Title: Ultrasonographic evaluation for intra-abdominal fluid after cesarean delivery

132 Pages·2015·2.52 MB·English

Presenting Author: Kristi M. Ward
Position: Au.D/Ph.D Student
Principal Investigator: Tina M. Grieco-Calub, Ph.D
Department: Communication Sciences & Disorders
Clinical, or Basic Science, or Public Health and Social Sciences:
Clinical Research
Email: [email protected]

Title: Age-related differences in listening effort during degraded speech recognition

Summary:
Listening effort refers to the cognitive resources required for speech perception. When in
complex acoustic environments, listeners are tasked with understanding speech that has been
severely degraded. To aid perception, listeners must reallocate a greater portion of their limited
cognitive resources and thus, expend more effort. The recruitment of cognitive resources,
however, is dependent on the underlying cognitive function of the listener. These processes,
such as attention, are known to remain immature throughout childhood and peak in early
adulthood. Thus, there are likely age-dependent differences in the use of top-down cognitive
resources during effortful listening.

Objective:
The current study aims to objectively measure listening effort in normal hearing children
and young adults using a dual-task paradigm. Specifically, this study tests the hypotheses that
1) listening effort on a degraded speech recognition task will vary by age, and 2) modulating
selective attention during a degraded speech recognition task will have a greater effect on
children than adults. Measuring age-related changes in listening effort is the first step toward
developing a clinically feasible measure of listening effort in individuals with hearing loss who
are especially prone to mental fatigue.

Methods:
Children (8-12 years old) and young adults (18-25 years old) perform the same dual-task
paradigm. The dual-task paradigm consists of two simultaneously presented tasks: a primary
speech recognition task that is either unprocessed or spectrally degraded by 4-, 6-, or 8-channel
noiseband vocoding and a secondary visual sequencing task. Participants first perform each
task in isolation as a baseline measure of performance and then concurrently as part of the
dual-task paradigm. Change in performance on the secondary task from baseline to the dual-
task condition is used to quantify listening effort where poorer performance is indicative of more
effortful listening.

Results & Conclusions:
Children exhibit a greater decline in reaction time and accuracy on the secondary task
than adults, thus suggesting that they are dedicating a greater portion of their cognitive
resources to the degraded speech recognition task. However, the children’s listening effort is
highly variable across the degraded listening conditions. Ongoing data collection and analyses
will further examine how listening effort is driven by age-related differences in cognitive function.
Presenting Author: Dong Xu, MD
Position: Research Assistant Professor
Principal Investigator: Lauren M. Pachman, MD
Department: Pediatrics
Clinical, or Basic Science, or Public Health and Social Sciences: Clinical Science
Email: [email protected]

Title: Aromatase Gene Expression is Upregulated in Diagnostic Muscle Biopsies from Girls with
Untreated Juvenile Dermatomyositis

Dong Xu, MD1, 2; Akadia Kachaochana, BS1; Adam Ostrower, BS1; John S Coon, V, BS3;
Gabrielle A. Morgan, MA1; Hong Zhao, MD, Ph.D3; Chiang-Ching Huang, PhD 4; Serdar E Bulun,
MD3, Lauren M. Pachman, MD1, 2

Ann & Robert H. Lurie Children’s Hospital of Chicago Research Center, Program of Excellence
in Cure-Juvenile Myositis (JM) Research, Northwestern University Feinberg School of
Medicine1. Department of Pediatrics, Division of Rheumatology2, Department of Obstetrics and
Gynecology3, Northwestern University Feinberg School of Medicine, Chicago, IL. Department of
Preventive Medicine4, University of Wisconsin at Milwaukee, Milwaukee, WI

Background: We observed: WT-1 was massively hypomethylated in muscle biopsies (MBx)
from untreated or treated active JDM. Others had shown: 1) WT-1 controls the proximal
promoter II activity of aromatase, which regulates estrogen synthesis; 2) proinflammatory
cytokines elicit aromatase production through its distal aromatase promoter I.4.

Hypothesis: Dysregulated estrogen homeostasis may play a role in JDM pathophysiology.

