Publications by authors named "Elaine Cassidy"

14 Publications

  • Page 1 of 1

Efficacy and cost savings with the use of a minimal sedation / anxiolysis protocol for intra-articular corticosteroid injections in children with juvenile idiopathic arthritis: a retrospective review of prospectively collected data.

Pediatr Rheumatol Online J 2019 Mar 20;17(1):11. Epub 2019 Mar 20.

Department of Pediatric Anesthesiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue Pittsburgh, Pittsburgh, PA, 15224, USA.

Background: Intra-articular corticosteroid injections (IACI) are frequently used in the treatment of juvenile idiopathic arthritis. There is a paucity of evidence-based research describing methods of pain and anxiety control for this procedure. IACI were mostly performed under general anesthesia for children younger than 13 years old in our institution as of 2014. We started to integrate sedation services more commonly in our institution with the minimal sedation/anxiolysis (MSA) protocol outlined as an alternative to general anesthesia for IACI in 2015. The purpose of this study was to evaluate the effectiveness and cost savings of a minimal sedation protocol for intra-articular corticosteroid injections in juvenile idiopathic arthritis patients after instituting this protocol at our institution.

Methods: The MSA protocol included nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention. A retrospective review of prospectively collected data was performed on a total of 80 consecutive patients with juvenile idiopathic arthritis who underwent joint injections using the protocol.

Results: The procedure was successfully completed in greater than 95% of the patients. The median pain score (measured on a verbal numeric scale of 0-10) reported by the patient was 1 (IQR 0-2.5), by the parent 1 (IQR 0-2), by the rheumatologist 1 (IQR 0-1), and by the sedationist 1 (IQR 0-1). Degree of motion during the procedure was reported by the rheumatologist and the sedationist as none in 68% of the patients, mild in 36% and moderate in 6%. Patient, parent, rheumatologist and sedationist rated satisfaction as very high in the vast majority (94%). Emesis was reported in only 2 (2.5%) patients, no significant adverse events were reported, and no patients progressed to a deeper level of sedation than intended. Financial analysis revealed a 33% cost reduction compared with the use of general anesthesia in the operating room.

Conclusions: A minimal sedation/anxiolysis protocol (including nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention), provides safe and effective analgesia for intra-articular corticosteroid injection in a subset of patients with juvenile idiopathic arthritis and offers a lower cost alternative to general anesthesia.
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http://dx.doi.org/10.1186/s12969-019-0312-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425704PMC
March 2019

Serum S100A8/A9 and S100A12 Levels in Children With Polyarticular Forms of Juvenile Idiopathic Arthritis: Relationship to Maintenance of Clinically Inactive Disease During Anti-Tumor Necrosis Factor Therapy and Occurrence of Disease Flare After Discontinuation of Therapy.

Arthritis Rheumatol 2019 03 24;71(3):451-459. Epub 2019 Jan 24.

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Objective: To determine the relationship between serum levels of S100A8/A9 and S100A12 and the maintenance of clinically inactive disease during anti-tumor necrosis factor (anti-TNF) therapy and the occurrence of disease flare following withdrawal of anti-TNF therapy in patients with polyarticular forms of juvenile idiopathic arthritis (JIA).

Methods: In this prospective, multicenter study, 137 patients with polyarticular-course JIA whose disease was clinically inactive while receiving anti-TNF therapy were enrolled. Patients were observed for an initial 6-month phase during which anti-TNF treatment was continued. For those patients who maintained clinically inactive disease over the 6 months, anti-TNF was withdrawn and they were followed up for 8 months to assess for the occurrence of flare. Serum S100 levels were measured at baseline and at the time of anti-TNF withdrawal. Spearman's rank correlation test, Mann-Whitney U test, Kruskal-Wallis test, receiver operating characteristic (ROC) curve, and Kaplan-Meier survival analyses were used to assess the relationship between serum S100 levels and maintenance of clinically inactive disease and occurrence of disease flare after anti-TNF withdrawal.

