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PURPOSE: As the largest integrated health care system in the United States, the Veterans Health Administration (VA) is a leader in telehealth-delivered care. All 10 million Veterans cared for within the VA are eligible for telehealth. The VA cares for approximately 46,000 Veteran patients with newly diagnosed cancer and an estimated 400,000 prevalent cases annually. With nearly 38% of VA health care system users residing in rural areas and only 44% of rural counties having an oncologist, many Veterans lack local access to specialized cancer services. METHODS: We describe the VA's National TeleOncology (NTO) Service. NTO was established to provide Veterans with the opportunity for specialized treatment regardless of geographical location. Designed as a hub-and-spoke model, VA oncologists from across the country can provide care to patients at spoke sites. Spoke sites are smaller and rural VA medical centers that are less able to independently provide the full range of services available at larger facilities. In addition to smaller rural spoke sites, NTO also provides subspecialized oncology care to Veterans located in larger VA medical facilities that do not have subspecialties available or that have limited capacity. RESULTS: As of fiscal year 2021, 23 clinics are served by or engaged in planning for delivery of NTO and there are 24 physicians providing care through the NTO virtual hub. Most NTO physicians continue to provide patient care in separate traditional in-person clinics. Approximately 4,300 unique Veterans have used NTO services. Approximately half (52%) of Veterans using NTO lived in rural areas. Most of these Veterans had more than one remote visit through NTO. CONCLUSION: NTO is a state-of-the-art model that has the potential to revolutionize the way cancer care is delivered, which should improve the experience of Veterans receiving cancer care.

Rare variants (RVs) genetic association studies enable researchers to uncover the variation in phenotypic traits left unexplained by common variation. Traditional single-variant analysis lacks power; thus, researchers have developed various methods to aggregate the effects of RVs across genomic regions to study their collective impact. Some existing methods utilize a static delineation of genomic regions, often resulting in suboptimal effect aggregation, as neutral subregions within the test region will result in an attenuation of signal. To pinpoint genomic regions enriched for disease-associated RVs, we developed a novel method, DYNATE (DYNamic Aggregation TEsting). DYNATE dynamically and hierarchically aggregates smaller genomic regions into larger ones and performs multiple testing for disease associations with controlled weighted false discovery rate. Extensive numerical simulations demonstrate the superior performance of DYNATE under various scenarios compared to existing methods. Importantly, DYNATE-identified regions have higher enrichment levels of disease-associated RVs. We applied DYNATE to an amyotrophic lateral sclerosis (ALS) study and identified a new gene,EPG5, harboringpossibly pathogenic mutations.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its long-term outcomes may be jointly caused by a wide range of clinical, social, and economic characteristics. Studies aiming to identify mechanisms for SARS-CoV-2 morbidity and mortality must measure and account for these characteristics to arrive at unbiased, accurate conclusions. We sought to inform the design, measurement, and analysis of longitudinal studies of long-term outcomes among people infected with SARS-CoV-2. We fielded a survey to an interprofessional group of clinicians and scientists to identify factors associated with SARS-CoV-2 infection and subsequent outcomes. Using an iterative process, we refined the resulting list of factors into a consensus causal diagram relating infection and 12-month mortality. Finally, we operationalized concepts from the causal diagram into minimally sufficient adjustment sets using common medical record data elements. Total 31 investigators identified 49 potential risk factors for and 72 potential consequences of SARS-CoV-2 infection. Risk factors for infection with SARS-CoV-2 were grouped into five domains: demographics, physical health, mental health, personal social, and economic factors, and external social and economic factors. Consequences of coronavirus disease 2019 (COVID-19) were grouped into clinical consequences, social consequences, and economic consequences. Risk factors for SARS-CoV-2 infection were developed into a consensus directed acyclic graph for mortality that included two minimally sufficient adjustment sets. We present a collectively developed and iteratively refined list of data elements for observational research in SARS-CoV-2 infection and disease. By accounting for these elements, studies aimed at identifying causal pathways for long-term outcomes of SARS-CoV-2 infection can be made more informative.