Methods: Ten girls (5 regular, 5 irregular menses) with JDM had MRI-directed IRB-consented
MBx (mean age 9.0±3 yrs) were compared with MBx from 4 orthopedic control girls (16.0±1.0
yrs). Muscle total RNA was assayed for aromatase gene expression levels, qPCR (Taqman).
Mesoscale measured plasma levels of proinflammatory cytokines (IL6, IL-1β and TNF-α, t test).
The association of the level of aromatase gene expression with disease activity scores (DAS)
for skin, muscle, and total score was determined.

Results: Aromatase mRNA levels were 9.78 fold higher in JDM MBx compared with healthy
controls (p=0.004), but did not differ between JDM girls with either regular or irregular menses
(p=0.4). Aromatase levels were not associated with any DAS. Promoter I.4 was the dominant
aromatase promoter identified in JDM MBx. In JDM plasma, IL-6, IL-1β and TNF-α levels were
elevated compared to controls (p<0.05).

Conclusion: Aromatase upregulation may be associated with JDM pathophysiology. We
speculate: 1) elevated proinflammatory cytokines induce aromatase expression via the distal
aromatase promoter I.4 in JDM; 2) high aromatase leading to increased local estrogen
biosynthesis in muscle tissue may contribute to the targeted distribution of muscle involvement
characteristic of JDM.
Presenting Author: Suneel D Kamath, MD
Position: Internal Medicine Resident, PGY-2
Principal Investigator: Brandon McMahon, MD
Department: Internal Medicine, Hematology/Oncology
Clinical, or Basic Science, or Public Health and Social Sciences: Clinical Research
Email: [email protected]
Title: Permanent Inferior Vena Cava Filters in Patients with Active Malignancy
Summary and Objectives: The use of inferior vena cava (IVC) filters continues to rise in the
cancer population. However, data regarding efficacy and complication rates are limited. In this
study, we examined the use of permanent IVC filters in cancer patients.
Methods: This was a retrospective, single-center study of oncology patients who underwent
permanent IVC filter placement from 2009 to 2013. Patients were followed prospectively from time
of filter placement. Data collected included demographics, type and stage of malignancy, indication
for placement, rate of recurrent venous thromboembolism (VTE) and time from filter placement to
death. Only patients with active cancer were included.
Sample: 175 patients were included. Patient characteristics are shown in table 1.
Results: The indications for placement were: bleeding (54%), thrombocytopenia (16%), extensive
clot burden (8%), recurrent VTE on anticoagulation (8%), recent or upcoming procedure (7%),
cardiopulmonary compromise (3%) and other (4%). 15% of patients had no contraindication to
anticoagulation or failure of anticoagulation. 39% were treated with anticoagulation post-filter.
Recurrent VTE occurred in 45 patients (26%). A total of 71 recurrent VTEs were observed,
including 9 pulmonary emboli. 48% of recurrent VTEs occurred on anticoagulation. 88% of patients
had died by study end, largely from progressive cancer. Median time from filter placement to death
was 2.14 months (range 0.07-65).
Conclusions: Recurrent VTE following permanent IVC filter placement is common in patients with
malignancy-associated thrombosis. Time from filter placement to death was short, indicating need
for more discriminate utilization in patients with advanced cancer. These results emphasize the
need for prospective studies evaluating efficacy and safety of IVC filters in patients with
malignancy-associated thrombosis.
Table 1: Patient characteristics
Age, median (range) 65 (21-98)
Male sex, N (%) 78 (45%)
History of VTE, N (%) 66 (38%)
Cancer Stage, N (%) Stage I: 3 (2%)
Stage II: 6 (3%)
Stage III: 10 (6%)
Stage IV: 122 (70%)
N/A: 39 (22%)
Site of Malignancy, N (%) Gastrointestinal: 57 (33%)
Hematologic: 36 (21%)
Lung: 31 (18%)
Genitourinary: 19 (11%)
Brain: 15 (9%)
Gynecologic: 14 (8%)
Other: 8 (5%)
Presenting Author: Kara A. DeWalt, BA
Position: Research Assistant
Principal Investigator: Sumanta K. Pal, MD
Department of Medical Oncology & Experimental Therapeutics,
City of Hope Comprehensive Cancer Center, Duarte, CA
Department: Preventive Medicine
Clinical, or Basic Science, or Public Health and Social Sciences: Clinical Research
Email: [email protected]

Title: Comparison of radiographic characteristics of renal cell carcinoma (RCC) brain
metastases treated with vascular endothelial growth factor (VEGF)-directed therapies or
radiotherapy

Background: With improvements in systemic therapy for metastatic RCC (mRCC), an
increased frequency of brain metastases (BM) has been observed, perhaps owing to the central
nervous system (CNS) serving as a sanctuary site. The response of BM to VEGF-directed
therapies has been poorly characterized.

