Publications by authors named "John Doucette"

63 Publications

Alexithymia, Affective Lability, Impulsivity, and Childhood Adversity in Borderline Personality Disorder.

J Pers Disord 2021 Mar;35(Supplement A):114-131

Mental Health Research, Education, and Clinical Center (MIRECC VISN-2), James J. Peters VA Medical Center, Bronx, New York.

Long-standing theories of borderline personality disorder (BPD) suggest that symptoms develop at least in part from childhood adversity. Emotion dysregulation may meaningfully mediate these effects. The current study examined three factors related to emotion dysregulation-alexithymia, affective lability, and impulsivity-as potential mediators of the relation between childhood adversity and BPD diagnosis in 101 individuals with BPD and 95 healthy controls. Path analysis compared three distinct models informed by the literature. Results supported a complex mediation model wherein (a) alexithymia partially mediated the relation of childhood adversity to affective lability and impulsivity; (b) affective lability mediated the relation of childhood adversity to BPD diagnosis; and (c) affective lability and impulsivity mediated the relation of alexithymia to BPD diagnosis. Findings suggest that affective lability and alexithymia are key to understanding the relationship between childhood adversity and BPD. Interventions specifically targeting affective lability, impulsivity, and alexithymia may be particularly useful for this population.
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http://dx.doi.org/10.1521/pedi_2021_35_513DOI Listing
March 2021

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study.

Am J Emerg Med 2021 Feb 5;44:148-156. Epub 2021 Feb 5.

Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY, USA.

Objective: To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

Methods: A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

Results: Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

Conclusions: Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.
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http://dx.doi.org/10.1016/j.ajem.2021.02.004DOI Listing
February 2021

The Prescription of Long-Acting Opioids for Working-Age Patients With Workers' Compensation or Chronic Illness Diagnoses in the United States: From the National Ambulatory Medical Care Survey (NAMCS), 2010 to 2016.

J Occup Environ Med 2021 Mar;63(3):251-255

Augusta University/University of Georgia Medical Partnership, Athens, Georgia (Ms Topper); Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai (Ms Rosas, Dr Doucette, Dr Nabeel); New York Medical College (NYMC) (Ms Aarkoti), New York, New York.

Objective: To examine associations of workers' compensation, chronic conditions, age, sex, and race/ethnicity with primary prescription of long-acting opioids (LAO) among working-age patients in ambulatory care.

Methods: Using the National Ambulatory Medical Care Survey (2010 to 2016), we conducted descriptive, bivariate, and multivariate logistic regression analyses of patients aged 18 to 64 with an LAO as their primary medication.

Results: Those prescribed an LAO were more likely to be men (adjusted odds ratio [aOR] = 1.48, 95% CI 1.13, 1.91), have workers' compensation (aOR = 2.00, 95% CI 1.12, 3.57), or have diagnoses of lower back pain (aOR = 4.70, 95% CI 3.51, 6.29), arthritis (aOR = 1.53, 95% CI 1.11, 2.09), or depression (aOR = 1.69; 95% CI 1.24, 2.31). Hispanic ethnicity/race had a lower likelihood of LAO use compared with non-Hispanic White (aOR = 0.58; 95% CI 0.37, 0.90).

Conclusions: Male sex, workers' compensation, and diagnoses of lower back pain, arthritis, or depression were independently associated with increased LAO prescription odds.
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http://dx.doi.org/10.1097/JOM.0000000000002119DOI Listing
March 2021

Luminal narrowing alone allows an accurate diagnosis of Crohn's disease small bowel strictures at cross-sectional imaging.

J Crohns Colitis 2020 Dec 15. Epub 2020 Dec 15.

BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

Background And Aims: Current consensus recommendations define small bowel strictures (SBS) in Crohn's disease (CD) on imaging as luminal narrowing with unequivocal upstream bowel dilation. The aim of this study was to 1) evaluate the performance of cross-sectional imaging for SBS diagnosis in CD using luminal narrowing with upstream SB dilation and luminal narrowing with or without upstream dilation, and 2) compare the diagnostic performance of CT and MR enterography (MRE) for SBS diagnosis.

Methods: One hundred and eleven CD patients (81 with pathologically confirmed SBS, 30 controls) who underwent CT and/or MRE were assessed. Two radiologists (R1, R2) blinded to pathology findings independently assessed the presence of luminal narrowing and upstream SB dilation. Statistical analysis was performed for a) luminal narrowing with or without SB upstream dilation ("possible SBS"), b) luminal narrowing with upstream SB dilation ≥3cm ("definite SBS").

Results: Sensitivity for detecting SBS was significantly higher using "possible SBS" (R1, 82.1%; R2, 77.9%) compared to "definite SBS" (R1, 62.1%; R2, 65.3%; p<0.0001) with equivalent specificity (R1, 96.7%; R2, 93.3%; p>0.9). Using criterion "possible SBS", sensitivity/specificity were equivalent between CT (R1, 87.3%/93.3%; R2, 83.6%/86.7%) and MRE (R1, 75.0%/100%; R2: 70.0%/100%). Using criterion "definite SBS", CT showed significantly higher sensitivity (78.2%) compared to MRE (40.0%) for R1 but not R2 with similar specificities (CT, 86.7%-93.3%; MRE, 100%).

Conclusion: SBS can be diagnosed using luminal narrowing alone without the need for upstream dilation. CT and MRE show similar diagnostic performance for SBS diagnosis using luminal narrowing with or without upstream dilation.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa256DOI Listing
December 2020

Association of quantitative CT lung density measurements and lung function decline in World Trade Center workers.

Clin Respir J 2020 Nov 26. Epub 2020 Nov 26.

Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: Occupational exposures at the WTC site after 11 September 2001 have been associated with presumably inflammatory chronic lower airway diseases.

Aims: In this study, we describe the trajectories of expiratory air flow decline, identify subgroups with adverse progression, and investigate the association of those trajectories with quantitative computed tomography (QCT) imaging measurement of increased and decreased lung density.

Methods: We examined the trajectories of expiratory air flow decline in a group of 1,321 former WTC workers and volunteers with at least three periodic spirometries, and using QCT-measured low (LAV%, -950 HU) and high (HAV%, from -600 to -250 HU) attenuation volume percent. We calculated the individual regression line slopes for first-second forced expiratory volume (FEV slope), identified subjects with rapidly declining ("accelerated decliners") and increasing ("improved"), and compared them to subjects with "intermediate" (0 to -66.5 mL/year) FEV slope. We then used multinomial logistic regression to model those three trajectories, and the two lung attenuation metrics.

