Publications by authors named "Hope Kincaid"

18 Publications

  • Page 1 of 1

Relationship Between Vaccination Status and Biopsychosocial Characteristics in Sheltered Adolescents.

Cureus 2021 Jan 8;13(1):e12575. Epub 2021 Jan 8.

Emergency and Hospital Medicine, University of South Florida Morsani College of Medicine/Lehigh Valley Health Network Campus, Allentown, USA.

Introduction Homeless youth are a vulnerable population. A volunteer clinic supported by medical students in northeastern Pennsylvania provides shelter and healthcare to adolescents seeking refuge. We set out to determine the immunization status of youth in the shelter and evaluate for associations of immunization deficiency with demographics or biopsychosocial factors. Methods After IRB approval, a retrospective cohort study was performed from existing clinical records at the shelter 2/2015-9/2019. Chart abstraction included variables such as demographics (including age, sex, and race/ethnicity), biopsychosocial factors (including childhood trauma/abuse history, substance abuse history, and sexual activity), and immunization history. Results A total of 440 charts were analyzed. When comparing demographics of patients that had complete vaccine regimens versus those who did not, the race was statistically significant (p=.006). The most prominent difference in race was seen for Black/African American patients; only 19.57% had a completed vaccine regimen documented. Regarding immunization history, vaccine schedules of hepatitis B, measles mumps rubella (MMR), inactivated polio vaccine (IPV), and varicella were most likely to be complete; pneumococcal conjugate vaccine (PCV) 13, rotavirus, influenza, and human papillomavirus vaccine (HPV) were least likely. There was no association found between a completed vaccine regimen and biopsychosocial variables. A larger portion of females (37.35%) completed the HPV vaccine compared to males (23.14%) (p=.009). Conclusions In this single-site study, this vulnerable, at-risk population of sheltered adolescents lacked the vaccinations recommended by the Centers for Disease Control and Prevention. Racial disparities further compounded this vulnerability for Black/African American teens. Additionally, a significantly greater number of female patients received the HPV vaccine compared to males.
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http://dx.doi.org/10.7759/cureus.12575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870128PMC
January 2021

The Modified Fisher Scale Lacks Interrater Reliability.

Neurocrit Care 2020 Nov 16. Epub 2020 Nov 16.

Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: The modified Fisher scale (mFS) is a critical clinical and research tool for risk stratification of cerebral vasospasm. As such, the mFS is included as a common data element by the National Institute of Neurological Disorders and Stroke SAH Working Group. There are few studies assessing the interrater reliability of the mFS.

Methods: We distributed a survey to a convenience sample with snowball sampling of practicing neurointensivists and through the research survey portion of the Neurocritical Care Society Web site. The survey consisted of 15 scrollable CT scans of patients with SAH for mFS grading, two questions regarding the definitions of the scale criteria and demographics of the responding physician. Kendall's coefficient of concordance was used to determine the interrater reliability of mFS grading.

Results: Forty-six participants (97.8% neurocritical care fellowship trained, 78% UCNS-certified in neurocritical care, median 5 years (IQR 3-6.3) in practice, treating median of 80 patients (IQR 50-100) with SAH annually from 32 institutions) completed the survey. By mFS criteria, 30% correctly identified that there is no clear measurement of thin versus thick blood, and 42% correctly identified that blood in any ventricle is scored as "intraventricular blood." The overall interrater reliability by Kendall's coefficient of concordance for the mFS was moderate (W = 0.586, p < 0.0005).

Conclusions: Agreement among raters in grading the mFS is only moderate. Online training tools could be developed to improve mFS reliability and standardize research in SAH.
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http://dx.doi.org/10.1007/s12028-020-01142-8DOI Listing
November 2020

Sex Differences in Substance Use and Misuse: A Toxicology Investigators' Consortium (ToxIC) Registry Analysis.

Subst Abuse Rehabil 2020 29;11:23-31. Epub 2020 Sep 29.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, PA 18103, USA.

Background: Variations between male and female populations are previously reported in classes of harmfully used/misused drugs, severity of substance use disorder and risk of relapse. The aim of this study was to provide a review of bedside medical toxicologist managed, sex-specific poisonings in adults that present with harmful drug use/misuse.

