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1.  Translational neural engineering: multiple perspectives on bringing benchtop research into the clinical domain 
Journal of neural engineering  2008;5(1):P16-P20.
A half-day forum to address a wide range of issues related to translational neural engineering was conducted at the annual meeting of the Biomedical Engineering Society. Successful practitioners of translational neural engineering from academics, clinical medicine and industry were invited to share a diversity of perspectives and experiences on the translational process. The forum was targeted towards traditional academic researchers who may be interested in the expanded funding opportunities available for translational research that emphasizes product commercialization and clinical implementation. The seminar was funded by the NIH with support from the Rehabilitation Institute of Chicago. We report here a summary of the speaker viewpoints with particular focus on extracting successful strategies for engaging in or conducting translational neural engineering research. Daryl Kipke, PhD, (Department of Biomedical Engineering at the University of Michigan) and Molly Shoichet, PhD, (Department of Chemical Engineering at the University of Toronto) gave details of their extensive experience with product commercialization while holding primary appointments in academic departments. They both encouraged strong clinical input at very early stages of research. Neurosurgeon Fady Charbel, MD, (Department of Neurosurgery at the University of Illinois at Chicago) discussed his role in product commercialization as a clinician. Todd Kuiken, MD, PhD, (Director of the Neural Engineering for Artificial Limbs at the Rehabilitation Institute of Chicago, affiliated with Northwestern University) also a clinician, described a model of translational engineering that emphasized the development of clinically relevant technology, without a strong commercialization imperative. The clinicians emphasized the importance of communicating effectively with engineers. Representing commercial neural engineering was Doug Sheffield, PhD, (Director of New Technology at Vertis Neuroscience, Inc.) who strongly encouraged open industrial–academic partnerships as an efficient path forward in the translational process. Joe Pancrazio, PhD, a Program Director at NIH’s National Institute of Neurological Disorders and Stroke, emphasized that NIH funding for translational research was aimed at breaking down scientific barriers to clinic entrance. Vivian Weil, PhD, (Director of Center for the Study of Ethics in the Professions at the Illinois Institute of Technology) a specialist on ethics in science and engineering, spoke of the usefulness of developing a code of ethics for addressing ethical aspects of translation from the bench to clinical implementation and of translation across disciplines in multi-disciplinary projects. Finally, the patient perspective was represented by Mr Jesse Sullivan. A double-arm amputee and patient of Dr Kuiken’s, Mr Sullivan demonstrated the critically important role of the patient in successful translational neural engineering research.
doi:10.1088/1741-2560/5/1/P02
PMCID: PMC2729702  PMID: 18310805
2.  B.M.A. Annual Meeting, Sydney, 10–16 August: Report of Proceedings 
British Medical Journal  1968;3(5616):485-492.
The One Hundred and Thirty-sixth Annual Meeting of the British Medical Association was held in Sydney from 10 to 16 August jointly with the Seventh Annual Meeting of the Australian Medical Association. Both meetings were associated with the Third Australian Medical Congress. It was the second Annual Meeting of the Association to be held in Australia, the previous one having been in Melbourne in 1935. Four plenary sessions were held on successive mornings, while meetings of various sections were held in the afternoons. An account of the first part of the Meeting is given below. The remainder will be reported next week.
Images
PMCID: PMC1986422
3.  Expertise, Time, Money, Mentoring, and Reward: Systemic Barriers That Limit Education Researcher Productivity—Proceedings From the AAMC GEA Workshop 
Background
To further evolve in an evidence-based fashion, medical education needs to develop and evaluate new practices for teaching, learning, and assessment. However, educators face barriers in designing, conducting, and publishing education research.
Objective
To explore the barriers medical educators face in formulating, conducting, and publishing high-quality medical education research, and to identify strategies for overcoming them.
Methods
A consensus workshop was held November 5, 2013, at the Association of American Medical Colleges annual meeting. A working group of education research experts and educators completed a preconference literature review focusing on barriers to education research. During the workshop, consensus-based and small group techniques were used to refine the broad themes into content categories. Attendees then ranked the most important barriers and strategies for overcoming them with the highest potential impact.
Results
Barriers participants faced in conducting quality education research included lack of (1) expertise, (2) time, (3) funding, (4) mentorship, and (5) reward. The strategy considered most effective in overcoming these barriers involved building communities of education researchers for collaboration and networking, and advocating for education researchers' interests. Other suggestions included trying to secure increased funding opportunities, developing mentoring programs, and encouraging mechanisms to ensure protected time.
Conclusions
Barriers to education research productivity clearly exist. Many appear to result from feelings of isolation that may be overcome with systemic efforts to develop and enable communities of practice across institutions. Finally, the theme of “reward” is novel and complex and may have implications for education research productivity.
doi:10.4300/JGME-D-14-00340.1
PMCID: PMC4535205  PMID: 26279767
4.  Proceedings of the 2010 National Toxicology Program Satellite Symposium 
Toxicologic pathology  2010;39(1):240-266.
The 2010 annual National Toxicology Program (NTP) Satellite Symposium, entitled “Pathology Potpourri,” was held in Chicago, Illinois, in advance of the scientific symposium sponsored jointly by the Society of Toxicologic Pathology (STP) and the International Federation of Societies of Toxicologic Pathologists (IFSTP). The goal of the annual NTP Symposium is to present current diagnostic pathology or nomenclature issues to the toxicologic pathology community. This article presents summaries of the speakers' presentations, including diagnostic or nomenclature issues that were presented, along with select images that were used for voting or discussion. Some topics covered during the symposium included a comparison of rat and mouse hepatocholangiocarcinoma, a comparison of cholangiofibrosis and cholangiocarcinoma in rats, a mixed pancreatic neoplasm with acinar and islet cell components, an unusual preputial gland tumor, renal hyaline glomerulopathy in rats and mice, eosinophilic substance in the nasal septum of mice, INHAND nomenclature for proliferative and nonproliferative lesions of the CNS/PNS, retinal gliosis in a rat, fibroadnexal hamartoma in rats, intramural plaque in a mouse, a treatment-related chloracne-like lesion in mice, and an overview of mouse ovarian tumors.
doi:10.1177/0192623310391680
PMCID: PMC3096448  PMID: 21177527
NTP Satellite Symposium; INHAND nomenclature; hepatocholangiocarcinoma; acinar-islet cell; preputial gland; hyaline glomerulopathy; eosinophilic substance; ependymoma; axonal degeneration; retinal gliosis; fibroadnexal hamartoma; intramural plaque; chloracne; ovary; cholangiocarcinoma
5.  Genomics in personalized cancer medicine and its impact on early drug development in China: report from the 6th Annual Meeting of the US Chinese Anti-Cancer Association (USCACA) at the 50th ASCO Annual Meeting 
Chinese Journal of Cancer  2014;33(8):371-375.
The 6th Annual Meeting of the United States Chinese Anti-Cancer Association (USCACA) was held in conjunction with the 50th Annual Meeting of American Society of Clinical Oncology (ASCO) on May 30, 2014 in Chicago, Illinois, the United States of America. With a focus on personalized medicine, the conference featured novel approaches to investigate genomic aberrations in cancer cells and innovative clinical trial designs to expedite cancer drug development in biomarker-defined patient populations. A panel discussion further provided in-depth advice on advancing development of personalized cancer medicines in China. The conference also summarized USCACA key initiatives and accomplishments, including two awards designated to recognize young investigators from China for their achievements and to support their training in the United States. As an effort to promote international collaboration, USCACA will team up with Chinese Society of Clinical Oncology (CSCO) to host a joint session on “Breakthrough Cancer Medicines” at the upcoming CSCO Annual Meeting on September 20th, 2014 in Xiamen, China.
doi:10.5732/cjc.014.10110
PMCID: PMC4135365  PMID: 25096543
Genomics; cancer; personalized medicine
6.  Adherence to anti-diabetic drugs among patients with Type 2 diabetes mellitus at Muhimbili National Hospital, Dar es Salaam, Tanzania- A cross-sectional study 
Introduction
Adherence to diabetes mellitus treatment regimens among Type 2 diabetes patients in Tanzania has not been well documented. This study sought to assess adherence to antidiabetic drugs and associated factors among patients with Type 2 diabetes mellitus.
