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Prior authorization is a process that health insurance companies use to determine if a patient's health insurance will cover certain medical treatments, procedures, or medications. Prior authorization requests are common in adult congenital and pediatric cardiology (ACPC) due to need for advanced diagnostics, complex procedures, disease-specific medications, and the heterogeneity of the ACPC population. Prior authorizations in ACPC are rarely denied, but nonetheless, they are often accompanied by significant administrative burden on clinical care teams and delays in patient care. Prior authorizations have been implicated in worsening care inequities. The prior authorization process is insurer specific with differences between commercial and public insurers. Prior authorization rejections were previously found to be more common for women, racial minorities, those with low education, and in low-income groups. Prior authorization unduly burdens routine diagnostics, routine interventional and surgical procedures, and routine cardiac specific medication use in the ACPC population. This manuscript highlights the burdens of prior authorization and advocates for the elimination of prior authorization for ACPC patients.
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Cardiología , Autorización Previa , Adulto , Niño , Humanos , FemeninoRESUMEN
Purpose of Review: Exposure to trauma accelerates during the adolescence, and due to increased behavioral and psychiatric vulnerability during this developmental period, traumatic events during this time are more likely to cause a lasting impact. In this article, we use three case studies of hospitalized adolescents to illustrate the application of trauma-informed principles of care with this unique population. Recent Findings: Adolescents today are caught in the crosshairs of two syndemics-racism and other structural inequities and the COVID-19 pandemic. Increased hospitalizations and mental health diagnoses during the past two years signal toxic levels of stress affecting this group. Trauma-informed care promotes health, healing, and equity. Summary: This concept of the "trauma-informed approach" is still novel; through examples and practice, providers can learn to universally apply the trauma-informed care framework to every patient encounter to address the harmful effects of trauma and promote recovery and resilience.
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BACKGROUND: Intravenous contrast-enhanced imaging is invaluable in diagnosing pathology following liver transplantation. Given the potential risk of contrast nephropathy associated with iodinated computed tomography contrast, alternate contrast modalities need to be examined, especially in the setting of renal insufficiency. The purpose of this study was to examine the renal safety of MRI with gadolinium following liver transplantation. METHODS: The study involved a retrospective analysis of 549 cases of abdominal MRI with low-dose gadobenate dimeglumine in liver transplant recipients at a single center. For each case, serum creatinine values before and after the MRI were compared. In addition, cases were analyzed for the development of nephrogenic systemic fibrosis. RESULTS: Pre-MRI creatinine values ranged from 0.32 to 6.57 mg/dL (median, 1.28 g/dL), with 191 cases having values ≥1.5 mg/dL (median, 1.86 g/dL). A comparison of the pre- and post-MRI creatinine values showed no significant difference, including those patients with pre-MRI values ≥1.5 mg/dL (mean change of -0.04 [95% confidence interval, -0.07 to -0.01; P = 0.004]). No cases of nephrogenic systemic fibrosis were noted. CONCLUSIONS: Our findings suggest that, irrespective of baseline renal function, MRI with gadobenate dimeglumine is a nonnephrotoxic imaging modality in liver transplant recipients. Importantly, this intravenous contrast-enhanced imaging modality can be considered in those posttransplant patients who have a contraindication to computed tomography contrast due to renal insufficiency.
