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Item ACUTE Heart Failure Risk Stratification: A Step Closer to the Holy Grail?(American Heart Association, 2019-02-26) Collins, Sean P.; Pang, Peter S.; Emergency Medicine, School of MedicineItem Changes in insulin sensitivity over time and associated factors in HIV-infected adolescents(Lippincott, Williams & Wilkins, 2018-03-13) Geffner, Mitchell E.; Patel, Kunjal; Jacobson, Denise L.; Wu, Julia; Miller, Tracie L.; Hazra, Rohan; Gerschenson, Mariana; Sharma, Tanvi; Silio, Margarita; Jao, Jennifer; Takemoto, Jody K.; Van Dyke, Russell B.; Dimeglio, Linda A.; Pediatric HIV/AIDS Cohort Study (PHACS); Pediatrics, School of MedicineOBJECTIVE: To compare prevalence of insulin resistance between perinatally HIV-infected (PHIV+) and perinatally HIV-exposed, but uninfected adolescents (PHEU), determine incidence of and contributory factors to new and resolved cases of insulin resistance in PHIV+, and evaluate glucose metabolism. DESIGN: Cross-sectional design for comparison of prevalence among PHIV+ and PHEU. Longitudinal design for incidence and resolution of insulin resistance among PHIV+ at risk for these outcomes. METHODS: The source population was adolescents from pediatric HIV clinics in the United States and Puerto Rico participating in the Pediatric HIV/AIDS Cohort Study, an ongoing prospective cohort study designed to evaluate impact of HIV infection and its treatment on multiple domains in preadolescents and adolescents. Insulin resistance was assessed by homeostatic model assessment of insulin resistance. Those with incident insulin resistance underwent 2-h oral glucose tolerance test and HbA1c. Baseline demographic, metabolic, and HIV-specific variables were evaluated for association with incident or resolved insulin resistance. RESULTS: Unadjusted prevalence of insulin resistance in PHIV+ was 27.3 versus 34.1% in PHEU. After adjustment for Tanner stage, age, sex, and race/ethnicity, there was no significant difference between groups. Factors positively associated with developing insulin resistance included female sex, higher BMI z score, and higher waist circumference; those associated with resolving insulin resistance included male sex and lower BMI z score. CONCLUSION: Prevalence of insulin resistance in PHIV+ and PHEU was substantially higher than that reported in HIV-uninfected nonoverweight youth, but similar to that in HIV-uninfected obese youth. Factors associated with incident or resolved insulin resistance among PHIV+ were similar to those reported in HIV-negative obese youth. However, a contributory role of HIV infection and/or its treatment to the incident risk of insulin resistance cannot be excluded.Item Clinical Ultrasound Is Safe and Highly Specific for Acute Appendicitis in Moderate to High Pre-test Probability Patients(eScholarship, 2018-05) Corson-Knowles, Daniel; Russell, Frances M.; Emergency Medicine, School of MedicineIntroduction: Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The goal of this study was to determine if a heterogeneous group of emergency physicians (EP) could diagnose acute appendicitis on CUS in patients with a moderate to high pre-test probability. Methods: This was a prospective, observational study of a convenience sample of adult and pediatric patients with suspected appendicitis. Sonographers received a structured, 20-minute CUS training on appendicitis prior to patient enrollment. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure was considered a positive study. Non-visualization or indeterminate studies were considered negative. We collected pre-test probability of acute appendicitis based on a 10-point visual analog scale (moderate to high was defined as >3), and confidence in CUS interpretation. The primary objective was measured by comparing CUS findings to surgical pathology and one week follow-up. Results: We enrolled 105 patients; 76 had moderate to high pre-test probability. Of these, 24 were children. The rate of appendicitis was 36.8% in those with moderate to high pre-test probability. CUS were recorded by 33 different EPs. The sensitivity, specificity, and positive and negative likelihood ratios of EP-performed CUS in patients with moderate to high pre-test probability were 42.8% (95% confidence interval [CI] [25-62.5%]), 97.9% (95% CI [87.5-99.8%]), 20.7 (95% CI [2.8-149.9]) and 0.58 (95% CI [0.42-0.8]), respectively. The 16 false negative scans were all interpreted as indeterminate. There was one false positive CUS diagnosis; however, the sonographer reported low confidence of 2/10. Conclusion: A heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. This data adds support for surgical consultation without further imaging beyond CUS in the appropriate clinical setting.Item Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath(WB Saunders, 2015-04) Russell, Frances M.; Moore, Christopher L.; Courtney, D. Mark; Kabrhel, Christopher; Smithline, Howard A.; Nordenholz, Kristen E.; Richman, Peter B.; O’Neil, Brian J.; Plewa, Michael C.; Beam, Daren