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Incidence, Prediction, and Causes of Unplanned 30-Day Hospital Admission After Ambulatory Procedures

Bijan Teja, Dana Raub, Sabine Friedrich, Paul Rostin, Maria D. Patrocínio, Jeffrey C. Schneider, Changyu Shen, Gabriel A. Brat, Timothy T. Houle, Robert W. Yeh, Matthias Eikermann
2020 Anesthesia and Analgesia  
Unanticipated hospital admission is regarded as a measure of adverse perioperative patient care. However, previously published studies for risk prediction after ambulatory procedures are sparse compared to those examining readmission after inpatient surgery. We aimed to evaluate the incidence and reasons for unplanned admission after ambulatory surgery and develop a prediction tool for preoperative risk assessment. This retrospective cohort study included adult patients undergoing ambulatory,
more » ... ncardiac procedures under anesthesia care at 2 tertiary care centers in Massachusetts, United States, between 2007 and 2017 as well as all hospitals and ambulatory surgery centers in New York State, United States, in 2014. The primary outcome was unplanned hospital admission within 30 days after discharge. We created a prediction tool (the PREdicting admission after Outpatient Procedures [PREOP] score) using stepwise backward regression analysis to predict unplanned hospital admission, based on criteria used by the Centers for Medicare & Medicaid Services, within 30 days after surgery in the Massachusetts hospital network registry. Model predictors included patient demographics, comorbidities, and procedural factors. We validated the score externally in the New York state registry. Reasons for unplanned admission were assessed. A total of 170,983 patients were included in the Massachusetts hospital network registry and 1,232,788 in the New York state registry. Among those, the observed rate of unplanned admission was 2.0% (3504) and 1.7% (20,622), respectively. The prediction model showed good discrimination in the training set with C-statistic of 0.77 (95% confidence interval [CI], 0.77-0.78) and satisfactory discrimination in the validation set with C-statistic of 0.71 (95% CI, 0.70-0.71). The risk of unplanned admission varied widely from 0.4% (95% CI, 0.3-0.4) among patients whose calculated PREOP scores were in the first percentile to 21.3% (95% CI, 20.0-22.5) among patients whose scores were in the 99th percentile. Predictions were well calibrated with an overall ratio of observed-to-expected events of 99.97% (95% CI, 96.3-103.6) in the training and 92.6% (95% CI, 88.8-96.4) in the external validation set. Unplanned admissions were most often related to malignancy, nonsurgical site infections, and surgical complications. We present an instrument for prediction of unplanned 30-day admission after ambulatory procedures under anesthesia care validated in a statewide cohort comprising academic and nonacademic hospitals as well as ambulatory surgery centers. The instrument may be useful in identifying patients at high risk for 30-day unplanned hospital admission and may be used for benchmarking hospitals, ambulatory surgery centers, and practitioners.
doi:10.1213/ane.0000000000004852 pmid:32427660 fatcat:fpv7mnplojclhlmobxqnunv55m

Upregulation of hypoxia inducible factor is associated with attenuation of neuronal injury in neonatal piglets undergoing deep hypothermic circulatory arrest