Methods
A cross-sectional study was conducted among type 2 diabetes mellitus patients who were attending the Diabetic clinic of Muhimbili National hospital between May 2009 and February 2010. Assement ofadherence to antidiabetic medications was based on patients’ self-reported recall of skipped days without taking medications, over the past one week and three months. Data wereentered and analyzed using Statistical Package for Social Sciences (SPSS Inc. Chicago, Illinois version 16). The crude and adjusted odds ratio (COR/ AOR) and 95% Confidence Interval (CI) were performed to determine factors associated with anti-diabetic medications adherence and a p-value of 0.05 or less was considered statistically significant.
Results
Adherence rates to antidiabetic drugs were found to be 60.2% and 71.2% at one week and three months respectively. High cost of medication was significantly associated with anti-diabetic non-adherence. Adherence to anti-diabetic drugs significantly increased with an increase in number of non-diabetic medications.
Conclusion
Adherence to antidiabetic drugs was found to be suboptimal. Patients with other medical conditions in addition to diabetes mellitus are more likely to adhere to anti-diabetic medications. There is a need for the responsible authorities to set policies that subsidize cost of anti-diabetic drugs to improve adherence and reduce associated complications.
doi:10.11604/pamj.2014.17.252.2972
PMCID: PMC4189860  PMID: 25309652
Type 2 diabetes mellitus; anti-diabetic drugs; drug adherence; Tanzania
7.  A plan to prevent adolescent pregnancy and reduce infant mortality. 
Public Health Reports  1987;102(1):80-86.
In Illinois, particularly in Chicago, the infant mortality rate is higher than that for the nation as a whole. Unless infant mortality in Illinois declines at a faster rate, the State will not meet the objective for reducing infant mortality specified by the Surgeon General of the Public Health Service. Low birth weight infants are at high risk of medical problems, if not death, and teenage mothers have an increased risk of bearing low birth weight infants. This paper presents a program aimed at the primary prevention of adolescent pregnancy. The three-component, interactive program--sex education, adolescent clinic services, and community support and involvement--is proposed for preventing adolescent pregnancy which, in turn, will decrease the rate of births of low birth weight infants and, consequently, the rate of infant mortality in target areas of Illinois. Medical and college students will be trained to teach the sex education course and to serve as counselors. A clinic will provide primary care, contraceptive education, and access to contraceptives. The clinic staff will be a resource for the community as well as for the adolescents. In the target areas, church and community members will sponsor health fairs and discussions of adolescent pregnancy at church and at parent-teacher association meetings. The overlapping activities of the instructors, clinic personnel, and church and community members will give continuity and consistency to the prevention message directed to the adolescents.
PMCID: PMC1477726  PMID: 3101128
8.  Establishing a Canadian national clinical trials network for kidney disease: proceedings of a planning workshop 
Knowledge generation through randomized controlled trials (RCTs) is critical to advance the medical evidence base, inform decision-making, and improve care and outcomes. Unfortunately, nephrology has typically lagged behind other medical specialties in this regard. The establishment of formal clinical trial networks can facilitate the successful conduct of RCTs and has significantly increased the number of RCTs performed worldwide in other medical specialties. No such formal network of nephrology trialists exists in Canada. On April 24, 2014, the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) Clinical Trials Committee held a stakeholder engagement meeting to address this gap and improve the nephrology clinical trial landscape in Canada. The meeting was held in Vancouver in association with the 2014 Canadian Society of Nephrology Annual General Meeting and was co-sponsored by the Kidney Foundation of Canada and CANN-NET. Attendees included nephrologists from university- and non-university-affiliated nephrology practices, administrators, and representatives from the Kidney Foundation of Canada. Through structured presentations and facilitated group discussions, the group explored the extent to which nephrology trials are currently happening in Canada, barriers to leading or participating in larger investigator-initiated trials, and strategies to improve clinical trial output in nephrology in Canada. The themes and action items arising from this meeting are discussed.
Electronic supplementary material
The online version of this article (doi:10.1186/s40697-015-0080-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s40697-015-0080-7
PMCID: PMC4650502  PMID: 26583070
9.  Mediterranean Diet and Depressive Symptoms Among Older Adults Over Time 
Objective
To examine whether adherence to a Mediterranean-based dietary pattern is predictive of depressive symptoms among older adults.
Design
Generalized estimating equation models were used to test the association between a Mediterranean-based dietary pattern and depressive symptoms over time. Models were adjusted for age, sex, race, education, income, widowhood, antidepressant use, total calorie intake, body mass index, smoking, alcohol consumption, number of self-reported medical conditions, cognitive function, and physical disability.
Setting
Chicago, Illinois.
Participants
Community-dwelling participants (n=3502) of the Chicago Health and Aging Project aged 65+ years (59% African American) who had no evidence of depression at the baseline.
Measurements
Adherence to a Mediterranean-based dietary pattern was assessed by the MedDietScore. Dietary evaluation was performed with a food frequency questionnaire at baseline and related to incident depression as measured by the presence of four or more depressive symptoms from the 10-item version of the Center for Epidemiologic Studies Depression scale.
Results
Over an average follow-up of 7.2 years, greater adherence to a Mediterranean-based diet was associated with a reduced number of newly occurring depressive symptoms (parameter estimate = -0.002, standard error = 0.001; p = 0.04). The annual rate of developing depressive symptoms was 98.6% lower among persons in the highest tertile of a Mediterranean-based dietary pattern compared with persons in the lowest tertile group.
Conclusion
Our results support the hypothesis that adherence to a diet comprised of vegetables, fruits, whole grains, fish, and legumes may protect against the development of depressive symptoms in older age.
doi:10.1007/s12603-012-0437-x
PMCID: PMC4454450  PMID: 23636545
Diet; mediterranean dietary pattern; depressive symptoms; older adults
10.  Maternal Serum Lipids in Women with Pre-eclampsia 
Background:
Evidence of increased oxidative stress due to endothelial dysfunction in pre-eclampsia has been well-established. Increase in the oxidative stress is associated with abnormal lipid profile.
Aim:
The aim of the study is to compare serum lipids in pre-eclamptic women and healthy pregnant women.
Subjects and Methods:
In this case-control study, blood samples were collected from 40 pregnant females diagnosed as pre-eclampsia and 80 normal pregnant females at the Department of Obstetrics and Gynecology at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia between February 2009 and January 2010. We evaluated serum levels of total cholesterol, low-density lipoprotein and high-density lipoprotein cholesterol and triglyceride in women with pre-eclampsia and those of women with normal pregnancies. Data was analyzed using SPSS for Windows (version 17.0, SPSS Inc., Chicago, Illinois, USA). The data is presented descriptively and test for significance was done using the student t-test for continous data.
Results:
Women with pre-eclampsia exhibited higher serum triglyceride levels compared with normal pregnant women (P < 0.01). Other measured serum lipids did not differ significantly in the two groups.
Conclusion:
We recommend that any pregnant female with higher serum triglyceride concentrations may be further investigated for pre-eclampsia. Further large scale multicenter studies are required to establish the use of measuring serum triglyceride levels to screen the pregnant females for pre-eclampsia.
doi:10.4103/2141-9248.139358
PMCID: PMC4160696  PMID: 25221720
Lipids; Pre-eclampsia; Triglycerides
11.  Lumbar Disk Herniation Surgery: Outcome and Predictors 
Global Spine Journal  2014;4(4):233-244.
Study Design A retrospective cohort study.
Objectives To determine the outcome and any differences in the clinical results of three different surgical methods for lumbar disk herniation and to assess the effect of factors that could predict the outcome of surgery.
Methods We evaluated 148 patients who had operations for lumbar disk herniation from March 2006 to March 2011 using three different surgical techniques (laminectomy, microscopically assisted percutaneous nucleotomy, and spinous process osteotomy) by using Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire, Resumption of Activities of Daily Living scale and changes of visual analog scale (VAS) for low back pain and radicular pain. Our study questionnaire addressed patient subjective satisfaction with the operation, residual complaints, and job resumption. Data were analyzed with SPSS version 16.0 (SPSS, Inc., Chicago, Illinois, United States). Statistical significance was set at 0.05. For statistical analysis, chi-square test, Mann-Whitney U test, Kruskal-Wallis test, and repeated measure analysis were performed. For determining the confounding factors, univariate analysis by chi-square test was used and followed by logistic regression analysis.