Introduction: Studies using electronic health record (EHR) data often have a limited number of years available for analysis. There is a trade off between the look back period length used to define baseline characteristics and follow up duration used to define outcomes. Objective: Quantify the impact of 6, 12, and 24 month look back periods on the association between diabetes (DM) and subsequent cardiovascular (CV) events using EHR data alone and in combination with Medicare claims. Methods: EHR data from an academic health system and a federally qualified health center from 2009-2014 were linked to Medicare claims data. Eligibility criteria were age ≥65 years, Durham County address, 24 months of continuous enrollment after first claim, EHR encounter in the 2011 index year, and no history of cardiovascular disease (CVD) in the 24 months prior to the index date (i.e., look back period). DM was defined using EHR ICD-9 codes, HbA1c ≥6.5%, or glucose lowering medication, and using claims based diagnosis codes or glucose lowering medication. The outcome was a major CV event (myocardial infarction, stroke, or cardiac procedure) defined by diagnosis or procedure codes. Hazard ratios (HR) compared time to the outcome between patients with and without DM. Results: In 5473 patients, mean age was 77 years, 67% were female and 28% were Black. The prevalence of DM using EHR data only increased with a longer look back period (6 months [19%]; 12 months [21%]; 24 months [23%]) but was less than the prevalence using all available data from EHRs and claims together (28%) (Table 1A). Shorter look back periods resulted in higher HRs (6 month HR=1.64) as compared to HRs from longer look back periods (24 month HR=1.41) using EHR data alone or all available data from the EHR and claims together (HR=1.43) (Table 1B). Conclusions: To avoid over estimating associations, studies of CVD using EHR data to identify baseline conditions may want to use 12-24 month look back periods in the absence of additional administrative data. This may also lead to a shorter follow-up period.

Alternatives have emerged for patients ineligible for cardiac transplantation under standard criteria. The purpose of our study was to compare outcomes in patients ineligible for cardiac transplantation under standard criteria, treated either with extended criteria cardiac transplantation (ECCT) or a continuous flow destination therapy left ventricular assist device (CF DT-LVAD). From 2005 to 2012, patients treated with either ECCT or CF DT-LVAD at our institution were retrospectively analyzed. In the overall unmatched cohort, we examined mortality and other outcomes, including index hospitalization length of stay, renal function, stroke, and readmission rates. After propensity score (PS) matching, outcomes were compared between ECCT and CF DT-LVAD recipients. Overall, 62 patients underwent ECCT, and 146 patients were treated with CF DT-LVAD. The 2-year mortality estimate for ECCT recipients was 27.3% (95% confidence interval 15.5% to 39.1%) and for CF DT-LVAD recipients was 11.2% (95% confidence interval 4.8% to 17.6%). After PS matching of 39 patients from each treatment group, there was no significant difference in overall survival after 2 years (p = 0.346). In both unmatched and PS-matched analyses, CF DT-LVAD patients compared with ECCT had a significantly higher estimated glomerular filtration rate at 1 year but also had significantly higher hospital readmission rates. Stroke also more commonly occurred after CF DT-LVAD compared with ECCT (17 vs 5, unmatched; and 2 vs 1, PS matched). However, there was no significant difference between PS-matched groups in 2-year stroke-free survival (p = 0.371). In conclusion, ECCT and CF DT-LVAD in select patients are comparable therapies with respect to 2-year survival.

Objectives The purpose of this study was to examine changes in a broad panel of biomarkers following left ventricular assist device (LVAD) support in advanced heart failure (HF). Background LVAD therapy mechanically unloads the failing heart and may result in reversal of certain aspects of the end-stage HF phenotype. Changes in markers of myocardial stress, fibrosis, inflammation, fluid homeostasis, and renal injury in this setting are unknown. Methods Amino-terminal pro-B-type natriuretic peptide (NT-proBNP), galectin-3, ST2, copeptin, growth differentiation factor (GDF)-15, C-reactive protein (CRP), and neutrophil gelatinase associated lipocalin (NGAL) levels were measured in frozen plasma collected from 37 individuals prior to continuous flow LVAD implantation and a median of 136 (interquartile range: 94 to 180) days after implantation. Results The median age of patients was 68 years old. LVAD therapy was associated with significant decreases in NT-proBNP (3,093 to 2,090 pg/ml; p = 0.02), ST2 (67.5 to 45.2 ng/ml, p 0.001), hs-CRP (22.4 to 11.9 mg/l; p = 0.01), and copeptin (103 to 94 pmol/l; p = 0.003) but not NGAL (132 to 135 ng/ml; p = 0.06). Despite improvement over time, absolute values of each biomarker remained extremely abnormal. Greater reductions in biomarkers were noted in individuals with >25% decrease in NT-proBNP concentrations but reached statistical significance only in the case of galectin-3 (p = 0.01). Conclusions The biomarker profile in patients after LVAD placement improves but nonetheless remains significantly abnormal. Our results suggest the need for targeted therapeutic interventions to mitigate such abnormalities and potentially increase rates of myocardial recovery.

