Browsing by Subject "Treatment Outcome"
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Item Aspirin Use Is Associated with Improved Outcomes in Inflammatory Breast Cancer Patients(2023-05-01T05:00:00.000Z) Johns, Christopher Lee; Kim, D. W. Nathan; Alluri, Prasanna; Liu, Yu-LunPURPOSE: Inflammatory breast cancer (IBC) is the most aggressive form of breast cancer and has a high propensity for distant metastases. Our previous data suggested that aspirin (ASA) use may be associated with reduced risk of distant metastases in aggressive BC; however, there are no reported studies on the potential benefit of ASA use in patients with IBC. METHODS: Data from patients with non-metastatic IBC treated between 2000-2017 at two institutions, were reviewed. Overall survival (OS), disease-free survival (DFS), and distant metastasis-free survival (DMFS) were performed using Kaplan-Meier analysis. Univariate and multivariable logistic regression models were used to identify significant associated factors. RESULTS: Of 59 patients meeting the criteria for analysis and available for review, 14 ASA users were identified. ASA users demonstrated increased OS (p=.03) and DMFS (p=.02), with 5-year OS and DMFS of 92% (p=.01) and 85% (p=.01) compared to 51% and 43%, respectively, for non-aspirin users. In univariate analysis, pT stage, pN stage, and aspirin use were significantly correlated (p < .05) with OS and DFS. On multivariable analysis, ASA use (HR=.11, CI 0.01- 0.8) and lymph node stage (HR=5.9, CI 1.4-25.9) remained significant for OS and DFS (aspirin use (HR =0.13, CI 0.03-0.56) and lymph node stage (HR=5.6, CI 1.9-16.4). CONCLUSION: ASA use during remission was associated with significantly improved OS and DMFS in patients with IBC. These results suggest that ASA may provide survival benefits to patients with IBC. Prospective clinical trials of ASA use in patients with high-risk IBC in remission should be considered.Item An Assessment of Severity of Illness of Pediatric Musculoskeletal Infections: 1994-2009(2013-06-01) Sun, David Q.; Copley, Lawson A. B.PURPOSE: Care of children with osteomyelitis requires multi-disciplinary collaboration. This study evaluates the impact of evidence-based guidelines for pediatric osteomyelitis when applied by a multi-disciplinary team. METHODS: Guidelines for pediatric osteomyelitis were developed and implemented by a multi-disciplinary team comprised of orthopedics, pediatrics, infectious disease, nursing, and social work who met daily to conduct rounds and make treatment decisions. Children who were treated according to the guidelines (g) were compared to those who had been treated prior to the guidelines (ng) by retrospective review and statistical analysis. RESULTS: 210 children of the 2002-2004 cohort (ng) were compared to 61 children of the 2009 cohort (g). No significant differences between the two cohorts were noted for age, race, gender, incidence of Methicillin-resistant Staphylococcus aureus (g=26.2%; ng=18.1%), incidence of Methicillin-sensitive Staphylococcus aureus (g=27.9%; ng=23.8%), bacteremia, or surgeries. Significant differences between cohorts were noted (p<0.05) for each of the following: timing of initial MRI (g=1.0 day; ng=2.5 days); clindamycin as initial antibiotic (g= 85.3%; ng=12.8%); blood cultures before antibiotic administration (g=91.8% ; ng=79.5%); tissue cultures from infection site (g=78.7%; ng=62.9%); identification of organism by tissue or blood culture (g=73.8%; ng=60.0%); antibiotic changes (g=1.4 changes; ng=2.0 changes); and mean oral antibiotic duration (g=43.7 days; ng=27.7 days). Children treated with guidelines had clinically important trends of a shorter total length of stay (g=9.7 days; ng=12.8 days; p=0.054), and lower readmission rate (g=6.6%; ng=11.4%; p=0.34). CONCLUSION: Evidence-based treatment guidelines applied by a multi-disciplinary team resulted in more efficient diagnostic work-up, higher rate of identifying the causative organism, improved adherence to initial antibiotic recommendations with fewer antibiotic changes during treatment. Additionally, there were trends toward lower readmission rate and lower length of hospitalization. The establishment of evidence-based treatment guidelines will allow for the standardization of evaluation and treatment of children with musculoskeletal infections for severity of illness comparisons between cohorts separated through time and geographic location.Item Association of Vitamin D Serum Concentration with Infection Outcomes for Children after Surgery(2016-01-19) Aboul-Fettouh, Nader; Williams, Timothy; Ploski, Roxana; Griffin, Allison; Szmuk, PeterVitamin D insufficiency and deficiency has been associated with various disease states and lower health outcomes. In the adult population, higher vitamin D levels correlated with decreased odds of in-hospital morbidity and mortality. However, no study examined the role of Vit D on the perioperative and post-operative outcomes in the pediatric patient population. We hypothesized that vitamin D deficient pediatric patients will have a higher incidence of composite infectious complications. As a secondary outcome we will analyze whether there is a relationship between the patient's vitamin D levels and hospital length of stay. With IRB approval we performed an EPIC search for all Children's Health patients from 2011 to 2015 where at least one 25-hydroxyvitamin D level was determined within the perioperative period (1 month pre- and post-surgery). Patients were included if they were less than 18 years of age and had underwent non-cardiac surgery. Patients were excluded if they did not receive general anesthesia, stayed less than one night in the hospital, had an American Society of Anesthesiologists Physical Status greater than 4, or underwent emergent surgery. Pertinent information including details of the surgery and relevant past medical history were collected for each patient to help analyze the data set and account for confounding factors. In order to have access to a larger number of patients, this project was performed in collaboration with Cleveland Clinic (Cleveland, OH). The EPIC search provided us with 1600 patient charts from CMC or Children's Health-Plano, and 850 were included into the study after being screened using the criteria noted previously. After analyzing the data, The incidence of infection were 5.5%, 5.8%, 4.9%, 5.8%, and 11.7% for patients with vitamin D level ≤13, 14-19, 20-25, 26-34, and ≥35 ng/ml, respectively. The odds of having infection did not differ significantly among the five vitamin D groups. Secondly, no difference was found in the length of hospital stay among the five vitamin D groups (P = 0.55). Vitamin D levels do not seem to be associated with infection or length of hospital stay in pediatric surgical patients. Other baseline and surgical factors have probably a stronger influence on in-hospital infection and length of hospital stay than vitamin D levels.Item Borderline Personality Features