Meridian Hills, IN, United States
Meridian Hills, IN, United States
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Bennett-Guerrero E.,Duke University | Zhu H.,Allergy | Herman A.E.,Duke University | Bandarenko N.,Duke University | McMahon T.J.,Allergy
Transfusion | Year: 2014

Background Pretransfusion washing of red blood cells (RBCs) stored for a longer duration may have theoretical advantages but few data exist to support this practice. In many hospital settings, use of a point-of-care cell washer could conceivably be used to quickly wash allogeneic RBCs before transfusion. The purpose of this preliminary study was to compare a point-of-care device with a common blood bank device for washing longer-stored RBCs.Study Design and Methods Forty RBC units stored for 40 to 42 days were randomized to washing with the COBE 2991 device (Terumo BCT; FDA-cleared for washing stored RBCs) or the Cell Saver Elite (Haemonetics; FDA-cleared point-of-care device for processing and washing fresh autologous shed whole blood). Supernatant and unit RBCs from unwashed (baseline) and washed blood were assayed for potassium, lactate, intracellular ATP, percentage of RBC recovery, cell-free hemoglobin, RBC microparticles, and RBCs were examined for susceptibility to hemolysis by physical stress.Results Both devices recovered a high percentage of RBCs and efficiently removed extracelluar potassium. Washing with the Elite resulted in significant increases in cell-free Hb, percent hemolysis, and RBC microparticle production, whereas washing with the COBE 2991 did not (fold Δ = 2.1 vs. 1.0, 4.6 vs. 1.2, 2.0 vs. 1.1, respectively; p < 0.05). Hemolysis induced by physical stress was not altered by washing.Conclusion Although point-of-care washing of longer-stored RBCs is appealing, these preliminary data suggest that transfusion of washed, longer-stored units could result in potentially greater exposure to plasma free Hb. More data are needed before this practice can be routinely recommended. © 2014 AABB.

Kraft B.D.,Allergy and Critical Care Medicine | Colman E.C.,Allergy and Critical Care Medicine | Mahmood K.,Allergy and Critical Care Medicine | Hartwig M.G.,Duke University | And 2 more authors.
American journal of respiratory and critical care medicine | Year: 2016

RATIONALE: Central airway stenosis (CAS) after lung transplantation has been attributed in part to chronic airway ischemia; however, little is known about the time course or significance of large airway hypoxia early after transplantation.OBJECTIVES: To evaluate large airway oxygenation and hypoxic gene expression during the first month after lung transplantation and their relation to airway complications.METHODS: Subjects who underwent lung transplantation underwent endobronchial tissue oximetry of native and donor bronchi at 0, 3, and 30 days after transplantation (n = 11) and/or endobronchial biopsies (n = 14) at 30 days for real-time polymerase chain reaction of hypoxia-inducible genes. Patients were monitored for 6 months for the development of transplant-related complications.MEASUREMENTS AND MAIN RESULTS: Compared with native endobronchial tissues, donor tissue oxygen saturations (Sto2) were reduced in the upper lobes (74.1 ± 1.8% vs. 68.8 ± 1.7%; P < 0.05) and lower lobes (75.6 ± 1.6% vs. 71.5 ± 1.8%; P = 0.065) at 30 days post-transplantation. Donor upper lobe and subcarina Sto2 levels were also lower than the main carina (difference of -3.9 ± 1.5 and -4.8 ± 2.1, respectively; P < 0.05) at 30 days. Up-regulation of hypoxia-inducible genes VEGFA, FLT1, VEGFC, HMOX1, and TIE2 was significant in donor airways relative to native airways (all P < 0.05). VEGFA, KDR, and HMOX1 were associated with prolonged respiratory failure, prolonged hospitalization, extensive airway necrosis, and CAS (P < 0.05).CONCLUSIONS: These findings implicate donor bronchial hypoxia as a driving factor for post-transplantation airway complications. Strategies to improve airway oxygenation, such as bronchial artery re-anastomosis and hyperbaric oxygen therapy merit clinical investigation.

Holland A.E.,Physiotherapy | Holland A.E.,La Trobe University | Holland A.E.,Institute for Breathing and Sleep | Hill C.J.,Institute for Breathing and Sleep | And 4 more authors.
Respiratory Medicine | Year: 2012

