Hyannis, MA, United States
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Li C.,National University of Singapore | Shi L.,Shandong University | Yan Y.,National University of Singapore | Gordon B.R.,Massachusetts Eye and Ear Infirmary | And 3 more authors.
Current Allergy and Asthma Reports | Year: 2013

Chronic rhinosinusitis (CRS) is a complex inflammatory disease with variable disease manifestation. Though external risk factors are associated with development and/or persistence of CRS, the host mucosal response is also important, as nasal epithelium acts as a physical and immune barrier. Under inflammatory stress, the nasal epithelium can undergo injury, followed by a rapid remodeling response ranging from epithelial hyperplasia, to goblet-cell metaplasia, to denudation, loss of cilia, fibrosis, and basement membrane thickening. Identification of gene expression signatures and molecular pathways in CRS pathogenesis have now begun to contribute significantly to a better understanding of the genetic and molecular alterations underlying CRS development and progression. Genetic studies are especially illuminating when multiple gene variants synergize within a permissive environmental context, and are expected to guide development of more effective therapeutic targets for CRS treatment. © 2012 Springer Science+Business Media New York.

Zhu J.H.,National University of Singapore | Lee H.P.,National University of Singapore | Lim K.M.,National University of Singapore | Gordon B.R.,Massachusetts Eye and Ear Infirmary | And 2 more authors.
Respiratory Physiology and Neurobiology | Year: 2012

We evaluated, by CFD simulation, effects of accessory ostium (AO) on maxillary sinus ventilation. A three-dimensional nasal model was constructed from an adult CT scan with two left maxillary AOs (sinus I) and one right AO (sinus II), then compared to an identical control model with all AOs sealed (sinuses III and IV). Transient simulations of quiet inspiration and expiration at 15. L/min, and nasal blow at 48. L/min, were calculated for both models using low-Reynolds-number turbulent analysis. At low flows, ventilation rates in sinuses with AOs (I. ≈. 0.46. L/min, II. ≈. 0.54. L/min), were both more than a magnitude higher than sinuses without AOs (III. ≈. 0.019. L/min, IV. ≈. 0.020. L/min). Absence of AO almost completely prevented sinus ventilation. Increased ventilation of sinuses with AOs is complex. Under high flow conditions mimicking nose blowing, in sinuses II, III, and IV, the sinus flow rate increased. In contrast, the airflow direction through sinus I reversed between inspiration and expiration, while it remained almost constant throughout the respiration cycle in sinus II. CFD simulation demonstrated that AOs markedly increase maxillary sinus airflow rates and alter sinus air circulation patterns. Whether these airflow changes impact maxillary sinus physiology or pathophysiology is unknown. © 2012 Elsevier B.V.

The International Nurses Association is pleased to welcome Julie Smith, RN, to their prestigious organization with her upcoming publication in the Worldwide Leaders In Healthcare. Julie Smith is a Senior Clinical Complaint Specialist working for Haemonetics in Braintree, Massachusetts. With over five years of experience in the field, she specializes in clinical analysis. Julie is also affiliated with Cape Cod Hospital and Tobey Hospital. Julie obtained her nursing degree from Cape Cod Community College in 2011 after receiving a Bachelor of Science Degree in Communications  from Vermont’s Norwich University in 1995. Julie uses her knowledge and skill gained from being a registered nurse for her role as a clinical analyst and senior clinical complaint specialist. She remains a member of the American Nurses Association and says that her success is due to her drive and passion. When not working, Julie likes to spend quality time with her four children. Learn more about Julie Smith here: http://inanurse.org/network/index.php?do=/4133218/info/ and read her upcoming publication in Worldwide Leaders In Healthcare.

