Fung H.B.,James ters Veterans Affairs Medical Center |
Monteagudo-Chu M.O.,Kingsbrook Jewish Medical Center
American Journal Geriatric Pharmacotherapy | Year: 2010
Background: Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and death among the elderly. Objective: This article reviews information on CAP among the elderly, including age-related changes, predisposing risk factors, causes, treatment strategies, and prevention. Methods: Searches of MEDLINE (January 1990-November 2009), International Pharmaceutical Abstracts (January 1990-November 2009), and Google Scholar were conducted using the terms community-acquired pneumonia, pneumonia, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Studies that reported diagnostic criteria as well as the treatment outcomes achieved in adult patients with CAP were selected for this review. Results: Three practice guidelines, 5 reviews, and 43 studies on CAP in the elderly were identified in the literature search. Based on those publications, risk factors that predispose the elderly to pneumonia include comorbid conditions, poor functional and nutritional status, consumption of alcohol, and smoking. The clinical presentation of pneumonia in the elderly (≥65 years of age) may be subtle, lacking the typical acute symptoms (fever, cough, dyspnea, and purulent sputum) observed in younger adults. Pneumonia should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status, with or without lower respiratory tract symptoms such as cough, purulent sputum, and dyspnea. Treatment of CAP in the elderly should be guided by the latest recommendations of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS), along with consideration of local rates and patterns of antimicrobial resistance, as well as individual patient risk factors for acquiring less common or more resistant pathogens. Recommended empiric antimicrobial regimens generally consist of either a β-lactam plus a macrolide or a respiratory fluoroquinolone alone. Adherence to the IDSA/ATS guidelines has been found to improve in-hospital mortality (adherence vs nonadherence, 8%; 95% CI, 7%-10% vs 17%; 95% CI, 14%-20%; P< 0.01), length of hospital stay (8 days; interquartile range [IQR], 5-15 vs 10 days; IQR, 6-24 days, respectively; P < 0.01), and time to clinical stability in elderly patients with CAP (percentage of stable patients by day 7, 71%; 95% CI, 68%-74% vs 57%; 95% CI, 53%-61%, respectively; P < 0.01). All elderly patients should be vaccinated against pneumococcal disease and influenza based on recommendations from the Centers for Disease Control and Prevention. Lifestyle modifications and nutritional support are also important elements in the prevention of pneumonia in the elderly. Conclusion: Adherence to established guidelines, along with customization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk factors, likely will improve the treatment outcome of elderly patients with CAP. © 2010 Excerpta Medica Inc. All rights reserved.
Goldstein N.,Mount Sinai School of Medicine |
Carlson M.,Mount Sinai School of Medicine |
Livote E.,James ters Veterans Affairs Medical Center |
Kutner J.S.,University of Colorado at Denver
Annals of Internal Medicine | Year: 2010
Background: Communication about the deactivation of implantable cardioverter-defibrillators (ICDs) in patients near the end of life is rare. Objective: To determine whether hospices are admitting patients with ICDs, whether such patients are receiving shocks, and how hospices manage ICDs. Design: Cross-sectional survey. Setting: Randomly selected hospice facilities. Participants: 900 hospices, 414 of which responded fully. Measurements: Frequency of admission of patients with ICDs, frequency with which patients received shocks, existence of ICD deactivation policies, and frequency of deactivation. Results: 97% of hospices admitted patients with ICDs, and 58% reported that in the past year, a patient had been shocked. Only 10% of hospices had a policy that addressed deactivation. On average, 42% (95% CI, 37% to 48%) of patients with ICDs had the shocking function deactivated. Limitation: The study relied on the knowledge of hospice administrators. Conclusion: Hospices are admitting patients with ICDs, and patients are being shocked at the end of life. Ensuring that hospices have policies in place to address deactivation may improve the care for patients with these devices. The authors provide a sample deactivation policy (available at www.annals.org). Primary Funding Source: National Institute of Aging and National Institute of Nursing Research.
Pratchett L.C.,James ters Veterans Affairs Medical Center |
Yehuda R.,James ters Veterans Affairs Medical Center
Development and Psychopathology | Year: 2011
The effects of childhood abuse are diverse, and although pathology is not the only outcome, psychiatric illness, including posttraumatic stress disorder (PTSD), can develop. However, adult PTSD is less common among those who experienced single-event traumas as children than it is among those who experienced childhood abuse. In addition, PTSD is more common among adults than children who experienced childhood abuse. Such evidence raises doubt about the direct, causal link between childhood trauma and adult PTSD. The experience of childhood trauma, and in particular abuse, has been identified as a risk factor for subsequent development of PTSD following exposure to adult trauma, and a substantial literature identifies revictimization as a factor that plays a pivotal role in this trajectory. The literature on the developmental effects of childhood abuse and pathways to revictimization, when considered in tandem with the biological effects of early stress in animal models, may provide some explanations for this. Specifically, it seems possible that permanent sensitization of the hypothalamic-pituitary-adrenal axis and behavioral outcomes are a consequence of childhood abuse, and these combine with the impact of retraumatization to sustain, perpetuate, and amplify symptomatology of those exposed to maltreatment in childhood. © 2011 Cambridge University Press.
Post J.B.,James ters Veterans Affairs Medical Center
American Journal of Kidney Diseases | Year: 2010
Biocompatibility of a dialyzer membrane has been defined largely by the degree to which it activates complement. Modifications of the cellulose membrane and the development of synthetic membranes have minimized the activation of complement and its associated complications. However, less is known about the blood-dialyzer membrane interactions that may occur in membranes made of the same synthetic polymer. A patient is described who developed dialysis-associated thrombocytopenia using a Fresenius Medical Care Optiflux polysulfone membrane (F-160) that significantly improved when switched to the polysulfone Asahi REXEED 25S membrane (AR-25S). A comparison of postdialysis d-dimer level suggests that the F-160 membrane activated the coagulation pathway to a greater extent than the AR-25S. Subtle differences between the internal surfaces of the membranes that are manufacturer specific may be responsible for exposing this patient's unique predisposition to thrombosis and thrombocytopenia. Despite the advances in membrane biocompatibility, differences may exist among membranes made of the same synthetic polymer.
