Publications by authors named "Mahmoud Abdel-Rasoul"

80 Publications

Racial Disparities in Overall Survival and Surgical Treatment for Early Stage Lung Cancer by Facility Type.

Clin Lung Cancer 2021 Jan 22. Epub 2021 Jan 22.

Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: Early stage Non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. There are persistent racial disparities for the receipt of surgery and overall survival rate for early stage NSCLC. The facility type where patients receive NSCLC treatment may directly impact racial disparities.

Methods: A total of 111,009 patients with the American Joint Committee on Cancer TNM clinical stage I and II NSCLC that were reported to the National Cancer Data Base were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. A multivariate adjusted multinomial logistic regression was used to evaluate differences in the probability of undergoing surgery based on race and facility type. Kaplan Meier 3 and 5-year overall survival estimates were calculated for black and white patients based on treatment and the facility type where patients received care.

Results: We identified 99,767 white (89.87%) and 11,242 (10.12%) black patients with early stage NSCLC. Black patients were more likely to undergo surgery at academic facilities (OR: 1.12; 95% CI: 1.01-1.24; P-value = .04) compared to community facilities. Black patients treated at academic facility types demonstrated significantly better 3 and 5-year overall survival compared to black patients treated at community facilities (Log Rank P-value < .0001).

Conclusion: Black patients with early stage NSCLC who were treated at academic facility types had a significantly higher overall survival compared black patients treated at community facility types. The odds of black patients undergoing surgery were higher at academic facilities compared to community facilities.
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http://dx.doi.org/10.1016/j.cllc.2021.01.007DOI Listing
January 2021

Enoxaparin Dose Requirements to Achieve Therapeutic Low-molecular-weight Heparin Anti-factor Xa Levels in Infants and Young Children.

J Pediatr Hematol Oncol 2021 Jan 27. Epub 2021 Jan 27.

Departments of Pharmacy Pediatric Hematology, Oncology and Bone Marrow Transplant, Nationwide Children's Hospital Department of Biomedical Informatics, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH Mayo Clinic, Rochester, MN.

Introduction: Enoxaparin is commonly used to treat pediatric thrombosis. Several small retrospective studies have suggested that infants and young children require higher enoxaparin doses to achieve therapeutic anti-factor Xa levels compared with adults.

Materials And Methods: This is a retrospective study of hospitalized children who received enoxaparin for the treatment of thrombosis at a free-standing children's hospital. The primary objective was to ascertain the enoxaparin dose required to achieve an anti-factor Xa level of 0.5 to 1.0 U/mL among 4 age groups in a large cohort of infants and young children between 60 days and 5 years of age.

Results: A total of 176 infants and children were evaluated. The majority of patients were less than 1 year of age (n=104). An inverse relationship between enoxaparin dose needed to achieve therapeutic anti-factor Xa levels and patient age was noted, particularly in the first year of life. Patients who were 60 days to less than 7 months at the time of enoxaparin initiation (n=73) required the highest mean dose among the age groups at 1.73 mg/kg subcutaneously every 12 hours (P<0.0001).

Conclusion: Infants and young children require higher doses of enoxaparin to achieve therapeutic anti-factor Xa levels compared with adults.
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http://dx.doi.org/10.1097/MPH.0000000000002066DOI Listing
January 2021

Efficacy of Intravenous Tranexamic Acid in Reducing Perioperative Blood Loss and Blood Product Transfusion Requirements in Patients Undergoing Multilevel Thoracic and Lumbar Spinal Surgeries: A Retrospective Study.

Front Pharmacol 2020 30;11:566956. Epub 2020 Nov 30.

Department of Anesthesiology, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, United States.

Acute perioperative blood loss is a common and potentially major complication of multilevel spinal surgery, usually worsened by the number of levels fused and of osteotomies performed. Pharmacological approaches to blood conservation during spinal surgery include the use of intravenous tranexamic acid (TXA), an anti-fibrinolytic that has been widely used to reduce blood loss in cardiac and orthopedic surgery. The primary objective of this study was to assess the efficacy of intraoperative TXA in reducing estimated blood loss (EBL) and red blood cell (RBC) transfusion requirements in patients undergoing multilevel spinal fusion. This a single-center, retrospective study of subjects who underwent multilevel (≥7) spinal fusion surgery who received (TXA group) or did not receive (control group) IV TXA at The Ohio State University Wexner Medical Center between January 1st, 2016 and November 30th, 2018. Patient demographics, EBL, TXA doses, blood product requirements and postoperative complications were recorded. A total of 76 adult subjects were included, of whom 34 received TXA during surgery (TXA group). The mean fusion length was 12 levels. The mean total loading, maintenance surgery and total dose of IV TXA was 1.5, 2.1 mg per kilo (mg/kg) per hour and 33.8 mg/kg, respectively. The mean EBL in the control was higher than the TXA group, 3,594.1 [2,689.7, 4,298.5] vs. 2,184.2 [1,290.2, 3,078.3] ml. Among all subjects, the mean number of intraoperative RBC and FFP units transfused was significantly higher in the control than in the TXA group. The total mean number of RBC and FFP units transfused in the control group was 8.1 [6.6, 9.7] and 7.7 [6.1, 9.4] compared with 5.1 [3.4, 6.8] and 4.6 [2.8, 6.4], respectively. There were no statistically significant differences in blood product transfusion rates between both groups. Additionally, there were no significant differences in the incidence of 30-days postoperative complications between both groups. Our results suggest that the prophylactic use of TXA may reduce intraoperative EBL and RBC unit transfusion requirements in patients undergoing multilevel spinal fusion procedures ≥7 levels.
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http://dx.doi.org/10.3389/fphar.2020.566956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793852PMC
November 2020

Economic impact of pharmacist interventions in pediatric ambulatory care clinics.

J Am Pharm Assoc (2003) 2020 Dec 21. Epub 2020 Dec 21.

Objectives: Ambulatory care pharmacists have a unique opportunity to identify and prevent adverse drug events (ADEs) throughout a patient's treatment course. These interventions can reduce unexpected clinic visits or hospitalizations, which may lead to decreased health care costs. However, research on this topic has not been conducted in the pediatric population. This study explored the economic impact of pharmacist interventions related to ADEs in pediatric ambulatory care clinics. The primary objective was to determine the total cost avoidance of pharmacist interventions associated with the prevention or management of ADEs in pediatric ambulatory care clinics. The secondary objectives were to describe and quantify pharmacist interventions related to the prevention and management of ADEs in pediatric ambulatory care clinics.

Methods: Pharmacist interventions from pediatric ambulatory care clinics were collected from an electronic health record. These interventions were categorized into 1 of 4 categories: drug interaction, drug not indicated, prevent or manage ADE, or prevent or manage drug allergy. A review panel consisting of ambulatory care pharmacists reviewed the interventions. The expected probability of the event occurring was classified according to the Nesbit method (0-0.6), and the level of care necessary to treat the potential ADE was determined. The levels of care included hospitalization, ambulatory care, and self-care. The cost avoidance associated with each prevented ADE was calculated by multiplying the probability of the ADE occurring by the average charge of the expected level of care.