Betz M.E.,University of Colorado at Denver | Sullivan A.F.,Massachusetts General Hospital | Manton A.P.,Cape Cod Hospital | Espinola J.A.,Massachusetts General Hospital | And 3 more authors.
Depression and Anxiety | Year: 2013

Background We sought to examine the knowledge, attitudes, and practices of emergency department (ED) providers concerning suicidal patient care and to identify characteristics associated with screening for suicidal ideation (SI). Methods Six hundred thirty-one providers at eight EDs completed a voluntary, anonymous survey (79% response rate). Results The median participant age was 35 (interquartile range: 30-44) years and 57% of the participants were females. Half (48%) were nurses and half were attending (22%) or resident (30%) physicians. More expressed confidence in SI screening skills (81-91%) than in skills to assess risk severity (64-70%), counsel patients (46-56%), or create safety plans (23-40%), with some differences between providers. Few thought mental health provider staffing was almost always sufficient (6-20%) or that suicidal patient treatment was almost always a top ED priority (15-21%). More nurses (37%, 95% confidence interval [CI] 31-42%) than physicians (7%, 95% CI 4-10%) reported screening most or all patients for SI; this difference persisted after multivariable adjustment. In multivariable analysis, other factors associated with screening most or all patients for SI were self-confidence in skills, (odds ratio [OR] 1.60, 95% CI 1.17-2.18), feeling that suicidal patient care was a top ED priority (OR 1.73, 95% CI 1.11-2.69) and 5+ postgraduate years of clinical experience (OR 2.06, 95% CI 1.03-4.13). Conclusions ED providers reported confidence in suicide screening skills but gaps in further assessment, counseling, or referral skills. Efforts to promote better identification of suicidal patients should be accompanied by a commensurate effort to improve risk assessment and management skills, along with improved access to mental health specialists. © 2013 Wiley Periodicals, Inc.

Gordon B.R.,Cape Cod Hospital | Gordon B.R.,Massachusetts Eye and Ear Infirmary | Gordon B.R.,Harvard University
Otolaryngologic Clinics of North America | Year: 2011

The allergic march is a progression of atopic disease from eczema to asthma, and then to allergic rhinoconjunctivitis. It appears to be caused by a regional allergic response with breakdown of the local epithelial barrier that initiates systemic allergic inflammation. Genetic and environmental factors predispose to developing the allergic march. There are data to support 4 possible interventions to prevent the allergic march from progressing to asthma: (1) supplements of dietary probiotics, (2) exclusive breast feeding during the first few months of life, or, alternatively (3) use of extensively hydrolyzed infant formulas, (4) treatment with inhalant allergen immunotherapy by either subcutaneous or sublingual methods. © 2011 Elsevier Inc.

Gordon B.R.,Cape Cod Hospital | Gordon B.R.,Harvard University | Gordon B.R.,Massachusetts Eye and Ear Infirmary
Otolaryngologic Clinics of North America | Year: 2014

Vitamin D (vitD3) deficiency occurs frequently and has profound effects on health, especially asthma. This article examines how current knowledge of vitD3 actions and the worldwide distribution of vitD3 deficiency influences everyday clinical allergy practice. Within the limits of current knowledge, the article concisely explains the molecular nature of vitD3 actions, reviews key vitD3 research as it applies to clinical care, answers questions about the potential clinical impact of low vitD3 levels, and discusses use and safety of vitD3 supplements. © 2014 Elsevier Inc.

Gorin D.R.,Cape Cod Hospital | Perrino L.,Cape Cod Hospital | Potter D.M.,Saba University | Ali T.Z.,Saba University
Journal of Vascular Surgery | Year: 2012

Objective: There has been an increasing awareness of the superiority of native arteriovenous fistulas (AVFs) over prosthetic grafts for dialysis access. Many AVFs fail to mature, however, and others develop stenosis while in use. There is growing experience in treating these patients in the interventional suite with percutaneous balloon angioplasty. These procedures, however, are expensive, uncomfortable, and inconvenient for patients and physicians, and involve exposure to radiation and intravenous contrast in patients who are often not on dialysis. This study reviews our experience with ultrasound-guided angioplasty of AVFs in the office setting. Methods: A retrospective review was performed of all patients treated in our practice with ultrasound-guided AVF angioplasty, from May 2009 to April 2011. The need for intervention was determined by examination and duplex ultrasound. All patients referred to the practice with failing or nonmaturing AVFs were treated in the office under ultrasound guidance, unless a central venous stenosis was suspected. All procedures were performed with the patient under local anesthesia by a single surgeon, and preprocedure, periprocedure, and postprocedure ultrasounds were performed in a single vascular laboratory. Results: There were 31 AVFs in 30 patients in the study. Fifty-five interventions were performed, 48 for AVFs failing to mature and seven for stenosis in functioning AFVs. The 90-day patency was 93%. The overall complication rate was 11%. Two patients had proximal stenosis that could not be crossed (one patient required surgical revision and one patient refused further treatment and thrombosed). There were four perifistular hematomas; three of these resulted in AFV thrombosis. No patients required hospitalization or urgent surgical intervention. Eighty-five percent of patients treated for AVF failing to mature achieved a functional fistula. Conclusions: AVF intervention can be performed safely and effectively under ultrasound guidance in the office setting and is a valuable tool in the management of dialysis access patients. © 2012 Society for Vascular Surgery.