and Treatment Outcomes in an Adolescent Intensive Outpatient Treatment Population(2016-08-25) Rial, Katherine Vera; Foxwell, Aleksandra; Kennard, Beth D.; Moore, Patricia SinclairBorderline Personality Disorder (BPD) is a common psychiatric disorder associated with severe functional impairment, high rates of suicide, comorbid mental disorders, frequent utilization of mental health treatment, and therefore, high cost to society in both adults and adolescents. Although treatments have been developed to treat BPD in adults, little is known about the effectiveness of treatments in adolescents, in particular in an intensive outpatient setting. The current study examined differences in clinical characteristics among adolescents with and without borderline features who participated in an intensive outpatient program (IOP) for suicidal behaviors. In addition, this study examined whether borderline features predicted treatment outcomes at discharge. Fifty-eight participants, ages 13-17 (14.98±1.15), were categorized into adolescents with BPD features and those without. Assessments include the Concise Health Risk Tracking form (CHRT; self-report), Columbia Suicide Severity Rating Scale (C-SSRS; clinician-rated), Quick Inventory of Depressive Symptomatology- Adolescent version (QIDS-A; self-report), and the 11-item Borderline Personality Features scale for Children (BPFSC-11; self-report). Statistical analyses include chi-square and ANOVA for demographic and clinical characteristics. Spearman's correlations and a hierarchical linear regression were used to examine treatment outcomes. Results indicate that adolescents with BPD features presented to treatment with more severe depression and suicide risk than adolescents without BPD features. Following IOP treatment, adolescents with BPD features continued to endorse more severe depressive symptoms than those without BPD features. However, there was no statistical difference between groups in regards to suicidality. The presence of BPD features did not predict depression severity at discharge, but the relationship appeared to be trending.Item Cholecystitis Fast Track Pathway Provides Safe, Value Based Care on Busy Acute Care Surgery Service(2021-05-01T05:00:00.000Z) Houshmand, Natasha Nazerani; Reed, W. Gary; Cripps, Michael W.; Phelps, EleanorBACKGROUND: Fast track (FT) pathways have been adopted across a multitude of elective surgeries, with the culmination of their progress resulting in higher value-based care of the patient. However, these programs have been slow to be adopted into the acute care surgery (ACS) realm. We hypothesized that a FT pathway implemented in an ACS service would safely hasten patient progress to the operating room while decreasing patient length of stay. To minimize variation, we have selected a singular, common operation, the cholecystectomy, which can be compared across two hospitals with well-established ACS services, one with a FT pathway and one with a traditional pathway. METHODS: All patients at both hospitals that underwent an urgent or emergent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019 and October 31, 2019 were queried using CPT codes. Patients that required a conversion to open or partial cholecystectomy were excluded because they no longer qualified for the fast track pathway. Retrospective chart review was used to gather information relating to the patients' demographics, presentation, operative and hospital course, and outcomes. Time to OR and hospital length of stay were the primary outcomes. RESULTS: There was a total of 479 urgent or emergent laparoscopic cholecystectomies performed during the 6 months for acute cholecystitis. Four hundred and thirty (89.8%) were performed under the FT pathway and 49 (10.2%) were performed under the traditional pathway. The median [IQR] time to the OR following surgical consultation was not different between the two pathways: 14.1 hours [8.3-29.0 hours] for FT and 18.5 hours [11.9-25.9 hours] for traditional (p=0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours, [14.2-40.4] vs 38.5 hours, [28.3-56.3]; p<0.0001). Under the FT pathway, 33% of patients were admitted to the hospital and 75.6% were discharged from the PACU, as compared to 91.8% and 12.2% on the traditional pathway, respectively (both p<0.0001). 59.6% of FT patients received a phone call follow up, as opposed to the traditional pathway where all patients had clinic follow up (p<0.001). ED bounce back rate, readmission rates, and complication rates were similar between the FT and traditional pathways (p>0.2 for all). On multivariate analysis, having a fast track pathway was an independent predictor of discharge within 24 hours of surgical consultation (OR 7.6, 95% CI 2.9-20.2, p<0.0001). CONCLUSION: Use of a fast track program for patients with acute cholecystitis has a significant positive impact on hospital resource utilization without compromise of clinical outcomes. Shorter times in the hospital and fewer clinic appointments benefit the hospital, surgeon, and patient. Incorporation of a FT pathway into all areas of ACS should be investigated.Item Comparing Distribution-Based and Anchor-Based Minimal Clinically Important Difference Values for Temporomandibular Disorder(2011-10-03) Ingram, Megan Elizabeth; Gatchel, Robert J.; Haggard, Robbie; Chiu, Chung-YiThe current study is a continuation of studies by Gatchel and colleagues. Data were collected from 101 patients at several community dental clinics. Based on the patients' initial evaluations, they were randomly assigned to one of three treatment groups: Low Risk/Non-intervention Group; High Risk/Biobehavioral Group; or High Risk/Self-Care Group. This study attempted to better understand and objectively quantify meaningful symptom relief by determining the minimal clinically important difference (MCID) for temporomandibular joint disorder (TMD). Despite limitations and controversy with determining the most appropriate method, this information will play an important role in determining treatment effectiveness for not only TMD, but for other pain conditions as well. The most commonly referenced methods for determining meaningful change are the distribution- and anchor-based approaches. Distribution-based minimal detectable change (MDC) values were calculated using the formula 95% CI=1.96 x Square Root(2) x SEM, while the anchor-based approach minimal clinically important change (MCID) values were calculated using a Receiver Operating Curve (ROC). Both mean particle size and broadness of distribution served as two separate functional anchors, and normal range and .5 SD as two separate cutoff methods. Despite some variability, the MCID values were relatively consistent with the MDC values regardless of method, anchor, or cutoff for both the Physical Component Scale (PCS) and Mental Component Scale (MCS) of the SF-36. The Characteristic Pain Inventory and Graded Chronic Pain Scale showed a narrow range of variation within the MCID values; however, the