US Academic Health Centers Research Articles

Osteoporosis is not associated with reoperation or pseudarthrosis after anterior cervical discectomy and fusion through 4-years’ follow-up: a retrospective cohort study of US academic health centers

BACKGROUND CONTEXTOsteoporosis has been proposed as a risk factor for reoperation after anterior cervical discectomy and fusion (ACDF), yet this potential association has been understudied, with conflicting results to date. PURPOSEThis study examines the hypothesis that adults with osteoporosis would have an increased risk of reoperation after ACDF compared to matched adults without osteoporosis. STUDY DESIGN/SETTINGRetrospective cohort study. PATIENT SAMPLETwo matched cohorts (mean age: 62 years; 75% female), each with 1,019 patients, who underwent primary ACDF. Cohorts were determined by the presence or absence of a diagnosis of osteoporosis. OUTCOME MEASURESIncidence of reoperation occurring over 4 years postoperatively, with our primary outcome being the risk ratio (RR) of reoperation with 95% confidence intervals (CI). Secondary outcomes included risk and mean count of oral opioid prescriptions and risk of pseudoarthrosis. METHODSWe utilized the TriNetX network to identify adults undergoing their first ACDF from 2004 to 2020, excluding those with serious pathology, and divided patients into 2 cohorts: osteoporosis and nonosteoporosis. Patients were propensity matched according to key risk factors for reoperation. RESULTSPatients with osteoporosis had no statistically significant or meaningful difference in risk of reoperation compared to nonosteoporotic patients over 4-years’ follow-up [95% CI] (17.3% vs. 16.5%; RR: 1.05 [0.86, 1.27]; p=.6361). Similarly, there were no significant differences in the risk of pseudoarthrosis (26.5% vs. 29.1%; RR: 0.91 [0.79, 1.05]; p=.1820), oral opioid prescription (75.0% vs. 76.0%; RR: 0.99 [0.94, 1.04]; p=.6067), or mean oral opioid prescription count (11.5 vs. 11.8; p=.7040). CONCLUSIONCompared to matched nonosteoporosis controls, osteoporosis was not associated with a statistically significant or clinically meaningful increase in risk of reoperation in adults over 4 years after ACDF. Furthermore, osteoporosis was not associated with a significant or meaningful risk of pseudoarthrosis or oral opioid prescription after ACDF, although more research is needed for corroboration. Additional research is needed to clarify whether those with osteoporosis have meaningful differences in pain and function compared to those without osteoporosis following ACDF.

Experiences of Leaders in Diversity, Equity, and Inclusion in US Academic Health Centers

The murder of George Floyd in 2020 spurred an outpouring of calls for racial justice in the United States, including within academic medicine. In response, academic health centers announced new antiracism initiatives and expanded their administrative positions related to diversity, equity, and/or inclusion (DEI). To understand the experiences of DEI leaders at US allopathic medical schools and academic health centers, ie, the structure of their role, official and unofficial responsibilities, access to resources, institutional support, and challenges. This qualitative study used key informant interviews with participants who held formal DEI positions in their school of medicine, health system, or department. Interviews were conducted from December 2020 to September 2021. Transcripts were coded using a phenomenographic approach, with iterative concurrent analysis to identify thematic categories across participants. Data were analyzed from January to December 2021. Formal DEI role. Questions elicited reflection on the responsibilities of the role and the strengths and challenges of the unit or office. A total of 32 participants (18 of 30 [56%] cisgender women; 16 [50%] Black or African American, 6 [19%] Latinx or Hispanic, and 8 [25%] White) from 27 institutions with a mean (range) of 14 (3-43) years of experience in medical education were interviewed. More than half held a dean position (17 [53%]), and multiple participants held 2 or more titled DEI roles (4 [13%]). Two-thirds self-identified as underrepresented in medicine (20 [63%]) and one-third as first generation to attend college (11 [34%]). Key themes reflected ongoing challenges for DEI leaders, including (1) variability in roles, responsibilities, and access to resources, both across participants and institutions as well as within the same position over time; (2) mismatch between institutional investments and directives, including insufficient authority, support staff, and/or funding, and reduced efficacy due to lack of integration with other units within the school or health system; (3) lack of evidence-based practices, theories of change, or standards to guide their work; and (4) work experiences that drive and exhaust leaders. Multiple participants described burnout due to increasing demands that are not met with equivalent increase in institutional support. In this qualitative study, DEI leaders described multiple institutional challenges to their work. To effectively address stated goals of DEI, medical schools and academic centers need to provide leaders with concomitant resources and authority that facilitate change. Institutions need to acknowledge and implement strategies that integrate across units, beyond one leader and office. Policymakers, including professional organizations and accrediting bodies, should provide guidance, accountability mechanisms, and support for research to identify and disseminate evidence for best practices. Creating statements and positions, without mechanisms for change, perpetuates stagnation and injustice.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers.

Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers

We undertook a study to evaluate the current state of pedagogy on antiracism, including barriers to implementation and strengths of existing curricula, in undergraduate medical education (UME) and graduate medical education (GME) programs in US academic health centers. We conducted a cross-sectional study with an exploratory qualitative approach using semistructured interviews. Participants were leaders of UME and GME programs at 5 institutions participating in the Academic Units for Primary Care Training and Enhancement program and 6 affiliated sites from November 2021 to April 2022. A total of 29 program leaders from the 11 academic health centers participated in this study. Three participants from 2 institutions reported the implementation of robust, intentional, and longitudinal antiracism curricula. Nine participants from 7 institutions described race and antiracism-related topics integrated into health equity curricula. Only 9 participants reported having "adequately trained" faculty. Participants mentioned individual, systemic, and structural barriers to implementing antiracism-related training in medical education such as institutional inertia and insufficient resources. Fear related to introducing an antiracism curriculum and undervaluing of this curriculum relative to other content were identified. Through learners and faculty feedback, antiracism content was evaluated and included in UME and GME curricula. Most participants identified learners as a stronger voice for transformation than faculty; antiracism content was mainly included in health equity curricula. Inclusion of antiracism in medical education requires intentional training, focused institutional policies, enhanced foundational awareness of the impact of racism on patients and communities, and changes at the level of institutions and accreditation bodies.

Provision of Onsite Childcare in US Academic Health Centers: What Factors Make a Difference?

Challenges to work-life balance, including childcare, have been cited as major barriers to career advancement for women in academic medicine. We performed a cross-sectional study to investigate the availability of onsite childcare at academic health centers (AHCs) for US medical schools and examined institutional characteristics associated with its provision. Data from the Association of American Medical Colleges (AAMC) were used to identify US medical schools by region, type (private vs. public, community-based vs. not), financial relationship to the university, and numbers of female medical students, faculty, chairs, and deans. We assessed onsite childcare from publicly available information on institutional websites, plus phone calls to human resources departments at medical centers and/or medical schools. Our study identified 144 US medical schools from the AAMC database and collected complete data for 136 (95%). Most AHCs offered onsite childcare (62%, 84/136). AHCs in the Midwest (78%) were most likely to have onsite childcare, whereas AHCs in the Southwest were least likely (14%, p<.001). No associations were demonstrated between onsite childcare and the proportion of female chairs or female faculty, or the AHC's financial relationship with the parent university. Although accessible childcare is critical to the upward mobility of women in medicine, more than a third of AHCs do not offer onsite childcare. As more women in medicine navigate childcare demands, the expansion of accessible, quality onsite childcare at AHCs is needed to promote a diverse academic workforce.