Results: Of the 8755 interventions documented, 212 were included, leading to a total cost avoidance of $307,210 (range $76,802-$1,071,053). The estimated cost avoidance from each ADE subtype was $128,283 from drug interaction, $20,727 from drug not indicated, $157,993 from prevent or manage ADE, and $207 from prevent or manage drug allergy.

Conclusion: Pediatric ambulatory care pharmacists optimize health care cost savings through the prevention and management of ADEs as integrated members of the health care team.
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http://dx.doi.org/10.1016/j.japh.2020.11.009DOI Listing
December 2020

Nomograms for predicting overall and recurrence-free survival after trimodality therapy for esophageal adenocarcinoma.

J Surg Oncol 2021 Mar 17;123(4):881-890. Epub 2020 Dec 17.

Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.

Background: Locally advanced esophageal carcinoma is treated with neoadjuvant chemoradiation and esophagectomy. Patients may still experience recurrence and death despite undergoing potentially curative trimodality therapy. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after the completion of trimodality therapy.

Methods: A total of 215 patients with esophageal adenocarcinoma underwent trimodality therapy from September 2010 to April 2018. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts.

Results: On multivariate analysis, clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, body mass index, age, and number of lymph nodes removed were predictive variables for overall survival. Clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, age, and positive lymph nodes were significant predictors of RFS in a multivariate model. The nomogram for OS had good predictive ability (Harrell's Concordance index [C-index]: 0.71 [95% confidence interval {CI}: 0.66-0.76]). The nomogram for RFS also performed well (C-index: 0.70 [95% CI: 0.65-0.74]).

Conclusion: Our nomograms can accurately predict OS and RFS after trimodality therapy and may provide guidance regarding adjuvant therapy and surveillance.
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http://dx.doi.org/10.1002/jso.26349DOI Listing
March 2021

Nomograms for Predicting Overall and Recurrence-free Survival From Pathologic Stage IA and IB Lung Cancer After Lobectomy.

Clin Lung Cancer 2020 Oct 22. Epub 2020 Oct 22.

Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: Stage I non-small-cell lung cancer (NSCLC) is potentially curable with surgical resection. Significant proportions of patients may still experience recurrence and death despite undergoing curative surgery. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after lobectomy.

Patients And Methods: A total of 301 patients with the American Joint Committee on Cancer pathologic stage IA and IB NSCLC who underwent open, thoracoscopic, or robotic lobectomy from January 2011 to April 2017 were analyzed. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts based on nomogram scores.

Results: Histology (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.10-0.56; P = .002), lymphovascular invasion (HR, 0.46; 95% CI, 0.29-0.74; P = .001), smoking status (HR, 3.46; 95% CI, 1.25-9.55: P = .02), and total lymph nodes removed (HR, 1.05; 95% CI, 1.01-1.10; P = .021) were significant predictors for OS in a multivariate model. Lymphovascular invasion (HR, 0.55; 95% CI, 0.36-0.83; P = .0040), smoking status (HR, 2.56; 95% CI, 1.16-5.62; P = .02), total lymph nodes removed (HR, 1.04; 95% CI, 1.00-1.08; P = .029), and tumor size (HR, 1.30; 95% CI, 1.30-1.68; P = .047) were significant predictors of RFS in a multivariate model.

Conclusion: Nomograms can predict OS and RFS for pathologic stage IA and IB NSCLC after lobectomy regardless of operative approach. The risk for death and recurrence after stratification by the nomogram scores may provide guidance regarding adjuvant therapy and surveillance.
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http://dx.doi.org/10.1016/j.cllc.2020.10.009DOI Listing
October 2020

Safety, feasibility, and acceptability of patient-controlled anxiolysis with dexmedetomidine for burn-care dressing changes: an open-label, single-arm, pilot study.

Int J Burns Trauma 2020 15;10(5):269-278. Epub 2020 Oct 15.

Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio University Wexner Medical Center Columbus, OH, USA.

Anxiety is common among patients with burn injury, occurring frequently surrounding wound care. Few pharmacologic interventions targeting anxiety in burn injury have been evaluated. This study aimed to evaluate patient-controlled anxiolysis using dexmedetomidine (PCA-DEX) in patients undergoing burn dressing changes. This was a prospective, open-label, single-arm pilot study to determine the feasibility, safety, and acceptability of PCA-DEX. PCA-DEX included a loading dose, continuous infusion, and patient-administered boluses during dressing changes for up to 5 days. Vital signs were monitored throughout PCA-DEX. Procedural pain and anxiety were evaluated before and after each dressing change. Nursing and patient satisfaction were evaluated after each dressing change. Twenty patients were included; 9 (45%) males and 11 females (55%) with a mean age of 45.1 ± 16.9 years and median total body surface area burn injury of 7 [IQR 4-9.5]%. Median heart rate and systolic blood pressure prior to PCA-DEX on day 1 were 82 [75-97] bpm and 147 [128-170] mmHg. Overall PCA-DEX was tolerated well with a median heart rate of 72 [66-82] bpm and systolic blood pressure 115 [99-141] mmHg after PCA-DEX. One patient was withdrawn due to severe bradycardia (heart rate < 45 bpm) not attributed to PCA-DEX; 4 patients experienced mild hypotension (systolic blood pressure 85-89/diastolic blood pressure 45-49 mmHg), all of which resolved without intervention. The majority of both nurses and patients were either satisfied or highly satisfied with PCA-DEX overall (78.1% for nursing, 86.5% for patients). PCA-DEX is a novel, safe and feasible method of anxiolysis during burn dressing changes with high patient and nurse satisfaction rates. A randomized, controlled trial is warranted to confirm the efficacy of PCA-DEX.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675207PMC
October 2020

Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery: The Neurobics Randomized Clinical Trial.

JAMA Surg 2021 Feb;156(2):148-156

Renaissance School of Medicine, Department of Anesthesiology, Stony Brook University, Stony Brook, New York.

Importance: Postoperative delirium in older adults is a common and costly complication after surgery. Cognitive reserve affects the risk of postoperative delirium, and thus preoperative augmentation of reserve as a preventive technique is of vital interest.

Objective: To determine whether cognitive prehabilitation reduces the incidence of postoperative delirium among older adults.

Design, Setting, And Participants: This was a prospective, single-blinded randomized clinical trial conducted from March 2015 to August 2019 at the Ohio State University Wexner Medical Center in Columbus. Patients 60 years and older undergoing major, noncardiac, nonneurological surgery under general anesthesia, with an expected hospital stay of at least 72 hours, were eligible for trial inclusion. Patients were excluded for preoperative cognitive dysfunction and active depression.

Interventions: Participation in electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions.

Main Outcomes And Measures: The primary outcome was incidence of delirium between postoperative day 0 to day 7 or discharge, as measured by a brief Confusion Assessment Method, Memorial Delirium Assessment Scale, or a structured medical record review. Secondary outcomes compared delirium characteristics between patients in the intervention and control groups.

