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News Article | January 5, 2016
Site: news.yahoo.com

Dr. Uzma Samadani is chair for traumatic brain injury research at Hennepin County Medical Center and associate professor of neurosurgery at the University of Minnesota. Dr. Robert Glatter is director of sports medicine and traumatic brain injury in the Department of Emergency Medicine at Lenox Hill Hospital and assistant professor at the Hofstra North Shore-LIJ School of Medicine. The authors and four colleagues recently published "The Football Decision" (Amazon Digital Services, 2015) and contributed this related article to Live Science's Expert Voices: Op-Ed & Insights. You hear about it in news stories and see it in movies: People are struggling to understand what the risk is of a concussion causing long-term brain damage. Their biggest fear is that they will develop chronic traumatic encephalopathy (CTE), which results in abnormal deposits of proteins in the brain, possibly causing a severe form of early onset dementia. Despite its discovery in 1957 by renowned neurologist Dr. Macdonald Critchley, CTE was only recently defined, diagnostically, by a U.S. National Institutes of Health (NIH)-funded committee, when the members met to spell out CTE criteria in February 2015. Now, with the opening of the movie "Concussion," starring Will Smith, which tells the story of Dr. Bennet Omalu, the pathologist who discovered CTE in Mike Webster and several other NFL players, more attention is being paid to the long-term risks associated with concussions . The movie is an emotional portrayal of patients with CTE, and resulted in a recent editorial by Dr. Omalu calling for a ban on football, hockey and soccer in children under the age of 18. [Concussions Linked to Brain Changes in Former NFL Players ] But is a ban for children in sports the right answer? The public response that followed Dr. Omalu's editorial about an all-out ban has been mixed. Some people have said that they believe that this goes way too far, with potentially negative implications for a child's social and emotional development. Other parents who are fearful of CTE have said that, until we have further information about the exact mechanisms and genetic influences that define a higher-risk profile for developing CTE, it might be safest to put such a ban in place. There are three reasons why a ban is the wrong answer. First, it's impossible to legislate away all adolescent risk-taking behaviors. The adolescent brain is not fully myelinated — the nerves have not fully attained their coverings. Rather than sending signals through relatively few established pathways, as it does in adults, the brain tries multiple pathways. Thus, the adolescent brain has high synaptic plasticity (the ability to change direction) and is wildly creative, relative to the more inhibited, fully myelinated — and degenerating — adult brain. Legislation won't change this biological fact: Children are more impulsive, less restrained and more inclined to take risks. Football is on the riskier end of the spectrum of sports: In tackle football, there are about 10 deaths per million participants per year (not all due to brain trauma), but it is still less risky than equestrian sports (20 deaths per million per year) and skiing, snowboarding, skateboarding or bicycling (each with 10 to 15 deaths per million per year). The second reason not to eliminate tackle football is that it's not entirely clear that eliminating all risk-taking behaviors from childhood is in the interest of our society. When they're playing football, children learn to assess risk based not only on their own capabilities, but also on the capabilities of their teammates, who are there to protect the other members of the team and work for everyone's interests. This capacity for rapid risk assessment and plan execution, and the reliance on teamwork and the assessment of evolving challenges may serve our children well in their later professional lives. Without the experience of some risk in childhood, we might not have adults who engage in risk-taking behaviors — like astronauts, explorers, entrepreneurs, fire rescue personnel or surgeons, for example. In our book, "The Football Decision," we surveyed neurosurgical department chairs and brain injury experts, and found that they are at least 16 times more likely than typical undergraduates to have played contact sports in college. They are 1.5 times more likely than the average American to have sustained a concussion. And, 83 percent of neurosurgeons would allow their own children to play contact sports.

Apple F.S.,Clinical Pathology Laboratories | Apple F.S.,University of Minnesota | Ler R.,Hennepin County Medical Center | Murakami M.M.,Hennepin County Medical Center
Clinical Chemistry | Year: 2012

BACKGROUND: Between-assay comparability of 99th percentiles for cardiac troponin concentrations has not been assessed systematically in a single population for a large number of assays. METHODS: We determined 99th percentiles for 19 cardiac troponin assays in heparin plasma samples from a population of 272 and 252 presumably healthy males and females, respectively. The assays evaluated included 1 cardiac troponin T (cTnT) assay from Roche and 18 cTnI assays from Abbott, Alere, Beckman, bioMerieux, Instrumentation Laboratory, Ortho-Clinical Diagnostics, Singulex, Siemens, and Roche. Five of these assays were categorized as high-sensitivity, 9 as sensitive-contemporary, and 5 as point-of-care (POC) assays. RESULTS: For high-sensitivity cTnI (hs-cTnI) assays 99th percentiles varied from 23 to 58 ng/L. At least 80% of individuals had measurable hs-cTnI, whereas only 25% had measurable high-sensitivity cTnT. All highsensitivity cardic troponin assays had 99th percentiles that were 1.2-2.4-fold higher in males than females. For the 9 sensitive-contemporary cTnI assays, 99th percentiles varied from 12 to 392 ng/L, and only the Beckman assay gave measurable concentrations in a substantial portion of the population (35% vs ≤6% for the others). Seven of these 9 assays had 1.3-5.0-fold higher 99th percentiles for males than females. For 5 cTnI POC assays, 99th percentiles varied from < 10 to 40 ng/L. The Instrumentation Laboratory assay gave measurable results in 27.8% of study participants vs ≤6% for the others. Correlations were generally poor among assays. CONCLUSIONS: Among cardiac troponin assays 99th percentile concentrations appear to differ. Highsensitivity assays provide measurable cardiac troponin results in a substantially greater fraction of presumably healthy individuals. © 2012 American Association for Clinical Chemistry.