Methods: Patients (pts) with mRCC BM were identified from an institutional database.
Selection of pts was further refined to pts who had received either VEGF-directed therapy
during their diagnosis with BM or radiotherapy directed to their BM. Only those pts with brain
MRI straddling systemic therapy and radiotherapy were selected for analysis. Imaging studies
were anonymized and transmitted to an independent radiologist for review. Descriptive
statistics were applied to characterize the change in sum of long axis dimensions (SLD) in two
separate groups: (1) pts treated with VEGF-directed therapy and (2) pts treated with
radiotherapy.

Results: Of 276 pts with mRCC in our institutional database, 34 pts with BM were identified. Of
these pts, 6 pts had serial MRI assessments at time points straddling receipt of VEGF-directed
therapy. Pts had received sunitinib (n=2), sorafenib (n=2) or bevacizumab (n=2). A further 13
pts received radiotherapy with MRI imaging straddling delivery of either stereotactic radiation
therapy (SRT) and whole brain radiotherapy (WBRT). Of these 19 patients, all patients had
clear cell histology, and 13 patients were male. In pts receiving VEGF-directed agents, the
average change in SLD of BM was -13.8%. In pts receiving radiotherapy, the average change
in SLD was -6.5% (-13.0% in pts receiving SRT and +2.0% in pts receiving WBRT).
Qualitatively, greater tumor necrosis and lesser rim enhancement was observed in post-
treatment scans amongst pts receiving VEGF-directed agents.

Conclusions: This pilot study suggested differences in CNS response with VEGF-directed
therapy and radiotherapy. Multicenter collaborations are underway to validate these results in
larger series.
Presenting Author: Mary E. Lohman, BA
Position: Medical Student
Principal Investigator: Kevin J. O’Leary, MD
Department: Hospital Medicine
Clinical, or Basic Science, or Public Health and Social Sciences:
Clinical Research
Email: [email protected]

Title: The Effect of Tablet Computers with a Mobile Patient Portal Application on Hospitalized
Patients’ Knowledge and Activation

Background: The hospital setting presents multiple challenges to patient comprehension of the
care plan. Care teams are dynamic and information regarding complex treatments is typically
communicated verbally, without supplementation. As a consequence, patients often have poor
knowledge of team members and cannot name planned tests, procedures or current
medications. In the outpatient setting, patient portals have been used to inform and involve
patients in their care. The utility of patient portals in the hospital setting has not been evaluated.

Objective: To evaluate the impact of a mobile patient portal application on inpatient knowledge
and activation.

Sample: 202 general medicine inpatients were recruited from two similar teaching service units
between June and October 2014. Participants were assigned to the intervention unit (n=100) or
control unit (n=102) by hospital admissions.

Methods: We conducted a cluster randomized control trial. Intervention unit patients received a
tablet computer with a patient portal application for use during their hospital stay. The portal
leveraged select information from the electronic health record including scheduled tests,
procedures and active medications, as well as team member names, pictures and role
descriptions. Patients on both units were interviewed on their second or third hospital day to
assess knowledge and activation. Patients were asked to name their nurse, team physicians,
physician roles, tests and procedures planned for the day, medications started, and medications
stopped since admission. To assess patient knowledge, patient responses were compared in a
blinded manner to data from the patient’s physician and medical record. Patient activation was
assessed with the Short Form of the Patient Activation Measure (PAM-SF).

Results: Intervention unit patients were younger compared to control unit patients (46.7±16.7
vs. 51.4±17.3; p=0.05). There was no difference between groups in sex, race, educational level
or Elixhauser index. A higher percentage of intervention unit patients correctly named ≥1
physician name (56.0% vs. 29.4%; p<0.001) and ≥1 physician role (47.0% vs. 15.7%; p<0.001).
Patient knowledge of nurse names, planned tests, new medications, and discontinued
medications did not significantly differ between groups. Intervention unit patients had a higher
PAM-SF score but the difference was not statistically significant (64.1±13.4 vs. 62.7±12.8;
p=0.46). Analysis using multivariable models adjusting for age showed similar results.