Background: Pulmonary rehabilitation improves functional capacity and symptoms in the interstitial lung diseases (ILDs), however there is marked variation in outcomes between individuals. The aim of this study was to establish the impact of the aetiology and severity of ILD on response to pulmonary rehabilitation. Methods: Forty-four subjects with ILD, including 25 with idiopathic pulmonary fibrosis (IPF), underwent eight weeks of pulmonary rehabilitation. Relationships between disease aetiology, markers of disease severity and response to pulmonary rehabilitation were assessed after eight weeks and six months, regardless of program completion. Results: In IPF, greater improvements in 6-minute walk distance (6MWD) immediately following pulmonary rehabilitation were associated with larger forced vital capacity (r = 0.49, p = 0.01), less exercise-induced oxyhaemoglobin desaturation (r S = 0.43, p = 0.04) and lower right ventricular systolic pressure (r = -0.47, p = 0.1). In participants with other ILDs there was no relationship between change in 6MWD and baseline variables. Less exercise-induced oxyhaemoglobin desaturation at baseline independently predicted a larger improvement in 6MWD at six month follow-up. Fewer participants with IPF had clinically important reductions in dyspnoea at six months compared to those with other ILDs (25% vs 56%, p = 0.04). More severe dyspnoea at baseline and diagnosis other than IPF predicted greater improvement in dyspnoea at six months. Conclusions: Patients with IPF attain greater and more sustained benefits from pulmonary rehabilitation when disease is mild, whereas those with other ILDs achieve benefits regardless of disease severity. Early referral to pulmonary rehabilitation should be considered in IPF. © 2011 Elsevier Ltd. All rights reserved.

Irwin R.S.,Allergy | Irwin R.S.,ass Memorial Medical Center
Otolaryngologic Clinics of North America | Year: 2010

Unexplained cough is a diagnosis of exclusion that should not be made until a thorough validated diagnostic evaluation is performed, specific and appropriate validated treatments have been tried and failed, and uncommon causes have been ruled out. When chronic cough remains troublesome after the initial work up, determine that a protocol has been used that has been shown to lead to successful results. If such a protocol has been used, next consider whether or not pitfalls in management have been avoided. If they have been, the frequency of truly unexplained chronic cough usually should not exceed 10%. While patients with truly unexplained coughs have an overly sensitive cough reflex, the mere presence of an overly sensitive cough reflex does not by itself explain why they do not get better, because most patients with chronic cough, even those who respond to treatment and get better, have demonstrable heightened cough sensitivity. Management options include referral to a cough clinic with interdisciplinary expertise, speech therapy, and self-limited trials of drugs, preferentially with those shown to be effective in randomized, double-blind placebo-controlled trials in patients with unexplained chronic cough. © 2010 Elsevier Inc. All rights reserved.

Lumry W.,Asthma and Allergy Research Associates | Manning M.E.,Allergy | Hurewitz D.S.,Allergy Clinic of Tulsa | Davis-Lorton M.,Winthrop Rheumatology | And 3 more authors.
Journal of Pediatrics | Year: 2013

Objectives: To evaluate the use of Cinryze (nanofiltered C1-esterase inhibitor [C1 INH-nf]) for the acute management and prevention of hereditary angioedema attacks in the subgroup of children and adolescents who participated in 2 placebo-controlled and 2 open-label extension studies. Study design: In the acute-attack treatment studies, the efficacy of 1000 U of C1 INH-nf (with an additional 1000 U given 1 hour later if needed) was assessed based on the time to the start of symptomatic relief and the proportion of patients experiencing relief within 4 hours of therapy. In the prophylaxis studies, C1 INH-nf 1000 U was given twice weekly, and efficacy was based on the frequency of attacks. Results: Across 4 studies, 46 children received a total of 2237 C1 INH-nf infusions. The median time to the start of unequivocal relief in the acute-attack treatment study (n = 12) was 30 minutes with C1 INH-nf, compared with 2 hours for placebo. In the open-label extension (n = 22), clinical relief began within 4 hours of therapy in 89% of attacks. In the prophylaxis study (n = 4), the number of attacks was reduced by approximately 2-fold with C1 INH-nf compared with placebo. In the prophylaxis open-label extension (n = 23), the median monthly attack rate decreased from 3.0 before treatment to 0.39 with C1 INH-nf use. Conclusion: In children, C1 INH-nf was well tolerated, provided relief from symptoms of hereditary angioedema attacks, and reduced the rate of attacks. © Copyright 2013 Mosby Inc. All rights reserved.

Gergen P.J.,Allergy | Togias A.,Allergy
Immunology and Allergy Clinics of North America | Year: 2015

The inner city has long been recognized as an area of high asthma morbidity and mortality. A wide range of factors interact to create this environment. These factors include well-recognized asthma risk factors that are not specific to the inner city, the structure and delivery of health care, the location and function of the urban environment, and social inequities. In this article, these facets are reviewed, and successful and unsuccessful interventions are discussed, to understand what is needed to solve this problem. © 2015.