Results Ninety-four percent of our patients were satisfied with the results of their surgeries. VAS documented an overall 93.3% success rate for reduction of radicular pain. Laminectomy resulted in better outcome in terms of JOA Back Pain Evaluation Questionnaire. The outcome of surgery did not significantly differ by age, sex, level of education, preoperative VAS for back, preoperative VAS for radicular pain, return to previous job, or level of herniation.
Conclusion Surgery for lumbar disk herniation is effective in reducing radicular pain (93.4%). All three surgical approaches resulted in significant decrease in preoperative radicular pain and low back pain, but intergroup variation in the outcome was not achieved. As indicated by JOA Back Pain Evaluation Questionnaire–Low Back Pain (JOABPQ-LBP) and lumbar function functional scores, laminectomy achieved significantly better outcome compared with other methods. It is worth mentioning that relief of radicular pain was associated with subjective satisfaction with the surgery among our study population. Predictive factors for ineffective surgical treatment for lumbar disk herniation were female sex and negative preoperative straight leg raising. Age, level of education, and preoperative VAS for low back pain were other factors that showed prediction power.
doi:10.1055/s-0034-1390010
PMCID: PMC4229371  PMID: 25396104
lumbar disk herniation; surgery; outcome; predictors
12.  Classification of impacted mandibular third molars on cone-beam CT images 
Background
Neurological involvement is a serious complication associated to the surgical removal of impacted mandibular third molars and the radiological investigation is the first mandatory step to assess the risk of a possible post-operative injury to the inferior alveolar nerve (IAN). The aim of this study was to introduce a new radiological classification that could be normally used in clinical practice to assess the relationship between an impacted third molar and mandibular canal on cone beam CT (CBCT) images.
Material and Methods
CBCT images of 80 patients (133 mandibular third molars) were independently studied by three members of the surgical team to draw a classification that could describe all the possible relationships between third molar and IAN on the cross-sectional images. Subsequently, the study population was subdivided according to this classification. The SPSS software, version 15.0 (SPSS® Inc., Chicago, Illinois, USA) was used for the statistical analysis.
Results
Eight different classes were proposed (classes 0-7) and six of them (classes 1-6) were subdivided in two subtypes (subtypes A-B). The distribution of classes showed a prevalence of buccal or apical course of the mandibular canal followed by lingual position and inter-radicular one. No differences have resulted in terms of anatomic relationship between males and females apart from a higher risk of real contact without corticalization of the canal when the IAN had a lingual course for female group. Younger patients showed an increased rate of direct contact with a reduced calibre of the canal and/or without corticalization.
Conclusions
The use of this classification could be a valid support in clinical practice to obtain a common language among operators in order to define the possible relationships between an impacted third molar and the mandibular canal on CBCT images.
Key words:CBCT, classification, inferior alveolar nerve, third molars.
doi:10.4317/jced.51984
PMCID: PMC4483328  PMID: 26155337
13.  Measuring use patterns of online journals and databases 
Purpose: This research sought to determine use of online biomedical journals and databases and to assess current user characteristics associated with the use of online resources in an academic health sciences center.
Setting: The Library of the Health Sciences–Peoria is a regional site of the University of Illinois at Chicago (UIC) Library with 350 print journals, more than 4,000 online journals, and multiple online databases.
Methodology: A survey was designed to assess online journal use, print journal use, database use, computer literacy levels, and other library user characteristics. A survey was sent through campus mail to all (471) UIC Peoria faculty, residents, and students.
Results: Forty-one percent (188) of the surveys were returned. Ninety-eight percent of the students, faculty, and residents reported having convenient access to a computer connected to the Internet. While 53% of the users indicated they searched MEDLINE at least once a week, other databases showed much lower usage. Overall, 71% of respondents indicated a preference for online over print journals when possible.
Conclusions: Users prefer online resources to print, and many choose to access these online resources remotely. Convenience and full-text availability appear to play roles in selecting online resources. The findings of this study suggest that databases without links to full text and online journal collections without links from bibliographic databases will have lower use. These findings have implications for collection development, promotion of library resources, and end-user training.
PMCID: PMC153164  PMID: 12883574
14.  Trends in Laboratory Test Volumes for Medicare Part B Reimbursements, 2000–2010 
Context
Changes in reimbursements for clinical laboratory testing may help us assess the effect of various variables, such as testing recommendations, market forces, changes in testing technology, and changes in clinical or laboratory practices, and provide information that can influence health care and public health policy decisions. To date, however, there has been no report, to our knowledge, of longitudinal trends in national laboratory test use.
Objective
To evaluate Medicare Part B–reimbursed volumes of selected laboratory tests per 10 000 enrollees from 2000 through 2010.
Design
Laboratory test reimbursement volumes per 10 000 enrollees in Medicare Part B were obtained from the Centers for Medicare & Medicaid Services (Baltimore, Maryland). The ratio of the most recent (2010) reimbursed test volume per 10 000 Medicare enrollees, divided by the oldest data (usually 2000) during this decade, called the volume ratio, was used to measure trends in test reimbursement. Laboratory tests with a reimbursement claim frequency of at least 10 per 10 000 Medicare enrollees in 2010 were selected, provided there was more than a 50% change in test reimbursement volume during the 2000–2010 decade. We combined the reimbursed test volumes for the few tests that were listed under more than one code in the Current Procedural Terminology (American Medical Association, Chicago, Illinois). A 2-sided Poisson regression, adjusted for potential overdispersion, was used to determine P values for the trend; trends were considered significant at P < .05.
Results
Tests with the greatest decrease in reimbursement volumes were electrolytes, digoxin, carbamazepine, phenytoin, and lithium, with volume ratios ranging from 0.27 to 0.64 (P < .001). Tests with the greatest increase in reimbursement volumes were meprobamate, opiates, methadone, phencyclidine, amphetamines, cocaine, and vitamin D, with volume ratios ranging from 83 to 1510 (P < .001).
Conclusions
Although reimbursement volumes increased for most of the selected tests, other tests exhibited statistically significant downward trends in annual reimbursement volumes. The observed changes in reimbursement volumes may be explained by disease prevalence and severity, patterns of drug use, clinical or laboratory practices, and testing recommendations and guidelines, among others. These data may be useful to policy makers, health systems researchers, laboratory directors, and industry scientists to understand, address, and anticipate trends in laboratory testing in the Medicare population.
doi:10.5858/arpa.2013-0149-OA
PMCID: PMC4698806  PMID: 23738761
15.  Arthrodesing Operations on the Feet 
Dr. Edwin Warner Ryerson was born in New York City, graduated from Harvard, then trained at Boston Children’s Hospital [1]. After visiting centers in Berlin and Vienna he moved to Chicago in 1899, where he accepted a post at Rush Medical College. In 1916 he was named professor and head of orthopaedics at the University of Illinois College of Medicine. Owing to WWI he entered military service in 1918–1919. Afterward he became head of orthopaedics at Northwestern University until his retirement from the university in 1935. He continued in private practice until 1947, when he retired to Florida.
Dr. Ryerson maintained a lifelong interest in teaching and service to the orthopaedic community. He became a member of the American Orthopaedic Association in 1905 and was President in 1925. Dr. Ryerson was active in the Clinical Orthopaedic Society, which also had a role in forming American Academy of Orthopaedic Surgeons [4]. In the archives of the AAOS, he was described as “a forensic and parliamentary expert” [6]. He was a founding member of the American Board of Orthopaedic Surgery in 1934, became its vice President in 1935, and served on the Board until 1940 [11].
