Jocelyn Andrel

A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening.

Colorectal cancer screening is underutilized. The objective of the current study was to determine whether targeted and tailored interventions can increase screening use.

Risk of Major Bleeding with Concomitant Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients Receiving Long-Term Warfarin Therapy

Study Objectives. To characterize the safety of concomitant aspirin, clopidogrel, and warfarin therapy after percutaneous coronary intervention (PCI), and to identify patient characteristics that increase the risk of hemorrhage.

Impact of obesity on perioperative morbidity and mortality after pancreaticoduodenectomy.

BACKGROUND Obesity has been implicated as a risk factor for perioperative and postoperative complications. The aim of this study was to determine the impact of obesity on morbidity and mortality in patients undergoing pancreaticoduodenectomy (PD). STUDY DESIGN Between January 2000 and July 2007, 262 patients underwent PD at Thomas Jefferson University Hospital, of whom 240 had complete data, including body mass index (BMI; calculated as kg/m(2)) for analysis. Data on BMI, preoperative parameters, operative details, and postoperative course were collected. Patients were categorized as obese (BMI >or= 30), overweight (BMI >or= 25 and < 30), or normal weight (BMI < 25). Complications were graded according to previously published scales. Other end points included length of postoperative hospital stay, blood loss, and operative duration. Analyses were performed using univariate and multivariable models. RESULTS There were 103 (42.9%) normal-weight, 71 (29.6%) overweight, and 66 (27.5%) obese patients. There were 5 perioperative deaths (2.1%), with no differences across BMI categories. A significant difference in median operative duration and blood loss between obese and normal-weight patients was identified (439 versus 362.5 minutes, p = 0.0004; 650 versus 500 mL, p = 0.0139). In addition, median length of stay was significantly longer for BMI (9.5 versus 8 days, p = 0.095). Although there were no significant differences in superficial wound infections, obese patients did have an increased rate of serious complications compared with normal-weight patients (24.2% versus 13.6%, respectively; p = 0.10). CONCLUSIONS Obese patients undergoing PD have a substantially increased blood loss and longer operative time but do not have a substantially increased length of postoperative hospital stay or rate of serious complications. These findings should be considered when assessing patients for operation and when counseling patients about operative risk, but they do not preclude obese individuals from undergoing definitive pancreatic operations.

Pretreatment FDG‐PET standardized uptake value as a prognostic factor for outcome in head and neck cancer

We studied the potential prognostic significance of pretreatment 18‐fluorodeoxyglucose‐positron emission tomography (FDG‐PET) standardized uptake value (SUV) in squamous cell carcinoma of the head and neck (SCCHN).

A Randomized Controlled Trial of a Tailored Navigation and a Standard Intervention in Colorectal Cancer Screening

Background: This randomized, controlled trial assessed the impact of a tailored navigation intervention versus a standard mailed intervention on colorectal cancer screening adherence and screening decision stage (SDS). Methods: Primary care patients (n = 945) were surveyed and randomized to a Tailored Navigation Intervention (TNI) Group (n = 312), Standard Intervention (SI) Group (n = 316), or usual care Control Group (n = 317). TNI Group participants were sent colonoscopy instructions and/or stool blood tests according to reported test preference, and received a navigation call. The SI Group was sent both colonoscopy instructions and stool blood tests. Multivariable analyses assessed intervention impact on adherence and change in SDS at 6 months. Results: The primary outcome, screening adherence (TNI Group: 38%, SI Group: 33%, Control Group: 12%), was higher for intervention recipients than controls (P = 0.001 and P = 0.001, respectively), but the two intervention groups did not differ significantly (P = 0.201). Positive SDS change (TNI Group: +45%, SI Group: +37%, and Control Group: +23%) was significantly greater among intervention recipients than controls (P = 0.001 and P = 0.001, respectively), and the intervention group difference approached significance (P = 0.053). Secondary analyses indicate that tailored navigation boosted preferred test use, and suggest that intervention impact on adherence and SDS was attenuated by limited access to screening options. Conclusions: Both interventions had significant, positive effects on outcomes compared with usual care. TNI versus SI impact had a modest positive impact on adherence and a pronounced effect on SDS. Impact: Mailed screening tests can boost adherence. Research is needed to determine how preference, access, and navigation affect screening outcomes. Cancer Epidemiol Biomarkers Prev; 22(1); 109–17. ©2012 AACR.