Methods: ToxIC Registry cases ≥19 and ≤65 years old, with harmful drug use or misuse during the timeframe June 2010-December 2016, were studied. Demographics, primary agents of toxic exposure, administration route and complications were analyzed. Descriptive methods were used in the analysis.

Results: The database included 51,440 cases. Of these, 3426 cases were analyzed in which the primary reason for the encounter was harmful substance use/misuse. Females were found to harmfully use/misuse pharmaceutical drugs (N=806, 65.6%) more than nonpharmaceutical drugs (N=423, 34.4%). Males more frequently used nonpharmaceutical drugs (N=1189, 54.1%) than pharmaceutical drugs (1008, 45.9%). Analgesics were used by females (N= 215, 18.2%) and males (N=137, 6.6%). Sedative hypnotics were used by females (N=165, 14%) and males (N=160, 7.8%). Psychoactive agents were used by males (N=325, 15.8%) and females (N=67, 5.7%). Sympathomimetics were used by males (N=381, 18.5%) and females (N=151, 12.8%). The majority of both male and female participants, 1712 (57.9%), utilized an oral route of administration. However, 312 (16.5%) of males utilized inhalation vs 73 (6.8%) of females inhaled their substance.

Conclusion: There were sex-specific differences among patients evaluated for harmful substance use/misuse by toxicologists. Considering these differences in regards to management and preventive approaches may be indicated.
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http://dx.doi.org/10.2147/SAR.S263165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532888PMC
September 2020

Characteristics of Transgender Patient Cases Managed by a Toxicologist: an Analysis of the Toxicology Investigator's Consortium (ToxIC) Registry: January 2017-June 2019.

J Med Toxicol 2021 01 17;17(1):16-26. Epub 2020 Jun 17.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, 1909 Earls Court, Allentown, PA, 18103, USA.

Introduction: The Toxicology Investigators Consortium (ToxIC) database, created in 2010 by the American College of Medical Toxicology (ACMT), compiles data recorded by medical toxicologists. In January 2017, the data field for transgender (and if transgender, male-to-female or female-to-male) was added to the ToxIC form. Little is known regarding trends in poisonings among transgender patients. We sought to review consultations managed by a bedside toxicologist and provide descriptive data in trends among types of exposures within the transgender demographic.

Methods: A retrospective ToxIC database evaluation of cases in which the patient identified as transgender were reviewed from January 2017-June 2019 and descriptive demographics reported.

Results: The registry contained 113 cases that involved transgender patients. Of those with complete data, 41 (36.6%) were male-to-female, 68 (60.7%) were female-to-male, and 3 (2.7%) identified as gender non-conforming. Of those with complete data, the most common reason for encounter was intentional use of a pharmaceutical drug (N = 97, 85.8%), of which 85 (87.6%) were classified as intentional pharmaceutical use intended for self-harm. Analgesics were the most common class of drugs used out of those reported (N = 24, 22%). Forty-six (90.2%) patients aged 13-18 with complete data were identified as encounters due to self-harm. Attempt at self-harm was the most common reason for intentional pharmaceutical encounter among the sample of transgender patients with complete data (N = 85, 87.6%); with female-to-male patients having an N = 53 (77.9%).

Conclusion: Among transgender patients in the ToxIC registry, the most common primary reason for the encounter was intentional use of a pharmaceutical drug intended for self-harm. In this small cohort, there were some age and transition differences in prevalence. These findings may inform poisoning prevention practices as well as sex- and gender-based management of patients in this vulnerable population.
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http://dx.doi.org/10.1007/s13181-020-00789-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785623PMC
January 2021

Sex Differences in Pediatric Poisonings by Age Group: a Toxicology Investigators' Consortium (ToxIC) Analysis (2010-2016).

J Med Toxicol 2020 10 2;16(4):423-443. Epub 2020 Jun 2.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA.

Objective: To review pediatric poisonings evaluated at the bedside by medical toxicologists and reported in the ToxIC registry, by sex and age group.

Methods: Pediatric poisoning cases age ≤18 years, reported between January 2010 and December 2016, were reviewed. Descriptive statistics were used to describe study variables by age group and sex.

