Albert Einstein Healthcare Network

Philadelphia, PA, United States

Albert Einstein Healthcare Network

Philadelphia, PA, United States
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Salami A.,Albert Einstein Healthcare Network | Alvarez N.H.,Albert Einstein Healthcare Network | Joshi A.R.T.,Albert Einstein Healthcare Network
HPB | Year: 2017

Background: Previous studies have described pessimistic attitudes of physicians toward recommending surgery for early-stage pancreatic adenocarcinoma. However, the impact of geographic region on recommendation patterns of surgical treatment for potentially resectable pancreatic cancer is unknown. Methods: The SEER registry was used to identify patients with early-stage pancreatic adenocarcinoma (AJCC I-II) [2004-2013]. The exposure of interest was geographic region of diagnosis: Midwest, West, Southeast or Northeast. The endpoints of interest were recommendation of no surgery, and overall survival. Results: A total of 24,408 patients were identified [Midwest - 10.6%, West - 50.1%, Southeast - 21.7% and Northeast - 17.6%]. Overall, 38% of patients had a recommendation of no surgery by their provider. On univariate analysis, the likelihood of having a recommendation of no surgery was lowest in the NE [OR: Northeast (0.8), West (1.6), Southeast (1.3), and Midwest (Ref); p < 0.05 for all]. This association persisted following risk adjustment. Geographic region was an independent predictor of mortality, irrespective of resection status. Conclusion: Significant disparities in surgical treatment recommendation patterns and survival for early-stage pancreatic cancer exist based on geographic location. Improved adherence to guideline-driven treatment recommendations, standardization of care processes, and regionalization may help stem the existing variability in care and outcomes. © 2017 International Hepato-Pancreato-Biliary Association Inc.

Scherer L.,Albert Einstein Healthcare Network | Zappolo K.,Albert Einstein Healthcare Network
Physician Assistant Clinics | Year: 2017

Abdominal pain, pelvic pain, and vaginal bleeding are common symptoms in emergency departments. It is essential in the care of these patients to assume that everyone is pregnant until proved otherwise. The general approach to patients with abdominal/pelvic pain and/or vaginal bleeding should be similar regardless of pregnancy status, first addressing the patient's airway, breathing, and circulation before proceeding with a more in-depth evaluation. It is important in the evaluation of all pregnant patients to rule out life-threatening diagnoses first, and stay cognizant that pregnant patients may have symptoms that are secondary to a non–pregnancy-related diagnosis. © 2017 Elsevier Inc.

Katz P.O.,Albert Einstein Healthcare Network | Rex D.K.,Indiana University | Epstein M.,Annapolis flyer cab | Grandhi N.K.,Gastroenterology Research Consultants of Greater Cincinnati | And 4 more authors.
American Journal of Gastroenterology | Year: 2013

OBJECTIVES:Optimal bowel preparation is vital for the efficacy and safety of colonoscopy. The inconvenience, discomfort, required consumption of large volumes of product, and potential adverse effects associated with some bowel preparations deter patients from colonoscopy and may provide inadequate cleansing. A dual-action, non-phosphate, natural orange-flavored, low-volume preparation containing sodium picosulfate and magnesium citrate (P/MC) is currently being reviewed for bowel cleansing.METHODS:This was a phase 3, randomized, multicenter, assessor-blinded, prespecified non-inferiority, head-to-head study to investigate the efficacy, safety, and tolerability of day-before administration of P/MC vs. 2L polyethylene glycol solution and two 5-mg bisacodyl tablets (2L PEG-3350 and bisacodyl tablets (HalfLytely and Bisacodyl Tablets Bowel Prep Kit)) in adult patients preparing for colonoscopy (SEE CLEAR II Study). The primary objective of the study was to demonstrate the non-inferiority of P/MC to 2L PEG-3350 and bisacodyl tablets in overall colon cleansing using a modified Aronchick scale. In addition, efficacy in the ascending, mid (transverse and descending), and recto-sigmoid segments of colon was evaluated using a modified Ottawa scale. Patient acceptability and tolerability of the bowel preparations were assessed via a standard questionnaire. Safety was assessed based on the monitoring of adverse events (AEs) and meaningful findings on clinical evaluations including physical examinations, vital sign measurements, and electrocardiograms (ECGs).RESULTS:A total of 603 patients were randomized to receive either P/MC (n=300) or 2L PEG-3350 and bisacodyl tablets (n=303). Based on the Aronchick scale, successful overall cleansing was similar in patients receiving P/MC (83.0%) and patients receiving 2L PEG-3350 and bisacodyl tablets (79.7%). P/MC demonstrated non-inferiority to 2L PEG-3350 and bisacodyl tablets in overall cleansing of the colon, as measured by the Aronchick scale. Similarly, the efficacy of P/MC, as measured by the Ottawa scale, was non-inferior to 2L PEG-3350 and bisacodyl tablets in cleansing the ascending, mid, and recto-sigmoid segments of the colon. Patient-reported acceptability and tolerability for each item examined on the questionnaire was significantly greater for P/MC compared with 2L PEG-3350 and bisacodyl tablets (P<0.0001).Treatment-emergent AEs related to the bowel preparation reported by 1% of patients receiving P/MC or 2L PEG-3350 and bisacodyl tablets were nausea (3.0% vs. 4.3%), vomiting (1.4% vs. 2.0%), and headache (2.7% vs. 1.7%). No clinically meaningful changes were noted in either treatment arm in data collected from physical examinations, vital sign measurements, and ECGs.CONCLUSIONS:When administered as a day-before dose, the bowel cleansing effects of P/MC were non-inferior compared with 2L PEG-3350 and bisacodyl tablets using the clinician-rated Aronchick and Ottawa scales. Treatment acceptability was significantly more favorable in patients receiving P/MC than in patients receiving 2L PEG-3350 and bisacodyl tablets.

