Memorial Hermann Texas Medical Center

Houston, TX, United States

Memorial Hermann Texas Medical Center

Houston, TX, United States
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Gonzalez-Lara M.F.,Instituto Nacional Of Ciencias Medicas Y Nutricion Salvador Zubiran | Sifuentes-Osornio J.,Instituto Nacional Of Ciencias Medicas Y Nutricion Salvador Zubiran | Ostrosky-Zeichner L.,Memorial Hermann Texas Medical Center
Drugs | Year: 2017

Despite increasing rates of invasive fungal infections being reported globally, only a single antifungal drug has been approved during the last decade. Resistance, toxicity, drug interactions and restricted routes of administration remain unresolved issues. This review focuses on new antifungal compounds which are currently in various clinical phases of development. We discuss two azoles with a tetrazole moiety that allows selective activity against the fungal CYP: VT-1161 for Candida infections and VT-1129 for cryptococcal meningoencephalitis. We also discuss two glucan synthesis inhibitors: CD101, an echinocandin with an increased half-life, and SCY-078 with oral bioavailability and increased activity against echinocandin-resistant isolates. Among the polyenes, we discuss MAT023, an encochleated amphotericin B formulation that allows oral administration. Two novel classes of antifungal drugs are also described: glycosylphosphatidylinositol inhibitors, and the leading drug APX001, which disrupt the integrity of the fungal wall; and the orotomides, inhibitors of pyrimidine synthesis with the leading drug F901318. Finally, a chitin synthesis inhibitor and progress on human monoclonal antifungal antibodies are discussed. © 2017 Springer International Publishing AG

Sieg A.,Memorial Hermann Texas Medical Center | Nappi J.,Medical University of South Carolina
Journal of Pharmacy Technology | Year: 2015

Background: Anticoagulation is standard practice for the prevention and treatment of thromboembolic events. Two of the newer agents, rivaroxaban (Xarelto) and dabigatran (Pradaxa) are being utilized frequently in the inpatient and outpatient settings. Prescribers may not appreciate the need for dose reduction in the setting of renal insufficiency. Objective: The objective of this study was to evaluate whether rivaroxaban and dabigatran were dosed according to recommendations in the package insert for patients with renal insufficiency. Methods: Eligible patients were those >18 years of age who received rivaroxaban or dabigatran as an inpatient or had a prescription filled from the outpatient pharmacy. The use of the Cockcroft-Gault equation was utilized to calculate creatinine clearance to evaluate whether patients had appropriate manufacturer recommended dose reductions based on their renal function. Results: There were very few patients (8 of 355, or 2.3%) who should have received a reduced dose when creatinine clearance was calculated utilizing actual body weight. In those patients with renal insufficiency, 3 of 6 (50.0%) patients receiving rivaroxaban and 1 of 2 (50%) patients receiving dabigatran were appropriately dosed. When ideal body weight was substituted for creatinine clearance calculation, there were 15 patients receiving rivaroxaban and 10 patients receiving dabigatran who fell below the creatinine clearance threshold for dose reduction. Conclusions: Based on this evaluation, very few patients required a dose reduction due to renal insufficiency. It is important for clinicians to always monitor renal function when utilizing these medications to optimize the benefits of the new oral anticoagulants while limiting potential deleterious effects. Furthermore, it is necessary to ensure that actual body weight is being utilized for creatinine clearance calculations with the new oral anticoagulants and not to base dosing on estimated glomerular filtration rate or other calculated creatinine clearance as this could lead to inappropriate dose reductions. © The Author(s) 2015.