Conclusions: Use of a patient portal improves patient knowledge of team member names and
roles. This intervention did not change patient knowledge of the care plan or patient activation.
Presenting Author: Elise M Gilbert, PharmD
Position: Infectious Diseases Clinical Pharmacist, Northwestern Memorial
Hospital; Assistant Professor of Pharmacy Practice, Chicago State
University College of Pharmacy
Principal Investigator: Marc Scheetz, PharmD
Department: Pharmacy
Clinical, or Basic Science, or Public Health and Social Sciences: Clinical
Email: [email protected]

Title: Antibacterial Consumption Is Variably Associated with Vancomycin Resistant Enterococci
Horizontal Transmission Rates

Summary/Objective: Proliferation of antimicrobial resistance often occurs as a function of de
novo resistant organism emergence or transmission of resistant species. Horizontal
transmissions (HTs) of resistant organisms may result from the density of inpatients at many
institutions, shared staff and equipment, and missed hand hygiene opportunities by healthcare
workers. This study will investigate the association between antimicrobial consumption (AC),
hand hygiene (HH), and horizontal resistant organism transmission at a tertiary medical center.

Methods: A single center retrospective database review and data exploration study was
conducted from 1/2012 – 12/2013. A vancomycin resistant Enterococci (VRE) HT event was
defined as pulsed field gel electrophoresis with ≤3 band difference and bed trace data indicating
geographic and temporal patient interactions. An event was excluded if the patient was <18
years old. The Centers for Disease Control and Prevention Antimicrobial Use and Resistance
module was utilized to produce days of therapy (DOT)-based AC for inpatient locations: medical
intensive care (MICU), hematology/oncology (H/O1, H/O2) and stem cell transplant (SCT). HH
was defined using floor audit data. Multiple linear regression models were constructed using a
backward stepwise approach (P<0.1 required for model inclusion) for each location to assess
the contribution of location-specific AC to VRE HT rates.

Results: 119 HT events were included. HH data was not significantly predictive of VRE HTs.
Aztreonam predicted decreased VRE HTs in the MICU (p=0.024), while vancomycin predicted
increased VRE HTs on H/O1 (p=0.038). No significant associations of AC with VRE HTs were
observed for H/O2 or SCT.