MCID values calculated were significantly higher than the MDC values reported for the same measures. Findings indicated that the PCS component of the SF-36 provided stronger evidence of clinically meaningful change. The PCS resulted in asymptotic values closer to .1 (at the 90% confidence interval) with areas under the curve that better fit the model compared to the other subjective measures (considered fair at .701 when using the normal range and .740 when using .5SD for the Biobehavioral Group). Additionally, broadness of distribution resulted in more clinically meaningful changes as a result of better metric values when comparing the biobehavioral versus the self-care groups.Item Computer-Administered Patient Reported Outcomes (PRO) and Psychiatric Screening in Outpatient Pain Patients: Effect of a Point-of-Care Biopsychosocial Patient Health Report on Treatment Outcomes(2012-08-13) Swanholm, Eric Neal; Gatchel, Robert J.RATIONALE: Chronic pain is a widespread health problem that carries steep costs for both individuals and society. Pain-related complaints represent one of the most common presenting symptoms across ambulatory care settings. Individuals with chronic pain often have comorbid psychiatric symptoms and/or psychosocial dysfunction. Given the related impact on treatment and health-care costs, tracking psychiatric and psychosocial outcomes is beneficial for chronic pain patients, their health care providers, and service providers. Outcome-tracking interventions that could positively affect treatment outcomes hold potential benefits for patient care. PURPOSE: The purpose of the present study was to examine the effects of the regular collection and results feedback prior to the point-of-care on multiple patient-reported outcome (PRO) domains in outpatient pain patients. Maximizing ecological validity and non-disruption of clinic flow were given significant focus in the study design and process. PATIENTS AND METHODS: This study used repeated measures and was conducted in an outpatient pain management and interdisciplinary treatment clinic (2 anesthesiologists, 1 psychiatrist, 1 psychologist, 1 counselor, 1 physical therapist). A total of 69 pain patients were randomly assigned to one of two protocol-based PRO feedback intervention groups (separate feedback to both patients and providers [Dual Feedback]; Provider-Only Feedback) or a non-intervention group (Chart-Review Only). Assessments were completed prior to the point-of-care; feedback for intervention groups was based upon a real-time, automated report generated from their PRO data. Data were gathered on touch-screen tablet-pc’s using multiple computer-adaptive-tests from the NIH-sponsored Patient Reported Outcomes Measurement Information Systems (PROMIS) Assessment Center platform; outcome domains included pain-related functioning (Pain Disability Questionnaire [PDQ]; VAS pain rating; PROMIS Physical Functioning, Pain Behavior, and Pain Interference), psychological symptoms and psychosocial variables (PROMIS Depression, Anxiety, Sleep-Related Impairment, Fatigue, Social Functioning; hypomania history screen; Pain Medication Questionnaire [PMQ; opioid misuse risk]), global HRQoL (PROMIS Mental and Physical Health domains), treatment alliance (Working Alliance Inventory [WAI]; ratings from both patients and providers]), and illness perception and optimism (Brief Illness Perception Questionnaire [BIPQ]; Life Orientation Test- Revised). Performance-based data (walking time, grip strength, range-of-motion/flexibility) were collected by the physical therapist for study patients whose treatment included a PT component (e.g. interdisciplinary pain program, individual services). Significant covariates were identified and incorporated into the primary analyses. Primary outcomes were the individual measures within each outcome domain. Analyses utilized mixed-effects modeling with random coefficients and multiple regression in comparisons of all three study groups. Secondary analysis included tabulation of completion time and comparisons between a Combined Feedback group (both intervention groups) and Chart-Review Only. RESULTS: Significant covariates included treatment type, history of psychiatric diagnosis, and a biological family history of psychiatric diagnosis. Comparing Dual Feedback vs. Chart Review Only, patients in the Dual Feedback intervention had significantly better outcomes over time for a number of domain outcomes; specifically, in pain-related functioning/symptoms (PDQ [P = .003]; PROMIS Pain Interference [P = .023]; VAS pain [P = .03]), psychological and psychosocial variables (PROMIS Anger [P = .001]; PROMIS Anxiety [P = .012]; PROMIS Depression [P = .029]; PROMIS Sleep-Related Impairment [P = .001]; PROMIS Social Functioning – Satisfaction with Discretionary Social Activities [P = .047]), PROMIS Global HrQOL (Mental Health [P = .021]; Physical Health [P = .032]), treatment alliance (WAI – Bond [patient-rated][P = .046]), illness perceptions (BIPQ – Consequence [P = .017]; BIPQ – Timeline [P = .011]; BIPQ – Treatment Control [P = .029]), and one performance-based measure (Walk Time [P = .007]). Similarly, patients in the Provider-Only group had better outcomes over time for multiple outcome domains; including, pain-related functioning/symptoms (PDQ [P = .033]; PROMIS Pain Interference [P = .031]; PROMIS Fatigue [P = .036]; PROMIS Physical Functioning [P = .049]), psychological and psychosocial variables (PMQ [opioid misuse risk][P = .041]), treatment alliance (WAI – Bond [patient-rated][P = .076]; WAI – Bond [provider-rated][P = .008]), illness perceptions (BIPQ – Timeline [P = .048]; BIPQ – Personal Control [P = .027]), and one performance-based measure (Walk Time [P = .035]). Comparisons between patients in the Dual Feedback and Provider-Only Feedback groups were significant for a few domain outcomes. Compared to Provider-Only Feedback, Dual Feedback had better outcomes over time for multiple domain measures; including, the PDQ (P = .085), PROMIS Anger (P = .000), PROMIS Anxiety (P = .018), and BIPQ – Treatment Control (P = .015). Conversely, the Provider-Only group had better outcome scores over time for PROMIS Global HrQOL (Mental Health (P = .032); Physical Health (P = .074). Analyses of process variables showed a mean completion time of 15.8 minutes for the entire assessment; completion-time statistics were also calculated for the 11 PROMIS computer-adaptive-tests (M = 7.57 minutes [all PROMIS CAT’s]; M = 41.3 second per measure, SD = 9.3 seconds) and other primary outcomes (PDQ, PMQ, BIPQ) (M = 8.23 minutes total; M = 2.74 minutes per measure, SD = .99 minutes). CONCLUSION: The provision of dual feedback (patient and providers) from PRO data collected prior to the point-of-care had an impact on several outcomes from multiple domains (pain-related functioning, psychological symptoms, psychosocial variables, illness perception, walking performance) over time, compared to patients who received no point-of-care feedback. To a lesser extent, group by time effects were also observed in comparisons between patients receiving provider-only feedback and those with no feedback. Brought together, high ecological validity was maintained with minimal disruption of clinic flow; likely contributing factors include the use of a set framework for outcome-tracking, protocol-based delivery of feedback, and efficiency of administration. This is the first study to show the potential benefits of providing PRO data feedback to both patients and providers prior to the point-of-care.Item Does Delay to Surgery in Type III Supracondylar Humerus Fractures Lead to Longer Surgical Times and More Difficult Reductions?