Results: Over the 6-month initial phase with anti-TNF therapy, the disease state reverted from clinically inactive to clinically active in 24 (18%) of the 130 evaluable patients with polyarticular-course JIA; following anti-TNF withdrawal, 39 (37%) of the 106 evaluable patients experienced a flare. Serum levels of S100A8/A9 and S100A12 were elevated in up to 45% of patients. Results of the ROC analysis revealed that serum S100 levels did not predict maintenance of clinically inactive disease during anti-TNF therapy nor did they predict disease flare after treatment withdrawal. Elevated levels of S100A8/A9 were not predictive of the occurrence of a disease flare within 30 days, 60 days, 90 days, or 8 months following anti-TNF withdrawal, and elevated S100A12 levels had a modest predictive ability for determining the risk of flare within 30, 60, and 90 days after treatment withdrawal. Serum S100A12 levels at the time of anti-TNF withdrawal were inversely correlated with the time to disease flare (r = -0.36).

Conclusion: Serum S100 levels did not predict maintenance of clinically inactive disease or occurrence of disease flare in patients with polyarticular-course JIA, and S100A12 levels were only moderately, and inversely, correlated with the time to disease flare.
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http://dx.doi.org/10.1002/art.40727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6393224PMC
March 2019

Risk, Timing, and Predictors of Disease Flare After Discontinuation of Anti-Tumor Necrosis Factor Therapy in Children With Polyarticular Forms of Juvenile Idiopathic Arthritis With Clinically Inactive Disease.

Arthritis Rheumatol 2018 09 25;70(9):1508-1518. Epub 2018 Jul 25.

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Objective: To determine the frequency, time to flare, and predictors of disease flare upon withdrawal of anti-tumor necrosis factor (anti-TNF) therapy in children with polyarticular forms of juvenile idiopathic arthritis (JIA) who demonstrated ≥6 months of continuous clinically inactive disease.

Methods: In 16 centers 137 patients with clinically inactive JIA who were receiving anti-TNF therapy (42% of whom were also receiving methotrexate [MTX]) were prospectively followed up. If the disease remained clinically inactive for the initial 6 months of the study, anti-TNF was stopped and patients were assessed for flare at 1, 2, 3, 4, 6, and 8 months. Life-table analysis, t-tests, chi-square test, and Cox regression analysis were used to identify independent variables that could significantly predict flare by 8 months or time to flare.

Results: Of 137 patients, 106 (77%) maintained clinically inactive disease while receiving anti-TNF therapy for the initial 6 months and were included in the phase of the study in which anti-TNF therapy was stopped. Stopping anti-TNF resulted in disease flare in 39 (37%) of 106 patients by 8 months. The mean/median ± SEM time to flare was 212/250 ± 9.77 days. Patients with shorter disease duration at enrollment, older age at onset and diagnosis, shorter disease duration prior to experiencing clinically inactive disease, and shorter time from onset of clinically inactive disease to enrollment were found to have significantly lower hazard ratios for likelihood of flare by 8 months (P < 0.05).

Conclusion: Over one-third of patients with polyarticular JIA with sustained clinically inactive disease will experience a flare by 8 months after discontinuation of anti-TNF therapy. Several predictors of lower likelihood of flare were identified.
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http://dx.doi.org/10.1002/art.40509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115300PMC
September 2018

High Levels of DEK Autoantibodies in Sera of Patients With Polyarticular Juvenile Idiopathic Arthritis and With Early Disease Flares Following Cessation of Anti-Tumor Necrosis Factor Therapy.

Arthritis Rheumatol 2018 04 22;70(4):594-605. Epub 2018 Feb 22.

University of Michigan, Ann Arbor.

Objective: The nuclear oncoprotein DEK is an autoantigen associated with juvenile idiopathic arthritis (JIA), especially the oligoarticular subtype. DEK is a secreted chemotactic factor. Abundant levels of DEK and DEK autoantibodies are found in inflamed synovium in JIA. We undertook this study to further characterize the nature of DEK autoantibodies in screening serum samples from 2 different cohorts that consisted mostly of patients with JIA.

Methods: DEK autoantibody levels were analyzed in sera from 33 JIA patients, 13 patients with other inflammatory conditions, and 11 healthy controls, as well as in 89 serum samples from JIA patients receiving anti-tumor necrosis factor (anti-TNF) therapy. Recombinant His-tagged full-length DEK protein (1-375 amino acids [aa]) and the 187-375-aa and 1-350-aa His-tagged DEK fragments made in a baculovirus system were used for enzyme-linked immunosorbent assay (ELISA) and immunoblotting. The C-terminal 25-aa fragment of DEK was expressed in a glutathione S-transferase-tagged vector. ELISA results were calculated as area under the curve by the trapezoidal rule.