Bellon J.R.,Dana-Farber Cancer Institute | Golshan M.,Dana-Farber Cancer Institute | Solin L.J.,Albert Einstein Healthcare Network
Annals of Surgical Oncology | Year: 2015

Multiple randomized trials, as well as a meta-analysis of these studies, have confirmed the equivalence of breast-conservation and mastectomy. In addition, in unselected populations, adjuvant radiation therapy following lumpectomy has been shown to decrease in-breast recurrence and improve overall survival. However, radiation has morbidity, and is costly and inconvenient. Multiple efforts to minimize treatment have been studied, including omitting radiation in low-risk populations, as well as in those with significant competing risks. Central to these efforts has been an increased awareness of the inherent biology, allowing treatment to be more precisely tailored to the risks posed by each individual patient’s disease. In addition, an improved understanding of the radio-responsiveness of both tumor and adjacent normal tissue has permitted safe use of short-course (hypofractionated) radiation. Studies are ongoing to determine the most appropriate candidates for both hypofractionated treatment and omission of radiation entirely. The optimal management of ductal carcinoma in situ is also a subject of intense study. Multiple trials have attempted to identify patients who can safely forego radiation and, more recently, molecular predictors of recurrence have been developed to further fine-tune this low-risk population. © 2015, Society of Surgical Oncology.

Dallal R.M.,Albert Einstein Healthcare Network | Hatalski A.,Albert Einstein Healthcare Network | Trang A.,Albert Einstein Healthcare Network | Chernoff A.,Albert Einstein Healthcare Network
Surgery for Obesity and Related Diseases | Year: 2012

Background: Identifying the predictors of co-morbidity improvement after gastric bypass surgery (Roux-en-Y gastric bypass) might give insight into disease pathophysiology. Methods: We performed an observational study of 949 patients undergoing primary RYGB from 2005 to 2010. Multivariate mixed models were used to determine the predictors of change in hemoglobin A1c (HbA1c), lipids, systemic blood pressure, and C-reactive protein. Results: Greater weight loss, decreased severity of initial disease, and a greater initial body mass index predicted a significantly greater likelihood of improvement in nearly all measured parameters. Male gender predicted greater improvement in diastolic blood pressure and low-density lipoprotein and triglyceride levels. Younger patients had a greater improvement in blood pressure. Improvement in the lipid profile was independent of weight loss, and improved glycemic control was strongly dependent on weight loss. Of the 949 patients, 33% had diabetes before RYGB. A mean of 388 days after RYGB, 66% of these patients had an HbA1c of <6.5, with their mean HbA1c decreasing from 8.0 to 5.9. A greater decrease in HbA1c was also seen in patients who initially were only treated with oral hypoglycemic agents compared with those receiving insulin. The low-density lipoprotein cholesterol levels decreased significantly from a mean of 108 to 87 mg/dL. High-density lipoprotein increased by a mean of 10 mg/dL in both men and women. Also, 15% of the patients had a triglyceride level of <200 mg/dL before RYGB and only 1.1% did so afterward. The mean C-reactive protein level decreased from 5.0 to 1.6 mg/dL. We measured a 20% reduction in patients with measured hypertension after RYGB. Conclusion: RYGB resulted in dramatic improvement in cardiovascular risk factors, with several significant predictors of outcome. © 2012 American Society for Metabolic and Bariatric Surgery.

