Semi‐supervised joint learning for longitudinal clinical events classification using neural network models

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163377/2/sta4305.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163377/1/sta4305_am.pd

Increasing ultraviolet light exposure is associated with reduced mortality from Clostridium difficile infection

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166256/1/ueg2bf00112.pd

Longitudinal study of short‐term corticosteroid use by working‐age adults with diabetes mellitus: Risks and mitigating factors

BackgroundThis study assessed the frequency of short‐term oral corticosteroid use in adults with diabetes, examined the incidence of fractures, venous thromboembolism (VTE), and hospitalization for sepsis after corticosteroid use, and evaluated whether preventative medications mitigated adverse events.MethodsA longitudinal study (2012–14) was conducted of 1 548 945 adults (aged 18–64 years) who received healthcare coverage through a large national health insurer. Incidence rate ratios (IRR) were calculated using conditional Poisson regression.ResultsShort‐term oral corticosteroids were used by 23.9%, 20.8%, and 20.9% of adults with type 2 diabetes, type 1 diabetes, and no diabetes, respectively, during the 3‐year period (P < 0.001). Baseline risks of fracture, VTE, and sepsis were greater for individuals with than without diabetes (P < 0.001). The combined effect of having diabetes and using corticosteroids was greater than the sum of the individual effects (synergy indices of 1.17, 1.23, 1.30 for fracture, VTE, and sepsis, respectively). The IRR for VTE in the 5–30 days after corticosteroid use was 3.62 (95% confidence interval [CI] 2.41–5.45). Fractures increased in the 5–30 days after corticosteroid use (IRR 2.06; 95% CI 1.52, 2.80), but concomitant use of ergocalciferol mitigated this risk (IRR 1.13; 95% CI 0.12, 11.07). The risk of hospitalization for sepsis was elevated with corticosteroid use (IRR 3.79; 95% CI 2.05, 7.01), but was mitigated by the concomitant use of statins.ConclusionsShort‐term oral corticosteroid use is common in adults with diabetes and is associated with an elevated, but low, risk of adverse events. The findings suggest that preventative medications may mitigate risk.摘要背景这项研究在成年糖尿病患者中评估了短期使用口服糖皮质激素的频率,  调查了使用糖皮质激素后骨折与静脉血栓栓塞(venous thromboembolism, VTE)的发生率以及脓毒症的住院率,  并且评估了预防性用药是否会减少不良事件。方法这是一项在1548945名具有大型国家健康保险公司医疗保险的成年(年龄为18‐64岁)患者中进行的纵向研究(2012‐14)。使用有条件的Poisson回归分析来计算发病率比(incidence rate ratios, IRR)。结果在这3年期间,  短期使用口服糖皮质激素治疗的2型糖尿病、1型糖尿病以及非糖尿病成年患者的比例分别为23.9%、20.8%与20.9%(P < 0.001)。与非糖尿病患者相比,  糖尿病患者基线时的骨折、VTE以及脓毒症的风险都更高(P < 0.001)。患糖尿病以及使用糖皮质激素的联合效应大于个体效应之和(骨折、VTE以及脓毒症的协同指数分别为1.17、1.23、1.30)。使用糖皮质激素后的5‐30日内发生VTE的IRR为3.62(95%置信区间[CI]为2.41‐5.45)。使用糖皮质激素后的5‐30日内发生骨折的风险增加(IRR为2.06;95% CI为1.52, 2.80),  但同时使用麦角骨化醇治疗可以减少这种风险(IRR为1.13;95% CI为0.12, 11.07)。使用糖皮质激素后脓毒症的住院风险也增加了(IRR为3.79;95% CI为2.05, 7.01),  但是同时使用他汀类药物治疗可以减少这种风险。结论成年糖尿病患者短期使用口服糖皮质激素治疗很常见并且与不良事件风险轻度升高有关。这项研究结果表明预防性用药可以减少这种风险。HighlightsAdults with diabetes mellitus have a greater risk of fracture, venous thromboembolism, and sepsis than those without diabetes; the use of corticosteroids, even for short durations, increases this risk.Vitamin D mitigated the risk of fracture in patients with diabetes who used corticosteroids, and statins decreased the likelihood of hospitalization for sepsis in corticosteroid users with diabetes.Corticosteroids should be used with caution in patients with diabetes and mitigating factors should be considered.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144644/1/jdb12631.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144644/2/jdb12631_am.pd

Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm

Background and study aims Colonic polyps > 1 cm in size are commonly managed using hot polypectomy techniques. The most frequent adverse events (delayed bleeding, post-polypectomy syndrome, and perforation) are related to electrocautery-induced injury. We hypothesized that cold resection of large polyps may have similar efficacy and improved safety compared to hot polypectomy. Our aims were to evaluate efficacy and safety of piecemeal cold snare resection of colonic polyps > 1 cm. Patients and methods Patients undergoing lift and piecemeal cold snare polypectomy of non-pedunculated colon polyps > 1 cm from October 2013 to September 2015 were identified retrospectively. Efficacy was defined by the absence of residual adenomatous tissue at endoscopic follow-up. Adverse events (AEs), including post-procedural bleeding, bowel perforation, or post-procedural pain requiring hospitalization were assessed by chart review and telephone follow-up.  Results Seventy-three patients underwent piecemeal cold snare polypectomy for 94 colon polyps > 1 cm with 56 of 73 patients completing follow-up on 72 polyps. Residual or recurrent adenoma was found in 7 cases (9.7 %). Median polyp size was significantly greater in those with residual/recurrent adenoma (37.1 vs. 19.1 mm, P < .0001). There were no AEs among all 73 patients enrolled. Conclusions Piecemeal cold snare resection of colon polyps > 1 cm is feasible, safe and efficacious when compared to published hot polypectomy data. Additional observational and randomized comparative effectiveness studies are necessary to demonstrate comparable adenoma eradication and improved safety advantage over existing hot snare polypectomy techniques

Meta-analysis: re-treatment of genotype I hepatitis C nonresponders and relapsers after failing interferon and ribavirin combination therapy

Aliment Pharmacol Ther 2010; 32: 969–983The efficacy of re-treating genotype I hepatitis C virus (HCV) patients who failed combination therapy with interferon/pegylated interferon (PEG-IFN) and ribavirin remains unclear.To quantify sustained virological response (SVR) rates with different re-treatment regimens through meta-analysis of randomized controlled trials (RCTs).Randomized controlled trials of genotype I HCV treatment failure patients that compared currently available re-treatment regimens were selected. Two investigators independently extracted data on patient population, methods and results. The pooled relative risk of SVR for treatment regimens was computed using a random effects model.Eighteen RCTs were included. In nonresponders to standard interferon/ribavirin, re-treatment with high-dose PEG-IFN combination therapy improved SVR compared with standard PEG-IFN combination therapy (RR = 1.49; 95% CI: 1.09–2.04), but SVR rates did not exceed 18% in most studies. In relapsers to standard interferon/ribavirin, re-treatment with high-dose PEG-IFN or prolonged CIFN improved SVR (RR = 1.57; 95% CI: 1.16–2.14) and achieved SVR rates of 43–69%.In genotype I HCV treatment failure patients who received combination therapy, re-treatment with high-dose PEG-IFN combination therapy is superior to re-treatment with standard combination therapy, although SVR rates are variable for nonresponders (≤18%) and relapsers (43–69%). Re-treatment may be appropriate for select patients, especially relapsers and individuals with bridging fibrosis or compensated cirrhosis.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79170/1/j.1365-2036.2010.04427.x.pd

Validation of a tool predicting important findings on computed tomography among Crohn’s disease patients

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166167/1/ueg2bf00677.pd

Patient and provider‐level barriers to hepatitis C screening and linkage to care: A mixed‐methods evaluation