BackgroundAdrenocortical carcinoma (ACC) is a rare, aggressive disease with no apparent change in treatment or survival in the United States over the past two decades. Our objective was to determine whether treatment patterns or clinical outcomes vary by hospital case volume.MethodsPatients with ACC were identified from the National Cancer Database (1998-2011). High-volume centers (HVCs) were defined by a case load of ≥4 cases of primary adrenal malignancy annually, which corresponded to the 90th percentile. All other facilities were considered low-volume centers (LVCs).ResultsA total of 2,765 ACC patients were treated across 1,046 facilities. Compared to patients treated at LVCs, patients treated at HVCs were younger (50 vs. 54years), with larger tumors (11.2 vs. 10.5cm), and underwent higher rates of surgery (78.8 vs. 73.4%), radical resection (17.3 vs. 13.9%), regional lymph node evaluation (23.2 vs. 18.8%), and chemotherapy including mitotane (43.8 vs. 31.0%, all p&nbsp

BackgroundWe describe nationally representative patterns of utilization and short-term outcomes from robotic versus open thyroidectomy for thyroid cancer.MethodsDescriptive statistics and multivariable analysis were used to analyze patterns of use of robotic thyroidectomy from the National Cancer Database (2010-2011). Short-term outcomes were compared between patients undergoing robotic versus open thyroidectomy, while adjusting for confounders.ResultsA total of 68,393 patients with thyroid cancer underwent thyroidectomy; 225 had robotic surgery and 57,729 underwent open surgery. Robotic thyroid surgery use increased by 30% from 2010 to 2011 (p=0.08). Robotic cases were reported from 93 centers, with 89 centers performing

BACKGROUND Patterns of failure after neoadjuvant chemoradiotherapy and surgery for esophageal cancer are poorly defined.

Importance Data from animal models show that the administration of dextroamphetamine combined with task-relevant training facilitates recovery after focal brain injury. Results of clinical trials in patients with stroke have been inconsistent. Objectives To collect data important for future studies evaluating the effect of dextroamphetamine combined with physiotherapy for improving poststroke motor recovery and to test the efficacy of the approach. Design, Setting, Participants This pilot, double-blind, block-randomized clinical trial included patients with cortical or subcortical ischemic stroke and moderate or severe motor deficits from 5 rehabilitation hospitals or units. Participants were screened and enrolled from March 2001 through March 2003. The primary outcome was assessed 3 months after stroke. Study analysis was completed December 31, 2015. A total of 1665 potential participants were screened and 64 were randomized. Participants had to begin treatment 10 to 30 days after ischemic stroke. Data analysis was based on intention to treat. Interventions Participants were allocated to a regimen of 10 mg of dextroamphetamine (n = 32) or placebo (n = 32) combined with a 1-hour physical therapy session beginning 1 hour after drug or placebo administration every 4 days for 6 sessions in addition to standard rehabilitation. Main Outcomes and Measures The primary outcome was the difference between groups in change in Fugl-Meyer motor scores from baseline to 3 months after stroke (intention to treat with dextroamphetamine). Secondary exploratory measures included the National Institutes of Health Stroke Scale, Canadian Neurological Scale, Action Research Arm Test, modified Rankin Scale score, Functional Independence Measure, Ambulation Speed and Distance, Mini-Mental State Examination, Beck Depression Inventory, and Stroke Impact Scale. Results Among the 64 patients randomized to dextroamphetamine vs placebo (55% men; median age, 66 years; age range, 27-91 years), no overall treatment-associated difference in the mean (SEM) change in Fugl-Meyer motor scores from baseline to 3 months after stroke was noted (−18.65 [2.27] points with dextroamphetamine vs −20.83 [2.94] points with placebo;P = .58). No overall treatment-associated differences in any of the study’s secondary measures and no differences in subgroups based on stroke location or baseline severity were found. No adverse events were attributed to study treatments. Conclusions and Relevance Treatment with dextroamphetamine combined with physical therapy did not improve recovery of motor function compared with placebo combined with physical therapy as assessed 3 months after hemispheric ischemic stroke. The studied treatment regimen was safe. Trial Registration ClinicalTrials.gov identifier:NCT01905371

