Corrales-Medina V.F.,Ottawa Hospital Research Institute |
Corrales-Medina V.F.,University of Ottawa |
Musher D.M.,Baylor College of Medicine |
Musher D.M.,Michael bakey Va Medical Center |
And 6 more authors.
Circulation | Year: 2012
Background-Community-acquired pneumonia (CAP) affects > 5 million adults each year in the United States. Although incident cardiac complications occur in patients with community-acquired pneumonia, their incidence, timing, risk factors, and associations with short-term mortality are not well understood. Methods and Results-A total of 1343 inpatients and 944 outpatients with community-acquired pneumonia were followed up prospectively for 30 days after presentation. Incident cardiac complications (new or worsening heart failure, new or worsening arrhythmias, or myocardial infarction) were diagnosed in 358 inpatients (26.7%) and 20 outpatients (2.1%). Although most events (89.1% in inpatients, 75% in outpatients) were diagnosed within the first week, more than half of them were recognized in the first 24 hours. Factors associated with their diagnosis included older age (odds ratio [OR]=1.03; 95% confidence interval [CI], 1.02-1.04), nursing home residence (OR, 1.8; 95% CI, 1.2-2.9), history of heart failure (OR, 4.3; 95% CI, 3.0-6.3), prior cardiac arrhythmias (OR, 1.8; 95% CI, 1.2-2.7), previously diagnosed coronary artery disease (OR, 1.5; 95% CI, 1.04-2.0), arterial hypertension (OR, 1.5; 95% CI, 1.1-2.1), respiratory rate ≥ 30 breaths per minute (OR, 1.6; 95% CI, 1.1-2.3), blood pH < 7.35 (OR, 3.2; 95% CI, 1.8-5.7), blood urea nitrogen ≥ 30 mg/dL (OR, 1.5; 95% CI, 1.1-2.2), serum sodium < 130 mmol/L (OR, 1.8; 95% CI, 1.02-3.1), hematocrit ≥ 30% (OR, 2.0; 95% CI, 1.3-3.2), pleural effusion on presenting chest x-ray (OR, 1.6; 95% CI, 1.1-2.4), and inpatient care (OR, 4.8; 95% CI, 2.8-8.3). Incident cardiac complications were associated with increased risk of death at 30 days after adjustment for baseline Pneumonia Severity Index score (OR, 1.6; 95% CI, 1.04-2.5). Conclusions-Incident cardiac complications are common in patients with community-acquired pneumonia and are associated with increased short-term mortality. Older age, nursing home residence, preexisting cardiovascular disease, and pneumonia severity are associated with their occurrence. Further studies are required to test risk stratification and prevention and treatment strategies for cardiac complications in this population. Copyright © s 2012 American Heart Association. All rights reserved.
Daniels S.K.,University of Houston |
Daniels S.K.,Michael bakey Va Medical Center |
Anderson J.A.,Michael bakey Va Medical Center |
Anderson J.A.,Baylor College of Medicine |
And 2 more authors.
Stroke | Year: 2012
BACKGROUND AND PURPOSE-: Screening for dysphagia is essential to the implementation of preventive therapies for patients with stroke. A systematic review was undertaken to determine the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard. METHODS-: Four databases from 1985 through March 2011 were searched using the terms cerebrovascular disease, stroke deglutition disorders, and dysphagia. Eligibility criteria were: homogeneous stroke population, comparison to instrumental examination, clinical examination without equipment, outcome measures of dysphagia or aspiration, and validity of screening items reported or able to be calculated. Articles meeting inclusion criteria were evaluated for methodological rigor. Sensitivity, specificity, and predictive capabilities were calculated for each item. RESULTS-: Total source documents numbered 832; 86 were reviewed in full and 16 met inclusion criteria. Study quality was variable. Testing swallowing, generally with water, was the most commonly administered item across studies. Both swallowing and nonswallowing items were identified as predictive of aspiration. Neither swallowing protocols nor validity were consistent across studies. CONCLUSIONS-: Numerous behaviors were found to be associated with aspiration. The best combination of nonswallowing and swallowing items as well as the best swallowing protocol remains unclear. Findings of this review will assist in development of valid clinical screening instruments. © 2012 American Heart Association, Inc.
