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Biomedical subjects

Steve Davis

Publications and source records attributed to Steve Davis.

At least 19 recordsLinked to original sources

Prioritizing regions of candidate genes for efficient mutation screening.

The availability of the complete sequence of the human genome has dramatically facilitated the search for disease-causing sequence variations. In fact, the rate-limiting step has shifted from the discovery and characterization of candidate genes to the actual screening of human populations and the subsequent interpretation of observed variations. In this study we tested the hypothesis that some segments of candidate genes are more likely than others to contain disease-causing variations and that these segments can be predicted bioinformatically. A bioinformatic technique, prioritization of annotated regions (PAR), was developed to predict the likelihood that a specific coding region of a gene will harbor a disease-causing mutation based on conserved protein functional domains and protein secondary structures. This method was evaluated by using it to analyze 710 genes that collectively harbor 4,498 previously identified mutations. Nearly 50% of the genes were recognized as disease-associated after screening only 9% of the complete coding sequence. The PAR technique identified 90% of the genes as containing at least one mutation, with less than 40% of the screening resources that traditional approaches would require. These results suggest that prioritization strategies such as PAR can accelerate disease-gene identification through more efficient use of screening resources.

Computational Biology↗

Neonates with hypoplastic left heart syndrome have ultrasound evidence of abnormal superior mesenteric artery perfusion before and after modified Norwood procedure.

OBJECTIVE: To a) describe superior mesenteric artery resistive index, as an estimate of perfusion, before and after modified Norwood; and b) assess incidence of diastolic flow reversal in the superior mesenteric artery before and after modified Norwood. DESIGN: Prospective observational trial. SETTING: Children's hospital pediatric intensive care unit. PATIENTS: Ten newborns with hypoplastic left heart syndrome. INTERVENTIONS: Ultrasound documentation of superior mesenteric artery diastolic flow direction and measurement of superior mesenteric artery resistive index 24-48 hrs before and 24-48 hrs after modified Norwood. MEASUREMENTS AND MAIN RESULTS: Seven males and three females were enrolled. There was no change between the superior mesenteric artery resistive index pre- vs. postoperatively-0.99 (95% confidence interval, 0.85, 1.12) vs. 1.07 (95% confidence interval, 1.0, 1.15) (p = .13). Incidence of retrograde diastolic blood flow in the superior mesenteric artery was not different pre- vs. postoperatively (70% vs. 50%, p = .41). No patients developed necrotizing enterocolitis and all survived to hospital discharge. CONCLUSIONS: Ultrasound measurements in neonates with hypoplastic left heart syndrome suggest that superior mesenteric artery perfusion, as measured by resistive index, is impaired. Superior mesenteric artery diastolic flow reversal is common before and immediately after modified Norwood.

Enterocolitis, Necrotizing↗

Do weekends or evenings matter in a pediatric intensive care unit?

OBJECTIVE: To assess what independent influence, if any, weekend or evening admission to a pediatric intensive care unit (PICU) staffed 24 hrs/day, 7 days/wk by in-house, board-certified pediatric intensivists might have on mortality. DESIGN AND PATIENTS: A retrospective study of 5,968 consecutive admissions to the PICU from August 1996 to December 2003 for patients aged 0 days to 21 yrs. SETTING: A single, 14-bed, multidisciplinary PICU at an academic medical center. MEASUREMENTS: Standardized mortality ratios of observed-to-predicted mortality were derived with their corresponding p values. Multivariate logistic regression was used to test the independent effect of weekend admission, weekend discharge/death, and evening PICU admission on mortality for the entire sample and, separately, for only emergency admissions, controlling for other significant predictor variables or interaction terms. RESULTS: Overall, crude mortality was significantly higher on the weekend (weekday, 2.2%; weekend, 5.0% [p = .0000]) and in the evening (day, 2.1%; evening, 3.8% [p = .0004]). Assessing the entire sample using multivariate logistic regression, neither weekend admission (p = .146), weekend discharge/death (p = .348), nor evening PICU admission (p = .711) showed a significant relationship with mortality controlling for other significant factors. Limiting the scope to the emergency admissions subset, neither weekend admission (p = .135), weekend discharge/death (p = .278), nor evening PICU admission (p = .867) were significant predictors of mortality. Weekend and evening admissions differed in important ways from weekday and daytime admissions, making simple comparisons of crude mortality rates inappropriate. Weekend and evening admissions were more likely to be emergency, nonoperative patients; have a lower Pediatric Risk of Mortality III score but have a higher overall predicted mortality risk; and differ in the distributions of patients by primary diagnosis. CONCLUSIONS: Using multivariate logistic regression to control for important clinical differences, neither weekend admission, weekend discharge/death, nor evening admission had a significant independent effect on mortality risk in the entire sample or for the emergency patient subset. Our findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists.

Adolescent↗

Factors associated with early extubation after cardiac surgery in young children.