Results: A total of 12,699 cases were analyzed. There were 7517 females and 5182 males. Those < 2 years old represented 12.5% of the study group (n = 1584), 17.2% were 2-6 years old (n = 2178), 8.6% were 7-12 years old (n = 1097), and 61.7% were 13-18 years old (n = 7840). The most common primary reasons for encounter were intentional pharmaceutical with 4900 females and 1836 males; intentional non-pharmaceutical with 952 females and 1213 males; unintentional pharmaceutical with 539 females and 644 males; and unintentional non-pharmaceutical with 435 females and 593 males. Overall, pharmaceuticals were the most commonly involved agents, including analgesics (20.9% of cases) and antidepressants (11% of cases): 27.8% of females and 10.7% of males were reportedly exposed to an analgesic.13.7% of females and 7.0% of males were reportedly exposed to an antidepressant. Among 1584 cases under 2 years, there were 747 females and 837 males; among 2178 cases aged 2-6 years, there were 954 females and 1224 males; among 1097 cases aged 7-12 years, there were 555 females and 542 males; and among 7840 cases aged 13-18 years, there were 5261 females and 2579 males. Death was reported in 0.7% of the cases: 20 females and 18 males. 6.1% of cases were managed with intubation: 421 females and 351 males.

Conclusions: Sex-based characteristics of poisonings varied by age group among pediatric poisoning presentations reported to the ToxIC registry and further research is needed to determine implications for education and prevention efforts.
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http://dx.doi.org/10.1007/s13181-020-00781-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554275PMC
October 2020

Sex Differences in Pediatric Poisonings by Age Group: a Toxicology Investigators' Consortium (ToxIC) Analysis (2010-2016).

J Med Toxicol 2020 10 2;16(4):423-443. Epub 2020 Jun 2.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA.

Objective: To review pediatric poisonings evaluated at the bedside by medical toxicologists and reported in the ToxIC registry, by sex and age group.

Methods: Pediatric poisoning cases age ≤18 years, reported between January 2010 and December 2016, were reviewed. Descriptive statistics were used to describe study variables by age group and sex.

Results: A total of 12,699 cases were analyzed. There were 7517 females and 5182 males. Those < 2 years old represented 12.5% of the study group (n = 1584), 17.2% were 2-6 years old (n = 2178), 8.6% were 7-12 years old (n = 1097), and 61.7% were 13-18 years old (n = 7840). The most common primary reasons for encounter were intentional pharmaceutical with 4900 females and 1836 males; intentional non-pharmaceutical with 952 females and 1213 males; unintentional pharmaceutical with 539 females and 644 males; and unintentional non-pharmaceutical with 435 females and 593 males. Overall, pharmaceuticals were the most commonly involved agents, including analgesics (20.9% of cases) and antidepressants (11% of cases): 27.8% of females and 10.7% of males were reportedly exposed to an analgesic.13.7% of females and 7.0% of males were reportedly exposed to an antidepressant. Among 1584 cases under 2 years, there were 747 females and 837 males; among 2178 cases aged 2-6 years, there were 954 females and 1224 males; among 1097 cases aged 7-12 years, there were 555 females and 542 males; and among 7840 cases aged 13-18 years, there were 5261 females and 2579 males. Death was reported in 0.7% of the cases: 20 females and 18 males. 6.1% of cases were managed with intubation: 421 females and 351 males.

Conclusions: Sex-based characteristics of poisonings varied by age group among pediatric poisoning presentations reported to the ToxIC registry and further research is needed to determine implications for education and prevention efforts.
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http://dx.doi.org/10.1007/s13181-020-00781-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554275PMC
October 2020

A Retrospective Cohort Study to Assess the Impact of an Inpatient Infectious Disease Telemedicine Consultation Service on Hospital and Patient Outcomes.

Clin Infect Dis 2020 02;70(5):763-770

Network Office of Research and Innovation, Lehigh Valley Health Network, Allentown, Pennsylvania.

Background: Here, we review our experience of providing inpatient infectious disease (ID) consultations using real-time interactive telemedicine assessments. We sought to obtain a baseline and document trends regarding the use of telemedicine ID (teleID) consults as an adjunct to the standard of care through the time period in which teleID consultations were introduced.