Controlled and Cardiac-Restricted Overexpression of the Arginine Vasopressin V1A Receptor Causes Reversible Left Ventricular Dysfunction Through Gαq-Mediated Cell Signaling

BACKGROUND [Arg8]-vasopressin (AVP) activates 3 G-protein-coupled receptors: V1A, V2, and V1B. The AVP-V1A receptor is the primary AVP receptor in the heart; however, its role in cardiac homeostasis is controversial. To better understand AVP-mediated signaling in the heart, we created a transgenic mouse with controlled overexpression of the V1A receptor. METHODS AND RESULTS The V1A receptor transgene was placed under the control of the tetracycline-regulated, cardiac-specific α-myosin heavy chain promoter (V1A-TG). V1A-TG mice had a normal cardiac function phenotype at 10 weeks of age; however, by 24 weeks of age, tetracycline-transactivating factor/V1A-TG mouse hearts had reduced cardiac function, cardiac hypertrophy, and dilatation of the ventricular cavity. Contractile dysfunction was also observed in isolated adult cardiac myocytes. When V1A receptor transgene was induced to be expressed in adult mice (V1A-TG(Ind)), left ventricular dysfunction and dilatation were also seen, albeit at a later time point. Because the V1A receptor mediates cell signaling through Gα(q) protein, we blocked Gα(q) signaling by crossing tetracycline-transactivating factor/V1A mice with transgenic mice that expressed a small inhibitory peptide against Gα(q). Gα(q) blockade abrogated the development of the heart failure phenotype in tetracycline-transactivating factor/V1A-TG mice. The heart failure phenotype could be reversed by administration of doxycycline. CONCLUSIONS Our results demonstrate a role for V1A-mediated signaling in the development of heart failure and support a role for V1A blockade in the treatment of patients with elevated levels of vasopressin.

Obesity and other predictors of absenteeism in Philadelphia school children.

BACKGROUND Limited data indicate that obese children are absent from school more than their normal-weight peers. We analyzed administrative data from a large urban school district to investigate the association of obesity and student sociodemographic characteristics with absenteeism. METHODS We analyzed 291,040 records, representing 165,056 unique students (grades 1-12). Obesity status was classified according to Centers for Disease Control and Prevention age- and sex-specific percentiles for body mass index (BMI) and analyses were based on negative binomial regression. RESULTS Overall rates of overweight and obesity were 17% and 20%, respectively, and the estimated absence rate was 17 absences per 180 student-days. Obesity was weakly associated with increased school absences. The association was present mainly among the most obese students (BMI >99th percentile), who had an 11% greater absence rate compared to normal-weight students. Compared to white students, Hispanics and African Americans had higher absence rates (14% and 10%, respectively), and Asians had lower absence rates (43%). Students eligible for free or reduced-cost meals had 24% higher absence rates than those who were not eligible. CONCLUSIONS Overweight and obesity do not seem strongly associated with school absence, except among extremely obese children. Race and poverty appear to affect absences to a greater extent than overweight and obesity. Additional research is needed to investigate the contribution of contextual factors in schools and neighborhoods. This study suggests that data routinely collected in schools could be used to track childhood obesity and to efficiently evaluate public health interventions designed to decrease childhood obesity.

Adjuvant Versus Salvage Radiation Therapy for Prostate Cancer Patients With Adverse Pathologic Features: Comparative Analysis of Long-term Outcomes.