Bart G.,Hennepin County Medical Center | Bart G.,University of Minnesota
Journal of Addictive Diseases | Year: 2012

Illicit use of opiates is the fastest growing substance use problem in the United States, and the main reason for seeking addiction treatment services for illicit drug use throughout the world. It is associated with significant morbidity and mortality related to human immunodeficiency virus, hepatitis C, and overdose. Treatment for opiate addiction requires long-term management. Behavioral interventions alone have extremely poor outcomes, with more than 80% of patients returning to drug use. Similarly poor results are seen with medication-assisted detoxification. This article provides a topical review of the three medications approved by the Food and Drug Administration for long-term treatment of opiate dependence: the opioid-agonist methadone, the partial opioid-agonist buprenorphine, and the opioid-antagonist naltrexone. Basic mechanisms of action and treatment outcomes are described for each medication. Results indicate that maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction. Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. Oral naltrexone is ineffective in treating opiate addiction, but recent studies using extended-release naltrexone injections have shown promise. Although no direct comparisons between extended-release naltrexone injections and either methadone or buprenorphine exist, indirect comparison of retention shows inferior outcome compared with methadone and buprenorphine. Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication. © 2012 Taylor and Francis Group, LLC.

Sandoval Y.,Hennepin County Medical Center | Smith S.W.,Hennepin County Medical Center | Thordsen S.E.,Hennepin County Medical Center | Apple F.S.,University of Minnesota
Journal of the American College of Cardiology | Year: 2014

Supply/demand (type 2) myocardial infarction is a commonly encountered clinical challenge. It is anticipated that it will be detected more frequently once high-sensitivity cardiac troponin assays are approved for clinical use in the United States. We provide a perspective that is based on available data regarding the definition, epidemiology, etiology, pathophysiology, prognosis, management, and controversies regarding type 2 myocardial infarction. Understanding these basic concepts will facilitate the diagnosis and treatment of these patients as well as ongoing research efforts. © © 2014 by the American College of Cardiology Foundation Published by Elsevier Inc.

Schmidt A.H.,Hennepin County Medical Center
Journal of Orthopaedic Trauma | Year: 2011

Objectives: To compare hospital charges and length of stay in a series of adult patients with isolated, otherwise uncomplicated tibia fractures with and without acute compartment syndrome (ACS). Design: Retrospective case-control study. Setting: Urban Level I trauma center. Patients: Forty-six previously healthy adults with isolated tibia fractures (open or closed), with or without ACS but without other complication, associated injury, or social circumstance that influenced hospital stay or charges. Intervention: Intramedullary nailing in all patients with immediate fasciotomy and delayed fasciotomy closure in the subset of patients who developed ACS. Main Outcome Measure: Hospital length of stay in days and hospital charges. Results: Forty-six otherwise uncomplicated patients with isolated tibial shaft fractures were identified. Twelve fractures were open. ACS occurred in five patients, all with closed fractures. In 41 patients without ACS (12 open fractures, 29 closed fractures), the mean hospital stay was 3.0 days and mean hospital charges were $23,800. The five patients with ACS underwent a mean of 1.6 additional surgeries to treat the fasciotomy wound, were hospitalized for a mean of 9.0 days, and the mean hospital charges were $49,700. These differences were highly significant for hospital stay (P < 0.005) and charges (P < 0.00004). In contrast, there were no differences in length of stay or hospital charges in patients with closed or open fractures, respectively. Conclusion: The cost of ACS is significant, resulting in hospital stays that are increased threefold and hospital charges that are more than doubled in this cohort of patients. The impact of compartment syndrome on these factors was more important than whether the fracture was open or closed. In addition to the obvious benefit to the patient, methods that decrease the incidence of compartment syndrome and need for fasciotomy such as improved diagnosis to prevent unnecessary fasciotomy and methods to reduce intramuscular pressure and avoid fasciotomy in cases of incipient ACS would also be of value in reducing medical costs. Copyright © 2011 by Lippincott Williams & Wilkins.