Foulkes-Murzycki J.E.,University of Massachusetts Medical School | Foulkes-Murzycki J.E.,Stanford University | Rosi C.,University of Massachusetts Medical School | Kurt Yilmaz N.,University of Massachusetts Medical School | And 2 more authors.
ACS Chemical Biology | Year: 2013

Understanding the interdependence of multiple mutations in conferring drug resistance is crucial to the development of novel and robust inhibitors. As HIV-1 protease continues to adapt and evade inhibitors while still maintaining the ability to specifically recognize and efficiently cleave its substrates, the problem of drug resistance has become more complicated. Under the selective pressure of therapy, correlated mutations accumulate throughout the enzyme to compromise inhibitor binding, but characterizing their energetic interdependency is not straightforward. A particular drug resistant variant (L10I/G48V/I54V/V82A) displays extreme entropy-enthalpy compensation relative to wild-type enzyme but a similar variant (L10I/G48V/I54A/V82A) does not. Individual mutations of sites in the flaps (residues 48 and 54) of the enzyme reveal that the thermodynamic effects are not additive. Rather, the thermodynamic profile of the variants is interdependent on the cooperative effects exerted by a particular combination of mutations simultaneously present. © 2012 American Chemical Society.

Friedman P.L.,Cape Cod Hospital | Montgomery S.,Cape Cod Hospital | Matas N.,Cape Cod Hospital
Journal of Cardiovascular Electrophysiology | Year: 2010

Sotalol and a Broken Heart. An 82-year-old woman with persistent atrial fibrillation underwent successful electrical cardioversion and was begun on sotalol. After 3 days of in-hospital observation she had only mild lengthening of the QT interval. Two weeks later in clinic, the day after her husband's unexpected death, she was noted to have profound QT interval prolongation. Although she was asymptomatic and echocardiography did not disclose regional wall motion abnormalities consistent with takotsubo cardiomyopathy, she probably had a forme fruste of stress cardiomyopathy. Following emotional trauma, a period of heightened vigilance for ventricular proarrhythmia is probably warranted in women treated with antiarrhythmic drugs that lengthen repolarization. © 2010 Wiley Periodicals, Inc.

Gordon B.R.,Cape Cod Hospital
Current opinion in otolaryngology & head and neck surgery | Year: 2010

PURPOSE OF REVIEW: Patch testing has rapidly become an important clinical allergy tool, but is underutilized in the evaluation of complex patients, especially when these patients have skin disorders and respiratory allergies, food allergies, or eosinophilic enteritis. Learning when and how to use patch tests thus adds to any practitioner's diagnostic abilities.RECENT FINDINGS: This review discusses selected studies from the past year, grouped into immunology, pediatric testing, contact allergy, food allergy, and drug allergy.SUMMARY: Patch tests can detect a wide range of sensitivities to inorganic and organic chemicals, drugs, biologic molecules, inhalants acting as contactants, food allergens, allergens that have not been commercially extracted, and solid allergens. Because patch tests detect the full range of immunologic reactions, Gell and Coombs type I to IV, they may be uniquely reactive when other allergy tests are negative. Because of the large number of published studies that utilize patch testing, clinicians often can use a literature search of prior studies of similar problems, or for particular allergens, to choose technical details that make successful patch testing more likely.

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