Results: Of the 699 patients approached for trial participation, 322 completed consent and 268 were randomized. Subsequently, 17 patients were excluded, leaving 251 patients in the primary outcome analysis. A total of 125 patients in the intervention group and 126 control patients were included in the final analysis (median [interquartile range] age, 67 [63-71] years; 163 women [64.9%]). Ninety-seven percent of the patients in the intervention group completed some brain exercise (median, 4.6 [interquartile range, 1.31-7.4] hours). The delirium rate among control participants was 23.0% (29 of 126). With intention-to-treat analysis, the delirium rate in the intervention group was 14.4% (18 of 125; P = .08). Post hoc analysis removed 4 patients who did not attempt any cognitive exercise from the intervention group, yielding a delirium rate of 13.2% (16 of 121; P = .04). Secondary analyses among patients with delirium showed no differences in postoperative delirium onset day or duration or total delirium-positive days across study groups.

Conclusions And Relevance: The intervention lowered delirium risk in patients who were at least minimally compliant. The ideal activities, timing, and effective dosage for cognitive exercise-based interventions to decrease postoperative delirium risk and burden need further study.

Trial Registration: ClinicalTrials.gov Identifier: NCT02230605.
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http://dx.doi.org/10.1001/jamasurg.2020.4371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7658803PMC
February 2021

The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma.

J Gastrointest Surg 2020 Oct 6. Epub 2020 Oct 6.

Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA.

Background: Operable esophageal carcinoma is potentially curable with surgical resection. The short-term outcomes and overall survival rate for operable esophageal carcinoma may be impacted by the healthcare facility type where patients receive care.

Methods: A total of 37, 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Data Base at over 12,721 facilities were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazard models were used to evaluate differences in overall survival between facility types, which accounted for facility esophageal cancer volume. Propensity score methodology with inverse probability of treatment weighting was used to adjust for patient related baseline differences between facility types.

Results: Patients with clinical stage I-III esophageal carcinoma who underwent esophagectomy at academic healthcare facilities had a significantly better overall survival compared with patients who underwent esophagectomy at community healthcare facilities [HR = 0.89: CI [0.84-0.95] (p = 0.0005)]. The rate of esophagectomy was significantly higher at the academic facilities (49.0% versus 26.5%; p < 0.0001). The 30-day and 90-day mortality rates for esophagectomy were significantly better for patients who underwent esophagectomy for esophageal cancer at the academic facility types.

Conclusion: Patients with clinical stage I-III esophageal carcinoma who received care at academic facility types had significantly better overall survival compared with community facility types. The utilization of esophagectomy was significantly higher and the short-term surgical outcomes were better for patients treated at academic facility types.
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http://dx.doi.org/10.1007/s11605-020-04817-xDOI Listing
October 2020

Family-centered communication: A pilot educational intervention using deliberate practice and patient feedback.

Patient Educ Couns 2020 Sep 28. Epub 2020 Sep 28.

Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH USA.

Objective: There are few opportunities in medical education dedicated to learning skills for effective communication in life altering patient scenarios. We therefore aimed to develop and assess a longitudinal advanced communication curriculum for pediatric residents using patient feedback and deliberate practice.

Methods: Pediatric residents at a large academic center were randomized into 2 groups. The intervention group received 6 educational sessions from 2019 to 2020, parent feedback of performance via the Communication Assessment Tool (CAT), and monthly communication tips. Communication skills of both groups were assessed at the end of the intervention.

Results: We collected 937 CAT assessments on 36 first-year residents. The intervention group demonstrated statistically significant improvement in communication skills from pre to post assessment (p = 0.0063, (odds ratio (OR) 1.76, 95 % confidence interval (CI) [1.17, 2.63]) compared to the control group (p = 0.080, OR 1.41, 95 % CI [0.96, 2.05]).

Conclusions: There are patient and self-identified performance gaps in communication skills for pediatric residents, underscoring the need for formalized curricula dedicated to these skills.

Practice Implications: Our study highlights the value of deliberate practice and the integration of family feedback as an educational tool in communication skills development.
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http://dx.doi.org/10.1016/j.pec.2020.09.033DOI Listing
September 2020

Linoleic Acid-Rich Oil Supplementation Increases Total and High-Molecular-Weight Adiponectin and Alters Plasma Oxylipins in Postmenopausal Women with Metabolic Syndrome.

Curr Dev Nutr 2020 Sep 21;4(9):nzaa136. Epub 2020 Aug 21.

Program of Human Nutrition, Department of Human Sciences, The Ohio State University, Columbus, OH, USA.

Background: The onset of menopause increases the risk of metabolic syndrome (MetS). Adiponectin is an adipokine associated with insulin sensitivity that is lower in people with MetS. Supplementing diets with linoleic acid (LA)-rich oil increased adiponectin concentrations and improved glucose control in women with type 2 diabetes. The effect of LA on adipokines, especially total and the bioactive form of adiponectin, high-molecular-weight (HMW) adiponectin, in women with MetS is unknown.

Objectives: The aim of this study was to explore the effect of supplementation of the diet with an oil rich in LA on adipokines in women with MetS. The effect of the LA-rich oil (LA-oil) on oxylipins, key metabolites that may influence inflammation and metabolism, was also explored.

Methods: In this open-label single-arm pilot study, 18 postmenopausal nondiabetic women with MetS enrolled in a 2-phase study were instructed to consume LA-rich vegetable oil (10 mL/d) as part of their habitual diets. Women consumed an oleic acid-rich oil (OA-oil) for 4 wk followed by an LA-oil for 16 wk. Fasting concentrations of adipokines, fatty acids, oxylipins, and markers of glycemia and inflammation were measured.

Results: After 4 wk of OA-oil consumption, fasting glucose and total adiponectin concentrations decreased whereas fasting C-reactive protein increased. After 16 wk of LA-oil supplementation total and HMW adiponectin and plasma oxylipins increased. Markers of inflammation and glycemia were unchanged after LA-oil consumption.

Conclusions: Supplementation with LA-oil increased total and HMW adiponectin concentrations and altered plasma oxylipin profiles. Larger studies are needed to elucidate the links between these changes and MetS.This trial was registered at clinicaltrials.gov as NCT02063165.
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http://dx.doi.org/10.1093/cdn/nzaa136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475005PMC
September 2020

Prospective Decision Analysis Study of Clinical Genomic Testing in Metastatic Breast Cancer: Impact on Outcomes and Patient Perceptions.

JCO Precis Oncol 2019 18;3. Epub 2019 Nov 18.

The Ohio State University College of Medicine, Columbus, OH.

Purpose: To evaluate the impact of targeted DNA sequencing on selection of cancer therapy for patients with metastatic breast cancer (MBC).

Patients And Methods: In this prospective, single-center, single-arm trial, patients with MBC were enrolled within 10 weeks of starting a new therapy. At enrollment, tumor samples underwent next-generation sequencing for any of 315 cancer-related genes to high depth (> 500×) using FoundationOne CDx. Sequencing results were released to providers at the time of disease progression, and physician treatment recommendations were assessed via questionnaire. We evaluated three prespecified questions to assess patients' perceptions of genomic testing.

