Background Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital m... more Background Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care suggest the use of SOFA scores to allocate medical resources during the COVID-19 pandemic. Research question Are SOFA scores elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients? Study design and methods Retrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged �18 admitted with COVID-19 from March 29 th to August 1 st , 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcome was SOFA score, with peak score within 24 hours of admission dichotomized as <6 or �6.
Journal of Investigative Dermatology Symposium Proceedings, Oct 1, 2017
The Surveillance, Epidemiology, and End Results (SEER 18) database is the largest national regist... more The Surveillance, Epidemiology, and End Results (SEER 18) database is the largest national registry for cancer-related patient data in the United States. Despite these advances, Black populations consistently have shown poorer survival statistics, possibly due to later stages of presentation, increased tumor aggressiveness, treatment noncompliance, among other debated causes. Our goal in this study is to look at a socioeconomic marker that may link all of these causes, namely median income level, and derive the extent of influence a patient's financial resources can have on overall survival. Study Design: Retrospective cohort study. Setting: Surveillance, Epidemiology, and End Results (SEER 18) Database, April 2015 Update. Methods: Original cases from the aforementioned database were identified, with unknown racial status cases excluded from the final dataset. Survival Data by geographical county was collected from the SEER database and correlated to US Census Bureau median income data to uncover meaningful statistical relationships. Results: Whites were found to overall fare better than Blacks for all time intervals (Year 1 to Year 5) following diagnosis, based on mean survival data (p<0.05). Blacks were noted to have higher survival rates for the same time intervals (Year 1 to Year 5) when survival statistics adjusted for income (p<0.05). Conclusion: Significance correlations were seen between income and overall survival. When race was accounted for, blacks were noted to have a higher survival rate than whites. These findings accentuate a major socioeconomic issue to address within the policy-making framework and endorse earlier intervention for underprivileged populations.
Scholarly consensus is lacking for the risk stratification of patients who present with acute or ... more Scholarly consensus is lacking for the risk stratification of patients who present with acute or subacute dermatologic conditions of the lower extremity, particularly cellulitis and its mimickers. This lack of consensus leads to overconsumption of hospital resources and may result in delayed recognition and treatment, adversely affecting patient outcomes. In this retrospective chart review, our aim was to test a set of clinical criteria-acute onset, erythema, pyrexia, history of associated trauma, tenderness, unilaterality (presence on 1 limb only), and leukocytosis-in patients with a known diagnosis of cellulitis or noncellulitis, as determined by dermatology consultation. We hope that these criteria can help clinicians better quantify risk based on history, physical examination, and risk factors, and thus help differentiate emergent and nonemergent dermatologic conditions of the lower extremity.
Obstetrics and Gynecology Clinics of North America, Jun 1, 1997
This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent rese... more This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent research. Because of the nature of the existing literature, specifically case reports and retrospective analyses, this article is primarily descriptive in nature. Extrapelvic endometriosis is discussed based on some main areas of occurrence, including gastrointestinal, urinary, and thoracic; other areas are also reviewed. What is known about the epidemiology, pathogenesis, diagnosis, and treatment of extrapelvic endometriosis is highlighted. Areas for future direction of research in the field are also identified.
Using quantitative RT-PCR, the mean fold increase in expression of CGB in endometrial samples of ... more Using quantitative RT-PCR, the mean fold increase in expression of CGB in endometrial samples of non-visualized IUP (n¼5) compared to non-pregnant endometrium, was 20.2 (AE2.0), which was significantly greater (n¼5; p<0.01 by t-test) than the 8.0 (AE2.8) fold-increase observed in EP. CONCLUSIONS: The early trophoblast biomarker CGB is detectable in uterine aspirates of non-visualized presumed IUP at a large threshold difference compared to endometrium from EP. This is consistent with localized CGB expression by the invasive syncytiotrophoblast. This preliminary data suggests that molecular targets to specific early placental markers could be utilized for diagnosis of pregnancy location after direct endometrial sampling.
repeated practice outside of the clinical setting. Improvements to the model have already been ma... more repeated practice outside of the clinical setting. Improvements to the model have already been made, including the addition of a carotid artery to increase anatomic fidelity.