The article reproduced here describes the triple arthrodesis [9]. Ryerson modified a technique earlier described by Hoke which advocated fusing the subtalar and talo-navicular joints [7]. According to Campbell [5] Ryerson popularized the name “triple arthrodesis.” Hoke had not mentioned fusion of the calcaneo-cuboid joint, although Gill, in a discussion following Hoke’s description states, “an additional arthrodesis os calcis and cuboid is unnecessary.” Thus, it is possible Ryerson introduced the third fusion of the triple arthrodesis, although the record is not clear on this point. Ryerson’s operation, however, was commonly used to stabilize the hindfoot in polio patients, and continues to be used less commonly today for other indications. It is likely Ryerson met Adolf Lorenz (1854–1946), the Professor of Orthopaedics at the University of Vienna at the time of his visit [8, 10]. Lorenz, in turn, had trained with Eduard Albert (1841–1900) who conceived the idea of arthrodesis for paralyzed extremities [2, 3]. As with most surgeons of the time, Ryerson wrote on a wide variety of topics related to spine surgery, infection, and congenital anomalies, although he seemed to have a particular interest in foot surgery.Edwin W. Ryerson, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
A Tribute to the First President of the American Academy of Orthopaedic Surgeons. Edwin W. Ryerson, M.D. 1872–1961. J Bone Joint Surg Am. 1965;47:1274–1275.Albert E. Einige Fälle künstliche Ankylosenbildung an paralytischen Gliedmaßen. Wien med Presse. 1882;23:725.Albert E. Some cases of artificial anklyosis of paralytic extremities. In: Bick EM, ed. Classics of Orthopaedics. Philadelphia: J.B. Lippincott Company: 1976.Brown T. The American Orthopaedic Association: A Centennial History. Chicago, IL: The American Orthopaedic Association; 1987.Campbell WC. Operative Orthopedics. Saint Louis: C.V. Mosby Co.; 1939.Heck CV. Commemorative Volume 1933–1983 Fifty Years of Progress. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Hoke M. An operation for stabilizing paralytic feet. Amer J Orthop Surg. 1921;3:494–507.Kotz R, Engel A, Schiller C, ed. 100 Jahre Orthopädie an der Universität Wien. Vienna, Austria: Verlag der Wiener Medizinischen Akademie; 1987.Ryerson EW. Arthrodesing operations on the feet. J Bone Joint Surg Am. 1923;5:453–471.Skopec M. Adolf Lorenz und das Ringen um die Verselbständigung der Orthopädie in Wien. In: Wyklicky H, ed. 100 Jahre Orthopädie an der Universität Wien. Vienna, Austria: 1987:1–45.Wickstrom JK. Fifty years of the American Board of Orthopaedic Surgery. 1934. Clin Orthop Relat Res. 1990;257:3–10.
doi:10.1007/s11999-007-0035-0
PMCID: PMC2505279  PMID: 18196368
16.  Comparison of Healthcare Utilization Among Patients Treated With Alcoholism Medications 
Objectives
To determine in a large claims database the healthcare utilization and costs associated with treatment of alcohol dependence with medications vs no medication and across 4 US Food and Drug Administration (FDA)–approved medications.
Study Design
Claims database analysis.
Methods
Eligible adults with alcohol dependence claims (n = 27,135) were identified in a commercial database (MarketScan; Thomson Reuters Inc, Chicago, Illinois). Following propensity score–based matching and inverse probability weighting on demographic, clinical, and healthcare utilization variables, patients who had used an FDA-approved medication for alcohol dependence (n = 2977) were compared with patients who had not (n = 2977). Patients treated with oral naltrexone hydrochloride (n = 2064), oral disulfiram (n = 2076), oral acamprosate calcium (n = 5068), or extended-release injectable naltrexone (naltrexone XR) (n = 295) were also compared for 6-month utilization rates of alcoholism medication, inpatient detoxification days, alcoholism-related inpatient days, and outpatient services, as well as inpatient charges.
Results
Patients who received alcoholism medications had fewer inpatient detoxification days (706 vs 1163 days per 1000 patients, P <.001), alcoholism-related inpatient days (650 vs 1086 days, P <.001), and alcoholism-related emergency department visits (127 vs 171, P = .005). Among 4 medications, the use of naltrexone XR was associated with fewer inpatient detoxification days (224 days per 1000 patients) than the use of oral naltrexone (552 days, P = .001), disulfiram (403 days, P = .049), or acamprosate (525 days, P <.001). The group receiving naltrexone XR also had fewer alcoholism-related inpatient days than the groups receiving disulfiram or acamprosate. More patients in the naltrexone XR group had an outpatient substance abuse visit compared with patients in the oral alcoholism medication groups.
Conclusion
Patients who received an alcoholism medication had lower healthcare utilization than patients who did not. Naltrexone XR showed an advantage over oral medications in healthcare utilization and costs.
PMCID: PMC4160801  PMID: 21348558
17.  Internet-Based Device-Assisted Remote Monitoring of Cardiovascular Implantable Electronic Devices 
Executive Summary
Objective
The objective of this Medical Advisory Secretariat (MAS) report was to conduct a systematic review of the available published evidence on the safety, effectiveness, and cost-effectiveness of Internet-based device-assisted remote monitoring systems (RMSs) for therapeutic cardiac implantable electronic devices (CIEDs) such as pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. The MAS evidence-based review was performed to support public financing decisions.
Clinical Need: Condition and Target Population
Sudden cardiac death (SCD) is a major cause of fatalities in developed countries. In the United States almost half a million people die of SCD annually, resulting in more deaths than stroke, lung cancer, breast cancer, and AIDS combined. In Canada each year more than 40,000 people die from a cardiovascular related cause; approximately half of these deaths are attributable to SCD.
Most cases of SCD occur in the general population typically in those without a known history of heart disease. Most SCDs are caused by cardiac arrhythmia, an abnormal heart rhythm caused by malfunctions of the heart’s electrical system. Up to half of patients with significant heart failure (HF) also have advanced conduction abnormalities.
Cardiac arrhythmias are managed by a variety of drugs, ablative procedures, and therapeutic CIEDs. The range of CIEDs includes pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. Bradycardia is the main indication for PMs and individuals at high risk for SCD are often treated by ICDs.
Heart failure (HF) is also a significant health problem and is the most frequent cause of hospitalization in those over 65 years of age. Patients with moderate to severe HF may also have cardiac arrhythmias, although the cause may be related more to heart pump or haemodynamic failure. The presence of HF, however, increases the risk of SCD five-fold, regardless of aetiology. Patients with HF who remain highly symptomatic despite optimal drug therapy are sometimes also treated with CRT devices.
With an increasing prevalence of age-related conditions such as chronic HF and the expanding indications for ICD therapy, the rate of ICD placement has been dramatically increasing. The appropriate indications for ICD placement, as well as the rate of ICD placement, are increasingly an issue. In the United States, after the introduction of expanded coverage of ICDs, a national ICD registry was created in 2005 to track these devices. A recent survey based on this national ICD registry reported that 22.5% (25,145) of patients had received a non-evidence based ICD and that these patients experienced significantly higher in-hospital mortality and post-procedural complications.
In addition to the increased ICD device placement and the upfront device costs, there is the need for lifelong follow-up or surveillance, placing a significant burden on patients and device clinics. In 2007, over 1.6 million CIEDs were implanted in Europe and the United States, which translates to over 5.5 million patient encounters per year if the recommended follow-up practices are considered. A safe and effective RMS could potentially improve the efficiency of long-term follow-up of patients and their CIEDs.
Technology
In addition to being therapeutic devices, CIEDs have extensive diagnostic abilities. All CIEDs can be interrogated and reprogrammed during an in-clinic visit using an inductive programming wand. Remote monitoring would allow patients to transmit information recorded in their devices from the comfort of their own homes. Currently most ICD devices also have the potential to be remotely monitored. Remote monitoring (RM) can be used to check system integrity, to alert on arrhythmic episodes, and to potentially replace in-clinic follow-ups and manage disease remotely. They do not currently have the capability of being reprogrammed remotely, although this feature is being tested in pilot settings.
Every RMS is specifically designed by a manufacturer for their cardiac implant devices. For Internet-based device-assisted RMSs, this customization includes details such as web application, multiplatform sensors, custom algorithms, programming information, and types and methods of alerting patients and/or physicians. The addition of peripherals for monitoring weight and pressure or communicating with patients through the onsite communicators also varies by manufacturer. Internet-based device-assisted RMSs for CIEDs are intended to function as a surveillance system rather than an emergency system.
Health care providers therefore need to learn each application, and as more than one application may be used at one site, multiple applications may need to be reviewed for alarms. All RMSs deliver system integrity alerting; however, some systems seem to be better geared to fast arrhythmic alerting, whereas other systems appear to be more intended for remote follow-up or supplemental remote disease management. The different RMSs may therefore have different impacts on workflow organization because of their varying frequency of interrogation and methods of alerts. The integration of these proprietary RM web-based registry systems with hospital-based electronic health record systems has so far not been commonly implemented.
