Sandra D. Griffith

A new Elixhauser-based comorbidity summary measure to predict in-hospital mortality.

Background:Recently, van Walraven developed a weighted summary score (VW) based on the 30 comorbidities from the Elixhauser comorbidity system. One of the 30 comorbidities, cardiac arrhythmia, is currently excluded as a comorbidity indicator in administrative datasets such as the Nationwide Inpatient Sample (NIS), prompting us to examine the validity of the VW score and its use in the NIS. Methods:Using data from the 2009 Maryland State Inpatient Database, we derived weighted summary scores to predict in-hospital mortality based on the full (30) and reduced (29) set of comorbidities and compared model performance of these and other comorbidity summaries in 2009 NIS data. Results:Weights of our derived scores were not sensitive to the exclusion of cardiac arrhythmia. When applied to NIS data, models containing derived summary scores performed nearly identically (c statistics for 30 and 29 variable-derived summary scores: 0.804 and 0.802, respectively) to the model using all 29 comorbidity indicators (c=0.809), and slightly better than the VW score (c=0.793). Each of these models performed substantially better than those based on a simple count of Elixhauser comorbidities (c=0.745) or a categorized count (0, 1, 2, or ≥3 comorbidities; c=0.737). Conclusions:The VW score and our derived scores are valid in the NIS and are statistically superior to summaries using simple comorbidity counts. Researchers wishing to summarize the Elixhauser comorbidities with a single value should use the VW score or those derived in this study.

Thoughts of Death and Self-Harm in Patients With Epilepsy or Multiple Sclerosis in a Tertiary Care Center

BACKGROUND Patients with epilepsy or multiple sclerosis (MS) have high risks of depression and increased risks of suicide, but little is known about their risks of suicidal ideation. OBJECTIVE We sought to (1) estimate the prevalence of thoughts of being better off dead or of self-harm among patients with epilepsy or MS, (2) identify risk factors for such thoughts, and (3) determine whether any risk factors interact with depression to predict such thoughts. METHODS A Cleveland Clinic database provided information on 20,734 visits of 6586 outpatients with epilepsy or MS. Outcome measures were thoughts of death or self-harm (Patient Health Questionnaire [PHQ] item-9), and total score ≥10 for the 8 remaining PHQ items (probable major depression). Generalized estimating equations accounted for repeat visits in tests of associations of PHQ item-9 responses with depression, age, sex, race, household income, disease severity, and quality of life. RESULTS Prevalence of thoughts of death or self-harm averaged 14.4% overall (epilepsy, 14.0% and MS, 14.7%). Factors associated with positive PHQ item-9 responses in epilepsy were depression and male sex, modified by poor quality of life. Factors associated with positive PHQ item-9 in MS were depression, male sex, medical comorbidity, and poor quality of life; the effect of depression was worse with greater MS severity and being unmarried. CONCLUSIONS Among patients with common neurologic disorders (epilepsy or MS), 14%-15% reported thoughts of death or self-harm associated with illness severity, depression, quality of life, male sex, and being unmarried. Such patients require further evaluation of clinical outcomes and effects of treatment.

Comparison of Electronic Screening for Suicidal Risk With the Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an Outpatient Psychiatric Clinic.

