We assess whether patient satisfaction scores differ for individual emergency physicians accordin... more We assess whether patient satisfaction scores differ for individual emergency physicians according to the clinical setting in which patients are treated. We obtained Press Ganey satisfaction survey results from June 2013 to August 2014 for patients treated in either an urban hospital emergency department (ED) or 2 affiliated suburban urgent care centers. The same physicians work in all 3 facilities. Physicians with available survey results from at least 10 patients in both settings were included. Survey scores range from 1 (very poor) to 5 (very good). Survey questions directly assessed physicians' courtesy, ability to keep patients informed about their treatment, concern for patient comfort, listening ability, and the overall care at the facility. We calculated differences in mean urgent care and ED scores for individual physicians, along with the mean of these differences. Our primary outcome was the mean difference between urgent care and ED score with respect to physician co...
Background. Thromboembolic events are major causes of morbidity, and prevention is important. We ... more Background. Thromboembolic events are major causes of morbidity, and prevention is important. We aimed to compare chemical prophylaxis (CP) and mechanical prophylaxis (MP) as methods of prevention in nonsurgical patients on mechanical ventilation. Methods. We performed a retrospective study of adult patients admitted to the Cooper University Hospital ICU between 2002 and 2010. Patients on one modality of prophylaxis throughout their stay were included. The CP group comprised 329 patients and the MP group 419 patients. The primary outcome was incidence of thromboembolic events. Results. Acuity measured by APACHE II score was comparable between the two groups (p = 0.215). Univariate analysis showed 1 DVT/no PEs in the CP group and 12 DVTs/1 PE in the MP group (p = 0.005). Overall mortality was 34.3% and 50.6%, respectively. ICU LOS was similar. Hospital LOS was shorter in the MP group. Multivariate analysis showed a significantly higher incidence of events in the MP prophylaxis group (odds ratio 9.9). After excluding patients admitted for bleeding in both groups, repeat analysis showed again increased events in the MP group (odds ratio 2.9) but this result did not reach statistical significance. Conclusion. Chemical methods for DVT/PE prophylaxis seem superior to mechanical prophylaxis in nonsurgical patients on mechanical ventilation and should be used when possible.
ABSTRACT Antenatal and postpartum depression holds potential serious health risks for a mother an... more ABSTRACT Antenatal and postpartum depression holds potential serious health risks for a mother and her fetus. Treatment modalities are sparsely studied in regards to their efficacy. Participants in the third trimester of pregnancy who scored 10 or greater on the Edinburgh Postnatal Depression Scale were offered psychoeducational sessions. They were given a questionnaire before and after to determine the usefulness of the session. Data from the postpartum Edinburgh Postnatal Depression Scale were compared with the Edinburgh Postnatal Depression Scale scores in the third trimester. Of those qualified to enroll, 39.3% agreed to participate and 9.1% of those participated in psychoeducational sessions. For the pretest survey, the mean score was 72.92 and the average posttest score was 79.17 (P=.108). For the second educational session, the mean pretest score was 67.06 and the posttest score was 89.41 (P=.02). When comparing the Edinburgh Postnatal Depression Scale between the third trimester and the postpartum period for individuals who did not enroll, who enrolled but did not attend an educational course, and who enrolled and attended courses, respectively, the median change was a decrease in score by 9, 7, and 5.50 points (P=.555). There was a general increase in test scores when comparing pretest and posttest surveys; therefore, both courses resulted in a knowledge gain. Our recruitment numbers are small but similar to those in published studies on behavioral therapy intervention. This demonstrates a need to study a more efficient method on how to get these high-risk patients preventative help.
The journal of trauma and acute care surgery, 2015
Bedside procedures are seldom subject to the same safety precautions as operating room (OR) proce... more Bedside procedures are seldom subject to the same safety precautions as operating room (OR) procedures. Since July 2013, we have performed a multidisciplinary checklist before all bedside bronchoscopy-guided percutaneous tracheostomy insertions (BPTIs). We hypothesized that the implementation of this checklist before BPTI would decrease adverse procedural events. A prospective study of all patients who underwent BPTI after checklist implementation (PostCL, 2013-2014, n = 63) at our Level I trauma center were compared to all patients (retrospectively reviewed historical controls) who underwent BPTI without the checklist (PreCL, 2010-2013, n = 184). Exclusion criteria included age less than 16 years, OR, and open tracheostomy. The checklist included both a procedural and timeout component with the trauma technician, respiratory therapist, nurse, and surgeon. Demographics and variables focusing on BPTI risk factors were compared. Variables associated with the primary end point, adverse...
INTRODUCTION A woman has an 11% lifetime risk for pelvic organ prolapse and a third of patients w... more INTRODUCTION A woman has an 11% lifetime risk for pelvic organ prolapse and a third of patients who undergo corrective surgery have repeat procedures. 1 Methods of repair vary greatly and there is limited evidence to help guide surgeons to determine which techniques have better outcomes. The high rates of failure with traditional colporrhaphy 2 have reconstruction. This has led to the debate as to what graft material is best? To help answer this question one has to as well as patient perception regarding success of the surgery and improvement in their quality of life. Our study presented here evaluates the objective, subjective and quality of life outcomes for a single surgeon's use of synthetic mesh over an eighteen month period for the correction of pelvic organ prolapse. MATERIALS AND METHODS After institutional review board approval, a cohort of subjects who underwent polypropylene mesh augmented vaginal reconstruction between June 2005 and December 2006 were asked to partic...