Conclusions: Changes in consumption of certain antibacterial agents were variably correlated
with VRE HT rates, and this effect is location specific. Further studies are necessary to
elucidate the full clinical significance of these findings.
Presenting Author: Sarah E Uttal BS
Position: Medical Student
Principal Investigator: Josh Levitsky MD, MS
All Authors: Lisa B VanWagner, Brittany Lapin, Tanvi Subramanian, Amanda
Jichlinski, Joshua Lee, Brian Poole, Madeleine Heldman, Eduardo
Bustamante, Suvai Gunasekaran, Christopher S Tapia,
Annapoorani Veerappan, She-Yan Wong
Department: Medicine- Gastroenterology and Hepatology, Surgery-Organ
Transplantation
Clinical, or Basic Science, or Public Health and Social Sciences:
Clinical research
Email: [email protected]
Title: Improved but persistent poor functional performance at 1 year after liver transplantation:
Predictors of performance and opportunities for intervention
Summary/Objective: Functional impairment is common in chronic liver disease (CLD) and
improvement is expected following liver transplantation (LT). The 6-minute walk distance
(6MWD) is an objective measure of functional performance. The purpose of this study was to
compare 6MWD in LT recipients over time compared to healthy controls (HC) and CLD patients.
Sample/Methods: 6MWD was prospectively measured in 162 ambulatory participants (50 HC,
62 CLD, 50 LT) using a standard protocol. Sex, age, and BMI were used to calculate ideal
6MWD. Chi-square, ANOVA, and Pearson coefficients compared actual and % predicted
6MWD (%6MWD) across groups. Multivariable mixed models assessed predictors of 6MWD
improvement.
Results: Mean participant age was 53.5 (13.0) years, 39.5% female, 39.1% non-white. LT
recipient %6MWD was 65.3 (22.8)% at a mean of 71.8 (65.1) days, improving to 79.1 (19.9)%
by 287.3 (138.2) days post-LT (p<0.01). At 1-year post-LT male, but not female, %6MWD [80.4
(19.5)%] remained worse than both CLD [93.3 (13.7)%] and HC [91.9 (14.3)%] participants
(p=0.03, Figure). LT recipient 6MWD was directly correlated with male sex (r=0.47, p<0.05) and
hepatitis C (r=0.59, p<0.01) and inversely correlated with nonalcoholic steatohepatitis (NASH)
(r=-0.52, p<0.01). 6MWD also showed strong correlation with physical component score on the
SF-36 in all groups (r=0.51, p<0.01). In multivariate analysis, hepatitis C remained an
independent predictor of 6MWD improvement (p=0.048). There was a trend towards worse
6MWD in NASH recipients (p=0.06). Patients with no rehospitalizations have a longer 6MWD
compared to patients with rehospitalizations (p=0.096). At 1-month post-LT, only 5/46 (10.9%)
of recipients were enrolled in a rehabilitation program and at 1-year none were participating.
Conclusions: 6MWD is lower in male patients up to 1 year post-LT as compared to HC and
CLD patients. Among LT recipients, male sex and NASH are associated with poorer 6-minute
walk performance, which is a simple and inexpensive measure of functional performance that
can be easily applied in clinical practice. A minority of LT recipients are enrolled in a
rehabilitation program highlighting the opportunity for early lifestyle intervention to potentially
improve functional capacity after LT.
Figure: Percent predicted 6MWD over time stratified by group and sex
Presenting Author: Pietro Bortoletto, BS
Position: Medical Student
Principal Investigator: Pietro Bortoletto, BS
Department: Department of Obstetrics and Gynecology-Division of REI
Clinical, or Basic Science, or Public Health and Social Sciences:
Clinical & Women’s Health Research
Email: [email protected]

Title: A Cost-effectiveness Analysis of Morcellation Hysterectomy for Fibroids
Study Objective: To estimate the cost-effectiveness of eliminating morcellation in the surgical
treatment of leiomyomas from a societal perspective.
Measurements: A decision analysis model was constructed using probabilities, costs, and
utility data from published sources. A cost-effectiveness analysis analyzing both quality-adjusted
life years (QALYs) and cases disseminated cancer was performed to determine the incremental
cost-effectiveness ratio (ICER) of eliminating morcellation as a tool in the surgical treatment of
leiomyomas. Costs and utilities were discounted using standard methodology. The base case
included health care system costs and costs incurred by the patient for surgery-related
disability. One way sensitivity analyses were performed to assess the effect of various
assumptions.
Main Results: A strategy of non-morcellation hysterectomy via laparotomy cost more
($30,359.92 versus $20,853.15) and yielded more QALYs (21.284 versus 21.280) relative to
morcellation hysterectomy. The ICER for non-morcellation hysterectomy compared to
morcellation hysterectomy was $2,184,172 per QALY. The cost to prevent one case of
disseminated cancer was $10,540,832. Health care costs (prolonged hospitalizations) and costs
to patients of prolonged time away from work were the primary drivers of cost differential
between the two strategies. Even when the incidence of occult sarcoma in leiomyoma surgery
was ranged to twice that reported by proponents of banning morcellation (0.98) the ICER for
non-morcellation hysterectomy was $644.393.30.
Conclusions: Eliminating morcellation hysterectomy as a treatment for fibroids is not cost-
effective under a wide variety of probability and cost assumptions. Performing laparotomy for all
patients who might otherwise be candidates for morcellation hysterectomy is a costly policy from
a societal perspective.
Presenting Author: Vidhya DS Illuri, MD
Position: Endocrinology Fellow
Principal Investigator: Amisha Wallia, MD, MS
Department: Division of Endocrinology, Metabolism, and Molecular Medicine,
Center for Healthcare Studies
Clinical, or Basic Science, or Public Health and Social Sciences:
Clinical Science
Email: [email protected]

Title: A Failure Mode Effects and Criticality Analysis Identifies Variability in Inpatient Diabetes
Education Comprehension as a High Risk Failure in Transitions of Care

