Dartmouth–Hitchcock Medical Center is New Hampshire's only academic medical center and is headquartered on a 225-acre campus in the heart of the Upper Connecticut River Valley, in Lebanon, New Hampshire. DHMC is New Hampshire's only Level I trauma center, one of only three in northern New England, and it includes New Hampshire's only air ambulance service. Wikipedia.
Jobst B.C.,Dartmouth Hitchcock Medical Center |
Cascino G.D.,Mayo Medical School
JAMA - Journal of the American Medical Association | Year: 2015
IMPORTANCE: Epilepsy surgery is indicated for patients with focal seizures who do not respond to appropriate antiepileptic drug therapy consisting of 2 or more medications. OBJECTIVES: To review resective surgery outcomes for focal epilepsy, to identify which patients benefit the most, and to discuss why epilepsy surgerymay not be universally accepted. EVIDENCE REVIEW: Medline and Cochrane databases were searched between January 1993 and June 2014 for randomized clinical trials, meta-analyses, systematic reviews, and large retrospective case series (>300 patients) using Medical Subject Headings and indexed text terms. Fifty-five articles were included. Subpopulations and prognostic factors were identified. Systematic reviews for cognitive, psychiatric, quality-of-life, and psychosocial outcomes were included. FINDINGS: Two randomized clinical trials enrolling 118 patients with temporal lobe epilepsy found greater freedom from seizures with surgery when compared with continued medical treatment (58%vs 8%[n = 80] and 73%vs 0%[n = 38], P < .001). Nine systematic reviews and 2 large case series of medically refractory patients treated with surgery reported seizure-free outcomes in 34%to 74%of patients (median, 62.4%). The remainder of systematic reviews and meta-analyses examined subpopulations. Epilepsy surgery was less effective when there were extratemporal lesions, the epilepsy was not associated with a structural lesion, or both. Seizure-free outcomes were similar between children and adults. Hippocampal sclerosis and benign tumors were associated with better outcomes relative to other pathologies. Similar procedures such as selective amygdalohippocampectomy and temporal lobectomy for temporal lobe epilepsy were associated with subtle differences in seizure and neuropsychological outcome. There is low perioperative mortality (0.1%-0.5%) from epilepsy surgery. The most frequent neurologic complication is visual field defect occurring from temporal lobe resection. Quality of life improved after surgery but improved the most in patients who were seizure-free after surgery. CONCLUSIONS AND RELEVANCE: Epilepsy surgery reduced seizure activity in randomized clinical trials when compared with continued medical therapy. Long-term cognitive, psychiatric, psychosocial, and quality-of-life outcomes were less well defined. Despite good outcomes from high-quality clinical trials, referrals of patients with seizures refractory to medical treatment remain infrequent. Copyright 2015 American Medical Association. All rights reserved.
Sites B.D.,Dartmouth Hitchcock Medical Center
Regional anesthesia and pain medicine | Year: 2010
Ultrasound-guided regional anesthesia (UGRA) is a growing area of both clinical and research interest. The following document contains the work produced by a joint committee from ASRA and the European Society of Regional Anesthesia and Pain Therapy. This joint committee was established to recommend to members and institutions the scope of practice, the teaching curriculum, and the options for implementing the medical practice of UGRA.This document specifically defines the following:1. 10 common tasks used when performing an ultrasound-guided nerve block,2. The core competencies and skill sets associated with UGRA,3. A training practice pathway for postgraduate anesthesiologists, and4. A residency-based training pathway.In both the residency and postgraduate pathways, training, competency, and proficiency requirements include both didactic and experiential components. The Joint Committee recommends that the decision to grant UGRA privileges be based at the individual institution level. Each institution that conducts UGRA is encouraged to support a productive quality improvement process.
Abou Tayoun A.N.,Dartmouth Hitchcock Medical Center
Clinical chemistry | Year: 2013
Cystic fibrosis is a life-threatening genetic disorder that has been associated with mutations in the CFTR [cystic fibrosis transmembrane conductance regulator (ATP-binding cassette sub-family C, member 7)] gene. Hundreds of CFTR mutations have been detected to date. Current CFTR genotyping assays target a subset of these mutations, particularly a mutation panel recommended by the American College of Medical Genetics for carrier screening of the general population. Fast sequencing of the entire coding sequence in a scalable manner could expand the detection of CFTR mutations and facilitate management of costs and turnaround times in the clinical laboratory. We describe a proof-of-concept CFTR assay that uses PCR target enrichment and next-generation sequencing on the Ion Torrent Personal Genome Machine™ (PGM™) platform. The scalability of the assay was demonstrated, with an average mean depth of coverage ranging from 500× to 3500×, depending on the number of multiplexed patient samples and the Ion Torrent chip used. In a blinded study of 79 previously genotyped patient DNA samples and cell lines, our assay detected most of the mutations, including single-nucleotide variants, small insertions and deletions, and large copy-number variants. The reproducibility was 100% for detecting mutations in independent runs. Our assay demonstrated high specificity, with only 2 false-positive calls (at 2184delA) found in 2 samples caused by a sequencing error in a homopolymer stretch of sequence. The detection rate for variants of unknown significance was very low in the targeted region. With continued optimization and system refinements, PGM sequencing promises to be a powerful, rapid, and scalable means of clinical diagnostic sequencing.
