Clark D. Kensinger

Accuracy of FDG-PET to diagnose lung cancer in areas with infectious lung disease: A meta-analysis

IMPORTANCE Positron emission tomography (PET) combined with fludeoxyglucose F 18 (FDG) is recommended for the noninvasive diagnosis of pulmonary nodules suspicious for lung cancer. In populations with endemic infectious lung disease, FDG-PET may not accurately identify malignant lesions. OBJECTIVES To estimate the diagnostic accuracy of FDG-PET for pulmonary nodules suspicious for lung cancer in regions where infectious lung disease is endemic and compare the test accuracy in regions where infectious lung disease is rare. DATA SOURCES AND STUDY SELECTION Databases of MEDLINE, EMBASE, and the Web of Science were searched from October 1, 2000, through April 28, 2014. Articles reporting information sufficient to calculate sensitivity and specificity of FDG-PET to diagnose lung cancer were included. Only studies that enrolled more than 10 participants with benign and malignant lesions were included. Database searches yielded 1923 articles, of which 257 were assessed for eligibility. Seventy studies were included in the analysis. Studies reported on a total of 8511 nodules; 5105 (60%) were malignant. DATA EXTRACTION AND SYNTHESIS Abstracts meeting eligibility criteria were collected by a research librarian and reviewed by 2 independent reviewers. Hierarchical summary receiver operating characteristic curves were constructed. A random-effects logistic regression model was used to summarize and assess the effect of endemic infectious lung disease on test performance. MAIN OUTCOME AND MEASURES The sensitivity and specificity for FDG-PET test performance. RESULTS Heterogeneity for sensitivity (I2 = 87%) and specificity (I2 = 82%) was observed across studies. The pooled (unadjusted) sensitivity was 89% (95% CI, 86%-91%) and specificity was 75% (95% CI, 71%-79%). There was a 16% lower average adjusted specificity in regions with endemic infectious lung disease (61% [95% CI, 49%-72%]) compared with nonendemic regions (77% [95% CI, 73%-80%]). Lower specificity was observed when the analysis was limited to rigorously conducted and well-controlled studies. In general, sensitivity did not change appreciably by endemic infection status, even after adjusting for relevant factors. CONCLUSIONS AND RELEVANCE The accuracy of FDG-PET for diagnosing lung nodules was extremely heterogeneous. Use of FDG-PET combined with computed tomography was less specific in diagnosing malignancy in populations with endemic infectious lung disease compared with nonendemic regions. These data do not support the use of FDG-PET to diagnose lung cancer in endemic regions unless an institution achieves test performance accuracy similar to that found in nonendemic regions.

Closing the loop: a process evaluation of inpatient care team communication

Interprofessional communication is a core component of healthcare delivery in inpatient settings and a key contributor to safe and efficient inpatient care. Communication is implicated in two-thirds of medical errors and accounts for a significant proportion of nurse and clinician time.1–4 Inpatient teams rely on multiple communication methods ranging from paging and stationary telephones to wireless mobile devices, but comparative evaluations of communication systems are largely limited to qualitative outcomes.5–10 With respect to safety and efficiency, key measures of communication system performance include frequency of task disruption and reliability of ‘closed loop’ communication, meaning the sender receives a sufficient response to address the communication need. We sought to understand communication processes in two different patient care areas of a single hospital using traditional (non-mobile) versus mobile phones and to quantify how each mode of communication affects task disruption, efficiency and reliability of closed-loop communication. Our interprofessional team of providers, nurses and administrative leaders mapped processes for nurse-to-provider communication on two types of medical and surgical units that use different communication systems at Vanderbilt University Medical Center, a southeastern US academic medical centre. In both settings, nurses initiated messages by sending alphanumeric pages to clinicians. In the traditional (non-mobile) setting, providers called back a stationary unit phone, typically answered by the unit medical receptionist, who then located the nurse to answer the phone. In the …

Longitudinal Assessment of Cardiac Morphology and Function Following Kidney Transplantation

Abnormal cardiac morphology is a risk factor for cardiovascular complications in kidney transplant patients. A supraphysiologic level of fibroblast growth factor 23 (FGF‐23) has been associated with myocardial hypertrophy in this patient population. Our aim was to evaluate the change in cardiac morphology and function following kidney transplantation and to evaluate the association between the change in FGF‐23 concentrations and cardiac morphology.

Can donors with high donor risk indices be used cost‐effectively in liver transplantation in US Transplant Centers?

In an effort to quantify the impact of donor risk factors on recipient outcomes, the donor risk index (DRI) was developed. A high DRI correlates with poorer post‐transplant survival. In this study, high‐DRI donors are classified as those having DRIs >2.0, while low‐DRI donors have DRIs <2.0. The aim of this study was to evaluate the cost‐effectiveness of high‐DRI donor use in US Transplant Centers. A Markov‐based decision analytic model was created to simulate outcomes for an allocation scheme using only low‐DRI donors versus a scheme using both low‐ and high‐DRI donors. Baseline values and ranges were determined from published data and Medicare cost data. Sensitivity analyses were conducted to test model strength and parameter variability. An allocation scheme in which only low‐DRI donors were used generated 5.2 quality‐adjusted life years (QALYs) at a cost of

An Outcome-based Approach to Assign Meld Exception Points for Patients With Hepatocellular Cancer

83 000/QALY. An allocation scheme using both low‐ and high‐DRI donors generated 5.9 QALYs at a cost of

A comparison of patency and interventions in thigh versus Hemodialysis Reliable Outflow grafts for chronic hemodialysis vascular access

66 000/QALY. Sensitivity analyses supported the use of an allocation scheme using both low‐ and high‐DRI donors. The overall contribution of high‐DRI grafts to the donor pool and the resultant reduction in wait‐list mortality make them cost‐effective.

Long term evolution of endothelial function during kidney transplantation

Background Current Model for End-Stage Liver Disease (MELD) exception points provided to patients with hepatocellular cancer (HCC) are not based on outcome data and advantage these patients compared to those listed based on laboratory values (LABMELD). We sought to develop a data-based assignment for exception points for patients with HCC that equalizes outcomes among HCC and LABMELD patients. Methods We used Scientific Registry of Transplant Recipients data to compare patients listed with HCC who received exception points versus patients listed with LABMELD. Nation- and region-specific data were examined for (1) a composite outcome for adverse events of death, delisting, or becoming ineligible for transplant; and (2) transplant rate. We also determined MELD progression rates for LABMELD patients. Candidates listed with LABMELD scores were compared with those listed with 22 exception points for HCC (HCC22) to determine the LABMELD for which statistical parity was achieved for our composite outcome. Results HCC22 candidates time to adverse event were comparable to LABMELD scores of 16 (LABMELD16) candidates (range, 15-19), whereas time to transplant was comparable to LABMELD22 candidates (range, 21-23). LABMELD22 candidates had 2.1 times greater risk of adverse event compared with HCC22 (95% confidence interval, 1.9-2.4; range, 1.5-2.4). Progression among LABMELD16 candidates whose scores did not improve was similar across regions and averaged 0.94 points/month (95% confidence interval, 0.88-0.99, range 0.80-1.04). Conclusions To equalize the occurrence of an adverse outcome, the proper listing MELD for patients with HCC is 16, with approximately 1 additional point/month. These results provide a data-driven algorithm to increase fairness in listing priority.