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Lesión Renal Aguda/inducido químicamente , Medios de Contraste/efectos adversos , Trasplante de Hígado/efectos adversos , Imagen por Resonancia Magnética/efectos adversos , Meglumina/análogos & derivados , Dermopatía Fibrosante Nefrogénica/inducido químicamente , Compuestos Organometálicos/efectos adversos , Complicaciones Posoperatorias/diagnóstico por imagen , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/epidemiología , Administración Intravenosa , Adulto , Anciano , Biomarcadores/sangre , Medios de Contraste/administración & dosificación , Creatinina/sangre , Femenino , Georgia/epidemiología , Humanos , Incidencia , Masculino , Meglumina/administración & dosificación , Meglumina/efectos adversos , Persona de Mediana Edad , Dermopatía Fibrosante Nefrogénica/diagnóstico , Dermopatía Fibrosante Nefrogénica/epidemiología , Compuestos Organometálicos/administración & dosificación , Complicaciones Posoperatorias/epidemiología , Insuficiencia Renal/diagnóstico , Insuficiencia Renal/epidemiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
Nonalcoholic fatty liver disease is associated with metabolic risk factors including hypertension and dyslipidemia and may progress to liver fibrosis. Studies have shown that hepatic steatosis and fibrosis are heritable, but whether they have a significant shared gene effect is unknown. This study examined the shared gene effects between hepatic steatosis and fibrosis and their associations with metabolic risk factors. This was a cross-sectional analysis of a prospective cohort of well-characterized, community-dwelling twins (45 monozygotic, 20 dizygotic twin pairs, 130 total subjects) from southern California. Hepatic steatosis was assessed with magnetic resonance imaging-proton density fat fraction and hepatic fibrosis with magnetic resonance elastography. A standard bivariate twin additive genetics and unique environment effects model was used to estimate the proportion of phenotypic variance between two phenotypes accounted for by additive genetic effects and individual-specific environmental effects. Genetic correlations estimated from this model represent the degree to which the genetic determinants of two phenotypes overlap. Mean (± standard deviation) age and body mass index were 47.1 (±21.9) years and 26.2 (±5.8) kg/m2 , respectively. Among the cohort, 20% (26/130) had hepatic steatosis (magnetic resonance imaging-proton density fat fraction ≥5%), and 8.2% (10/122) had hepatic fibrosis (magnetic resonance elastography ≥3 kPa). Blood pressure (systolic and diastolic), triglycerides, glucose, homeostatic model assessment of insulin resistance, insulin, hemoglobin A1c, and low high-density lipoprotein had significant shared gene effects with hepatic steatosis. Triglycerides, glucose, homeostatic model assessment of insulin resistance, insulin, hemoglobin A1c, and low high-density lipoprotein had significant shared gene effects with hepatic fibrosis. Hepatic steatosis and fibrosis had a highly significant shared gene effect of 0.756 (95% confidence interval 0.716-1, P < 0.0001). CONCLUSIONS: Genes involved with steatosis pathogenesis may also be involved with fibrosis pathogenesis. (Hepatology 2016;64:1547-1558).
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Enfermedades en Gemelos/genética , Hígado Graso/genética , Cirrosis Hepática/genética , Estudios Transversales , Enfermedades en Gemelos/metabolismo , Hígado Graso/metabolismo , Femenino , Humanos , Cirrosis Hepática/metabolismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: In considering treatment allocation for patients with early esophageal adenocarcinoma, the incidence of lymph node metastasis is a critical determinant; however, this has not been well defined or stratified by the relevant clinical predictors of lymph node spread. METHODS: Data from the Surveillance, Epidemiology, and End Results database of the National Cancer Institute were abstracted from 2004 to 2010 for patients with early-stage esophageal adenocarcinoma. The incidence of lymph node involvement for patients with Tis, T1a, and T1b tumors was examined and was stratified by predictors of spread. RESULTS: A total of 13,996 patients with esophageal adenocarcinoma were evaluated. Excluding those with advanced, metastatic, and/or invasive (T2-T4) disease, 715 patients with Tis, T1a, and T1b tumors were included. On multivariate analysis, tumor grade (odds ratio [OR], 2.76; 95% confidence interval [95% CI], 1.58-4.82 [P<.001]), T classification (OR, 0.47; 95% CI, 0.24-0.91 [P =.025]), and tumor size (OR, 2.68; 95% CI, 1.48-4.85 [P = .001]) were found to be independently associated with lymph node metastases. There was no lymph node spread noted with Tis tumors. For patients with low-grade (well or moderately differentiated) tumors measuring <2 cm in size, the risk of lymph node metastasis was 1.7% for T1a (P<.001) and 8.6% for T1b (P = .001) tumors. CONCLUSIONS: For patients with low-grade Tis or T1 tumors measuring ≤2 cm in size, the incidence of lymph node metastasis appears to be comparable to the mortality rate associated with esophagectomy. For highly selected patients with early esophageal adenocarcinomas, the results of the current study support the recommendation that local endoscopic resection can be considered as an alternative to surgical management when followed by rigorous endoscopic and radiographic surveillance. Cancer 2016;122:2150-7. © 2016 American Cancer Society.