Currently there are 2 general types of RMSs: those that transmit device diagnostic information automatically and without patient assistance to secure Internet-based registry systems, and those that require patient assistance to transmit information. Both systems employ the use of preprogrammed alerts that are either transmitted automatically or at regular scheduled intervals to patients and/or physicians.
The current web applications, programming, and registry systems differ greatly between the manufacturers of transmitting cardiac devices. In Canada there are currently 4 manufacturers—Medtronic Inc., Biotronik, Boston Scientific Corp., and St Jude Medical Inc.—which have regulatory approval for remote transmitting CIEDs. Remote monitoring systems are proprietary to the manufacturer of the implant device. An RMS for one device will not work with another device, and the RMS may not work with all versions of the manufacturer’s devices.
All Internet-based device-assisted RMSs have common components. The implanted device is equipped with a micro-antenna that communicates with a small external device (at bedside or wearable) commonly known as the transmitter. Transmitters are able to interrogate programmed parameters and diagnostic data stored in the patients’ implant device. The information transfer to the communicator can occur at preset time intervals with the participation of the patient (waving a wand over the device) or it can be sent automatically (wirelessly) without their participation. The encrypted data are then uploaded to an Internet-based database on a secure central server. The data processing facilities at the central database, depending on the clinical urgency, can trigger an alert for the physician(s) that can be sent via email, fax, text message, or phone. The details are also posted on the secure website for viewing by the physician (or their delegate) at their convenience.
Research Questions
The research directions and specific research questions for this evidence review were as follows:
To identify the Internet-based device-assisted RMSs available for follow-up of patients with therapeutic CIEDs such as PMs, ICDs, and CRT devices.
To identify the potential risks, operational issues, or organizational issues related to Internet-based device-assisted RM for CIEDs.
To evaluate the safety, acceptability, and effectiveness of Internet-based device-assisted RMSs for CIEDs such as PMs, ICDs, and CRT devices.
To evaluate the safety, effectiveness, and cost-effectiveness of Internet-based device-assisted RMSs for CIEDs compared to usual outpatient in-office monitoring strategies.
To evaluate the resource implications or budget impact of RMSs for CIEDs in Ontario, Canada.
Research Methods
Literature Search
The review included a systematic review of published scientific literature and consultations with experts and manufacturers of all 4 approved RMSs for CIEDs in Canada. Information on CIED cardiac implant clinics was also obtained from Provincial Programs, a division within the Ministry of Health and Long-Term Care with a mandate for cardiac implant specialty care. Various administrative databases and registries were used to outline the current clinical follow-up burden of CIEDs in Ontario. The provincial population-based ICD database developed and maintained by the Institute for Clinical Evaluative Sciences (ICES) was used to review the current follow-up practices with Ontario patients implanted with ICD devices.
Search Strategy
A literature search was performed on September 21, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from 1950 to September 2010. Search alerts were generated and reviewed for additional relevant literature until December 31, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search.
Inclusion Criteria
published between 1950 and September 2010;
English language full-reports and human studies;
original reports including clinical evaluations of Internet-based device-assisted RMSs for CIEDs in clinical settings;
reports including standardized measurements on outcome events such as technical success, safety, effectiveness, cost, measures of health care utilization, morbidity, mortality, quality of life or patient satisfaction;
randomized controlled trials (RCTs), systematic reviews and meta-analyses, cohort and controlled clinical studies.
Exclusion Criteria
non-systematic reviews, letters, comments and editorials;
reports not involving standardized outcome events;
clinical reports not involving Internet-based device assisted RM systems for CIEDs in clinical settings;
reports involving studies testing or validating algorithms without RM;
studies with small samples (<10 subjects).
Outcomes of Interest
The outcomes of interest included: technical outcomes, emergency department visits, complications, major adverse events, symptoms, hospital admissions, clinic visits (scheduled and/or unscheduled), survival, morbidity (disease progression, stroke, etc.), patient satisfaction, and quality of life.
Summary of Findings
The MAS evidence review was performed to review available evidence on Internet-based device-assisted RMSs for CIEDs published until September 2010. The search identified 6 systematic reviews, 7 randomized controlled trials, and 19 reports for 16 cohort studies—3 of these being registry-based and 4 being multi-centered. The evidence is summarized in the 3 sections that follow.
1. Effectiveness of Remote Monitoring Systems of CIEDs for Cardiac Arrhythmia and Device Functioning
In total, 15 reports on 13 cohort studies involving investigations with 4 different RMSs for CIEDs in cardiology implant clinic groups were identified in the review. The 4 RMSs were: Care Link Network® (Medtronic Inc,, Minneapolis, MN, USA); Home Monitoring® (Biotronic, Berlin, Germany); House Call 11® (St Jude Medical Inc., St Pauls, MN, USA); and a manufacturer-independent RMS. Eight of these reports were with the Home Monitoring® RMS (12,949 patients), 3 were with the Care Link® RMS (167 patients), 1 was with the House Call 11® RMS (124 patients), and 1 was with a manufacturer-independent RMS (44 patients). All of the studies, except for 2 in the United States, (1 with Home Monitoring® and 1 with House Call 11®), were performed in European countries.
The RMSs in the studies were evaluated with different cardiac implant device populations: ICDs only (6 studies), ICD and CRT devices (3 studies), PM and ICD and CRT devices (4 studies), and PMs only (2 studies). The patient populations were predominately male (range, 52%–87%) in all studies, with mean ages ranging from 58 to 76 years. One study population was unique in that RMSs were evaluated for ICDs implanted solely for primary prevention in young patients (mean age, 44 years) with Brugada syndrome, which carries an inherited increased genetic risk for sudden heart attack in young adults.
Most of the cohort studies reported on the feasibility of RMSs in clinical settings with limited follow-up. In the short follow-up periods of the studies, the majority of the events were related to detection of medical events rather than system configuration or device abnormalities. The results of the studies are summarized below:
The interrogation of devices on the web platform, both for continuous and scheduled transmissions, was significantly quicker with remote follow-up, both for nurses and physicians.
In a case-control study focusing on a Brugada population–based registry with patients followed-up remotely, there were significantly fewer outpatient visits and greater detection of inappropriate shocks. One death occurred in the control group not followed remotely and post-mortem analysis indicated early signs of lead failure prior to the event.
Two studies examined the role of RMSs in following ICD leads under regulatory advisory in a European clinical setting and noted:
– Fewer inappropriate shocks were administered in the RM group.
– Urgent in-office interrogations and surgical revisions were performed within 12 days of remote alerts.
– No signs of lead fracture were detected at in-office follow-up; all were detected at remote follow-up.
Only 1 study reported evaluating quality of life in patients followed up remotely at 3 and 6 months; no values were reported.
Patient satisfaction was evaluated in 5 cohort studies, all in short term follow-up: 1 for the Home Monitoring® RMS, 3 for the Care Link® RMS, and 1 for the House Call 11® RMS.
– Patients reported receiving a sense of security from the transmitter, a good relationship with nurses and physicians, positive implications for their health, and satisfaction with RM and organization of services.
– Although patients reported that the system was easy to implement and required less than 10 minutes to transmit information, a variable proportion of patients (range, 9% 39%) reported that they needed the assistance of a caregiver for their transmission.
– The majority of patients would recommend RM to other ICD patients.
– Patients with hearing or other physical or mental conditions hindering the use of the system were excluded from studies, but the frequency of this was not reported.
Physician satisfaction was evaluated in 3 studies, all with the Care Link® RMS:
– Physicians reported an ease of use and high satisfaction with a generally short-term use of the RMS.
– Physicians reported being able to address the problems in unscheduled patient transmissions or physician initiated transmissions remotely, and were able to handle the majority of the troubleshooting calls remotely.
– Both nurses and physicians reported a high level of satisfaction with the web registry system.
2. Effectiveness of Remote Monitoring Systems in Heart Failure Patients for Cardiac Arrhythmia and Heart Failure Episodes
Remote follow-up of HF patients implanted with ICD or CRT devices, generally managed in specialized HF clinics, was evaluated in 3 cohort studies: 1 involved the Home Monitoring® RMS and 2 involved the Care Link® RMS. In these RMSs, in addition to the standard diagnostic features, the cardiac devices continuously assess other variables such as patient activity, mean heart rate, and heart rate variability. Intra-thoracic impedance, a proxy measure for lung fluid overload, was also measured in the Care Link® studies. The overall diagnostic performance of these measures cannot be evaluated, as the information was not reported for patients who did not experience intra-thoracic impedance threshold crossings or did not undergo interventions. The trial results involved descriptive information on transmissions and alerts in patients experiencing high morbidity and hospitalization in the short study periods.