Faraz Kerendi, Michael E. Halkos, Hajime Kin, Joel S. Corvera, Daniel J. Brat, Mary B. Wagner, Jakob Vinten-Johansen, Zhi-Qing Zhao, Joseph M. Forbess, Kirk R. Kanter, Mary E. Kelley, Paul M. Kirshbom
2005 Journal of Thoracic and Cardiovascular Surgery  
Prolonged deep hypothermic circulatory arrest is known to cause neurological injury. Hypoxia inducible factor, a transcription factor that mediates adaptive changes during hypoxia, is neuroprotective in models of ischemic brain injury, in part by upregulating erythropoietin. This study tested the hypothesis that upregulation of hypoxia inducible factor and erythropoietin by preconditioning with hypoxia or the hypoxia-mimetic agents deferoxamine and cobalt chloride would be neuroprotective in a
more » ... iglet model of deep hypothermic circulatory arrest. Methods: Anesthetized neonatal piglets were randomized to 4 preconditioning groups (15 per group): hypoxia, deferoxamine, cobalt chloride, or control (NaCl vehicle). Brain hypoxia inducible factor and erythropoietin contents were assessed by means of Western blotting at 3, 8, and 24 hours after treatment (n ϭ 3 per time point). Twenty-four hours after treatment, 6 to 7 animals per group underwent cardiopulmonary bypass and 110 minutes of deep hypothermic circulatory arrest. After recovery, serial neurobehavioral examinations were conducted for 6 days, after which histopathologic brain injury and neuronal apoptosis (cleaved caspase 3) were assessed. Results: Erythropoietin expression was not significantly increased by any of the pretreatment strategies. In contrast, there was a significant upregulation of hypoxia inducible factor by pretreatment with deferoxamine and cobalt chloride (P ϭ .002). Neurobehavioral measures revealed no significant differences in time to recovery or extent of injury. Examination of histopathologic brain injury in the hippocampus revealed that pretreatment with deferoxamine (0.4 Ϯ 0.3) and cobalt chloride (0.5 Ϯ 0.3) were associated with significantly less neuronal loss than pretreatment with hypoxia or control (2.8 Ϯ 0.5, P ϭ .004). Finally, cleaved caspase 3 (a marker of apoptotic cell death) was also shown to be diminished in the cobalt and deferoxamine groups, but the difference was not significantly different from the value in the control group. Conclusions: In contrast to hypoxia, deferoxamine and cobalt chloride preconditioning upregulated hypoxia inducible factor and were associated with histopathologic neuroprotection after exposure to cardiopulmonary bypass and prolonged deep hypothermic circulatory arrest. From the Division of Cardiothoracic Surgery,
doi:10.1016/j.jtcvs.2005.05.045 pmid:16214523 fatcat:uozxphw25zbsdbyaihiw6wh2zu

Proceedings of the Comprehensive Oncology Network Evaluating Rare CNS Tumors (NCI-CONNECT) Oligodendroglioma Workshop

Marta Penas-Prado, Jing Wu, Daniel P Cahill, Daniel J Brat, Joseph F Costello, Paul G Kluetz, J Gregory Cairncross, Martin van den Bent, Roel G W Verhaak, Orwa Aboud, Peter Burger, Susan M Chang (+7 others)
2019 Neuro-Oncology Advances  
General Overview of Clinical Trial Efficacy Endpoints Presented by Paul G. Kluetz, M.D., U.S. Food and Drug Administration.  ...  Based on these findings, Brat et al. are developing clinical decision support algorithms to predict patient outcomes and guide treatment decisions. Like the Japanese cohort, Brat et al.'  ... 
doi:10.1093/noajnl/vdz048 pmid:33289010 pmcid:PMC7212866 fatcat:vrb5wyhbu5dobh43e46myoljd4

The impact of histopathology and NAB2–STAT6 fusion subtype in classification and grading of meningeal solitary fibrous tumor/hemangiopericytoma

Karen Fritchie, Kassandra Jensch, Evgeny A. Moskalev, Alissa Caron, Sarah Jenkins, Michael Link, Paul D. Brown, Fausto J. Rodriguez, Andrew Guajardo, Daniel Brat, José E. Velázquez Vega, Arie Perry (+11 others)
2018 Acta Neuropathologica  
Meningeal solitary fibrous tumor (SFT)/hemangiopericytoma (HPC) is a rare tumor with propensity for recurrence and metastasis. Although multiple classification schemes have been proposed, optimal risk stratification remains unclear, and the prognostic impact of fusion status is uncertain. We compared the 2016 WHO CNS tumor grading scheme (CNS-G), a three-tier system based on histopathologic phenotype and mitotic count, to the 2013 WHO soft-tissue counterpart (ST-G), a two-tier system based on
more » ... totic count alone, in a cohort of 133 patients [59 female, 74 male; mean age 54 years (range 20-87)] with meningeal SFT/HPC. Tumors were pathologically confirmed through review of the first tumor resection (n = 97), local recurrence (n = 35), or distant metastasis (n = 1). A STAT6 immunostain showed nuclear expression in 132 cases. NAB2-STAT6 fusion was detected in 99 of 111 successfully tested tumors (89%) including the single STAT6 immunonegative tumor. Tumors were classified by CNS-G as grade 1 (n = 43), 2 (n = 41), or 3 (n = 49), and by ST-G as SFT (n = 84) or malignant SFT (n = 49). Necrosis was present in 16 cases (12%). On follow-up, 42 patients had at least one subsequent recurrence or metastasis (7 metastasis only, 33 recurrence only, 2 patients had both). Twenty-nine patients died. On univariate analysis, necrosis (p = 0.002), CNS-G (p = 0.01), and ST-G (p = 0.004) were associated with recurrence-free (RFS) but not overall survival (OS). NAB2-STAT6 fusion type was not significantly associated with RFS or OS, but was associated with phenotype. A modified ST-G incorporating necrosis showed higher correlation with RFS (p = 0.0006) and remained significant (p = 0.02) when considering only the primary tumors. From our data, mitotic rate and necrosis appear to stratify this family of tumors most accurately and could be incorporated in a future grading scheme.
doi:10.1007/s00401-018-1952-6 pmid:30584643 pmcid:PMC6513906 fatcat:js6fvebhjbfujgo6lnymhlicfm