Why the Lab? What is Really Motivating General Surgery Residents to Take Time for Dedicated Research

Over one third of general surgery residents interrupt their clinical training to pursue dedicated research time (DRT), which has financial implications for programs and residents. Studies have examined the impact of DRT on academic outcomes, but little is known about why residents pursue DRT. Therefore, this study aimed to examine resident motivations regarding DRT in order to gain an understanding of resident goals and challenges surrounding this phase of training. Surgical residents currently participating in DRT and residents considering completing DRT were recruited to participate. Members of the research team at each institution conducted interviews and focus groups, which were recorded and transcribed. Data was analyzed using the qualitative method of open and focused coding. Identified themes guided the development of a conceptual framework. Interviews and focus groups were held at three geographically diverse US academic health centers. Twenty-one surgery residents participated. Reasons for pursuing DRT fell into 1 of 3 themes: strategic career planning, professional development, and personal rejuvenation. Residents described the perceived need for publications or networking to enhance future competitiveness for desired fellowships or academic appointments. Residents also expressed the desire to have time for career exploration and to cultivate mentorship for their professional career. The need to take time off for more personal reasons, including burnout, was pervasive. Additionally, many in DRT felt under-supported in developing their research skills and expressed a desire for more formal instruction and guidance from mentors. General surgery residents' motivations to pursue DRT are multifactorial. Professional development is a pervasive motivation and includes learning skills that can be applied to future research. Current DRT programs may be inadequate in supporting residents to achieve this goal. These results can be used to inform programmatic efforts to optimize DRT for residents and mentors alike.

Proactive safety awareness and violence prevention training for professional students.

In response to the growing number of violent acts on college/university campuses in the US, a pilot safety awareness and violence prevention (SAVP) training was developed and collaboratively implemented for first-year dental and pharmacy students at a US academic health center. The study assessed student knowledge of violent behavior, warning signs emphasizing active shooter situations, response strategies when witnessing or experiencing violence, and awareness of available violence prevention resources. In 2014, a presurvey/postsurvey design was approved by the Institutional Review Board and used to assess knowledge before and after SAVP training by the university police department. As part of the new student orientation, 90% of the dental students and 100% of the pharmacy students simultaneously participated in the training and afterwards completed both number-coded surveys. This resulted in a 96% response rate. Data were analyzed using SAS. A comparison of presurvey/postsurvey responses show notable increases on 4 key topics: awareness of actions to take if witnessing violent crime (+49%) or encountering active shooter situation (+74%), awareness of violent behavior warning signs (+63%), and knowledge of available violence prevention resources (+86%). Findings from this study demonstrate that integrating SAVP training in new student orientation can increase safety awareness among dental and pharmacy students. SAVP training can augment the uptake of current campus resources given there was an observed increase in knowledge of availability. Collaborating with the university police department is key to this replicable proactive SAVP program for dental and pharmacy students.

An institution-wide faculty mentoring program at an academic health center with 6-year prospective outcome data.

There is discontent and turnover among faculty at US academic health centers because of the challenges in balancing clinical, research, teaching, and work-life responsibilities in the current healthcare environment. One potential strategy to improve faculty satisfaction and limit turnover is through faculty mentoring programs. A Mentor Leadership Council was formed to design and implement an institution-wide faculty mentoring program across all colleges at an academic health center. The authors conducted an experimental study of the impact of the mentoring program using pre-intervention (2011) and 6-year (2017) post-intervention faculty surveys that measured the long-term effectiveness of the program. The percent of faculty who responded to the surveys was 45.9% (656/1428) in 2011 and 40.2% (706/1756) in 2017. For faculty below the rank of full professor, percent of faculty with a mentor (45.3% vs. 67.1%, P < 0.001), familiarity with promotion criteria (81.7% vs. 90.0%, P = 0.001), and satisfaction with department's support of career (75.6% vs. 84.7%, P = 0.002) improved. The percent of full professors serving as mentors also increased from 50.3% in 2011 to 68.0% in 2017 (P = 0.002). However, the percent of non-retiring faculty considering leaving the institution over the next 2 years increased from 18.8% in 2011 to 24.3% in 2017 (P = 0.02). Implementation of an institution-wide faculty mentoring program significantly improved metrics of career development and faculty satisfaction but was not associated with a reduction in the percent of faculty considering leaving the institution. This suggests the need for additional efforts to identify and limit factors driving faculty turnover.