Achieving practice change can be challenging when guidelines shift from a selective risk‐based strategy to a broader population health strategy, as occurred for hepatitis C (HCV) screening (2012‐2013). We aimed to evaluate patient and provider barriers that contributed to suboptimal HCV screening and linkage‐to‐care rates after implementation of an intervention to improve HCV screening and linkage‐to‐care processes in a large, public integrated healthcare system following the guidelines change. As part of a mixed‐methods study, we collected data through patient surveys (n = 159), focus groups (n = 9) and structured observation of providers and staff (n = 9). We used these findings to then inform domains for the second phase, which consisted of semi‐structured interviews with patients across the screening‐treatment continuum (n = 24) and providers and staff at primary care and hepatology clinics (n = 21). We transcribed and thematically analysed interviews using an integrated inductive and deductive framework. We identified lack of clarity about treatment cost, treatment complications and likelihood of cure as ongoing patient‐level barriers to screening and linkage to care. Provider‐level barriers included scepticism about establishing HCV screening as a quality metric given competing clinical priorities, particularly for patients with multiple comorbidities. However, most felt positively about adding HCV as a quality metric to enhance HCV screening and linkage to care. Provider engagement yielded suggestions for process improvements that resulted in increased stakeholder buy‐in and real‐time enhancements to the HCV screening process intervention. Systematic data collection at baseline and during practice change implementation may facilitate adoption and adaptation to improve HCV screening guideline implementation. Findings identified several key opportunities and lessons to enhance the impact of practice change interventions to improve HCV screening and treatment delivery.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/155892/1/jvh13278.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/155892/2/jvh13278_am.pd

Identification of symptom domains in ulcerative colitis that occur frequently during flares and are responsive to changes in disease activity

<p>Abstract</p> <p>Background</p> <p>Ulcerative colitis disease activity is determined by measuring symptoms and signs. Our aim was to determine which symptom domains are frequent and responsive to change in the evaluation of disease activity, which are those defined by three criteria: 1) they occur frequently during flares; 2) they improve during effective therapy for ulcerative colitis; and 3) they resolve during remission.</p> <p>Methods</p> <p>Twenty-eight symptom domains, 16 from standard indices and 12 novel domains identified by ulcerative colitis patient focus groups, were evaluated. Sixty subjects with ulcerative colitis were surveyed, rating each symptom on the three criteria with a 100 mm Visual Analogue Scale. Frequent and responsive symptoms were defined <it>a priori </it>as those whose median Visual Analogue Scale rating for all 3 criteria was significantly greater than 50.</p> <p>Results</p> <p>Thirteen of the 28 symptom domains were identified as both frequent in ulcerative colitis flares and responsive to changes in disease activity. Seven of these 13 symptom domains were novel symptoms derived from ulcerative colitis patient focus groups including stool mucus, tenesmus, fatigue, rapid postprandial bowel movements, and inability to differentiate liquid or gas from solid stool when rectal urgency occurs. Ten of the 16 symptom domains from standard indices were either infrequent or unresponsive to changes in disease activity.</p> <p>Conclusion</p> <p>Only some of the symptoms of ulcerative colitis that are important to patients are included in standard indices, and several symptoms currently measured are not frequent or responsive to change in ulcerative colitis patients. Development of survey measures of these symptom domains could significantly improve the assessment of disease activity in ulcerative colitis.</p

Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients With suspected biliary complications

Diagnostic endoscopic retrograde cholangiopancreatography (D‐ERCP) is commonly performed for the evaluation of biliary complications after orthotopic liver transplantation (OLT). This practice is contrary to the national trend of reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes. Our aim was to evaluate the clinical yield and complications of D‐ERCP in OLT recipients. In this retrospective study, 165 OLT recipients who underwent ERCP between January 2006 and December 2010 at the University of Michigan were divided into 2 groups: (1) a therapeutic endoscopic retrograde cholangiopancreatography (T‐ERCP) group (if they met prespecified criteria that suggested a high likelihood of endoscopic intervention) and (2) a D‐ERCP group (if there was clinical suspicion of biliary disease but they did not meet any criteria). The 2 groups were compared with respect to the proportion of subjects undergoing high‐yield ERCP, which was defined as a procedure resulting in a clinically important intervention that modified the disease course. 66.3% of the D‐ERCP procedures were classified as high‐yield, whereas 90.1% of the T‐ERCP procedures were ( P < 0.001). Serious complications were infrequent in both groups. A survey of practitioners caring for OLT recipients suggested that the rate of high‐yield D‐ERCP seen in this study is congruent with what is considered acceptable in clinical practice. In conclusion, although T‐ERCP is more likely to reveal a pathological process requiring an intervention, D‐ERCP appears to be an acceptable clinical strategy for OLT recipients because of the high likelihood of a high‐yield study and the low rate of serious complications. Liver Transpl, 2012. © 2012 AASLD.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/95170/1/23535_ftp.pd