Mutational landscape of gastric adenocarcinoma in Chinese: Implications for prognosis and therapy

Kexin Chen, Da Yang, Xiangchun Li, Baocun Sun, Fengju Song, Wenfeng Cao, Daniel J. Brat, Zhibo Gao, Haixin Li, Han Liang, Yanrui Zhao, Hong Zheng (+20 others)
2015 Proceedings of the National Academy of Sciences of the United States of America  
Gastric cancer (GC) is a highly heterogeneous disease. To identify potential clinically actionable therapeutic targets that may inform individualized treatment strategies, we performed whole-exome sequencing on 78 GCs of differing histologies and anatomic locations, as well as whole-genome sequencing on two GC cases, each with three primary tumors and two matching lymph node metastases. The data showed two distinct GC subtypes with either high-clonality (HiC) or low-clonality (LoC). The HiC
more » ... ype of intratumoral heterogeneity was associated with older age, TP53 (tumor protein P53) mutation, enriched C > G transition, and significantly shorter survival, whereas the LoC subtype was associated with younger age, ARID1A (AT rich interactive domain 1A) mutation, and significantly longer survival. Phylogenetic tree analysis of whole-genome sequencing data from multiple samples of two patients supported the clonal evolution of GC metastasis and revealed the accumulation of genetic defects that necessitate combination therapeutics. The most recurrently mutated genes, which were validated in a separate cohort of 216 cases by targeted sequencing, were members of the homologous recombination DNA repair, Wnt, and PI3K-ERBB pathways. Notably, the drugable NRG1 (neuregulin-1) and ERBB4 (V-Erb-B2 avian erythroblastic leukemia viral oncogene homolog 4) ligand-receptor pair were mutated in 10% of GC cases. Mutations of the BRCA2 (breast cancer 2, early onset) gene, found in 8% of our cohort and validated in The Cancer Genome Atlas GC cohort, were associated with significantly longer survivals. These data define distinct clinicogenetic forms of GC in the Chinese population that are characterized by specific mutation sets that can be investigated for efficacy of single and combination therapies. clonality | exome sequencing | mutation | ERBB | BRCA2 G astric cancer (GC) is the fourth most common cancer and the second leading cause of cancer death worldwide, accounting for 8% of all newly diagnosed cancers and 10% of cancer mortality(1). Environmental risk factors for GC include a high-salt diet, smoking, and infectious agents (1), including the bacterium Helicobacter pylori (2), and Epstein Barr Virus (3). Consistent with its complicated etiology (e.g., diet) and anatomical environment, GC is clinically and pathologically highly heterogeneous (4), with a large variation in 5-y survival rates in different countries, and even different cities in the same country (5, 6). This clinical heterogeneity is mirrored by concomitant heterogeneous molecular signatures in GC mRNA, protein, and miRNA expression profiles (7, 8) . Standard treatment strategies have largely ignored the heterogeneity and individuality of different subtypes of GC. The current approach entails surgical removal of the tumor followed by adjuvant fluoropyrimidine, taxane, and platinum-based chemotherapy doublets or triplets, especially for advanced GC, and this is exacerbated by the lack of reliable markers to predict response. Recently, the US Food and Drug Administration and the European Medicines Agency have approved Trastuzumab for patients with HER2-overexpressing metastatic GC, which represent less than 15% of the disease population. The high incidence of GC in Asian countries and its increasing incidence in Western countries point to a clear need for developing more effective therapies for GC as well as the discovery of markers that predict their therapeutic response. Genome sequencing has emerged as a powerful tool to identify potential driving oncogenic targets for therapeutic intervention. Wang et al. sequenced 22 samples from Hong Kong GC patients and identified mutations in genes involved in chromatin modification Significance We have identified a lethal subtype of gastric cancer (GC) that is characterized by high levels of clonal heterogeneity and TP53 (tumor protein P53) mutation. We have also uncovered key novel mutations in the targetable NRG1 (neuregulin-1) and ERBB4 (V-Erb-B2 avian erythroblastic leukemia viral oncogene homolog 4) ligand-receptor pair and identified BRCA2 (breast cancer 2, early onset) mutations as new genetic markers to predict better survival for GC. Our study represents a novel approach for GC personalized medicine and identified novel clinical actionable therapies for GC therapy.
doi:10.1073/pnas.1422640112 pmid:25583476 pmcid:PMC4313862 fatcat:cwvfqz45tbbnrklbhigryghiti