Results: The mean longitudinal FEV slopes for the entire study population, and its intermediate, decliner, and improved subgroups were, respectively, -40.4, -34.3, -106.5, and 37.6 mL/year. In unadjusted and adjusted analyses, LAV% and HAV% were both associated with "accelerated decliner" status (OR , 95% CI 2.37, 1.41-3.97, and 1.77, 1.08-2.89, respectively), compared to the intermediate decline.

Conclusions: Longitudinal FEV decline in this cohort, known to be associated with QCT proximal airway inflammation metric, is also associated with QCT indicators of increased and decreased lung density. The improved FEV trajectory did not seem to be associated with lung density metrics.
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http://dx.doi.org/10.1111/crj.13313DOI Listing
November 2020

A new face of the HPV epidemic: Oropharyngeal cancer in the elderly.

Oral Oncol 2020 Aug 31;109:104687. Epub 2020 Aug 31.

Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, 1184 Fifth Avenue, New York, NY 10029, United States. Electronic address:

Objectives: As the human papillomavirus (HPV) epidemic continues to grow, the number of elderly patients with oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing. Despite this observation, this cohort remains understudied. We aimed to understand HPV prevalence and characteristics within this cohort as well as its impact on disease control in elderly patients.

Methods And Materials: We identified patients aged ≥70 with newly diagnosed, non-metastatic, OPSCC treated with curative intent at our institution from 2007 to 2018. Logistic regression and survival analyses were used for outcome-specific endpoints.

Results: In total, 88 patients were identified with a median age of 73 (interquartile range [IQR]: 71-78) and a median Charlson Comorbidity Index of 6 (IQR: 5-7). Eighty-two percent were ECOG 0 or 1 performance. Of note, 70% of the cohort had HPV+ tumors. Fifty-one percent of patients were AJCC 8th edition stage I/II and 49% were stage III/IV. Median follow-up time was 2.5 years (IQR: 0.9-4.7). Eight percent had surgery alone, 27% underwent adjuvant RT, and 64% received definitive RT. Sixty-four percent received concurrent chemotherapy. By both univariate and multivariable analyses, HPV+ status was significantly associated with improved locoregional control (LRC), overall survival (OS), and disease specific survival (DSS).

Conclusions: In our cohort of elderly patients with OPSCC, the majority was HPV+, which was associated with improved clinical outcomes. There are many challenges when managing elderly patients with OPSCC, but as the population ages and the HPV epidemic evolves, these patients should be considered for elderly specific clinical trials.
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http://dx.doi.org/10.1016/j.oraloncology.2020.104687DOI Listing
August 2020

Nonoperative Management of Hallux Limitus Using a Novel Forefoot Orthosis.

J Foot Ankle Surg 2020 Nov - Dec;59(6):1192-1196. Epub 2020 May 29.

Dean and Associate Professor of Pre-Clinical Sciences, New York College of Podiatric Medicine, New York, NY.

Hallux limitus is among the most common arthritides of the foot and ankle, with increasing incidence in the aging population. Despite its prevalence and disease burden, treatment of the condition remains poorly understood. Many patients will fail initial conservative management, whereas controversy exists surrounding indications for and outcomes of surgery. The present study sought to examine the impact of a novel forefoot orthosis on foot function, pain, and plantar pressure distributions in patients with symptomatic hallux limitus. Nineteen adult patients completed a questionnaire consisting of the 23-item Foot Function Index and a 10-point visual analogue scale measuring pain. Standing pedobarographic maps were generated using a foot scanning system. Participants were instructed to wear the orthosis in athletic shoes for 4 weeks. Eighteen participants (94.7%) experienced improvements in foot function and pain, with 12 (63.2%) reporting complete resolution of pain at the end of the 4-week trial. Mean Foot Function Index scores improved significantly from 43.0% at baseline to 11.0% with the orthosis (p < .001). Similarly, mean visual analogue scale pain scores decreased significantly from 4.87 to 1.18 (p < .001). Pedobarographic analysis while wearing the orthosis demonstrated increased ability of participants to bear weight on the arthritic hallux metatarsophalangeal joint and restoration of physiologic stance. Compared to existing products, the device was well tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery.
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http://dx.doi.org/10.1053/j.jfas.2019.11.008DOI Listing
May 2020

Quantitative CT Evidence of Airway Inflammation in WTC Workers and Volunteers with Low FVC Spirometric Pattern.

Lung 2020 06 1;198(3):555-563. Epub 2020 Apr 1.

Department of Environmental Medicine and Public Health, Icahn School of Medicine At Mount Sinai, New York, NY, USA.

Background: The most common abnormal spirometric pattern reported in WTC worker and volunteer cohorts has consistently been that of a nonobstructive reduced forced vital capacity (low FVC). Low FVC is associated with obesity, which is highly prevalent in these cohorts. We used quantitative CT (QCT) to investigate proximal and distal airway inflammation and emphysema in participants with stable low FVC pattern.

Methods: We selected study participants with at least two available longitudinal surveillance spirometries, and a chest CT with QCT measurements of proximal airway inflammation (wall area percent, WAP), end-expiratory air trapping, suggestive of distal airway obstruction (expiratory to inspiratory mean lung attenuation ratio, MLA), and emphysema (percentage of lung volume with attenuation below - 950 HU, LAV%). The comparison groups in multinomial logistic regression models were participants with consistently normal spirometries, and participants with stable fixed obstruction (COPD).

Results: Compared to normal spirometry participants, and after adjusting for age, sex, race/ethnicity, BMI, smoking, and early arrival at the WTC disaster site, low FVC participants had higher WAP (OR 1.24, 95% CI 1.06, 1.45, per 5% unit), suggestive of proximal airway inflammation, but did not differ in MLA, or LAV%. COPD participants did not differ in WAP with the low FVC ones and were more likely to have higher MLA or LAV% than the other two subgroups.

Discussion: WTC workers with spirometric low FVC have higher QCT-measured WAP compared to those with normal spirometries, but did not differ in distal airway and emphysema measurements, independently of obesity, smoking, and other covariates.
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http://dx.doi.org/10.1007/s00408-020-00350-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245558PMC
June 2020

Comparison of Liquid Chromatography Mass Spectrometry and Enzyme-Linked Immunosorbent Assay Methods to Measure Salivary Cotinine Levels in Ill Children.

