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Study Design: This study retrospectively analyzes prospectively collected data.Objective: Here we aim to develop predictive models for 3-month medical and surgical readmission after elective lumbar surgery, based on a multi-institutional, national spine registry.Summary Of Background Data: Unplanned readmissions place considerable stress on payers, hospitals, and patients. Medicare data reveals a 30-day readmission rate of 7.8% for lumbar-decompressions and 13.0% for lumbar-fusions, and hospitals are now being penalized for excessive 30-day readmission rates by virtue of the Hospital Readmissions Reduction Program.Methods: The Quality and Outcomes Database (QOD) was queried for patients undergoing elective lumbar surgery for degenerative diseases. The QOD prospectively captures 3-month readmissions through electronic medical record (EMR) review and self-reported outcome questionnaires. Distinct multivariable logistic regression models were fitted for surgery-related and medical readmissions adjusting for patient and surgery-specific variables.Results: Of the total 33,674 patients included in this study 2079 (6.15%) reported at least one readmission during the 90-day postoperative period. The odds of medical readmission were significantly higher for older patients, males versus females, African Americans versus Caucasion, those with higher American Society of Anesthesiologists (ASA) grade, diabetes, coronary artery disease, higher numbers of involved levels, anterior only or anterior-posterior versus posterior approach; also, for patients who were unemployed compared with employed patients and those with high baseline Oswestry Disability Index (ODI). The odds of surgery-related readmission were significantly greater for patients with a higher body mass index (BMI), a higher ASA grade, female versus male, and African Americans versus Caucasians; also, for patients with severe depression, more involved spinal levels, anterior-only surgical approaches and higher baseline ODI scores.Conclusion: In this study we present internally validated predictive models for medical and surgical readmission after elective lumbar spine surgery. These findings set the stage for targeted interventions with a potential to reduce unnecessary readmissions, and also suggest that medical and surgical readmissions be treated as distinct clinical events.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

BACKGROUND: Substantial morbidity and excessive care variation are seen with pediatric pneumonia. Accurate risk-stratification tools to guide clinical decision-making are needed. METHODS: We developed risk models to predict severe pneumonia outcomes in children (<18 years) by using data from the Etiology of Pneumonia in the Community Study, a prospective study of community-acquired pneumonia hospitalizations conducted in 3 US cities from January 2010 to June 2012. In-hospital outcomes were organized into an ordinal severity scale encompassing severe (mechanical ventilation, shock, or death), moderate (intensive care admission only), and mild (non-ntensive care hospitalization) outcomes. Twenty predictors, including patient, laboratory, and radiographic characteristics at presentation, were evaluated in 3 models: a full model included all 20 predictors, a reduced model included 10 predictors based on expert consensus, and an electronic health record (EHR) model included 9 predictors typically available as structured data within comprehensive EHRs. Ordinal regression was used for model development. Predictive accuracy was estimated by using discrimination (concordance index). RESULTS: Among the 2319 included children, 21% had a moderate or severe outcome (14% moderate, 7% severe). Each of the models accurately identified risk for moderate or severe pneumonia (concordance index across models 0.78-0.81). Age, vital signs, chest indrawing, and radiologic infiltrate pattern were the strongest predictors of severity. The reduced and EHR models retained most of the strongest predictors and performed as well as the full model. CONCLUSIONS: We created 3 risk models that accurately estimate risk for severe pneumonia in children. Their use holds the potential to improve care and outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS]. METHODS: We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics. RESULTS: Of 112 029 pregnant women, 31 354 [28%] filled ≥1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001] to have depression (5.3% vs 2.7%], anxiety disorder (4.3% vs 1.6%] and to smoke tobacco (41.8% vs 25.8%]. Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001]. In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P < .001], opioid type (P < .001], number of daily cigarettes smoked (P < .001], and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67-2.60]] were associated with greater risk of developing NAS. CONCLUSIONS: Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS. [ABSTRACT FROM AUTHOR]