Baker J.V.,Hennepin County Medical Center
Journal of the American Heart Association | Year: 2013

HIV infection leads to activation of coagulation, which may increase the risk for atherosclerosis and venous thromboembolic disease. We hypothesized that HIV replication increases coagulation potentially through alterations in extrinsic pathway factors. Extrinsic pathway factors were measured among a subset of HIV participants from the Strategies for Management of Anti-Retroviral Therapy (SMART) trial. Thrombin generation was estimated using validated computational modeling based on factor composition. We characterized the effect of antiretroviral therapy (ART) treatment versus the untreated state (HIV replication) via 3 separate analyses: (1) a cross-sectional comparison of those on and off ART (n=717); (2) a randomized comparison of deferring versus starting ART (n=217); and (3) a randomized comparison of stopping versus continuing ART (n=500). Compared with viral suppression, HIV replication consistently showed short-term increases in some procoagulants (eg, 15% to 23% higher FVIII; P<0.001) and decreases in key anticoagulants (eg, 5% to 9% lower antithrombin [AT] and 6% to 10% lower protein C; P<0.01). The net effect of HIV replication was to increase coagulation potential (eg, 24% to 48% greater thrombin generation from computational models; P<0.01 for all). The pattern of changes from HIV replication was reversed with ART treatment and consistent across all 3 independent comparisons. HIV replication leads to complex changes in extrinsic pathway factors, with the net effect of increasing coagulation potential to a degree that may be clinically relevant. The key influence of changes in FVIII and AT suggests that HIV-related coagulation abnormalities may involve changes in hepatocyte function in the context of systemic inflammation.

Leatherman J.,Hennepin County Medical Center
Chest | Year: 2015

Acute exacerbations of asthma can lead to respiratory failure requiring ventilatory assistance. Noninvasive ventilation may prevent the need for endotracheal intubation in selected patients. For patients who are intubated and undergo mechanical ventilation, a strategy that prioritizes avoidance of ventilator-related complications over correction of hypercapnia was first proposed 30 years ago and has become the preferred approach. Excessive pulmonary hyperinflation is a major cause of hypotension and barotrauma. An appreciation of the key determinants of hyperinflation is essential to rational ventilator management. Standard therapy for patients with asthma undergoing mechanical ventilation consists of inhaled bronchodilators, corticosteroids, and drugs used to facilitate controlled hypoventilation. Nonconventional interventions such as heliox, general anesthesia, bronchoscopy, and extracorporeal life support have also been advocated for patients with fulminant asthma but are rarely necessary. Immediate mortality for patients who are mechanically ventilated for acute severe asthma is very low and is often associated with out-of-hospital cardiorespiratory arrest before intubation. However, patients who have been intubated for severe asthma are at increased risk for death from subsequent exacerbations and must be managed accordingly in the outpatient setting. © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS.

Frostbite can be a devastating and even debilitating injury. Early identification and proper treatment of frostbite is critical in saving digits and limbs. Tissue plasminogen activator (tPA) has been shown to be effective in reducing the number of digits amputated after severe frostbite injury. Nothing has been presented in the podiatric literature regarding the use of tPA in treating frostbite patients for preserving toes and feet. Intravenous tPA and IV heparin were used to treat severe frostbite injuries that did not show improvement after rapid rewarming, had absent Doppler pulses in the distal limb or digits, showed limited or no perfusion by Tc-99 3-phase bone scan, and had no contraindications to use of tPA. All 11 patients included in this study were treated at Hennepin County Medical Center between 2008 and 2010. A total of 73 digits (upper and lower extremity) were considered at risk for amputation after evaluation with Tc-99 bone scan. Of those digits that were affected, 43 were amputated. Intravenous tPA is a safe and effective treatment to reduce the number of digital amputations after severe frostbite injury. The authors' protocol for treating severe frostbite includes the use of tPA. Levels of Evidence: Therapeutic, Level IV.

Kinney T.,Hennepin County Medical Center
Surgical Clinics of North America | Year: 2010

A high-quality pancreatic protocol computed tomography (CT) is the primary imaging modality for diagnosing and staging pancreatic malignancy. The main limitation of CT is the lack of sensitivity for early pancreatic lesions. Endoscopic ultrasound (EUS) provides an excellent complement to CT for both diagnosis and staging of pancreatic cancer, and allows easy access for needle aspiration and tissue diagnosis. Magnetic resonance (MR) can be helpful for evaluating small hepatic nodules or cystic lesions of the pancreas, but in general, the role of MR and positron emission tomography remains limited to special situations when the results of CT and EUS are equivocal. © 2010 Elsevier Inc.

Maripuri S.,Hennepin County Medical Center | Kasiske B.L.,Hennepin County Medical Center
Transplantation Reviews | Year: 2014

Since its regulatory approval in 1995, mycophenolate mofetil (MMF) has largely replaced azathioprine (AZA) as the anti-metabolite immunosuppressive of choice in kidney transplantation. While the initial industry-sponsored clinical trials suggested strong reductions in the incidence of acute rejection in the first six months post transplantation, long-term follow-up studies have failed to demonstrate a similar degree of benefit in overall graft and patient survival. In addition, several subsequent studies have raised questions on the potential attenuating effects of calcineurin inhibitor choice on MMF efficacy when compared to AZA. This review will revisit the question of whether the available evidence continues to support the superiority of MMF over AZA in kidney transplantation outcomes while comprehensively reviewing the available evidence from clinical trial data, systematic reviews, and registry studies. © 2014 Elsevier Inc.

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