(2017-01-17) Prabhakar, Pooja; Elliott, Marilyn; Ho, ChristineBACKGROUND: As numerous studies have shown that delay in reduction of pediatric supracondylar humerus fractures (SCHFx) does not affect clinical outcomes, and as many hospitals adopt dedicated daytime trauma operative time, more type III SCHFx are being pinned non-emergently after hospital admission. We sought to determine if delay in surgical treatment of type III SCHFx would affect the length of operative time. METHODS: This is an IRB-approved, retrospective review of a series of 317 modified Gartland type III supracondylar fractures treated operatively at a tertiary referral center from 2011 to 2013. Mean patient age was 5.4 years (range, 2-10y). To balance the study design, 15 hours was selected as the cut-off between early and delayed treatment. A total of 53.6% (170/317) fractures were treated early, and 46.4% (147/317) were delayed. Surgical time was defined as "incision start" to "incision close". Fluoroscopy time was use as a surrogate for difficulty of reduction. RESULTS: Time from injury to OR was shorter for high-energy fractures (fractures with soft tissue or neurovascular injury) versus low energy fractures (12.9 vs. 15.2 hours, p < 0.0001); however, surgical time (37.3 vs. 31.9 minutes, p = 0.005) and fluoroscopy time (54.4 vs. 48.4 sec, p = 0.032) were longer in high-energy fractures vs. low-energy fractures. Among low energy fractures, no significant difference was detected in surgical time between the early and delayed treatment groups (32.0 vs. 31.9 minutes, p = 0.284) or in the fluoroscopy time (50.6 vs. 46.5 seconds, p = 0.778). Additionally, there was no statistically significant difference found in surgical or fluoroscopy time with the presence of a surgical assistant. Mean surgical time when the attending surgeon was alone was 29.3 minutes, compared to 38.6 min with a fellow, 33.5 min with a resident, 34.8 min with a mid-level practitioner, and 40.9 min with both a fellow and resident (p=0.065). Mean fluoroscopy time when the surgeon was alone was 42 seconds, compared to 58.3 sec with a fellow, 51 sec with a resident, 47.6 sec with a mid-level practitioner, and 53.4 sec with multiple trainees (p=0.102). CONCLUSIONS: Delay in surgery did not result in a longer surgical time or more difficult reduction for type III SCHFx. Patients with low energy fractures still underwent a shorter operative time even with delay from injury to surgery. When excluding high-energy injuries, surgical treatment of Gartland type III SCHFxs may be delayed without increasing surgical time or difficulty of reduction.Item Does Depressive Severity Have an Immediate Effect on Therapeutic Distance at Mid-Acute Phase in Cognitive Therapy for Recurrent Major Depressive Disorder?(2011-02-01) Bowers, Alycia D.; Minhajuddin, AbuThe degree to which severity of depression predicted Therapeutic Distance (TD) was researched with 375 patients with recurrent Major Depressive Disorder who received Cognitive Therapy. Therapeutic Distance was calculated by subtracting Working Alliance Inventory-Form C (WAI-C) from Working Alliance Inventory-Form T (WAI-T). Therapeutic Distance of each of the three subscales of the WAI was also calculated in order to determine whether the severity of depression predicted TD in the Bond, Task, or Goal subscales. The extent to which the severity of depression had an effect on the TD from midpoint to endpoint of the study was determined. Furthermore, the severity of depression and response to treatment at the first blind evaluation was analyzed. Results suggested that depressive severity was not predictive of TD overall or of the three subscales. However, when looking at TD over time, it seems that TD task is significantly different from midpoint to endpoint of the acute phase CT. Additionally, it appears that regardless of the severity of depression, the working alliance was established rather quickly and remained fairly stable throughout the acute phase of the study.Item Dynamic Magnetic Resonance Imaging for Tumor Prognosis(2006-08-11) Jiang, Lan; Mason, Ralph P.Breast and prostate cancers are the most common non-smoking cancers among American women and men. Radiotherapy and chemotherapy in conjunction with surgery are the most common treatment protocols in the clinic. However, a lot of experimental and clinical studies have shown that tumor hypoxia and the microcirculation play a very important role in cancer progression and therapy. There is strong evidence that hypoxic cells are one of the major reasons for failure to control tumors with conventional radiotherapy and chemotherapy. Several approaches (hyperthermia and carbogen inhalation), which improve tumor oxygenation during radiotherapy and chemotherapy, have been used in clinical trials. There is increasing demand for tumor prognostic information in the clinical setting. So far, increasing clinical data have indicated that poorly oxygenated tumors have poor prognosis. To better understand the underlying tumor physiological mechanisms, it is very important to develop novel non-invasive approaches to accurately assess tumor microcirculation and oxygenation for further therapy planning. However, these parameters have been extremely difficult to assess in routine clinical practice and have therefore not been easily integrated in to general patient care. With development of MRI the non-invasive technique, BOLD (Blood Oxygenation Level Dependent) contrast MRI, has been widely used for neuroscience research to detect brain activations. Because deoxyhemoglobin (dHbO2) is paramagnetic and oxyhemoglobin (HbO2) is non-magnetic, the change of concentration of deoxyhemoglobin and oxyhemoglobin can cause a Bulk Magnetic Susceptibility (BMS) change and the T2* signal response during MR imaging. Here, I applied this technique to assess tumor physiological characteristics. In order to study the BOLD mechanism, I designed a phantom system and built it for in-vitro study. Since inhalation of oxygen could cause variation in the blood flow and oxygenation, and BOLD MRI is sensitive to both these factors, it becomes very important to explore the correlation between the BOLD response and these two factors. Considering the different vascular orientation, the angle between vessel and the static magnetic field (BItem