Esquenazi A.,Gait and Motion Analysis Laboratory | Lee S.,Gait and Motion Analysis Laboratory | Packel A.T.,Gait and Motion Analysis Laboratory | Braitman L.,Albert Einstein Healthcare Network
PM and R | Year: 2013

Objectives: (1) To compare the effects of robotic-assisted treadmill training (RATT) and manually assisted treadmill training (MATT) in participants with traumatic brain injury (TBI) and (2) to determine the potential impact on the symmetry of temporal walking parameters, 6-minute walk test, and the mobility domain of the Stroke Impact Scale, version 3.0 (SIS). Design: Randomized prospective study. Subjects: A total of 16 participants with TBI and a baseline over ground walking self-selected velocity (SSV) of ≥0.2 m/s to 0.6 m/s randomly assigned to either the RATT or MATT group. Intervention: Gait training for 45 minutes, 3 times a week with either RATT or MATT for a total of 18 training sessions. Outcome Measures: Primary: Overground walking SSV, maximal velocity. Secondary: Spatiotemporal symmetry, 6-minute walk test, and SIS. Results: Between-group differences were not statistically significant for any measure. However, from pretraining to post-training, the average SSV increased by 49.8% for the RATT group (P = .01) and by 31% for MATT group (P = .06). The average maximal velocity increased by 14.9% for the RATT group (P = .06) and by 30.8% for the MATT group (P = .01). Less staffing and effort was needed for RATT in this study. Step-length asymmetry ratio improved during SSV by 33.1% for the RATT group (P = .01) and by 9.1% for the MATT group (P = .73). The distance walked increased by 11.7% for the robotic group (P = .21) and by 19.3% for manual group (P = .03). A statistically significant improvement in the mobility domain of the SIS was found for both groups (P ≤ .03). Conclusions: The results of this study demonstrate greater improvement in symmetry of gait (step length) for RATT and no significant differences between RATT and MATT with regard to improvement in gait velocity, endurance, and SIS. Our study provides evidence that participants with a chronic TBI can experience improvements in gait parameters with gait training with either MATT or RATT. © 2013 American Academy of Physical Medicine and Rehabilitation.

Ray M.A.,Florida Atlantic University | Turkel M.C.,Albert Einstein Healthcare Network
Advances in Nursing Science | Year: 2014

In the culture of health care, nurses are challenged to understand their values and beliefs as humanistic within complex technical and economically driven bureaucratic systems. This article outlines the language of social justice and human rights and the advance of a Theory of Relational Caring Complexity, which offers insights into caring as emancipatory nursing praxis. Recommendations provide knowledge of the struggle to balance economics, technology, and caring. As nurses practice from a value-driven, philosophical, and ethical social justice framework, they will find "their voice" and realize the full potential that the power of caring has on patient and organizational outcomes. Copyright © 2014 Lippincott Williams & Wilkins.

Rex D.K.,Indiana University | Katz P.O.,Albert Einstein Healthcare Network | Bertiger G.,Hillmont GI | Vanner S.,Queen's University | And 3 more authors.
Gastrointestinal Endoscopy | Year: 2013

Background: New bowel cleansers for colonoscopy that lead to improved efficacy, safety, and tolerability are needed. Objective: This study evaluated a nonphosphate, dual-action, low-volume, orange-flavored preparation containing sodium picosulfate and magnesium citrate (P/MC). Design: Multicenter, assessor-blinded, randomized, noninferiority study. Setting: University hospitals, academic medical centers, and private clinics across the United States. Patients: Adults preparing for colonoscopy. Interventions: P/MC versus 2 L of polyethylene glycol solution (2L PEG-3350) and two 5-mg bisacodyl tablets. Main Outcome Measurements: This phase 3 study investigated the efficacy, safety, and tolerability of split-dose administration of P/MC versus day-before dosing of 2L PEG-3350 and two 5-mg bisacodyl tablets (SEE CLEAR I study). Efficacy was evaluated by using the Aronchick and Ottawa scales; noninferiority and superiority analyses were performed. Safety was assessed by monitoring adverse events (AEs). Tolerability was measured via a patient questionnaire. Results: The intent-to-treat population consisted of 601 patients who self-administered P/MC (n = 304) or 2L PEG-3350 and bisacodyl tablets (n = 297). P/MC was superior to 2L PEG-3350 and bisacodyl tablets in overall colon cleansing (84.2% vs 74.4%; 1-sided 97.5% confidence interval [CI], 3.4) (Aronchick scores of excellent or good) and in cleansing of the ascending (89.5% vs 78.8%; 1-sided 97.5% CI, 4.9), mid (transverse and descending) (92.4% vs 85.9%; 1-sided 97.5% CI, 1.6), and rectosigmoid (92.4% vs 87.2%; 1-sided 97.5% CI, 0.4) segments of the colon (Ottawa scores of excellent, good, or fair). Commonly reported AEs related to the bowel preparations were nausea, vomiting, headache, and chills. Patient-reported tolerability, including ease of consumption and taste, was significantly higher for P/MC than 2L PEG-3350 and bisacodyl tablets (P <.0001). Limitations: Because of differences in administration and volume of the bowel preparations, the study was designed to be a single-assessor, blinded study. Conclusions: The bowel-cleansing effects and patient acceptability of split-dose P/MC were superior to day-before dosing with 2L PEG-3350 and bisacodyl tablets. © 2013 by the American Society for Gastrointestinal Endoscopy.