Continuous Vagal Neuromonitoring Using the Laryngeal Adductor Reflex: Can Preincision Dyssynchrony Predict Intraoperative Nerve Behavior?

The laryngeal adductor reflex (LAR) is an airway-protective response triggered by sensory laryngeal receptors and resulting in bilateral vocal fold adduction. The normal morphology of the early R1 response resembles that of the compound muscle action potential (CMAP). However, in a small subset of patients, the morphology is dyssynchronous with multiple peaks. This study investigates whether preoperative LAR dyssynchrony predicts intraoperative nerve behavior during thyroid surgeries. Retrospective case-control study. US academic health center. Opening and closing LAR waveforms from 200 patients with normal preoperative laryngeal examinations monitored continuously during thyroid surgeries using the LAR were analyzed. Area under the curve (AUC) and number of "events" during surgery (defined as any transient decline in AUC >50% baseline) were determined for patients who demonstrated opening dyssynchronous LAR traces compared to demographically matched controls. Six patients had opening dyssynchronous LAR traces. These patients had significantly greater declines in R1 AUC than demographically matched patients with opening synchronized R1 traces (P = .007). Upon thyroid removal, 1 patient converted from a dyssynchronous to synchronous trace. Preincision dyssynchronous LAR waveforms may indicate subclinical, potentially reversible, neuropathy of the recurrent laryngeal nerve (RLN) and predict intraoperative RLN behavior. Preincision knowledge of R1 dyssynchrony can facilitate surgical planning as such patients may glean particular benefit from continuous intraoperative nerve monitoring, frequent tissue relaxation, and saline irrigation as means to minimize nerve stress intraoperatively.

Value of Global Surgical Activities for US Academic Health Centers: A Position Paper by the Association for Academic Surgery Global Affairs Committee, Society of University Surgeons Committee on Global Academic Surgery, and American College of Surgeons' Operation Giving Back

Academic global surgery value to low- and middle-income countries (LMICs) is increasingly understood, yet value to academic health centers (AHCs) remains unclear. A task force from the Association for Academic Surgery Global Affairs Committee and the Society for University Surgeons Committee on Global Academic Surgery designed and disseminated a survey to active US academic global surgeons. Questions included participant characteristics, global surgeon qualifications, trainee interactions, academic output, productivity challenges, and career models. The task force used the survey results to create a position paper outlining the value of academic global surgeons to AHCs. The survey had a 58% (n= 36) response rate. An academic global surgeon has a US medical school appointment, spends dedicated time in an LMIC, spends vacation time doing mission work, or works primarily in an LMIC. Most spend 1 to 3 months abroad annually, dedicating <25% effort to global surgery, including systems building, teaching, research, and clinical care. Most are university-employed and 65% report compensation is equivalent or greater than colleagues. Academic support includes administrative, protected time, funding. Most institutions do not use specific global surgery metrics to measure productivity. Barriers include funding, clinical responsibilities, and salary support. Academic global surgeons spend a modest amount of time abroad, require minimal financial support, and represent a low-cost investment in an under-recognized scholarship area. This position paper suggests measures of global surgery that could provide opportunities for AHCs and surgical departments to expand missions of service, education, and research and enhance institutional reputation while achieving societal impact.