Validation of a Derived International Patient Severity Phenotype to Support COVID-19 Analytics from Electronic Health Record Data [article]

Jeffrey G. Klann, Griffin M Weber, Hossein Estiri, Bertrand Moal, Paul Avillach, Chuan Hong, Victor M Castro, Thomas Maulhardt, Amelia LM Tan, Alon Geva, Brett K Beaulieu-Jones, Alberto Malovini (+28 others)
2020 medRxiv   pre-print
Murphy, Brat, and Kohane contributed equally. Klann led the study and writing the manuscript. CONTRIBUTIONS All authors approved the manuscript and contributed substantially.  ... 
doi:10.1101/2020.10.13.20201855 fatcat:oq6ont3dcfcgzpyobhc5d37xhu

Validation of an Internationally Derived Patient Severity Phenotype to Support COVID-19 Analytics from Electronic Health Record Data

Jeffrey G Klann, Griffin M Weber, Hossein Estiri, Bertrand Moal, Paul Avillach, Chuan Hong, Victor Castro, Thomas Maulhardt, Amelia L M Tan, Alon Geva, Brett K Beaulieu-Jones, Alberto Malovini (+30 others)
2021 JAMIA Journal of the American Medical Informatics Association  
Murphy, Brat, and Kohane contributed equally. Klann led the study and writing the manuscript. CONTRIBUTIONS All authors approved the manuscript and contributed substantially.  ... 
doi:10.1093/jamia/ocab018 pmid:33566082 pmcid:PMC7928835 fatcat:lef5r7lnsjfyposxkee3di5nn4

M.-É. BOISMARD, Le martyre de Jean l'apôtre, J. Gabalda et Cie Éditeurs, Paris 1996

Stanisław Mędala
1998 Ruch Biblijny i Liturgiczny  
Commentaire historique, Paris 1994, s. 339-379), w którym oby dwaj autorzy bronią lekcji zamiennej "Jan, brat Jakuba" w Dz 12, 2, za miast "Jakub, brat Jana".  ...  Drugim tekstem jest lekcja zamienna w Dz 12, 2 "Jan, brat Jakuba". W ostatnim, piątym rozdziale (s. 63-75) M.-É. Boismard poddaje kry tycznej analizie wypowiedzi św.  ...  STANISŁAW MĘDALA CM PAUL de CLERCK, Zrozumieć liturgię, Wydawnictwo "Jedność", Kielce 1997, ss. 191 .  ... 
doi:10.21906/rbl.686 fatcat:badljew2rngbtgs3jyyyqavgyy

Cap-Dependent Translational Inhibition Establishes Two Opposing Morphogen Gradients in Drosophila Embryos