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Adenocarcinoma/diagnóstico , Adenocarcinoma/epidemiología , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/epidemiología , Adenocarcinoma/mortalidad , Adenocarcinoma/terapia , Toma de Decisiones Clínicas , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/terapia , Femenino , Humanos , Ganglios Linfáticos/patología , Metástasis Linfática , Masculino , Clasificación del Tumor , Estadificación de Neoplasias , Oportunidad Relativa , Vigilancia de la Población , Prevalencia , PronósticoRESUMEN
PURPOSE: Interscalene brachial plexus blocks are performed for perioperative management of surgeries involving the shoulder. Historically, these procedures employed anatomic landmarks (AL) to determine the location of the brachial plexus as it passes between the anterior and middle scalene muscles in the neck. In this study, we compared the actual location of the brachial plexus as found with sonography (US) to the anticipated location using AL. METHODS: The location of the brachial plexus was evaluated using US and AL in 96 subjects. The distance between the two locations was measured. A multivariate analysis of variance was used to determine the significance of the difference and a 2 × 2 analysis of variance was used to compare differences in gender, height, and body mass index. RESULTS: The brachial plexus was located on average 1.8 cm inferior (p = 0.0001) and 0.2 cm lateral (p = 0.09) to the location determined with AL. A significant difference was also associated with gender (p = 0.03), but not with height or body mass index. CONCLUSIONS: US is a reliable method that accurately pinpoints the roots of the brachial plexus. The brachial plexus is often located inferior to the location anticipated using AL. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:411-415, 2016.
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Puntos Anatómicos de Referencia , Plexo Braquial/anatomía & histología , Plexo Braquial/diagnóstico por imagen , Ultrasonografía/métodos , Adolescente , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
Renal dysfunction in cirrhosis carries a high morbidity and mortality. Given the potential risk of contrast-induced nephropathy associated with iodinated intravenous contrast used in computed tomography (CT), alternate contrast modalities for abdominal imaging in liver transplant candidates need to be examined. The purpose of this study was to examine the renal safety of magnetic resonance imaging (MRI) with gadolinium in patients awaiting liver transplantation. The study involved a retrospective analysis of 352 patients of abdominal MRI with low-dose gadobenate dimeglumine (MultiHance) (0.05 mmol/kg) in patients with cirrhosis and without renal replacement therapy at a single center during the period from 2007 to 2013. For each case, serum creatinine before and within a few days after the MRI were compared. In addition, the patients were analyzed for the development of nephrogenic systemic fibrosis (NSF), a reported complication of gadolinium in chronic kidney disease. The pre-MRI serum creatinine values ranged from 0.36 to 4.86 mg/dL, with 70 patients (20%) having values ≥ 1.5 mg/dL. A comparison of the pre- and post-MRI serum creatinine values did not demonstrate a clinically significant difference (mean change = 0.017 mg/dL; P = 0.38), including those patients with a pre-MRI serum creatinine ≥ 1.5 mg/dL. In addition, no cases of NSF were noted. In conclusion, our findings suggest that MRI with low-dose gadobenate dimeglumine (MultiHance) is a nonnephrotoxic imaging modality in liver transplant candidates, and its use can be cautiously expanded to liver transplant candidates with concomitant renal insufficiency.