National Trends in Vestibular Schwannoma Surgery: Influence of Patient Characteristics on Outcomes

Objective To characterize current vestibular schwannoma (VS) surgery outcomes with a nationwide database and identify factors associated with increased complications and prolonged hospital course. Study Design Retrospective review utilizing the University HealthSystem Consortium national inpatient database. Setting US academic health centers. Subjects and Methods Data from patients undergoing VS surgery were analyzed over a 3-year time span (October 2012 to September 2015). Surgical outcomes, such as length of stay (LOS), complications, and mortality, were analyzed on the basis of race, sex, age, and comorbidities during the 30-day postoperative period. Results A total of 3697 VS surgical cases were identified. The overall mortality rate was 0.38%, and the overall complication rate was 5.3%. Advanced age significantly affected intensive care unit LOS, mortality, and complications ( P = .04). Comorbidities, including hypertension, obesity, and depression, also significantly increased complication rates ( P = .02). Sixty-eight patients (1.8%) had a history of irradiation, and they had a significantly increased LOS ( P = .03). Conclusion Modern VS surgery has a low mortality rate and a relatively low rate of complications. Several factors contribute to high complication rates, including age and comorbidities. These data will help providers in counseling patients on which treatment course might be best suited for them.

Mentoring Faculty: A US National Survey of Its Adequacy and Linkage to Culture in Academic Health Centers.

The aims of this study were to (1) describe the quantity and quality of mentoring faculty in US academic health centers (AHCs), (2) measure associations between mentoring and 12 dimensions that reflect the culture of AHCs, and (3) assess whether mentoring predicts seriously contemplating leaving one's institution. During 2007-2009, our National Initiative on Gender, Culture and Leadership in Medicine (C - Change) conducted a cross-sectional study of faculty from 26 representative AHCs in the United States using the 74-item C - Change Faculty Survey to assess relationships of faculty characteristics and various aspects of the institutional culture (52% response rate). Among the 2178 eligible respondents (assistant, associate, and full professors), we classified their mentoring experience as either inadequate, neutral, or positive. In this national sample, 43% of the 2178 respondents had inadequate mentoring; only 30% had a positive assessment of mentoring. There was no statistical difference by sex, minority status, or rank. Inadequate mentoring was most strongly associated with less institutional support, lower self-efficacy in career advancement, and lower scores on the trust/relationship/inclusion scale. The percent of faculty who had seriously considered leaving their institution was highest among those who had inadequate mentoring (58%), compared to those who were neutral (28%) or had positive mentoring (14%) (all paired comparisons, p < .001). In a national survey of faculty of US AHCs, mentoring was frequently inadequate and this was associated with faculty contemplating leaving their institutions. Positive mentoring, although less prevalent, was associated with many other positive dimensions of AHCs.

A growing opportunity: Community gardens affiliated with US hospitals and academic health centers

BackgroundCommunity gardens can reduce public health disparities through promoting physical activity and healthy eating, growing food for underserved populations, and accelerating healing from injury or disease. Despite their potential to contribute to comprehensive patient care, no prior studies have investigated the prevalence of community gardens affiliated with US healthcare institutions, and the demographic characteristics of communities served by these gardens. MethodsIn 2013, national community garden databases, scientific abstracts, and public search engines (e.g., Google Scholar) were used to identify gardens. Outcomes included the prevalence of hospital-based community gardens by US regions, and demographic characteristics (age, race/ethnicity, education, household income, and obesity rates) of communities served by gardens. ResultsThere were 110 healthcare-based gardens, with 39 in the Midwest, 25 in the South, 24 in the Northeast, and 22 in the West. Compared to US population averages, communities served by healthcare-based gardens had similar demographic characteristics, but significantly lower rates of obesity (27% versus 34%, P<.001). ConclusionsHealthcare-based gardens are located in regions that are demographically representative of the US population, and are associated with lower rates of obesity in communities they serve.