Follicular thyroid carcinoma (FTC) and follicular variant of papillary thyroid carcinoma (FV-PTC) are difficult entities to distinguish based on cytology prior to pathologic evaluation of surgical specimens but may have different treatment algorithms. The current study describes trends in rates of FTC versus FV-PTC in the U.S. and develops a risk assessment tool to aid clinicians in predicting final diagnosis and shaping treatment plans. Relative rates of FTC and FV-PTC in the surveillance, epidemiology, and end results (SEER) database were evaluated for temporal trends from 1988 to 2011. Using multivariable logistic regression, a simplified scoring system was developed to estimate the risk of FTC versus FV-PTC using patient and tumor characteristics. The National Cancer Data Base was used for model validation. Of 115,091 thyroid cancer cases in the SEER database from 1988 to 2011, 23,980 involved FTC (n = 5056; 21 %) or FV-PTC (n = 18,924; 79 %). In 1988, half of follicular cases were FV-PTC; however, FV-PTC accounted for over 85 % of these lesions by 2010. Increasing age >45 years, male gender, black race, increasing tumor size, and distant metastases were strongly associated with increased risk of FTC, while lymph node disease and extrathyroidal extension were associated with FV-PTC. A bedside risk assessment nomogram using these preoperative variables classified patient risk of FTC from 2 to 70 %. FV-PTC has become the dominant malignancy with follicular cytology, accounting for >85 % of these cases. A simple bedside risk assessment tool can risk stratify patients with follicular lesions and inform patient and clinician discussions and decision making.

Purpose Cervical lymph node metastases are recognized as a prognostic indicator only in patients age 45 years or older with papillary thyroid cancer (PTC); patients younger than age 45 years are perceived to have low-risk disease. The current American Joint Committee on Cancer staging for PTC in patients younger than age 45 years does not include cervical lymph node metastases. Our objective was to test the hypothesis that the presence and number of cervical lymph node metastases have an adverse impact on overall survival (OS) in patients younger than age 45 years with PTC. Patients and Methods Adult patients younger than age 45 years undergoing surgery for stage I PTC (no distant metastases) were identified from the National Cancer Data Base (NCDB; 1998-2006) and from SEER 1988-2006 data. Multivariable models were used to examine the association of OS with the presence of lymph node metastases and number of metastatic nodes. Results In all, 47,902 patients in NCDB (11,740 with and 36,162 without nodal metastases) and 21,855 in the SEER database (5,188 with and 16,667 without nodal metastases) were included. After adjustment, OS was compromised for patients with nodal metastases compared with patients who did not have them (NCDB: hazard ratio (HR), 1.32; 95% CI, 1.04 to 1.67; P = .021; SEER: HR, 1.29; 95% CI, 1.08 to 1.56; P = .006). After adjustment, increasing number of metastatic lymph nodes was associated with decreasing OS up to six metastatic nodes (HR, 1.12; 95% CI, 1.01 to 1.25; P = .03), after which more positive nodes conferred no additional mortality risk (HR, 0.99; 95% CI, 0.99 to 1.05; P = .75). Conclusion Our results suggest that cervical lymph node metastases are associated with compromised survival in young patients, warranting consideration of revised American Joint Committee on Cancer staging. A change point of six or fewer metastatic lymph nodes seems to carry prognostic significance, thus advocating for rigorous preoperative screening for nodal metastases.

Background The Selvester QRS score is an electrocardiographic tool designed to quantify myocardial scar. It was updated in 2009 to expand its usefulness in patients with conduction abnormalities such as bundle-branch and fascicular blocks. There is need to further validate the updated score in a broader group of patients with cardiovascular disease and conduction abnormalities. We primarily hypothesized that the updated score could distinguish between presence and absence of scar by cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement in 4 groups of patients with distinct conduction abnormalitites. Methods A total of 193 patients were retrospectively identified that had received an electrocardiogram (ECG) and a CMR scan at Duke University Medical Center between January 2011 and August 2013: 62 with left bundle-branch block, 51 with right bundle-branch block (RBBB), 43 with left anterior fascicular block (LAFB), and 37 with RBBB + LAFB. Scar sizes estimated by ECG and by CMR were compared using scatterplots, modified Bland-Altman plots, and receiver operating characteristics curves. Results Of 193 patients, 96 (50%) had no scar by CMR. The QRS score generally overestimated CMR scar. The area under the curve ranged between 0.62 and 0.65 for the different conduction types, and 95% confidence intervals included 0.5 for all conduction types. Performance was slightly improved in LAFB and RBBB + LAFB by excluding all points derived from leads V 4 -V 6 . Conclusions The Selvester QRS score for use in conduction abnormalities needs to be improved, primarily its specificity, to enable effective clinical use in a population with a wide range of left ventricular ejection fraction and low pretest probability of myocardial scar.