Price R.B.,University of Pittsburgh |
Mathew S.J.,Michael bakey Va Medical Center |
Mathew S.J.,Baylor College of Medicine
CNS Drugs | Year: 2015
Ketamine, a widely used anesthetic agent, is currently being investigated as a novel therapeutic for depression and suicidality. Ketamine has garnered substantial attention from researchers, clinicians, media outlets, and patients alike, but numerous questions remain. One of the compelling features of ketamine is the rapidity of its antidepressant effects, which peak just 24 h after infusion, setting it apart from other existing treatments. Ketamine's rapid time course has inspired research efforts to explore its potential as a life-saving therapy for patients at imminent risk of suicide. In this article, we review current evidence supporting the rapid effects of ketamine on suicidal ideation in the context of unipolar and bipolar depression. We then discuss several future directions that are necessary before ketamine can be considered a viable treatment option for suicidality in clinical settings. These include: testing for a specific anti-suicidal effect - separate from overall antidepressant effects - to ascertain whether ketamine might hold promise for a broader class of suicidal patients; ensuring that acute benefits of ketamine can be prolonged over a clinically meaningful timeframe; and developing a better understanding of the mechanisms by which ketamine might reduce suicide risk. Such efforts will enable the field to more accurately assess the potential of ketamine, as well as its limitations, allowing for appropriate placement within the context of comprehensive clinical care for suicide prevention. © 2015 Springer International Publishing Switzerland.
Shahani L.,Michael bakey Va Medical Center |
Hamill R.J.,Michael bakey Va Medical Center |
Hamill R.J.,Michael bakey Veterans Affairs Medical Center
Translational Research | Year: 2016
Immune reconstitution inflammatory syndrome (IRIS) is characterized by improvement in a previously incompetent human immune system manifesting as worsening of clinical symptoms secondary to the ability of the immune system to now mount a vigorous inflammatory response. IRIS was first recognized in the setting of human immunodeficiency virus, and this clinical setting continues to be where it is most frequently encountered. Hallmarks of the pathogenesis of IRIS, independent of the clinical presentation and the underlying pathogen, include excessive activation of the immune system, with increased circulating effector memory T cells, and elevated levels of serum cytokines and inflammatory markers. Patients with undiagnosed opportunistic infections remain at risk for unmasking IRIS at the time of active antiretroviral therapy (ART) initiation. Systematic screening for opportunistic infections before starting ART is a key element to prevent this phenomenon. Appropriate management of IRIS requires prompt recognition of the syndrome and exclusion of alternative diagnoses, particularly underlying infections and drug resistance. Controlled studies supporting the use of pharmacologic interventions in IRIS are scare, and recommendations are based on case series and expert opinions. The only controlled trial published to date, showed reduction in morbidity in patients with paradoxical tuberculosis-related IRIS with the use of oral corticosteroids. There are currently limited data to recommend other anti-inflammatory or immunomodulatory therapies that are discussed in this review, and further research is needed. Ongoing research regarding the immune pathogenesis of IRIS will likely direct future rational therapeutic approaches and clinical trials. © 2016 Elsevier Inc.
Kar B.,Baylor College of Medicine |
Kar B.,Michael bakey Va Medical Center |
Gregoric I.D.,Baylor College of Medicine |
Basra S.S.,Baylor College of Medicine |
And 2 more authors.