American Journal of Obstetrics and Gynecology, 2014
Cancer is diagnosed in approximately 1 per 1000 pregnant women. Lifesaving cancer therapy given t... more Cancer is diagnosed in approximately 1 per 1000 pregnant women. Lifesaving cancer therapy given to the mother during pregnancy appears in conflict with the interest of the developing fetus. Often, termination of pregnancy is suggested but has not been proven in any type of cancer to improve maternal prognosis, while very few studies have documented the long-term effects of in utero chemotherapy exposure on child outcome. To counsel patients about the risk of continuing a pregnancy while undergoing cancer treatment, we performed developmental testing to provide more detailed follow-up on children exposed in utero to chemotherapy. Mother-infant pairs, enrolled in the Cancer and Pregnancy Registry, were offered developmental testing for children who were ≥18 months of age. Based on age, the Bayley Scales of Infant Development-Third Edition, the Wechsler Preschool and Primary Scale of Intelligence-Revised, the Wechsler Intelligence Scale for Children, Third Edition, or the Wechsler Individual Achievement Test was administered. All parents or primary caregivers completed the Child Behavior Checklist, a parent questionnaire to assess behavior and emotional issues. Results of children exposed to chemotherapy before delivery were compared with children whose mothers were also diagnosed with cancer during pregnancy but did not receive chemotherapy before delivery. No significant differences were noted in cognitive skills, academic achievement, or behavioral competence between the chemotherapy-exposed group and the unexposed children. Of children, 95% scored within normal limits on cognitive assessments; 71% and 79% of children demonstrated at or above age equivalency in mathematics and reading scores, respectively; and 79% of children scored within normal limits on measures of behavior. Older children had significantly higher rates of internalizing behavior problems. We could not demonstrate a significant difference in cognitive ability, school performance, or behavioral competence for children exposed to chemotherapy in utero compared with nonexposed controls. The majority of these children scored within normal limits on all developmental measures. Premature birth was more prevalent in the chemotherapy-exposed group yet did not predict developmental outcome. Older children in the sample demonstrated higher rates of internalizing behavior problems.
Journal of Maternal-Fetal and Neonatal Medicine, 2014
Abstract Objective: To determine the optimal time for initiating group B streptococcus (GBS) anti... more Abstract Objective: To determine the optimal time for initiating group B streptococcus (GBS) antibiotic prophylaxis for women in spontaneous preterm labor. Methods: In total, 227 women delivering singleton infants after presenting with spontaneous preterm labor and intact membranes at 24 0/7-36 6/7 weeks were evaluated, as well as 150 undelivered women with threatened preterm labor during the same time period. The date and time of each cervical examination throughout labor were recorded. We calculated the percentages who would have correctly received at least 4 h of GBS prophylaxis if antibiotics were routinely initiated for various cervical dilatation thresholds during labor, as well as the percentage of undelivered women who would have received unnecessary antibiotic exposure at each cervical dilatation cutoff. Results: Delaying antibiotics until cervical dilatation reached 2 cm or greater would have resulted in 62.1% receiving four or more hours of antibiotics, compared to 66.5% if antibiotics were started on all women at admission (p = 0.33), while significantly reducing unnecessary antibiotic exposure in undelivered women from 100% to 62.0% (p < 0.001). The 2-cm threshold was applicable regardless of gestational age period or prior vaginal delivery ≥ 20 weeks. Conclusions: GBS antibiotic prophylaxis may reasonably be withheld for women with suspected preterm labor until the cervix reaches 2 cm or greater at any time during labor.
Fever and hypothermia (dysthermia) are associated with poor outcomes in patients with brain injur... more Fever and hypothermia (dysthermia) are associated with poor outcomes in patients with brain injuries. The authors sought to study the epidemiology of dysthermia on admission to the intensive care unit (ICU) and the effect on in-hospital case fatality in a mixed cohort of patients with brain injuries. The authors conducted a multicenter retrospective cohort study in 94 ICUs in the United States. Critically ill patients with neurological injuries, including acute ischemic stroke (AIS), aneurysmal subarachnoid hemorrhage (aSAH), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), who were older than 17 years and consecutively admitted to the ICU from 2003 to 2008 were selected for analysis. In total, 13,587 patients were included in this study; AIS was diagnosed in 2973 patients (22%), ICH in 4192 (31%), aSAH in 2346 (17%), and TBI in 4076 (30%). On admission to the ICU, fever was more common among TBI and aSAH patients, and hypothermia was more common among ICH patients. In-hospital case fatality was more common among patients with hypothermia (OR 12.7, 95% CI 8.4-19.4) than among those with fever (OR 1.9, 95% CI 1.7-2.1). Compared with patients with ICH (OR 2.0, 95% CI 1.8-2.3), TBI (OR 1.5, 95% CI 1.3-1.8), and aSAH (OR 1.4, 95% CI 1.2-1.7), patients with AIS who developed fever had the highest risk of death (OR 3.1, 95% CI 2.5-3.7). Although all hypothermic patients had an increased mortality rate, this increase was not significantly different across subgroups. In a multivariable analysis, when adjusted for all other confounders, exposure to fever (adjusted OR 1.3, 95% CI 1.1-1.5) or hypothermia (adjusted OR 7.8, 95% CI 3.9-15.4) on admission to the ICU was found to be significantly associated with in-hospital case fatality. Fever is frequently encountered in the acute phase of brain injury, and a small proportion of patients with brain injuries may also develop spontaneous hypothermia. The effect of fever on mortality rates differed by neurological diagnosis. Both early spontaneous fever and hypothermia conferred a higher risk of in-hospital death after brain injury.