Int J Environ Res Public Health 2020 02 12;17(4). Epub 2020 Feb 12.

Department of Psychology, San Diego State University, San Diego, CA 92123, USA.

: Cotinine is the preferred biomarker to validate levels of tobacco smoke exposure (TSE) in children. Compared to enzyme-linked immunosorbent assay methods (ELISA) for quantifying cotinine in saliva, the use of liquid chromatography tandem mass spectrometry (LC-MS/MS) has higher sensitivity and specificity to measure very low levels of TSE. We sought to compare LC-MS/MS and ELISA measures of cotinine in saliva samples from children overall and the associations of these measures with demographics and TSE patterns. : Participants were nonsmoking children (N = 218; age mean (SD) = 6.1 (5.1) years) presenting to a pediatric emergency department. Saliva samples were analyzed for cotinine using both LC-MS/MS and ELISA. Limit of quantitation (LOQ) for LC-MS/MS and ELISA was 0.1 ng/ml and 0.15 ng/ml, respectively. Intraclass correlations (ICC) across methods = 0.884 and was consistent in sex and age subgroups. The geometric mean (GeoM) of LC-MS/MS = 4.1 (range: < LOQ - 382 ng/mL; 3% < LOQ) which was lower ( < 0.0001) than the ELISA GeoM = 5.7 (range: < LOQ - 364 ng/mL; 5% < LOQ). Similar associations of cotinine concentrations with age ( < -0.10, < 0.0001), demographic characteristics (e.g., income), and number of cigarettes smoked by caregiver ( > 0.07, < 0.0001) were found regardless of cotinine detection method; however, cotinine associations with sex and race/ethnicity were only found to be significant in models using LC-MS/MS-derived cotinine. : Utilizing LC-MS/MS-based cotinine, associations of cotinine with sex and race/ethnicity of child were revealed that were not detectable using ELISA-based cotinine, demonstrating the benefits of utilizing the more sensitive LC-MS/MS assay for cotinine measurement when detecting low levels of TSE in children.
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http://dx.doi.org/10.3390/ijerph17041157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068296PMC
February 2020

Using the delayed spatial alternation task to assess environmentally associated changes in working memory in very young children.

Neurotoxicology 2020 03 16;77:71-79. Epub 2019 Dec 16.

Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

Background: Working memory (WM) is critical for problem solving and reasoning. Beginning in infancy, children show WM capacity increasing with age but there are few validated tests of WM in very young children. Because rapid brain development may increase susceptibility to adverse impacts of prenatal neurotoxicant exposure, such as lead, tests of WM in very young children would help to delineate onset of developmental problems and windows of susceptibility.

Purpose: Our objective was to assess the feasibility of administering a Delayed Spatial Alternation Task (DSAT) to measure WM among 18- and 24-month old children enrolled in an ongoing longitudinal birth cohort study and compare DSAT performance with age and general cognitive development. We further explored whether prenatal lead exposure impacted DSAT performance.

Methods: We assessed 457 mother-child pairs participating in the Programming Research in Obesity, GRowth, Environment and Social Stressors (PROGRESS) Study in Mexico City. The DSAT and Bayley Scales of Infant Development (BSID-III) were administered at 18- and 24-months. Lead was measured in maternal blood collected during pregnancy (MBPb) and in a subsample of children at 24-months (CBPb). We regressed DSAT measures on MBPb and CBPb, child sex, and maternal age, education, socioeconomic status, and household smoking. We compared DSAT performance to BSID-III performance with adjusted residuals.

Results: 24-month children perform better on the DSAT than 18-month children; 24-month subjects reached a higher level on the DSAT (3.3 (0.86) vs. 2.4 (0.97), p < 0.01), and had a higher number of correct responses (20.3 vs. 17.2, p < 0.01). In all DSAT parameters, females performed better than males. Maternal education predicted better DSAT performance; household smoking predicted worse DSAT performance. A higher number of correct responses was associated with higher BSID-III Cognitive scales at 18 months (r = 0.20, p < 0.01) and 24 months (r = 0.27, p < 0.01). MBPb and CPBb did not significantly predict DSAT performance.

Conclusion: Improved performance on the DSAT with increasing age, the positive correlation with the BSID-III cognitive and language scales and the correlation with common sociodemographic predictors of neurodevelopment demonstrate the validity of the DSAT as a test of infant development.
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http://dx.doi.org/10.1016/j.neuro.2019.12.009DOI Listing
March 2020

Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis.

J Intensive Care Med 2021 Mar 27;36(3):277-283. Epub 2019 Nov 27.

Institute for Critical Care Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement.

Method: In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE.

Results: We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance.

Conclusions: Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.
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http://dx.doi.org/10.1177/0885066619890324DOI Listing
March 2021

Increased pulmonary artery diameter is associated with reduced FEV in former World Trade Center workers.

Clin Respir J 2019 Oct 19;13(10):614-623. Epub 2019 Aug 19.

Department of Medicine, New York University School of Medicine, New York, New York.

Rationale: Occupational exposures at the WTC site after September 11, 2001 have been associated with several presumably inflammatory lower airway diseases. Pulmonary arterial enlargement, as suggested by an increased ratio of the diameter of the pulmonary artery to the diameter of the aorta (PAAr) has been reported as a computed tomographic (CT) scan marker of adverse respiratory health outcomes, including WTC-related disease. In this study, we sought to utilize a novel quantitative CT (QCT) measurement of PAAr to test the hypothesis that an increased ratio is associated with FEV below each subject's statistically determined lower limit of normal (FEV  < LLN).

Methods: In a group of 1,180 WTC workers and volunteers, we examined whether FEV  < LLN was associated with an increased QCT-measured PAAr, adjusting for previously identified important covariates.

Results: Unadjusted analyses showed a statistically significant association of FEV  < LLN with PAAr (35.3% vs 24.7%, P = 0.0001), as well as with height, body mass index, early arrival at the WTC disaster site, shorter WTC exposure duration, post-traumatic stress disorder checklist (PCL) score, wall area percent and evidence of bronchodilator response. The multivariate logistic regression model confirmed the association of FEV  < LLN with PAAr (OR 1.63, 95% CI 1.21, 2.20, P = 0.0015) and all the unadjusted associations, except for PCL score.

