Akron General Medical Center

Akron, OH, United States

Akron General Medical Center

Akron, OH, United States
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Watkins R.R.,Akron General Medical Center | Watkins R.R.,Northeast Ohio Medical University | Lemonovich T.L.,University Hospitals Case Medical Center
Current Opinion in Infectious Diseases | Year: 2012

PURPOSE OF REVIEW: Infections in lung transplant recipients (LTRs) are a serious complication that is associated with high mortality. Early and accurate diagnosis is critical in the management of these infections in order to achieve improved outcomes. This review focuses on studies published in the last 2 years related to the evaluation and management of infections following lung transplantation. RECENT FINDINGS: Valganciclovir is well tolerated and effective for long-term cytomegalovirus prophylaxis. Recently published guidelines recommend that foscarnet be added to ganciclovir for patients with life-threatening or sight-threatening disease while waiting for genotypic assay results because of ganciclovir-resistant strains. Mycobacterium abscessus has emerged as a significant pathogen in LTRs and should be eradicated in potential recipients before transplantation is performed. Preoperative Aspergillus colonization appears to not increase the risk of death after transplant. Azithromycin is protective against the development of bronchiolitis obliterans syndrome (BOS) and reduces mortality in LTRs. Eradication of Staphylococcus aureus in patients colonized prior to surgery can decrease postoperative surgical site infections from it by 80%. RNA interference therapy improves the symptoms of BOS in LTRs but does not have a direct antiviral effect. SUMMARY: Although life-saving for most recipients, lung transplantation can be complicated by serious postoperative infections. Additional prospective studies are needed to better elucidate the role of molecular testing in the diagnosis of infections, to determine whether eradication of S. aureus colonization improves outcomes in LTRs, and to further evaluate the role of RNA interference therapy for infections in LTRs. © 2012 Lippincott Williams & Wilkins, Inc.

Watkins R.R.,Akron General Medical Center | Lemonovich T.L.,University Hospitals Case Medical Center | File Jr. T.M.,Summa Health System
Core Evidence | Year: 2012

Methicillin-resistant Staphylococcus aureus (MRSA), including community-associated and hospital-associated strains, is a major cause of human morbidity and mortality. Treatment options have become limited due to the emergence of MRSA strains with decreased sensitivity to vancomycin, which has long been the first-line therapy for serious infections. This has prompted the search for novel antibiotics that are efficacious against MRSA. Linezolid, an oxazolidinone class of antibiotic, was approved by the Food and Drug Administration in 2000 for treatment of MRSA infections. Since then, there have been a multitude of clinical trials and research studies evaluating the effectiveness of linezolid against serious infections, including pneumonia (both community- and hospital-acquired), skin and soft-tissue infections such as diabetic foot ulcers, endocarditis, osteomyelitis, prosthetic devices, and others. The primary aim of this review is to provide an up-to-date evaluation of the clinical evidence for using linezolid to treat MRSA infections, with a focus on recently published studies, including those on nosocomial pneumonia. Other objectives are to analyze the cost-effectiveness of linezolid compared to other agents, and to review the pharmokinetics and pharmacodynamics of linezolid, emphasizing the most current concepts. © 2012 Watkins et al, publisher and licensee Dove Medical Press Ltd.

Varma N.,Cleveland Clinic | Michalski J.,Biotronik Inc | Epstein A.E.,University of Pennsylvania | Schweikert R.,Akron General Medical Center
Circulation: Arrhythmia and Electrophysiology | Year: 2010