Half of solid organ transplant (tx) patients (pts) develop hyperglycemia and 10-20% develop
diabetes mellitus (DM). DM care has many transitions (50% tx pts never make follow up). A
Failure Mode Effects and Criticality Analysis (FMECA), an engineering risk assessment
method, was used to identify and rank failures in the transitions of DM care from hospital
discharge (d/c) to outpatient at Northwestern Memorial Hospital. An intervention to mitigate the
risks will be developed.
Thirty-one providers (18 NP/PA/PharmD, 5 MD, 8 RN/DE/staff) across disciplines involved in
DM care of post-liver tx pts participated in an FMECA, along with 6 pts & 3 caregivers.
Participants described their roles/tasks in the (1) steps of post-tx DM care (2) failures of each
step, and (3) frequency, impact, and safeguards of each failure. Providers were also directly
observed. A criticality score (Severity X Occurrence) was calculated for each failure and
ranked (Risk Priority Number [RPN] = Severity X Occurrence X Detection).
Sixty-seven steps were identified, (13 ICU, 24 floor, and 30 d/c). Most failures (N=69) occurred
during d/c with "variability in DM education (DE) comprehension" [RPN=630] ranked as a high
risk failure. [Figure] Root causes include lack of DE delivery standardization and access to
training materials and home supplies.
Presenting Author: Brian M. Hoff, PharmD
Position: Infectious Diseases Pharmacy Resident
Principle Investigator: Marc Scheetz, PharmD, MSc
Department: Pharmacy
Clinical, or Basic Science, or Public Health and Social Sciences: Clinical
Email: [email protected]

Title: High-Dose Non-Extended Interval Aminoglycosides Not Associated With Improved
Pulmonary Function in Adult Cystic Fibrosis Patients

Background: Aminoglycosides are administered as high-dose, extended infusion (HDEI)
schemes as a standard of care for Cystic Fibrosis (CF) exacerbations. Dosing more frequently
than every 24 hours (e.g. every 12 hours) has been suggested to improve outcomes [i.e. high-
dose, non-extended interval (HDNEI)]. We evaluated the impact of transitioning from HDNEI to
HDEI AG dosing protocol on pulmonary function testing (PFT) among adult CF patients.

Methods: We conducted a retrospective, observational study of patients admitted to
Northwestern Memorial Hospital between 1/1/05 and 1/16/14. Patients were included if they
were > 18 years old. Disease progression between the regimens (HDNEI and HDEI) was
quantified as FEV and FVC pre-infection and after therapy. Exacerbation recurrence was also
1
analyzed. Treatment related adverse events (AEs) were assessed from the medical record and
included cochleotoxicity, vestibulotoxicity, and nephrotoxicity. PFT outcomes were analyzed
using paired t-tests. Exacerbation recurrence and AE incidence were analyzed using Chi-square
or Fishers exact tests.

Results: Overall, 31 HDNEI and 20 HDEI patients were included. The mean (SD) improvement
in FEV from baseline to the end of therapy (EOT) was 0.35 L (0.37) for HDNEI patients and
1
0.17 L (0.24) for HDEI patients (P=0.11). The mean (SD) improvement in FVC from baseline to
EOT was 0.32 L (0.43) for HDNEI patients and 0.24 L (0.36) for HDEI patients (P=0.57).
Recurrence of exacerbation was common in both HDNEI and HDEI groups at 74.1% and
60.0%, respectively (P=0.28). The incidence of AEs related to HDNEI and HDEI AG dosing was
low and consisted of acute kidney injury (0% v. 5%; P=0.39), ototoxicity (0% v. 20%; P=0.33),
intractable headaches (6.4% v. 5.0%; P>0.99), and dizziness (0% v. 10.0%; P=0.14). Tinnitus
was not observed. The composite incidence of any AE among patients receiving HDNEI and
HDEI did not differ significantly (6.4% v. 20.0%; P=0.14).

Conclusions: No differences were observed between HDNEI and HDEI. Studies with higher
power are needed to clarify the most optimal strategy for CF exacerbations; however, adult CF
patients are a limited population. HDEI seems prudent unless long term beneficial outcomes are
demonstrated.