Siddiqi T.A.,Allergy | Hill J.,Allergy | Huckleberry Y.,University of Arizona | Parthasarathy S.,Allergy
Respiratory Care | Year: 2014

Calcium channel blockers (CCBs) overdose can be life-threatening when manifest as catastrophic shock and non-cardiogenic pulmonary edema. We describe a case of massive overdose of multiple medications, including sustained-release verapamil, which was resistant to conventional support. Initial treatment for CCB overdose is primarily supportive, and includes fluid resuscitation. The mechanism of non-cardiogenic pulmonary edema is not well known, and reported cases have been successfully treated with mechanical ventilation. Circulatory shock may fail to respond to atropine, glucagon, and calcium in severely poisoned patients, and vasopressors are usually required. Attempting to overcome calcium-channel antagonism with the supra-therapeutic doses of calcium salts is clinically indicated to reverse hypotension and bradycardia. There is evidence that hyperinsulinemia-euglycemia therapy is superior to other therapies for CCB poisoning, and the mechanism is thought to be the insulin-mediated active transport of glucose into the cells, which counters the CCB-induced intra-cellular carbohydrate-deficient state. Conventional decontamination measures are ineffective in accelerating clearance of CCB. Experience with intravenous lipid emulsion for lipophilic drug overdose, such as verapamil, is limited, but has been proposed as a rescue therapy and might improve cardiac inotropy through intravascular sequestration of the lipophilic CCB. © 2014 Daedalus Enterprises.

Superficial bacterial folliculitis (SBF) is more common in the dog than other mammalian species. Until recently, a successful outcome in cases of canine SBF was possible by administering a potentiated amoxicillin, a first generation cephalosporin or a potentiated sulfonamide. Unfortunately, this predictable susceptibility has changed, because methicillin resistant Staphylococcus pseudintermedius (MRSP) and Staphylococcus aureus (MRSA) are becoming more prevalent in canine SBF cases. The increasing frequency of multidrug resistance complicates the selection of antimicrobial therapy. Antimicrobial agents that were once rarely used in cases of canine SBF, such as amikacin, rifampicin and chloramphenicol, are becoming the drugs of choice, based on bacterial culture and susceptibility testing. Furthermore, changes in antimicrobial susceptibility have helped to re-emphasize the importance of a multimodal approach to treatment of the disease, including topical therapy. Due to the increasing frequency of identification of highly resistant Staphylococcus spp., topical antimicrobial therapy, including the use of diluted sodium hypochlorite (bleach), is becoming necessary to successfully treat some cases of canine SBF. Other important antiseptics that can be used include chlorhexidine, benzoyl peroxide, ethyl lactate, triclosan and boric acid/acetic acid. This review discusses the diagnostic and therapeutic management of canine SBF, with a special emphasis on treating methicillin resistant staphylococcal infections. © 2013 Elsevier Ltd.

Lunn M.L.,Allergy | Santos C.B.,Allergy | Craig T.J.,Allergy
Annals of Allergy, Asthma and Immunology | Year: 2010

Background: Hereditary angioedema (HAE) is an autosomal dominant disorder characterized by a deficiency of C1 esterase inhibitor (C1 INH) protein or function. Guidelines do not exist regarding diagnostic criteria or routine testing of family members of patients with HAE. Laboratory data for diagnosis include complement factor 4 level; C1 INH antigenic protein level, which is reduced in approximately 85% of patients with HAE; and C1 INH functional assay, which is considered an unreliable test in the United States secondary to inconsistent standardization of assays. Objectives: To assess the shortcomings of diagnosing HAE and to determine whether family members of patients with HAE are being adequately screened. Methods: The top physician prescribers of danazol in the United States were screened via an Internet questionnaire focusing on the diagnosis and current management of HAE. To assess the patient perspective on HAE, affected individuals in the United States, the United Kingdom, France, Germany, and the Netherlands participated in the Web-based International Survey of Patient Experience of Hereditary Angioedema. Results: All 80 physicians who completed the survey were allergist or immunologists with a mean of 7 patients with C1 INH deficiency in their practices. Almost 84% of physician respondents used C1 INH level and function for diagnosis, and 63.8% used complement factor 4 levels. A total of 313 patients with HAE completed the survey. Respondents noted that only 48% of immediate family members and 26% of extended family members had been tested. Conclusion: Guidelines could potentially alleviate delays in diagnosis and incorrect diagnoses and could lead to adequate screening of family members. © 2010 American College of Allergy, Asthma & Immunology.

Rance K.S.,Allergy
Journal of Multidisciplinary Healthcare | Year: 2011

Nurse practitioners (NPs) have a unique opportunity as frontline caregivers and patient educators to recognize, assess, and effectively treat the widespread problem of uncontrolled asthma. This review provides a perspective on the role of the NP in implementing the revised National Asthma Education and Prevention Program (NAEPP) Guidelines put forth by the National Heart, Lung, and Blood Institute, thereby helping patients achieve and maintain asthma control. A literature search of PubMed was performed using the terms asthma, nurse practitioner, asthma control, burden, impact, morbidity, mortality, productivity, quality of life, uncontrolled asthma, NAEPP guidelines, assessment, pharmacotherapy, safety. Despite the increased morbidity and mortality and impaired quality of life attributable to uncontrolled asthma, the 2007 NAEPP asthma guidelines are greatly underused. NPs have an opportunity to identify patients at risk and provide enhanced care and education for asthma control. Often, NPs can prescribe medication for and manage these patients, but it is necessary to be able to discern which patients require referral to a specialist. © 2011 Rance.

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