The Effectiveness of Biopsychosocial Interventions at the Dallas Spinal Rehabilitation Center: Applying the NIDRR Logic Model(2013-09-10) Siles, Melisa Garcia; Chiu, Chung-Yi; Wolf, Tina; Casenave, Gerald W.BACKGROUND: The National Institute on Disability and Rehabilitation Research has developed a program evaluation framework, the NIDRR logic model describing and assessing the relationship between planning, implementing, and evaluating outcomes in rehabilitation service environments, such as the Dallas Spinal Rehabilitation Center. Standard primary care facilities have treated chronic pain with narcotic medications; however, controversies surrounding the lack of long-term efficacy, risk of addiction, and the physical and psychological side effects of these medications continue to be heavily debated. There is strong evidence to support a biopsychosocial treatment approach for chronic pain which reduces narcotic dependence and restores daily functioning. The purpose of this study is to assess the effectiveness of the comprehensive interdisciplinary pain rehabilitation (IPR) program at the DSRC based on the NIDRR logic model. SUBJECTS: A total of 226 patients (131 males [58%] and 95 females [42%]) with chronic pain were admitted to the IPR program at the DSRC between January 2010 and December 2012. Among the 226 patients, 150 patients required medication tapering at admission. The average age of patients was 47 years old (SD= 9.74). The DSRC assigned patients to one of two groups after assessing the severity of their chronic pain curbing their ADL limitations, their social functioning, and their individualized treatment goals; 60 patients were in the chronic pain program, and 166 patients were in the functional restoration program. Patients attended between 80 hours to 160 hours of treatment that included medication management, physical therapy, cognitive-behavioral therapy with psychoeducation and biofeedback, and vocational counseling. METHOD: The current study is a descriptive design. All patients completed self-report measures assessing their current level of pain, functioning, depression, anxiety, and fear-avoidance beliefs at pre- and post-treatment. A dependent paired-samples t-test was used to assess the significance of treatment effect. RESULTS: Overall, significant improvements were seen among patients in the areas of independent functioning, depression, anxiety, fear-avoidance beliefs, medication tapering, and return to work status. Physical demand level, assessing independent functioning, improved significantly, t(225)=27.79, p=.000, among all patients. Results indicated significant improvements in depression scores, t(225)=13.38, p= .000, and anxiety scores, t(225)= 12.94, p= .000. Average fear-avoidance beliefs pertaining to physical activity improved significantly, t(225)= 13.68, p= .000, as did those beliefs pertaining to work, t(223)= 15.33, p= .000. Additionally, 93% of patients successfully returned to work after completion of the program, and 96% of patients who required tapering at admission successfully tapered or discontinued their medication use. Improvements were also found within each treatment group. Physical demand level in the chronic pain program improved significantly, t(59)=12.19, p.000. Results indicated significant improvements in depression scores, t(59)= 5.79, p= .000, as well as anxiety scores, t(59)= 5.83, p=.000. Average fear-avoidance beliefs pertaining to physical activity improved significantly, t(59)= 7.16, p= .000, as did those beliefs pertaining to work, t(59)=8.77, p= .000. Forty-four (73%) patients in the chronic pain program successfully returned to work. Of the 45 patients that required medication tapering at admission, 101 (96%) tapered or discontinued their medications. DISCUSSION: The NIDRR logic model has provided an excellent framework to assess treatment effectiveness in rehabilitation centers. Findings suggest that a biopsychosocial approach for chronic pain (e.g., the IPR program) is effective and efficient in diminishing overall distress and corroborating more biopsychosocial long-term effects than a short term quick fix of narcotic medications.Item Efficacy of Botswana's National Cancer Treatment Strategy: A Preliminary Analysis of Radiation Therapy in Breast Cancer Patients(2021-05-01T05:00:00.000Z) Shah, Sidrah Mariam; Grover, Surbhi; Chang, Mary; Nwachukwu, ChikaBACKGROUND: Breast cancer is a significant threat to public health in low- and middle-income countries (LMIC) globally, with the observation of an alarming increase in incidence in sub-Saharan Africa. Radiation Therapy (RT) is an essential component of breast cancer treatment and many LMIC currently lack access to RT. In Botswana, cancer care for citizens is paid for by the government, which has resulted in a unique investment in RT compared to other countries in the region. However, breast cancer mortality remains high, warranting further investigation into patient access to and receipt of RT. OBJECTIVE: This project seeks to investigate and present preliminary data on the percentage of breast cancer patients in Botswana qualifying for RT who actually went on to initiate RT. Demographic and clinical characteristics of breast cancer patients in Botswana are also presented. METHODS: Demographic, clinical, and treatment information was collected prospectively on all breast cancer patients presenting to the Breast Multidisciplinary Team (MDT) clinic at Princess Marina Hospital (PMH) in Gaborone, Botswana from January 2015 to October 2020. Patients with incomplete treatment information were excluded from the analysis. Patients who should have received RT were identified based on National Comprehensive Cancer Network (NCCN) guidelines. RESULTS: A total of 131 patients were included in the analysis. Of these, 29.8% were HIV-positive and 77.5% presented with advanced-stage disease. The vast majority of patients underwent mastectomy, and only 35% received chemotherapy. Based on NCCN guidelines, 121 patients qualified for receipt of radiation. In this population of breast cancer patients in Botswana, 92.6% of patients who needed RT received it. CONCLUSION: Based on this preliminary analysis, the investment of Botswana's Ministry of Health in RT for its citizens is seeing encouraging success among breast cancer patients. This analysis was limited by incomplete treatment information on the majority of breast cancer patients in this cohort, limiting the sample size in the final analysis. Further study is needed to characterize completion of RT in this population and factors that affect this.Item Expectancy, Adherence, and Depression as Predictors of Therapeutic Outcome as Measured by PTSD Symptoms in Veterans with MST(2012-05-18) Azimipour, Solaleh; Surís, Alina; North, Carol S.; Thoman, Lisa V.BACKGROUND: The aim of this study was to explore the association between treatment outcome expectancy, adherence to treatment, and depressive symptoms on symptom reduction in the treatment of PTSD