MedicalResearch.com Interview with: Jennifer Lynn Sherr, MD, PhD Assistant Professor of Pediatrics (Endocrinology) Yale School of Medicine Medical Research: What is the background...
MedicalResearch.com Interview with:
John A. Elefteriades, MD
William W.L. Glenn Professor of Surgery
Chief of Cardiothoracic Surgery
Director, Aortic Institute at Yale-New Haven
Yale University School of Medicine
Medical Research: What is the background for this study? What are the main findings?
Dr. Elefteriades: The race to map the human genome was declared completed in 2003, at a cost of 3 billion dollars for the international collaborative university group and 300 million dollars for Craig Venter at Celera. Whole exome sequencing can now be performed at a cost of only several thousand dollars per individual. So, whole exome sequencing (also called Next Generation Sequencing) can now be applied to understand and treat diseases of many organ systems.
In this study, we applied whole exome sequencing to study over 100 patients with thoracic aneurysm.
In the late 1990s, both Dr. Diana Milewicz in Texas and our group at Yale had determined that many thoracic aortic aneurysms were genetically transmitted. Dr. Milewicz went on to identify many of the causative mutations. In this study, we were able to look, by whole exome sequencing performed on saliva, for all 21 mutations known to cause thoracic aortic aneurysm--all at one time in one comprehensive genetic test. We were able to protect patients with the most serious discovered mutations by early surgery, the need for which could not otherwise have been apparent. (more…)
MedicalResearch.com Interview with:
Xiao Xu, Ph.D. Assistant Professor
Department of Obstetrics, Gynecology & Reproductive Sciences
Yale School of Medicine
Medical Research: What is the background for this study? What are the main findings?
Dr. Xiao Xu: While research has shown hospital variation in costs of care for other conditions, we know little about whether and how hospitals differ in costs of childbirth related care. With nearly 4 million births each year, childbirth is the most common reason for hospital admission in the U.S. Understanding the pattern and causes of variation in resource utilization during childbirth among hospitals can help inform strategies to reduce costs. Our study used data from 463 hospitals across the country and analyzed hospital costs of maternity care for low-risk births. We found that hospital varied widely in average facility costs per maternity stay. (more…)
lResearch.com Interview with:
Ingrid M. Nembhard PhD MS
Yale University
New Haven, CT
Medical Research: What is the background for this study? What are the main findings?
Dr. Nembhard: Many health care organizations (hospital, medical groups, etc.) have sought to address well-documented quality problems by implementing evidence-based innovations, that is, practices, policies, or technologies that have been proven to work in other organizations. The benefits of these innovations are often not realized because adopting organizations experience implementation failure—lack of skillful and consistent use of innovations by intended users (e.g., clinicians). Past research estimates that implementation failure occurs at rates greater than 50% in health care. The past work also shows organizational factors expected to be facilitators of implementation are not always helpful.
In this work, we examined a possible explanation for the mixed results: different innovation types have distinct enabling factors. Based on observation and statistical analyses, we differentiated role-changing innovations, altering what workers do, from time-changing innovations, altering when tasks are performed or for how long. We then examined our hypothesis that the degree to which access to groups that can alter organizational learning—staff, management, and external network— facilitates implementation depends on innovation type. Our longitudinal study of 517 hospitals’ implementation of evidence-based practices for treating heart attack confirmed our thesis for factors granting access to each group: improvement team’s representativeness (of affected staff), senior management engagement, and network membership. Although team representativeness and network membership were positively associated with implementing role-changing practices, senior management engagement was not. In contrast, senior management engagement was positively associated with implementing time-changing practices, whereas team representativeness was not, and network membership was not unless there was limited management engagement.
(more…)MedicalResearch.com Interview with: Brett King, M.D., Ph.D. Assistant Professor of Dermatology Yale University School of Medicine Medical Research: What is the background for this...
MedicalResearch.com Interview with:
Aileen Gariepy, MD, MPH
Assistant Professor Section of Family Planning
Department of Obstetrics, Gynecology, and Reproductive Sciences
Yale School of Medicine
New Haven, CT
Medical Research: What is the background for this study? What are the main findings?
Dr. Gariepy: Women who have just given birth are often highly motivated to prevent a rapid, repeat pregnancy. For women who desire the contraceptive implant, a highly effective reversible form of contraception that is placed in the arm and can last for 3 years, new research shows that it is more cost-effective to place the implant while women are still in the hospital after giving birth, compared to delaying insertion to the postpartum visit 6-8 weeks later which is currently the most common practice.