Results: DEK autoantibody levels were significantly higher in patients with polyarticular JIA than in those with oligoarticular JIA, and were higher in patients with polyarticular JIA who had more active disease after cessation of anti-TNF therapy. Immunoblotting against the C-terminal 25-aa fragment of DEK confirmed that this section of the DEK molecule is the most immunogenic domain.

Conclusion: DEK autoantibody levels are higher in patients with polyarticular JIA than in those with oligoarticular JIA, and higher in patients who have disease flares after cessation of anti-TNF therapy. The C-terminal 25-aa fragment is the most immunogenic portion of DEK. These findings are significant with respect to the nature of DEK autoantibodies, their contribution to JIA pathogenesis, and their implications for JIA management.
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http://dx.doi.org/10.1002/art.40404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5876119PMC
April 2018

Patients with non-Jo-1 anti-tRNA-synthetase autoantibodies have worse survival than Jo-1 positive patients.

Ann Rheum Dis 2014 Jan 19;73(1):227-32. Epub 2013 Feb 19.

Department of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine, , Pittsburgh, Pennsylvania, USA.

Objective: To compare the cumulative survival and event free survival in patients with Jo-1 versus non-Jo-1 anti-tRNA synthetase autoantibodies (anti-synAb).

Methods: Anti-synAb positive patients initially evaluated from 1985 to 2009 were included regardless of the connective tissue disease (CTD) diagnosis. Clinical data were extracted from a prospectively collected database and chart review. Survival between Jo-1 and non-Jo-1 was compared by log rank and Cox proportional hazards methods.

Results: 202 patients possessed anti-synAb: 122 Jo-1 and 80 non-Jo-1 (35 PL-12; 25 PL-7; 9 EJ; 6 KS; 5 OJ). The diagnoses at first visit for Jo-1 and non-Jo-1 patients were myositis in 83% and 40.0%, overlap or undifferentiated CTD in 17% and 47.5%, and systemic sclerosis in 0% and 12.5%, respectively (p<0.001). The median delay in diagnosis was 0.4 years in Jo-1 patients versus 1.0 year in non-Jo-1 patients (p<0.001). The most common causes of death in the overall cohort were pulmonary fibrosis in 49% and pulmonary hypertension in 11%. The 5- and 10-year unadjusted cumulative survival was 90% and 70% for Jo-1 patients, and 75% and 47% for non-Jo-1 patients (p<0.005). The hazard ratio (HR) of non-Jo-1 patients compared with Jo-1 patients was 1.9 (p=0.01) for cumulative and 1.9 (p=0.008) for event free survival from diagnosis. Age at first diagnosis and diagnosis delay but not gender, ethnicity and CTD diagnosis influenced survival.

Conclusions: Non-Jo-1 anti-synAb positive patients have decreased survival compared with Jo-1 patients. The difference in survival may be partly attributable to a delay in diagnosis in the non-Jo-1 patients.
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http://dx.doi.org/10.1136/annrheumdis-2012-201800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031026PMC
January 2014

Chronic granulomatous disease presenting as aseptic ascites in a 2-year-old child.

Case Reports Immunol 2013 28;2013:927897. Epub 2013 Jan 28.

The Paul C. Gaffney Diagnostic Referral Service, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.

Chronic granulomatous disease (CGD) is a rare inherited immunodeficiency syndrome that results from abnormal nicotinamide adenine dinucleotide phosphate (NADPH) oxidase function. This defect leads to recurrent catalase-positive bacterial and fungal infections as well as associated granuloma formation. We review the case of a 2-year-old boy who presented with ascites and fever of an unknown origin as manifestations of CGD. Cultures were negative for infection throughout his course, and CGD was suspected after identification of granulomas on peritoneal biopsy. Genetic testing revealed a novel mutation in the CYBB gene underlying his condition. This paper highlights the importance of considering CGD in the differential diagnosis of fever of unknown origin and ascites in children.
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http://dx.doi.org/10.1155/2013/927897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207586PMC
November 2014

Employing policy and purchasing levers to increase the use of evidence-based practices in community-based substance abuse treatment settings: reports from single state authorities.

Eval Program Plann 2011 Nov 2;34(4):366-74. Epub 2011 Mar 2.