Objectives:To compare long-term outcomes of men with adverse pathologic features after adjuvant radiation therapy (ART) versus salvage radiation therapy (SRT) after radical prostatectomy at our institution. Methods:Patients treated with postprostatectomy radiation therapy with pT3 tumors, or pT2 with positive surgical margins, were identified. Cumulative freedom from biochemical failure (FFBF), freedom from metastatic failure (FFMF), and overall survival rates were estimated utilizing the Kaplan-Meier method. Multivariate analyses were performed to determine independent prognostic factors correlated with study endpoints. Propensity score analyses were performed to adjust for confounding because of nonrandom treatment allocation. Results:A total of 186 patients with adverse pathologic features treated with ART or SRT were identified. The median follow-up time after radical prostatectomy was 103 and 88 months after completion of radiation therapy. The Kaplan-Meier estimates for 10-year FFBF was 73% and 41% after ART and SRT, respectively (log-rank, P=0.0001). Ten-year FFMF was higher for patients who received ART versus SRT (98.6% vs. 80.9%, P=0.0028). On multivariate analyses there was no significant difference with respect to treatment group in terms of FFBF, FFMF, and overall survival after adjusting for propensity score. Conclusions:Although unadjusted analyses showed improved FFBF with ART, the propensity score-adjusted analyses demonstrated that long-term outcomes of patients treated with ART and SRT do not differ significantly. These results, with decreased effect size of ART after adjusting for propensity score, demonstrate the potential impact of confounding on observational research.

Safety of Iodinated Intravenous Contrast Medium Administration in Sickle Cell Disease

BACKGROUND Increased sickling of erythrocytes following intravenous iodinated contrast has been described in patients with sickle cell disease. In vitro, the effect is correlated with the tonicity, viscosity, acidity, and ionic nature of contrast media. Less erythrocyte sickling is observed in vitro with second-generation low- and iso-osmolar contrast agents. Clinical impact of these newer intravenous contrast agents has not been investigated. PURPOSE To review adverse outcomes following contrast administration in a cohort of patients with sickle cell disease. METHODS Inpatients with sickle cell disease who received iodinated intravenous were identified. Medical records were reviewed for evidence of worsening crisis and occurrence of adverse events within 48 hours of contrast administration. Data points were further analyzed with the goal of identifying predictors of adverse outcome. RESULTS There were 132 imaging studies that met inclusion criteria in 79 patients, mostly with homozygous hemoglobin S. The low-osmolar contrast Optiray (Coviden Imaging Inc., Hazelwood, Mo) was used in 45%. Administration of fluids, Mucomyst (Bristol-Myers Squibb, New York, NY), oxygen, or blood transfusion preceded 58% of studies. Minor adverse events followed 16% of studies, with new or worsening pain being most common (12%). Contrast-induced nephropathy occurred in 1.5%, resolving in all cases. Prehydration was associated with a decreased incidence of adverse events (P=.02). CONCLUSION Adverse events related to intravenous contrast occur in sickle cell disease patients at a rate similar to the general population, without an increase in contrast-induced nephropathy. Subjective reports of new or worsening pain crisis do not translate to objective findings. Beneficial diagnostic imaging can be performed without increased risk of serious complication in this population.

Factors associated with colorectal cancer screening decision stage

OBJECTIVE This paper reports on factors associated with colorectal cancer (CRC) screening decision stage (SDS) in screening-eligible primary care patients. METHODS Baseline telephone survey data (i.e., sociodemographic background, CRC screening perceptions, and SDS) were obtained for 1515 patients in a randomized behavioral intervention trial. Respondents reported SDS, a measure of proximity to actual screening, after listening to descriptions of screening stool blood testing and flexible sigmoidoscopy as had never heard of (NHO), were not considering or were undecided (NCU), or decided to do (DTD) each test. Polychotomous regression analyses were performed to differentiate participants by SDS. RESULTS At baseline, SDS was distributed as follows: NHO (8%), NCU (41%), and DTD (51%). We found that individuals who had DTD compared to those who were NCU about screening were older (OR=0.64), had prior cancer screening (OR=1.43), believed screening is important (OR=3.44), and had high social support (OR=2.49). Persons who were NCU compared to NHO participants were female (OR=2.18), were white (OR=2.35), had prior cancer screening (OR=2.81), and believed screening is important (OR=2.44). CONCLUSIONS Prior screening and belief in screening importance were found to be consistently associated with SDS across comparisons, while older age, gender, race, and social support were not.