Eric S. Armbrecht

The SIP68: An abbreviated sickness impact profile for disability outcomes research

The Sickness Impact Profile (SIP) is one of the most widely recognized generic health status instruments, but its length has often left it out of consideration for outcomes research. We assess a short alternative, the Sickness Impact Profile 68 (SIP68), for retest and proxy reliability, validity, and scaling properties, in a population of adults with disability (PWD). For convergent validity, the SIP68 was compared to the instrumental activities of daily living (IADLs), activities of daily living (ADLs) and the short-form 36 (SF-36). We completed 398 interviews with PWD, 131 index–proxy sets, and 40 retests. Retest intraclass correlations were above 0.75 for all scales and dimensions except the physical dimension (0.61). Proxy reliability ranged from 0.26 (psychological autonomy and communication) to 0.85 (somatic autonomy). Correlation between the SIP68 and SIP was 0.94 overall; between the SIP68 and similar scales of the SF-36 correlations was moderate, and highest for physical health scales. We repeated the SIP68 development factor analysis and reproduced a structure of the full SIP that included 65 of SIP68 items. However, 36 additional items were retained that are not part of the SIP68. Overall, the SIP68 shows promise for use as a disability outcomes tool.

The effect of red blood cell transfusion on tissue oxygenation and microcirculation in severe septic patients

BackgroundMicrocirculation plays a vital role in the development of multiple organ failure in severe sepsis. The effects of red blood cell (RBC) transfusions on these tissue oxygenation and microcirculation variables in early severe sepsis are not well defined.MethodsThis is a prospective, observational study of patients with severe sepsis requiring RBC transfusions of one to two units of non-leukoreduced RBCs for a hemoglobin < 7.0, or for a hemoglobin between 7.0 and 9.0 with lactic acidosis or central venous oxygen saturation < 70%. This study took place in a 54-bed, medical-surgical intensive care unit of a university-affiliated hospital. Thenar tissue oxygen saturation was measured by using a tissue spectrometer on 21 patients, and a vaso-occlusive test was performed before and 1 hour after transfusion. The sublingual microcirculation was assessed with a Sidestream Dark Field device concomitantly on 11 of them.ResultsRBC transfusion resulted in increase in hemoglobin (7.23 (± 0.87) to 8.75 (± 1.06) g/dl; p < 0.001). RBC transfusion did not globally affect near-infrared spectrometry (NIRS)-derived variables. However, percent change in muscle oxygen consumption was negatively correlated with baseline (r = - 0.679, p = 0.001). There was no statistically significant correlation between percent change in vascular reactivity and baseline (p = 0.275). There was a positive correlation between percent change in oxygen consumption and percent change in vascular reactivity (r = 0.442, p = 0.045). In the 11 patients, RBC transfusion did not globally affect NIRS-derived variables or SDF-derived variables. There was no statistically significant correlation between percent change in small vessel perfusion and baseline perfusion (r = -0.474, p = 0.141), between percent change in small vessel flow and baseline flow (r = -0.418, p = 0.201), or between percent change in small vessel perfusion and percent change in small vessel flow (r = 0.435, p = 0.182).ConclusionsIn a small sample population, muscle tissue oxygen consumption, microvascular reactivity and sublingual microcirculation were globally unaltered by RBC transfusion in severe septic patients. However, muscle oxygen consumption improved in patients with low baseline and deteriorated in patients with preserved baseline. Future research with larger samples is needed to further examine the association between RBC transfusion and outcomes of patients resuscitated early in severe sepsis, with an emphasis on elucidating the potential contribution of microvascular factors.

The association between sleep-disordered breathing and enuresis in children.

To evaluate the prevalence of nocturnal enuresis in children diagnosed with sleep disordered breathing (SDB) and the effect of adenotonsillectomy (T&A) on nocturnal enuresis.