Conclusions: In WTC workers, FEV  < LLN is associated with elevated PAAr which, although likely multifactorial, may be related to distal vasculopathy, as has been hypothesized for chronic obstructive pulmonary disease.
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http://dx.doi.org/10.1111/crj.13067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783324PMC
October 2019

Association of Obesity with Quantitative Chest CT Measured Airway Wall Thickness in WTC Workers with Lower Airway Disease.

Lung 2019 08 28;197(4):517-522. Epub 2019 Jun 28.

Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.

Background: We previously reported that wall area percent (WAP), a quantitative CT (QCT) indicator of airway wall thickness and, presumably, inflammation, is associated with adverse longitudinal expiratory flow trajectories in WTC workers, but that obesity and weight gain also seemed to be independently predictive of the latter. Previous studies have reported no association between WAP and obesity, so we investigated that association in nonsmoking WTC-exposed individuals and healthy unexposed controls.

Methods: We assessed WAP using the Chest Imaging Platform QCT system in a segmental bronchus in 118 former WTC workers, and 89 COPDGene® WTC-unexposed and asymptomatic subjects. We used multiple regression to model WAP vs. body mass index (BMI) in the two groups, adjusting for important subject and CT image characteristics.

Results: Unadjusted analyses revealed significant differences between the two groups with regards to WAP, age, gender, scan pixel spacing and slice interval, but not BMI or total lung capacity. In adjusted analysis, there was a significant interaction between BMI and WTC exposure on WAP. BMI was significantly and positively associated with WAP in the WTC group, but not in the COPDGene® group, but stratified analyses revealed that the effect was significant in WTC subjects with clinical evidence of lower airway disease (LAD).

Discussion: Unlike non-diseased subjects, BMI was significantly associated with WAP in WTC workers and, in stratified analyses, the association was significant only among those with LAD. Our findings suggest that this adverse effect of obesity on airway structure and inflammation may be confined to already diseased individuals.
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http://dx.doi.org/10.1007/s00408-019-00246-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7209578PMC
August 2019

A mixed-integer linear programming optimization model framework for capturing expert planning style in low dose rate prostate brachytherapy.

Phys Med Biol 2019 03 27;64(7):075007. Epub 2019 Mar 27.

Department of Mechanical Engineering, 10-237 Donadeo Innovation Centre for Engineering, University of Alberta, Edmonton, AB T6G 1H9, Canada.

Low dose rate (LDR) brachytherapy is a minimally invasive form of radiation therapy, used to treat prostate cancer, and it involves permanent implantation of radioactive sources (seeds) inside of the prostate gland. Treatment planning in brachytherapy involves a decision making process for the placement of the sources in order to deliver an effective dose of radiation to cancerous tissue in the prostate while sparing the surrounding healthy tissue. Such a decision making process can be modeled as a mixed-integer linear programming (MILP) problem. In this paper, we introduce a novel MILP optimization model framework for interstitial LDR prostate brachytherapy designed to explicitly mimic the qualities of treatment plans produced manually by expert planners. Our approach involves incorporating a unique set of clinically important constraints, called spatial constraints, into the optimization model. Computational results for an initial model reflecting clinical practice at our cancer center show that the treatment plans produced largely capture the spatial and dosimetric characteristics of manual plans created by expert planners.
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http://dx.doi.org/10.1088/1361-6560/ab075cDOI Listing
March 2019

A mixed-integer linear programming optimization model framework for capturing expert planning style in low dose rate prostate brachytherapy.

Phys Med Biol 2019 03 27;64(7):075007. Epub 2019 Mar 27.

Department of Mechanical Engineering, 10-237 Donadeo Innovation Centre for Engineering, University of Alberta, Edmonton, AB T6G 1H9, Canada.

Low dose rate (LDR) brachytherapy is a minimally invasive form of radiation therapy, used to treat prostate cancer, and it involves permanent implantation of radioactive sources (seeds) inside of the prostate gland. Treatment planning in brachytherapy involves a decision making process for the placement of the sources in order to deliver an effective dose of radiation to cancerous tissue in the prostate while sparing the surrounding healthy tissue. Such a decision making process can be modeled as a mixed-integer linear programming (MILP) problem. In this paper, we introduce a novel MILP optimization model framework for interstitial LDR prostate brachytherapy designed to explicitly mimic the qualities of treatment plans produced manually by expert planners. Our approach involves incorporating a unique set of clinically important constraints, called spatial constraints, into the optimization model. Computational results for an initial model reflecting clinical practice at our cancer center show that the treatment plans produced largely capture the spatial and dosimetric characteristics of manual plans created by expert planners.
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http://dx.doi.org/10.1088/1361-6560/ab075cDOI Listing
March 2019

Percutaneous versus surgical tracheostomy: timing, outcomes, and charges.

Laryngoscope 2018 12 3;128(12):2844-2851. Epub 2018 Oct 3.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objectives/hypothesis: The purpose of this study was to compare timing of procedure, patient characteristics, outcomes, and charges for patients who underwent percutaneous versus surgical tracheostomy.

Study Design: Retrospective cohort study.

Methods: A retrospective analysis was performed for all patients who underwent tracheostomy in 2015 to 2016 in New York State. Patients were identified using International Classification of Diseases, 10th Revision, Clinical Modification codes and stratified to the type of tracheostomy performed. The primary outcome of interest was mortality at index stay. Secondary outcomes of interest included length of stay and total hospitalization charges.

Results: Of the 8,682 patients, 2,488 (28.7%) underwent percutaneous and 6,194 (71.3%) underwent surgical tracheostomy. At hospitals where both procedures were performed, percutaneous tracheostomy patients were older, had more comorbidities, and had lower income (P < .05). Timing of the tracheostomy relative to admission did not affect the type of tracheostomy performed. While controlling for patient characteristics and complications during the visit, percutaneous tracheostomy was associated with increased mortality (odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.03-1.33, P = .0153) and increased hospital charges (OR: + 7.76%, 95% CI: 5.4-10.11, P < .0001). Length of stay was not affected by procedure type.

Conclusions: Surgical tracheostomies are more commonly performed than percutaneous tracheostomies across New York State. Older, lower-income, and sicker patients have a higher chance of receiving percutaneous tracheostomies. Percutaneous approaches were associated with statistically significant increased mortality and higher charges despite no difference in length of stay. Further studies are needed to determine if these differences in outcomes are clinically significant.