Results: In all, 100 patients underwent genomic testing, with a median of five mutations (range, 0 to 13 mutations) detected per patient. Genomic testing revealed one or more potential therapies in 98% of patients (98 of 100), and 60% of patients (60 of 100) had one or more recommended treatments with level I/II evidence for actionability. Among the 94 genomic text reports that were released, there was physician questionnaire data for 87 patients (response rate, 92.6%) and 31.0% of patients (27 of 87) had treatment change recommended by their physician. Of these, 37.0% (10 of 27) received the treatment supported by genomic testing. We did not detect a statistically significant difference in time-to-treatment failure (log-rank = .87) or overall survival ( = .71) among patients who had treatment change supported by genomic testing versus those who had no treatment change. For patients who completed surveys before and after genomic testing, there was a significant decrease in confidence of treatment success, specifically among patients who did not have treatment change supported by genomic testing (McNemar's test of agreement = .001).

Conclusion: In this prospective study, genomic profiling of tumors in patients with MBC frequently identified potential treatments and resulted in treatment change in a minority of patients. Patients whose therapy was not changed on the basis of genomic testing seemed to have a decrease in confidence of treatment success.
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http://dx.doi.org/10.1200/PO.19.00090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446448PMC
November 2019

Early Postoperative Functional Assessment Predicts Non-Home Discharge After Pulmonary Lobectomy.

Ann Thorac Surg 2020 Sep 3. Epub 2020 Sep 3.

Division of Thoracic Surgery, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio. Electronic address:

Background: Non-home hospital disposition is an important patient-centric quality measure, and is increasingly tied to reimbursements. We sought to determine the value of early postoperative functional assessment to predict non-home discharge.

Methods: Patients undergoing elective pulmonary lobectomy between May 2017 and December 2018 were identified from The Society of Thoracic Surgery database at a single institution. Early postoperative functional assessment using the Boston University Activity Measure for Post-Acute Care (AM-PAC) basic mobility short form was routinely performed by the inpatient rehabilitation services. The association of baseline patient characteristics and AM-PAC scores with nonhospital discharge was analyzed.

Results: A total of 241 patients (median age 65 years, 59% female) underwent lobectomy. First postoperative functional assessment was performed at a median of 1 day (interquartile range, 1 to 2) after surgery. Median AM-PAC score was 18 (interquartile range, 17 to 19), correlating to a 47% functional impairment in daily activities. Thirteen patients (5.4%) were discharged to an extended care facility instead of home. Non-home discharge was more commonly observed for patients of older age or with prior history of stroke. First postoperative AM-PAC score was able to discriminate hospital disposition (area under the curve 0.714; 95% confidence interval, 0.594 to 0.834; P = .009). Adjusted for patient factors and performance status, first postoperative AM-PAC score was independently associated with non-home discharge (odds ratio 0.54, 95% confidence interval, 0.36 to 0.81; P = .003).

Conclusions: Early postoperative functional impairment assessment using AM-PAC may be useful to predict non-hospital discharge after pulmonary lobectomy. Attention to these factors may be used to aid early disposition planning, and adjust preventative strategies.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.096DOI Listing
September 2020

An Analysis of Outcomes after Transition from Open to Minimally Invasive Ivor Lewis Esophagectomy.

Ann Thorac Surg 2020 Sep 1. Epub 2020 Sep 1.

Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center.

Background: The morbidity and mortality remain relatively high for transthoracic esophagectomy with open thoracotomy. We compared a total laparoscopic and thoracoscopic Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases.

Methods: This is a retrospective review of 259 patients diagnosed with esophageal carcinoma who underwent M-ILE (n=173) or O-ILE (n=86) from April 2009 to March 2019. The postoperative morbidity and mortality were reported for each group. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Recurrence-free and overall survival rates were compared on an intention to treat basis (ITT).

Results: The IPTW cohort included 249 patients with esophageal carcinoma who underwent M-ILE (n=163) or O-ILE (n=86). The overall rate of postoperative adverse events was significantly higher after IPTW adjustment in the O-ILE group (54.2% vs. 39.02%, p = 0.0386). The median hospital length of stay was 8.0 days [IQR: 7.0 - 9.0] for the M-ILE group compared to 10.0 days [IQR: 8.0-14.0] for the O-ILE group [p<0.0001]. The 3-year overall survival (OS) for the M-ILE group was 64.63% (95% CI: 54.7 - 72.9) compared to 54.76% (95% CI: 39.9 - 67.4) for the O-ILE group (p=0.447). The 3-year recurrence-free survival (RFS) rate did not differ significantly between the groups [p=0.461].

Conclusions: The M-ILE approach demonstrated short-term clinical outcomes that were superior to O-ILE at our institution. The survival rate and recurrence-free survival rate for M-ILE were not significantly different from O-ILE for esophageal carcinoma.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.071DOI Listing
September 2020

Use of the MMPI-2 personality profile in predicting 30-day ED-visits and readmissions following primary bariatric surgery.

Surg Endosc 2020 Sep 2. Epub 2020 Sep 2.

Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, N718 Doan Hall, 410 W. 10th Ave, Columbus, OH, 43210, USA.

Background: Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is used for psychological screening of bariatric surgery (BS) candidates. To date, no studies have analyzed the relationship between MMPI-2 and early returns to hospital. The aim of this study was to determine whether high T scores on the MMPI-2 clinical scales were associated with early return to hospital after primary bariatric surgery.

Methods: Patients who completed an MMPI-2 evaluation, undergoing primary BS from 2014 to 2016 were evaluated. T score for the tested scales were collected and stratified into a high T score (T > 65) vs not (T < 65). The optimal 'cut-point' (specific number of high T scores predicting likelihood for 30-day ED-visit/hospital readmission) was calculated using Youden's Index (J) = Max(c) [sensitivity (c) + specificity (c) - 1], where c = number of scales with a T score > 65. Patients were stratified based on the optimal cut-point which was determined to be ≥ 4 high T scores. Univariate and multivariate logistic regression analyses were used to identify differences between groups and predictors for early ED-visits and hospital readmissions.

Results: 375 patients had psychological evaluations available for review. Patients were divided into those with ≥ 4 high T scores (Scr; n = 86) versus not (Scr ; n = 289). Multivariate analysis showed Scr (aOR 2.99, CI 1.20-7.47; p = 0.019), bipolar disorder (aOR 4.82, CI 1.25-18.83; p = 0.022), and urgent hospital complications (aOR 6.81, CI 2.02-22.91; p = 0.002), were significant independent predictors of 30-day readmissions. Early ED-visits were significantly predicted by public insurance (aOR 3.30, CI 1.22-8.91; p = 0.019), but the effect of the Scr profile (aOR 2.42, CI 0.97-6.09; p = 0.06), while influential, did not reach significance.

Conclusion: Differences in personality traits may be associated increased 30-day readmissions following primary bariatric surgery. Our study represents a novel application of the MMPI-2.
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http://dx.doi.org/10.1007/s00464-020-07944-3DOI Listing
September 2020

The Academic Facility Type Is Associated With Improved Overall Survival for Early-Stage Lung Cancer.

Ann Thorac Surg 2021 01 29;111(1):261-268. Epub 2020 Jun 29.

Thoracic Surgery Division, Ohio State University Wexner Medical Center, Columbus, Ohio.