Pediatric access to dermatologists: Medicaid versus private insurance

BACKGROUND There is disparity in access to outpatient care for Medicaid beneficiaries. This inequity disproportionately impacts children. Access for children with skin disease may be especially limited. OBJECTIVE We sought to compare access to dermatologists for new pediatric patients insured by Medicaid versus a private plan. METHODS We surveyed 13 metropolitan markets by conducting secret-shopper scripted telephone calls to dermatology providers listed by Medicaid health plans. Paired calls, differing by insurance type, were made to each office on the same day, portraying a parent requesting a new appointment for a child with eczema. RESULTS We called the offices of 723 Medicaid-listed providers. Final analysis included 471 dermatologists practicing general dermatology. Of these, an average of 44% refused a new Medicaid-insured pediatric patient. The average wait time for an appointment did not significantly vary between insurance types. Assuming that dermatologists not listed as Medicaid providers do not see Medicaid-insured children, our data indicate that pediatric Medicaid acceptance rates ranged from 6% to 64% by market, with an overall market size-weighted average acceptance rate of 19%. Relative reimbursement levels for Medicaid-insured patients did not correlate with acceptance rates. LIMITATIONS Although the most current health plan directories were used to create calling lists, these are dynamic. The sample sizes of confirmed appointments were in part limited by a lack of referral letters and/or health plan identification numbers. Only confirmed appointments were used to calculate average wait times. CONCLUSIONS Access to dermatologists is limited for Medicaid-insured children with eczema.

Obstructive sleep apnea in children

To study the correlation between obstructive sleep apnea (OSA), obesity, behavior, and quality of life.

Evaluation of the definitions of "high-risk" cutaneous squamous cell carcinoma using the american joint committee on cancer staging criteria and national comprehensive cancer network guidelines.

Recent guidelines from the American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) have been proposed for the assessment of “high-risk” cutaneous squamous cell carcinomas (cSCCs). Though different in perspective, both guidelines share the common goals of trying to identify “high-risk” cSCCs and improving patient outcomes. Thus, in theory, both definitions should identify a similar proportion of “high-risk” tumors. We sought to evaluate the AJCC and NCCN definitions of “high-risk” cSCCs and to assess their concordance. Methods. A retrospective review of head and neck cSCCs seen by an academic dermatology department from July 2010 to November 2011 was performed. Results. By AJCC criteria, most tumors (n = 211,82.1%) were of Stage 1; 46 tumors (13.9%) were of Stage 2. Almost all were of Stage 2 due to size alone (≥2 cm); one tumor was “upstaged” due to “high-risk features.” Using the NCCN taxonomy, 231 (87%) of tumors were “high-risk.” Discussion. This analysis demonstrates discordance between AJCC and NCCN definitions of “high-risk” cSCC. Few cSCCs are of Stage 2 by AJCC criteria, while most are “high-risk” by the NCCN guidelines. While the current guidelines represent significant progress, further studies are needed to generate a unified definition of “high-risk” cSCC to optimize management.

Hybrid versus Norwood procedure for hypoplastic left heart syndrome: Contemporary series from a single center

OBJECTIVE Two different strategies have emerged in the initial palliation for hypoplastic left heart syndrome, the conventional Norwood operation and the so-called hybrid procedure. We have used each of these at our center. The purpose of the present study was to compare the outcomes of both procedures. METHODS From 2007 to 2012, 40 patients presented to the Cardinal Glennon Childrens Medical Center with hypoplastic left heart syndrome or 1 of its variants. Of the 40 patients, 24 underwent a hybrid procedure and 16 a Norwood procedure for initial palliation. The medical records, echocardiograms, and cardiac catheterization data were retrospectively reviewed. Standard statistical analysis was performed. RESULTS The patients who underwent the hybrid procedure weighed less than those who underwent the Norwood procedure. Overall unadjusted survival was better in the Norwood group, although this did not reach statistical significance. Overall hospital resource usage was similar in both cohorts, taking into account both first and second palliation stages. CONCLUSIONS In our review, we found no statistically significant difference in survival or resource usage between those patients undergoing the Norwood procedure and those undergoing a hybrid procedure as initial palliation for hypoplastic left heart syndrome.