Background: An angiotensin receptor-neprilysin inhibitor (ARNI) is the preferred renin-angiotensin system (RAS) inhibitor for heart failure with reduced ejection fraction (HFrEF). Among eligible patients, insurance status and prescriber concern regarding out-of-pocket costs may constrain early initiation of ARNI and other new therapies., Objectives: In this study, the authors sought to evaluate the association of insurance and other social determinants of health with ARNI initiation at discharge from HFrEF hospitalization., Methods: The authors analyzed ARNI initiation from January 2017 to June 2020 among patients with HFrEF eligible to receive RAS inhibitor at discharge from hospitals in the Get With The Guidelines-Heart Failure registry. The primary outcome was the proportion of ARNI prescription at discharge among those prescribed RAS inhibitor who were not on ARNI on admission. A logistic regression model was used to determine the association of insurance status, U.S. region, and their interaction, as well as self-reported race, with ARNI initiation at discharge., Results: From 42,766 admissions, 24,904 were excluded for absolute or relative contraindications to RAS inhibitors. RAS inhibitors were prescribed for 16,817 (94.2%) of remaining discharges, for which ARNI was prescribed in 1,640 (9.8%). Self-reported Black patients were less likely to be initiated on ARNI compared to self-reported White patients (OR: 0.64; 95% CI: 0.50-0.81). Compared to Medicare beneficiaries, patients with third-party insurance, Medicaid, or no insurance were less likely to be initiated on ARNI (OR: 0.47 [95% CI: 0.31-0.72], OR: 0.41 [95% CI: 0.25-0.67], and OR: 0.20 [95% CI: 0.08-0.47], respectively). ARNI therapy varied by hospital region, with lowest utilization in the Mountain region. An interaction was demonstrated between the impact of insurance disparities and hospital region., Conclusions: Among patients hospitalized between 2017 and 2020 for HFrEF who were prescribed RAS inhibitor therapy at discharge, insurance status, geographic region, and self-reported race were associated with ARNI initiation., Competing Interests: Funding Support and Author Disclosures This research was partially funded by American Heart Association Strategically Focused Research Network (18SFRN34110369 to Dr Davogustto). Dr Harrell has received funding support from VICTR (The Vanderbilt Institute for Clinical and Translational Research). VICTR is funded by the NCATS (National Center for Advancing Translational Sciences) CTSA (Clinical Translational Science Award) Program, Award Number 5UL1TR002243-03. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The Get With The Guidelines–Heart Failure program is provided by the American Heart Association and sponsored in part by Novartis, Boehringer Ingelheim, Novo Nordisk, AstraZeneca, Bayer, Tylenol, and Alnylam Pharmaceuticals. Dr Greene has received research support from the Duke University Department of Medicine Chair’s Research Award, American Heart Association, Amgen, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Cytokinetics, Merck, Novartis, Pfizer, and Sanofi; has served on advisory boards or as consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim/Lilly, Bristol Myers Squibb, Corteria Pharmaceuticals, CSL Vifor, Cytokinetics, Lexicon, Merck, Roche Diagnostics, Sanofi, scPharmaceuticals, Tricog Health, and Urovant Pharmaceuticals; and has received speaker fees from Bayer, Boehringer Ingelheim, Cytokinetics, Lexicon, and Roche Diagnostics; none of these activities are related to the content of the present work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

National Institutes of Health Stroke Scale (NIHSS), measured a few hours to days after stroke onset, is an attractive outcome measure for stroke research. NIHSS at the time of presentation (baseline NIHSS) strongly predicts the follow-up NIHSS. Because of the need to account for the baseline NIHSS in the analysis of follow-up NIHSS as an outcome measure, a common and intuitive approach is to define study outcome as the change in NIHSS from baseline to follow-up (ΔNIHSS). However, this approach has important limitations. Analyzing ΔNIHSS implies a very strong assumption about the relationship between baseline and follow-up NIHSS that is unlikely to be satisfied, drawing into question the validity of the resulting statistical analysis. This reduces the precision of the estimates of treatment effects and the power of clinical trials that use this approach to analysis. ANCOVA allows for the analysis of follow-up NIHSS as the dependent variable while adjusting for baseline NIHSS as a covariate in the model and addresses several challenges of using ΔNIHSS outcome using simple bivariate comparisons (eg, a t test, Wilcoxon rank-sum, linear regression without adjustment for baseline) for stroke research. In this article, we use clinical trial simulations to illustrate that variability in NIHSS outcome is less when follow-up NIHSS is adjusted for baseline compared to ΔNIHSS and how a reduction in this variability improves the power. We outline additional, important clinical and statistical arguments to support the superiority of ANCOVA using the final measurement of the NIHSS adjusted for baseline over, and caution against using, the simple bivariate comparison of absolute NIHSS change (ie, delta).