Background: Early-stage non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. The overall survival rate for early-stage NSCLC may be determined by the healthcare facility type where patients receive their lung cancer treatment.

Methods: A total of 103,748 cases with the American Joint Committee on Cancer clinical stage I and II NSCLC that were reported to the National Cancer Database at over 1150 facilities were analyzed in this study. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazards models were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting was used to adjust for facility volume and patient-related baseline differences between facility types.

Results: Patients with early-stage NSCLC who were treated at academic facility types had a significantly better median overall survival (63.2 months) compared with patients who received care at community healthcare facilities (54.2 months) (hazard ratio, 0.86; 95% confidence interval, 0.82-0.91; P < .0001). The surgical quality outcomes for NSCLC surgery, including 30-day mortality, 90-day mortality, and the median number of lymph nodes removed were significantly better for patients treated at the academic facility types.

Conclusions: Patients with early-stage NSCLC who were treated at academic facility types had a significantly higher overall median survival compared with patients treated at community facility types. The short-term surgical quality outcomes were significantly better for patients who underwent surgery for early-stage NSCLC at academic facility types.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.051DOI Listing
January 2021

Metastatic breast cancer patient perceptions of somatic tumor genomic testing.

BMC Cancer 2020 May 6;20(1):389. Epub 2020 May 6.

The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, USA.

Background: To assess metastatic breast cancer (MBC) patient psychological factors, perceptions, and comprehension of tumor genomic testing.

Methods: In a prospective, single institution, single-arm trial, patients with MBC underwent next-generation sequencing at study entry with sequencing results released at progression. Patients who completed surveys before undergoing sequencing were included in the present secondary analysis (n = 58). We administered four validated psychosocial measures: Center for Epidemiologic Studies Depression Scale, Beck Anxiety Inventory, Trust in Physician Scale, and Communication and Attitudinal Self-Efficacy scale for Cancer. Genetic comprehension was assessed using 7-question objective and 6-question subjective measures. Longitudinal data were assessed (n = 40) using paired Wilcoxon signed rank and McNemar's test of agreement.

Results: There were no significant differences between the beginning and end of study in depression, anxiety, physician trust, or self-efficacy (median time on study: 7.6 months). Depression and anxiety were positively associated with each other and both negatively associated with self-efficacy. Self-efficacy decreased from pre- to post-genomic testing (p = 0.05). Objective genetics comprehension did not significantly change from pre- to post-genomic testing, but patients expressed increased confidence in their ability to teach others about genetics (p = 0.04). Objective comprehension was significantly lower in non-white patients (p = 0.02) and patients with lower income (p = 0.04).

Conclusions: This is the only study, to our knowledge, to longitudinally evaluate multiple psychological metrics in MBC as patients undergo tumor genomic testing. Overall, psychological dimensions remained stable over the duration of tumor genomic testing. Among patients with MBC, depression and anxiety metrics were negatively correlated with patient self-efficacy. Patients undergoing somatic genomic testing had limited genomic knowledge, which varied by demographic groups and may warrant additional educational intervention.

Clinical Trial Information: NCT01987726, registered November 13, 2013.
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http://dx.doi.org/10.1186/s12885-020-06905-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201768PMC
May 2020

Recurrence After Stereotactic Body Radiation Therapy Versus Lobectomy for Non-Small Cell Lung Cancer.

Ann Thorac Surg 2020 09 27;110(3):998-1005. Epub 2020 Apr 27.

Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio. Electronic address:

Background: Although lobectomy remains the standard of care for early-stage non-small cell lung cancer, several studies suggest equipoise between lobectomy and stereotactic body radiation therapy (SBRT). However randomized evidence is lacking. We compared outcomes of early-stage non-small cell lung cancer patients treated with lobectomy or SBRT.

Methods: We included clinical T1-2N0 non-small cell lung cancer treated with lobectomy or SBRT to a biologically effective dose of ≥100 Gy. We used Cox proportional hazards and nearest-neighbor propensity score (2:1) matching to adjust for confounders. Kaplan-Meier curves were used to assess survival and recurrence.

Results: We identified 554 patients treated with lobectomy (n = 389) or SBRT (n = 165) at our institution between 2008 and 2018. After propensity score matching, there were 132 SBRT patients and 85 lobectomy patients. SBRT was associated with increased local recurrence (hazard ratio [HR], 6.80; 95% confidence interval [CI], 1.92-24.10; P = .003) and regional nodal recurrence (HR, 2.58; 95% CI, 1.17-5.68; P = .018), and with worse overall survival (HR, 2.00; 95% CI, 1.21-3.32; P = .007) and progression-free survival (HR, 2.34; 95% CI, 1.50-3.67; P < .001). There was no difference in distant recurrence (HR, 1.19; 95% CI, 0.57-2.52; P = .64).

Conclusions: We found superior outcomes in patients with early-stage non-small cell lung cancer treated with lobectomy compared with SBRT, including locoregional control. These findings should be interpreted with caution because of selection bias but underscore the importance of robust randomized prospective data to clarify the relative efficacy of these modalities.
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http://dx.doi.org/10.1016/j.athoracsur.2020.03.073DOI Listing
September 2020

National Utilization of Surgery and Outcomes for Primary Tracheal Cancer in the United States.

Ann Thorac Surg 2020 09 23;110(3):1012-1022. Epub 2020 Apr 23.

Thoracic Surgery Division, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio. Electronic address:

Background: Tracheal cancer (TC) is a rare disease, and surgical treatment requires a high level of expertise. We sought to determine the treatment patterns and surgical outcomes of TC in the United States.

Methods: The National Cancer Database was queried for all cases of primary invasive TC without distant metastatic disease between 2004 and 2015. Primary surgical treatment and outcomes were analyzed. Factors associated with utilization of surgery and overall survival were tested using regression analysis.

Results: Of 1379 identified TC patients, 338 patients (25%) were treated surgically. Among resected patients, most had adenoid cystic (48%) or squamous cell (28%) carcinoma. Median length of hospital stay after resection was 7 days (interquartile range, 3-8), and 30-day mortality was 1.4%. Most nonsurgically managed patients underwent radiation (63%). Factors associated with surgical resection were younger age, higher education level, tumor size, and adenoid cystic histology. On multivariate analysis patients were also more likely to undergo surgery if they traveled a farther distance for treatment (>45 km; odds ratio, 1.53; 95% confidence interval, 1.09-2.13) or were treated at academic centers (odds ratio, 1.68; 95% confidence interval, 1.25-2.26). Five-year overall survival was 71% after resection, 39% after surgical debulking, and 31% without surgery (P < .001).

Conclusions: National surgical outcomes for resection of TC demonstrate low perioperative mortality and excellent long-term prognosis. However, few nonmetastatic TC patients underwent surgery, indicating disparities in access to optimal surgical care and variability in practice patterns at a national level.
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http://dx.doi.org/10.1016/j.athoracsur.2020.03.048DOI Listing
September 2020

Prognostic value and therapeutic implications of expanded molecular testing for resected early stage lung adenocarcinoma.

Lung Cancer 2020 05 18;143:60-66. Epub 2020 Mar 18.