Powell R.J.,Dartmouth Hitchcock Medical Center
Journal of Vascular Surgery | Year: 2012
Critical limb ischemia (CLI) represents the most severe degree of peripheral arterial disease and is associated with significant morbidity and mortality. In patients with CLI who do not have revascularization options, major amputation is required within 1 year in as many as 40% of patients. Biologic therapies, which include gene therapy and cellular therapy, offer the potential to promote wound healing and prevent amputation in patients who otherwise have poor options for revascularization. Several recent phase 2 trials have shown acceptable safety and suggest that these biological therapies have the potential to improve outcomes in patients with no-option CLI. Phase 3 trials are now in progress. This report summarizes the recent results of, and future plans for, gene and cellular therapy clinical trials in patients with CLI. © 2012 Society for Vascular Surgery.
Lacy B.E.,Dartmouth Hitchcock Medical Center
Clinical Gastroenterology and Hepatology | Year: 2015
Irritable bowel syndrome (IBS) is a highly prevalent disorder that is characterized by symptoms of abdominal pain, bloating, constipation, and/or diarrhea. The diagnosis can be made using Rome III criteria or published guidelines after taking a thoughtful history, excluding warning signs, and performing a careful physical examination. Limited testing (ie, complete blood count and C-reactive protein level) may be useful in appropriate patients. A number of pharmacologic options are available, although many patients fail to respond to pharmacologic therapy. Although several IBS diets frequently are recommended, data supporting their use are limited. This article provides a rationale as to why specific diets might improve IBS symptoms and evaluates published trials. © 2015 AGA Institute.
Lahey T.,Dartmouth Hitchcock Medical Center
Academic Medicine | Year: 2012
Medical students' interest in global health outreach work is intense and growing. Yet, medical students' global health outreach work is fraught with ethical complexity: Students must make challenging resource allocation decisions in an unfamiliar setting while providing complicated care with evolving expertise across power gradients and geographical as well as cultural boundaries. Inadequate training in the recognition and resolution of the ethical issues inherent in this work likely endangers future service work participation and undercuts the efficacy of medical students' global health outreach work. The author describes how the medical school curriculum can empower medical students to recognize and resolve ethical issues encountered in global health outreach work.To achieve this goal, he proposes a curriculum in the ethics of global health outreach to train students to understand (1) the ethical justifications for global health outreach work, (2) the drivers of global health disparities, (3) the key ethical issues raised by global health outreach, and (4) how to resolve ethical quandaries encountered during global health outreach work through collaboration. Beyond specific topical content, a medical school curriculum in the ethics of global health outreach should emphasize the importance of local collaboration and longitudinal mentorship of medical students. Medical school training in the recognition and resolution of the ethical issues attendant on global health outreach work prepares students not only for more sophisticated work in international settings but also for the ethical complexities of medical practice closer to home. © by the Association of American Medical Colleges.
Bernat J.L.,Dartmouth Hitchcock Medical Center
Nature Reviews Neurology | Year: 2013
Circulatory-respiratory or brain tests are widely accepted for definition and determination of death, but have several controversial issues. Both determinations have been stimulated by organ donation, but must be valid independently of this process. Current controversies in brain death include whether the definition is conceptually coherent, whether the whole-brain or brainstem criterion is correct, whether one neurological examination or two should be required, and when to conduct the examination following therapeutic hypothermia. Controversies about the circulatory determination of death include the minimum duration of asystole that is sufficient for death to be declared, and whether the distinction between permanent and irreversible cessation of circulatory functioning is important. In addition, the goal of organ donation raises issues such as the optimal way to time and conduct the request conversation with family members of the patient, and whether the Dead Donor Rule should be abandoned. Copyright © 2013 Macmillan Publishers Limited.