in Veterans. SUBJECTS: Participants were female and male veterans from a large Southwestern Veterans Administration Healthcare System. A total of 129 participants were randomized to receive cognitive processing therapy (CPT) or present-centered therapy (PCT). Participants completed baseline assessments prior to starting 12 sessions of therapy. METHODS: Data from the Clinician Administered PTSD Scale (CAPS), the PTSD Checklist (PCL), Beck Depression Inventory II (BDI-II), the 16-Item Quick Inventory of Depression Symptomatology (QIDS), Expectancy of Therapeutic Outcome (ETO), homework assigned to the participants, and the number of therapy sessions completed were used in the analysis of the hypotheses. Spearman correlations and multiple regressions were used to analyze the data RESULTS: Both number of sessions attended in the CPT group and number of sessions attended in both groups combined were significantly associated with an improvement in depression symptoms as measured by change in the QIDS score (CPT ? = .31, both ? = .29). Attendance to sessions in the CPT group was not associated with change in the PCL score. The total average minutes spent on homework in the CPT group was significantly associated with worsening of PTSD symptoms as measured by an increase in the CAPS score (? = -.51) in one model and by an increase in the PCL score (? = -.30) in a separate model. The percent of homework assignments completed in the CPT group was significantly associated with improvement in PTSD symptoms as measured by a decrease in the CAPS score (? = .32). A significant relationship was found between outcome expectancy and the number of sessions attended in the PCT group (? = .42;.39). The relationship between baseline depression symptom level as measured by the QIDS and the total average number of minutes spent on homework fell short of significance in the CPT group, p = .07. There were no significant associations between baseline depression and treatment outcome expectancy. DISCUSSION: Greater outcome expectancy was associated with increased attendance to sessions in the PCT group, but not in the CPT group. However, greater expectancy did not predict adherence to homework and the amount of time spend doing homework. As expected, in the CPT group as well as both groups together, greater attendance to sessions was associated with an improvement in symptoms of depression. Greater adherence to homework assignments was associated with an improvement in PTSD symptoms. Contrary to predictions however, greater time spent doing the homework was associated with a worsening of PTSD symptoms and greater depression at baseline was associated with greater time spent completing homework. Furthermore, baseline depression did not predict treatment outcome expectancy, and expectancy did not predict PTSD and depression symptoms at treatment completion. IMPLICATIONS: A greater expectation of benefit from treatment could be an indication that an individual is motivated to change. It is possible that expectations of treatment, attendance to therapy sessions, and completing homework in between sessions, are the key to benefiting from therapy.Item Factors that Predict Poor Outcome after Treatment of Un-Ruptured Anterior Communicating Artery Aneurysms(2014-02-04) Krishnan, Govind; White, JonathanINTRODUCTION: Management of un-ruptured anterior communicating artery (ACOM) aneurysm is variable. The objective of this study was to identify demographic information, presentation indices, and clinical information that could help predict pattern outcomes after undergoing treatment for an un-ruptured ACOM aneurysm. METHODS: The study was a retrospective review of 139 patients with un-ruptured ACOM aneurysms from 2007 to 2012, who underwent either microsurgical clipping or endovascular coiling to treat the aneurysm. Demographics, medical history, presenting condition and patient outcomes were analyzed. The outcome of the treatment was quantified using the Glasgow Outcomes Score. A score of 3 or greater at discharge was considered favorable. Multivariate regression analysis was used to identify significant predictors of poor outcomes. RESULTS: A favorable outcome at discharge was achieved in 116 of the 139 total patients (83.45%). Multivariate analysis identified patient age grated than 70 (p<0.005), history of prior brain injury or surgery (p<0.005), current but not precious smoking (p<0.05), aneurysms of size greater than 20 mm (p<0.05), duration of temporary occlusions greater than 20 minutes (p<0.001), and the use of microsurgical clipping (p<0.005) as significant predictors of poor outcome. CONCLUSION: Age over 70, prior history of brain injury, current smoking, and an aneurysm size greater than 20 mm, along with the use of clipping and a duration of temporary occlusion greater than 20 minutes are the strongest predictors of poor outcome from treatment of un-ruptured ACOM aneurysms. This would indicate that treatment should be reconsidered in patients with any of the above risk factors and coiling should be attempted whenever possible.Item Functional Outcomes in Patients with Full Thickness Hand Burns(2020-03-10) Vu, Kevin Quochuy; Holavanahalli, Radha; Kowalske, Karen; Hynan, Linda S.BACKGROUND: There has been previous work objectively examining the severe contractures that develop with hand burns, but few have correlated severity with functional outcome. While contracture definitions exist for restrictions in range of motion (ROM), they have not been linked to prognostic use and functional outcome. OBJECTIVE: The objective of this study is to correlate severity of hand contracture in joints of the hand with differences in functional outcomes scores at discharge. METHODS: This multicenter study uses the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) database, otherwise known as the Burn Injury Model Systems (BMS) National Database. A sample of 95 patients with ROM measurements and the SF-36 physical component score (PCS) to measure functional outcome was used. Patients were grouped by ROM into mild, moderate, or severe contracture definitions. Inclusion criteria included those with burn injuries as defined by the American Burn Association who had recorded ROM deficits. Patients with post-injury amputations were excluded. Statistical analyses were conducted to compare the maximum severity of contracture in both hands on the PCS when the maximum contracture was classified as mild, moderate, or severe. Secondary analysis was used to also compare PCS between mild and moderate versus severe contracture groups. RESULTS: There was no significant difference in PCS for mild, moderate or severe contracture (p = 0.858). There was a downward trend noted in the means between each contracture group, as well as several outliers in the moderate contracture group. Secondary analysis between a combined mild and moderate versus severe contracture group showed no significant difference in PCS between the two groups (p = 0.654) CONCLUSION: The results of this study suggest that although there is a downward trend in PCS that correlates with severity of contracture, the difference in functional outcome as measured by the PCS is not significant between the different ratings of contracture severity. Future studies involving long-term PCSItem The Impact of Medical Therapy on Short- and Long-Term Outcomes of Surgical Therapy for Culture-Positive Infective Endocarditis(2014-02-04) Squiers, John; Xu, David; DiMaio, J. MichaelBACKGROUND: Valve surgery is recommended for a limited number of patients with infective endocarditis (IE) meeting complicated, often anecdotal, criteria. Up to half of patients receiving medical therapy for culture-positive IE are prescribed inappropriate antibiotics for the etiologic microorganism. The impact of medical therapy on surgical outcomes is not well defined by existing literature. Design and Setting: Retrospective, observational cohort study conducted from 1990 to 2013. Data were collected from patient charts. Antibiotic therapy was graded as appropriate or inappropriate according to the most recent guidelines of the American Heart Association. Participants: 286 consecutive patients with culture-positive IE by the Duke Modified Criteria undergoing therapeutic valve surgery. 177 (62%) received appropriate antibiotic therapy and 93 (33%) received inappropriate antibiotic therapy. Antibiotic regimens of the 16 (5%) remaining patients could not be assessed. RESULTS: Kaplan-Meier survival analysis showed no statistical difference in survival between the appropriate and inappropriate therapy groups (p=0.795). Intraoperative deaths occurred in 3.4% of the appropriate therapy group and 3.2% of the inappropriate therapy group. All-cause mortality within 30 days of operation was 15% (95%CI: 10,20) in the appropriate group and 12% (5,20) in the inappropriate group. Two-year and five-year survival rates were 62% (55,70) and 48% (40,58) in the appropriate group and 63% (54,75) and 52% (42,65) in the inappropriate group. Contingency analysis of potentially confounding variables revealed the two cohorts had few statistically significant differences in frequencies of etiologic microorganism and comorbidities. There were no statistically significant differences between the groups in their gender composition, racial composition, mean age, or frequencies of affected valves. CONCLUSION: Although appropriate antibiotics are clearly superior for patients receiving medical therapy alone to treat IE, it appears that short-term and long-term survival of patients undergoing valve surgery are not affected by the appropriateness of prior medical therapy. This suggests that among the many variables physicians must weigh when considering surgical therapy for IE, the patients' antibiotic therapy regimen may not be an important factor. Further analysis may reveal other variables predictive of short or long-term mortality in these patients. Acknowledgment: Supported in part by an Alpha Omega Alpha Carolyn L. Kuckein Student Research FellowshipItem The Impact of Radiation and Chemotherapy on Outcomes in Patients Who Complete Implant-Based Breast Reconstruction(2018-01-23) Jayaraman, Avinash P.; Hampton, Savannah N.; Nair, Lekshmi A.; Venutolo, Christopher; Haddock, Nicholas T.; Teotia, Sumeet S.INTRODUCTION: Treatments for breast cancer include neoadjuvant chemotherapy (NACT), adjuvant chemotherapy (ACT), radiation (RAD), and combinations of these therapies. Many of these patients will choose to pursue implant-based breast reconstruction concurrently with these treatments. Effects of these therapies on the outcomes of implant-based reconstructions have not been studied fully. METHODS: From January 2012 to December 2016 two surgeons performed 542 breast reconstructions using tissue expanders (TE). The number of patients choosing implants who completed reconstruction was n=272. They were split into 8 groups based on therapy received: Group 1 (no treatment, n=139), Group 2 (NACT, n=32), Group 3 (ACT, n=44), Group 4 (NACT+ACT, n=14), Group 5 (NACT+RAD, n=17), Group 6 (ACT+RAD, n=13), Group 7 (RAD, n=12), Group 8 (ACT+NACT+RAD, n=1). Group 8 was excluded because it had only one patient, leaving n=271. ANOVA (df between groups = 6, df within groups = 264) and Tukey HSD were run to compare differences in the percentages of patients with infections requiring IV antibiotics, necrosis requiring operation, seroma, and TE exchange for new TE. Numbers of different surgeries were also counted. RESULTS: Comorbidities and age were equivalent across groups, except for Group 7 (55.7 yr) and Group 4 (41.6 yr), p=.03. There were no significant differences in percentages of patients with infection requiring IV antibiotics (p=.32), necrosis requiring operation (p=.09), or seroma (p=.40). For patients who required replacement of TE with another TE due to complication, only Group 1 (1.4%) vs Group 6 (15.4%) had a significant difference, p=.04. There were no differences in the mean numbers of complication-related surgeries before implant placement (p=.07), complication-related surgeries after implant placement (p=.30), revision surgeries (p=.98), or total surgeries (p=.29). There were no significant differences in the percentages of patients receiving at least one complication-related surgery before implant (p=.16), at least one complication-related surgery after implant (p=.85), or at least one revision surgery (p=.94). CONCLUSION: Among most patients who choose to undergo implant-based reconstruction in an academic practice, we found no significant differences in complication rates, mean numbers of surgeries per patient, and percentages of patients undergoing different types of surgeries. Although patients with combined adjuvant chemotherapy and radiation had a higher rate of TE exchange for new TE due to complication, the rates of other complications and surgeries were comparable. Given these results, practice trends in breast reconstruction can remain cautiously optimistic for patients choosing implant-based reconstruction concurrently with cancer treatments.Item A Newly Discovered Frontotemporal Nerve: Implications in Treatment of Migraine Headache and Migraine Surgery(2017-01-17) Chung, Michael; Pezeshk, Ronnie; Li, Xingchen; Amirlak, BardiaBACKGROUND: Migraine headaches are a debilitating disease affecting 37 million people, with an incidence of 18% for women and 6% of men. Due to incomplete efficacy of traditional medications, patients often seek more invasive treatments. Surgical decompression of peripheral cranial and spinal nerves at several anatomically studied trigger sites has demonstrated significant efficacy in bringing permanent relief to migraine sufferers. However, some patients who undergo surgery still have residual pain. Up to 17.8% of patients have emergence of pain at a secondary site postoperatively. A theory to explain incomplete surgical outcome is failure to identify and release unknown culprit nerves. In our experience doing frontal