Department of Public Health & Preventive Medicine, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, United States.

State public health authorities are critical to the successful implementation of science based addiction treatment practices by community-based providers. The literature to date, however, lacks examples of state level policy strategies that promote evidence-based practices (EBPs). This mixed-methods study documents changes in two critical state-to-provider strategies aimed at accelerating use of evidence-based practices: purchasing levers (financial incentives and mechanisms) and policy or regulatory levers. A sample of 51 state representatives was interviewed. Single State Authorities for substance abuse treatment (SSAs) that fund providers directly or through managed care were significantly more likely to have contracts that required or encouraged evidence-based interventions, as compared to SSAs that fund providers indirectly through sub-state entities. Policy levers included EBP-related legislation, language in rules and regulations, and evidence-based criteria in state plans and standards. These differences in state policy are likely to result in significant state level variations regarding both the extent to which EBPs are implemented by community-based treatment providers and the quality of implementation.
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http://dx.doi.org/10.1016/j.evalprogplan.2011.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670771PMC
November 2011

The localized scleroderma skin severity index and physician global assessment of disease activity: a work in progress toward development of localized scleroderma outcome measures.

J Rheumatol 2009 Dec 15;36(12):2819-29. Epub 2009 Oct 15.

Division of Rheumatology, Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Objective: To develop and evaluate a Localized Scleroderma (LS) Skin Severity Index (LoSSI) and global assessments' clinimetric property and effect on quality of life (QOL).

Methods: A 3-phase study was conducted. The first phase involved 15 patients with LS and 14 examiners who assessed LoSSI [surface area (SA), erythema (ER), skin thickness (ST), and new lesion/extension (N/E)] twice for inter/intrarater reliability. Patient global assessment of disease severity (PtGA-S) and Children's Dermatology Life Quality Index (CDLQI) were collected for intrarater reliability evaluation. The second phase was aimed to develop clinical determinants for physician global assessment of disease activity (PhysGA-A) and to assess its content validity. The third phase involved 2 examiners assessing LoSSI and PhysGA-A on 27 patients. Effect of training on improving reliability/validity and sensitivity to change of the LoSSI and PhysGA-A was determined.

Results: Interrater reliability was excellent for ER [intraclass correlation coefficient (ICC) 0.71], ST (ICC 0.70), LoSSI (ICC 0.80), and PhysGA-A (ICC 0.90) but poor for SA (ICC 0.35); thus, LoSSI was modified to mLoSSI. Examiners' experience did not affect the scores, but training/practice improved reliability. Intrarater reliability was excellent for ER, ST, and LoSSI (Spearman's rho = 0.71-0.89) and moderate for SA. PtGA-S and CDLQI showed good intrarater agreement (ICC 0.63 and 0.80). mLoSSI correlated moderately with PhysGA-A and PtGA-S. Both mLoSSI and PhysGA-A were sensitive to change following therapy.

Conclusion: mLoSSI and PhysGA-A are reliable and valid tools for assessing LS disease severity and show high sensitivity to detect change over time. These tools are feasible for use in routine clinical practice. They should be considered for inclusion in a core set of LS outcome measures for clinical trials.
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http://dx.doi.org/10.3899/jrheum.081284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690503PMC
December 2009

Disparities in physician care: experiences and perceptions of a multi-ethnic America.

Health Aff (Millwood) 2008 Mar-Apr;27(2):507-17

Department of Health Policy and Management, Harvard School of Public Health, in Boston, Massachusetts, USA.

This 2007 Harvard School of Public Health/Robert Wood Johnson Foundation survey of 4,334 randomly selected U.S. adults compared perceptions of the quality of physician care among fourteen racial and ethnic groups with those of whites. On each measure examined, at least five and as many as eleven subgroups perceived their care to be significantly worse than care for whites. In many instances, subgroups were at least fifteen percentage points more negative than whites. This was true for Central/South Americans, Chinese Americans, and Korean Americans on five of seven measures. Many of the differences remained after socioeconomic characteristics and language skills were controlled for.
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http://dx.doi.org/10.1377/hlthaff.27.2.507DOI Listing
December 2008

Disparities in health: perspectives of a multi-ethnic, multi-racial America.

Health Aff (Millwood) 2007 Sep-Oct;26(5):1437-47

Harvard School of Public Health, Boston, Massachusetts, USA.