Background: Studies across the healthcare spectrum consistently show that sharing and comparing data across institutions improves the quality of patient care. Whether comparing data about healthcare ethics consultation (HCEC) would similarly improve quality is unknown due to the lack of research on HCEC data sharing and comparison. Methods: To explore this possibility, we analyzed data from two academic medical centers in the Central-Southern United States that both employ a shared, robust coding system for ethics consultations (N = 703 cases total over 2.5 years) using descriptive and chi-square statistics, correlation coefficients and logistic regressions. Results: Our findings relate to patient age, care location, requestor role, and ethical themes, which together contribute to an improved evidence base for explanatory analyses and quality improvement initiatives. Conclusions: We conclude it is possible to analyze and compare HCEC activities across separate institutions using a standardized approach to data gathering, that this approach is consistent with concurrent narrative case review and assessment, and that cross-institutional comparisons are meaningful. Our results suggest future comparative analyses will require additional standardization of advanced measures for describing and analyzing HCEC activities.

AKI is a complex clinical condition associated with high mortality, morbidity, and health care costs. Despite improvements in methodology and design of clinical trials, and advances in understanding the underlying pathophysiology of rodent AKI, no pharmacologic agent exists for the prevention or treatment of AKI in humans. To address the barriers that affect successful clinical translation of drug targets identified and validated in preclinical animal models of AKI in this patient population, the National Institute of Diabetes and Digestive and Kidney Diseases convened the "AKI Outcomes: Overcoming Barriers in AKI" workshop on February 10-12, 2015. The workshop used a reverse translational medicine approach to identify steps necessary to achieve clinical success. During the workshop, breakout groups were charged first to design feasible, phase 2, proof-of-concept clinical trials for delayed transplant graft function, prevention of AKI (primary prevention), and treatment of AKI (secondary prevention and recovery). Breakout groups then were responsible for identification of preclinical animal models that would replicate the pathophysiology of the phase 2 proof-of-concept patient population, including primary and secondary end points. Breakout groups identified considerable gaps in knowledge regarding human AKI, our understanding of the pathophysiology of AKI in preclinical animal models, and the fidelity of cellular and molecular targets that have been evaluated preclinically to provide information regarding human AKI of various etiologies. The workshop concluded with attendees defining a new path forward to a better understanding of the etiology, pathology, and pathophysiology of human AKI., (Copyright © 2018 by the American Society of Nephrology.)

Importance: Pulmonary hypertension (PH) is diagnosed by a mean pulmonary arterial pressure (mPAP) value of at least 25 mm Hg during right heart catheterization (RHC). While several studies have demonstrated increased mortality in patients with mPAP less than that threshold, little is known about the natural history of borderline PH., Objective: To test the hypothesis that patients with borderline PH have decreased survival compared with patients with lower mPAP and frequently develop overt PH and to identify clinical correlates of borderline PH., Design, Setting, and Participants: Retrospective cohort study from 1998 to 2014 at Vanderbilt University Medical Center, comprising all patients undergoing routine RHC for clinical indication. We extracted demographics, clinical data, invasive hemodynamics, echocardiography, and vital status for all patients. Patients with mPAP values of 18 mm Hg or less, 19 to 24 mm Hg, and at least 25 mm Hg were classified as reference, borderline PH, and PH, respectively., Exposures: Mean pulmonary arterial pressure., Main Outcome and Measures: Our primary outcome was all-cause mortality after adjusting for clinically relevant covariates in a Cox proportional hazards model. Our secondary outcome was the diagnosis of overt PH in patients initially diagnosed with borderline PH. Both outcomes were determined prior to data analysis., Results: We identified 4343 patients (mean [SD] age, 59 [15] years, 51% women, and 86% white) among whom the prevalence of PH and borderline PH was 62% and 18%, respectively. Advanced age, features of the metabolic syndrome, and chronic heart and lung disease were independently associated with a higher likelihood of borderline PH compared with reference patients in a logistic regression model. After adjusting for 34 covariates in a Cox proportional hazards model, borderline PH was associated with increased mortality compared with reference patients (hazard ratio, 1.31; 95% CI, 1.04-1.65; P = .001). The hazard of death increased incrementally with higher mPAP, without an observed threshold. In the 70 patients with borderline PH who underwent a repeated RHC, 43 (61%) had developed overt PH, with a median increase in mPAP of 5 mm Hg (interquartile range, -1 to 11 mm Hg; P < .001)., Conclusions and Relevance: Borderline PH is common in patients undergoing RHC and is associated with significant comorbidities, progression to overt PH, and decreased survival. Small increases in mPAP, even at values currently considered normal, are independently associated with increased mortality. Prospective studies are warranted to determine whether early intervention or closer monitoring improves clinical outcomes in these patients.

