Lyndon B Johnson General Hospital

Houston, TX, United States

Lyndon B Johnson General Hospital

Houston, TX, United States
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Vance D.A.,Neonatal Intensive Care Unit | Demel S.,Dell | Kirksey K.,Lyndon B Johnson General Hospital | Moynihan M.,Neonatal Intensive Care Unit | Hollis K.,Seton Healthcare Family
Advances in Neonatal Care | Year: 2015

Background: Infants, especially those born prematurely, are at increased risk for skin breakdown because of the immaturity and fragility of their skin. Following a review of existing skin risk assessment tools, we concluded that none provided valid, clear, and concise assessment criteria and direction for treatment interventions specifically for use with neonates. Purpose: To examine the risk factors of skin breakdown in infants using the knowledge of interprofessional providers who routinely care for infants. Combined with scientific knowledge, this could potentially result in a valid, reliable, and useable skin risk assessment tool. Methods: Using an online survey tool, 2 rounds of the Delphi technique were conducted with interprofessional providers who routinely care for infants. During round 1, participants were asked, "What do you perceive as risk factors for skin breakdown in neonates?" Responses for round 1 were categorized into themes. In round 2, respondents were asked to rank the importance of these themes using a 5-point Likert scale. Results: These data resulted in the creation of the Seton Infant Skin Risk Assessment Tool, currently being further validated through a retrospective chart review. Responses were categorized into themes, including the use of medical devices, postmenstrual age/birth weight, activity/movement, comorbidities, skin integrity/tolerance, moisture/chemicals, and nutrition/hydration. Implications for Practice: All infants in neonatal intensive care units (NICUs) are at risk of skin breakdown. Matching a risk assessment tool with routine skin assessment and a risk-related care plan could result in a reduction of skin breakdown in these infants. Implications for Research: A retrospective study of infants in 2 Level III NICUs and 1 Level IV NICU is being finalized, which will result in an infant skin risk assessment tool as well as a tool describing methods to minimize each risk factor. Further research will be needed to test the interrater reliability and validity of the tool and increase knowledge of skin breakdown prevention practices. © 2015 by the National Association of Neonatal Nurses.

Chung C.,Lyndon B Johnson General Hospital | Pherwani N.,Cardinal Health
American Journal of Health-System Pharmacy | Year: 2013

Purpose. The pharmacology, pharmacokinetics, clinical efficacy, safety, and administration of ziv-aflibercept in combination therapy for metastatic colorectal cancer (mCRC) are reviewed. Summary. Ziv-aflibercept (Zaltrap, Regeneron Pharmaceuticals and sanofi-aventis) is a novel recombinant fusion protein that targets the angiogenesis signaling pathway of tumor cells by blocking vascular endothelial growth factor (VEGF) receptors that play a key role in tumor growth and metastasis; it is a more potent VEGF blocker than bevacizumab. Ziv-aflibercept is approved by the Food and Drug Administration for use in combination with fluorouracil, irinotecan, and leucovorin (the FOLFIRI regimen) for second-line treatment of patients with mCRC who have disease progression during first-line oxaliplatin-based chemotherapy. A Phase III trial demonstrated that relative to FOLFIRI therapy alone, the use of ziv-aflibercept was associated with significantly improved patient response, overall survival, and progression-free survival in patients with good performance status at baseline, including some who had received prior bevacizumab therapy. The most common grade 3 or 4 adverse effects associated with ziv-aflibercept use in clinical studies were neutropenia, hypertension, and diarrhea; the U.S. product labeling warns of potential hemorrhage and other treatment-related risks. Conclusion. Current clinical data are insufficient to directly compare ziv-aflibercept and bevacizumab when used with standard combination chemotherapy as first- or second-line regimens for mCRC. The role of ziv-aflibercept is currently limited to the second-line setting in combination with irinotecan-based regimens in mCRC patients who have not received irinotecan previously. The role of ziv-aflibercept in chemotherapy for other tumor types is yet to be determined. Copyright © 2013 American Society of Health-System Pharmacists Inc. All rights reserved.