Methods: Data were pulled via manual, retrospective chart reviews of the electronic medical record. Primary outcomes included lengths of stay (LOS), antibiotic usage, and relapse incidences.

Results: There were a total of 244 patients at 1 remote hospital site who were provided with ID consultations, either in person, via teleID, or both. Before the availability of teleID (pre-teleID), there were 73 patients transferred for ID consults, while 171 patients were seen via teleID once available. While all 73 patients in the pre-teleID group were transferred from the remote hospital to the hub hospital, only 14 (8.2%) of all remote hospital patients assessed by teleID were transferred. Patient LOS across both facilities decreased when patients were seen via teleID, compared to pre-teleID (P = .0001). The median number of days that patients received antibiotics decreased in the teleID group (median 15, interquartile range [IQR] 9-25), compared to the pre-teleID group (median 19, IQR 11-28), but this decrease was not statistically significant (P = .0770). There was no statistically significant difference in relapse rates, although data were lacking because of patients being lost to follow-up.

Conclusions: ID telemedicine practice directed at inpatients appears to be a promising route of care.
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http://dx.doi.org/10.1093/cid/ciz293DOI Listing
February 2020

Impact of Palliative Care on Resource Utilization and Quality in the Care of Patients Undergoing Therapeutic Hypothermia.

Ther Hypothermia Temp Manag 2020 Mar 21;10(1):37-44. Epub 2019 Feb 21.

Lehigh Valley Health Network, OACIS/Palliative Medicine, Allentown, Pennsylvania.

Few studies have been done assessing the impact of palliative care on patients suffering cardiac arrest and requiring therapeutic hypothermia (TH). We conducted a retrospective cohort study to compare resource utilization and quality indicators among patients undergoing TH with and without palliative care consultation. Data were collected, over a two-year period, from the institutional international cardiac arrest registry database and electronic medical record review. One hundred twenty-nine patients were screened, 102 met inclusion criteria. Sixty-four patients (63%) had a palliative care consult. None of the differences between the groups' prehospital clinical characteristics were significant (functional status  = 0.29; cerebral performance (CPC) score  = 0.16). The overall mortality rate of participants was 53%, with a rate of 47% for the nonpalliative care group and 56% of the palliative care group ( = 0.38). There was a decrease in resource utilization in the palliative care group, with discontinuation in lab tests showing significance ( = 0.04). All quality indicators were addressed more frequently in the palliative care group ( = < 0.0001). More patients in the palliative care group (56%) than in the nonpalliative care group (39%) had a do not resuscitate order placed ( = 0.10). Our results show reduced resource utilization and improved quality of care in patients undergoing TH treatment when palliative care is involved. These findings suggest that palliative care should be an integral part of the treatment guidelines for this patient population.
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http://dx.doi.org/10.1089/ther.2018.0050DOI Listing
March 2020

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus.

Headache 2019 01 25;59(1):69-76. Epub 2018 Jul 25.

Brownwood Specialty Care Center, The Villages, FL, USA.

Background: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.

Methods: Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection.

Results: Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001).

Conclusion: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.
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http://dx.doi.org/10.1111/head.13390DOI Listing
January 2019

Perception and Practice Among Emergency Medicine Health Care Providers Regarding Discharging Patients After Opioid Administration.

Clin Ther 2018 02 20;40(2):214-223.e5. Epub 2018 Jan 20.

Department of Emergency Medicine, Lehigh Valley Hospital and Health Network/USF MCOM, Allentown, PA.

Purpose: This study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics.

Methods: A cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of >180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate.

Findings: Thirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patient's functional status and vital signs (median, 2.00; interquartile range, 2.00-3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN.

Implications: Most study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN.
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http://dx.doi.org/10.1016/j.clinthera.2018.01.001DOI Listing
February 2018

Impact of Race Versus Education and Race Versus Income on Patients' Motivation to Participate in Clinical Trials.

J Racial Ethn Health Disparities 2018 10 26;5(5):1042-1051. Epub 2017 Dec 26.

Lehigh Valley Health Network, Cedar Crest Boulevard and I-78, Allentown, PA, 18103, USA.