Objectives: No prospectively derived or validated decision tools identify emergency department (ED) patients with acute heart failure (AHF) at low risk for 30-day adverse events who are thus potential candidates for safe ED discharge. This study sought to accomplish that goal., Background: The nearly 1 million annual ED visits for AHF are associated with high proportions of admissions and consume significant resources., Methods: We prospectively enrolled 1,033 patients diagnosed with AHF in the ED from 4 hospitals between July 20, 2007, and February 4, 2011. We used an ordinal outcome hierarchy, defined as the incidence of the most severe adverse event within 30 days of ED evaluation (acute coronary syndrome, coronary revascularization, emergent dialysis, intubation, mechanical cardiac support, cardiopulmonary resuscitation, and death)., Results: Of 1,033 patients enrolled, 126 (12%) experienced at least one 30-day adverse event. The decision tool had a C statistic of 0.68 (95% confidence interval: 0.63 to 0.74). Elevated troponin (p < 0.001) and renal function (p = 0.01) were significant predictors of adverse events in our multivariable model, whereas B-type natriuretic peptide (p = 0.09), tachypnea (p = 0.09), and patients undergoing dialysis (p = 0.07) trended toward significance. At risk thresholds of 1%, 3%, and 5%, we found 0%, 1.4%, and 13.0% patients were at low risk, with negative predictive values of 100%, 96%, and 93%, respectively., Conclusions: The STRATIFY decision tool identifies ED patients with AHF who are at low risk for 30-day adverse events and may be candidates for safe ED discharge. After external testing, and perhaps when used as part of a shared decision-making strategy, it may significantly affect disposition strategies. (Improving Heart Failure Risk Stratification in the ED [STRATIFY]; NCT00508638)., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The incidence and longitudinal trends of patients with ST-elevation myocardial infarction (STEMI) presenting to United States (US) emergency departments (EDs) are currently unknown. Efforts to use effective treatments for cardiovascular disease may decrease ED STEMI presentation. We conducted a descriptive epidemiological analysis of STEMI visits to EDs from 2006 to 2011 using the Nationwide ED Sample, the largest source of US ED data, to determine the incidence of patients with STEMIs presenting to the US EDs. We included adult ED visits with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of STEMI and calculated incidence rates for STEMI ED visits using US census population data. Incidence calculations were stratified by age group, geographic region, and year. From 2006 to 2011, there was a mean of 258,106 STEMIs presenting to EDs per year, decreasing from 300,466 in 2006 to 227,343 in 2011. Incidence of ED STEMI visits per 10,000 adults decreased from 10.1 (95% confidence interval [CI] 9.8 to 10.8) in 2006 to 7.3 (95% CI 6.8 to 7.8) in 2011. The Midwest had the highest rate of ED STEMIs at 10.0 (95% CI 9.2 to 10.8) and the West had the lowest with 6.6 (95% CI 6.1 to 7.0). The incidence of STEMI decreased for all age groups during the study period. In conclusion, we report the first national estimates of STEMI presentation to US EDs, which demonstrate decreasing incidence across all age groups and all geographic regions from 2006 to 2011. A decreasing STEMI incidence may affect the quality and timeliness of STEMI care. Continued national STEMI surveillance is needed to guide healthcare resource allocation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