Banki F.,University of Houston | Khalil K.,University of Houston | Kott M.M.,University of Houston | Kott M.M.,Lyndon B Johnson General Hospital | Cota A.L.,University of Houston
Annals of Thoracic Surgery | Year: 2010

Thymic carcinomas are rare malignant neoplasms. We present a case of adenoid cystic carcinoma of thymus in a 65-year-old woman that was initially misdiagnosed and was treated as non-small cell carcinoma of the lung. We describe the clinical and pathologic features of this extremely rare thymic epithelial tumor, with survival at 2 years and 6 months of follow-up. © 2010 The Society of Thoracic Surgeons.

Babbar S.,Truman Medical Center Hospital Hill | Chauhan S.P.,Lyndon B Johnson General Hospital
Journal of Maternal-Fetal and Neonatal Medicine | Year: 2015

The primary objective of this survey was to ascertain the opinions, practices and knowledge about exercise, including yoga, during pregnancy; the secondary objective to compare the responses among women with body mass index (BMI) <30kg/m versus ≥30kg/m. Survey consisted of 20 multiple choice questions assessing demographics and exercise practices, and five questions testing their knowledge about it during pregnancy (ACOG Committee Opinion # 267). Of the 500 surveys distributed, 84% (422) responses were analyzed. While 86% of women responded that exercise during pregnancy is beneficial, 83% felt it was beneficial to start prior to pregnancy, and walking was considered the most beneficial (62%). The majority (64%) of respondents were currently exercising during pregnancy and 51% exercised 2-3 times/week. Among the five questions testing knowledge about prenatal exercise, majority (range 60 to 92%) were aware of ACOG recommendations. About half had a BMI ≥30. Knowledge about benefits of exercise during pregnancy did not differ significantly between obese and non-obese. Yoga was tried significantly more among non-obese, 65% believed it is beneficial, and 40% had attempted yoga before pregnancy. In our population, the majority believes that exercise, including yoga, is beneficial and they are active. © 2014 Informa UK Ltd. All rights reserved: reproduction in whole or part not permitted.

Chung C.,Lyndon B Johnson General Hospital | Reilly S.,Ben Taub General Hospital
American Journal of Health-System Pharmacy | Year: 2015

Purpose. The pharmacology, pharmacokinetics, clinical efficacy, safety, administration, cost, and place in therapy of trametinib for the treatment of metastatic melanoma are reviewed. Summary. Approximately 40-60% of malignant melanomas have gene mutations at codon 600 of the BRAF gene that result in the activation of the mitogen-activated protein kinase (MAPK) pathway. Trametinib is the first-in-class mitogen-activated, extracellular signal-regulated kinase (MEK) inhibitor that targets a kinase in the MAPK pathway that plays a key role in oncogenic cell proliferation, survival, invasion, tumor angiogenesis, and escape from apoptosis. It is approved by the Food and Drug Administration for use in patients whose tumors express the BRAF V600E or V600K gene mutations. Moreover, trametinib is also indicated for use in combination with dabrafenib (a BRAF inhibitor). Trametinib is not indicated in patients who have received prior BRAF-inhibitor therapy due to poor response and possible cross- resistance. The most common adverse effects associated with the use of trametinib for both monotherapy and combination therapy are rash, diarrhea, peripheral edema, fatigue, and dermatitis. The recommended dosage of trametinib monotherapy is 2 mg orally once daily until disease progression or unacceptable toxicity occurs. With a daily dose of 2 mg, an estimated 30-day course of treatment would cost approximately $9135. Conclusion. Trametinib, a novel MEK inhibitor, provides an alternative therapy for patients with BRAF V600 E/K metastatic melanoma as a single agent or in combination therapy for patients not previously treated with a BRAF inhibitor. More studies are needed to determine the safe and effective combination or sequencing of trametinib with other therapies. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved.