The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, USA; Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.

Objectives: This study aimed to evaluate the prognostic and potential therapeutic value of expanded molecular testing of resected early-stage lung ACA.

Methods: We analyzed 324 patients who underwent lobectomy and lymphadenectomy for clinical Stage I&II lung ACA between 2011-2017. Molecular testing was routinely performed, first by PCR-based Sanger sequencing and FISH and then expanded to a 20 and then 50-gene next generation sequencing (NGS) panel. The frequency of mutations by testing method and their association with disease-free (DFS) and overall survival (OS) were tested.

Results: A total of 241 patients (74.4%) had at least one somatic mutation detected, with KRAS exon 2 (38.1%) and EGFR (17.9%) being the most common. TP53 was the most frequent co-existing mutation. Detection of at least one mutation increased from 49% with selective PCR/FISH testing to 82% with limited NGS/FISH, and 91% with extended NGS/FISH (p < 0.001). The rate of actionable mutations increased from 18% to 32% and 45% with expansion of molecular testing, respectively (p = 0.001). Using NGS, an additional 10 cases with EGFR mutations, and other rare mutations were found, including BRAF (5.9%), MET (5.6%), ERBB2 (4.1%), PIK3CA (2.3%), and DDR2 (2.1%). The expansion of FISH testing resulted in one additional detection of ROS1 and RET (1%) rearrangement. KRAS mutation was associated with worse DFS (HR 1.87; 95%CI 1.14-3.06) and OS (HR 2.09; 95%CI 1.11-3.92). BRAF mutation detected in NGS tested patients was also associated with decreased DFS (HR3.80; 95%CI 1.46-9.89) and OS (HR 7.37; 95%CI 2.36-22.99) on multivariate analysis.

Conclusion: The expansion of molecular testing has resulted in a substantial increase in the detection of potentially therapeutically significant mutations in resected early-stage ACA. KRAS and BRAF mutation status by NGS was prognostic for relapse and survival. These data emphasize opportunities for clinical trials in a growing number surgical ACA patients with available targeted therapies.
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http://dx.doi.org/10.1016/j.lungcan.2020.03.012DOI Listing
May 2020

Inverse Association Between the Quantity of Human Peripheral Blood CXCR5+IFN-γ+CD8+ T Cells With De Novo DSA Production in the First Year After Kidney Transplant.

Transplantation 2020 11;104(11):2424-2434

Department of Surgery, Division of Transplant Surgery, Comprehensive Transplant Center, The Ohio State University, Columbus, OH.

Background: We recently reported that a novel CXCR5IFN-γCD8 T-cell subset significantly inhibits posttransplant alloantibody production in a murine transplant model. These findings prompted the current study to investigate the association of human CD8 T cells with the same phenotype with the development of de novo donor-specific antibody (DSA) after kidney transplantation.

Methods: In the current studies, we prospectively and serially analyzed peripheral blood CD8 and CD4 T-cell subsets and monitored for the development of de novo DSA in kidney transplant recipients during the first-year posttransplant. We report results on 95 first-time human kidney transplant recipients with 1-year follow-up.

Results: Twenty-three recipients (24.2%) developed de novo DSA within 1-year posttransplant. Recipients who developed DSA had significantly lower quantities of peripheral CXCR5IFN-γCD8 T cells (P = 0.01) and significantly lower ratios of CXCR5IFN-γCD8 T cell to combined CD4 Th1/Th2 cell subsets (IFN-γCD4 and IL-4CD4 cells; P = 0.0001) compared to recipients who remained DSA-negative over the first-year posttransplant.

Conclusions: Our data raise the possibility that human CXCR5IFN-γCD8 T cells are a homolog to murine CXCR5IFN-γCD8 T cells (termed antibody-suppressor CD8 T cells) and that the quantity of CXCR5IFN-γCD8 T cells (or the ratio of CXCR5IFN-γCD8 T cells to Th1/Th2 CD4 T cells) may identify recipients at risk for development of DSA.
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http://dx.doi.org/10.1097/TP.0000000000003151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415482PMC
November 2020

The Effect of Increased Intraocular Pressure During Steep Trendelenburg Positioning in Robotic Prostatectomy and Hysterectomy on Structural and Functional Ocular Parameters.

Anesth Analg 2020 04;130(4):975-982

Department of Ophthalmology, The Ohio State University, Wexner Medical Center, Columbus, Ohio.

Background: Robotic prostatectomy and robotic hysterectomy require steep Trendelenburg positioning. Many authors documented significant increases in intraocular pressure (IOP) during steep Trendelenburg. However, the long-term biological effect of a significant increase in IOP on the structural and functional ocular system is unknown. This study examines the effect of a significant increase in IOP on the visual acuity, retinal nerve fiber layer thickness (RNFLT), and ganglion cell complex (GCC) thickness in 52 patients without preexisting ocular disease of both genders before and 3 months after their procedures.

Methods: This was a prospective cohort study. The total number of patients included was 56, then 3 females and 1 male case were excluded, totaling 28 robotic hysterectomies and 24 robotic prostatectomies were performed. Patients underwent complete eye examination before the procedure and 3 months after, measuring the main outcome of RNFLT and the secondary outcomes of GCC thickness, foveal threshold (FT), mean deviation (MD), and pattern standard deviation (PSD). These outcomes were analyzed using linear mixed-effects models. On the day of surgery, we examined the IOP after induction of anesthesia, at the end of steep Trendelenburg, and in the recovery room.

Results: There were significant differences in IOP values at the end of steep Trendelenburg versus after induction and 45-60 minutes post-awakening (P < .001 for both groups). No difference between IOP 45 and 60 minutes post-awakening and IOP after induction was observed in either group. The highest IOPs occurred at the end of the steep Trendelenburg time point for both groups. The mean duration of steep Trendelenburg in robotic prostatectomy was 184.6 minutes (standard deviation [SD] = 30.8), while the mean duration in robotic hysterectomy was 123.0 minutes (SD = 29.8). All ophthalmologic examinations were normal preoperatively and 3 months postoperatively. The ocular parameters in the retina and optic disk did not differ significantly before surgery and 3 months after.

Conclusions: There is a significant increase in IOP during steep Trendelenburg positioning. There was no significant difference in the ocular parameters examined 3 months after the procedure in this cohort.
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http://dx.doi.org/10.1213/ANE.0000000000004547DOI Listing
April 2020

Long-Term Oncologic Outcomes After Robotic Lobectomy for Early-stage Non-Small-cell Lung Cancer Versus Video-assisted Thoracoscopic and Open Thoracotomy Approach.

Clin Lung Cancer 2020 05 13;21(3):214-224.e2. Epub 2019 Oct 13.

Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.

Background: Although robotic-assisted lobectomy has been increasingly used for resection of non-small-cell lung cancer (NSCLC), the long-term oncologic outcomes compared with video-assisted thoracoscopic surgery (VATS) and the open thoracotomy approach have remained ill-defined.