In 2015, there will be an estimated 11.3 million cancer survivors. With an increasing population of cancer survivors, it is imperative to understand the treatment options available and outcomes for chemotherapy-related cardiomyopathy. Anthracycline-based chemotherapy causes heart failure in approximately 5% of patients. Orthotopic heart transplantation (OHT) is an option for cancer survivors in complete remission who develop end-stage heart failure. We examined retrospective OHT data collected from the United Network of Organ Sharing from 1987 to 2011. The primary aim was to characterize the survival in patients with either the primary diagnosis of "dilated cardiomyopathy: Adriamycin" (DCA) versus "all other" causes of cardiomyopathy. The secondary aim was to define the differences in the primary cause of death and to describe the temporal relationship of DCA OHT. The United Network of Organ Sharing database identified 453 OHTs for the diagnosis of DCA and 51,312 OHTs for all other causes of cardiomyopathy. The DCA group was significantly younger with a greater percentage of women. After adjusting for age, gender, and history of malignancy, the 10-year survival curves showed that patients with DCA have an improved survival compared to those with all other causes of cardiomyopathy (hazard ratio 1.28, p = 0.026). No difference was found in the primary cause of death between the 2 groups. A statistically significant increasing temporal trend was seen in the number of OHTs for the diagnosis DCA. In conclusion, patients who undergo OHT for DCA have favorable 10-year survival, making OHT a good therapeutic option for end-stage heart failure due to anthracyclines. Additionally, no increased risk of cancer-related deaths was found in the DCA group, demonstrating that recurrent malignancy does not affect long-term survival. The temporal trends demonstrated that DCA remains a significant problem for cancer survivors., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Given the unsustainable costs of US health care, universal agreement exists among payers, regulatory agencies, and other health care stakeholders that reform must include substantial improvements in the quality, effectiveness, and value of health care delivery. The Institute of Medicine and the American Recovery and Reinvestment Act of 2009 have called for the establishment of prospective registries to capture patient-centered data from real-world practice as a high priority to guide evidence-based reform. As a result, the American Association of Neurological Surgeons launched the National Neurosurgery Quality and Outcomes Database (N(2)QOD) and began enrolling patients in March 2012 into its initial pilot project: a web-based lumbar spine module. As a nationwide, prospective longitudinal registry utilizing patient reported outcome instruments, the N(2)QOD lumbar spine surgery pilot aims to systematically measure and aggregate surgical safety and 1-year postoperative outcome data from approximately 30 neurosurgical practices across the US with the primary aim of demonstrating the feasibility and validity of standardized 1-year outcome measurement from everyday real-world practice. At the end of the pilot year, 1) risk-adjusted modeling will be developed for the safety, quality, and effectiveness of lumbar surgical care (morbidity, readmission, improvements in pain, disability, quality of life, and return to work); 2) data integrity and validation will be demonstrated via internal quality control analyses and auditing, and 3) the feasibility of obtaining a high level of follow-up (~80%) of nationwide 1-year outcome measurement will be established. N(2)QOD will use only prospective clinical data, will avoid the use of administrative data proxies, and will rely on neurosurgically relevant risk factors for risk adjustment. Once national benchmarks of quality and effectiveness are accurately established and validated utilizing practice-based data extractors in the pilot year, N(2)QOD aims to introduce non-full-time employee (FTE)-dependent methodologies such as electronic medical record auto-extraction. N(2)QOD's non-FTE-dependent methodologies can then be validated against practice-based data extractor-derived measures of safety and effectiveness with the aim of more rapid expansion into the majority of US practice groups. The general overview, methods, and registry design of the N(2)QOD pilot year (lumbar module) are presented here.

Clinical research needs to be more useful to patients, clinicians, and other decision makers. To meet this need, more research should focus on patient-centered outcomes, compare viable alternatives, and be responsive to individual patients' preferences, needs, pathobiology, settings, and values. These features, which make comparative effectiveness research (CER) fundamentally patient-centered, challenge researchers to adopt or develop methods that improve the timeliness, relevance, and practical application of clinical studies. In this paper, we describe 10 priority areas that address 3 critical needs for research on patient-centered outcomes (PCOR): (1) developing and testing trustworthy methods to identify and prioritize important questions for research; (2) improving the design, conduct, and analysis of clinical research studies; and (3) linking the process and outcomes of actual practice to priorities for research on patient-centered outcomes. We argue that the National Institutes of Health, through its clinical and translational research program, should accelerate the development and refinement of methods for CER by linking a program of methods research to the broader portfolio of large, prospective clinical and health system studies it supports. Insights generated by this work should be of enormous value to PCORI and to the broad range of organizations that will be funding and implementing CER., (© 2011 Wiley Periodicals, Inc.)

There is increasing interest in utilizing novel markers of cardiovascular disease risk, and consequently, there is a need to assess the value of their use. This scientific statement reviews current concepts of risk evaluation and proposes standards for the critical appraisal of risk assessment methods. An adequate evaluation of a novel risk marker requires a sound research design, a representative at-risk population, and an adequate number of outcome events. Studies of a novel marker should report the degree to which it adds to the prognostic information provided by standard risk markers. No single statistical measure provides all the information needed to assess a novel marker, so measures of both discrimination and accuracy should be reported. The clinical value of a marker should be assessed by its effect on patient management and outcomes. In general, a novel risk marker should be evaluated in several phases, including initial proof of concept, prospective validation in independent populations, documentation of incremental information when added to standard risk markers, assessment of effects on patient management and outcomes, and ultimately, cost-effectiveness.