When the costs associated with the implant insertion and the costs of unintended pregnancy are compared in women who receive immediate contraceptive implant insertion (while still in the hospital after giving birth) to women who are asked to come back in 6-8 weeks for the implant insertion (delayed insertion), immediate insertion is expected to save $1,263 per patient. Based on these estimates, for every 1,000 women using postpartum implant, immediate placement is expected to avert 191 unintended pregnancies and save $1,263,000 compared with delayed insertion in the first year. Cost savings would continue to increase for the second and third year after insertion.
In fact, over half of U.S. pregnancies are unintended. Maternal and infant care costs for unintended pregnancies amount to $11.1 billion annually for public insurance programs alone. The immediate postpartum period (after delivery but before discharge home) provides an ideal opportunity for initiating contraceptives as patients are motivated and timing is convenient.
However, the majority of insurance company policies do not provide coverage for insertion of the contraceptive implant when the new mother is still in the hospital. This lack of reimbursement is the most significant barrier to providing this highly effective contraceptive method for women who have just delivered a baby. Surprisingly, the reason most insurance companies do not offer reimbursement for immediate insertion is due to an outdated insurance protocol, “the global obstetric fee” which precludes separate reimbursement of individual procedures (like inserting the implant).
The main reason that immediate insertion results in cost savings is because more women will get the implant compared to a strategy of delayed insertion. Women can get pregnant again within 4 weeks of delivering a baby. Starting contraception as soon as possible after giving birth is important because most women will resume sexual activity before their postpartum office visit and therefore will be at risk of pregnancy. And approximately 35% of women do not return for a postpartum visit.
Even for women who want another pregnancy soon, the implant has benefits. When women conceive and deliver a baby within 2 years of last giving birth, there is a significantly higher risk of poor maternal and neonatal outcomes, including preterm birth, low birth weight, and even early neonatal and maternal death. Birth spacing is better for moms and babies.
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MedicalResearch.com Interview with:
James V. Freeman MD, MPH, MS
Yale University School of Medicine
New Haven, CT
Medical Research: What is the background for this study? What are the main findings?
Dr. Freeman: Atrial fibrillation (AF) substantially increases the risk of major adverse clinical outcomes such as stroke and death, but it can also cause frequent symptoms, affect patient’s functional status, and impair their quality of life. While prior studies have reported the range of AF-related symptoms in patient populations, these studies were generally from highly selected patients and referral based practices, and may not reflect results in community practice or results with contemporary AF management. Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF), a large, contemporary, prospective, community-based outpatient cohort, we evaluated the type and frequency of symptoms in patients with Atrial fibrillation. In addition, we measured the degree to which physician assessed symptom severity (using the European Heart Rhythm Association [EHRA] classification system) was correlated with patient reported quality of life (assessed by the Atrial Fibrillation Effect on QualiTy-of-life [AFEQT] questionnaire). Finally, we association between symptoms or quality of life with clinical outcomes, including death, hospitalization, stroke and major bleeding.
In our community-based study, the majority of AF patients (61.8%) were symptomatic (EHRA >2) and 16.5% had severe or disabling symptoms (EHRA 3-4). EHRA symptom class was well correlated with the AFEQT quality of life score (Spearman correlation coefficient -0.39). Over 1.8 years of follow-up, Atrial fibrillation symptoms were associated with a higher risk of hospitalization (adjusted HR for EHRA ≥2 vs EHRA 1 1.23, 95% CI 1.15-1.31) and a borderline higher risk of major bleeding. Lower quality of life was associated with a higher risk of hospitalization (adjusted HR for lowest quartile of AFEQT vs highest 1.49, 95% CI 1.2-1.84), but not other major adverse events including death. (more…)
MedicalResearch.com Interview with:
Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS, Associate Professor, Department of Surgery
Director, The Breast Center -- Smilow Cancer Hospital at Yale-New Haven, Assistant Director -- Global Oncology, Yale Comprehensive Cancer Center
Program Director, Yale Interdisciplinary Breast Fellowship
Yale University School of Medicine Breast Centerm
New Haven, CT,
Medical Research: What is the background for this study? What are the main findings?