Park F. Cho, Chiara Gamberi, Yoon Andrew Cho-Park, Ian B. Cho-Park, Paul Lasko, Nahum Sonenberg
2006 Current Biology  
Inhibition of hb mRNA translation requires an mRNP complex (the NRE complex), which consists of Nanos (Nos), Pumilio (Pum), and Brain tumor (Brat) proteins, and the Nos responsive element (NRE) present  ...  protein that represses caudal (cad) mRNA translation [10], also inhibits hb mRNA translation by interacting simultaneously with the mRNA 5 0 cap structure (m 7 GpppN, where N is any nucleotide) [11] and Brat  ...  Lev (brat fs1 ) for reagents; J. Laliberte for confocal microscopy; Guillaume Lesage in the Cell Imaging and Analysis Network (  ... 
doi:10.1016/j.cub.2006.08.093 pmid:17055983 pmcid:PMC2238800 fatcat:hxyvw3mc2zdcxlnk6jtvx55kga

Extract of a Letter from Paul Panton Esq; Of Plaswgyn in Anglesey, to the Honourable Daines Barrington, V. P. concerning the Increase of Population in Anglesey

Paul Panton
1773 Philosophical Transactions  
le fervants Paul Panton.  ...  . 3, I7z2* DEAR SIR, Read Feb. :5sT Wifhed to halre feIlt you a iller ac-I773-t COU£1t of the Rate of population ia this inand; brat fO little care has leetl taken to preferve the pariflR-regi{ters tllat  ... 

Page 117 of National Union Catalog Vol. 8, Issue [page]

1958 National Union Catalog  
Title: PG5038 .C3J3 (Vyd. 1., Praha, Ceskosloven- i Dflo brat¥i Oapko) lidech. 61-47927 t Capek, Karel, 1890-1938.  ...  The authorized translation from the Czech by Paul Selver. Freely adapted for the English stage by Nigel Playfair and Clifford Bax. London, New York, Oxford University Press ,1960, vi, 71 p.  ... 

Brain Tumor Regulates Neuromuscular Synapse Growth and Endocytosis in Drosophila by Suppressing Mad Expression

W. Shi, Y. Chen, G. Gan, D. Wang, J. Ren, Q. Wang, Z. Xu, W. Xie, Y. Q. Zhang
2013 Journal of Neuroscience  
Furthermore, biochemical analyses showed upregulated levels of Mad protein but normal mRNA levels in the larval brains of brat mutants, suggesting that Brat suppresses Mad translation.  ...  In agreement with the morphological and physiological phenotypes, loss of Brat resulted in reduced FM1-43 uptake at the NMJ terminals, indicating that brat regulates synaptic endocytosis.  ...  O'Connor (University of Minnesota, Saint Paul, MN) and muscle-specific Mhc-Gal4 from C. Goodman (Howard Hughes Medical Institute, Chevy Chase, MD). The mutant brat 11 strain was from D.  ... 
doi:10.1523/jneurosci.0386-13.2013 pmid:23884941 pmcid:PMC6618673 fatcat:wtva5biwrbcmne7kll3puowksm

Page 21 of Quiver Vol. 57, Issue [page]

1922 Quiver  
o> a A «ele A fi"; — arog Ys paul | Brat, WUT aN “Mint, oy = ~ il ‘ Listening-in Everybody just now is talking about the wonders of Wireless.  ... 

Page 789 of The Insurance Law Journal Vol. 6, Issue 10 [page]

1877 The Insurance Law Journal  
Brats, & Aus & Atus, att’ys for Appellants. Berry, J. 1.  ...  Paul F.and M. Ins. Co. vs. Allis et al. SUPREME COURT OF MINNESOTA." © a Appeal from the Court of Common Pleas, County of Ramsey. ST. PAUL FIRE AND MARINE INS. Co., Respondent, vs.  ... 

Page 225 of Mid-Continent Magazine Vol. 1, Issue 3 [page]

1892 Mid-Continent Magazine  
, had dem nded something ex- tra, or plain Paul would have been ashock to his re spec’ iul self-importance.  ...  had taken the apostles straight through in naming her broo., but the sounding prefix had remained in his case, prob- ably for no other reason than ‘hat his individuality inner I had heard, is a black brat  ... 
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