Trends in Antibacterial Use in US Academic Health Centers

Antibacterial drug use is a major risk factor for bacterial resistance, but little is known about antibacterial use in US hospitals. The objectives of this study were to characterize trends in antibacterial use in a sample of US hospitals and to identify predictors of use. We measured systemic antibacterial use from validated claims data at 22 university teaching hospitals from January 1, 2002, through December 31, 2006, and we examined potential predictors of use in 2006, including hospital and patient demographics and antibacterial stewardship policies. A total of 775,731 adult patients were discharged in 35 hospitals during 2006, and 492,721 (63.5%) received an antibacterial drug. The mean (SD) total antibacterial use increased from 798 (113) days of therapy per 1000 patient days in 2002 to 855 (153) in 2006 (P < .001). Fluoroquinolones were the most commonly used antibacterial class from 2002 through 2006, and use remained stable. Piperacillin sodium-tazobactam sodium and carbapenem use increased significantly, and aminoglycoside use declined. Cefazolin sodium was the most commonly used antibacterial drug in 2002 and 2003 but was eclipsed by vancomycin hydrochloride in 2004. The strongest predictor of broad-spectrum antibacterial use was explained by differences across hospitals in the mean durations of therapy. Total antibacterial use in adults increased significantly from 2002 through 2006 in this sample of academic health centers, driven by increases in the use of broad-spectrum agents and vancomycin. These developments have important implications for acquired resistance among nosocomial pathogens, particularly for methicillin-resistant Staphylococcus aureus (MRSA).

Involvement Abroad of U.S. Academic Health Centers and Major Teaching Hospitals: The Developing Landscape

To compile information about major offshore clinical, education, and research programs and operations of U.S. academic health centers (AHCs) and major teaching hospitals, and to describe how these offshore activities relate to each institution's underlying mission and to the organizational mechanisms that link the activities to the organization's core mission while protecting the organization from potential risks. The authors collected information regarding the major offshore activities of 16 AHCs and major teaching hospitals from a variety of sources during the months of March to May 2007. The data sources included telephone interviews with leaders of each organization's offshore activities, review of information on each organization's Web site, and a review of the literature on this topic. A framework was then developed to distinguish the type and scale of offshore activities among these 16 organizations. The extent and nature of offshore activities varies widely across the studied institutions, ranging from a limited number of education and training programs to major commitments to deliver patient care, education, and research services offshore. Offshore activities seem to follow a four-stage development path, which the authors describe. There seem to be four reasons that US AHCs and major teaching hospitals are engaging in these offshore activities. Development of offshore activities requires a major commitment and is only appropriate for those AHCs whose mission is to serve a global market and who are able to dedicate significant faculty, management, and staff resources. While some have achieved tangible benefits, the creation of truly global AHCs will require many years of development with uncertain results.

Current Status of Integrating Information Technologies into the Clinical Research Enterprise within US Academic Health Centers

Little information exists about the incorporation of information technologies (ITs) into clinical research processes within US academic health centers (AHCs). Therefore, we queried a group of 37 leading AHCs regarding...

Incidence and Risk Factors for Thromboembolism in Patients with Hematologic Malignancies Undergoing Allogeneic and Autologous Stem Cell Transplantation.