Response: Every year in the US, nearly 300,000 women are diagnosed with breast cancer -- the majority of these will have early stage breast cancer, and will opt for breast conserving surgery to remove their disease. The goal of this operation is to remove the cancer with a rim of normal tissue all the way around it (i.e., a margin), but sadly, 20-40% of women will have cancer cells at the edge of the tissue that is removed, often mandating a return trip to the operating room to remove more tissue to ensure that no further disease is left behind. No one likes to go back to the operating room -- so we asked the question, "How can we do better?". Surgeons have debated various means of obtaining clear margins. Some have advocated taking routine cavity shave margins -- a little bit more tissue all the way around the cavity after the tumor is removed at the first operation. Others have argued that this may not be necessary; that one could use intraoperative imaging of the specimen and gross evaluation to define where more tissue may need to be removed (if at all) -- i.e., selective margins. We conducted a randomized controlled trial to answer this question. We told surgeons to do their best operation, using intraoperative imaging and gross evaluation, and removing selective margins as they saw fit. After they were happy with the procedure they had performed and were ready to close, we opened a randomization envelope intraoperatively, and surgeons were either instructed to close as they normally would ("NO SHAVE"), or take a bit more tissue all the way around the cavity ("SHAVE").
Patients in both groups were evenly matched in terms of baseline characteristics. The key finding was that patients who were randomized to the "SHAVE" group half as likely to have positive final margins and require a re-operation than patients in the "NO SHAVE" group. On their postoperative visit, we asked patients, before they knew which group they had been randomized to, what they thought of their cosmetic results. While the volume of tissue excised in the "SHAVE" group was higher than in the "NO SHAVE" group, the distribution of patient-perceived cosmetic outcomes were identical in both groups. Complication rate was also no different between the two groups. We will be following patients for five years for long-term cosmetic and recurrence outcomes. (more…)
MedicalResearch.com Interview with:
Thomas M. Gill, M.D
Humana Foundation Professor of Medicine (Geriatrics)
Professor of Epidemiology and of Investigative Medicine
Director Yale Program on Aging and Yale Center for Disability and Disabling Disorders
Director, Yale Training Program in Geriatric Clinical Epidemiology and Aging-Related Research
Medical Research: What is the background for this study? What are the main findings?h
Response: Understanding the disabling process at the end of life is essential for informed decision-making among older persons, their families, and their physicians.
We know from prior research that the course of disability at the end of life does not follow a predictable pattern for most older persons. This raises the question about what is driving the development and progression of disability at the end of life.
We identified six distinct trajectories of disability in the last year of life, ranging from the least disabled to most disabled. We found that the course of disability in the last year of life closely tracked the monthly prevalence of hospitalization for each of the six trajectories.
(more…)MedicalResearch.com Interview with: Cary P. Gross MD Professor of General Medicine, of Epidemiology (Chronic Diseases) and of Faculty of Arts and Sciences Yale...
MedicalResearch.com Interview with:
Dr. Pina Violano, RN, PhD
Trauma Department, Yale-New Haven Hospital,
Injury Free Coalition for Kids of New Haven
Yale-New Haven Children’s Hospital
New Haven 06510, CT
MedicalResearch: What is the background for this study?
Dr. Violano: In July of 2012, Connecticut became one of the first states to enact legislation to ensure the safety and appropriate evaluation and management of sports-related concussions (SRC) among High School students. SRCs are a common occurrence in high school sports with their diagnosis increasing over the last decade. While the exact reasons are not known, public health campaign efforts and education may have facilitated improvement in the evaluation and detection of sports-related concussions and may have contributed to increase awareness and treatment.
MedicalResearch: What are the main findings?
Dr. Violano: Evaluation of two emergency department records revealed a marked increase in the frequency of high school student athletes being treated for sports-related concussions after the implementation of Connecticut’s SRC law. This suggests that Connecticut’s legislation is effective in improving the evaluation and detection of sports-related concussions in high school students.
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MedicalResearch.com Interview with:
Douglas E. Brash, PhD
Professor of Therapeutic Radiology and Dermatology
Yale School of Medicine New Haven, CT
MedicalResearch: What is the background for this study? What are the main findings?
Dr. Brash: We wanted to know whether the origin of melanoma differed from other cancers because of the melanin. It has long been known that blondes and redheads are sensitive to sunlight, but the prevailing view was that this was because their skin is light. But there are light-skinned, dark-haired people in countries near the equator and they don't have the high skin cancer incidence seen in Australia. Several labs, including ours, had irradiated cells or mice with UV and found more cell death in cells containing melanin than cells lacking melanin. In the last couple of years, two papers have focused attention on the issue; one study found that irradiating mice with UVA only gave melanomas if the skin contained melanin and the other study found that mice genetically predisposed to UV-induced melanoma developed melanomas even without UV if they also had red melanin.
The most important findings are:
First, our skin continues to be damaged by sunlight even when we're out of the sun.
Second, the melanin pigment in your skin is bad for you as well as good: it may be carcinogenic as well as protective.