Patients And Methods: Society of Thoracic Surgeons outcomes data and surveillance records of patients with stage I-IIIa NSCLC who had undergone lobectomy by robotic-assisted, VATS, or the open approach at a single center from 2012 to 2017 were reviewed. Propensity score adjustment by inverse probability of treatment weighting was used to balance the baseline characteristics. Recurrence and survival were analyzed and compared by the operative approach.

Results: The inverse probability of treatment weighting-adjusted cohort included 514 patients with NSCLC who had undergone robotic-assisted (n = 245), VATS (n = 118), and open (n = 151) lobectomy, with similar patient and disease characteristics. The minimally invasive procedures were associated with a shorter median hospital length of stay (robotic, 5.2 days; VATS, 4.9 days; open, 7.3 days; P < .001) and 0-adjusted 30-day mortality rate. With a median follow-up period of 45 months, the incidence for locoregional recurrence (robotic, 7%; VATS, 6%; open, 8%; P = .9) and distant failure (robotic, 14%; VATS, 18%; open, 17%; P = .9) was similar. The 5-year overall survival for robotic-assisted, VATS, and open lobectomy was 63%, 55%, and 65%, respectively (P = .56). No difference was found in stage-specific survival for stage I, II, and IIIa. On multivariate analysis, the robotic approach was associated with no differences in overall survival and recurrence-free survival compared with VATS and open lobectomy.

Conclusion: Robotic lobectomy was associated with durable freedom of recurrence and long-term survival equivalent to those achieved with VATS and the traditional open thoracotomy approach.
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http://dx.doi.org/10.1016/j.cllc.2019.10.004DOI Listing
May 2020

Evaluation of the Efficacy of Enoxaparin in the Neonatal Intensive Care Unit.

Am J Perinatol 2019 Oct 26. Epub 2019 Oct 26.

Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio.

Objective:  This article evaluates the efficacy of enoxaparin when targeting anti-factor Xa levels of 0.5 to 1 units per milliliter in the neonatal intensive care unit.

Study Design:  This is a retrospective chart review of 45 neonates receiving enoxaparin for the treatment of venous thromboembolism. Enoxaparin dosing and corresponding anti-factor Xa levels were collected. Time to resolution of clot was confirmed by imaging and compared between clots in various locations.

Results:  The median time to clot resolution was 76 days (interquartile range 40-91 days). Clot location, postnatal age, and sex at the clot onset were significantly associated with time to clot resolution in a multivariable Cox model (-value: 0.03, 0.03, and < 0.01, respectively). Of the 54 patients analyzed for safety, 5 patients (9.3%) experienced bleeding events resulting in the discontinuation of enoxaparin.

Conclusion:  Based on our findings, 50% of all patients evaluated, regardless of thrombus location, achieved resolution within the first 76 days of therapy. Clots located in the extremities tended to resolve sooner, hence earlier reimaging should be considered.
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http://dx.doi.org/10.1055/s-0039-1698456DOI Listing
October 2019

Propensity-score adjusted comparison of pathologic nodal upstaging by robotic, video-assisted thoracoscopic, and open lobectomy for non-small cell lung cancer.

J Thorac Cardiovasc Surg 2019 11 28;158(5):1457-1466.e2. Epub 2019 Aug 28.

Thoracic Surgery Division, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio.

Objective: To assess the effectiveness of intraoperative lymph node (LN) staging by comparing upstaging between robotic-assisted surgery, video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach for lobectomy for non-small cell lung cancer.

Methods: We retrospectively analyzed 1053 patients with clinical stage N0/N1 non-small cell lung cancer who underwent lobectomy at 2 centers between 2011 and 2018. Propensity score adjustment by inverse probability of treatment weighting was used to balance baseline characteristics. The primary end point was LN upstaging.

Results: A total of 911 patients (254 robotic, 296 VATS, and 261 open) were included in the inverse probability of treatment weighting adjusted analysis. The overall rate of LN upstaging was highest with open lobectomy (21.8%), followed by robotic (16.2%), and VATS (12.3%) (P = .03). Mediastinal N2 upstaging was observed in similar frequencies (open 6.9% vs robotic 6.3% vs VATS 4.4%; P = .6). No differences were seen for total LN counts, but were observed in the number of stations sampled (mean, open 4.0 vs robotic 3.8 vs VATS 3.6; P = .001). On multivariate analysis, LN upstaging was lower for VATS compared with open (odds ratio, 0.50; 95% confidence interval, 0.29-0.85), but not different between robotic and open (odds ratio, 0.72; 95% confidence interval, 0.44-1.18). No significant differences were seen in mediastinal N2 upstaging between groups.

Conclusions: Pathologic LN upstaging following lobectomy for clinically N0/N1 NSCLC remains high. Compared with a traditional thoracotomy approach, robotic lobectomy was associated with similar and VATS with lower overall nodal upstaging. A thorough evaluation of hilar and mediastinal LNs remains critical to ensure accurate staging by detection of occult LN metastases.
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http://dx.doi.org/10.1016/j.jtcvs.2019.06.113DOI Listing
November 2019

Using timbre to improve performance of larger auditory alarm sets.

Ergonomics 2019 Dec 22;62(12):1617-1629. Epub 2019 Oct 22.

Department of Surgery, The Ohio State University , Columbus , OH , USA.

Identifiability and perceived urgency were compared for two sets of alarms in a healthcare inpatient setting. One contained currently used alarms where possible, with new sounds added as needed. The other was designed together, was more heterogenous, used timbre to encode intended similarities and explicitly encoded intended urgency across the set. Twenty nurses reported the identity and perceived urgency of the sounds in each set. Participants correctly identified the sound (0.89 0.77) and alarm category (0.93 0.82) more often in the new set than in the baseline set. In addition, multiple sounds in the new set were more identifiable. The new sounds also had a larger range of perceived urgency and better urgency match. The results indicate that timbre is well-suited to encode alarm groupings in larger alarm sets and that this, along with increased heterogeneity and explicit urgency mapping, improves alarm set performance. Clinical alarms are frequently misidentified. We found that making alarms more acoustically rich, using timbre to convey alarm groups, and explicitly encoding intended urgency improved identifiability and urgency match. These findings can be used to improve alarm performance across all safety-critical industries.
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http://dx.doi.org/10.1080/00140139.2019.1676473DOI Listing
December 2019

Do You Really Mean It? Assessing the Strength, Frequency, and Reliability of Applicant Commitment Statements During the Anesthesiology Residency Match.

Anesth Analg 2019 09;129(3):847-854

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Despite the critical nature of the residency interview process, few metrics have been shown to adequately predict applicant success in matching to a given program. While evaluating and ranking potential candidates, bias can occur when applicants make commitment statements to a program. Survey data show that pressure to demonstrate commitment leads applicants to express commitment to multiple institutions including telling >1 program that they will rank them #1. The primary purpose of this cross-sectional observational study is to evaluate the frequency of commitment statements from applicants to 5 anesthesiology departments during a single interview season, report how often each statement is associated with a successful match, and identify how frequently candidates incorrectly represented commitments to rank a program #1.

Methods: During the 2014 interview season, 5 participating anesthesiology programs collected written and verbal communications from applicants. Three residency program directors independently reviewed the statements to classify them into 1 of 3 categories; guaranteed commitment, high rank commitment, or strong interest. Each institution provided a deidentified rank list with associated commitment statements, biographical data, whether candidates were ranked-to-match, and if they successfully matched.