Malignant struma ovarii (MSO) is a germ cell tumor of the ovary histologically identical to differentiated thyroid cancers. There is a paucity of data on this neoplasm, with fewer than 200 reported cases. The primary objective of this study was to examine the survival rate of women diagnosed with MSO using data from the Surveillance, Epidemiology, and End RESULTS (SEER) database. Secondary objectives were to describe the demographic, clinical, pathologic, and treatment characteristics of this population.A retrospective analysis was performed of prospectively collected cancer registry data. A total of 68 patients were identified in the SEER database, 1973-2011. The chi-square test, Student's t-test, and Kaplan-Meier curves were employed for data analyses.All 68 patients were females with a mean age at diagnosis of 43.0 years. Nearly 33% underwent unilateral oophorectomy, 28.6% bilateral oophorectomy, and 28.6% oophorectomy and omentectomy, and 4.8% were treated with debulking surgery. Pelvic radiation was administered to 12.3% of patients. The mean tumor size was 52.8 mm; 80% of malignant struma ovarii were SEER staged as local. Overall survival rates at 5, 10, and 20 years were 96.7%, 94.3%, and 84.9% respectively. Among the patients, there were six deaths recorded; only one was attributed to MSO. Six individuals (8.8%) had a concomitant or subsequent diagnosis of thyroid cancer. Four patients underwent total thyroidectomy, three patients had radioactive iodine, and one patient underwent external beam radiation. Two thirds of thyroid cancers extended outside the thyroid gland. All six patients with thyroid cancer were alive at the end of follow-up.It was observed that patients with malignant struma ovarii had an excellent disease-specific survival rate, regardless of the management strategy employed. However, MSO patients had a high risk for developing aggressive thyroid cancers. Therefore, MSO patients may benefit from routine thyroid imaging once the diagnosis of MSO is established.

Context: Papillary thyroid cancer (PTC) patients 1.0 cm, regardless of age. Objective: Our objective was to examine the impact of extent of surgery on overall survival (OS) in patients Design, Setting, and Patients: Adult patients Main Outcome Measure: Multivariable modeling was used to compare OS for patients undergoing total thyroidectomy vs lobectomy. Results: In total, 29 522 patients in NCDB (3151 lobectomy, 26 371 total thyroidectomy) and 13 510 in SEER (1379 lobectomy, 12 131 total thyroidectomy) were included. Compared with patients undergoing lobectomy, patients having total thyroidectomy more often had extrathyroidal and lymph node disease. At 14 years, unadjusted OS was equivalent between total thyroidectomy and lobectomy in both databases. After adjustment, OS was similar for total thyroidectomy compared with lobectomy across all patients with tumors of 1.1 to 4.0 cm (NCDB: hazard ratio = 1.45 [confidence interval = 0.88–2.51], P = 0.19; SEER: 0.95 (0.70–1.29), P = 0.75) and when stratified by tumor size: 1.1 to 2.0 cm (NCDB: 1.12 [0.50–2.51], P = 0.78; SEER: 0.95 [0.56–1.62], P = 0.86) and 2.1 to 4.0 cm (NCDB: 1.93 [0.88–4.23], P = 0.10; SEER: 0.94 [0.60–1.49], P = 0.80). Conclusions: After adjusting for patient and clinical characteristics, total thyroidectomy compared with thyroid lobectomy was not associated with improved survival for patients

BackgroundNonfunctional pancreatic neuroendocrine tumors (PNETs) ≤2cm have uncertain malignant potential, and optimal treatment remains unclear. Objectives of this study were to better understand their malignant potential, determine whether extent of surgery or lymph node dissection is associated with overall survival (OS), and identify other factors associated with OS.MethodsPatients with nonfunctional PNETs ≤2cm were identified from the National Cancer Data Base (1998 to 2011). Descriptive statistics were used for patient characteristics and surgical resection patterns. Five-year OS was estimated using Kaplan-Meier analyses across extent of surgery and compared using the log-rank test. Cox proportional regression modeling was used to test the association between survival and extent of surgery.ResultsA total of 1854 patients with nonfunctional PNETs ≤2cm were included. From 1998 to 2011, these tumors increased three-fold as a proportion of all PNETs. Among tumors≤0.5cm, 33% presented with regional lymph node metastases and 11% with distant metastases. Five-year OS for patients not undergoing surgery was 27.6% vs. 83.0% for partial pancreatectomy, 72.3% for pancreaticoduodenectomy, and 86.0% for total pancreatectomy (p&nbsp