Third, the chemistry underlying these events, chemical excitation of electrons, has not been seen in mammals before. (more…)
MedicalResearch.com Interview with:
David L. Katz, MD MPH FACPM FACP
President of the American College of Lifestyle Medicine
Yale University Prevention Research Center
Derby, CT; Griffin Hospital, Derby, CT
Medical Research: What is the background for this study? What are the main findings?
Dr. Katz: We have long advised patients at risk for heart disease to avoid eggs- but have thought relatively little about what they might wind up eating instead. While coronary care units banish eggs, they routinely serve white bread, bagels, pancakes, etc. In general, the exclusion of eggs from the diet may result in more sugary, starchy foods- and if so, might do net harm. We have previously studied egg intake in healthy and dyslipidemic adults, and seen no adverse effects on blood flow or biomarkers in the short term (6 wks). This study examined this issue in adults with coronary artery disease- and again, no adverse effects were seen.
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MedicalResearch.com Interview with:
Karthik Murugiah MBBS
Fellow in Cardiovascular Medicine
Yale School of Medicine
Center for Outcomes Research and Evaluation (CORE)
New Haven, CT 06510
Medical Research: What is the background for this study? What are the main findings?
Response: Aortic valve disease is common among older people and frequently requires valve replacement. 1-year survival after open surgical aortic valve replacement is high (9 in 10 survive the year after surgery). Our study focuses on the experience of these survivors in terms of the need for hospitalization during the year after surgery.
Among patients >65 years of age enrolled in Medicare who underwent surgical replacement of their aortic valve and survived at least one year, 3 in 5 were free from hospitalization during that year. Both, the rates of hospitalization and the average total number of days spent in the hospital in the year following surgery have been decreasing all through the last decade (1999 to 2010).
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MedicalResearch.com Interview with:
Dr. James Yu
Yale School of Medicine
Cancer Outcomes, Public Policy, and Effectiveness Research Center
Yale School of Medicine
Department of Therapeutic Radiology
New Haven, Connecticut
Medical Research: What is the background for this study? What are the main findings?
Response: Hypo fractionated radiation has been shown to be safe and effective, and more convenient for women with early stage breast cancer after lumpectomy. It also has been identified by ASTRO as a practice that physicians can adopt to reduce healthcare expenses for patients and for society. We looked at the National Cancer Database, a database created by the American College of Surgeons for trends in the use of hypo fractionated radiation for breast cancer through 2011. We found that the use of hypofractionated radiation had increased to 22.8% in 2011. I found this remarkable as it predated the ASTRO choosing widely guidelines, and indicated to me that physicians were already thinking of ways of making treatment more convenient and affordable for patients and insurers.
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MedicalResearch.com Interview with:
Dan Yamin PhD
Postdoctoral Associate
Yale School of Public Health
New Haven, CT 06520
Medical Research: What is the background for this study?
Dr. Yamin: With limited resources, West Africa is currently overwhelmed by the most devastating Ebola epidemic known to date. In our research, we seek to address two questions:
MedicalResearch.com Interview with
David A. Fiellin, M.D.
Professor of Medicine, Investigative Medicine and Public Health
Yale University School of Medicine
Medical Research: What are the main findings of the study?
Dr. Fiellin: The main finding of our randomized clinical trial, conducted in primary care, was that among prescription opioid dependent patients, ongoing buprenorphine therapy resulted in better treatment retention and reduced illicit opioid use when compared to buprenorphine taper (detoxification).
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MedicalResearch.com Interview with:
David L. Katz, MD, MPH, FACPM, FACP
Director, Yale University Prevention Research Center
Griffin Hospital
Medical Research: What are the main findings of the study?
Dr. Katz: We did not see any adverse effects of short-term, daily egg ingestion in adults with established coronary artery disease.
Medical Research: What was most surprising about the results?
Dr. Katz: Eggs are routinely banned from 'heart healthy diets.' in particular eggs are always absent from cardiac care units, with egg beaters substituting. However, these same units routinely serve products with refined starch and added sugar. The scientific basis for excluding eggs from diets to improve cardiac health has long been suspect. Here, we show that in the short term at least, there are no discernible harms of daily egg ingestion even in adults with heart disease.
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MedicalResearch.com Interview with
Lynn E. Fiellin, M.D.
Associate Professor of Medicine
Director, play2PREVENT Lab
Yale University School of Medicine
New Haven, CT 06510
Medical Research: What are the main findings of the study?