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Cirrosis Hepática/complicaciones , Trasplante de Hígado , Imagen por Resonancia Magnética/métodos , Meglumina/análogos & derivados , Compuestos Organometálicos/administración & dosificación , Insuficiencia Renal/diagnóstico , Espera Vigilante/métodos , Medios de Contraste/administración & dosificación , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Gadolinio , Humanos , Infusiones Intravenosas , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/cirugía , Masculino , Meglumina/administración & dosificación , Persona de Mediana Edad , Insuficiencia Renal/complicaciones , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
PURPOSE: To determine whether a Bayesian network trained on a large database of patient demographic risk factors and radiologist-observed findings from consecutive clinical mammography examinations can exceed radiologist performance in the classification of mammographic findings as benign or malignant. MATERIALS AND METHODS: The institutional review board exempted this HIPAA-compliant retrospective study from requiring informed consent. Structured reports from 48 744 consecutive pooled screening and diagnostic mammography examinations in 18 269 patients from April 5, 1999 to February 9, 2004 were collected. Mammographic findings were matched with a state cancer registry, which served as the reference standard. By using 10-fold cross validation, the Bayesian network was tested and trained to estimate breast cancer risk by using demographic risk factors (age, family and personal history of breast cancer, and use of hormone replacement therapy) and mammographic findings recorded in the Breast Imaging Reporting and Data System lexicon. The performance of radiologists compared with the Bayesian network was evaluated by using area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. RESULTS: The Bayesian network significantly exceeded the performance of interpreting radiologists in terms of AUC (0.960 vs 0.939, P = .002), sensitivity (90.0% vs 85.3%, P < .001), and specificity (93.0% vs 88.1%, P < .001). CONCLUSION: On the basis of prospectively collected variables, the evaluated Bayesian network can predict the probability of breast cancer and exceed interpreting radiologist performance. Bayesian networks may help radiologists improve mammographic interpretation.
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Neoplasias de la Mama/clasificación , Neoplasias de la Mama/diagnóstico por imagen , Modelos Estadísticos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Teorema de Bayes , Neoplasias de la Mama/patología , Diagnóstico Diferencial , Detección Precoz del Cáncer , Femenino , Humanos , Mamografía , Persona de Mediana Edad , Curva ROC , Sistema de Registros , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: The purpose of our study was to create a breast cancer risk estimation model based on the descriptors of the National Mammography Database using logistic regression that can aid in decision making for the early detection of breast cancer. MATERIALS AND METHODS: We created two logistic regression models based on the mammography features and demographic data for 62,219 consecutive mammography records from 48,744 studies in 18,269 [corrected] patients reported using the Breast Imaging Reporting and Data System (BI-RADS) lexicon and the National Mammography Database format between April 5, 1999 and February 9, 2004. State cancer registry outcomes matched with our data served as the reference standard. The probability of cancer was the outcome in both models. Model 2 was built using all variables in Model 1 plus radiologists' BI-RADS assessment categories. We used 10-fold cross-validation to train and test the model and to calculate the area under the receiver operating characteristic curves (A(z)) to measure the performance. Both models were compared with the radiologists' BI-RADS assessments. RESULTS: Radiologists achieved an A(z) value of 0.939 +/- 0.011. The A(z) was 0.927 +/- 0.015 for Model 1 and 0.963 +/- 0.009 for Model 2. At 90% specificity, the sensitivity of Model 2 (90%) was significantly better (p < 0.001) than that of radiologists (82%) and Model 1 (83%). At 85% sensitivity, the specificity of Model 2 (96%) was significantly better (p < 0.001) than that of radiologists (88%) and Model 1 (87%). CONCLUSION: Our logistic regression model can effectively discriminate between benign and malignant breast disease and can identify the most important features associated with breast cancer.
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Neoplasias de la Mama/diagnóstico por imagen , Modelos Logísticos , Mamografía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo/métodos , Sensibilidad y Especificidad , Estados UnidosRESUMEN
PURPOSE: Recent development of percutaneous left atrial appendage (LAA) occlusion devices has underscored the need for an accurate understanding of LAA morphology and the interchangeability of results from differing imaging modalities. The purpose of this study is to assess LAA morphology and location in AF patients, directly comparing transesophageal echocardiography (TEE), planar cardiac computed tomography (CT), and three-dimensional segmented CT reconstructions. METHODS: Fifty-three patients underwent adequate TEE and cardiac CT. Quantitative measurements of maximal LAA orifice diameters, widths, and depths were obtained from each imaging modality. Left atrial and LAA volumes were measured using segmented CT. RESULTS: The mean LAA orifice diameter for segmented CT, planar CT, and TEE was 28.5 +/- 4.5, 26.3 +/- 4.1, and 26.1 +/- 6.4 mm, respectively. CONCLUSIONS: LAA orifice measurements among these imaging modalities are not interchangeable. This difference may be clinically significant because of the need for accurate sizing of LAA occlusion devices. Use of preprocedural segmented CT may improve initial device sizing.