Roldan C.J.,University of Houston | Roldan C.J.,University of Texas Health Science Center at Houston | Roldan C.J.,Memorial Hermann Texas Medical Center | Roldan C.J.,Lyndon B Johnson General Hospital | And 3 more authors.
Pain Physician | Year: 2017

Background: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) have sufficient scientific support for their use as tissue protectors. Preliminary studies suggest that their angiotensin-II type 2 receptor (AT2R)-blocking properties have a beneficial profile in the treatment of neuropathic pain. Objectives: The purpose of the current study was to quantify the extent of the somatosensory effects of ACEI and ARB in cancer patients with chemotherapy-induced peripheral neuropathy. Study Design: We performed a retrospective review of cancer patients with peripheral neuropathy of the upper limbs induced by known neurotoxic anti-cancer agents. Setting: Pain Medicine department at academic tertiary care cancer center. Methods: Using our quantitative sensory testing (QST) data bank, we retrospectively compared the tactile function and the touch, sharp, and thermal thresholds of patients who were previously receiving ACEI or ARB for high blood pressure with these variables in controls who were not receiving ACEI or ARB. Results: Of the 209 patients available for analysis, 145 met inclusion criteria. Baseline characteristics of patients included were generally similar. We identified 29 patients who were receiving AT2R inhibitors prior to starting chemotherapy. Touch thresholds were statistically lower in the thenar aspect of hand in the study group (patients who received AT2R inhibitors) than in the control group [mean (± SD), median 3.03 g (± 11.05), median 0.56 g and 6.75 g (± 18.28), 0.56 g, respectively (P = 0.0441)]. Similarly, the cold pain threshold was statistically higher at the thenar area for the study group [mean (± SD), median 13.23°C (± 8.02), 11.73°C] than for controls [9.89°C (± 6.62), 10.05°C (P = 0.0369)]. Limitations: Inadequacies in the original data acquisition and documentation of the QST and the medical records could not be addressed due to the retrospective nature of the study. Similarly, a discrepancy on the size of the comparison groups could not be reconciled. In addition, based on the available information and the lack of documented concomitant pain levels, we did not find an objective parameter able to correlate the QST findings with pain levels. Conclusions: AT2R inhibitors might offer partial and selective neuroprotective qualities of the myelinated fibers A-β and A-δ in cancer patients who receive neurotoxic chemotherapy. © 2017, American Society of Interventional Pain Physicians. All rights reserved.

Lee Y.,Memorial Hermann Texas Medical Center | Weeks P.A.,Memorial Hermann Texas Medical Center
ASAIO Journal | Year: 2015

The purpose of this analysis is to assess the effectiveness of heparin anticoagulation in cardiogenic shock patients with TandemHeart percutaneous ventricular assist device support for which the institution's TandemHeart heparin protocol was implemented compared to those managed without protocol. This retrospective analysis included 15 patients in the protocol group and 10 patients in the nonprotocol group. Patients in the protocol group had a higher percentage of therapeutic activated partial thromboplastin time (aPTT) and lower percentage of supra-therapeutic aPTT values compared to the nonprotocol group. We conclude that TandemHeart anticoagulation may be more effectively managed through the use of a protocol than without any protocol. © 2014 by the American Society for Artificial Internal Organs.

Ostrosky-Zeichner L.,University of Houston | Ostrosky-Zeichner L.,Memorial Hermann Texas Medical Center
American Journal of Medicine | Year: 2012

Despite the availability of newer antifungal drugs, outcomes for patients with invasive fungal infections (IFIs) continue to be poor, in large part due to delayed diagnosis and initiation of appropriate antifungal therapy. Standard histopathologic diagnostic techniques are often untenable in at-risk patients, and culture-based diagnostics typically are too insensitive or nonspecific, or provide results after too long a delay for optimal IFI management. Newer surrogate markers of IFIs with improved sensitivity and specificity are needed to enable earlier diagnosis and, ideally, to provide prognostic information and/or permit therapeutic monitoring. Surrogate assays should also be accessible and easy to implement in the hospital. Several nonculture-based assays of newer surrogates are making their way into the medical setting or are currently under investigation. These new or up-and-coming surrogates include antigens/antibodies (mannan and antimannan antibodies) or fungal metabolites (d-arabinitol) for detection of invasive candidiasis, the Aspergillus cell wall component galactomannan used to detect invasive aspergillosis, or the fungal cell wall component and panfungal marker β-glucan. In addition, progress continues with use of polymerase chain reaction or other nucleic acid or molecular-based assays for diagnosis of either specific or generic IFIs, although the various methods must be better standardized before any of these approaches can be more fully implemented into the medical setting. Investigators are also beginning to explore the possibility of combining newer surrogate markers with each other or with more standard diagnostic approaches to improve sensitivity, specificity, and capacity for earlier diagnosis, at a time when fungal burden is still relatively low and more responsive to antifungal therapy.