3. Comparative Effectiveness of Remote Monitoring Systems for CIEDs
Seven RCTs were identified evaluating RMSs for CIEDs: 2 were for PMs (1276 patients) and 5 were for ICD/CRT devices (3733 patients). Studies performed in the clinical setting in the United States involved both the Care Link® RMS and the Home Monitoring® RMS, whereas all studies performed in European countries involved only the Home Monitoring® RMS.
3A. Randomized Controlled Trials of Remote Monitoring Systems for Pacemakers
Two trials, both multicenter RCTs, were conducted in different countries with different RMSs and study objectives. The PREFER trial was a large trial (897 patients) performed in the United States examining the ability of Care Link®, an Internet-based remote PM interrogation system, to detect clinically actionable events (CAEs) sooner than the current in-office follow-up supplemented with transtelephonic monitoring transmissions, a limited form of remote device interrogation. The trial results are summarized below:
In the 375-day mean follow-up, 382 patients were identified with at least 1 CAE—111 patients in the control arm and 271 in the remote arm.
The event rate detected per patient for every type of CAE, except for loss of atrial capture, was higher in the remote arm than the control arm.
The median time to first detection of CAEs (4.9 vs. 6.3 months) was significantly shorter in the RMS group compared to the control group (P < 0.0001).
Additionally, only 2% (3/190) of the CAEs in the control arm were detected during a transtelephonic monitoring transmission (the rest were detected at in-office follow-ups), whereas 66% (446/676) of the CAEs were detected during remote interrogation.
The second study, the OEDIPE trial, was a smaller trial (379 patients) performed in France evaluating the ability of the Home Monitoring® RMS to shorten PM post-operative hospitalization while preserving the safety of conventional management of longer hospital stays.
Implementation and operationalization of the RMS was reported to be successful in 91% (346/379) of the patients and represented 8144 transmissions.
In the RM group 6.5% of patients failed to send messages (10 due to improper use of the transmitter, 2 with unmanageable stress). Of the 172 patients transmitting, 108 patients sent a total of 167 warnings during the trial, with a greater proportion of warnings being attributed to medical rather than technical causes.
Forty percent had no warning message transmission and among these, 6 patients experienced a major adverse event and 1 patient experienced a non-major adverse event. Of the 6 patients having a major adverse event, 5 contacted their physician.
The mean medical reaction time was faster in the RM group (6.5 ± 7.6 days vs. 11.4 ± 11.6 days).
The mean duration of hospitalization was significantly shorter (P < 0.001) for the RM group than the control group (3.2 ± 3.2 days vs. 4.8 ± 3.7 days).
Quality of life estimates by the SF-36 questionnaire were similar for the 2 groups at 1-month follow-up.
3B. Randomized Controlled Trials Evaluating Remote Monitoring Systems for ICD or CRT Devices
The 5 studies evaluating the impact of RMSs with ICD/CRT devices were conducted in the United States and in European countries and involved 2 RMSs—Care Link® and Home Monitoring ®. The objectives of the trials varied and 3 of the trials were smaller pilot investigations.
The first of the smaller studies (151 patients) evaluated patient satisfaction, achievement of patient outcomes, and the cost-effectiveness of the Care Link® RMS compared to quarterly in-office device interrogations with 1-year follow-up.
Individual outcomes such as hospitalizations, emergency department visits, and unscheduled clinic visits were not significantly different between the study groups.
Except for a significantly higher detection of atrial fibrillation in the RM group, data on ICD detection and therapy were similar in the study groups.
Health-related quality of life evaluated by the EuroQoL at 6-month or 12-month follow-up was not different between study groups.
Patients were more satisfied with their ICD care in the clinic follow-up group than in the remote follow-up group at 6-month follow-up, but were equally satisfied at 12- month follow-up.
The second small pilot trial (20 patients) examined the impact of RM follow-up with the House Call 11® system on work schedules and cost savings in patients randomized to 2 study arms varying in the degree of remote follow-up.
The total time including device interrogation, transmission time, data analysis, and physician time required was significantly shorter for the RM follow-up group.
The in-clinic waiting time was eliminated for patients in the RM follow-up group.
The physician talk time was significantly reduced in the RM follow-up group (P < 0.05).
The time for the actual device interrogation did not differ in the study groups.
The third small trial (115 patients) examined the impact of RM with the Home Monitoring® system compared to scheduled trimonthly in-clinic visits on the number of unplanned visits, total costs, health-related quality of life (SF-36), and overall mortality.
There was a 63.2% reduction in in-office visits in the RM group.
Hospitalizations or overall mortality (values not stated) were not significantly different between the study groups.
Patient-induced visits were higher in the RM group than the in-clinic follow-up group.
The TRUST Trial
The TRUST trial was a large multicenter RCT conducted at 102 centers in the United States involving the Home Monitoring® RMS for ICD devices for 1450 patients. The primary objectives of the trial were to determine if remote follow-up could be safely substituted for in-office clinic follow-up (3 in-office visits replaced) and still enable earlier physician detection of clinically actionable events.
Adherence to the protocol follow-up schedule was significantly higher in the RM group than the in-office follow-up group (93.5% vs. 88.7%, P < 0.001).
Actionability of trimonthly scheduled checks was low (6.6%) in both study groups. Overall, actionable causes were reprogramming (76.2%), medication changes (24.8%), and lead/system revisions (4%), and these were not different between the 2 study groups.
The overall mean number of in-clinic and hospital visits was significantly lower in the RM group than the in-office follow-up group (2.1 per patient-year vs. 3.8 per patient-year, P < 0.001), representing a 45% visit reduction at 12 months.
The median time from onset of first arrhythmia to physician evaluation was significantly shorter (P < 0.001) in the RM group than in the in-office follow-up group for all arrhythmias (1 day vs. 35.5 days).
The median time to detect clinically asymptomatic arrhythmia events—atrial fibrillation (AF), ventricular fibrillation (VF), ventricular tachycardia (VT), and supra-ventricular tachycardia (SVT)—was also significantly shorter (P < 0.001) in the RM group compared to the in-office follow-up group (1 day vs. 41.5 days) and was significantly quicker for each of the clinical arrhythmia events—AF (5.5 days vs. 40 days), VT (1 day vs. 28 days), VF (1 day vs. 36 days), and SVT (2 days vs. 39 days).
System-related problems occurred infrequently in both groups—in 1.5% of patients (14/908) in the RM group and in 0.7% of patients (3/432) in the in-office follow-up group.
The overall adverse event rate over 12 months was not significantly different between the 2 groups and individual adverse events were also not significantly different between the RM group and the in-office follow-up group: death (3.4% vs. 4.9%), stroke (0.3% vs. 1.2%), and surgical intervention (6.6% vs. 4.9%), respectively.
The 12-month cumulative survival was 96.4% (95% confidence interval [CI], 95.5%–97.6%) in the RM group and 94.2% (95% confidence interval [CI], 91.8%–96.6%) in the in-office follow-up group, and was not significantly different between the 2 groups (P = 0.174).
The CONNECT Trial
The CONNECT trial, another major multicenter RCT, involved the Care Link® RMS for ICD/CRT devices in a15-month follow-up study of 1,997 patients at 133 sites in the United States. The primary objective of the trial was to determine whether automatically transmitted physician alerts decreased the time from the occurrence of clinically relevant events to medical decisions. The trial results are summarized below:
Of the 575 clinical alerts sent in the study, 246 did not trigger an automatic physician alert. Transmission failures were related to technical issues such as the alert not being programmed or not being reset, and/or a variety of patient factors such as not being at home and the monitor not being plugged in or set up.
The overall mean time from the clinically relevant event to the clinical decision was significantly shorter (P < 0.001) by 17.4 days in the remote follow-up group (4.6 days for 172 patients) than the in-office follow-up group (22 days for 145 patients).
– The median time to a clinical decision was shorter in the remote follow-up group than in the in-office follow-up group for an AT/AF burden greater than or equal to 12 hours (3 days vs. 24 days) and a fast VF rate greater than or equal to 120 beats per minute (4 days vs. 23 days).