Chung C.,Lyndon B Johnson General Hospital | Chung C.,Kennewick General Hospital | Lam M.S.H.,Kaiser Permanente
American Journal of Health-System Pharmacy | Year: 2013

Purpose. The pharmacology, pharmacokinetics, clinical efficacy, safety, and administration of pertuzumab in patients with metastatic human epidermal growth factor receptor type 2 (HER2)-positive breast cancer are reviewed. Summary. Disease progression in HER2-positive breast cancer is often due to resistance to or a lack of efficacy of trastuzumab-based anti-HER2 therapy. Pertuzumab is the first humanized monoclonal antibody in a new class of drugs, the HER dimerization inhibitors, approved by the Food and Drug Administration for the first-line treatment of patients with metastatic HER2-positive breast cancer who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease. Since pertuzumab binds to a different epitope than trastuzumab, combination therapy with pertuzumab and trastuzumab results in a more complete blockade of HER2 signaling than trastuzumab monotherapy. The efficacy of adding pertuzumab to trastuzumab-docetaxel dual therapy was demonstrated in a pivotal randomized multicenter Phase III trial, which showed a significant benefit in terms of progression-free survival, with improved overall survival, in favor of the triple therapy as an initial regimen in treatment-naive patients with metastatic HER2-positive breast cancer. The combination of pertuzumab and trastuzumab has been found to have a tolerable toxicity profile. As clinical trials of pertuzumab for adjuvant, neoadjuvant, and metastaticdisease treatment continue, its role in the treatment of HER2-positive breast cancer will continue to evolve. Conclusion. Pertuzumab, a novel HER2 dimerization inhibitor, has been shown to be effective in the treatment of metastatic HER2-positive breast cancer when used in combination with trastuzumab and docetaxel and is recommended for first-line therapy. Copyright © 2013 American Society of Health-System Pharmacists Inc. All rights reserved.

Orejuela F.J.,University of Texas Health Science Center at Houston | Orejuela F.J.,Lyndon B Johnson General Hospital | Shek K.L.,University of Sydney | Dietz H.P.,University of Sydney
International Urogynecology Journal and Pelvic Floor Dysfunction | Year: 2012

Introduction and hypothesis: The goal of the study was to define the time needed to obtain maximal organ descent and hiatal distension during Valsalva measured by transperineal ultrasound. Secondarily, we aimed to describe the timing of these events in relationship to each other. Methods: We undertook a retrospective review of the stored ultrasound volume datasets of 50 patients with pelvic organ prolapse. Data on organ descent and hiatal distension were obtained in 10 volumes from rest to maximal Valsalva. Results: On average, a Valsalva maneuver lasted 9.4 s (range 5 to 18). It took patients on average about six volumes (approximately 5-6 s) to reach 80% of maximum organ descent. The time to maximum organ descent was 8.9 s and the time to maximum distension of the levator hiatus was 8.2 s, p=0.031. Conclusions: In order to obtain adequate assessment of pelvic organ prolapse, a Valsalva maneuver should last at least 6 s. Hiatal distension seems to precede pelvic organ descent. © The International Urogynecological Association 2011.

Chung C.,Lyndon B Johnson General Hospital
American Journal of Health-System Pharmacy | Year: 2014

Purpose. The pharmacology, pharmacokinetics, clinical efficacy, and safety of a first-in-class protein synthesis inhibitor for use in treatment-resistant chronic myeloid leukemia (CML) are reviewed. Summary. Omacetaxine mepesuccinate (Synribo, Teva Pharmaceuticals) is a potent plant alkaloid isolated from Cephalotaxus (Chinese yew tree) species. It has a mechanism of action distinct from that of the standard first-line therapy for CML, tyrosine kinase inhibitors (TKIs), and has demonstrated efficacy in adult patients with chronic- or accelerated-phase CML who develop intolerance to two or more TKIs or experience multiple TKI treatment failures. Two open-label Phase II trials (combined n = 108) demonstrated that omacetaxine produced a major cytogenetic response in 18.4% of patients with chronic-phase CML and a major hematologic response in 14.3% of patients with accelerated-phase CML (median duration of reponse, 12.5 and 4.7 months, respectively). Symptom improvement or improved overall survival in omacetaxine-treated patients has not been demonstrated. In clinical trials to date, the most common grade 1-4 adverse reactions included thrombocytopenia, anemia, neutropenia, diarrhea, nausea, fatigue, and asthenia. The drug is administered subcutaneously on an intermittent schedule (14 days on, 14 days off during induction; 7 days on, 21 days off during maintenance). Research to better delineate omacetaxine's optimal role in the management of CML and other hematologic malignancies (e.g., acute myelogenic leukemia) is ongoing. Conclusion. Omacetaxine, a novel protein synthesis inhibitor, provides an alternative therapy for patients with CML who have experienced TKI treatment failures or are intolerant of two or more TKIs. Copyright © 2014 American Society of Health-System Pharmacists Inc. All rights reserved.

