB used logistic regression analyses to evaluate the platelet count, aspartate aminotransferase (AST) to platelet ratio index (APRI), AST to alanine aminotransferase (ALT) ratio (AAR) and Lok index (all non-invasive blood markers) as predictors of variceal bleeding in (1) all patients with UGIB and (2) patients with cirrhosis and UGIB. 2233 patients admitted for UGIB were identified; 1034 patients had cirrhosis (46%) and of these, 555 patients (54%) had acute UGIB due to esophageal varices. In all patients with UGIB, the platelet count (cut-off 122,000/mm3), APRI (cut-off 5.1), AAR (cut-off 2.8) and Lok index (cut-off 0.9) had area under the curve (AUC)s of 0.80 0.82, 0.64, and 0.80, respectively, for predicting the presence of varices prior to endoscopy. To predict varices as the culprit of bleeding, the platelet count (cut-off 69,000), APRI (cut-off 2.6), AAR (cut-off 2.5) and Lok Index (0.90) had AUCs of 0.76, 0.77, 0.57 and 0.73, respectively. Finally, in patients with cirrhosis and UGIB, logistic regression was unable to identify optimal cut-off values useful for predicting varices as the culprit bleeding lesion for any of the non-invasive markers studied. For all patients with UGIB, non-invasive markers appear to differentiate patients with varices from those without varices and to identify those with a variceal culprit lesion. However, these markers could not distinguish between a variceal culprit and other lesions in patients with cirrhosis.

A survey of statistical packages on microcomputers

The results of a survey of statistical packages for microcomputers are presented. Questionnaires were sent to known statistical software producers, and completed questionnaires were obtained on 26 packages. This information is presented along with partial information on 32 other known packages. A brief listing of packages available on larger microcomputer systems is also presented. Finally, we also stress the need for reviews of the microcomputer statistical packages.

The Beneficial Effect of Beta-Blockers in Patients With Cirrhosis, Portal Hypertension and Ascites

Background: Patients with cirrhosis and portal hypertensive complications have reduced survival. As such, it has been suggested that nonselective beta‐blocker therapy in patients with advanced ascites is harmful. The aim of this study was, therefore, to determine the risk of mortality in patients with cirrhosis and ascites taking nonselective beta‐blocker therapy for the prevention of variceal hemorrhage. Materials and Methods: This study was a retrospective analysis of 2,419 patients with cirrhosis and portal hypertension admitted to Parkland Memorial Hospital (a university‐affiliated county teaching hospital) from 2003‐2010. Patients were subdivided into those with varices only, ascites only and those with both varices and ascites. The primary outcome measure for this study was all‐cause in‐hospital mortality. Results: Overall, 68 of 1,039 (6.5%) patients taking beta‐blockers died during their hospitalization, while 223 of 1,380 (16.2%) patients not taking beta‐blockers died (P < 0.001). Beta‐blocker use was also assessed in specific cohorts; mortality was 21.1% in patients with severe ascites with varices who were not taking beta‐blockers compared with 8.9% in patients who were taking beta‐blockers (P = 0.05). Overall, fewer patients taking beta‐blockers died compared with those not taking beta‐blockers in patients with varices only (6.4% versus 12.1%) and those with ascites with or without varices (6.6% versus 18.1%) (P < 0.001). Conclusions: Mortality was lower in patients with cirrhosis and portal hypertension taking nonselective beta‐blockers than in those not taking beta‐blockers. The use of nonselective beta‐blockers provided a significant survival benefit in patients with all grades of ascites, including those with severe ascites.

Upper Gastrointestinal Bleeding Caused by Severe Esophagitis: A Unique Clinical Syndrome

BackgroundWe have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis.AimWe aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis.MethodsWe conducted a retrospective matched case–control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions.ResultsEpidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86xa0% (102/119) than in controls 55xa0% (196/357) (pxa0<xa00.0001), while melena was less common in patients with esophagitis 38xa0% (45/119) than in controls 68xa0% (244/357) (pxa0<xa00.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (pxa0=xa00.01, and pxa0<xa00.0001, respectively). Length of hospital stay (pxa0=xa00.002), rebleeding rate at 42xa0days (pxa0=xa00.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis.ConclusionsWe have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with favorable outcomes.

Use of a pressure sensing sheath: comparison with standard means of blood pressure monitoring in catheterization procedures

Purpose Monitoring of blood pressure (BP) during procedures is variable, depending on multiple factors. Common methods include sphygmomanometer (BP cuff), separate radial artery catheterization, and side port monitoring of an indwelling sheath. Each means of monitoring has disadvantages, including time consumption, added risk, and signal dampening due to multiple factors. We sought an alternative approach to monitoring during procedures in the catheterization laboratory. Methods A new technology involving a 330 µm fiberoptic sensor embedded in the wall of a sheath structure was tested against both radial artery catheter and sphygmomanometer readings obtained simultaneous with readings recorded from the pressure sensing system (PSS). Correlations and Bland–Altman analysis were used to determine whether use of the PSS could substitute for these standard techniques. Results The results indicated highly significant correlations in systolic, diastolic, and mean arterial pressures (MAP) when compared against radial artery catheterization (p<0.0001), and MAP means differed by <4%. Bland–Altman analysis of the data suggested that the sheath measurements can replace a separate radial artery catheter. While less striking, significant correlations were seen when PSS readings were compared against BP cuff readings. Conclusions The PSS has competitive functionality to that seen with a dedicated radial artery catheter for BP monitoring and is available immediately on sheath insertion without the added risk of radial catheterization. The sensor is structurally separated from the primary sheath lumen and readings are unaffected by device introduction through the primary lumen. Time delays and potential complications from radial artery catheterization are avoided.

Teaching Ethics in a Statistics Curriculum with a Cross-Cultural Emphasis

ABSTRACT Like most professional disciplines, the ASA has adopted ethical guidelines for its practitioners. To promote these guidelines, as well as to meet governmental and institutional mandates, U.S. universities are demanding more training on ethics within existing statistics graduate student curricula. Most of this training is based on the teachings of Western philosophers. However, many statistics graduate students are from Eastern cultures (particularly Chinese), and cultural and linguistic evidence indicates that Western ethics may be difficult to translate into the philosophical concepts common to students from different cultural backgrounds. This article describes how to teach cross-cultural ethics, with emphasis on the ASA Ethical Guidelines, within a graduate-level statistical consulting course. In particular, we present content that can help students overcome cultural and language barriers to gain an understanding of ethical decision-making that is compatible with both Western and Eastern philosophical models. Supplementary materials for this article are available online.