Biosecurity and Bioterrorism-biodefense Strategy Practice and Science, Jun 1, 2009
In this issue of Biosecurity and Bioterrorism, Matzo and colleagues introduce the roles of pallia... more In this issue of Biosecurity and Bioterrorism, Matzo and colleagues introduce the roles of palliative care in the response to catastrophic mass casualty events. This work is part of a larger effort supported by the Agency for Healthcare Research and Quality (AHRQ) to define and plan for the ‘‘altered standards of care’’ considered inevitable during a mass casualty event. Here we offer some additional perspective on a number of issues raised in their article. The authors and the AHRQ conferees are to be congratulated for their thoughtful deliberations and for disseminating their recommendations through the peerreviewed literature. We hope that publication of their work will both catalyze scholarly discourse on the subject and broaden the base of stakeholder input. Matzo and colleagues conclude that planning for the medical response to a mass casualty event should include provisions for palliative care surge capacity. The authors offer some creative ways to address this requirement, including developing Disaster Palliative Assistance Teams under the aegis of the Medical Reserve Corps or the National Disaster Medical System. Such teams could be specially trained and equipped to provide some level of palliative care under the demanding operational constraints of a mass casualty event response. These are valuable suggestions to planners at all jurisdictional tiers of response. Their assertion, however, that palliative care may ‘‘free up resources to optimize survival of others’’ is unproven and counterintuitive. The addition of a large number of patients rendered terminally ill or injured in a mass casualty event to the population of patients already receiving palliative care will certainly generate the need for palliative care surge capacity. Patients from a mass casualty event who will require some elements of palliative care include those who have been assigned to several different triage categories: (1) ‘‘expectant’’ patients, who are considered so unlikely to benefit from life-saving interventions that those interventions are not offered; (2) ‘‘immediate’’ patients, who could potentially survive with aggressive therapy, but limited medical or transportation resources render it temporarily unavailable; and (3) both ‘‘immediate’’ and ‘‘delayed’’ patients, who will eventually receive life-saving, definitive care but require supportive care, symptom control, and other comfort measures while waiting for it. Although the categories listed above are generally used in the field or emergency department triage of trauma victims who need surgical care, they can be readily correlated with patients requiring critical care during a pandemic. Different ethical principles inform management of the patients within these various triage categories. In the first, the availability or scarcity of resources has little bearing on whether attempts at curative therapy should be offered or provided. Palliative care is the only efficacious option for these patients, and the ethical principles relate primarily to proving that other therapeutic interventions would be futile. The second group faces rationing of potentially useful resources, and different ethical principles apply. It is the responsibility of planners and responders to minimize the size of this group through both prospective and real-time solutions to the challenges presented by various types of
Background: Healthcare settings represent a missed opportunity to systematically identify and add... more Background: Healthcare settings represent a missed opportunity to systematically identify and address mistreatment. Objective: Our objective was to obtain perspectives of older adults, caregivers, and emergency care providers regarding screening and intervention for elder mistreatment in the emergency department (ED) with a focus on utilizing digital health tools to facilitate the process. These findings will inform the development of a Web-based, digital health tool optimized for a tablet device to educate, screen, and facilitate reporting of elder mistreatment among patients presenting to the ED. Method: We conducted a qualitative study utilizing three in-person focus groups (N=31) with older adults from the community, caregivers for older adults, and clinicians and social workers who worked in the ED. Using a semi-structured interview guide, we identified attitudes about the process of divulging abuse, attitudes towards the ED as the location for screening and information delivery, and perceptions of digital tools for screening and information. Results: Participants identified numerous challenges to the disclosure of mistreatment, including feelings of vulnerability and concerns about losing their homes, social supports, and connection to caregivers. In contrast, they were uncertain about the benefits of disclosure. Digital tools were seen as helpful in terms of overcoming numerous challenges to screening, but participants suggested maintaining a human element to interactions. Conclusion: While challenges to elder mistreatment screening were identified, participants had recommendations for optimizing such efforts and responded positively to digital health tools as a means of screening.
Case 1 outcome Mrs. S. was clearly in dire straits and needed an interdisciplinary team of provid... more Case 1 outcome Mrs. S. was clearly in dire straits and needed an interdisciplinary team of providers to address her many medical, social, emotional, and spiritual issues. In addition, cultural differences could present unpredictable challenges. She was awake and alert at the time of the ED visit, but given her tenuous medical condition, the ED physician realized that this could change abruptly, so an in-person medical translator, who turned out to be a local college student from the patient's home
Background Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital m... more Background Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care suggest the use of SOFA scores to allocate medical resources during the COVID-19 pandemic. Research question Are SOFA scores elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients? Study design and methods Retrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged �18 admitted with COVID-19 from March 29 th to August 1 st , 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcome was SOFA score, with peak score within 24 hours of admission dichotomized as <6 or �6.