Although infrequent, similar low numbers of events involving low battery and VF detection/therapy turned off were noted in both groups. More alerts, however, were noted for out-of-range lead impedance in the RM group (18 vs. 6 patients), and the time to detect these critical events was significantly shorter in the RM group (same day vs. 17 days).
Total in-office clinic visits were reduced by 38% from 6.27 visits per patient-year in the in-office follow-up group to 3.29 visits per patient-year in the remote follow-up group.
Health care utilization visits (N = 6,227) that included cardiovascular-related hospitalization, emergency department visits, and unscheduled clinic visits were not significantly higher in the remote follow-up group.
The overall mean length of hospitalization was significantly shorter (P = 0.002) for those in the remote follow-up group (3.3 days vs. 4.0 days) and was shorter both for patients with ICD (3.0 days vs. 3.6 days) and CRT (3.8 days vs. 4.7 days) implants.
The mortality rate between the study arms was not significantly different between the follow-up groups for the ICDs (P = 0.31) or the CRT devices with defribillator (P = 0.46).
Conclusions
There is limited clinical trial information on the effectiveness of RMSs for PMs. However, for RMSs for ICD devices, multiple cohort studies and 2 large multicenter RCTs demonstrated feasibility and significant reductions in in-office clinic follow-ups with RMSs in the first year post implantation. The detection rates of clinically significant events (and asymptomatic events) were higher, and the time to a clinical decision for these events was significantly shorter, in the remote follow-up groups than in the in-office follow-up groups. The earlier detection of clinical events in the remote follow-up groups, however, was not associated with lower morbidity or mortality rates in the 1-year follow-up. The substitution of almost all the first year in-office clinic follow-ups with RM was also not associated with an increased health care utilization such as emergency department visits or hospitalizations.
The follow-up in the trials was generally short-term, up to 1 year, and was a more limited assessment of potential longer term device/lead integrity complications or issues. None of the studies compared the different RMSs, particularly the different RMSs involving patient-scheduled transmissions or automatic transmissions. Patients’ acceptance of and satisfaction with RM were reported to be high, but the impact of RM on patients’ health-related quality of life, particularly the psychological aspects, was not evaluated thoroughly. Patients who are not technologically competent, having hearing or other physical/mental impairments, were identified as potentially disadvantaged with remote surveillance. Cohort studies consistently identified subgroups of patients who preferred in-office follow-up. The evaluation of costs and workflow impact to the health care system were evaluated in European or American clinical settings, and only in a limited way.
Internet-based device-assisted RMSs involve a new approach to monitoring patients, their disease progression, and their CIEDs. Remote monitoring also has the potential to improve the current postmarket surveillance systems of evolving CIEDs and their ongoing hardware and software modifications. At this point, however, there is insufficient information to evaluate the overall impact to the health care system, although the time saving and convenience to patients and physicians associated with a substitution of in-office follow-up by RM is more certain. The broader issues surrounding infrastructure, impacts on existing clinical care systems, and regulatory concerns need to be considered for the implementation of Internet-based RMSs in jurisdictions involving different clinical practices.
PMCID: PMC3377571  PMID: 23074419
18.  Hospital utilization patterns and costs for adult sickle cell patients in Illinois. 
Public Health Reports  1997;112(1):44-51.
OBJECTIVES: To determine population size, demographic characteristics, hospital utilization patterns, the specialties of physicians providing care, and costs for hospitalized adult sickle cell patients in Illinois. METHODS: A statewide, administrative dataset for the two-year period from january 1992 through December 1993 was analyzed retrospectively. RESULTS: There were 8403 admissions among 1189 individual sickle cell patients for the two-year period. Eighty-five percent of patients resided in the Chicago metropolitan area. The median age of the 1189 patients was 29; two-thirds had Medicaid or Medicare coverage. Emergency departments were the primary source of admissions (85.7%). The most common admitting diagnosis was painful crisis (97.4%), and average length of stay was four days. The median number of admissions per patient was three; most patients (85%) used only one or two hospitals. A small group used more than four hospitals and accounted for 23% of statewide admissions. Primary care physicians cared for most patients, and total hospitalization charges were more than $59 million. CONCLUSIONS: In Illinois the adult sickle cell population is concentrated in major urban centers, primarily the Chicago metropolitan area. These patients accounted for approximately 8400 admissions and more than $59 million in hospital charges during the two-year study period. A small group of patients used multiple hospitals and accounted for more than 23% of total hospitalization charges. This study shows the necessity of and provides a useful framework for developing targeted programs for adult sickle cell patients as well as for training physicians to efficiently provide comprehensive health care services for this population.
PMCID: PMC1381838  PMID: 9018288
19.  Juvenile Myoclonic Epilepsy (JME): Neuropsychological Profile and Related Factors with Cognitive Dysfunction 
Iranian Journal of Psychiatry  2014;9(1):14-19.
Objective
The aim of present study was to verify possible cognitive dysfunction in the patients with Juvenile Myoclonic Epilepsy (JME) and its correlation to factors related to epilepsy and patients demographic variables.
Material and Methods
Thirty two consecutive patients with JME and 32 healthy controls were evaluated in neuropsychological domains including orientation, mental control, logical memory, forward and backward digit spans, visual memory, associative learning, and memory quotient (using Persian version of Wechsler Memory Scale (WMS)-Revised), preservative errors (using Wisconsin Card Sorting Test (WCST)), Stroop Test (color and word), IQ score (using Raven’s Progressive Matrices test), and depression (using the Persian version of Beck Depression Inventory (BDI)). SPSS 11.0 (SPSS Inc., Chicago, Illinois, USA) software was used for statistical analysis. Student’s t-test and the Mann-Whitney U-test were used for independent normally and non-normally distributed continuous variables, respectively.
Results
Our study showed significant differences between patients with JME and control group with respect to scores of mental control (p=0.015), forward digit span (p=0.004), total digit span (p=0.008) and IQ (p=0.003). In addition, age, education level, duration of epilepsy and medication showed an impact on several cognitive functions in the patients with JME.
Conclusion
It is indicated that JME is associated with impairment in specific cognitive domains, despite any evidence in favor of depression.
PMCID: PMC4277602  PMID: 25561943
Juvenile Myoclonic Epilepsy (JME); cognitive dysfunction; neuropsychological asessement, seizure
20.  Interdisciplinary multiinstitutional alliances in support of educational programs for health sciences librarians. 
This project responds to the need to identify the knowledge, skills, and expertise required by health sciences librarians in the future and to devise mechanisms for providing this requisite training. The approach involves interdisciplinary multiinstitutional alliances with collaborators drawn from two graduate schools of library and information science (University of Illinois at Urbana-Champaign and Indiana University) and two medical schools (University of Illinois at Chicago and Washington University). The project encompasses six specific aims: (1) investigate the evolving role of the health sciences librarian; (2) analyze existing programs of study in library and information science at all levels at Illinois and Indiana; (3) develop opportunities for practicums, internships, and residencies; (4) explore the possibilities of computing and communication technologies to enhance instruction; (5) identify mechanisms to encourage faculty and graduate students to participate in medical informatics research projects; and (6) create recruitment strategies to achieve better representation of currently underrepresented groups. The project can serve as a model for other institutions interested in regional collaboration to enhance graduate education for health sciences librarianship.
PMCID: PMC226197  PMID: 8913560
21.  Demographic features of subjects with congenital glaucoma 
Indian Journal of Ophthalmology  2014;62(5):565-569.
Context:
Congenital glaucoma is a potentially blinding ocular disease of the childhood. Identification of the possible associated risk factors and may be helpful for prevention or early detection of this public health problem.
Aims:
To demonstrate the demographic features of congenital glaucoma subjects.
Setting and Design:
The charts of congenital glaucoma patients referred to Tamcelik Glaucoma Center were retrospectively reviewed through the dates of 2000 and 2013.
Materials and Methods:
Analyzed data included diagnosis, age at first presentation, symptoms at first presentation, laterality of the disease, sex, presence of consanguinity, family history of congenital glaucoma, maturity of the fetus at delivery, and maternal age at conception.