nerve decompression on migraine patients, we noticed a previously undescribed accessory nerve in the frontotemporal area. This study reports the incidence and location of this nerve. METHODS: A retrospective review of 103 patients who underwent migraine decompression surgery at UT Southwestern was done. 27 patients were excluded, as they did not undergo frontal site decompression and the area was not visualized. For the included 76 patients, measurements of this nerve had been taken intraoperatively using high-definition endoscopic assistance. RESULTS: Of the original 103 patients reviewed, 76 patients had received frontal endoscopic decompression. Of that group, 56 were female. This frontotemporal nerve was present in 55%, and bilateral incidence was 57%. An accompanying vessel was also present 81% of the time. Both nerve and vessel varied in size. Consistently, the nerve exited a foramen in the frontal bone on average 3.4 cm (SD = 0.47 cm) superior to the lateral canthus. CONCLUSION: The identification and avulsion of this nerve may result in a better surgical response rate. Additionally, this nerve should be considered during nerve block and onabotulinum toxin injections to improve outcome and accuracy. A review of available anatomical textbooks and current literature did not yield a nerve similar to the one described here. Our description of this newly discovered nerve may have implications for other anatomical and surgical uses.Item Outcomes Following Sports-Related Concussion in School-Aged Children and Adolescents: The Influence of Psychological Factors(2018-07-30) Wilmoth, Kristin Michelle; Cullum, C. Munro; Bell, Kathleen R.; Hynan, Linda S.; Didehbani, Nyaz; Rossetti, HeidiAlthough neurocognitive performance has been a popular topic of investigation in sports-related concussion, biopsychosocial sequelae have received considerably less attention. We reviewed the literature on emotional and psychosocial functioning in school-aged children and adolescents following concussion. MEDLINE and PsycINFO database queries identified 604 studies examining psychological and/or social outcomes of mild traumatic brain injury in children, 11 of those specific to athletes. This small body of literature and extrapolation from the general pediatric concussion literature indicated behavioral disturbances present at least temporarily following injury. Postconcussive anxiety and depressive symptoms are common, though levels may be subclinical. Social and academic disruption was less clearly documented. To aid clinicians in anticipating the psychosocial needs of concussed student athletes, well-controlled and adequately powered research on emotional and psychosocial outcomes are needed. The impact of post-injury psychological functioning on concussion recovery is poorly understood, particularly in youth. To this end, we explored initial mood and sleep symptoms as predictors of prolonged symptom clearance in a sample of adolescents, controlling for previously established injury-related and demographic risk factors. Student athletes (aged 12-18, N=393, 55% male) evaluated in outpatient concussion clinics completed brief self-report anxiety, depression, sleep, and postconcussive symptom scales 0-2 weeks post-injury. Medical record review at three-month follow-up provided date of symptom clearance. Survival analysis for time to recovery was conducted based on 1) self-reported injury/medical factors: sex, psychiatric history, prior concussion history, loss of consciousness, amnesia, initial symptom severity, and 2) psychological factors: anxiety, depression, and sleep screeners. Having amnesia, greater postconcussive symptoms, and worse sleep quality decreased the odds of recovery across time points (HRs = 0.64-0.99, ps < .05) in the total sample. When separated by sex, only postconcussive symptoms were associated with recovery in females, while amnesia and depressive symptoms were the only significant predictors of recovery for males (HRs = 0.54-0.98, ps < .05). Our findings linked brief psychological screeners to prolonged recovery, even considering injury and medical factors. Assessment of mood and sleep may aid in identification of individuals at risk for worse outcomes, though further exploration of postconcussive psychological issues is warranted before drawing firm conclusions.Item Outcomes of Patients Diagnosed with Psychogenic Non-Epileptic Seizures(2021-05-01T05:00:00.000Z) Ramamurthy, Swetha; Das, Rohit; Dave, Hina; Pershern, LindseyBACKGROUND: Psychogenic Non-Epileptic Seizures (PNES) is a complex neuropsychiatric illness that is very difficult to diagnose due to complex comorbidities and symptoms. There are also several risk factors associated with development of PNES that can contribute to the patient's presentation. However, there is very little literature on patient outcomes, management guidelines, and prognostic factors. Therefore, patients may not receive treatment according to a standard of care or in a streamlined manner which may worsen patient outcomes. OBJECTIVE: This study will examine 1) if patient outcomes improve with psychiatric or multidisciplinary management and 2) the influence of specific risk factors on patient outcomes. METHODS: This was a retrospective cohort study with data from chart review of the Parkland EMR. A total of 122 patients were examined who were diagnosed with PNES during an EMU admission in 2016. Demographic variables, risk factors for PNES, and treatment intervention information were extracted from each patient chart to be compared with the primary outcome variable. Patient outcomes were measured by recurrent symptoms leading to ED visits and/or EMU admissions after the initial 2016 admission. Descriptive analysis was done using Excel while statistical analysis comparing independent variables to patient outcome variables was done using SPSS 25. If the independent variable was a categorical variable, chi-square tests were used, but for continuous variables, Kruskal-Wallis rank sum tests were used. RESULTS: Preliminary findings showed no significant associations between receiving any singular intervention and patient outcomes. Unexpectedly multidisciplinary management such as therapy and psychiatric follow-up had no significant relationship with patient outcomes. Risk factors that may be associated with increased recurrent PNES symptoms include prior psychiatric disorders, prior ED visits or EMU admissions, and socioeconomic factors such as type of insurance and homelessness. CONCLUSION: Although multidisciplinary management did not show significant reduction in readmissions or ED visits for PNES symptoms, prior literature shows that psychiatric/psychological involvement can improve PNES outcomes. Treatment of PNES should be tailored for patients based on psychiatric/neurologic comorbidities and risk factors. Future research will need to explore the benefits of combinations of interventions and a multidisciplinary clinic such as a PNES clinic for these patients.