BACKGROUND Patient-reported data can improve clinical care, including identifying patients who are at risk for suicide. METHODS In a tertiary care, psychiatric outpatient clinic, we compared computerized self-assessments of suicidal risk based on item 9 of the Patient Health Questionnaire-9 and an electronic version of the Columbia Suicide Severity Rating Scale (C-SSRS), using retrospective medical record review of clinical psychiatric assessments as the reference standard. We also surveyed patients׳ attitudes about participating in the process. We compared prevalence of suicidal risk rates by the 3 assessment methods as well as their sensitivity, specificity, and predictive value. RESULTS Observed prevalence of positive suicidal risk screenings differed significantly, ranking (1) Patient Health Questionnaire-9 item 9, 24% (343/1416; 95% CI: 22%-26%) < (2) C-SSRS, 6.0% (85/1416; 95% CI: 5.0%-7.4%) < (3) clinical assessment, 1.4% (20/1416; 95% CI: 0.9%-2.2%). The sensitivity of Patient Health Questionnaire-9 item 9 was 92% (78/85; 95% CI: 86%-98%) and the specificity was 81% (1107/1376; 95% CI: 78%-82%). The sensitivity of the C-SSRS was 95.0% (19/20; 95% CI: 75%-100%) and the specificity was 95% (1330/1396; 95% CI: 94%-96%). Of 100 patients surveyed, the screening was well accepted, with some concerns about confidentiality and adequate clinical follow-up. CONCLUSIONS As expected, Patient Health Questionnaire-9 item 9 generated much higher rates of apparently false-positive findings than the C-SSRS did, when compared with clinical assessment. C-SSRS backed with timely clinical assessment may be a useful and efficient method of screening for suicidal risk, provided that adequate, immediate clinical follow-up is available.

A method comparison study of timeline followback and ecological momentary assessment of daily cigarette consumption

INTRODUCTION Uncertainty exists about how best to measure daily cigarette consumption. Two common measures are timeline followback (TLFB), which involves structured, prompted recall, and ecological momentary assessment (EMA), which involves recording consumption, as it occurs, on a handheld electronic device. METHODS We evaluated the agreement between TLFB and EMA measures collected for 14 days prior to the target quit date from 236 smokers in a smoking cessation program. We performed a Bland-Altman analysis to assess agreement of TLFB and EMA using a regression-based model that allows for a nonuniform difference between methods and limits of agreement that can vary with the number of cigarettes smoked. RESULTS For pairs of measurements taken on the same smoker, TLFB counts were on average 3.2 cigarettes higher than EMA counts; this difference increased for larger numbers of cigarettes. Using a model that allows for variable limits of agreement, the width of the 95% interval ranged from 8.7 to 61.8 cigarettes, with an average of 26.4 cigarettes. Variation between the methods increased substantially for larger cigarette counts, leading to wider limits and poorer agreement for heavy smokers. DISCUSSION Throughout the measurement range, the estimated limits of agreement were far wider than the limits of clinical significance, defined a priori to be 20% of the number of cigarettes smoked. We conclude that TLFB and EMA cannot be considered equivalent for the assessment of daily cigarette consumption, especially for heavy smokers.

An active learning approach for rapid characterization of endothelial cells in human tumors.

Currently, no available pathological or molecular measures of tumor angiogenesis predict response to antiangiogenic therapies used in clinical practice. Recognizing that tumor endothelial cells (EC) and EC activation and survival signaling are the direct targets of these therapies, we sought to develop an automated platform for quantifying activity of critical signaling pathways and other biological events in EC of patient tumors by histopathology. Computer image analysis of EC in highly heterogeneous human tumors by a statistical classifier trained using examples selected by human experts performed poorly due to subjectivity and selection bias. We hypothesized that the analysis can be optimized by a more active process to aid experts in identifying informative training examples. To test this hypothesis, we incorporated a novel active learning (AL) algorithm into FARSIGHT image analysis software that aids the expert by seeking out informative examples for the operator to label. The resulting FARSIGHT-AL system identified EC with specificity and sensitivity consistently greater than 0.9 and outperformed traditional supervised classification algorithms. The system modeled individual operator preferences and generated reproducible results. Using the results of EC classification, we also quantified proliferation (Ki67) and activity in important signal transduction pathways (MAP kinase, STAT3) in immunostained human clear cell renal cell carcinoma and other tumors. FARSIGHT-AL enables characterization of EC in conventionally preserved human tumors in a more automated process suitable for testing and validating in clinical trials. The results of our study support a unique opportunity for quantifying angiogenesis in a manner that can now be tested for its ability to identify novel predictive and response biomarkers.

National Trends and In-hospital Complication Rates in More Than 1600 Hemispherectomies From 1988 to 2010: A Nationwide Inpatient Sample Study.