Nolan B.W.,Dartmouth Hitchcock Medical Center
Journal of vascular surgery | Year: 2012
Carotid artery stenting (CAS) vs endarterectomy (CEA) remains controversial and has been the topic of recent randomized controlled trials. The purpose of this study was to compare the practice and outcomes of CAS and CEA in a real world setting. This is a retrospective analysis of 7649 CEA and 430 CAS performed at 17 centers from 2003 to 2010 within the Vascular Study Group of New England (VSGNE). The primary outcome measures were (1) any in-hospital stroke or death and (2) any stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery were excluded. Multivariate logistic regression was performed to identify predictors of stroke or death in patients undergoing CAS. CEA was performed in 17 centers by 111 surgeons, while CAS was performed in 6 centers by 30 surgeons and 8 interventionalists. Patient characteristics varied by procedure. Patients undergoing CAS had a higher prevalence of coronary artery disease, congestive heart failure, diabetes, and prior ipsilateral CEA. Embolic protection was used in 97% of CAS. Shunts were used in 48% and patches in 86% of CEA. The overall in-hospital stroke or death rate was higher among patients undergoing CAS (2.3% vs 1.1%; P = .03). Overall stroke, death, or MI (2.8% CAS vs 2.1% CEA; P = .32) were not different. Asymptomatic patients had similar rates of stroke or death (CAS 0.73% vs CEA 0.89%; P = .78) and stroke, death, or MI (CAS 1.1% vs CEA 1.8%; P = .40). Symptomatic patients undergoing CAS had higher rates of stroke or death (5.1% vs 1.6%; P = .001), and stroke, death, or MI (5.8% vs 2.7%; P = .02). By multivariate analysis, major stroke (odds ratio, 4.5; 95% confidence interval [CI], 1.9-10.8), minor stroke (2.7; CI, 1.5-4.8), prior ipsilateral CEA (3.2, CI, 1.7-6.1), age >80 (2.1; CI, 1.3-3.4), hypertension (2.6; CI, 1.0-6.3), and a history of chronic obstructive pulmonary disease (1.6; CI, 1.0-2.4) were predictors of stroke or death in patients undergoing carotid revascularization. In our regional vascular surgical practices, the overall outcomes of CAS and CEA are similar for asymptomatic patients. However, symptomatic patients treated with CAS are at a higher risk for stroke or death. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Shaker M.,Dartmouth Hitchcock Medical Center
Current Opinion in Pediatrics | Year: 2014
PURPOSE OF REVIEW: The allergic march of childhood describes an association between atopic dermatitis, IgE-mediated food allergy, allergic asthma, and allergic rhinitis that begins with an atopic family history. This review summarizes recent insights into the nature of these conditions and their associations. RECENT FINDINGS: In recent years, common allergic diseases have become more prevalent and increased rates of food allergies remain incompletely understood. This review explores a newly described major genetic risk factor, a mutation in the skin matrix protein filaggrin, as it relates to the allergic march of childhood. New paradigms of understanding the interrelationships between atopic dermatitis, food allergy, and asthma are described. A surge of investigative effort has been directed toward the prevention and treatment of food allergy. Risk factors for allergic asthma in young children have been used to predict patient response to treatment. A recent practice parameter on furry animal/pet avoidance updates current understanding of allergen avoidance in modifying allergic phenotypes. SUMMARY: Understanding of the interrelationships of atopic diseases allows earlier diagnosis of allergic conditions in at-risk patient populations and may lead to novel approaches to health promotion and disease prevention. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Siegel C.A.,Dartmouth Hitchcock Medical Center
Alimentary Pharmacology and Therapeutics | Year: 2011
Background: Medical treatment for inflammatory bowel disease (IBD) has advanced significantly over the past decade, but it is important to communicate effectively the balance of benefits and risks of therapy to patients to facilitate informed medical decisions. Aim: To review the available data describing the risk of side effects of IBD medications and to describe effective methods for communicating risk. Methods: To identify relevant articles for this review, a PubMed search was conducted using relevant key words and phrases. In addition, reference lists from identified manuscripts were searched and recent abstracts from National meetings were reviewed. Results: The steroid-sparing medications used for the treatment of IBD all carry risks of both common and rare adverse events. Trade-offs need to be made between the risks of these medications vs. the risks of poorly treated disease and corticosteroids. There has been significant research on how best to present risk data to patients, which is summarized in this review. Conclusions To ensure that our patients understand their choices and feel comfortable with their treatment, we need to communicate risk data to patients clearly. Patients comprehend absolute numbers better than relative risk, and when available, pictorial representations of data are preferred over solely presenting numerical outcomes. © 2010 Blackwell Publishing Ltd.