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients' education and income. A self-administered survey asked outpatients to rank potential influential factors on a "0" to "4" significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < $30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.
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http://dx.doi.org/10.1007/s40615-017-0452-zDOI Listing
October 2018

Agreement between endoscopic ultrasound-guided fine-needle aspiration and endobiliary brush cytology in suspected pancreaticobiliary malignancies.

Endosc Int Open 2017 Dec 6;5(12):E1251-E1258. Epub 2017 Dec 6.

Department of Medicine, Division of Gastroenterology and Hepatology, Lehigh Valley Health Network, Allentown, Pennsylvania, United States.

Background And Study Aims:  For suspected pancreaticobiliary malignancies, endobiliary brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) remains the diagnostic test of choice despite historically poor and variable sensitivity. This has led to increased use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as an initial test. Recently, our institution began using a cytology brush that was designed specifically to collect a more substantial and higher-quality sample. The aim of this study was to investigate whether this brush design would provide more adequate samples and have high agreement with EUS-FNA in patients who underwent both procedures.

Patients And Methods:  A retrospective chart review was conducted of all patients who underwent both EUS-FNA and endobiliary brush cytology for suspicion of pancreaticobiliary malignancy from January 2013 to May 2015. A total of 41 patients met the inclusion criteria. Initially, sample quality was evaluated. Final cytology results were then assessed for agreement with EUS-FNA using Cohen's kappa. The effect of considering atypical cytology as negative was also uniquely evaluated by running separate analyses.

Results:  Brush cytology provided an adequate sample in 95.1 % of cases. Cohen's Kappa demonstrated moderate agreement between brush cytology and EUS-FNA: κ = 0.42 (  = 0.001). When atypical results were excluded, agreement increased: κ = 0.60 (  = 0.02), but remained moderate. If atypical results were considered "positive," the two procedures demonstrated equal cancer detection rates of 80.8 %.

Conclusions:  The studied brush provided more adequate samples compared with historical rates for brush cytology and had moderate agreement with EUS-FNA. If this brush truly increases sample adequacy, it could potentially provide results comparable to EUS-FNA at lower cost.
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http://dx.doi.org/10.1055/s-0043-119754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5718904PMC
December 2017

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

West J Emerg Med 2017 Aug 17;18(5):846-855. Epub 2017 Jul 17.

Lehigh Valley Health Network, Department of Emergency Medicine Research, Allentown, Pennsylvania.

Introduction: This study investigated factors that influence emergency medicine (EM) patients' decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties.

Methods: A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants' responses.

Results: A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient's gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285-2.389}], ID [OR:3.281, 95% CI{2.293-4.695}], and OB/GYN [OR:2.408, 95% CI{1.741-3.330}]). EM's rankings of "how well the research was explained" and whether "the knowledge learned would benefit others" as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated "risk of unknown side effects" as their strongest barrier. Regardless of the patients' race, "time commitment" was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218-2.136}], ID [OR:1.340, 95% CI{1.006-1.784}], or OB/GYN [OR:1.901, 95% CI{1.431-2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked "having all material provided in my own language" as the most helpful resource.

Conclusion: There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient's own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.
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http://dx.doi.org/10.5811/westjem.2017.5.33827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576620PMC
August 2017

Open Heart Surgery Does Not Increase the Incidence of Ipsilateral Ischemic Stroke in Patients with Asymptomatic Severe Carotid Stenosis.

J Stroke Cerebrovasc Dis 2017 Oct 13;26(10):2154-2159. Epub 2017 Jun 13.

Lehigh Valley Health Network, LVPG Neurology, Center for Advanced Health Care, Allentown, Pennsylvania.

Background And Purpose: We evaluated the incidence of perioperative stroke following the institution's 2007 practice change of discontinuing combined carotid endarterectomy and open heart surgery (OHS) for patients with severe carotid stenosis.

Methods: In this retrospective cohort study, we compared 113 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both from 2007 to 2011 with data collected from 2001 to 2006 from a similar group of patients. Our aim was to assess whether the practice change led to a greater incidence of stroke.