OBJECTIVE: Children undergoing congenital heart surgery require mechanical ventilation. We sought to identify pre- and intraoperative factors (PrO, IO) associated with successful early extubation <24 hrs. DESIGN AND PATIENTS: We performed a retrospective chart review of children <36 months old who underwent congenital heart surgery from January 1998 to July 1999. SETTING: Pediatric intensive care unit in a children's hospital. MEASUREMENTS: Generalized Estimating Equation models were fit to assess the association between PrO and IO and early extubation while accounting for the correlation between surgeries performed on the same patient. Estimated odds ratios (EOR) and 95% confidence intervals were calculated. Multivariable models were constructed using a forward selection process with inclusion criteria of p<.05. Multivariable models, which included PrO and IO variables, were adjusted for procedure group. The area under the receiver operating characteristic curve was computed for each model. RESULTS: A total of 203 children underwent 219 surgeries; 103 (47%) children were extubated in <24 hrs, with only one (1%) failed extubation. PrO variables associated with successful early extubation included age >6 months (EOR, 6.1), absence of pulmonary hypertension (EOR, 9.1), gestational age >36 wks (EOR, 4.6), and absence of congestive heart failure (EOR, 2.4). IO variables were less likely to be associated with successful early extubation. Our model of PrO variables with multiple factors showed that presence of two factors was associated with an EOR of 4.2 for successful early extubation compared with children with zero or one factor. Presence of three and four factors was associated with an EOR of 18.0 and 76.5, respectively. The area under the receiver operating characteristic curve for this model is 0.816. Incision type, complex vs. simple procedure, and palliative vs. complete repair were not associated with success of early extubation. CONCLUSIONS: Early extubation is possible in many very young children undergoing congenital heart surgery, with a low rate of failed extubation. The model would be improved by prospective validation with larger numbers at multiple institutions.

Female↗

Applying theory to the design of cultural competency training for medical students: a case study.

Although literature suggests that providing culturally sensitive care promotes positive health outcomes for patients, undergraduate medical education currently does not provide adequate cultural competency training. At most schools, cultural competency, as a formal, integrated, and longitudinal thread within the overall curriculum, is still in its infancy. In this article, the authors summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine. Evaluation of the results indicate that the course was successful in improving knowledge, attitudes, and skills related to cultural competence as well as bringing about positive changes in the medical school's approach to cultural competency training. Also discussed are the implications of the outcomes for the development of culturally competent physicians and how using appropriate theory can help achieve desired outcomes.

Clinical Competence↗

Serum creatinine and estimated creatinine clearance do not predict perioperatively measured creatinine clearance in neonates undergoing congenital heart surgery.

OBJECTIVE: To describe changes in creatinine clearance (CrCl) in a small group of neonates who underwent surgery for repair of transposition of the great arteries or palliation of hypoplastic left heart syndrome. To determine whether serum creatinine, urine output, or the Schwartz formula accurately predict measured CrCl in these patients. DESIGN: Prospective, randomized controlled trial with subsequent extraction of information regarding renal function from the database. SETTING: A 14-bed pediatric intensive care unit in a children's hospital. PATIENTS: A total of 14 neonates (hypoplastic left heart syndrome, 6; transposition of the great arteries, 8). MEASUREMENTS: Demographic information, urine output, serum creatinine, and 24-hr CrCl preoperatively and postoperatively on days 1 and 2. MAIN RESULTS: Weight, age, and body surface area were 3.3 +/- 0.6 kg, 8.2 +/- 6.9 days, and 0.2 +/- 0.02 m2, respectively. Urine output increased from 1.8 +/- 0.5 mL x kg(-1) x hr(-1) preoperatively to 2.4 +/- 0.8 mL x kg(-1) x hr(-1) on postoperative day 1 (p = .02) and 2.8 +/- 1.1 mL x kg(-1) x hr(-1) on postoperative day 2 (p = .007). Serum creatinine changed from 0.64 +/- 0.15 mg/dL preoperatively to 0.72 +/- 0.40 mg/dL on postoperative day 1 (p = .4, not significant) to 0.78 +/- 0.41 mg/dL on postoperative day 2 (p = .17, not significant). Measured CrCl changed from 22.8 +/- 9.4 mL x min(-1) x 1.73 m(-2) preoperatively to 25.1 +/- 31 mL x min(-1) x 1.73 m(-2) on postoperative day 1 (p = .77, not significant) and 24.9 +/- 19.9 on postoperative day 2 (p = .69, not significant). No difference in measured CrCl was noted based on hypoplastic left heart syndrome vs. transposition of the great arteries. Median overestimation of CrCl by the Schwartz equation was 58% preoperatively, 78% on postoperative day 1, and 53% on postoperative day 2. Clinically significant correlations were not noted between measured CrCl and serum creatinine or urine production preoperatively, on postoperative day 1, or on postoperative day 2. Bland-Altman plot demonstrated that the Schwartz equation was a biased and imprecise estimate of CrCl at all three time points. CONCLUSIONS: Perioperative CrCl is unpredictable in neonates with transposition of the great arteries and hypoplastic left heart syndrome. Serum creatinine, urine output, and the Schwartz formula do not accurately predict CrCl. Reliance on estimates of CrCl could result in toxic concentrations of drugs eliminated by the kidneys.

Cardiopulmonary Bypass↗