Background-Monitoring performance of implantable cardioverter-defibrillator (ICD) generators and leads is important. Methods available are with in-person evaluations or by automatic remote home monitoring (HM). These were prospectively evaluated and compared in the TRUST trial. The HM technology tested performed daily self-checks and databasing with rapid event notifications for out-of-range (including asymptomatic) conditions. Methods and Results-Patients (n=1339) were randomly assigned after ICD implant 2:1 to HM or to conventional groups. Both groups underwent scheduled checks every 3 months and were followed for 15 months. In HM, in-person office visits were scheduled at 3 and 15 months. At 6, 9, and 12 months, HM only was used with subsequent office visits if necessary. Between these time points, ICDs triggered event notifications for system integrity problems. Patients randomly assigned to conventional follow-up were evaluated with office visits only. HM and conventional patients were similar (age, 63.3±12.8 versus 64.0±12.1 years; 72.0% versus 73.1% male; New York Heart Association II class, 55.9% versus 60.4%; left ventricular ejection fraction, 29.0±10.7% versus 28.5±9.8%; coronary artery disease, 64.8% versus 71.7%; primary prevention, 72.2% versus 73.8%; DDD devices, 57.8% versus 56.6%). Four patients crossed over from conventional to HM because of advisories. Scheduled checks were more successfully accomplished in HM (92.7% versus 89.2% in conventional, P<0.001). Sixty-two device-related events (53 in HM versus 9 in conventional) were observed in 46 patients (40 [4.4%] in HM versus 6 [1.39%] in conventional, P=0.004). Forty-seven percent were asymptomatic. HM detected generator and lead problems earlier (HM versus conventional: median, 1 versus 5 days; P=0.05). A total of 20 device problems (eg, lead fracture, elective replacement indicators) requiring surgical revision (0.012 per patient-year) were found, 15 in HM and 5 in the conventional groups. Other events were managed nonsurgically (eg, reprogramming, initiation of antiarrhythmics). Conclusions-ICD lead and generator malfunction was infrequent and often asymptomatic. Only a minority of detected events required surgical intervention. Automatic HM enhanced discovery, permitted prompt detection, and facilitated management decisions. Longitudinal parameter trending, with component function evaluated daily by remote monitoring, may enable long-term performance assessment. © 2010 American Heart Association, Inc.

Varma N.,Cleveland Clinic | Epstein A.E.,University of Pennsylvania | Irimpen A.,Tulane University Medical Center | Schweikert R.,Akron General Medical Center | Love C.,Ohio State University
Circulation | Year: 2010

Background-: Monitoring implantable cardiac device function and patient condition is important. The Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) trial tested the hypothesis that remote home monitoring with automatic daily surveillance (HM) is safe and effective for implantable cardioverter-defibrillator follow-up for 1 year and enables rapid physician evaluation of significant events. Methods and results-: In total, 1339 patients were randomized 2:1 to HM or conventional follow-up. Follow-up checks occurred at 3, 6, 9, 12, and 15 months after implantation. HM was used before office visits at 3 and 15 months in the HM group. At 6, 9, and 12 months, HM only was used but was followed by office visits if necessary. Conventional patients were evaluated with office visits only. Scheduled office visits and unscheduled evaluations, incidence of morbidity, and time elapsed from first event occurrence in each patient to physician evaluation were tracked for each group. HM and conventional patients were similar (age, 63.3±12.8 versus 64.0±12.1 years; gender, 72.0% versus 73.1% male; New York Heart Association class II, 55.9% versus 60.4%; pathology: left ventricular ejection fraction, 29.0±10.7% versus 28.5±9.8%; coronary artery disease, 64.8% versus 71.7%; primary prevention indication, 72.2% versus 73.8%; and dual-chamber implants, 57.8% versus 56.6%). HM reduced total in-hospital device evaluations by 45% without affecting morbidity. In the HM group, 85.8% of all 6-, 9-, and 12-month follow-ups were performed remotely only, indicating that HM provided sufficient assessment in the majority. Median time to evaluation was <2 days in the HM group compared with 36 days in the conventional group (P<0.001) for all arrhythmic events. Conclusions-: HM is safe and allows more rapid detection of actionable events compared with conventional monitoring in patients with implantable electronic cardiac devices. © 2010 American Heart Association, Inc.