BACKGROUND Anatomic and functional hemispherectomies are relatively infrequent and technically challenging. The literature is limited by small samples and single institution data. OBJECTIVE We used the Nationwide Inpatient Sample (NIS) database to report on a large population of hemispherectomy patients and their in-hospital complication rates over a 23-year period. METHODS Between 1988 and 2010, we identified 304 pediatric hospitalizations in the NIS database where hemispherectomy was performed. Using the NIS weighting scheme, this inferred an estimated 1611 hospitalizations nationwide during this time period. Descriptive statistics were calculated on this inferred sample for patient and hospital characteristics and stratified by the presence of in-hospital complications. The adjusted odds of in-hospital complications and nonroutine discharge were estimated using multivariable models. RESULTS The mean age of the patients was 5.9 years; 46% were female, and 54% were white. In the inferred series, 909 hospitalizations (56%) encountered at least 1 in-hospital complication; 42% were surgery related, and 25% were related to the hospitalization itself. For every 1-year increase in age, there was a corresponding 8% increase in the odds of a nonroutine discharge, adjusting for other potential confounders (95% confidence interval: 1.01-1.16). The most common in-hospital complication was the need for a blood transfusion (30%), followed by meningitis (10%), hydrocephalus (8%), postoperative hematoma/stroke (8%), and adverse pulmonary event (8%). Thirty-three mortalities (2%) were inferred from this series. CONCLUSION This is the largest study to date examining hemispherectomy and associated in-hospital complication rates. This study supports early surgery in patients with medically intractable epilepsy and severe hemispheric disease.

Lumbar dorsal root Ganglia location: an anatomic and MRI assessment.

Background The dorsal root ganglion (DRG) is a key structure in the mechanism of symptomatic radicular pain, weakness and change in sensation. DRG localization can assist in the decision making process of which areas require decompression, and type of procedure that should be performed to treat radicular symptoms. In this study we determine dimensions of lumbar foramina, DRG and its relationship to the neuroforamina through anatomic and magnetic resonance imaging (MRI) evaluation Agreement between MRI and anatomic assessment of DRG location will be determined. Methods Sixteen embalmed cadavers, 10 females and 6 males, aged 68 to 106 years had an MRI of the thoracolumbar spine followed by dissection. Measurements made included foraminal height and width, DRG size and nerve root take off angle. The center of the DRG and its relationship to the foramina were measured and the probability of agreement between anatomic and MRI assessment were made. Results The greatest width of the DRG was 6.5mm bilaterally at L5 (range 3.2-6.5mm). The nerve root take off angle was largest at L5 on the left (range 50.5o-58.8o) and L4 on the right (range 50.5o-57.2o). The center of the DRG was found bilaterally in the medial zone of the foramen of L1-4 and lateral zone at L5. Foramina size increased from L1 to L5 in the ventral to dorsal and cephalad to caudal direction. Pedicle width increased from L1 to L5. The estimated overall probability of agreement between anatomic and MRI DRG location was 86.3% (95% confidence interval = 77.5% − 92.0%). Conclusions The percentage of agreement between MRI and anatomic evaluation of lumbar DRG location significantly exceeded our pre-defined threshold of 70% (p = 0.0013). Clinical Relevance Our results aid in surgical decision-making as true anatomic position can be directly correlated to whats seen on MRI.

Longitudinal Effect of CPAP on BP in Resistant and Nonresistant Hypertension in a Large Clinic-Based Cohort