Female Pelvic Medicine & Reconstructive Surgery, 2010
: To determine the attributes and motivation of physicians who pursue fellowship training in the ... more : To determine the attributes and motivation of physicians who pursue fellowship training in the subspecialties of Obstetrics and Gynecology (Ob/Gyn). : We surveyed current fellows and recent graduates from the ABOG recognized subspecialties in Ob/Gyn. Demographics and reasons for pursuing fellowship training were obtained. Significant differences between and among groups were determined using the Mann-Whitney U test and Pearson χ test. : Forty-two percent of those sent a survey responded. The majority were between ages 30 to 35 (65.7%), female (60.5%), married (74.5%), and White (68.8%). Over 55% in each subspecialty cited interest in subject area as the primary reason for choosing their fellowship. : Interest in subject remains the primary motivation for the majority of physicians choosing subspecialty fellowship training in Ob/Gyn. There is considerably more variation regarding what physicians' secondary motivation is and these reasons appear to vary according to the particular subspecialty.
To determine the prevalence of vitamin C (ascorbic acid [AA]) deficiency in patients with end-sta... more To determine the prevalence of vitamin C (ascorbic acid [AA]) deficiency in patients with end-stage renal disease, the effect of supplemental AA on plasma AA concentrations, and the extrinsic and intrinsic factors that affect plasma AA concentrations in this patient population. In study 1, we compared the effect of hemodialysis (HD) on plasma AA concentrations between patients with low and high pre-HD AA concentrations. In study 2, we analyzed kinetic and nonkinetic factors for their association with increased plasma AA concentrations in patients on maintenance HD. Study 1 was performed in a single outpatient HD clinic in Cherry Hill, New Jersey. Study 2 was performed in 4 outpatient HD clinics in Southern New Jersey. In study 1, we collected plasma samples from 8 adult patients on maintenance HD at various time points around their HD treatment and assayed them for AA concentration. In study 2, we enrolled 203 adult patients and measured pre-HD plasma AA concentrations. We ascertained supplemental AA use and assessed dietary AA intake. In study 1, plasma AA concentrations were compared during the intradialytic and interdialytic period. In study 2, pre-HD plasma AA concentrations were correlated with supplement use and demographic factors. Study 1 showed that over the course of a single HD treatment, the plasma AA concentration decreased by a mean (±standard deviation) of 60% (±6.6). In study 2, the median pre-HD plasma AA concentration was 15.7 μM (interquartile range, 8.7-66.8) in patients who did not take a supplement and 50.6 μM (interquartile range, 25.1-88.8) in patients who did take a supplement (P < .001). Supplement use, increasing age, and diabetes mellitus were associated with a pre-HD plasma AA concentration ≥30 μM. HD depletes plasma AA concentrations, and AA supplementation allows patients to achieve higher plasma AA concentrations.
Antimicrobial agents used to treat Clostridium difficile infection (CDI), such as metronidazole a... more Antimicrobial agents used to treat Clostridium difficile infection (CDI), such as metronidazole and vancomycin, have been used during antibiotic treatment of other infections to try to prevent the development of CDI. We evaluated the hypothesis that intensive care unit (ICU) patients who receive metronidazole as part of an antibiotic treatment regimen for sepsis have a lower risk of subsequently developing CDI. This was a nested case-control study in a cohort of ICU patients who received antibiotic therapy for sepsis. A total of 10 012 patients aged ≥ 18 years were admitted to the Cooper University Hospital medical/surgical ICU from 1/1/2003 to 12/31/2008. After applying inclusion criteria including having received antibiotic therapy for sepsis and subsequently having developed CDI, 67 cases were identified. The cases were matched for age, gender, date of ICU admission, and hospital length of stay to 67 controls that also received antibiotic therapy for sepsis but did not subsequently develop CDI. In the multivariate analysis, there was no association between metronidazole exposure and the risk of CDI (odds ratio (OR) = 0.57; p = 0.23). The only significant associations on multivariate analysis were antifungal therapy (OR = 0.30; p = 0.02) and aminoglycoside and/or colistin therapy (OR = 0.17; p = 0.02). No association was found between metronidazole use and subsequent CDI in ICU patients who received antibiotic therapy for sepsis.
Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) ca... more Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) care. This pilot study explored the impact of a curriculum designed to prepare future pediatricians to manage pain and provide comfort for children and infants with life-threatening conditions and to be more confident and competent in their EOL discussions with families. Participants included 8 postgraduate year (PGY)-2 residents in the study group and 9 PGY-3 residents in a control group. The EOL curriculum included 4, 1-hour sessions consisting of didactic lectures, videos, and small-group, interactive discussions. Topics included discussing EOL with families, withdrawal of care, and pain assessment and management. Curriculum evaluation used an objective structured clinical examination (OSCE), self-assessment confidence and competency questionnaire, and a follow-up survey 18 months after the intervention. The OSCE showed no statistically significant differences between PGY-2 versus PGY-3 residents in discussing EOL issues with family (mean = 48.3 [PGY-2] versus 41.0 [PGY-3]), managing withdrawal of care (mean = 20.9 [PGY-2] versus 18.91 [PGY-3]), and managing adolescent pain (mean = 30.97 [PGY-2] versus 29.27 [PGY-3]). The self-assessment confidence and competency scores improved significantly after the intervention for both PGY-2 residents (0.62 versus 0.86, P < .01) and PGY-3 residents (0.61 versus 0.85, P < .01). An EOL curriculum for PGY-2 pediatrics residents delivered during the intensive care unit rotation is feasible and may be effective. Residents reported the curriculum was useful in their practice.