Statistical Analysis Used:
Statistical Package for Social Sciences (SPSS) version 19.0 by IBM (SPSS Inc, Chicago, Illinois, USA) was used to compare the mean of continuous variables with Student's t-test and analysis of variance (ANOVA) and χ2 test was used to test differences in proportions of categorical variables.
Results:
The data of 600 eyes of 311 patients were analyzed. The distribution of primary and secondary congenital glaucoma among the patients were 63.3% (n = 197) and 36.7% (n = 114), respectively. Of the 311 patients, 57.2% (n = 178) were male and 42.8% (n = 133) were female. The overall frequency of bilateral disease was 92.3% (n = 287). Overall rate of consanguinity and positive family history was 45.3% (n = 141) and 21.2% (n = 66), respectively.
Conclusions:
Bilateral disease in this study was more common than previously reported studies. Positive family history was more frequent in primary congenital glaucoma although not statistically significant.
doi:10.4103/0301-4738.126988
PMCID: PMC4065506  PMID: 24881602
Congenital glaucoma; consanguinity; demographics; positive family history
22.  The impact of low-level lead toxicity on school performance among children in the Chicago Public Schools: a population-based retrospective cohort study 
Environmental Health  2015;14:21.
Background
Environmental lead exposure poses a risk to educational performance, especially among poor, urban children. Previous studies found low-level lead exposure was a risk factor for diminished academic abilities, however, this study is distinct because of the very large sample size and because it controlled for very low birth weight and early preterm birth–two factors closely associated with lower academic performance. In this study we examined the association between lead concentration in whole blood (B-Pb) of Chicago Public School (CPS) children and their performance on the 3rd grade Illinois Standard Achievement Tests (ISAT) reading and math scores.
Methods
We examined 58,650 children born in Chicago between 1994 and 1998 who were tested for blood lead concentration between birth and 2006 and enrolled in the 3rd grade at a CPS school between 2003 and 2006. We linked the Chicago birth registry, the Chicago Blood Lead Registry, and 3rd grade ISAT scores to examine associations between B-Pb and school performance.
Results
After adjusting for other predictors of school performance including poverty, race/ethnicity, gender, maternal education and very low birth weight or preterm-birth, we found that B-Pbs below 10 μg/dL were inversely associated with reading and math scores in 3rd grade children. For a 5 μg/dL increase in B-Pb, the risk of failing increased by 32% for reading (RR = 1.32, 95%CI = 1.26, 1.39) and math (RR = 1.32, 95%CI = 1.26, 1.39). The effect of lead on reading was non-linear with steeper failure rates at lower B-Pbs. We estimated that 13% of reading failure and 14.8% of math failure can be attributed to exposure to blood lead concentrations of 5 to 9 vs. 0 to 4 μg/dL in Chicago school children.
Conclusions
Early childhood lead exposure is associated with poorer achievement on standardized reading and math tests in the third grade, even at very low B-Pbs. Preventing lead exposure in early childhood is critical to improving school performance.
doi:10.1186/s12940-015-0008-9
PMCID: PMC4387706  PMID: 25889033
Blood lead concentration; Health disparities; Lead poisoning; School performance; Standardized tests; Urban lead exposure
23.  Proceedings of the 2010 Annual Meeting of the Fetal Alcohol Spectrum Disorders Study Group 
Alcohol (Fayetteville, N.y.)  2011;46(1):107-114.
The annual meeting of the Fetal Alcohol Spectrum Disorders Study Group (FASDSG) was held on June 26, 2010 in San Antonio, TX, as a satellite of the Research Society on Alcoholism meeting. The FASDSG membership includes clinical, basic and social scientists who meet to discuss recent advances and issues in FASD research. The central theme of the meeting was “Glia and Neurons: Teamwork in Pathology and Therapy.” Alcohol disruption of neuron development and alcohol-induced neurodegeneration is central to the pathology and clinical expression of FASD. The active role of glia as perpetrator, victim, or bystander in neurotoxicology and neurodegenerative processes has emerged at the forefront of adult CNS disorders and therapy. Glia and neuron-glial interactions hold the potential to elucidate causes and offer treatment of FASD as well. Growing evidence indicates that neurons and glia are direct targets of alcohol, but may also be vulnerable to molecules produced in peripheral systems as a result of alcohol exposure. Diagnostics and therapies can take advantage of these processes and biomarkers, and these may be applicable to CNS pathology in FASD. Two keynote speakers, Howard E. Gendelman, M.D., and Ernest M. Graham, M.D, addressed the role of glia and neuroinflammation in brain development and neurodegeneration. The invited speakers and FASDSG members discussed new paradigms in CNS development and discuss new strategies for understanding and treating neurodegenerative disease. Members of the FASDSG provided updates on new findings through presentation of breaking research in the FASt Data Sessions. Representatives of national agencies provided updates on programs, activities, and funding priorities. The Henry Rosett Award was presented to R. Louise Floyd, R.N., D.S.N. for her career contributions to the field of fetal alcohol research. The Student and Postdoctoral Fellow Research Merit Award was presented to Shonagh O’Leary-Moore, Ph.D. for her contributions to the field as a young investigator.
doi:10.1016/j.alcohol.2011.07.004
PMCID: PMC3258329  PMID: 21889288
24.  Proceedings of the 2008 annual meeting of the Fetal Alcohol Spectrum Disorders Study Group 
Alcohol (Fayetteville, N.Y.)  2009;43(4):333-339.
The annual meeting of the Fetal Alcohol Spectrum Disorders Study Group (FASDSG) was held on June 28, 2008 in Washington DC, as a satellite to the Research Society on Alcoholism meeting. The FASDSG membership includes clinical, basic and social scientists, who meet to discuss recent advances and issues in FASD research. The main theme of the meeting was “Factors that Influence Brain and Behavioral Development: Implications for Prevention and Intervention.” Two keynote speakers, Dr. Stephen Suomi and Dr. Carl Keen addressed how early environment and nutrition may influence outcome following prenatal alcohol exposure. The final keynote speaker, Kathy Mitchell, addressed issues regarding the relationship between scientists and the families with children with FASD. Members of the FASDSG provided updates on new findings through brief (FASt) data reports, and national agency representative provided updates of activities and funding priorities. Presentations were also made by recipients of the Student Research Merit award and Rosett award.
doi:10.1016/j.alcohol.2009.04.004
PMCID: PMC2709793  PMID: 19560631
fetal alcohol syndrome; fetal alcohol spectrum disorders; teratology; ethanol; prenatal
25.  Elder Self-neglect and Abuse and Mortality Risk in a Community-Dwelling Population 
Context
Both elder self-neglect and abuse have become increasingly prominent public health issues. The association of either elder self-neglect or abuse with mortality remains unclear.
Objective
To examine the relationship of elder self-neglect or abuse reported to social services agencies with all-cause mortality among a community-dwelling elderly population.
Design, Setting, and Participants
Prospective, population-based cohort study (conducted from 1993 to 2005) of residents living in a geographically defined community of 3 adjacent neighborhoods in Chicago, Illinois, who were participating in the Chicago Health and Aging Project (CHAP; a longitudinal, population-based, epidemiological study of residents aged ≥65 years). A subset of these participants had suspected elder self-neglect or abuse reported to social services agencies.
Main Outcome Measures
Mortality ascertained during follow-up and by use of the National Death Index. Cox proportional hazard models were used to assess independent associations of self-neglect or elder abuse reporting with the risk of all-cause mortality using time-varying covariate analyses.
Results
Of 9318 CHAP participants, 1544 participants were reported for elder self-neglect and 113 participants were reported for elder abuse from 1993 to 2005. All CHAP participants were followed up for a median of 6.9 years (interquartile range, 7.4 years), during which 4306 deaths occurred. In multivariable analyses, reported elder self-neglect was associated with a significantly increased risk of 1-year mortality (hazard ratio [HR], 5.82; 95% confidence interval [CI], 5.20–6.51). Mortality risk was lower but still elevated after 1 year (HR, 1.88; 95% CI, 1.67–2.14). Reported elder abuse also was associated with significantly increased risk of overall mortality (HR, 1.39; 95% CI, 1.07–1.84). Confirmed elder self-neglect or abuse also was associated with mortality. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels of cognitive or physical function.
Conclusion
Both elder self-neglect and abuse reported to social services agencies were associated with increased risk of mortality.
doi:10.1001/jama.2009.1109
PMCID: PMC2965589  PMID: 19654386

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