Al-Ali F.,Akron General Medical Center | Elias J.J.,Akron General Medical Center | Tomsick T.A.,University of Cincinnati | Liebeskind D.S.,University of California at Los Angeles | Broderick J.P.,University of Cincinnati
Stroke | Year: 2015

Background and Purpose-Until recently, acute ischemic stroke (AIS) trials have failed to show a benefit of endovascular therapy compared with standard therapy, leading some authors to recommend decreasing the time from ictus to revascularization to improve outcomes. We hypothesize that improving patient selection using the capillary index score (CIS) may also be a useful strategy. Methods-CIS was calculated, blinded to outcome, from pretreatment diagnostic cerebral angiograms for 78 subjects in the Interventional Management of Stroke III database with internal carotid artery and middle cerebral artery trunk occlusion. The CIS was dichotomized into favorable (fCIS=2 or 3) and poor (pCIS=0 or 1). Outcomes were categorized based on the modified Rankin Scale score at 90 days (0-2 considered a good outcome). Modified thrombolysis in cerebral infarction score 2b or 3 was considered good revascularization. Multivariable logistic regression was performed to relate CIS, time from ictus to revascularization, modified thrombolysis in cerebral infarction score, and National Institue of Health Stroke Scale score to good outcomes. Results-Only CIS and modified thrombolysis in cerebral infarction scores were correlated with good outcomes (P<0.01). Patients with fCIS and good revascularization achieved 71% modified Rankin Scale ≤2, compared with 13% for patients with pCIS and good revascularization. Conclusions-In this subset of patients from the Interventional Management of Stroke III Trial, CIS and modified thrombolysis in cerebral infarction were strong predictors of outcome after endovascular reperfusion. Using the CIS to improve patient selection could be a powerful strategy to improve rate of good outcomes in endovascular therapy. A randomized trial is needed. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424. © 2015 American Heart Association, Inc.

Watkins R.R.,Northeast Ohio Medical University | Watkins R.R.,Akron General Medical Center | Eckmann L.,University of California at San Diego
Current Infectious Disease Reports | Year: 2014

Giardiasis is a common yet neglected cause of diarrheal illness worldwide. Antimicrobial therapy is usually but not always effective and drug resistance has become an increasing concern. Several promising drug candidates have been recently identified that can overcome antibiotic resistance in Giardia. These include derivatives of 5-nitroimidazoles and benzimidazoles, as well as hybrid compounds created from combinations of different antigiardial drugs. High-throughput screening of large compound libraries has been a productive strategy for identifying antigiardial activity in drugs already approved for other indications, e.g. auranofin. This article reviews the current treatment of giardiasis, mechanisms of resistance, advances in drug and vaccine development, and directions for further research on this significant human pathogen. © 2014 Springer Science+Business Media New York.

Agito M.D.,Akron General Medical Center | Atreja A.,Mount Sinai School of Medicine | Rizk M.K.,Case Western Reserve University
Cleveland Clinic Journal of Medicine | Year: 2013

Recurrent Clostridium difficile infection has been a major challenge for patients and clinicians. Recurrence of infection after treatment with standard antibiotics is becoming more common with the emergence of more-resistant strains of C difficile. Fecal microbiota transplantation is an alternative treatment for recurrent C difficile infection, but it is not yet widely used.

Partin J.F.,Akron General Medical Center | Partin J.F.,Northeastern Ohio Universities | Mamounas E.P.,Aultman Health Foundation | Mamounas E.P.,Northeastern Ohio Universities
Annals of Surgical Oncology | Year: 2011