Level Of Evidence: NA Laryngoscope, 128:2844-2851, 2018.
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http://dx.doi.org/10.1002/lary.27334DOI Listing
December 2018

Impact of obesity on outcomes for patients with head and neck cancer.

Oral Oncol 2018 08 5;83:11-17. Epub 2018 Jun 5.

Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, 1184 Fifth Avenue, New York, NY 10029, United States. Electronic address:

Objectives: The prognostic role of obesity in head and neck squamous cell carcinoma (HNSCC) is not well defined. This study aims to determine its effect on disease-specific outcomes such as recurrence-free survival (RFS), locoregional recurrence-free survival (LRRFS), and distant metastasis-free survival (DMFS) in addition to overall survival (OS).

Methods: For patients with newly diagnosed HNSCC undergoing radiation therapy (RT) at a single institution, body mass index (BMI) at diagnosis was categorized as normal (18.5 to 24.9 kg/m), overweight (25 to 29.9 kg/m) and obese (≥30 kg/m). Outcomes were compared by BMI group using Cox regression.

Results: 341 patients of median age 59 (range, 20-93) who underwent curative RT from 2010 to 2017 were included. 58% had oropharynx cancer, 17% larynx and 15% oral cavity. 72% had stage IVA/B disease and 28% stage I-III. At diagnosis, 33% had normal BMI, 40% overweight, and 28% obese. 59% had definitive RT and 41% had postoperative RT. Alcoholic/smoking status, advanced tumor stage, hypopharynx/larynx tumors, and feeding tube placement were more common in patients with lower BMI (P < .05 for each). Median follow-up was 30 months (range, 3-91). Higher BMI was associated with improved OS (P < .05) and obesity was associated with longer RFS (P < .05) and DMFS (P < .05), but not LRRFS (P = .07) after adjusting for confounding variables.

Conclusion: Being overweight/obese at the time of HNSCC diagnosis is an independent prognostic factor conferring better survival, while obesity is independently associated with longer time to recurrence, primarily by improving distant control.
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http://dx.doi.org/10.1016/j.oraloncology.2018.05.027DOI Listing
August 2018

Falls in Older Patients with Cancer Undergoing Surgery: Prevalence and Association with Geriatric Syndromes and Levels of Disability Assessed in Preoperative Evaluation.

Curr Gerontol Geriatr Res 2018 15;2018:5713285. Epub 2018 May 15.

Department of Geriatrics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Falls are common among older adults. However, not much is known about the prevalence of falls among older patients with cancer. In 2015, older patients with cancer referred to Geriatrics service for preoperative evaluation were assessed for fall history, basic and instrumental activities of daily living (ADL and IADL), KPS, and use of assistive device. Of 806 patients, 215 (26.7%) patients reported fall. Incidence of last fall inside and outside home was 54.4% and 45.5%, respectively. Among patients with no falls, 33.6% had KPS ≤ 80 compared to 59.6% with one-time fall and 60.7% with multiple falls ( < 0.001). Among IADL, 8.5% of patients with no falls were unable to do shopping compared with 14.7% in one-time fall and 18.8% in multiple fallers ( < 0.001). In ADL items, the percentage of patients who were limited a lot in walking outside was 10.7% in no falls, 20.2% in one-time fall, and 27.1% in multiple fallers groups ( < 0.001). Only 17.8% of patients with no falls were using canes while 27.7% of patients with one-time fall and 38.8% with multiple falls were using canes ( < 0.001). Falls are prevalent among older patients with cancer. Fall history and number of falls are associated with functional status.
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http://dx.doi.org/10.1155/2018/5713285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977004PMC
May 2018

Active design in affordable housing: A public health nudge.

Prev Med Rep 2018 Jun 31;10:9-14. Epub 2018 Jan 31.

Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1043, New York, NY 10029, United States.

This pilot study investigates the impact of active design (AD) strategies on physical activity (PA) among adults living in two Leadership in Energy and Environmental Design (LEED) certified affordable housing developments in the South Bronx, New York. One building incorporates LEED Innovation in Design (ID) Credit: Design for Health through Increased Physical Activity. Tenants in an affordable housing building (AH) incorporating active design strategies completed PA self-assessments at their lease signing and one year later in 2015. Trained research assistants obtained body measurements. Residents of neighboring non-AD affordable housing (MCV) served as a comparison. Thirty four adults were recruited from AH and 29 from MCV, retention was 56% (n = 19) and 52% (n = 15) respectively at one year. The two groups' body mass index (BMI) and high-risk waist-to-hip ratio (WHR) were not statistically significantly different when analyzed as continuous variables, although BMI category had a greater decline at AH than at MCV (p = 0.054). There was a 31.5% increase in AH participants meeting MPA requirements and a statistically significant improvement in females (p = 0.031); while there was no change in the MCV participants overall or when stratified by gender. AH participants were significantly more likely to have reported increased stair use and less likely to have reported no change or decreased stair use than participants from MCV participants (p = 0.033). Housing has a role in individual health outcomes and behavior change, broad adoption of active design strategies in affordable housing is warranted to improve physical activity measures.
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http://dx.doi.org/10.1016/j.pmedr.2018.01.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984212PMC
June 2018

Increased Airway Wall Thickness is Associated with Adverse Longitudinal First-Second Forced Expiratory Volume Trajectories of Former World Trade Center workers.

Lung 2018 08 24;196(4):481-489. Epub 2018 May 24.

Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.

Rationale: Occupational exposures at the WTC site after September 11, 2001 have been associated with several presumably inflammatory lower airway diseases. In this study, we describe the trajectories of expiratory air flow decline, identify subgroups with adverse progression, and investigate the association of a quantitative computed tomography (QCT) imaging measurement of airway wall thickness, and other risk factors for adverse progression.

Methods: We examined the trajectories of expiratory air flow decline in a group of 799 former WTC workers and volunteers with QCT-measured (with two independent systems) wall area percent (WAP) and at least 3 periodic spirometries. We calculated individual regression lines for first-second forced expiratory volume (FEV), identified subjects with rapidly declining and increasing ("gainers"), and compared them to subjects with normal and "stable" FEV decline. We used multivariate logistic regression to model decliner vs. stable trajectories.