Purpose: To assess the burnout level among U.S. and Canadian medical school deans and to study how burnout relates to certain characteristics including hours worked, effectiveness, and support from family and colleagues., Method: Questionnaires were sent in September 2006 to 100 deans who had served at least one year. The questionnaire included 13 questions from the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures three subcomponents of burnout: emotional exhaustion, depersonalization, and personal accomplishment., Results: The response rate was 90%. The median age of participants was 60; the median length of service at the current institution was four years; the median number of hours worked per week was 70.0. Deans most frequently identified school budget deficits, loss of funding, and departure of key faculty as stressors. Whereas only 11% reported being dissatisfied with their positions, 33% reported it was likely they would step down within the next two years. The predominant pattern of MBI-HSS subscale scores in participating deans was moderate emotional exhaustion, moderate depersonalization, and high personal accomplishment. Only 2% of respondents satisfied all three subscale scores for high burnout. Emotional exhaustion was significantly directly associated with work week length and number of weekend days worked and was inversely associated with spousal support, length of service, and age., Conclusions: Despite having an "extreme" job, only 2% of deans exhibited high levels of burnout. A high sense of control and self-efficacy, a supportive family, increasing length of service, and increasing age may be factors which reduce burnout in deans.

Objective: To examine the effects of adjunctive postoperative massage and vibration therapy on short-term postsurgical pain, negative affect, and physiologic stress reactivity., Design: Prospective, randomized controlled trial. The treatment groups were: (1) usual postoperative care (UC); (2) UC plus massage therapy; or (3) UC plus vibration therapy., Setting: The University of Virginia Hospital Surgical Units, Gynecology-Oncology Clinic, and General Clinical Research Center., Subjects: One hundred and five (N = 105) women who underwent an abdominal laparotomy for removal of suspected cancerous lesions., Interventions: All patients received UC with analgesic medication. Additionally, the massage group received standardized 45-minute sessions of gentle Swedish massage on the 3 consecutive evenings after surgery and the vibration group received 20-minute sessions of inaudible vibration therapy (physiotones) on the 3 consecutive evenings after surgery, as well as additional sessions as desired., Outcome Measures: Sensory pain, affective pain, anxiety, distress, analgesic use, systolic blood pressure, 24-hour urine free cortisol, number of postoperative complications, and days of hospitalization., Results: On the day of surgery, massage was more effective than UC for affective (p = 0.0244) and sensory pain (p = 0.0428), and better than vibration for affective pain (p = 0.0015). On postoperative day 2, massage was more effective than UC for distress (p = 0.0085), and better than vibration for sensory pain (p = 0.0085). Vibration was also more effective than UC for sensory pain (p = 0.0090) and distress (p = .0090). However, after controlling for multiple comparisons and multiple outcomes, no significant differences were found., Conclusions: Gentle Swedish massage applied postoperatively may have minor effects on short-term sensory pain, affective pain, and distress among women undergoing an abdominal laparotomy for removal of suspected malignant tissues.

Objectives: To compare prognostic estimates made by seriously ill hospitalized patients, their surrogates, and their physicians about the patients' activities of daily living (ADLs) 2 months after admission; compare the accuracy of their estimates; and identify factors associated with the optimism and accuracy of these estimates., Design: Prospective cohort study., Setting: Five teaching hospitals., Participants: A subset (n = 716) of patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment., Measurements: Prognostic estimates of ADL function., Results: Physicians were less likely than patients or surrogates to give very high or very low estimates for future functioning. Seven of ten (69.3) patients who survived 2 months estimated that they would be functionally independent at Month 2, compared with 58.5 of their surrogates and 49.2 of their physicians. Agreement on prognosis was highest between patients and surrogates (64.2) and lowest between patients and physicians (48.4). Factors significantly associated with an optimistic estimate of independent functioning were better baseline ADL function, male gender, and higher level of education. Patients were significantly more accurate than surrogates and even more so than physicians in predicting independent functioning at Month 2. Worse baseline function and higher income were significantly associated with accurate estimation., Conclusion: At hospital admission, seriously ill patients were more optimistic about their prognosis for physical functioning at 2 months, and more accurate in their estimates, than surrogates and physicians. Physicians tended to underestimate the prognosis for future functioning. Physicians should consider patients' and families' estimates before giving advice about treatment options and discharge planning.