ObjectiveTo examine the association between the extent of surgery and overall survival in a large contemporary cohort of patients with papillary thyroid cancer (PTC).BackgroundGuidelines recommend total thyroidectomy for PTC tumors >1 cm, based on older data demonstrating an overall survival advantage for total thyroidectomy over lobectomy.MethodsAdult patients with PTC tumors 1.0-4.0 cm undergoing thyroidectomy in the National Cancer Database, 1998-2006, were included. Cox proportional hazards models were applied to measure the association between the extent of surgery and overall survival while adjusting for patient demographic and clinical factors, including comorbidities, extrathyroidal extension, multifocality, nodal and distant metastases, and radioactive iodine treatment.ResultsAmong 61,775 PTC patients, 54,926 underwent total thyroidectomy and 6849 lobectomy. Compared with lobectomy, patients undergoing total thyroidectomy had more nodal (7% vs 27%), extrathyroidal (5% vs 16%), and multifocal disease (29% vs 44%) (all Ps < 0.001). Median follow-up was 82 months (range, 60-179 months). After multivariable adjustment, overall survival was similar in patients undergoing total thyroidectomy versus lobectomy for tumors 1.0-4.0 cm [hazard ratio (HR) = 0.96; 95% confidence interval (CI), 0.84-1.09); P = 0.54] and when stratified by tumor size: 1.0-2.0 cm [HR = 1.05; 95% CI, 0.88-1.26; P = 0.61] and 2.1-4.0 cm [HR = 0.89; 95% CI, 0.73-1.07; P = 0.21]. Older age, male sex, black race, lower income, tumor size, and presence of nodal or distant metastases were independently associated with compromised survival (P < 0.0001).ConclusionsCurrent guidelines suggest total thyroidectomy for PTC tumors >1 cm. However, we did not observe a survival advantage associated with total thyroidectomy compared with lobectomy. These findings call into question whether tumor size should be an absolute indication for total thyroidectomy.

Background: To reduce readmissions rates for patients admitted with acute myocardial infarction (AMI) or congestive heart failure (CHF), Duke University Hospital piloted a program in which patients were contacted by telephone within 72 hours of discharge and asked a set of structured questions believed to identify gaps in care to reduce the risk of readmission. Methods: A cohort of 838 patients admitted between December 2012 and May 2013 with a primary diagnosis of AMI (n=374) or CHF (n=464) were identified by DRG for prospective telephone follow-up and analyzed retrospectively. For primary outcome analysis, readmission rates were compared between two groups: one that received the telephone intervention and one that did not. If successfully contacted, patients were asked about filling and complying with their prescriptions, knowledge of their follow-up appointment, and understanding their discharge instructions. A secondary outcome analysis evaluated readmission rates among the telephone-eligible subgroup. Results: Patient characteristics among those contacted vs. not contacted did not differ substantially for either AMI or CHF discharges. Among AMI patients, there was no association between contact attempt and readmission within 30 days (p = 0.719) or 90 days (p=0.803). This finding persisted after adjusting for the effect of age at hospitalization, disease group, race, gender, and payor (OR = 1.28, 95% CI = 0.61 - 2.68, p = 0.512 at 30 days; OR = 1.24, 95% CI = 0.65 - 2.37, p = 0.510 at 90 days). Among CHF patients, there was no association between contact attempt and readmission within 30 days (p = 0.156) or 90 days (p=0.904). This finding persisted after adjusting for the effect of age at hospitalization, disease group, race, gender, and payor (OR = 0.67, 95% CI = 0.35 - 1.25, p = 0.207 at 30 days; OR = 0.94, 95% CI = 0.56 - 1.55, p = 0.797 at 90 days). There was no association between telephone-eligible patients and readmission rates at 30 or 90 days for either condition. Among patients successfully contacted, there was no association between answers pertaining to post-discharge behavior and readmission rates for CHF or AMI. Conclusions: Early telephone follow-up targeting post-discharge behaviors was not observed to impact 30- or 90-day readmission rates for patients admitted to an academic medical center with CHF or AMI.