ABSTRACT It is well established that administration of glucocorticoids to women with an expected ... more ABSTRACT It is well established that administration of glucocorticoids to women with an expected preterm delivery decreases the incidence of respiratory distress syndrome (RDS) among infants delivered between 24 and 34 weeks’ gestation. Moreover, there is strong evidence that glucocorticoid administration significantly reduces the incidence of other indices of morbidity and improves survival. The standard regimen used in expectant mothers at risk for preterm delivery is 2 doses of betamethasone administered 24 hours apart. This regimen has been endorsed by the National Institutes of Health. This dosage interval was arbitrarily chosen in the initial studies investigating the effectiveness of glucocorticoids in this population. Increasing evidence suggests that the total dosage, rather than the interval, is important to achieve maximal neonatal benefit. The aim of this prospective, randomized, open study was to determine whether a regimen of administering betamethasone 12 hours apart would be as effective as the standard interval of 24 hours apart in preventing the occurrence of RDS in preterm infants. The study population was composed of mothers with singleton or multiple pregnancies between the gestational ages of 23 and 34 weeks who were at risk for preterm delivery. Eligible subjects were randomized to receive 2 doses of betamethasone 12 or 24 hours apart. There was no significant difference between the 2 cohorts in the incidence of RDS (36.5% vs 37.3%, P = NS). Approximately 12% of the women with the 24-hour dosage interval were unable to receive the complete course of corticosteroids. With the 12-hour dosing interval, this percentage was reduced to only 5%. An increased incidence of necrotizing enterocolitis among neonates was found with the 12-hour dosing (6.2% vs 0%, P = 0.03); however, this complication occurred infrequently, and the numbers available for analysis were small. These findings suggest that a betamethasone dosing interval of either 12 or 24 hours apart is equally effective for preventing RDS in neonates of expectant mothers at risk for premature birth.
To summarize trends in status epilepticus (SE) in the United States by age, race, sex, admission ... more To summarize trends in status epilepticus (SE) in the United States by age, race, sex, admission source, disposition, incidence rates, and mortality. Data from US National Hospital Discharge Survey were used from 1979 to 2010 to identify discharges with SE and common etiologies and complications of SE using International Classification of Diseases, 9th Revision, Clinical Modifications codes. Temporal trends in the incidence and in-hospital mortality of SE were examined with respect to age, sex, and race. We identified 760,117 discharges with SE over 32 years. The incidence of SE increased from 3.5 to 12.5/100,000 between 1979 and 2010, without a significant change in in-hospital mortality. Higher incidence, earlier age of onset, and higher mortality were observed among males. Age stratification revealed a "U-shaped" distribution with higher incidence at age <10 years (14.3/100,000) and age >50 years (approaching 28.4/100,000). In-hospital mortality, however, was the lowest (2.6 %) at age <10 years and approached 20.2 % with age ≥80 years. The incidence of SE was higher among blacks (13.7/100,000), compared to whites (6.9/100,000) and other races (7.4/100,000). Mortality, however, was lower among blacks (7.2 %) compared to whites and other races (9.8 and 9.2 %, respectively). Black men had the highest incidence (15.0/100,000), relatively younger age of onset (39.3 years) and the lowest mortality (5.6 %). A net temporal decline in the reported prevalence of epilepsy, central nervous system infections, and traumatic brain injury was noted among SE cohort. The incidence of SE increased nearly fourfold with relatively unchanged mortality. Gender and racial disparities exist in the incidence of SE, and age is an important predictor of mortality.
Most US hospitals distribute industry-sponsored formula sample packs. No research has examined ou... more Most US hospitals distribute industry-sponsored formula sample packs. No research has examined outcomes associated with sample pack removal as part of a hospital intervention to eliminate sample distribution postpartum. To examine prospectively hospital-based and breastfeeding outcomes associated with removal of industry-sponsored formula sample packs from the hospital. We enrolled mothers postpartum at Cooper University Hospital, an urban New Jersey hospital, in 2009-2010. For the first 6 months, all women received industry-sponsored formula samples packs (control group); for the next 6 months, all postpartum women received hospital-sponsored bags with no formula at source (intervention group). Research assistants blinded to the design called subjects weekly for 10 weeks to determine feeding practices. We enrolled 527 breastfeeding women (284 control; 243 intervention). At 10 weeks postpartum, 82% of control and 36% of intervention women (P < .001) reported receiving formula in the "diaper discharge bag." Kaplan-Meyer curves for any breastfeeding showed the intervention was associated with increased breastfeeding (P = .03); however, exclusive breastfeeding was not significantly different between intervention and controls (P = .46). In post hoc analysis, receiving no take-home formula in bottles from the hospital was associated with increased exclusive breastfeeding in control (P = .02) and intervention (P = .03) groups at 10 weeks. Although the hospital-branded replacement contained no formula at source, many women reported receiving bottles of formula from the hospital. Change in practice to remove industry-sponsored formula sample packs was associated with increased breastfeeding over 10 weeks, but the intervention may have had a greater impact had it not been contaminated.