Dr. Fiellin: The current findings are part of a larger study evaluating an interactive evidence-based video game, PlayForward: Elm City Stories, developed on the iPad and targeting risk reduction and HIV prevention in 333 young teens (ages 11-14). The larger study is examining a range of outcomes including knowledge, intentions, self-efficacy and actual behaviors and we are collecting at baseline, 6 weeks, 3, 6, 12, and 24 months. We are examining these outcomes in our experimental group compared with a control group playing a set of off-the-shelf games on the iPad. The current findings of the 196 teens who have completed the 6 weeks of gameplay and for whom we have baseline and 3 month data, reveal that, while the two groups had no differences in their baseline HIV risk knowledge, the PlayForward group had statistically significant gains in knowledge at 6 weeks (p<0.0001), sustained at 3 months (p<0.01). In addition, examining the association between exposure to the game and performance on the standardized assessments revealed that the number of game levels completed (a measure of exposure to the intervention) was positively correlated with knowledge gains measured at 3 months (r=0.42; p<0.001).
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MedicalResearch.com Interview with:
Aakriti Gupta, MD, MBBS
Center for Outcomes Research and Evaluation
Yale-New Haven Hospital,
New Haven, Connecticut
Medical Research: What were the main findings?
Dr. Gupta: Using a national database, we found that heart attack hospitalization rates for patients under the age of 55 have not declined in the past decade while their Medicare-age counterparts have seen a 20 percent drop.
We also found that among younger patients below 55 years of age, women fare worse because they have longer hospital stays, and are more likely to die in the hospital after a heart attack. Young women were also more likely to have higher prevalence of co-existing medical conditions including diabetes, high blood pressure and higher cholesterol levels. Overall, all patient groups in the study saw increases in these conditions including diabetes and high blood pressure in the past decade.
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MedicalResearch.com Interview with
Dr. Christopher Wildeman PhD
Associate Professor of Sociology
Faculty fellow at the Center for Research on Inequalities and the Life Course (CIQLE), and at the Institution for Social and Policy Studies (ISPS) at Yale University.
MedicalResearch.com: What are the main findings of the study?
Dr. Wildeman: There are four key findings in the study.
First, the cumulative risk of having a confirmed maltreatment report any time between birth and age 18 is much higher than most people would have thought. Fully 1 in 8 American children will experience this event at some point.
Second, the risk of experiencing this event is highly unequally distributed, with Black and Hispanic experiencing it much more than Hispanic, White, and (especially) Asian children. Between 1 in 4 and 1 in 5 Black children will have a confirmed maltreatment report at any time in their childhood. For Native American, the risk is about 1 in 7.
Third, the risk of maltreatment is quite similar for boys and girls.
Finally, the highest risks of child maltreatment are in the first few years of life, suggesting that interventions aiming to diminish maltreatment should focus on parents with very young children.
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Arya Mani, M.D.
Department of Internal Medicine and Genetics
Yale Cardiovascular Research Center
Yale, New Haven CT
MedicalResearch: What are the main findings of the study?
Dr. Mani: Our group has identified a gene that when mutated it causes a form of truncal (central) obesity that is associated with a cluster of coronary artery disease risk factors, including high blood pressure, insulin resistance and possibly elevated blood lipids. These associated risk factors are collectively known as the metabolic syndrome, which may lead to development of diseases such as diabetes and coronary artery disease, both of which were very prevalent in the populations we studied. All identified mutations by our group have been so far gain of function mutations, which means they increased the activity of the gene in pathways related to adipogenesis and gluconeogenesis.
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Ellen R. Meara
Associate Professor of The Dartmouth Institute
Adjunct Associate Professor in Economics & Nelson A. Rockefeller Center for Public Policy, Dartmouth College
MedicalResearch.com: What are the main findings of this study?
Answer: When insurance coverage for young adults rose by over 15 percentage points following Massachusetts' 2006 health reform, use of inpatient care for mental illness and substance use disorders fell and emergency department visits for these conditions grew more slowly for 19 to 25 year olds in Massachusetts relative to other states. Also, their care was much more likely to be paid for by private or public insurance insurers.
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MedicalResearch.com Interview with:
Behnood Bikdeli, MD
Yale/YNHH Center for Outcomes Research and Evaluation
One Church St, Suite 200
New Haven CT 0651
MedicalResearch.com: What are the main findings of the study?
Dr. Bikdeli: We determined the trends in hospitalizations and mortality from endocarditis among US older adults from 1999 to 2010. Endocarditis is the most serious cardiovascular infection and our study that had a very large sample, signified the high burden of endocarditis in this time period.
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