Results: A total of 7350 consecutive patients undergoing OHS during the specified time period were screened. Of these, 3030 had OHS between 2007 and 2011 but none were combined with carotid artery surgery (new cohort). The remaining 4320 had OHS before 2007 and 44 had combined procedures (old cohort). Of patients undergoing OHS during the 10-year period of observation, 230 had severe (>80%) carotid stenosis. In the old cohort (before 2007), carotid stenosis was associated with perioperative stroke in 2.5% of cases. None of the 113 patients having cardiac procedures after 2007 received combined carotid artery surgery; only 1 of these patients harboring severe carotid stenosis had an ischemic stroke (.9%) during the perioperative period. The difference in stroke incidence between the 2 cohorts was statistically significant (P = .002).

Conclusion: The incidence of stroke in patients with severe carotid artery stenosis undergoing OHS was lower after combined surgery was discontinued. Combined carotid and OHS itself seems to be an important risk factor for stroke.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.04.037DOI Listing
October 2017

Career interest and perceptions of nephrology: A repeated cross-sectional survey of internal medicine residents.

PLoS One 2017 16;12(2):e0172167. Epub 2017 Feb 16.

Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, United States of America.

Background: Interest in nephrology careers among internal medicine residents in the United States is declining. Our objective was to assess the impact of the presence of a nephrology fellowship training program on perceptions and career interest in nephrology among internal medicine residents. A secondary objective was to identify commonly endorsed negative perceptions of nephrology among internal medicine residents.

Methods: This was a repeated cross-sectional survey of internal medicine residents before (Group 1) and 3 years after (Group 2) the establishment of nephrology fellowship programs at two institutions. The primary outcome was the percentage of residents indicating nephrology as a career interest in Group 1 vs. Group 2. Secondary outcomes included the frequency that residents agreed with negative statements about nephrology.

Results: 131 (80.9%) of 162 residents completed the survey. 19 (14.8%) residents indicated interest in a nephrology career, with 8 (6.3%) indicating nephrology as their first choice. There was no difference in career interest in nephrology between residents who were exposed to nephrology fellows during residency training (Group 2) and residents who were not (Group 1). The most commonly endorsed negative perceptions of nephrology were: nephrology fellows have long hours/burdensome call (36 [28.1%] of residents agreed or strongly agreed), practicing nephrologists must take frequent/difficult call (35 [27.6%] agreed or strongly agreed), and nephrology has few opportunities for procedures (35 [27.3%] agreed or strongly agreed). More residents in Group 2 agreed that nephrology is poorly paid (8.9% in Group 1 vs. 20.8% in Group 2, P = 0.04), whereas more residents in Group 1 agreed that nephrologists must take frequent/difficult call (40.0% in Group 1 vs. 18.1% in Group 2, P = 0.02).

Conclusions: The initiation of a nephrology fellowship program was not associated with an increase in internal medicine residents' interest in nephrology careers. Residents endorsed several negative perceptions of nephrology, which may affect career choice.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0172167PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313227PMC
August 2017

Racial Differences Among Factors Associated with Participation in Clinical Research Trials.

J Racial Ethn Health Disparities 2016 Sep 8. Epub 2016 Sep 8.

Lehigh Valley Health Network, Cedar Crest Boulevard and I-78, Allentown, PA, 18103, USA.

Objective: To identify whether racial differences exist among various factors associated with patients' decision to participate in clinical research trials.

Methods: A self-administered, IRB-approved survey was utilized with inclusion criteria requiring subjects to be 18 years of age or older, having active patient status and ability to complete the survey without assistance. Subjects were asked to rate potential influential motivators, barriers, and facilitators on a "no influence" (0) to "most influence" (4) scale for participation in research that tests a new drug or device. Kruskal-Wallis testing was used to identify factors significantly associated with race.

Results: Analysis included 1643 surveys: 949 (57.8 %) Caucasian; 217 (13.2 %) African-American; 317 (19.3 %) Hispanic; 62 (3.8 %) Multiracial; and 98 (6.0 %) "Other" minorities. Statistically significant differences (p ≤ .02) by race were found for five out of ten motivating factors. "How well the research study is explained to me" had the highest mean value for all races except other minorities, for whom "Knowledge learned from my participation will benefit someone in the future" scored highest. "Risk of unknown side-effects" was the greatest barrier for all races.