We assess whether patient satisfaction scores differ for individual emergency physicians accordin... more We assess whether patient satisfaction scores differ for individual emergency physicians according to the clinical setting in which patients are treated. We obtained Press Ganey satisfaction survey results from June 2013 to August 2014 for patients treated in either an urban hospital emergency department (ED) or 2 affiliated suburban urgent care centers. The same physicians work in all 3 facilities. Physicians with available survey results from at least 10 patients in both settings were included. Survey scores range from 1 (very poor) to 5 (very good). Survey questions directly assessed physicians' courtesy, ability to keep patients informed about their treatment, concern for patient comfort, listening ability, and the overall care at the facility. We calculated differences in mean urgent care and ED scores for individual physicians, along with the mean of these differences. Our primary outcome was the mean difference between urgent care and ED score with respect to physician co...
Background. Thromboembolic events are major causes of morbidity, and prevention is important. We ... more Background. Thromboembolic events are major causes of morbidity, and prevention is important. We aimed to compare chemical prophylaxis (CP) and mechanical prophylaxis (MP) as methods of prevention in nonsurgical patients on mechanical ventilation. Methods. We performed a retrospective study of adult patients admitted to the Cooper University Hospital ICU between 2002 and 2010. Patients on one modality of prophylaxis throughout their stay were included. The CP group comprised 329 patients and the MP group 419 patients. The primary outcome was incidence of thromboembolic events. Results. Acuity measured by APACHE II score was comparable between the two groups (p = 0.215). Univariate analysis showed 1 DVT/no PEs in the CP group and 12 DVTs/1 PE in the MP group (p = 0.005). Overall mortality was 34.3% and 50.6%, respectively. ICU LOS was similar. Hospital LOS was shorter in the MP group. Multivariate analysis showed a significantly higher incidence of events in the MP prophylaxis group (odds ratio 9.9). After excluding patients admitted for bleeding in both groups, repeat analysis showed again increased events in the MP group (odds ratio 2.9) but this result did not reach statistical significance. Conclusion. Chemical methods for DVT/PE prophylaxis seem superior to mechanical prophylaxis in nonsurgical patients on mechanical ventilation and should be used when possible.
ABSTRACT Antenatal and postpartum depression holds potential serious health risks for a mother an... more ABSTRACT Antenatal and postpartum depression holds potential serious health risks for a mother and her fetus. Treatment modalities are sparsely studied in regards to their efficacy. Participants in the third trimester of pregnancy who scored 10 or greater on the Edinburgh Postnatal Depression Scale were offered psychoeducational sessions. They were given a questionnaire before and after to determine the usefulness of the session. Data from the postpartum Edinburgh Postnatal Depression Scale were compared with the Edinburgh Postnatal Depression Scale scores in the third trimester. Of those qualified to enroll, 39.3% agreed to participate and 9.1% of those participated in psychoeducational sessions. For the pretest survey, the mean score was 72.92 and the average posttest score was 79.17 (P=.108). For the second educational session, the mean pretest score was 67.06 and the posttest score was 89.41 (P=.02). When comparing the Edinburgh Postnatal Depression Scale between the third trimester and the postpartum period for individuals who did not enroll, who enrolled but did not attend an educational course, and who enrolled and attended courses, respectively, the median change was a decrease in score by 9, 7, and 5.50 points (P=.555). There was a general increase in test scores when comparing pretest and posttest surveys; therefore, both courses resulted in a knowledge gain. Our recruitment numbers are small but similar to those in published studies on behavioral therapy intervention. This demonstrates a need to study a more efficient method on how to get these high-risk patients preventative help.
The journal of trauma and acute care surgery, 2015
Bedside procedures are seldom subject to the same safety precautions as operating room (OR) proce... more Bedside procedures are seldom subject to the same safety precautions as operating room (OR) procedures. Since July 2013, we have performed a multidisciplinary checklist before all bedside bronchoscopy-guided percutaneous tracheostomy insertions (BPTIs). We hypothesized that the implementation of this checklist before BPTI would decrease adverse procedural events. A prospective study of all patients who underwent BPTI after checklist implementation (PostCL, 2013-2014, n = 63) at our Level I trauma center were compared to all patients (retrospectively reviewed historical controls) who underwent BPTI without the checklist (PreCL, 2010-2013, n = 184). Exclusion criteria included age less than 16 years, OR, and open tracheostomy. The checklist included both a procedural and timeout component with the trauma technician, respiratory therapist, nurse, and surgeon. Demographics and variables focusing on BPTI risk factors were compared. Variables associated with the primary end point, adverse...
INTRODUCTION A woman has an 11% lifetime risk for pelvic organ prolapse and a third of patients w... more INTRODUCTION A woman has an 11% lifetime risk for pelvic organ prolapse and a third of patients who undergo corrective surgery have repeat procedures. 1 Methods of repair vary greatly and there is limited evidence to help guide surgeons to determine which techniques have better outcomes. The high rates of failure with traditional colporrhaphy 2 have reconstruction. This has led to the debate as to what graft material is best? To help answer this question one has to as well as patient perception regarding success of the surgery and improvement in their quality of life. Our study presented here evaluates the objective, subjective and quality of life outcomes for a single surgeon's use of synthetic mesh over an eighteen month period for the correction of pelvic organ prolapse. MATERIALS AND METHODS After institutional review board approval, a cohort of subjects who underwent polypropylene mesh augmented vaginal reconstruction between June 2005 and December 2006 were asked to partic...