Background: Thromboembolism (TE) is a common complication of hospitalized non-transplant cancer patients. To date, the extent and impact of TE in stem cell transplant patients is unknown, in part because it is considered a low risk group given the high prevalence of thrombocytopenia. The purpose of this study is to evaluate the incidence of and risk factors for TE in cancer patients undergoing stem cell transplantation.Methods: We conducted a retrospective analysis of all discharge summaries from the 115 US academic health centers reporting to the University HealthSystem Consortium from 1995 to 2002. We identified a total of 7,087 patients with hematologic malignancies undergoing allogeneic and autologous stem cell transplantation. The incidence of and risk factors for venous and arterial TE was analyzed in univariate and multivariate logistic regression analysis with adjusted odds ratios as estimates of relative risk.Results: TE was reported in 389 (5.5%) transplant patients with 4.8% patients developing venous and 0.7% arterial TE. The incidence of TE was greater in allogeneic (6.8%) compared to autologous (4.8%) transplant patients (p<0.0001). Among those receiving allogeneic transplantations, BMT patients experienced a higher rate of TE than PBSC patients (7.5% vs 5.6%; p<0.05). In multivariate logistic regression analysis, the following clinical variables were significantly associated with TE in stem call transplant patients with hematologic malignancies: gram negative sepsis (OR=1.76; 1.02–3.02; p=0.04), gram positive sepsis (OR=1.75; 1.25–2.45; p=0.001), line infections (OR=1.48; 1.11–1.97; p=0.008), central venous catheters (OR=1.74; 1.39–2.17; P<0.0001), pulmonary disease (OR=1.87; 1.47–2.37; p<0.0001), liver disease (OR=1.31; 1.01–1.70; p=0.04) and length of stay >30 days (OR=1.66; 1.30–2.13; p<0.0001). Hodgkin's disease (OR= 0.59; 0.37–0.94; p=0.026) was associated with a lower risk of TE. In multivariate analysis, the type of transplant failed to remain an independent risk factor for TE after controlling for other transplant complications.Conclusions: This is the first substantive report on the incidence of thromboembolism in stem cell transplant patients. We found that thromboembolic events are a frequent complication in patients with hematologic malignancies undergoing stem cell transplantation. The incidence of TE is high among most subgroups studied. Prospective studies are needed to evaluate the efficacy and safety of thromboprophylaxis in this high-risk population.

Clinical Utility of D-dimer in Patients With Suspected Pulmonary Embolism and Nondiagnostic Lung Scans or Negative CT Findings

The diagnosis of pulmonary embolism is difficult because the clinical diagnosis is nonspecific and all of the objective tests have limitations. The assay for plasma d-dimer may be useful as an exclusion test if results are negative. We conducted a prospective cohort study that evaluated the clinical utility (usefulness) of an automated quantitative d-dimer test in the diagnosis of patients with suspected pulmonary embolism. Consecutive eligible patients who had clinically suspected PE with nondiagnostic lung scans or negative helical CT scan of the chest results underwent d-dimer testing. The d-dimer results were negative in 11 of 103 inpatients (10.6%, 95% confidence interval [CI], 5.5 to 18.3%) and 7 of 22 outpatients (31.8%, 95% CI, 13.9 to 54.9%; p = 0.02). Measurement of plasma d-dimer is of limited clinical utility for inpatients with clinically suspected pulmonary embolism and nondiagnostic lung scans or negative helical CT results at a US academic health center.

Capturing the power of academic medicine to enhance health and health care of the elderly in the USA

As in Japan, the US population is aging progressively, a trend that will challenge the health‐care system to provide for the chronic, multiple and complex needs of its elderly citizens. and as in Japan, the US academic health enterprise has only belatedly mounted a response to that challenge. Herein is reviewed a quarter of a century of the author's personal experience in developing new programs in gerontology and geriatric medicine from a base in the Department of Internal Medicine at three US academic health centers (AHC): The University of Washington (as Division Head), Johns Hopkins University (as Vice‐Chair), and Wake Forest University (as Chair). Rather than to build a program from a new department of geriatrics, this strategy was chosen to capture the power and resources of the department of internal medicine, the largest university department, to ‘gerontologize’ the institution, beginning with general internal medicine and all of the medical subspecialties (the approach also chosen to date at all but a handful of US AHC). The keystone of success at each institution has been careful faculty development through fellowship training in clinical geriatrics, education and research. Over the same interval major national progress has occurred, including expanded research and training at the National Institute on Aging and the Department of Veterans Affairs, and accreditation of more than 100 fellowship programs for training and certification of geriatricians. However, less than 1% of US medical graduates elect to pursue such training. Hence such geriatricians will remain concentrated at AHC, and most future geriatric care in the USA will be provided by a broad array of specialists, who will be educated and trained in geriatrics by these academic geriatricians.