East Palestine, OH, United States
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Wright J.T.,Case Western Reserve University | Williamson J.D.,Sticht Center on Aging | Whelton P.K.,Tulane University | Snyder J.K.,U.S. National Institutes of Health | And 13 more authors.
New England Journal of Medicine | Year: 2015

BACKGROUND The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain. METHODS We randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk, but without diabetes, to a systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). The primary composite outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. RESULTS At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensivetreatment group and 136.2 mm Hg in the standard-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). All-cause mortality was also significantly lower in the intensivetreatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90; P = 0.003). Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensivetreatment group than in the standard-treatment group. CONCLUSIONS Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. © 2015 Massachusetts Medical Society.


Morgan R.L.,Centers for Disease Control and Prevention | Baack B.,Centers for Disease Control and Prevention | Smith B.D.,Centers for Disease Control and Prevention | Yartel A.,Centers for Disease Control and Prevention | And 2 more authors.
Annals of Internal Medicine | Year: 2013

Background: Hepatitis C virus (HCV) is a leading cause of hepatocellular carcinoma (HCC). In the United States, this form of cancer occurs in approximately 15 000 persons annually. A systematic review of the evidence is needed to assess the benefits of treatment of HCV-infected persons on development of HCC. Purpose: To systematically review observational studies to determine the association between response to HCV therapy and development of HCC among persons at any stage of fibrosis and those with advanced liver disease. Data Sources: MEDLINE, EMBASE, CINAHL, the Cochrane Library, Web of Science, and the Database of Abstracts of Reviews and Effectiveness from inception through February 2012. Study Selection: English-language observational studies that compared therapy-derived sustained virologic response (SVR) with no response to therapy among HCV-infected persons, targeted an adult population, and had an average follow-up of at least 2 years. Data Extraction: Two investigators independently extracted data into uniform relative risk measures. The Grading of Recommendations Assessment, Development and Evaluation framework was used to determine the quality of the evidence. Data Synthesis: Thirty studies fulfilled the inclusion criteria, and 18 provided adjusted effect estimates that were used to calculate pooled relative risks. Among HCV-infected persons, SVR was associated with reduced risk for HCC (relative risk for all persons, 0.24 [95% CI, 0.18 to 0.31], moderate-quality evidence; advanced liver disease hazard ratio, 0.23 [CI, 0.16 to 0.35], moderate-quality evidence). Limitation: In the meta-analyses, some variables could not be controlled for because of the observational design of the included studies. Conclusion: Sustained virologic response after treatment among HCV-infected persons at any stage of fibrosis is associated with reduced HCC. The evidence was determined to be of moderate quality.


Nerandzic M.M.,Louis Stokes Cleveland Veterans Affairs Medical Center | Cadnum J.L.,Louis Stokes Cleveland Veterans Affairs Medical Center | Pultz M.J.,Louis Stokes Cleveland Veterans Affairs Medical Center | Donskey C.J.,Louis Stokes Cleveland Veterans Affairs Medical Center | Donskey C.J.,Geriatric Research
BMC Infectious Diseases | Year: 2010

