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Atlanta, GA, United States

Yellin S.A.,Emory University | Nugent A.,Emory Healthcare
Facial Plastic Surgery Clinics of North America

Nasal reconstruction remains a significant surgical challenge. The melolabial flap and its multiple variations relies on the robust vascularity and abundant subcutaneous fat of the melolabial fold, to transfer skin and soft tissue to the lower one-third of the nose, the nasal sidewall or as a replacement for nasal lining while hiding the donor scar in the melolabial crease. This content discusses pertinent cutaneous anatomy, patient selection, preparation and education, flap design, surgical techniques and post-operative considerations to enable the surgeon to achieve a reconstruction result that closely approximates the pre-injury state while producing limited donor site deformity. © 2011. Source

Teagarden D.L.,Emory Healthcare | Meador K.J.,Stanford University | Loring D.W.,Emory University
Epilepsy Research

Purpose: Vitamin D is important for bone health, and vitamin D deficiency may contribute to other disorders (e.g., autoimmune, infections, cancer, degenerative, diabetic, and vascular). Enzyme-inducing antiepileptic drugs have been particularly implicated for osteoporosis risk given their effects on vitamin D. We examined the prevalence of vitamin D deficiency in adult epilepsy patients. Methods: We conducted an observational study of consecutive epilepsy patients treated by two clinicians at the Emory University Epilepsy Center from 2008 to 2011 in order to determine the frequency of low vitamin D levels and possible differential antiepileptic drug risks. Vitamin D 25-OH levels were categorized as low (<20. ng/ml), borderline (20-29. ng/ml), or normal (≥30. ng/ml). Antiepileptic drugs were categorized based on their enzyme inducing properties. Descriptive and inferential statistics were employed. Results: Vitamin D levels were obtained on 596 patients with epilepsy. Mean age was 41 years (SD = 14; range = 18-81); 56% were women. Race/ethnicity was 55% Caucasian, 34% Black, 2% Asian, and 7% Unknown. The mean vitamin D level was 22.5 (SD = 11.9; range = <4 to 98), and 45% had level <20. ng/ml. Mean vitamin D levels ( F = 6.48, p = .002) and frequencies of vitamin D categories ( p = .002, Chi square test) differed across the antiepileptic drug groups. Vitamin D deficiency was present in 54% of enzyme-inducing and 37% of non-enzyme-inducing antiepileptic drugs groups. Conclusions: Vitamin D deficiency is common in patients with epilepsy on antiepileptic drugs. Monitoring of vitamin D should be considered as part of the routine management of patients with epilepsy. © 2014 Elsevier B.V. Source

Steinberg J.P.,Emory University | Robichaux C.,Emory Healthcare | Tejedor S.C.,Emory University | Reyes M.D.,Emory University | Jacob J.T.,Emory University
Infection Control and Hospital Epidemiology

objective. Many bloodstream infections (BSIs) occurring in patients with febrile neutropenia following cytotoxic chemotherapy are due to translocation of intestinal microbiota. However, these infections meet the National Healthcare Safety Network (NHSN) definition of central line-associated BSIs (CLABSIs). We sought to determine the differences in the microbiology of NHSN-defined CLABSIs in patients with and without neutropenia and, using these data, to propose a modification of the CLABSI definition. design. Retrospective review. setting. Two large university hospitals over 18 months. methods. All hospital-acquired BSIs occurring in patients with central venous catheters in place were classified using the NHSN CLABSI definition. Patients with postchemotherapy neutropenia (500 neutrophils/mm3 or lower) at the time of blood culture were considered neutropenic. Pathogens overrepresented in the neutropenic group were identified to inform development of a modified CLABSI definition. results. Organisms that were more commonly observed in the neutropenic group compared with the nonneutropenic group included Escherichia coli (22.7% vs 2.5%; P<.001) but not other Enterobacteriaceae, Enterococcus faecium (18.2% vs 6.1%; P =.002), and streptococci (18.2% vs 0%; P<.001). Application of a modified CLABSI definition (removing BSI with enterococci, streptococci, or E. coli) excluded 33 of 66 neutropenic CLABSIs and decreased the CLABSI rate in one study hospital with large transplant and oncology populations from 2.12 to 1.79 cases per 1,000 line-days. conclusions. Common gastrointestinal organisms were more common in the neutropenia group, suggesting that many BSIs meeting the NHSN criteria for CLABSI in the setting of neutropenia may represent translocation of gut organisms. These findings support modification of the NHSN CLABSI definition. © 2012 by The Society for Healthcare Epidemiology of America. All rights reserved. Source

Copland I.B.,Emory University | Garcia M.A.,Emory Healthcare | Waller E.K.,Emory University | Roback J.D.,Emory University | Galipeau J.,Emory University

Human platelet lysate (PL) represents an attractive alternative to fetal bovine serum (FBS) for the exvivo expansion of human mesenchymal stromal cells (MSCs). However, there is controversy whether MSCs propagated in unfractionated PL retain their immunosuppressive properties. Since fibrinogen can be a major component of PL, we hypothesized that the fibrinogen content in PL negatively affects the suppressor function of MSCs. Pools of outdated plateletpheresis products underwent a double freeze-thaw centrifugation and filtration to produce unfractionated platelet lysates (uPL), followed by a temperature controlled clotting procedure to produce a fibrinogen depleted platelet lysate (fdPL). Fibrinogen depletion affected neither the mitogenic properties of PL or growth factor content, however fdPL was less prone to develop precipitate over time. Functionally, fibrinogen interacted directly with MSCs, dose dependently increased IL-6, IL-8 and MCP-1 protein production, and compromised the ability of MSCs to up-regulate indoleamine dioxygenase (IDO), as well as, mitigate T-cell proliferation. Similarly uPL expanded MSCs showed a reduced capability of inducing IDO and suppressing T-cell proliferation compared to FBS expanded MSCs. Replacing uPL with fdPL largely restored the immune modulating effects of MSCs. Together these data suggest that fibrinogen negatively affects the immunomodulatory functions of MSCs and fdPL can serve as non-xenogenic mitogenic supplement for expansion of clinical grade MSCs for immune modulation. © 2013 Elsevier Ltd. Source

Teperman L.W.,New York University | Poordad F.,Cedars Sinai Medical Center | Bzowej N.,Hepatology and Gastroenterology Research Liver Transplant Program | Martin P.,University of Miami | And 7 more authors.
Liver Transplantation

Long-term prophylaxis with hepatitis B immunoglobulin (HBIG) for the prevention of hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) in patients with chronic HBV infection is inconvenient and costly. This randomized, prospective phase 2 study compared emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) after HBIG withdrawal to FTC/TDF plus HBIG for the prevention of HBV recurrence after OLT. Forty patients with a median time since liver transplantation of 3.4 years (interquartile range = 1.9-5.6 years) received 24 weeks of open-label FTC/TDF plus HBIG before randomization. Patients who maintained confirmed viral suppression were randomized to continue FTC/TDF plus HBIG (n = 19) or receive FTC/TDF alone (n = 18) for an additional 72 weeks. No patient experienced HBV recurrence through 72 weeks of the study while he or she was receiving the randomized treatment. Both treatment arms were safe and well tolerated; no serious or severe drug-related adverse events were observed. Renal function was consistent with that observed in a posttransplant population. The withdrawal of HBIG after 6 months' treatment with FTC/TDF should be considered in liver transplant recipients to prevent chronic HBV recurrence. Liver Transpl 19:594-601, 2013. © 2013 AASLD. Copyright © 2013 American Association for the Study of Liver Diseases. Source

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