The presence of activating gene mutations in the epidermal growth factor receptor of non-small cell lung cancer patients is predictive (improved progression-free survival and improved response rate) when treated with small molecule tyrosine kinase inhibitors such as gefitinib, erlotinib and afatinib. The two most common mutations that account for greater than 85% of all EGFR gene mutations are in-frame deletions in exon 19 (LREA deletions) and substitution in exon 21 (L858R). Exon 18 mutations occur much less frequently at about 4% of all EGFR gene mutations. Together, exon 19 deletion and exon 21 L858R gene substitution are present in about 10% of Caucasian patients and 20-40% of Asian patients with non-small cell lung cancer. T790M gene mutation at exon 20 is associated with acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors. Early studies showed that activating EGFR gene mutations are most common in patients with adenocarcinoma histology, women, never smokers and those of Asian ethnicity. A recent multi-center phase III trial suggested that frontline epidermal growth factor receptor tyrosine kinase inhibitor therapy with afatinib is associated with improved progression-free survival compared to chemotherapy regardless of race. Moreover, guidelines now suggest EGFR gene mutation testing should be conducted in all patients with lung adenocarcinoma or mixed lung cancers with an adenocarcinoma component, regardless of characteristics such as smoking status, gender or race. The success of targeted therapies in non-small cell lung cancer patients has changed the treatment paradigm in metastatic non-small cell lung cancer. However, despite a durable response of greater than a year, resistance to epidermal growth factor receptor tyrosine kinase inhibitors inevitably occurs. This mini-review describes the clinically relevant EGFR gene mutations and the efficacy/toxicity of small molecule epidermal growth factor receptor tyrosine kinase inhibitors as targeted therapies for these gene mutations. Therapeutic strategies to overcome resistance, including emerging and novel therapies, are discussed. © The Author(s) 2015.

Chung C.,Lyndon B Johnson General Hospital | Lee R.,Harris Health System
Pharmacotherapy | Year: 2014

Chronic lymphocytic leukemia (CLL) is a neoplasm resulting from the progressive accumulation of functionally incompetent monoclonal B lymphocytes in the blood, bone marrow, lymph nodes, and spleen. It is the most common leukemia in Western countries and typically occurs in elderly patients. Initial treatment of CLL often includes a first-generation anti-CD20 antibody (rituximab) with chemotherapy and is the current standard of treatment for "younger" old adults (< 70 yrs of age) or older, clinically fit patients. However, because disease progression and drug resistance are inevitable, patients typically die from their disease or treatment-related complications. Improved understanding of the B-cell receptor signaling pathway, which is essential for normal B-cell growth and tumorigenesis, has led to the development of targeted therapies, with improved short-term clinical outcomes. Ibrutinib, obinutuzumab, and idelalisib, three novel agents recently approved by the U.S. Food and Administration for CLL, all have the potential to change the treatment paradigm. In this article, we describe the pathogenesis of CLL and some of its prognostic factors. Emphasis is on the pharmacology, dosing, clinical efficacy, safety, and place of therapy of ibrutinib, obinutuzumab, and idelalisib. Investigational agents that target different parts of the CLL pathogenic pathway are also described. © 2014 Pharmacotherapy Publications, Inc.

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