Weeks P.A.,Memorial Hermann Texas Medical Center | Sieg A.,Memorial Hermann Texas Medical Center | Gass J.A.,Memorial Hermann Texas Medical Center | Rajapreyar I.,University of Texas Health Science Center at Houston
Heart Failure Reviews | Year: 2016

Sudden cardiac death remains a significant threat to the survival of patients with heart failure. Long-term cardiac remodeling predisposes these patients to develop malignant ventricular arrhythmias. Permanent implantable and temporary external defibrillators remain a mainstay for the prevention of sudden cardiac death in this population. For decades, researchers have attempted to identify reliable drug therapies to avoid such arrhythmias; however, to date, success has been inconsistent. This review aims to explore the evidence defining the role of drug therapies for direct and indirect suppression of arrhythmias that may cause sudden cardiac death in patients with heart failure. © 2016, Springer Science+Business Media New York.

PubMed | Memorial Hermann Texas Medical Center and University of Houston
Type: Journal Article | Journal: Pharmacotherapy | Year: 2016

To determine the safety and efficacy of high-dose subcutaneous unfractionated heparin (UFH) for prevention of venous thromboembolism (VTE) in overweight and obese patients.Single-center retrospective observational cohort study.Large academic tertiary care medical center.A total of 1335 adults who weighed more than 100 kg on admission and received either subcutaneous UFH 7500 units every 8 hours (751 patients [high-dose group]) or 5000 units every 8 hours (584 patients [low-dose group]) for VTE prophylaxis during their hospitalization between January 1, 2013, and August 31, 2014.The incidences of VTE and bleeding complications were assessed in each group. Each group was further divided into four groups based on their body mass index (BMI): overweight (BMI 25-29.9 kg/m(2) ), obese class I (BMI 30-34.9 kg/m(2) ), obese class II (BMI 35-39.9 kg/m(2) ), and obese class III (BMI 40 kg/m(2) ). The incidence of VTE was similar for patients in the high-dose group versus those in the low-dose group for all BMI categories. Bleeding complications were significantly higher for patients in the high-dose group. The proportion of patients with at least a 2-g/dl hemoglobin drop from admission was higher in patients in the high-dose groups in obese classes II and III: obese class II, 46 (30%) of 152 patients in the high-dose group versus 30 (18%) of 171 patients in the low-dose group (p<0.01); obese class III, 109 (25%) of 432 patients in the high-dose group versus 31 (12%) of 249 patients in the low-dose group (p<0.01). In addition, the proportion of patients who received at least 2 units of packed red blood cell transfusion was significantly higher in patients in the high-dose group who were in obese class III: 47 (11%) of 432 in the high-dose group versus 13 (5%) of 249 in the low-dose group (p<0.01).Administering a higher dose of heparin to patients weighing more than 100 kg may not impart additional efficacy in reducing the incidence of VTE. However, it may increase the risk for bleeding.

Jurado L.V.,Memorial Hermann Texas Medical Center | Gulbis B.E.,Memorial Hermann Texas Medical Center
Pharmacotherapy | Year: 2011