BACKGROUND Clinic-based effectiveness studies of sleep-disordered breathing (SDB) treatment in reducing BP in resistant hypertension (RHTN) vs non-RHTN are sparse. We hypothesize that CPAP use in SDB reduces BP significantly in RHTN and non-RHTN in a large clinic-based cohort. METHODS Electronic medical records were reviewed in patients with SDB and comorbid RHTN and non-RHTN for CPAP therapy initiation (baseline) and subsequent visits. We estimated generalizable BP changes from multivariable mixed-effects linear models for systolic BP (SBP), diastolic BP, and mean arterial pressure, adjusting for RHTN status, age, sex, race, BMI, cardiac history, and diabetes and repeated measure correlation. RESULTS Of 894 patients, 130 (15%) had RHTN at baseline (age, 58 ± 12 years; 52% men; BMI, 36 ± 9 kg/m(2)). Patients with RHTN had significantly higher BP overall (P < .001), most notably for SBP (6.9 mm Hg; 95% CI, 3.84, 9.94). In the year following CPAP initiation, improvements in BP indexes did not generally differ based on RHTN status in which RHTN status was a fixed effect. However, there was a significant decrease in SBP (3.08 mm Hg; 95% CI, 1.79, 4.37), diastolic BP (2.28; 95% CI, 1.56, 3.00), and mean arterial pressure (2.54 mm Hg; 95% CI, 1.73, 3.36) in both groups. CONCLUSIONS In this clinic-based effectiveness study involving patients closely followed for BP control, a significant reduction of BP measures (strongest for SBP) was observed in response to CPAP which was similar in RHTN and non-RHTN groups thus informing expected clinical CPAP treatment response.

National Incidence of Medication Error in Surgical Patients Before and After Accreditation Council for Graduate Medical Education Duty-Hour Reform

OBJECTIVE The Accreditation Council for Graduate Medical Education (ACGME) established duty-hour regulations for accredited residency programs on July 1, 2003. It is unclear what changes occurred in the national incidence of medication errors in surgical patients before and after ACGME regulations. DESIGN Patient and hospital characteristics for pre- and post-duty-hour reform were evaluated, comparing teaching and nonteaching hospitals. A difference-in-differences study design was used to assess the association between duty-hour reform and medication errors in teaching hospitals. SETTING We used the Nationwide Inpatient Sample database, which consists of approximately annual 20% stratified sample of all the United States nonfederal hospital inpatient admissions. PARTICIPANTS A query of the database, including 4 years before (2000-2003) and 8 years after (2003-2011) the ACGME duty-hour reform of July 2003, was performed to extract surgical inpatient hospitalizations (N = 13,933,326). The years 2003 and 2004 were discarded in the analysis to allow for a wash-out period during duty-hour reform (though we still provide medication error rates). RESULTS The Nationwide Inpatient Sample estimated the total national surgical inpatients (N = 135,092,013) in nonfederal hospitals during these time periods with 68,736,863 patients in teaching hospitals and 66,355,150 in nonteaching hospitals. Shortly after duty-hour reform (2004 and 2006), teaching hospitals had a statistically significant increase in rate of medication error (p = 0.019 and 0.006, respectively) when compared with nonteaching hospitals even after accounting for trends across all hospitals during this period. After 2007, no further statistically significant difference was noted. CONCLUSIONS After ACGME duty-hour reform, medication error rates increased in teaching hospitals, which diminished over time. This decrease in errors may be related to changes in training program structure to accommodate duty-hour reform.

The PROMIS physical function scale: A promising scale for use in patients with ischemic stroke

Objective: To evaluate the performance of the Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scale compared to the validated Stroke Impact Scale–16 (SIS-16) in ischemic stroke patients seen in an ambulatory cerebrovascular clinic. Methods: This was a retrospective cohort study. PROMIS PF (computer adaptive testing version) and SIS-16 measures were electronically collected on 1,946 ischemic stroke patients seen in a cerebrovascular clinic using an electronic platform from September 12, 2012, to June 16, 2015. Distribution of scores was compared to assess ceiling and floor effects. Correlations with other commonly used functional status scales were performed to assess convergent validity. Results: The SIS-16 and PROMIS PF had a 19.6% and <1% ceiling effect, respectively. Patients completed 16 SIS-16 items and a median of 4 (interquartile range 4–4) PROMIS PF items. Internal consistency of both SIS-16 and PROMIS PF was excellent. The SIS-16 had slightly but significantly higher correlations with the other functional scales than PROMIS PF. Conclusions: The use of PROMIS to obtain electronic patient-reported functional status in an ambulatory setting is feasible. PROMIS PF is an option for measurement of physical function in ischemic stroke patients. It had similar test characteristics as the SIS-16 but with lower patient burden and minimal ceiling effect.