Journal of Investigative Dermatology Symposium Proceedings, Oct 1, 2017
The Surveillance, Epidemiology, and End Results (SEER 18) database is the largest national regist... more The Surveillance, Epidemiology, and End Results (SEER 18) database is the largest national registry for cancer-related patient data in the United States. Despite these advances, Black populations consistently have shown poorer survival statistics, possibly due to later stages of presentation, increased tumor aggressiveness, treatment noncompliance, among other debated causes. Our goal in this study is to look at a socioeconomic marker that may link all of these causes, namely median income level, and derive the extent of influence a patient's financial resources can have on overall survival. Study Design: Retrospective cohort study. Setting: Surveillance, Epidemiology, and End Results (SEER 18) Database, April 2015 Update. Methods: Original cases from the aforementioned database were identified, with unknown racial status cases excluded from the final dataset. Survival Data by geographical county was collected from the SEER database and correlated to US Census Bureau median income data to uncover meaningful statistical relationships. Results: Whites were found to overall fare better than Blacks for all time intervals (Year 1 to Year 5) following diagnosis, based on mean survival data (p<0.05). Blacks were noted to have higher survival rates for the same time intervals (Year 1 to Year 5) when survival statistics adjusted for income (p<0.05). Conclusion: Significance correlations were seen between income and overall survival. When race was accounted for, blacks were noted to have a higher survival rate than whites. These findings accentuate a major socioeconomic issue to address within the policy-making framework and endorse earlier intervention for underprivileged populations.
Scholarly consensus is lacking for the risk stratification of patients who present with acute or ... more Scholarly consensus is lacking for the risk stratification of patients who present with acute or subacute dermatologic conditions of the lower extremity, particularly cellulitis and its mimickers. This lack of consensus leads to overconsumption of hospital resources and may result in delayed recognition and treatment, adversely affecting patient outcomes. In this retrospective chart review, our aim was to test a set of clinical criteria-acute onset, erythema, pyrexia, history of associated trauma, tenderness, unilaterality (presence on 1 limb only), and leukocytosis-in patients with a known diagnosis of cellulitis or noncellulitis, as determined by dermatology consultation. We hope that these criteria can help clinicians better quantify risk based on history, physical examination, and risk factors, and thus help differentiate emergent and nonemergent dermatologic conditions of the lower extremity.
Obstetrics and Gynecology Clinics of North America, Jun 1, 1997
This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent rese... more This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent research. Because of the nature of the existing literature, specifically case reports and retrospective analyses, this article is primarily descriptive in nature. Extrapelvic endometriosis is discussed based on some main areas of occurrence, including gastrointestinal, urinary, and thoracic; other areas are also reviewed. What is known about the epidemiology, pathogenesis, diagnosis, and treatment of extrapelvic endometriosis is highlighted. Areas for future direction of research in the field are also identified.
Using quantitative RT-PCR, the mean fold increase in expression of CGB in endometrial samples of ... more Using quantitative RT-PCR, the mean fold increase in expression of CGB in endometrial samples of non-visualized IUP (n¼5) compared to non-pregnant endometrium, was 20.2 (AE2.0), which was significantly greater (n¼5; p<0.01 by t-test) than the 8.0 (AE2.8) fold-increase observed in EP. CONCLUSIONS: The early trophoblast biomarker CGB is detectable in uterine aspirates of non-visualized presumed IUP at a large threshold difference compared to endometrium from EP. This is consistent with localized CGB expression by the invasive syncytiotrophoblast. This preliminary data suggests that molecular targets to specific early placental markers could be utilized for diagnosis of pregnancy location after direct endometrial sampling.
repeated practice outside of the clinical setting. Improvements to the model have already been ma... more repeated practice outside of the clinical setting. Improvements to the model have already been made, including the addition of a carotid artery to increase anatomic fidelity.