Journal of the American College of Cardiology | Year: 2011
Objectives We evaluated the efficacy and safety of the percutaneous ventricular assist device (pVAD) in patients in severe refractory cardiogenic shock (SRCS) despite intra-aortic balloon pump (IABP) and/or high-dose vasopressor support. Background SRCS is associated with substantial mortality despite IABP counterpulsation. Until recently, there was no rapid, minimally invasive means of providing increased hemodynamic support in SRCS. Methods A total of 117 patients with SRCS implanted with TandemHeart pVAD (CardiacAssist, Inc., Pittsburgh, Pennsylvania) were studied, of whom 56 patients (47.9%) underwent active cardiopulmonary resuscitation immediately before or at the time of implantation. Data was collected regarding clinical characteristics, hemodynamics, and laboratory values. Results Eighty patients had ischemic and 37 patients had nonischemic cardiomyopathy. The average duration of support was 5.8 ± 4.75 days. After implantation, the cardiac index improved from median 0.52 (interquartile range [IQR]: 0.8) l/(min·m2) to 3.0 (IQR: 0.9) l/(min·m2) (p < 0.001). The systolic blood pressure and mixed venous oxygen saturation increased from 75 (IQR: 15) mm Hg to 100 (IQR: 15) mm Hg (p < 0.001) and 49 (IQR: 11.5) to 69.3 (IQR: 10) (p < 0.001), respectively. The urine output increased from 70.7 (IQR: 70) ml/day to 1,200 (IQR: 1,620) ml/day (p < 0.001). The pulmonary capillary wedge pressure, lactic acid level, and creatinine level decreased, respectively, from 31.53 ± 10.2 mm Hg to 17.29 ± 10.82 mm Hg (p < 0.001), 24.5 (IQR: 74.25) mg/dl to 11 (IQR: 92) mg/dl (p < 0.001), and 1.5 (IQR: 0.95) mg/dl to 1.2 (IQR: 0.9) mg/dl (p = 0.009). The mortality rates at 30 days and 6 months were 40.2% and 45.3%, respectively. Conclusions The pVAD rapidly reversed the terminal hemodynamic compromise seen in patients with SRCS refractory to IABP and vasopressor support. © 2011 American College of Cardiology Foundation.
Carabello B.A.,Baylor College of Medicine |
Carabello B.A.,Michael bakey Va Medical Center
Heart Failure Clinics | Year: 2012
Structural cardiac volume overload comprises a group of heterogeneous diseases, each creating a nearly unique set of loading conditions on the left ventricle and/or right ventricle. In turn, the heart responds to each with unique patterns of remodeling, leading to both adaptive and maladaptive consequences. An understanding of these different patterns of hypertrophy and/or remodeling should be useful in developing strategies for the timing and correction of cardiac volume overload. © 2012.
Nguyen D.M.,Baylor College of Medicine |
Nguyen D.M.,Michael bakey Va Medical Center |
El-Serag H.B.,Baylor College of Medicine |
El-Serag H.B.,Michael bakey Va Medical Center
Gastroenterology Clinics of North America | Year: 2010
Obesity has received considerable attention as a major health hazard because of the increase in the prevalence of obesity not only in the United States but also in several other countries worldwide. Obesity is caused by an interaction of environmental factors, genetic predisposition, and human behavior, and is associated with an increased risk of numerous chronic diseases, from diabetes and cancers to many digestive diseases. The obesity epidemic exerts a heavy toll on the economy with its massive health care costs. This article describes some of the epidemiologic features of obesity, including global prevalence, secular trends, risk factors, and burden of illness related to obesity with special emphasis on obesity trends in the United States.