M.; Mastouri, Ronald; Kline, Jeffrey A.; Emergency Medicine, School of MedicineBACKGROUND: Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. METHODS: A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. RESULTS: A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). CONCLUSION: This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes.Item Longitudinal associations among relationship factors, partner change, and sexually transmitted infection acquisition in adolescent women(Lippincott, Williams & Wilkins, 2011-03) Ott, Mary A.; Katschke, Adrian; Tu, Wanzhu; Fortenberry, J. Dennis; Pediatrics, School of MedicineOBJECTIVES: New sex partners put adolescents at increased risk for sexually transmitted infections (STIs), even when these sex partners are nonoverlapping. Although the risk of partner change is well described, little is known about its antecedents. We prospectively examined associations between relationship characteristics, partner change, and subsequent STI during intervals of "serial monogamy." METHODS: As part of a longitudinal study, 332 adolescent women were interviewed and tested for gonorrhea, chlamydia, and trichomonas every 3 months for up to just over 6 years. Interviews covered partner-specific relationship characteristics and sexual behaviors. The quarterly interval, a 3-month period bracketed by interviews and STI testing, was the unit of analysis. We examined associations among relationship factors, partner change, and subsequent STI using a series of mixed regression models, controlling for age, STI at Time 1, and condom nonuse. RESULTS: Age, lower relationship quality, and lower levels of partner closeness to friends and family predicted partner change from Time 1 to Time 2. In turn, partner change was associated with acquisition of a new STI at Time 2. Although relationship factors did not exert a direct effect on STI at Time 2, they improved partner change-STI model fit. Similar patterns were seen with each organism. CONCLUSION: Relationship factors drive partner change, which in turn contributes to STI acquisition. STI prevention research may need to focus on the relationship antecedents to partner change, in addition to the partner change itself.Item Obtaining History with a Language Barrier in the Emergency Department: Perhaps not a Barrier After All(eScholarship Publishing, 2018-11) Litzau, Megan; Turner, Joseph; Pettit, Katie; Morgan, Zachary; Cooper, Dylan; Emergency Medicine, School of MedicineItem Prospective Comparison of Ultrasound-Guided Versus Palpation Techniques for Arterial Line Placement by Residents in a Teaching Institution(Accreditation Council for Graduate Medical Education, 2019-04) Yeap, Yar Luan; Wolfe, John W.; Stewart, Jennifer; Backfish, Kevin M.; Anesthesia, School of MedicineBackground: Arterial line insertion is traditionally done by blind palpation. Residents may need multiple attempts for successful insertion, leading to longer procedure times and many failed attempts. Objective: We hypothesized that ultrasound guidance (USG) would be faster and more successful than traditional blind palpation (TBP) for radial artery line placement by residents. Methods: Patients undergoing elective surgery requiring a radial arterial line were randomized to either the USG or TBP groups. Exclusion criteria included a need for arterial line placement in an awake patient, emergent surgery, or American Society of Anesthesiologists (ASA) physical status class VI. After the induction of anesthesia, a postgraduate year 3 (PGY-3) or PGY-4 anesthesia resident placed an arterial line by either USG or TBP. Results: A total of 412 patients and 85 of 106 residents (80%) in the training program were included. The 2 groups were similar with respect to sex, weight, height, ASA class, baseline systolic blood pressure, and baseline heart rate. USG was faster than TBP (mean times 171.1 ± 16.7 seconds versus 243.6 ± 23.5 seconds, P = .012), required fewer attempts (mean 1.78 ± 0.11 versus 2.48 ± 0.15, P = .035), and had an improved success rate (96% versus 90%, P = .012). Conclusions: We found that residents using USG in an academic institution resulted in significantly faster placement of the arterial lines, fewer attempts, and fewer catheters used.Item Race and sex differences in response to endothelin receptor antagonists for pulmonary arterial hypertension(Elsevier, 2012-01) Gabler, Nicole B.; French, Benjamin; Strom, Brian L.; Liu, Ziyue; Palevsky, Harold I.; Taichman, Darren B.; Kawut, Steven M.; Halpern, Scott D.; Biostatistics, School of Public HealthBackground Recently studied therapies for pulmonary arterial hypertension (PAH) have improved outcomes among populations of patients, but little is known about which patients are most likely to respond to specific treatments. Differences in endothelin-1 biology between sexes and between whites and blacks may lead to differences in patients' responses to treatment with endothelin receptor antagonists (ERAs). Methods We conducted pooled analyses of deidentified, patient-level data from six