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Apéndice Atrial/diagnóstico por imagen , Fibrilación Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Imagenología Tridimensional , Tomografía Computarizada por Rayos X/métodos , Análisis de Varianza , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Factors which influence lesion size from catheter-based cryoablation have not been well described. This study describes factors which influence lesion size during catheter cryoablation. METHODS AND RESULTS: Cryoablation was delivered to porcine left ventricular myocardium in a saline bath using 4- or 8-mm electrode catheters. Ablation was delivered with the electrodes either vertical or horizontal to the tissue and both with and without superfusate flow over the electrode. The effect of electrode contact pressure was tested. Lesion dimensions were measured. All experiments were duplicated to measure tissue temperatures at 1-, 2-, 3-, and 5-mm deep to the ablation electrode. The 8-mm electrode produced lower tissue temperatures and larger lesion volumes when compared with the 4-mm electrode (all P < 0.05). Superfusate flow slowed the rate of tissue cooling, markedly warmed tissue temperatures, and reduced lesion volume when compared with no flow conditions. By linear regression modeling, lesion sizes and tissue temperatures were related to the presence of superfusate flow, electrode orientation, contact pressure and electrode size, or catheter refrigerant flow rate (r2 for models = 0.90-0.96, all P < 0.001). Electrode temperature predicted lesion size or tissue temperatures only when analyzed independent of electrode size or refrigerant flow rate. CONCLUSIONS: Lesion sizes and tissue temperatures during catheter cryoablation are related to convective warming, electrode orientation, electrode contact pressure, and any of the following: electrode size, catheter refrigerant flow rate or electrode temperature. However, electrode temperature may be a poor predictor of lesion size and tissue temperature for a given catheter size.
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Criocirugía/métodos , Ventrículos Cardíacos/cirugía , Análisis de Varianza , Animales , Electrodos , Ventrículos Cardíacos/patología , Técnicas In Vitro , Modelos Lineales , Porcinos , TemperaturaRESUMEN
OBJECTIVES: The purpose of this study was to measure tissue temperatures associated with microbubble formation during radiofrequency (RF) ablation. BACKGROUND: Microbubble formation visualized by echocardiography has been used to indicate excessive tissue heating during RF pulmonary vein isolation. However, little is known about the tissue temperatures associated with microbubble formation. METHODS: Optical fluorometric thermometry probes were used to record tissue temperatures in isolated porcine atrium overlying either lung or esophageal tissue in a saline bath. RF energy was delivered through an irrigated ablation electrode during echocardiographic monitoring for microbubble formation. RESULTS: The maximal recorded tissue temperatures were 81.0 +/- 5.0 degrees C and 88.3 +/- 8.1 degrees C at the time of intermittent (type 1) microbubble formation for lung and esophageal preparations, respectively. During continuous (type 2) microbubble formation, the temperatures were 91.4 +/- 8.2 degrees C and 99.2 +/- 7.8 degrees C, respectively (both P < .001 vs type 1). Tissue temperatures averaged >100 degrees C at the time of "pops." The maximal recorded temperature occurred up to 4 mm deep in the tissues and frequently occurred external to the atrial tissue. The total RF lesion volumes for lung and esophageal preparations were related to the pattern of microbubble formation but not to total power delivered. After generation of type 1 bubbles, up to 60% reductions in RF energy were needed to restore target tissue temperatures of 65 degrees C. Gas chromatographic analysis of the microbubbles was consistent with steam formation. CONCLUSIONS: Microbubble formation during RF ablation represents excessive tissue heating to the point of steam formation. Maximal tissue heating may occur in the adjacent lung and esophagus during cooled ablation.