Ng B.,Michael bakey Va Medical Center |
Ng B.,Baylor College of Medicine |
Chu A.,University of Houston-Victoria
Clinical Rheumatology | Year: 2014
The purpose of this study is to explore patient factors associated with differences in methotrexate (MTX) dosing and to compare patient factors and MTX-dosing patterns between those who remained on MTX monotherapy and those who were switched or had additional therapy. A retrospective cohort of 7,017 patients with newly diagnosed rheumatoid arthritis (RA) was identified in the United States Department of Veterans Affairs administrative databases between 1 October 1999 and 30 September 2009. Regression analyses were used to study the association of MTX start and maximum dose attained with various patient characteristics and compare differences between groups who had therapeutic change (having switched to or added another anti-rheumatic agent or having steroids increased by 2.5 mg of prednisone or equivalent) with those remaining on MTX monotherapy. Abnormal serum creatinine (>1.5 mg/dL) was associated lower start and peak MTX doses (p<0.01). Older RA patients were less likely to attain peak MTX dose of 15 mg or more (p<0.01). Males and patients 75 and older (compared with <45) had lower risk of therapeutic change (hazard ratio, [HR] 0.80, 95 % confidence interval [CI] 0.72-0.90, and HR 0.42, 95% CI 0.42-0.36-0.50, respectively). Patients who attained higher peak MTX dose had lower risk of therapeutic change compared with those dosed at less than 15 mg/week (HR 0.85, 95% CI 0.77-0.92 for 15 to <20 and HR 0.79, 95% CI 0.72-0.86 for 20 or more). InjectableMTX use conferred lower risk of therapeutic change (HR 0.64, 95% CI 0.52-0.78). Two thirds did not attain a maximum MTX dose of 20 mg/week or more before therapeutic change occurred. Older age and renal insufficiency were barriers to the use of higher MTX maximum dosages. Use of injectable MTX and higher maximum MTX dose were independently associated with higher likelihood to remain on MTX monotherapy. Further studies are needed to explore targeted interventions thatmay optimize MTX dosing to improve success rates of MTX monotherapy. © 2013 Clinical Rheumatology.
Shorter D.,Michael bakey Va Medical Center |
Domingo C.B.,Michael bakey Va Medical Center |
Kosten T.R.,Baylor College of Medicine
Expert Opinion on Emerging Drugs | Year: 2015
Introduction: Cocaine use is a global public health concern of significant magnitude, negatively impacting both the individual as well as larger society. Despite numerous trials, the discovery of an effective medication for treatment of cocaine use disorder remains elusive.Areas covered: This article reviews the emerging pharmacotherapies for treatment of cocaine use disorder, focusing on those medications that are currently in Phase II or III human clinical trials. Articles reviewed were obtained through searches of PubMed, Ovid MEDLINE, Clinicaltrials.gov and the Pharmaprojects database.Expert opinion: Research into cocaine pharmacotherapy must continue to show innovation. Given that medications targeting single neurotransmitter systems have demonstrated little efficacy in treatment of cocaine use disorder, the recent focus on pharmacotherapeutic agents with multiple neurobiochemical targets represents an exciting shift in trial design and approach. Additionally, consideration of pharmacogenetics may be helpful in identification of subpopulations of cocaine-dependent individuals who may preferentially respond to medications. © 2014 Informa UK, Ltd.
Bujarski S.,Baylor College of Medicine |
Parulekar A.D.,Baylor College of Medicine |
Sharafkhaneh A.,Baylor College of Medicine |
Sharafkhaneh A.,Michael bakey Va Medical Center |
Hanania N.A.,Baylor College of Medicine
Current Allergy and Asthma Reports | Year: 2015
Asthma and chronic obstructive pulmonary disease (COPD) have traditionally been viewed as distinct clinical entities. Recently, however, much attention has been focused on patients with overlapping features of both asthma and COPD: those with asthma COPD overlap syndrome (ACOS). Although no universal definition criteria exist, recent publications attempted to define patients with ACOS based on differences in clinical features, radiographic findings, and diagnostic tests. Patients with ACOS make up a large percentage of those with obstructive lung disease and have a higher overall health-care burden. Identifying patients with ACOS has significant therapeutic implications particularly with the need for early use of inhaled corticosteroids and the avoidance of use of long-acting bronchodilators alone in such patients. However, unlike asthma and COPD, no evidence-based guidelines for the management of ACOS currently exist. Future research is needed to improve our understanding of ACOS and to achieve the best management strategies. © 2015, Springer Science+Business Media New York.