Study Objective. To compare the effects of vecuronium administered as an intravenous continuous infusion versus intermittent bolus doses in patients treated with therapeutic hypothermia after sudden cardiac arrest (SCA). Design. Retrospective medical record review. Setting. Cardiac care unit of a university-affiliated, level I trauma center. Patients. Of 123 adults treated with therapeutic hypothermia after SCA, 80 received continuous-infusion vecuronium 0.8 μg/kg/minute started 2 hours after cooling began or if shivering occurred (January 1, 2004-December 31, 2007), and 43 received intermittent boluses of vecuronium 0.05 mg/kg every 2 hours (January 1, 2008-September 30, 2009). Measurements and Main Results. The degree of neuromuscular blockade was measured with a train-of-four (TOF) test. Primary outcomes evaluated were time to achieve goal TOF response and percentage of time the TOF response was maintained at goal. Secondary outcomes included total daily dose of vecuronium, the vecuronium dose needed to achieve goal TOF response, percentage of TOF measurements above or below goal, and time to return of spontaneous respirations and time to extubation after the last dose of vecuronium. The goal TOF response was achieved significantly earlier in the bolus group than the continuous-infusion group (mean 5.9 vs 11.3 hrs, p=0.008). The mean total daily dose of vecuronium administered in the bolus group was significantly lower than that in the continuous-infusion group (51.7 vs 76.9 mg, p=0.002). The mean percentage of TOF measurements above goal was higher in the continuous-infusion group (33% vs 16%, p<0.0001), and the mean percentage of TOF measurements below goal was higher in the bolus group (43% vs 29%, p<0.0001). The median time to return of spontaneous respirations (6 vs 11 hrs, p=0.017) and time to extubation (29.5 vs 89.5 hrs, p<0.0001) were significantly shorter in the continuous-infusion group than the bolus group. Conclusion. Intermittent boluses of vecuronium were more effective in reaching a goal TOF response earlier compared with continuous-infusion vecuronium in patients treated with therapeutic hypothermia. The two dosing strategies were equally effective at maintaining a goal TOF response despite patients receiving a significantly lower daily dose of vecuronium in the intermittent-bolus group.

PubMed | University of Texas Health Science Center at Houston, Memorial Hermann Texas Medical Center and Rush University Medical Center
Type: Journal Article | Journal: Medical physics | Year: 2017

There are a number of commercially available flow phantoms for evaluating Doppler ultrasound systems. However, it may be hard to justify purchasing these phantoms if a hospital has a small number of ultrasound units to evaluate. In this study, we developed a simple flow phantom with parts available in a hospital to evaluate Doppler ultrasound systems.To create a flow reserve, one end of an IV line was connected to a 100 ml saline bag and the line was filled with saline. 20 ml of glycerin was injected into the saline bag to simulate blood like flow characteristics. The other end of the IV line was also connected to the saline bag to create a loop. The IV line was fed into an infusion pump (programmable up to 999 ml/hr) and was also placed between a uniform ultrasound phantom and a standoff gel pad. To minimize impedance differences, acoustic gel was used between the phantom and the gel pad. Doppler measurements were performed on two Philips iU22 ultrasound units using the L12-5 probes.The pulsatile flow of the solution in the IV line could be seen in the Doppler mode when the infusion pump was running. The color Doppler also indicated the direction of the flow via overlaid red or blue color on the grayscale B-mode ultrasound image of the IV line. The directionality of the flow could be confirmed by reversing the direction of the probe. The peak flow rates (cm/s) observed on the waveforms were reproducible within %10 when the measurements were repeated.A simple flow phantom can be developed from materials available in a hospital for routine evaluation of Doppler ultrasound systems.

PubMed | UT Health Medical School at Houston and Memorial Hermann Texas Medical Center
Type: Case Reports | Journal: Mycoses | Year: 2016

Cryptococcal infection is the third most common invasive fungal infection (IFI) among solid-organ transplant (SOT) recipients and is considered an important opportunistic infection due to its significant morbidity and mortality. To determine whether a cluster of cryptococcosis in heart transplant patients was of nosocomial nature, three cases of orthotopic heart transplant recipients with postoperative disseminated cryptococcal infection were investigated and paired with an environmental survey in a tertiary care hospital. The infection prevention department conducted a multidisciplinary investigation, which did not demonstrate any evidence of health care-associated environmental exposure. Moreover, multilocus sequence typing showed that one isolate was unique and the two others, although identical, were not temporally related and belong to the most common type seen in the Southern US. Additionally, all three patients had preexisting abnormalities of the CT chest scan and various degrees of acute and chronic rejection. Reactivation was suggested in all three patients. Screening methods may be useful to identify at risk patients and trigger a prophylactic or preemptive approach. However, more data is needed.

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