Biosecurity and Bioterrorism-biodefense Strategy Practice and Science, Jun 1, 2009
In this issue of Biosecurity and Bioterrorism, Matzo and colleagues introduce the roles of pallia... more In this issue of Biosecurity and Bioterrorism, Matzo and colleagues introduce the roles of palliative care in the response to catastrophic mass casualty events. This work is part of a larger effort supported by the Agency for Healthcare Research and Quality (AHRQ) to define and plan for the ‘‘altered standards of care’’ considered inevitable during a mass casualty event. Here we offer some additional perspective on a number of issues raised in their article. The authors and the AHRQ conferees are to be congratulated for their thoughtful deliberations and for disseminating their recommendations through the peerreviewed literature. We hope that publication of their work will both catalyze scholarly discourse on the subject and broaden the base of stakeholder input. Matzo and colleagues conclude that planning for the medical response to a mass casualty event should include provisions for palliative care surge capacity. The authors offer some creative ways to address this requirement, including developing Disaster Palliative Assistance Teams under the aegis of the Medical Reserve Corps or the National Disaster Medical System. Such teams could be specially trained and equipped to provide some level of palliative care under the demanding operational constraints of a mass casualty event response. These are valuable suggestions to planners at all jurisdictional tiers of response. Their assertion, however, that palliative care may ‘‘free up resources to optimize survival of others’’ is unproven and counterintuitive. The addition of a large number of patients rendered terminally ill or injured in a mass casualty event to the population of patients already receiving palliative care will certainly generate the need for palliative care surge capacity. Patients from a mass casualty event who will require some elements of palliative care include those who have been assigned to several different triage categories: (1) ‘‘expectant’’ patients, who are considered so unlikely to benefit from life-saving interventions that those interventions are not offered; (2) ‘‘immediate’’ patients, who could potentially survive with aggressive therapy, but limited medical or transportation resources render it temporarily unavailable; and (3) both ‘‘immediate’’ and ‘‘delayed’’ patients, who will eventually receive life-saving, definitive care but require supportive care, symptom control, and other comfort measures while waiting for it. Although the categories listed above are generally used in the field or emergency department triage of trauma victims who need surgical care, they can be readily correlated with patients requiring critical care during a pandemic. Different ethical principles inform management of the patients within these various triage categories. In the first, the availability or scarcity of resources has little bearing on whether attempts at curative therapy should be offered or provided. Palliative care is the only efficacious option for these patients, and the ethical principles relate primarily to proving that other therapeutic interventions would be futile. The second group faces rationing of potentially useful resources, and different ethical principles apply. It is the responsibility of planners and responders to minimize the size of this group through both prospective and real-time solutions to the challenges presented by various types of
Background: Healthcare settings represent a missed opportunity to systematically identify and add... more Background: Healthcare settings represent a missed opportunity to systematically identify and address mistreatment. Objective: Our objective was to obtain perspectives of older adults, caregivers, and emergency care providers regarding screening and intervention for elder mistreatment in the emergency department (ED) with a focus on utilizing digital health tools to facilitate the process. These findings will inform the development of a Web-based, digital health tool optimized for a tablet device to educate, screen, and facilitate reporting of elder mistreatment among patients presenting to the ED. Method: We conducted a qualitative study utilizing three in-person focus groups (N=31) with older adults from the community, caregivers for older adults, and clinicians and social workers who worked in the ED. Using a semi-structured interview guide, we identified attitudes about the process of divulging abuse, attitudes towards the ED as the location for screening and information delivery, and perceptions of digital tools for screening and information. Results: Participants identified numerous challenges to the disclosure of mistreatment, including feelings of vulnerability and concerns about losing their homes, social supports, and connection to caregivers. In contrast, they were uncertain about the benefits of disclosure. Digital tools were seen as helpful in terms of overcoming numerous challenges to screening, but participants suggested maintaining a human element to interactions. Conclusion: While challenges to elder mistreatment screening were identified, participants had recommendations for optimizing such efforts and responded positively to digital health tools as a means of screening.
Case 1 outcome Mrs. S. was clearly in dire straits and needed an interdisciplinary team of provid... more Case 1 outcome Mrs. S. was clearly in dire straits and needed an interdisciplinary team of providers to address her many medical, social, emotional, and spiritual issues. In addition, cultural differences could present unpredictable challenges. She was awake and alert at the time of the ED visit, but given her tenuous medical condition, the ED physician realized that this could change abruptly, so an in-person medical translator, who turned out to be a local college student from the patient's home
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Papers by Karen Jubanyik