American Journal of Obstetrics and Gynecology, 2014
Cancer is diagnosed in approximately 1 per 1000 pregnant women. Lifesaving cancer therapy given t... more Cancer is diagnosed in approximately 1 per 1000 pregnant women. Lifesaving cancer therapy given to the mother during pregnancy appears in conflict with the interest of the developing fetus. Often, termination of pregnancy is suggested but has not been proven in any type of cancer to improve maternal prognosis, while very few studies have documented the long-term effects of in utero chemotherapy exposure on child outcome. To counsel patients about the risk of continuing a pregnancy while undergoing cancer treatment, we performed developmental testing to provide more detailed follow-up on children exposed in utero to chemotherapy. Mother-infant pairs, enrolled in the Cancer and Pregnancy Registry, were offered developmental testing for children who were ≥18 months of age. Based on age, the Bayley Scales of Infant Development-Third Edition, the Wechsler Preschool and Primary Scale of Intelligence-Revised, the Wechsler Intelligence Scale for Children, Third Edition, or the Wechsler Individual Achievement Test was administered. All parents or primary caregivers completed the Child Behavior Checklist, a parent questionnaire to assess behavior and emotional issues. Results of children exposed to chemotherapy before delivery were compared with children whose mothers were also diagnosed with cancer during pregnancy but did not receive chemotherapy before delivery. No significant differences were noted in cognitive skills, academic achievement, or behavioral competence between the chemotherapy-exposed group and the unexposed children. Of children, 95% scored within normal limits on cognitive assessments; 71% and 79% of children demonstrated at or above age equivalency in mathematics and reading scores, respectively; and 79% of children scored within normal limits on measures of behavior. Older children had significantly higher rates of internalizing behavior problems. We could not demonstrate a significant difference in cognitive ability, school performance, or behavioral competence for children exposed to chemotherapy in utero compared with nonexposed controls. The majority of these children scored within normal limits on all developmental measures. Premature birth was more prevalent in the chemotherapy-exposed group yet did not predict developmental outcome. Older children in the sample demonstrated higher rates of internalizing behavior problems.
Journal of Maternal-Fetal and Neonatal Medicine, 2014
Abstract Objective: To determine the optimal time for initiating group B streptococcus (GBS) anti... more Abstract Objective: To determine the optimal time for initiating group B streptococcus (GBS) antibiotic prophylaxis for women in spontaneous preterm labor. Methods: In total, 227 women delivering singleton infants after presenting with spontaneous preterm labor and intact membranes at 24 0/7-36 6/7 weeks were evaluated, as well as 150 undelivered women with threatened preterm labor during the same time period. The date and time of each cervical examination throughout labor were recorded. We calculated the percentages who would have correctly received at least 4 h of GBS prophylaxis if antibiotics were routinely initiated for various cervical dilatation thresholds during labor, as well as the percentage of undelivered women who would have received unnecessary antibiotic exposure at each cervical dilatation cutoff. Results: Delaying antibiotics until cervical dilatation reached 2 cm or greater would have resulted in 62.1% receiving four or more hours of antibiotics, compared to 66.5% if antibiotics were started on all women at admission (p = 0.33), while significantly reducing unnecessary antibiotic exposure in undelivered women from 100% to 62.0% (p < 0.001). The 2-cm threshold was applicable regardless of gestational age period or prior vaginal delivery ≥ 20 weeks. Conclusions: GBS antibiotic prophylaxis may reasonably be withheld for women with suspected preterm labor until the cervix reaches 2 cm or greater at any time during labor.
Fever and hypothermia (dysthermia) are associated with poor outcomes in patients with brain injur... more Fever and hypothermia (dysthermia) are associated with poor outcomes in patients with brain injuries. The authors sought to study the epidemiology of dysthermia on admission to the intensive care unit (ICU) and the effect on in-hospital case fatality in a mixed cohort of patients with brain injuries. The authors conducted a multicenter retrospective cohort study in 94 ICUs in the United States. Critically ill patients with neurological injuries, including acute ischemic stroke (AIS), aneurysmal subarachnoid hemorrhage (aSAH), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), who were older than 17 years and consecutively admitted to the ICU from 2003 to 2008 were selected for analysis. In total, 13,587 patients were included in this study; AIS was diagnosed in 2973 patients (22%), ICH in 4192 (31%), aSAH in 2346 (17%), and TBI in 4076 (30%). On admission to the ICU, fever was more common among TBI and aSAH patients, and hypothermia was more common among ICH patients. In-hospital case fatality was more common among patients with hypothermia (OR 12.7, 95% CI 8.4-19.4) than among those with fever (OR 1.9, 95% CI 1.7-2.1). Compared with patients with ICH (OR 2.0, 95% CI 1.8-2.3), TBI (OR 1.5, 95% CI 1.3-1.8), and aSAH (OR 1.4, 95% CI 1.2-1.7), patients with AIS who developed fever had the highest risk of death (OR 3.1, 95% CI 2.5-3.7). Although all hypothermic patients had an increased mortality rate, this increase was not significantly different across subgroups. In a multivariable analysis, when adjusted for all other confounders, exposure to fever (adjusted OR 1.3, 95% CI 1.1-1.5) or hypothermia (adjusted OR 7.8, 95% CI 3.9-15.4) on admission to the ICU was found to be significantly associated with in-hospital case fatality. Fever is frequently encountered in the acute phase of brain injury, and a small proportion of patients with brain injuries may also develop spontaneous hypothermia. The effect of fever on mortality rates differed by neurological diagnosis. Both early spontaneous fever and hypothermia conferred a higher risk of in-hospital death after brain injury.