Our objective was to determine whether computed tomography angiography (CTA) measurements of pulmonary artery size can noninvasively assess hemodynamics and diagnose pulmonary hypertension (PH) secondary to sickle cell disease (SCD). Twenty SCD patients with confirmed PH were compared with 20 matched controls. Diameters of the pulmonary artery trunk and branches were measured with CTA and a semiautomatic segmentation algorithm. Measurements were normalized by body size and correlated (Spearman rank) with hemodynamic markers from right-heart catheterization. Receiver operating characteristic (ROC) curves were used to investigate the role of pulmonary artery sizes in diagnosing PH. Analysis of pulmonary artery sizes adjusted for body surface area (BSA) resulted in the most significant discrimination between subjects with PH secondary to SCD and controls (P < 0.001); PH was diagnosed accurately with an area under the ROC curve of 0.99. There was significant correlation between pulmonary artery sizes and body mass index (BMI) and BSA only in controls (r = 0.46–0.68, P < 0.04 for all). The most significant correlations with hemodynamic markers were found between BMI-adjusted pulmonary artery sizes and high systolic pulmonary arterial pressure, high pulmonary vascular resistance, high systemic vascular resistance, and low cardiac output (r = 0.47, 0.62, 0.61, and 0.66, respectively; P < 0.04 for all). BMI-adjusted CTA measures of the pulmonary artery relate to high pulmonary vascular resistance and reduced cardiac output in patients with SCD and PH. CTA with quantitative image analysis is a powerful noninvasive diagnostic tool for PH in SCD and shows promise as estimator of hemodynamic markers.

Purpose To evaluate, in a phase 1 study, the safety of neoadjuvant whole-pelvis radiation therapy (RT) administered immediately before radical prostatectomy in men with high-risk prostate cancer. Methods and Materials Twelve men enrolled and completed a phase 1 single-institution trial between 2006 and 2010. Eligibility required a previously untreated diagnosis of localized but high-risk prostate cancer. Median follow-up was 46 months (range, 14-74 months). Radiation therapy was dose-escalated in a 3 × 3 design with dose levels of 39.6, 45, 50.4, and 54 Gy. The pelvic lymph nodes were treated up to 45 Gy with any additional dose given to the prostate and seminal vesicles. Radical prostatectomy was performed 4-8 weeks after RT completion. Primary outcome measure was intraoperative and postoperative day-30 morbidity. Secondary measures included late morbidity and oncologic outcomes. Results No intraoperative morbidity was seen. Chronic urinary grade 2+ toxicity occurred in 42%; 2 patients (17%) developed a symptomatic urethral stricture requiring dilation. Two-year actuarial biochemical recurrence-free survival was 67% (95% confidence interval 34%-86%). Patients with pT3 or positive surgical margin treated with neoadjuvant RT had a trend for improved biochemical recurrence-free survival compared with a historical cohort with similar adverse factors. Conclusions Neoadjuvant RT is feasible with moderate urinary morbidity. However, oncologic outcomes do not seem to be substantially different from those with selective postoperative RT. If this multimodal approach is further evaluated in a phase 2 setting, 54 Gy should be used in combination with neoadjuvant androgen deprivation therapy to improve biochemical outcomes.

The interpretation of medical images benefits from anatomical and physiological priors to optimize computer-aided diagnosis applications. Diagnosis also relies on the comprehensive analysis of multiple organs and quantitative measures of soft tissue. An automated method optimized for medical image data is presented for the simultaneous segmentation of four abdominal organs from 4D CT data using graph cuts. Contrast-enhanced CT scans were obtained at two phases: non-contrast and portal venous. Intra-patient data were spatially normalized by non-linear registration. Then 4D convolution using population training information of contrast-enhanced liver, spleen and kidneys was applied to multiphase data to initialize the 4D graph and adapt to patient-specific data. CT enhancement information and constraints on shape, from Parzen windows, and location, from a probabilistic atlas, were input into a new formulation of a 4D graph. Comparative results demonstrate the effects of appearance, enhancement, shape and location on organ segmentation. All four abdominal organs were segmented robustly and accurately with volume overlaps over 93.6% and average surface distances below 1.1 mm.