Results: The mean longitudinal FEVslopes for the entire study population, and its stable, decliner, and gainer subgroups were, respectively, - 35.8, - 8, - 157.6, and + 173.62 ml/year. WAP was associated with "decliner" status (OR 1.08, 95% CI 1.02, 1.14, per 5% increment) compared to stable. Age, weight gain, baseline FEV percent predicted, bronchodilator response, and pre-WTC occupational exposures were also significantly associated with accelerated FEV decline. Analyses of gainers vs. stable subgroup showed WAP as a significant predictor in unadjusted but not consistently in adjusted analyses.

Conclusions: The apparent normal age-related rate of FEV decline results from averaging widely divergent trajectories. WAP is significantly associated with accelerated air flow decline in WTC workers.
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http://dx.doi.org/10.1007/s00408-018-0125-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129294PMC
August 2018

Abnormalities in Left Ventricular Rotation Are Inherent in Young Children with Repaired Tetralogy of Fallot and Are Independent of Right Ventricular Dilation.

Pediatr Cardiol 2018 Aug 11;39(6):1172-1180. Epub 2018 Apr 11.

Division of Pediatric Cardiology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, USA.

Left ventricular (LV) dysfunction is a risk factor for adverse outcomes in older children and adults with repaired Tetralogy of Fallot (rToF). Pulmonary regurgitation (PR), right ventricular (RV) dilation, and dysfunction have been shown to result in abnormal LV myocardial mechanics and dysfunction. The aim of our study was to evaluate LV rotational mechanics, especially apical rotation in young children with rToF with and without RV dilation. This is a retrospective, single center study in 28 asymptomatic young children with rToF (16 with RV dilation; 12 without RV dilation); 29 age-matched normal controls. RV and LV systolic and diastolic function was studied using conventional two-dimensional echocardiography (2DE) and speckle tracking echocardiography (STE). Rotational mechanics studied included basal and apical rotation (BR, AR), peak twist (calculated by difference between the apical and basal rotation), twist rate (TR), and untwist rate (UnTR). The mean age of the cohort was 4.7 years (± 2.3). Abnormal AR, BR, TR, and UnTR were noted in patients with rToF. The abnormalities were significant in magnitude as well as the direction of rotation; more pronounced in the absence of RV dilation. LV systolic and diastolic dysfunction as evidenced by abnormal AR and degree of untwist is inherent in rToF and not associated with RV dilation in rToF children. Abnormal BR may reflect a lack of maturation to adult type of rotational mechanics. Further longitudinal studies are required to study the progression of these abnormalities and their correlation with clinical outcomes.
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http://dx.doi.org/10.1007/s00246-018-1877-9DOI Listing
August 2018

Chest CT scan findings in World Trade Center workers.

Arch Environ Occup Health 2019 9;74(5):263-270. Epub 2018 May 9.

Division of Pediatric Pulmonary Medicine, Allergy and Immunology, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, University of Pittsburgh , Pittsburgh , PA.

We examined the chest CT scans of 1,453 WTC responders using the International Classification of High-resolution CT for Occupational and Environmental Respiratory Diseases. Univariate and bivariate analyses of potential work-related pleural abnormalities were performed with pre-WTC and WTC-related occupational exposure data, spirometry, demographics and quantitative CT measurements. Logistic regression was used to evaluate occupational predictors of those abnormalities. Chest CT scans were performed first at a median of 6.8 years after 9/11/2001. Pleural abnormalities were the most frequent (21.1%) across all occupational groups In multivariable analyses, significant pre-WTC occupational asbestos exposure, and work as laborer/cleaner were predictive of pleural abnormalities, with prevalence being highest for the Polish subgroup (n = 237) of our population. Continued occupational lung disease surveillance is warranted in this cohort.
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http://dx.doi.org/10.1080/19338244.2018.1452712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6474817PMC
February 2020

Factors Predictive of Receiving Adjuvant Radiotherapy in High-Intermediate-Risk Stage I Endometrial Cancer.

Int J Gynecol Cancer 2018 06;28(5):882-889

Departments of Radiation Oncology.

Objectives: Randomized trials have shown a local control benefit with adjuvant radiotherapy (RT) in high-intermediate-risk endometrial cancer patients, although not all such patients receive RT. We reviewed the National Cancer Data Base to investigate which patient/tumor-related factors are associated with delivery of adjuvant RT.

Methods: The National Cancer Data Base was queried for patients diagnosed with International Federation of Gynecology and Obstetrics 2009 stage I endometrioid adenocarcinoma from 1998 to 2012 who underwent surgery +/- adjuvant RT. Exclusion criteria were unknown stage/grade, nonsurgical primary therapy, less than 30 days' follow-up, RT of more than 6 months after surgery, or palliative treatment. High-intermediate risk was defined based on Post Operative Radiation Therapy in Endometrial Carcinoma 2 criteria: older than 60 years with stage IA grade 3 or stage IB grade 1-2.

Results: Seventeen thousand five hundred twenty-four met inclusion criteria, and the 13,651 patients with complete data were subjected to a multiple logistic regression analysis; 7814 (57.2%) received surgery alone, and 5837 (42.8%) received surgery + RT. Receipt of adjuvant RT was more likely among black women and women with higher income, Northeastern residence, diagnosis after 2010, greater than 50% myometrial invasion, and receipt of adjuvant chemotherapy (P < 0.05). Patients older than 80 years or those undergoing lymph node dissection were less likely to receive adjuvant RT (P < 0.05). Of those treated with RT, 44.0% received external beam therapy, 54.8% received vaginal cuff brachytherapy, and 0.6% received both. Among irradiated women, patients older than 80 years and those with Northeastern residence, treatment at academic facilities, diagnosis after 2004, and lymph node dissection were more likely to undergo brachytherapy over external beam radiation therapy (P < 0.05). Overall use of adjuvant RT was 28.8% between 1998 and 2004, 42.0% between 2005 and 2010, and 43.4% between 2011 and 2012; the difference between 1998-2004 and 2005-2010 was not statistically significant.

Conclusions: Fewer than half of patients with high-intermediate-risk endometrial cancer by Post Operative Radiation Therapy in Endometrial Carcinoma 2 criteria received adjuvant RT despite evidence demonstrating improved local control. Both patient- and tumor-related factors are associated with delivery of adjuvant RT and the modality selected.
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http://dx.doi.org/10.1097/IGC.0000000000001245DOI Listing
June 2018

Validation of Right Atrial Area as a Measure of Right Atrial Size and Normal Values of in Healthy Pediatric Population by Two-Dimensional Echocardiography.