Adlin E.V.,Temple University | Braitman L.E.,Albert Einstein Healthcare Network | Vasan R.S.,Boston University
American Journal of Hypertension | Year: 2013

BACKGROUNDIn low-renin hypertension (LRH), serum aldosterone levels are higher in those subjects with primary aldosteronism and may be lower in those with non-aldosterone mineralocorticoid excess or primary renal sodium retention. We investigated the hypothesis that the frequency distribution of aldosterone in LRH is bimodal.METHODSOf the 3,532 attendees at the sixth examination cycle of the Framingham Offspring Study, 1,831 were included in this cross-sectional analysis after we excluded those with conditions or taking medications such as antihypertensive drugs that might affect renin or aldosterone.RESULTSThree hundred three subjects (17%) had untreated hypertension (SBP ≥140mm Hg or DBP ≥90mm Hg). LRH, defined as plasma renin ≤5 mU/L, was present in 93 of those 303 hypertensive subjects (31%). Aldosterone values were adjusted statistically for age, sex, and the urinary sodium/creatinine ratio. In the subjects with LRH, the adjusted aldosterone distribution was bimodal (dip test for unimodality, P = 0.008). The adjusted aldosterone distribution was unimodal in the normal subjects (P = 0.98) and in the hypertensive subjects with normal plasma renin (P = 0.94).CONCLUSIONSIn this community-based sample of white subjects, those with low-renin hypertension had a bimodal adjusted aldosterone distribution. Subjects with normal-renin hypertension and subjects with normal blood pressure had unimodal adjusted aldosterone distributions. These findings suggest 2 pathophysiological variants of LRH, one that is aldosterone-dependent and one that is non-aldosterone-dependent. © 2013 © American Journal of Hypertension, Ltd. All rights reserved.

Dallal R.M.,Albert Einstein Healthcare Network | Trang A.,Albert Einstein Healthcare Network
Surgical Endoscopy and Other Interventional Techniques | Year: 2012

Background: Hospital lengths of stay (LOS) and readmission rates often are used by third parties to measure quality of outcomes despite only a few published series that analyze risk-adjusted data and predictors of these events. Methods: Single-institution retrospective multivariable analysis of consecutive Roux-en-Y gastric bypass (RYGB) patients was performed to determine variables that may influence LOS and the readmission rate. Results: Between 2006 and 2010, 1,065 consecutive RYGB procedures were analyzed. The mean initial body mass index (BMI) of the patients was 48.4 kg/m 2 (range 35-108 kg/m 2), and their mean age was 42 years (range 15-75 years). Of these patients, 42% were black and 31% were either Medicare or Medicaid beneficiaries. The average LOS was 1.8 days (range 1-59 days; median, 2 days). The hospital discharged 48% of these patients on postoperative day (POD) 1, 85% on POD 2, and 96% on POD 3. According to multivariable Poisson regression, the independent predictors of a longer LOS included longer procedure time, surgeon, BMI, black race, older age, and status as a Medicare/Medicaid beneficiary (all P < 0.01). Gender and measured comorbidities were not associated with LOS. However, this model was poorly predictive of LOS due to substantial unexplained variance (R 2 = 0.10). Complications were significantly associated with Medicare/Medicare status (odds ratio [OR] 2.0), older age (OR 1.03), and longer procedure time (OR 1.02) (P < 0.05). According to logistic regression, a 30-day readmission rate was predicted only by a LOS longer than 3 days for the primary procedure (P < 0.0005). Conclusions: Early discharge on postoperative day 1 is possible but nonmodifiable, and random patient factors challenge predictable discharge planning. Reliable discharge on postoperative day 1 is not likely with current technologies. © 2011 Springer Science+Business Media, LLC.

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