Background: Environmental surfaces play an important role in transmission of healthcare-associated pathogens. There is a need for new disinfection methods that are effective against Clostridium difficile spores, but also safe, rapid, and automated.Methods: The Tru-D™ Rapid Room Disinfection device is a mobile, fully-automated room decontamination technology that utilizes ultraviolet-C irradiation to kill pathogens. We examined the efficacy of environmental disinfection using the Tru-D device in the laboratory and in rooms of hospitalized patients. Cultures for C. difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) were collected from commonly touched surfaces before and after use of Tru-D.Results: On inoculated surfaces, application of Tru-D at a reflected dose of 22,000 μWs/cm2for ~45 minutes consistently reduced recovery of C. difficile spores and MRSA by >2-3 log10colony forming units (CFU)/cm2and of VRE by >3-4 log10CFU/cm2. Similar killing of MRSA and VRE was achieved in ~20 minutes at a reflected dose of 12,000 μWs/cm2, but killing of C. difficile spores was reduced. Disinfection of hospital rooms with Tru-D reduced the frequency of positive MRSA and VRE cultures by 93% and of C. difficile cultures by 80%. After routine hospital cleaning of the rooms of MRSA carriers, 18% of sites under the edges of bedside tables (i.e., a frequently touched site not easily amenable to manual application of disinfectant) were contaminated with MRSA, versus 0% after Tru-D (P < 0.001). The system required <5 minutes to set up and did not require continuous monitoring.Conclusions: The Tru-D Rapid Room Disinfection device is a novel, automated, and efficient environmental disinfection technology that significantly reduces C. difficile, VRE and MRSA contamination on commonly touched hospital surfaces. © 2010 Nerandzic et al; licensee BioMed Central Ltd.


Roncone D.P.,Louis Stokes Cleveland Veterans Affairs Medical Center
Optometry | Year: 2011

Background: Keratoectasia is a rare but well-known complication after laser-assisted in situ keratomileusis (LASIK). Patients with this condition can have high and irregular astigmatism. When the treatment of the high astigmatic correction cannot be accomplished surgically or when the keratoectasia patient rejects surgical enhancement, optical correction with devices such as soft or rigid gas-permeable contact lenses may be pursued. In fact, toric soft contact lenses are a good first option for fitting postoperative keratoectasia patients. Case report: A 58-year-old white male presented for an examination with a complaint of decreased distance vision in the right eye (OD) after having traditional LASIK for myopia with astigmatism in both eyes (OU) in 1999 and limbal relaxing incision enhancement OD in 2003. Refraction showed high mixed astigmatism OD (+1.75 -5.75×075). Slit lamp examination found irregularity of the cornea, evidenced by an inferior cone with pigmented Fleischer ring OD. Video keratometry had keratometry readings of 43.50 at 160, 39.87 at 070, elevated shape measure (0.40), elevated corneal irregularity measure (3.96), an inferior cone on the elevation map, and asymmetric bowtie with elongation inferonasally on the axial map, which confirmed the diagnosis of postoperative keratoectasia. Because new surgical treatments at that time for corneal ectasia were in their infancy and not approved by the U.S. Food and Drug Administration, the patient opted for a trial toric soft contact lens fitting, which improved his corrected distance visual acuity to 20/25. Conclusion: This case report confirms that toric soft contact lenses are a good first choice in fitting patients with high and irregular astigmatism from postoperative LASIK corneal ectasia. It also confirms that excellent vision and comfort with toric soft contact lenses is possible in these patients. © 2011.


Donskey C.J.,Louis Stokes Cleveland Veterans Affairs Medical Center | Kundrapu S.,Case Western Reserve University | Deshpande A.,Cleveland Clinic
Infectious Disease Clinics of North America | Year: 2015

Asymptomatic carriage of toxigenic strains of Clostridium difficile is common in health care facilities and the community. However, infection control efforts have traditionally focused almost entirely on symptomatic patients. There is now growing concern that asymptomatic carriers may be an underappreciated source of transmission. This article provides an overview of the pathogenesis and epidemiology of C difficile colonization, reviews the evidence that asymptomatic carriers shed spores and contribute to transmission, and examines practical issues related to prevention of transmission from carriers. © 2015.


Iacopetti C.L.,Case Western Reserve University | Packer C.D.,Louis Stokes Cleveland Veterans Affairs Medical Center
Clinical Medicine and Research | Year: 2014

Cannabis is the most widely used illicit drug in the United States, with lifetime prevalence of use estimated at 42% to 46%. The antiemetic properties of cannabis are well-known by the medical community and the general public; however, less well-recognized is the paradoxical potential for certain chronic users to develop hyperemesis. We describe in this case a patient with prior extensive work-up for nausea and vomiting and previous diagnosis of cyclic vomiting syndrome who presented with characteristic features of cannabinoid hyperemesis syndrome. We review the current literature for this condition and highlight potential mechanisms for its pathogenesis. © 2014 Marshfield Clinic.