This 2006 survey of 4,157 randomly selected U.S. adults compared perceptions of health care disparities among fourteen racial and ethnic groups to those of whites. Findings suggest that many ethnic minority groups view their health care situations differently and, often, more negatively than whites. A substantial proportion perceived discrimination in receiving health care, and many felt that they would not receive the best care if they were sick. Most differences remained when socioeconomic characteristics were controlled for. The variety of responses across racial groups demonstrates the importance of examining ethnic subgroups separately rather than combined into a single category.
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http://dx.doi.org/10.1377/hlthaff.26.5.1437DOI Listing
November 2007

Making "stone soup": improvements in clinic access and retention in addiction treatment.

Jt Comm J Qual Patient Saf 2007 Feb;33(2):95-103

Robert Wood Johnson Foundation, Princeton, New Jersey, USA.

Background: The Network for Improvement of Addiction Treatment (NIATx) provides 39 treatment organizations with collaborative learning opportunities and technical support to reduce waiting time between the first request for service and the first treatment session, reduce the number of patients who do not keep an appointment (no-shows), increase the number of people admitted to treatment, and increase continuation from the first through the fourth treatment session. ACADIA'S STORY-TREATMENT ON DEMAND: Given capacity constraints, only 25% of the clients scheduled for outpatient care at Acadia Hospital (Bangor, Maine) showed up for their assessment appointments, and only 19% made it into treatment. A variety of changes were introduced, including increasing staff availability to provide clients with assessments immediately on arrival (at 7:30 A.M.), establishing a clinician pool to handle client overflow, and allowing for same-day admission to intensive outpatient or chemical dependency services. These process improvements reduced the time from first contact to the first treatment session from 4.1 to 1.3 days (68%), reduced client no-shows, and increased continuation in treatment and transfers across levels of care.

Discussion: The successes experienced by organizations in the NIATx initiative should be useful for implementing change in other fields of service delivery.
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http://dx.doi.org/10.1016/s1553-7250(07)33011-0DOI Listing
February 2007

Collaborative design and implementation of a multisite community coalition evaluation.

Health Promot Pract 2006 Apr;7(2 Suppl):44S-55S

Allies Against Asthma, Center for Managing Chronic Disease, University of Michigan in Ann Arbor, Michigan, USA.

Evaluation designs assessing community coalitions must balance measures of how coalitions do their work and evidence that the coalitions are making a difference. The Allies cross-site evaluation attempts to determine the combined effects of the seven coalitions' work at the individual, organizational, and community levels. Principal components considered are (a) contextual factors of the coalition community, (b) coalition processes and structure, (c) planning and planning products, (d) implementation actions, (e) activities and collaborations, (f) anticipated intermediate outcomes, and (g) expected asthma related health outcomes. Measurements are quantitative and qualitative, and data generated by these methods are used as ends in themselves and as a way to confirm or inform other measures. Evaluation has been an integral part of the planning and implementation phases of the Allies coalition work, with a priority of involving all of the partners in conceiving of and deciding upon the elements of assessment.
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http://dx.doi.org/10.1177/1524839906287066DOI Listing
April 2006

Monetary incentives in support of academic achievement: results of a randomized field trial involving high-achieving, low-resource, ethnically diverse urban adolescents.

Eval Rev 2005 Jun;29(3):199-222

Interdisciplinary Studies in Human Development in the Graduate School of Education, University of Pennsylvania, USA.

Significant resources have been directed at understanding and alleviating the achievement gap in education. Most programs focused on this aim rely on a top-down approach, including funding for infrastructure improvement, curriculum development, class size, and teacher salaries. This article presents findings from a randomized field trial that evaluates a bottom-up approach in which high-achieving students of diverse racial and ethnic backgrounds from poor families are given monetary incentives to maintain their academic standing. The evaluation was designed to explore the role of monetary incentives as a mechanism for promoting resiliency in the face of poverty-related challenge. Discussion of what motivates students to learn is framed as a function of normal cognitive and socioemotional development in challenging environments. Evaluation findings indicate that monetary incentives are effective in promoting academic success to different degrees and for different reasons depending on students' perception of the meaning of the incentive in relation to their emergent identity.
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http://dx.doi.org/10.1177/0193841X04273329DOI Listing
June 2005