Publications

Suicide risk models are critical for prioritizing patients for intervention. We demonstrate a reproducible approach for training text classifiers to identify patients at risk. The models were effective in phenotyping suicidal behavior (F1=.94) and moderately effective in predicting future events (F1=.63).

BACKGROUND: In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited.

OBJECTIVE: This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies.

STUDY DESIGN: This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates.

RESULTS: Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter.

CONCLUSION: This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.

The management of newly diagnosed primary central nervous system lymphoma (PCNSL) includes administration of high-dose methotrexate based regimens followed by consolidation therapy to minimize the risk of relapse. However, the best consolidation strategy (autologous hematopoietic cell transplant [auto-HCT] vs. whole-brain radiotherapy [WBRT]) is controversial. Hence, we performed a systematic review and meta-analysis of all randomized controlled trials that compared auto-HCT versus WBRT consolidation for patients with PCNSL after first-line treatment.The primary outcome was overall survival (OS), while the secondary outcomes included progression-free survival (PFS), response rates (overall response rate [ORR] and complete remission [CR]), relapse rate, treatment-related mortality (TRM), and neuropsychological adverse events. We performed a pooled analysis of the single-arm studies that incorporated auto-HCT or WBRT consolidation and evaluated neurocognitive outcomes. Only two studies met the inclusion criteria (n = 240). There was no significant difference in OS (HR = 1.50; 95% CI = 0.95-2.36), PFS (HR = 0.99; 95% CI = 0.44-2.22), ORR (RR = 1.48; 95% CI = 0.90-2.44), CR rate (RR = 1.21; 95% CI = 0.90-1.63), relapse rate (RR = 0.46; 95% CI = 0.05-4.28), and TRM (RR = 5.67; 95% CI = 1.01-31.91). The neuropsychological tests to assess neurocognitive domains were different and inconsistently reported in the two studies and therefore we were unable to perform a meta-analysis but provide a descriptive assessment. Both the studies showed a significant decline in the attention/executive function (based on the trail making test A and trail making test B) in those receiving WBRT compared to auto-HCT. We found 9 single-arm phase II studies that reported data on outcomes associated with either auto-HCT (5 studies) or WBRT (4 studies) consolidation. Of these, two studies (n = 43) reported data on neurocognitive decline following auto-HCT consolidation. Pooled proportion of patients with neurocognitive decline in these studies was 6% (95% CI, 0%-17%) for those receiving auto-HCT and there was no heterogeneity between studies (I2  = 0%). Three studies (n = 122) reported data on neurocognitive decline following WBRT consolidation. Pooled proportion of patients with neurocognitive decline in these studies was 43% (95% CI, 11%-78%) for those receiving WBRT and there was high heterogeneity between studies (I2  = 94%). There was significant heterogeneity between subgroups (p = 0.035). The outcomes were not significantly different in patients with PCNSL receiving auto-HCT or WBRT consolidation therapies, however, there is a higher degree of neurocognitive decline associated with WBRT compared to auto-HCT consolidation. The decision to choose a consolidation strategy needs to be individualized based on age, frailty, and co-morbidities.

OBJECTIVE(S): To assess the association between pharmacist intervention counseling with medication adherence and quality of life. Also, to assess if these associations vary by the focus, structure, training, or robustness of the counseling.

METHODS: The initial search identified 1805 references, of which 62 randomized trials (RCTs) met inclusion criteria for the systematic review. Of the 62 RCTs, 60 (with 62 results) had extractable data for the meta-analysis. Data were pooled using a random-effects model.

RESULTS: Most study patients were older and taking multiple prescription drugs. The pooled results showed a statistically significant increase in the odds of medication adherence with the pharmacist counseling intervention versus no counseling (pooled odds ratio [OR] = 4.41; 95% confidence interval [CI] 2.46-7.91; P < 0.01). The results of a subgroup analysis suggest the primary disease, counseling focus, location, and robustness may modify the effect of pharmacist counseling on medication adherence. There was a statistically significant improvement in the quality of life with pharmacist counseling versus no pharmacist counseling (pooled standardized mean difference [SMD] = 0.69; 95% CI 0.41-0.96; P < 0.01). The results of a subgroup analysis suggest that counseling focus, location, training, robustness, and the measurement method, but not the disease category, may modify the effect of pharmacist counseling on quality of life.

CONCLUSION: The evidence supports pharmacist intervention counseling to increase mediation adherence and quality of life. The counseling location and structure may be significant factors in improving medication adherence. The overall methodological quality of evidence was very low.

BACKGROUND: Esophageal dysmotility has been attributed to opioid use. The goal was to assess the differences in pre- and post-treatment timed-barium esophagram (TBE) barium heights at 1 and 5 minutes and symptomatic response to treatment in esophagogastric junction outflow obstruction (EGJOO) patients according to opioid use status.

METHODS: We performed a retrospective cohort study. Consecutive patients with EGJOO were eligible for inclusion. Data were collected on demographics, pre and post-treatment 1 and 5 minutes TBE barium heights and symptom outcomes. Groups were compared according to opioid use.

RESULTS: Thirty-one EGJOO patients met the inclusion criteria. All patients were treated with pneumatic dilation. Of the 31 patients, 11 (35%) had opioid exposure and 20 (65%) did not. The median follow-up post-treatment was two months (range 1-47 months). There was no statistically significant difference in post-treatment outcomes for opioid exposed vs. unexposed groups. The median per cent decrease in the TBE barium height at 1 minute was 100% for the opioid exposed vs. 71% for the unexposed group (p = 0.92). The median per cent decrease in the TBE barium height at 5 minutes was zero % for the opioid exposed and unexposed groups (p = 0.67). The incidence of symptomatic improvement was 82% (9/11) for the opioid exposed group vs 95% (19/20) for the unexposed group (p = 0.28).