Conclusion: Racial differences exist not only between Caucasians and Minorities for the factors associated with their clinical trial participation, but also among different minority races themselves. To promote diversity in research, recruitment strategies for each individual race should be customized based on what matters to the target population.
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http://dx.doi.org/10.1007/s40615-016-0285-1DOI Listing
September 2016

Using Locally Derived Seroprevalence Data on Measles, Mumps, Rubella, and Varicella by Birth Cohort to Determine Risks for Vaccine-Preventable Diseases During International Travel.

J Travel Med 2015 Nov-Dec;22(6):396-402. Epub 2015 Sep 28.

Infectious Diseases, Allentown, PA, USA.

Background: Measles, mumps, rubella, and varicella (MMRV) were common childhood diseases in the United States prior to the introduction of their respective vaccines. Measles was declared eliminated in the United States in 2000. However, 628 cases were reported in 2014, the majority of which have been linked to international travel. The study team set out to investigate the seroprevalence of MMRV in our local population to determine whether such a process can lead to meaningful recommendations for assessing travelers at risk.

Methods: We conducted a cross-sectional seroprevalence study using a quota sampling method. A total of 460 leftover serum samples were collected from individuals born prior to 1996, who live in the Lehigh Valley region of southeast Pennsylvania. The samples were allocated to five birth-year cohorts, and the seroprevalence of each cohort to MMRV was compared. Additionally, overall seroprevalence of each disease was compared with data from prior national studies. Gender differences within each birth cohort were also assessed.

Results: The overall seroprevalence values of measles, mumps, rubella, and varicella were 85.8, 82.8, 96.6, and 97.4%, respectively. There were significant associations between seroprevalence and birth cohort for measles (p = 0.01) as well as mumps (p = 0.037). The overall seroprevalence for our study sample was significantly different from the national seroprevalence results of measles, mumps, and rubella.

Conclusions: Our study showed dramatically lower immunity rates for measles and mumps than those shown by prior national seroprevalence studies. The rates in many of the later birth cohorts born after 1966 were significantly lower than the rates reported as necessary to sustain herd immunity. Given that patients' immunization records are not always available or complete, collecting local seroprevalence data may be necessary to more accurately recommend antibody testing and vaccination during pre-travel assessments.
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http://dx.doi.org/10.1111/jtm.12235DOI Listing
August 2016

A prospective evaluation of the role of Vascular Endothelial Growth Factor (VEGF) and the immune system in stage III/IV melanoma.

Springerplus 2015 17;4:186. Epub 2015 Apr 17.

Lehigh Valley Health Network, Department of Hematology Oncology, John and Dorothy Morgan Cancer Center, 1240 S. Cedar Crest Blvd, Suite 401, Allentown, PA 18103 USA.

Background: The immune system and vascular endothelial growth factor (VEGF) may be influential in melanoma behavior. We performed a prospective, exploratory analysis in 10 stage III and 22 stage IV melanoma patients to observe factors influencing outcomes.

Patients And Methods: Patients accrued during 2010 and 2011 were treated according to standard protocols for disease stage. We analyzed selected biomarkers for predictive patterns of clinical response. Survival outcomes were calculated using Kaplan-Meier curves.

Results: Baseline LDH was negatively correlated with length of survival and positively correlated to baseline VEGF in stage IV melanoma patients. We found a positive correlation between peripheral blood Treg concentrations and baseline VEGF in stage IV patients. No stage III patients died during the study period; median survival for stage IV patients was 48 months using a Kaplan-Meier survival curve, which illustrates the enrichment for exceptional stage IV survivors. Six stage IV patients remain disease free, including 4 of the 10 patients who received IL-2 +/- metastatectomy.

Conclusions: Recent advances in immunotherapy have demonstrated durable therapeutic responses which may favorably impact survival. Examining T-cell characteristics of metastatic melanoma patients may gain further insight into underlying immunomodulation mechanisms to guide improved therapies.
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http://dx.doi.org/10.1186/s40064-015-0951-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411400PMC
May 2015