Female Pelvic Medicine & Reconstructive Surgery, 2010
: To determine the attributes and motivation of physicians who pursue fellowship training in the ... more : To determine the attributes and motivation of physicians who pursue fellowship training in the subspecialties of Obstetrics and Gynecology (Ob/Gyn). : We surveyed current fellows and recent graduates from the ABOG recognized subspecialties in Ob/Gyn. Demographics and reasons for pursuing fellowship training were obtained. Significant differences between and among groups were determined using the Mann-Whitney U test and Pearson χ test. : Forty-two percent of those sent a survey responded. The majority were between ages 30 to 35 (65.7%), female (60.5%), married (74.5%), and White (68.8%). Over 55% in each subspecialty cited interest in subject area as the primary reason for choosing their fellowship. : Interest in subject remains the primary motivation for the majority of physicians choosing subspecialty fellowship training in Ob/Gyn. There is considerably more variation regarding what physicians' secondary motivation is and these reasons appear to vary according to the particular subspecialty.
To determine the prevalence of vitamin C (ascorbic acid [AA]) deficiency in patients with end-sta... more To determine the prevalence of vitamin C (ascorbic acid [AA]) deficiency in patients with end-stage renal disease, the effect of supplemental AA on plasma AA concentrations, and the extrinsic and intrinsic factors that affect plasma AA concentrations in this patient population. In study 1, we compared the effect of hemodialysis (HD) on plasma AA concentrations between patients with low and high pre-HD AA concentrations. In study 2, we analyzed kinetic and nonkinetic factors for their association with increased plasma AA concentrations in patients on maintenance HD. Study 1 was performed in a single outpatient HD clinic in Cherry Hill, New Jersey. Study 2 was performed in 4 outpatient HD clinics in Southern New Jersey. In study 1, we collected plasma samples from 8 adult patients on maintenance HD at various time points around their HD treatment and assayed them for AA concentration. In study 2, we enrolled 203 adult patients and measured pre-HD plasma AA concentrations. We ascertained supplemental AA use and assessed dietary AA intake. In study 1, plasma AA concentrations were compared during the intradialytic and interdialytic period. In study 2, pre-HD plasma AA concentrations were correlated with supplement use and demographic factors. Study 1 showed that over the course of a single HD treatment, the plasma AA concentration decreased by a mean (±standard deviation) of 60% (±6.6). In study 2, the median pre-HD plasma AA concentration was 15.7 μM (interquartile range, 8.7-66.8) in patients who did not take a supplement and 50.6 μM (interquartile range, 25.1-88.8) in patients who did take a supplement (P < .001). Supplement use, increasing age, and diabetes mellitus were associated with a pre-HD plasma AA concentration ≥30 μM. HD depletes plasma AA concentrations, and AA supplementation allows patients to achieve higher plasma AA concentrations.
Antimicrobial agents used to treat Clostridium difficile infection (CDI), such as metronidazole a... more Antimicrobial agents used to treat Clostridium difficile infection (CDI), such as metronidazole and vancomycin, have been used during antibiotic treatment of other infections to try to prevent the development of CDI. We evaluated the hypothesis that intensive care unit (ICU) patients who receive metronidazole as part of an antibiotic treatment regimen for sepsis have a lower risk of subsequently developing CDI. This was a nested case-control study in a cohort of ICU patients who received antibiotic therapy for sepsis. A total of 10 012 patients aged ≥ 18 years were admitted to the Cooper University Hospital medical/surgical ICU from 1/1/2003 to 12/31/2008. After applying inclusion criteria including having received antibiotic therapy for sepsis and subsequently having developed CDI, 67 cases were identified. The cases were matched for age, gender, date of ICU admission, and hospital length of stay to 67 controls that also received antibiotic therapy for sepsis but did not subsequently develop CDI. In the multivariate analysis, there was no association between metronidazole exposure and the risk of CDI (odds ratio (OR) = 0.57; p = 0.23). The only significant associations on multivariate analysis were antifungal therapy (OR = 0.30; p = 0.02) and aminoglycoside and/or colistin therapy (OR = 0.17; p = 0.02). No association was found between metronidazole use and subsequent CDI in ICU patients who received antibiotic therapy for sepsis.
Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) ca... more Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) care. This pilot study explored the impact of a curriculum designed to prepare future pediatricians to manage pain and provide comfort for children and infants with life-threatening conditions and to be more confident and competent in their EOL discussions with families. Participants included 8 postgraduate year (PGY)-2 residents in the study group and 9 PGY-3 residents in a control group. The EOL curriculum included 4, 1-hour sessions consisting of didactic lectures, videos, and small-group, interactive discussions. Topics included discussing EOL with families, withdrawal of care, and pain assessment and management. Curriculum evaluation used an objective structured clinical examination (OSCE), self-assessment confidence and competency questionnaire, and a follow-up survey 18 months after the intervention. The OSCE showed no statistically significant differences between PGY-2 versus PGY-3 residents in discussing EOL issues with family (mean = 48.3 [PGY-2] versus 41.0 [PGY-3]), managing withdrawal of care (mean = 20.9 [PGY-2] versus 18.91 [PGY-3]), and managing adolescent pain (mean = 30.97 [PGY-2] versus 29.27 [PGY-3]). The self-assessment confidence and competency scores improved significantly after the intervention for both PGY-2 residents (0.62 versus 0.86, P < .01) and PGY-3 residents (0.61 versus 0.85, P < .01). An EOL curriculum for PGY-2 pediatrics residents delivered during the intensive care unit rotation is feasible and may be effective. Residents reported the curriculum was useful in their practice.