Pediatr Cardiol 2018 Jun 9;39(5):892-901. Epub 2018 Mar 9.

Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA.

Right atrial (RA) size is a prognostic indicator for heart failure and cardiovascular death in adults. Data regarding use of RA area (RAA) by two-dimensional echocardiography as a surrogate for RA size and allometric modeling to define appropriate indexing of the RAA are lacking. Our objective was to validate RAA as a reliable measure of RA size and to define normal reference values by transthoracic echocardiography (TTE) in a large population of healthy children and develop Z-scores using a validated allometric model for indexing RAA independent of age, sex, and body size. Agreement between RAA and volume by 2D, 3D TTE, and MRI was assessed. RAA not volume by 2D TTE is an excellent surrogate for RA size. RAA/BSA has an inverse correlation with BSA with a residual relationship to BSA (r = - 0.54, p < 0.0001). The allometric exponent (AE) derived for the entire cohort (0.85) also fails to eliminate the residual relationship. The entire cohort divided into two groups with a BSA cut-off of 1 m to provide the best-fit allometric model (r = 0). The AE by least square regression analysis for each group is 0.95 and 0.88 for BSA < 1 m and > 1 m, respectively, and was validated against an independent sample. The mean indexed RAA ± SD for BSA ≤ 1 m and > 1 m is 9.7 ± 1.3 cm and 8.7 ± 1.3 cm, respectively, and was used to derive Z-scores. RAA by 2D TTE is superior to 2D or 3D echocardiography-derived RA volume as a measure of RA size using CMR as the reference standard. RAA when indexed to BSA, decreases as body size increases. The best-fit allometric modeling is used to create Z scores. RAA/BSA for BSA < 1 m and RAA/BSA for those with BSA > 1 m can be used to derive Z scores.
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http://dx.doi.org/10.1007/s00246-018-1838-3DOI Listing
June 2018

A quality assurance investigation of CLABSI events: are there exceptions to never?

J Infect Prev 2018 Jan 28;19(1):22-28. Epub 2017 Jul 28.

Director of Surgical Intensive Care Unit, Mount Sinai Hospital, New York, NY, USA.

Background: In the USA, central line associated blood stream infections (CLABSIs) have been designated as 'never events', prompting initiatives towards a 'zero CLABSIs' standard. We propose that there are cascading risk factors predisposing certain patient cohorts to higher CLABSIs rates.

Methods: A retrospective review of all CLABSI infections over a 12-month period was undertaken. Risk factors examined included catheter type, insertion site and parenteral nutrition (PN) status. Additional factors analysed included acute kidney injury (AKI), chronic kidney disease (CKD) and hospital-acquired infections (HAIs).

Results: Thirty-four CLABSIs were identified in 33 adult patients (median age = 57 years). Temporary central venous catheters accounted for 12 (35%), peripherally inserted central catheters for five (14.7%), and permanent catheters for 17 CLABSIs (50%); the median duration from insertion was 15 days (interquartile range = 9-26). Among patient factors, immunosuppression and hyperglycaemia were the most common (n = 19, 55%), followed by PN and CKD (n = 17, 50.0%), AKI (n = 16, 47.1%) and HAIs (n = 13, 38.2%). A majority of patients with CLABSIs (n = 20 58.8%) had at least three risk factors.

Discussion: These findings reflect the complexity of CLABSIs with multiple patient and hospital factors influencing incidence. It suggests the need for further studies to re-calibrate the zero CLABSI model towards one with greater relevance.
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http://dx.doi.org/10.1177/1757177417720997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753946PMC
January 2018

Initial clinical assessment of "center-specific" automated treatment plans for low-dose-rate prostate brachytherapy.

Brachytherapy 2018 Mar - Apr;17(2):476-488. Epub 2017 Dec 1.

Department of Oncology, University of Alberta, Edmonton, AB, Canada, T6G 1Z2. Electronic address:

Purpose: To report results of an initial pilot study assessing iodine-125 prostate implant treatment plans created automatically by a new seed-placement method.

Methods And Materials: A novel mixed-integer linear programming method incorporating spatial constraints on seed locations in addition to standard dose-volume constraints was used to place seeds. The approach, described in detail elsewhere, was used to create treatment plans fully automatically on a retrospective basis for 20 patients having a wide range of prostate sizes and shapes. Corresponding manual plans used for patient treatment at a single institution were combined with the automated plans, and all 40 plans were anonymized, randomized, and independently evaluated by five clinicians using a common scoring tool. Numerical and clinical features of the plans were extracted for comparison purposes.

Results: A full 51% of the automated plans were deemed clinically acceptable without any modification by the five practitioners collectively versus 90% of the manual plans. Automated plan seed distributions were for the most part not substantially different from those for the manual plans. Two observed shortcomings of the automated plans were seed strands not intersecting the prostate and strands extending into the bladder. Both are amenable to remediation by adjusting existing spatial constraints.

Conclusions: After spatial and dose-volume constraints are set, the mixed-integer linear programming method is capable of creating prostate implant treatment plans fully automatically, with clinical acceptability sufficient to warrant further investigation. These plans, intended to be reviewed and refined as necessary by an expert planner, have the potential to both save planner time and enhance treatment plan consistency.
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http://dx.doi.org/10.1016/j.brachy.2017.10.012DOI Listing
January 2019

Interobserver Agreement Among Uveitis Experts on Uveitic Diagnoses: The Standardization of Uveitis Nomenclature Experience.

Am J Ophthalmol 2018 02 6;186:19-24. Epub 2017 Nov 6.

Department of Medicine, Texas A&M University College of Medicine, College Station, Texas.

Purpose: To evaluate the interobserver agreement among uveitis experts on the diagnosis of the specific uveitic disease.

Design: Interobserver agreement analysis.

Methods: Five committees, each comprised of 9 individuals and working in parallel, reviewed cases from a preliminary database of 25 uveitic diseases, collected by disease, and voted independently online whether the case was the disease in question or not. The agreement statistic, κ, was calculated for the 36 pairwise comparisons for each disease, and a mean κ was calculated for each disease. After the independent online voting, committee consensus conference calls, using nominal group techniques, reviewed all cases not achieving supermajority agreement (>75%) on the diagnosis in the online voting to attempt to arrive at a supermajority agreement.