Accurate ventricle volume estimates could improve the understanding and diagnosis of postoperative communicating hydrocephalus. For this category of patients, associated changes in ventricle volume can be difficult to identify, particularly over short time intervals. We present an automated segmentation algorithm that evaluates ventricle size from serial brain MRI examination. The technique combines serial T1- weighted images to increase SNR and segments the means image to generate a ventricle template. After pre-processing, the segmentation is initiated by a fuzzy c-means clustering algorithm to find the seeds used in a combination of fast marching methods and geodesic active contours. Finally, the ventricle template is propagated onto the serial data via non-linear registration. Serial volume estimates were obtained in an automated robust and accurate manner from difficult data.

The interpretation of medical images benefits from anatomical and physiological priors to optimize computer-aided diagnosis (CAD) applications. Diagnosis also relies on the comprehensive analysis of multiple organs and quantitative measures of soft tissue. An automated method optimized for medical image data is presented for the simultaneous segmentation of four abdominal organs from 4D CT data using graph cuts. Contrast-enhanced CT scans were obtained at two phases: non-contrast and portal venous. Intra-patient data were spatially normalized by non-linear registration. Then 4D erosion using population historic information of contrast-enhanced liver, spleen, and kidneys was applied to multi-phase data to initialize the 4D graph and adapt to patient specific data. CT enhancement information and constraints on shape, from Parzen windows, and location, from a probabilistic atlas, were input into a new formulation of a 4D graph. Comparative results demonstrate the effects of appearance and enhancement, and shape and location on organ segmentation.

The paper presents the automated segmentation of spleen and liver from contrast-enhanced CT images of normal and hepato/splenomegaly populations. The method used 4 steps: (i) a mean organ model was registered to the patient CT; (ii) the first estimates of the organs were improved by a geodesic active contour; (iii) the contrast enhancements of liver and spleen were estimated to adjust to patient image characteristics, and an adaptive convolution refined the segmentations; (iv) lastly, a normalized probabilistic atlas corrected for shape and location for the precise computation of each organ's volume and height (mid-hepatic liver height and cephalocaudal spleen height). Results from test data demonstrated the method's ability to accurately segment the spleen (RMS error = 1.09mm; DICE/Tanimoto overlaps = 95.2/91) and liver (RMS error = 2.3mm, and DICE/Tanimoto overlaps = 96.2/92.7). The correlations (R(2)) with clinical/manual height measurements were 0.97 and 0.93 for the spleen and liver respectively.

Introduction: Continuous infusion sedation is associated with adverse outcomes such as prolonged mechanical ventilation, extubation failure, increased risk for development of ventilator-associated pneumonia, and increased intensive care unit and hospital lengths of stay in critically ill adults. The purpose of this study was to examine excess sedation and incidence of extubation failure in pediatric patients. Methods: Data were retrospectively collected on consecutive patients who received mechanical ventilation longer than 48 hours with a continuous infusion benzodiazepine and/or opioid infusion longer than 24 hours between January 1, 2009 through October 31, 2012. The primary outcome was incidence of extubation failure in patients who were oversedated (defined by State Behavioral Scale (SBS) score of -3 or -2) within 72 hours of extubation compared to patients who were not oversedated. Secondary outcomes included evaluation of risk factors associated with oversedation and extubation failure. The primary endpoint was evaluated using a one-sided chi-square test at a significance level of p = 0.05. The risk factor analysis utilized univariate and multivariate logistic regression. Covariance-adjusted odds ratios and their corresponding 95% confidence intervals were estimated for the final set of risk factors in the models. Results: One hundred eight patients were included in the analysis, representing 62 oversedated patients and 46 non-oversedated patients. Groups were well matched with regards to baseline characteristics. Most patients received fentanyl and midazolam continuous infusions. There was no difference in extubation failure in oversedated patients versus non-oversedated patients [14 patients (22.58%) versus 7 patients (15.22%), respectively; p = 0.33]. After adjusting for potential risk factors, patients with lower Glasgow Coma Scale (GCS) scores prior to intubation (OR 1.15; 95% CI 0.74-0.97) and higher maximum benzodiazepine dose per day (OR 1.93; 95% CI 1.01-3.71) were associated with an increased risk of oversedation. Longer durations of mechanical ventilation (OR 1.10; 95% CI 0.97-1.25) and higher maximum benzodiazepine dose per day (OR 1.47; 95% CI 0.71-3.05) were associated with an increased risk of extubation failure. Conclusions: Rates of extubation failure were similar among oversedated versus non-oversedated patients. Higher maximum benzodiazepine dose per day was associated with increased risk for oversedation and extubation failure. Benzodiazepine dosing should potentially be re-evaluated in this population.