ABSTRACT It is well established that administration of glucocorticoids to women with an expected ... more ABSTRACT It is well established that administration of glucocorticoids to women with an expected preterm delivery decreases the incidence of respiratory distress syndrome (RDS) among infants delivered between 24 and 34 weeks’ gestation. Moreover, there is strong evidence that glucocorticoid administration significantly reduces the incidence of other indices of morbidity and improves survival. The standard regimen used in expectant mothers at risk for preterm delivery is 2 doses of betamethasone administered 24 hours apart. This regimen has been endorsed by the National Institutes of Health. This dosage interval was arbitrarily chosen in the initial studies investigating the effectiveness of glucocorticoids in this population. Increasing evidence suggests that the total dosage, rather than the interval, is important to achieve maximal neonatal benefit. The aim of this prospective, randomized, open study was to determine whether a regimen of administering betamethasone 12 hours apart would be as effective as the standard interval of 24 hours apart in preventing the occurrence of RDS in preterm infants. The study population was composed of mothers with singleton or multiple pregnancies between the gestational ages of 23 and 34 weeks who were at risk for preterm delivery. Eligible subjects were randomized to receive 2 doses of betamethasone 12 or 24 hours apart. There was no significant difference between the 2 cohorts in the incidence of RDS (36.5% vs 37.3%, P = NS). Approximately 12% of the women with the 24-hour dosage interval were unable to receive the complete course of corticosteroids. With the 12-hour dosing interval, this percentage was reduced to only 5%. An increased incidence of necrotizing enterocolitis among neonates was found with the 12-hour dosing (6.2% vs 0%, P = 0.03); however, this complication occurred infrequently, and the numbers available for analysis were small. These findings suggest that a betamethasone dosing interval of either 12 or 24 hours apart is equally effective for preventing RDS in neonates of expectant mothers at risk for premature birth.
To summarize trends in status epilepticus (SE) in the United States by age, race, sex, admission ... more To summarize trends in status epilepticus (SE) in the United States by age, race, sex, admission source, disposition, incidence rates, and mortality. Data from US National Hospital Discharge Survey were used from 1979 to 2010 to identify discharges with SE and common etiologies and complications of SE using International Classification of Diseases, 9th Revision, Clinical Modifications codes. Temporal trends in the incidence and in-hospital mortality of SE were examined with respect to age, sex, and race. We identified 760,117 discharges with SE over 32 years. The incidence of SE increased from 3.5 to 12.5/100,000 between 1979 and 2010, without a significant change in in-hospital mortality. Higher incidence, earlier age of onset, and higher mortality were observed among males. Age stratification revealed a "U-shaped" distribution with higher incidence at age <10 years (14.3/100,000) and age >50 years (approaching 28.4/100,000). In-hospital mortality, however, was the lowest (2.6 %) at age <10 years and approached 20.2 % with age ≥80 years. The incidence of SE was higher among blacks (13.7/100,000), compared to whites (6.9/100,000) and other races (7.4/100,000). Mortality, however, was lower among blacks (7.2 %) compared to whites and other races (9.8 and 9.2 %, respectively). Black men had the highest incidence (15.0/100,000), relatively younger age of onset (39.3 years) and the lowest mortality (5.6 %). A net temporal decline in the reported prevalence of epilepsy, central nervous system infections, and traumatic brain injury was noted among SE cohort. The incidence of SE increased nearly fourfold with relatively unchanged mortality. Gender and racial disparities exist in the incidence of SE, and age is an important predictor of mortality.
Most US hospitals distribute industry-sponsored formula sample packs. No research has examined ou... more Most US hospitals distribute industry-sponsored formula sample packs. No research has examined outcomes associated with sample pack removal as part of a hospital intervention to eliminate sample distribution postpartum. To examine prospectively hospital-based and breastfeeding outcomes associated with removal of industry-sponsored formula sample packs from the hospital. We enrolled mothers postpartum at Cooper University Hospital, an urban New Jersey hospital, in 2009-2010. For the first 6 months, all women received industry-sponsored formula samples packs (control group); for the next 6 months, all postpartum women received hospital-sponsored bags with no formula at source (intervention group). Research assistants blinded to the design called subjects weekly for 10 weeks to determine feeding practices. We enrolled 527 breastfeeding women (284 control; 243 intervention). At 10 weeks postpartum, 82% of control and 36% of intervention women (P < .001) reported receiving formula in the "diaper discharge bag." Kaplan-Meyer curves for any breastfeeding showed the intervention was associated with increased breastfeeding (P = .03); however, exclusive breastfeeding was not significantly different between intervention and controls (P = .46). In post hoc analysis, receiving no take-home formula in bottles from the hospital was associated with increased exclusive breastfeeding in control (P = .02) and intervention (P = .03) groups at 10 weeks. Although the hospital-branded replacement contained no formula at source, many women reported receiving bottles of formula from the hospital. Change in practice to remove industry-sponsored formula sample packs was associated with increased breastfeeding over 10 weeks, but the intervention may have had a greater impact had it not been contaminated.
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