randomized placebo-controlled trials of ERAs submitted to the US Food and Drug Administration to elucidate heterogeneity in treatment response. We estimated the interaction between treatment assignment (ERA vs placebo) and sex and between treatment and white or black race in terms of the change in 6-min walk distance from baseline to 12 weeks. Results Trials included 1,130 participants with a mean age of 49 years; 21% were men, 74% were white, and 6% were black. The placebo-adjusted response to ERAs was 29.7 m (95% CI, 3.7-55.7 m) greater in women than in men (P = .03). The placebo-adjusted response was 42.2 m for whites and −1.4 m for blacks, a difference of 43.6 m (95% CI, −3.5-90.7 m) (P = .07). Similar results were found in sensitivity analyses and in secondary analyses using the outcome of absolute distance walked. Conclusions Women with PAH obtain greater responses to ERAs than do men, and whites may experience a greater treatment benefit than do blacks. This heterogeneity in treatment-response may reflect pathophysiologic differences between sexes and races or distinct disease phenotypes.Item Ten-year results from the Natrelle 410 anatomical form-stable silicone breast implant core study(Oxford University Press, 2015-02) Maxwell, G. Patrick; Van Natta, Bruce W.; Bengtson, Bradley P.; Murphy, Diane K.; Department of Surgery, IU School of MedicineBACKGROUND: Silicone breast implants have long been used for breast augmentation and reconstruction. During this time, these medical devices have gone through a number of modifications to improve their safety, quality, and clinical outcome performance. OBJECTIVES: The authors conducted a 10-year study to determine the safety and effectiveness of Natrelle 410 silicone breast implants. METHODS: This prospective, multicenter study enrolled 941 subjects who were undergoing either augmentation, augmentation revision, reconstruction, or reconstruction revision. Data on complications, reoperations, explantations, and subject satisfaction were collected at annual clinic visits, and one-third of subjects underwent biennial magnetic resonance imaging (MRI) to screen for implant rupture. The authors used the Kaplan-Meier estimator to calculate risk rates for local complications, reoperations, and explantations. RESULTS: Capsular contracture rates increased approximately 1% per year from the previously reported 6-year rates. The rates were significantly lower than those from the Natrelle round gel core study. The overall rate of confirmed ruptured implants in subjects who underwent MRI was 5.7%. Eleven late seromas were reported. The most common reason for explantation was a subject requesting a size or style change. Satisfaction rates remained high through 10 years, with most subjects saying they were somewhat or definitely satisfied with their implants. CONCLUSIONS: This 10-year prospective trial demonstrated the long-term safety and effectiveness of Natrelle 410 anatomical form-stable implants. The complication rates were low and the satisfaction rates were high. LEVEL OF EVIDENCE 1: Therapeutic.Item Virtual Developmental Screening After Invasive Mechanical Ventilation in Children: A Prospective Cohort Pilot Study(Wolters Kluwer, 2022) Bartel, Nicholas J.; Boyle, David W.; Hines, Abbey C.; Tomlin, Angela M.; Nitu, Mara E.; Szczepaniak, Dorota; Abu-Sultaneh, Samer M. A.; Pediatrics, School of MedicineOBJECTIVES: With decreasing PICU mortality, survivor morbidity has increased. This study aims to evaluate feasibility of virtual PICU-led follow-up of patients at risk for pediatric postintensive care syndrome. DESIGN: Prospective cohort study. SETTING: Single-center, quaternary children's hospital. PATIENTS: Children less than or equal to 4 years without known preexisting neurodevelopmental deficits requiring greater than or equal to 12 hours mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age-appropriate Ages and Stages Questionnaires, Third Edition (ASQ-3) were administered via a web-based system at 3, 6, and 12 months following PICU discharge. Primary-care physicians were notified of results; at-risk patients were referred to early developmental intervention. Forty-eight patients enrolled with median age 11.5 months (interquartile range [IQR], 2-19.5 mo) and median mechanical ventilation duration 92.5 hours (IQR, 40.5-147 hr). Fifty-eight percent completed greater than or equal to 1 ASQ-3. Lower caregiver educational achievement, lower income, and single-caregiver status were associated with lower ASQ-3 completion rates. Of those completing any ASQ-3, 50% flagged as at-risk for developmental delay and referred to early developmental intervention. There was no association between patient characteristics and abnormal ASQ-3. CONCLUSIONS: Virtual caregiver-completed surveillance is a promising method to screen children for neurodevelopmental abnormalities following PICU hospitalization and facilitate early referral for developmental intervention, but special attention must be dedicated to families with limited resources for follow-up.