CONCLUSIONS: Patients with EGJOO seem to respond to treatment similarly regardless of being on opioids.

The American Diabetes Association's Standards of Medical Care in Diabetes emphasize the need for awareness regarding overbasalization (basal insulin doses >0.5 units/kg/day without bolus insulin) in the treatment of type 2 diabetes. However, outcomes data on the impact of overbasalization are limited. This post hoc analysis of a large randomized controlled trial suggests that an insulin therapy regimen involving overbasalization compared with a basal-bolus insulin regimen that avoids overbasalization is less effective at lowering A1C and may be associated with increased cardiovascular risk. Clinicians should consider alternative approaches to glycemic control before increasing basal insulin doses to >0.5 units/kg/day.

PURPOSE: Modified barium swallow study (MBSS) is a videofluoroscopic evaluation of oropharyngeal swallowing. Views of esophageal bolus flow during MBSS are permitted under speech-language pathology practice guidelines. However, controversy exists over its implementation. Poor consensus and limited practice guidance may lead to clinical practice variations. Aims of the investigation were to (a) describe current practice patterns of speech-language pathologist visualizing bolus flow through the esophagus during the MBSS, (b) understand areas of variation when incorporating esophageal visualization during the MBSS, and (c) determine clinicians' willingness to modify MBSS procedures to include esophageal imaging.

METHOD: A web-based survey (Qualtrics XM) consisting of 26 questions was distributed via web posting and e-mail to members of the American Speech-Language-Hearing Association Special Interest Group 13 and Dysphagia Café. The survey was open for 3 months. Descriptive and associative statistics were completed. Field-testing was performed prior to dissemination of the survey to address content validity.

RESULTS: A total of 321 individuals participated; 265 responses were used for analysis. Ninety-three percent of respondents viewed the esophagus during the MBSS. Twelve percent followed to the proximal esophagus, 15% to the mid esophagus, 66% to the lower esophagus, and 6% to varied levels. Variability was also reported in contrast type, volume administered, and nomenclature used. Interestingly, few people (3.61%) disagreed that esophageal visualization should be performed during MBSS.

CONCLUSIONS: Speech-language pathology respondents in this study visualize contrast flow through the esophagus and are enthusiastic about expanding the standard MBSS. However, results of the survey demonstrate a lack of uniformity in assessment practices. Unfortunately, this may impact the diagnostic accuracy and clinical utility when adding esophageal visualization to the MBSS. This study highlights the need for a standardized protocol and identifies current barriers and controversies that may prevent expanding the MBSS to more comprehensively evaluate individuals with dysphagia.

AIMS: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to have benefit in patients with heart failure (HF). Multiple systematic reviews and meta-analyses (SRs and MAs) of randomized control trials (RCTs) comparing SGLT2i to placebo have been performed. However, there is uncertainty in the quality of the evidence and associated efficacy. We performed an overview of SRs and MAs of RCTs to summarize the evidence related to the efficacy of SGLT2i for the management of HF.

METHODS AND RESULTS: A comprehensive search of three databases (the Cochrane Library, EMBASE, and PubMed) was conducted until February 21, 2021. All SRs of RCTs evaluating the efficacy of SGLT2i in patients with HF were eligible for inclusion. The primary outcome was all-cause mortality. Methodological quality was evaluated using the AMSTAR-2 assessment tool. The overall quality of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. The initial search yielded 3431 references, of which, eight SRs and MAs met the inclusion criteria. The methodological quality ranged from critically low to high. The overall quality of evidence ranged from very low to moderate. Most of the SRs and MAs showed benefits in all-cause mortality, HF-related hospitalizations, and KCCQ score change.

CONCLUSIONS: SGLT2i are possibly beneficial in patients with HF, however, none of the SRs and MAs compared the efficacy between different types of SGLT2i. Furthermore, this paper emphasizes the need for consistent reproducible conduct and reporting of SRs to generate high-quality evidence and facilitate clinical decision-making.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has driven a significant increase in the use of telehealth (TH) but little is published about changes in TH usage by pediatric infectious disease (PID) providers. We assessed their pre- and intra-pandemic TH usage and experience.

METHODS: The Pediatric Infectious Diseases Society Telehealth Work Group surveyed PID specialists in the United States and Canada from 6 December 2020 until 26 February 2021. Data collected included TH modalities, barriers, and satisfaction.

RESULTS: The survey response rate was 11.3% (288 of 2,550 PID clinicians) with 243 (96% of 253 analysis-eligible responses) managing children only. Women accounted for 62.1% (n = 157), 51.4% (130) of respondents devoted 50-99% of their time to direct patient care, and 93.3% (236) were located in the United States. The greatest increase in TH usage during the pandemic was in synchronous provider-patient communications (3.9-fold increase). During the pandemic, provider-provider TH increased by less than 10%, comfort with TH usage doubled from 42% to 91%, and satisfaction grew from 74% to 93.3% with different aspects of TH. The top challenge was incomplete or no physical examination (182, 71.9%). Multivariate analysis showed that pre-pandemic TH usage and lack of barriers, but not reimbursement, were significantly associated with higher intra-pandemic usage. EMR-integrated TH was associated with significantly higher usage and satisfaction. Over 70% of respondents anticipate continuing TH usage after the pandemic.

CONCLUSIONS: There was high intra-pandemic usage of, and increased comfort and satisfaction with telehealth by PID specialists. Our data help inform post-pandemic TH expectations and strategies.