Background: The development of multigene assays has proved useful in the clinical management of early-stage breast cancer. The 21-gene recurrence score (RS) assay has been shown to quantify risk of distant recurrence and predict chemotherapy benefit in node-negative and node-positive, estrogen-receptor (ER)-positive breast cancer patients. Small, single-institution series have shown that, compared with standard clinicopathologic criteria, use of RS significantly affects adjuvant chemotherapy recommendations. Methods: We performed a retrospective review of RS use and its effect on chemotherapy recommendations in nodenegative, ER-positive breast cancer patients at a tertiary care teaching hospital. Patient and tumor characteristics and adjuvant treatment information were obtained on 183 patients with RS results between January 2004 and October 2009. Risk categories were assigned based on the RS and on standard clinicopathologic criteria according to guidelines from NCCN, St. Gallen, and Adjuvant!. Results: A total of 14 patients were excluded for negative ER status (n = 2), insufficient data (n = 4), inclusion in TAILORx trial (n = 7), and recurrent breast cancer (n = 1), leaving 169 patients in the cohort. RS use increased 3-fold over the study period (from 18% in 2004 to 50% in 2009). Tumor grade, ER status, and PR status were significantly correlated with RS category. Overall concordance between RS and NCCN, St. Gallen, and Adjuvant! was 10, 48, and 50%, respectively. Depending on the guideline used for comparison, adjuvant therapy recommendations changed with the addition of the RS in 27-74% of cases. Conclusions: RS use is increasing, and the assay significantly reduced adjuvant chemotherapy utilization in nodenegative, ER-positive breast cancer patients. © Society of Surgical Oncology 2011.

Deep tissue injury (DTI) can rapidly evolve into a higher stage pressure ulcer. Use of pressure-redistribution surfaces is a widely accepted practice for the prevention of pressure ulcers in acute care patients, particularly in departments where care processes limit mobility. A 15-year-old patient developed a sacral DTI 24 hours after completion of a lengthy (12- hour) electrophysiology (EP) study and catheter ablation. A root cause analysis (RCA) conducted to investigate the origin of the hospital-acquired suspected DTI prompted a small investigation to evaluate the pressure-distribution properties of the EP lab surface and an OR table pad. Five healthy adult employee volunteers were evaluated in the supine position by placing a sensing mat between the volunteer and the test surface. Interface pressures (on a scale of 0 mm Hg to 100 mm Hg) were captured after a "settling in" time of 4 minutes, and the number of sensors registering very high pressures (above 90 mm Hg) across the surface were recorded. On the OR table pad, zero to six sensors registered >90 mm Hg compared to two to 20 sensors on the EP lab surface. These data, combined with the acquired DTI, initiated a change in EP lab surfaces. Although interface pressure measurements only provide information about one potential support surface characteristic, it can be helpful during an RCA. Studies to compare the effect of support surfaces in all hospital units on patient outcomes are needed.

Watkins R.R.,Akron General Medical Center
American family physician | Year: 2011

Community-acquired pneumonia is diagnosed by clinical features (e.g., cough, fever, pleuritic chest pain) and by lung imaging, usually an infiltrate seen on chest radiography. Initial evaluation should determine the need for hospitalization versus outpatient management using validated mortality or severity prediction scores. Selected diagnostic laboratory testing, such as sputum and blood cultures, is indicated for inpatients with severe illness but is rarely useful for outpatients. Initial outpatient therapy should include a macrolide or doxycycline. For outpatients with comorbidities or who have used antibiotics within the previous three months, a respiratory fluoroquinolone (levofloxacin, gemifloxacin, or moxifloxacin), or an oral beta-lactam antibiotic plus a macrolide should be used. Inpatients not admitted to an intensive care unit should receive a respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide. Patients with severe community-acquired pneumonia or who are admitted to the intensive care unit should be treated with a beta-lactam antibiotic, plus azithromycin or a respiratory fluoroquinolone. Those with risk factors for Pseudomonas should be treated with a beta-lactam antibiotic (piperacillin/tazobactam, imipenem/cilastatin, meropenem, doripenem, or cefepime), plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (levofloxacin or ciprofloxacin). Those with risk factors for methicillin-resistant Staphylococcus aureus should be given vancomycin or linezolid. Hospitalized patients may be switched from intravenous to oral antibiotics after they have clinical improvement and are able to tolerate oral medications, typically in the first three days. Adherence to the Infectious Diseases Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia has been shown to improve patient outcomes. Physicians should promote pneumococcal and influenza vaccination as a means to prevent community-acquired pneumonia and pneumococcal bacteremia.

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