Results: Program directors consistently differentiated among strong interest, high rank, and guaranteed commitment statements with κ coefficients of 0.9 (95% CI, 0.8-0.9) or greater between any pair of reviewers. Overall, 35.8% of applicants (226/632) provided a statement demonstrating at least strong interest and 5.4% (34/632) gave guaranteed commitment statements. Guaranteed commitment statements resulted in a 95.7% match rate to that program in comparison to statements of high rank (25.6%), strong interest (14.6%), and those who provided no statement (5.9%). For those providing guaranteed commitment statements, it can be assumed that the 1 candidate (4.3%) who did not match incorrectly represented himself. Variables such as couples match, "R" positions, and not being ranked-to-match on both advanced and categorical rank lists were eliminated because they can result in a nonmatch despite truthfully ranking a program #1.

Conclusions: Each level of commitment statement resulted in a progressively increased frequency of a successful match to the recipient program. Only 5.4% of applicants committed to rank a program #1, but these statements were very reliable. These data can help program directors interpret commitment statements and assist accurate evaluation of the interest of candidates throughout the match process.
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http://dx.doi.org/10.1213/ANE.0000000000004136DOI Listing
September 2019

The association between statins and colorectal cancer stage in the Women's Health Initiative.

Mol Clin Oncol 2019 Sep 4;11(3):252-258. Epub 2019 Jul 4.

Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI 48201, USA.

The anticarcinogenic effect of statins may reduce the metastatic potential of cancer cells leading to 'stage migration', with users more likely diagnosed with early rather than late stage cancer. The association between prior statin use and colorectal cancer (CRC) stage at diagnosis in the Women's Health Initiative (WHI) was investigated. The study population included 132,322 post-menopausal women, among which there were 2,628 pathologically confirmed cases of (3.3%), localized (43.6%), regional (40.4%) and distant (12.7%) stage CRC, after an average of 13.9 (SD=4.7) years of follow-up. To reduce the possibility of detection bias among women more likely to be prescribed statins, women who did not report a mammogram within 5 years of study entry and who had no health insurance or medical care provider (n=28,237) were excluded from the study. Stage was coded using SEER criteria into early ( and local) vs. late (regional and distant) stage disease. Hazards ratios (HR) and 95% confidence intervals (CIs) evaluating the association between statin use and diagnosis of late-stage CRC both at baseline and in a time-dependent manner were computed from multivariable-adjusted Cox proportional hazards analyses. In the multivariable time-dependent analysis, there was a lower hazard of late stage CRC among users of lipophilic statins compared with non-users (HR=0.80, 95% CI 0.66-0.98, P=0.029) and a marginally lower hazard of late stage CRC among users of lipophilic vs. hydrophilic statins (HR=0.70, 95% CI 0.49-1.01, P=0.058). The use of lipophilic statins was associated with a reduction in the proportion of CRC cases that were late stage at the time of diagnosis.
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http://dx.doi.org/10.3892/mco.2019.1895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688425PMC
September 2019

Impact of anticoagulation strategy and agents on extracorporeal membrane oxygenation therapy.

Perfusion 2019 11 6;34(8):671-678. Epub 2019 May 6.

Department of Pharmacy, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.

Introduction: Extracorporeal membrane oxygenation mandates balancing the risk of thromboembolic complications with bleeding. We aimed to evaluate pragmatic anticoagulation regimens during extracorporeal membrane oxygenation and compare thromboembolic and bleeding outcomes.

Methods: This retrospective, single-center study reviewed patients on venovenous or venoarterial extracorporeal membrane oxygenation for a minimum of 24 hours over a 5-year period. The primary outcome was composite thromboembolic events per day of extracorporeal membrane oxygenation. Secondary outcomes included composite bleeding complications, percent of measured activated partial thromboplastin times in goal range, and comparing events with therapeutic anticoagulation for the majority of the extracorporeal membrane oxygenation run (>50% of time on extracorporeal membrane oxygenation) versus non-therapeutic anticoagulation (therapeutic anticoagulation <50% of time).

Results: For the primary analysis, 100 patients received heparin, 10 received bivalirudin, and 43 were transitioned between heparin and bivalirudin. No significant differences were identified comparing the heparin group to the bivalirudin (RR = 0.427, p = 0.156) or transitioned group (RR = 1.274, p = 0.325). There were no differences in the rate of bleeding events when comparing the heparin group to the bivalirudin (RR = 0.626, p = 0.250) or transitioned group (RR = 0.742, p = 0.116). An increased number of adjustments to the anticoagulants was associated with a statistically higher rate of bleeding events per day (p = 0.006).

Conclusion: There were no differences in thromboembolic or bleeding events when comparing different anticoagulant regimens. Adjustments to the anticoagulants are more likely to occur when bleeding is observed. Due to variability in anticoagulation, there is a need to standardize anticoagulation with extracorporeal membrane oxygenation.
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http://dx.doi.org/10.1177/0267659119842809DOI Listing
November 2019

Pregabalin in the reduction of pain and opioid consumption after burn injuries: A preliminary, randomized, double-blind, placebo-controlled study.

Medicine (Baltimore) 2019 May;98(18):e15343

The Ohio State University Medical Center, Department of Anesthesiology.

Background: The primary objective of the study was to evaluate the efficacy of 300 milligrams (mg) and 600 mg of pregabalin compared to placebo in the reduction of pain in patients with noncritical partial and full thickness burn injuries.

Methods: A prospective, randomized, double-blinded, single center, placebo-controlled trial was conducted. Simple randomization method was used in this trial. After subjects met all the inclusion and none of the exclusion criteria, they were randomized and assigned to 1 of the 3 18-day treatments groups: Pregabalin 300 group, Pregabalin 600 group, or Placebo group. Demographics and clinical characteristics were recorded. The severity of pain was assessed by using the visual analog scale for pain intensity at baseline on day 3, day 9 ± 3, day 25 ± 7, day 90 ± 6, and day 180 ± 12.

Results: A total of 54 subjects were randomly assigned, and 51 were included in the data analysis. Demographics and clinical characteristics did not differ significantly between the 3 groups. There was a statistically significant difference in pain between the Pregabalin 300 and Pregabalin 600 groups (P-value = .0260). The Pregabalin 300 group had 17.93 units (95% confidence interval: 1.83-34.04) higher pain scores on average than the Pregabalin 600 group, regardless of time. The adjusted P-value comparing 0 to 300 was .1618, while the adjusted P-value for 0 versus 600 was .5304. There was an overall difference in pain across time regardless of study group (P-value = <.0001). An overall difference in opioid consumption (P-value = .0003) and BSHS (P-value = .0013) across time regardless of study group was noted.

Conclusions: Pregabalin could be part of a promising multimodal analgesic regimen in noncritical burn population. Future placebo-controlled studies assessing the use of pregabalin in burn victim patients may further endorse our findings.
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http://dx.doi.org/10.1097/MD.0000000000015343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6504294PMC
May 2019