Palmer E.C.,Sullivan University | Binns L.N.,Southern Arizona Veterans Affairs Healthcare System | Carey H.,Louis Stokes Cleveland Veterans Affairs Medical Center
Annals of Pharmacotherapy | Year: 2014

Objective: To provide a clinical overview of the antidepressant levomilnacipran. Data Sources: Articles were identified by searching the MEDLINE, PubMed, Cochrane Library, and Clinicaltrials.gov databases through March 2014 using the keyword levomilnacipran. The manufacturer provided additional information from unpublished phase II and phase III trials. Study Selection and Data Extraction: Any clinical trial conducted for at least 3 weeks and published in the English language was selected for review. Additional documentation, including the product dossier, package insert, pharmacokinetic studies, and poster presentations supplied by the manufacturer, was also evaluated. Data Synthesis: Levomilnacipran is the more potent enantiomer of milnacipran. It is a selective serotonin and norepinephrine reuptake inhibitor (SNRI), dosed from 20 to 120 mg daily for the treatment of major depressive disorder (MDD). Efficacy and tolerability were established during 3 phase III randomized, double-blind placebo-controlled trials finding levomilnacipran to be significantly more efficacious than placebo in reduction of Montgomery-Åsberg Depression Rating Scale scores. It is not known whether this agent is more efficacious than other antidepressants because direct comparison studies have not been conducted as of the time of this review. Conclusions: Levomilnacipran demonstrates efficacy and tolerability for short-term treatment of MDD in adults. Available evidence does not strongly indicate that there is a specific subpopulation of patients who would benefit from levomilnacipran over currently available SNRIs. Full characterization of the agent's place in therapy alongside multiple other agents with similar mechanisms and efficacy requires trials with longer duration and active comparators. © The Author(s) 2014.


Jain M.K.,Case Western Reserve University | Sangwung P.,Case Western Reserve University | Hamik A.,Case Western Reserve University | Hamik A.,Louis Stokes Cleveland Veterans Affairs Medical Center
Arteriosclerosis, Thrombosis, and Vascular Biology | Year: 2014

This invited review summarizes work presented in the Russell Ross lecture delivered at the 2012 proceedings of the American Heart Association. We begin with a brief overview of the structural, cellular, and molecular biology of Krüppel-like factors. We then focus on discoveries during the past decade, implicating Krüppel-like factors as key determinants of vascular cell function in atherosclerotic vascular disease. © 2013 American Heart Association, Inc.


Chee C.E.,Case Western Reserve University | Chee C.E.,Louis Stokes Cleveland Veterans Affairs Medical Center | Meropol N.J.,Case Western Reserve University
Oncologist | Year: 2014

The decision regarding adjuvant therapy for patients with stage II colon cancer remains a challenge. In contrast to stage III colon cancer, for which compelling clinical data support the use of adjuvant chemotherapy, the clinical benefit of systemic therapy in unselected patients with stage II disease is modest at best. Risk stratification based on clinicopathologic features and DNA mismatch repair status is commonly used in adjuvant therapy decisions, but these factors do not have a desired level of precision in identifying patients at high risk. Recently, gene expression platforms have been developed to further define risk and to assist in therapeutic decision making for patients with stage II disease. This review describes those platforms that are furthest along in clinical development, in an effort to place their potential clinical application in context. © AlphaMed Press 2014.


Naylor M.D.,University of Pennsylvania | Aiken L.H.,University of Pennsylvania | Kurtzman E.T.,George Washington University | Olds D.M.,Louis Stokes Cleveland Veterans Affairs Medical Center | Hirschman K.B.,University of Pennsylvania
Health Affairs | Year: 2011

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments. © 2011 by Project HOPE - The People-to-People Health Foundation, Inc.

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