A Systematic Review of Adenotonsillectomy as a Risk Factor for Childhood Obesity

Objective. Tonsillectomy is the most common major surgical procedure performed in children. There is evidence that tonsillectomy is associated with weight increase and may contribute to pediatric obesity. The study aimed to review the evidence that tonsillectomy with or without adenoidectomy is a risk factor for future obesity. Data Sources. Systematic literature search was performed using PubMed and Ovid. Review Methods. Systematic analysis of the literature from 1970 to 2009 on patients who underwent adenotonsillectomy (T&A) with preoperative and postoperative weight-based measurements. Results. Nine studies satisfied inclusion criteria. A total of 795 children were included. Preoperative weight ranged from normal to morbid obesity. In total, 656 children had demographic information recorded, and 53.35% of the children were male. Indication for surgery was not recorded in 336 patients. In 47.7% patients, the indication recorded was sleep-disordered breathing. The first group included 3 studies involving 127 children, and body mass index (BMI) increased by 5.5% to 8.2%. The second group included 3 studies involving 419 patients; the standardized weight scores increased in 46% to 100% of patients. The third group included 3 studies with 249 patients; the corrected weight increased postoperatively in 50% to 75% of patients. Morbidly obese patients (weight 130%-260% vs peers) remained unchanged postoperatively. Limitations. Each study was designed with different definitions of overweight and a range of follow-up periods. Demographic information was limited. Conclusions. A large population of normal and overweight children undergoing T&A gained a greater than expected amount of weight postoperatively, which suggests an association between T&A and weight gain. A significant need exists for a large study with consistent outcomes measured.

High-Dose Interleukin-2 (HD IL-2) Therapy Should Be Considered for Treatment of Patients with Melanoma Brain Metastases

A retrospective review was performed on patients with stable melanoma brain metastases treated with HD IL-2 therapy (720,000 IU/kg per dose intravenously; 14 doses, 2 cycles per course, maximum 2 courses) from January 1999 to June 2011 at Saint Louis University. There were 5 men and 3 women; median age was 52.2 years (26.8–61.1 years). One patient started treatment with lung lesions only (after resection of melanoma brain disease) and experienced partial response. Seven patients had brain metastases at treatment initiation. Median overall survival (mOS) for entire cohort (n = 8) was 8.7 months (2.1 to 19.0 months). All patients with brain metastases at first dose (n = 7) showed progressive disease; mOS was 6.7 months (range 2.1–18.2 months) for this group. Patients received radiosurgery and whole brain radiation before and after HD IL-2 therapy. One patient had symptoms suggestive of neurotoxicity. A history of alcohol abuse was revealed during admission. The patients symptoms improved with initiation of an alcohol withdrawal protocol. In this analysis, patients with melanoma brain metastases received HD IL-2 without treatment-related mortality. We think that HD IL-2 should be considered as a treatment option in patients with melanoma brain metastases who are otherwise eligible for therapy.

Comparison of fenestrated and nonfenestrated patients undergoing extracardiac fontan

BACKGROUND The purpose of this study is to compare morbidity and mortality between fenestrated (F, 61 patients) and nonfenestrated (NF, 54 patients) extracardiac Fontan patients during two eras from July 1995 to December 2010: era 1(1995 to 2004) and era 2 (2005 to 2010). METHODS Variables evaluated included morphology, hemodynamics, chest tube volume and duration, intensive care and hospital stay, oxygen saturation, neurologic events, rhythm, and readmissions for chylous effusions. Follow-up in 114 hospital survivors was longer in the nonfenestrated cohort (F, 5.0 ± 3.3 years; NF, 7.1 ± 4.6 years; p < 0.005). RESULTS Cohorts were similar in body size, morphology, and hemodynamics. Fenestration in hypoplastic left heart syndrome was appreciatively higher in era 2. Bypass time (F, 69 ± 27 minutes; NF, 57 ± 21 minutes) and conduit size (F, 18.8 mm; NF, 19.1 mm) were similar. There was 1 early nonfenestrated Fontan death (1 of 54; 2%) and 4 late deaths (F, 2 of 61, 5%; NF, 2 of 53, 4%; p = 0.86). Room air saturation was higher in NF patients (F, 89%; NF, 94%; p < 0.05). Total chest tube volume was similar, but fenestration was associated with greater chest tube drainage among hypoplastic left heart patients (HLHS, 5,582 ± 3,286 mL; non-HLHS, 3,405 ± 2,533 mL; p = 0.06; odds ratio; 2.0). Readmission to treat chylous effusions, loss of sinus rhythm, actuarial freedom from death, all neurologic events, pacemaker insertion, and Fontan takedown were similar in both cohorts. CONCLUSIONS Fenestration was associated with lower discharge oxygen saturations, but late outcomes in fenestrated and nonfenestrated patients are equivalent.