Results: A total of 5766 cases for the 25 diseases were evaluated. The overall mean κ for the entire project was 0.39, with disease-specific variation ranging from 0.23 to 0.79. After the formalized consensus conference calls to address cases that did not achieve supermajority agreement in the online voting, supermajority agreement overall was reached on approximately 99% of cases, with disease-specific variation ranging from 96% to 100%.

Conclusions: Agreement among uveitis experts on diagnosis is moderate at best but can be improved by discussion among them. These data suggest the need for validated and widely used classification criteria in the field of uveitis.
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http://dx.doi.org/10.1016/j.ajo.2017.10.028DOI Listing
February 2018

Characteristics of Vitamin B12 Deficiency in Patients With Plasma Cell Disorders.

Clin Lymphoma Myeloma Leuk 2017 Dec 12;17(12):e65-e69. Epub 2017 Jul 12.

Division of Hematology and Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

Background: Although increased rates of vitamin B12 deficiency have been reported in patients with plasma cell dyscrasias (PCDs), no mechanism has been identified. Excess free light chains (FLCs) could disrupt the renal proximal tubule receptors where B12 is reabsorbed. We sought to characterize the relationship between B12 deficiency and PCDs. We hypothesized that rates of B12 deficiency would be highest in patients with PCDs with high FLC burdens.

Methods: We reviewed the electronic medical records of 501 patients who met inclusion criteria (diagnosed PCD with documented serum B12 and FLC levels) to obtain clinical data recorded prior to patients' lowest B12 levels.

Results: Overall, 20.0% of patients had low vitamin B12. There was an expected negative correlation between estimated glomular filtration rate and FLC (r = -0.317; P < .001). However, low B12 levels were more prevalent in patients with preserved renal function (P = .047). Low B12 was associated with lower mean corpuscular volume (P = .037).

Conclusion: Higher FLC burden was associated with poor kidney function but not with low B12. Low B12 was seen more commonly in patients with preserved kidney function. Mean corpuscular volume was statistically but not clinically different between patients with low and normal B12 and, therefore, may not be a reliable indicator of B12 deficiency in PCDs. Prospective studies should compare B12 metabolites with FLC levels. Detection of B12 deficiency among patients with PCDs remains important to reduce neurologic dysfunction and cytopenias, sequelae common to B12 deficiency and PCDs.
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http://dx.doi.org/10.1016/j.clml.2017.07.001DOI Listing
December 2017

Strong correlations between empathy, emotional intelligence, and personality traits among podiatric medical students: A cross-sectional study.

Educ Health (Abingdon) 2016 Sep-Dec;29(3):186-194

Department of Pre-Clinical Sciences, New York College of Podiatric Medicine, New York, NY; Environmental Medicine and Public Health, Mount Sinai School of Medicine, New York, NY, USA.

Background: The ability of health-care providers to demonstrate empathy toward their patients results in a number of positive outcomes improving the quality of care. In addition, a provider's level of emotional intelligence (EI) can further the doctor-patient relationship, stimulating a more personalized and comprehensive manner of treating patients. Furthermore, personality traits of a clinician may positively or negatively influence that relationship, as well as clinical outcomes. This study was designed to evaluate empathy levels in podiatric medical students in a 4-year doctoral program. Moreover, this study aimed to determine whether EI, personality traits, and demographic variables exhibit correlations with the observed empathy patterns.

Methods: This cross-sectional study collected data using an anonymous web-based survey completed by 150 students registered at the New York College of Podiatric Medicine. There were four survey sections: (1) demographics, (2) empathy (measured by the Jefferson Scale of Physicians' Empathy), (3) EI (measured by the Assessing Emotions Scale), and (4) personality traits (measured by the NEO-Five-Factor Inventory-3).

Results: Empathy levels were significantly correlated with EI scores (r = 0.62, n = 150, P< 0.0001). All the five domains of personality were also shown to correlate with empathy scores, as well as with EI scores. With respect to demographics, Asian-American students had lower mean empathy scores than students of other races (P = 0.0018), females had higher mean empathy scores compared to men (P = 0.001), and undergraduate grade point average correlated with empathy scores in a nonmonotonic fashion (P = 0.0269).

Discussion: When measuring the variables, it was evident that there was a strong correlation between empathy, EI, and personality in podiatric medical students. Given the suggested importance and effect of such qualities on patient care, these findings may serve as guidance for possible amendments and warranted curriculum initiatives in medical education.
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http://dx.doi.org/10.4103/1357-6283.204224DOI Listing
September 2017

The high incidence of severe chronic kidney disease after intestinal transplantation and its impact on patient and graft survival.

Clin Transplant 2017 05 24;31(5). Epub 2017 Mar 24.

Recanati-Miller Transplant Institute, Mount Sinai Hospital, New York, NY, USA.

Introduction: Using data from the Scientific Registry of Transplant Recipients (SRTR), cumulative incidence, risk factors for, and impact on survival of severe chronic kidney disease (CKD) in intestinal transplantation (ITx) recipients were assessed.

Methods: First-time adult ITx recipients transplanted in the United States between January 1, 1990 and December 31, 2012 were included. Severe CKD after ITx was defined as: glomerular filtration rate (GFR) <30 mL/min/1.73 m , chronic hemodialysis initiation, or kidney transplantation (KTx). Survival analysis and extended Cox model were conducted.

Results: The cumulative incidence of severe CKD 1, 5, and 10 years after ITx was 3.2%, 25.1%, and 54.1%, respectively. The following characteristics were significantly associated with severe CKD: female gender (HR 1.34), older age (HR 1.38/10 year increment), catheter-related sepsis (HR 1.58), steroid maintenance immunosuppression (HR 1.50), graft failure (HR 1.76), ACR (HR 1.64), prolonged requirement for IV fluids (HR 2.12) or TPN (HR 1.94), and diabetes (HR 1.54). Individuals with higher GFR at the time of ITx (HR 0.92 for each 10 mL/min/1.73 m increment), and those receiving induction therapies (HR 0.47) or tacrolimus (HR 0.52) showed lower hazards of severe CKD. In adjusted analysis, severe CKD was associated with a significantly higher hazard of death (HR 6.20).

Conclusions: The incidence of CKD after ITx is extremely high and its development drastically limits post-transplant survival.
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http://dx.doi.org/10.1111/ctr.12942DOI Listing
May 2017