Siu A.L.,Mount Sinai School of Medicine |
Siu A.L.,James ters Veterans Affairs Medical Center
JAMA - Journal of the American Medical Association | Year: 2016
DESCRIPTION New US Preventive Services Task Force (USPSTF) recommendation on screening for autism spectrum disorder (ASD) in young children. METHODS The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of brief, formal screening instruments for ASD administered during routine primary care visits and the benefits and potential harms of early behavioral treatment for young children identified with ASD through screening. POPULATION This recommendation applies to children aged 18 to 30 months who have not been diagnosed with ASD or developmental delay and for whom no concerns of ASD have been raised by parents, other caregivers, or health care professionals. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in young children for whom no concerns of ASD have been raised by their parents or a clinician. (I statement). © 2016 American Medical Association.
Siu A.L.,Mount Sinai School of Medicine |
Siu A.L.,James ters Veterans Affairs Medical Center
Annals of Internal Medicine | Year: 2015
Description: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on counseling and interventions to prevent tobacco use and tobacco-related disease in adults, including pregnant women. Methods: The USPSTF reviewed the evidence on interventions for tobacco smoking cessation that are relevant to primary care (behavioral interventions, pharmacotherapy, and complementary or alternative therapy) in adults, including pregnant women. Population: This recommendation applies to adults aged 18 years or older, including pregnant women. Recommendations: The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration-approved pharmacotherapy for cessation to adults who use tobacco. (A recommendation) The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. (A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. (I statement) The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated). (I statement) © 2015 American College of Physicians.
Walker R.H.,Mount Sinai School of Medicine |
Walker R.H.,James ters Veterans Affairs Medical Center
Current Neurology and Neuroscience Reports | Year: 2011
Chorea is a common movement disorder that can be caused by a large variety of structural, neurochemical (including pharmacologic), or metabolic disturbances to basal ganglia function, indicating the vulnerability of this brain region. The diagnosis is rarely indicated by the simple phenotypic appearance of chorea, and can be challenging, with many patients remaining undiagnosed. Clues to diagnosis may be found in the patient's family or medical history, on neurologic examination, or upon laboratory testing and neuroimaging. Increasingly, advances in genetic medicine are identifying new disorders and expanding the phenotype of recognized conditions. Although most therapies at present are supportive, correct diagnosis is essential for appropriate genetic counseling, and ultimately, for future molecular therapies. © Springer Science+Business Media, LLC 2011.
Chuang P.Y.,Mount Sinai School of Medicine |
Menon M.C.,Mount Sinai School of Medicine |
He J.C.,Mount Sinai School of Medicine |
He J.C.,James ters Veterans Affairs Medical Center
Journal of Molecular Medicine | Year: 2013
Renal fibrosis is the culmination of processes driven by signaling pathways involving transforming growth factor-β family of cytokines, connective-tissue growth factor, nuclear factor κB, Wnt/β-catenin, Notch, and other growth factors. Many studies in experimental animal models have directly targeted these pathways and demonstrated efficacy in mitigating renal fibrosis. However, only a small fraction of these approaches have been attempted in human and even fewer have been successfully translated to clinical use for patient with kidney diseases. Drugs with proven efficacy for treatment of kidney diseases and tissue fibrosis exert some of their effects by interfering with components of these pathways. This review considers key molecular mediators of renal fibrosis and their potential as targets for treatment of renal fibrosis. © 2012 Springer-Verlag Berlin Heidelberg.
Flory J.D.,James ters Veterans Affairs Medical Center |
Flory J.D.,Mount Sinai School of Medicine |
Yehuda R.,James ters Veterans Affairs Medical Center |
Yehuda R.,Mount Sinai School of Medicine
Dialogues in Clinical Neuroscience | Year: 2015
Approximately half of people with post-traumatic stress disorder (PTSD) also suffer from Major Depressive Disorder (MDD). The current paper examines evidence for two explanations of this comorbidity. First, that the comorbidity reflects overlapping symptoms in the two disorders. Second, that the co-occurrence of PTSD and MDD is not an artifact, but represents a trauma-related phenotype, possibly a subtype of PTSD. Support for the latter explanation is inferred from literature that examines risk and biological correlates of PTSD and MDD, including molecular processes. Treatment implications of the comorbidity are considered. © 2015 AICH - Servier Research Group.
Walker R.H.,James ters Veterans Affairs Medical Center
CONTINUUM Lifelong Learning in Neurology | Year: 2013
PURPOSE OF REVIEW: Chorea is a relatively common movement disorder that can be caused by a large variety of structural, autoimmune, neurodegenerative, pharmacologic, and metabolic disturbances of basal ganglia function. The diagnosis is rarely indicated by the phenotypic appearance of chorea and can be challenging, with many patients remaining undiagnosed. This review highlights salient features that may be observed or elicited in the case of a person with chorea, which may provide an indication of the diagnosis. RECENT FINDINGS: Recent advances in genetics have identified genes for new disorders and expanded the phenotype of recognized conditions. New therapies include tetrabenazine, a presynaptic dopamine depleter, and deep brain stimulation. SUMMARY: Clues to diagnosis may be found in the patient's family or medical history, on neurologic examination, or upon laboratory testing and neuroimaging. While most therapies at present are supportive, correct diagnosis is essential for appropriate genetic counseling and ultimately for future molecular therapies. Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.