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PubMed | Michael key Medical Center, Malcom Randall Medical Center and Washington Medical Center
Type: Comparative Study | Journal: American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists | Year: 2015

The purpose of this study is to compare estimated blood volume (EBV) versus weight-based (WB) dosing of unfractionated heparin in terms of safety and ability to achieve therapeutic antifactor-Xa (AF-Xa) levels.This was a retrospective, cohort study including 32 male veterans who received UFH. Primary outcome measures included time until therapeutic anticoagulation, number of adjustments needed to achieve therapeutic anticoagulation, median AF-Xa levels and the percentage of patients who were therapeutic after the first and second levels. Safety was determined as the incidence of major and minor bleeding.EBV dosing may be associated with a decrease in the average time to therapeutic range (20.4 16.7 hours with EBV vs. 26.8 26 hours with WB; p = 0.404) and an increase in the percentage of patients achieving therapeutic anticoagulation after the first AF-Xa level (50% with EBV vs. 35.7% with WB; p = 0.611) although these results were not statistically significant. WB dosing required fewer adjustments (2.7 2.9 with WB vs. 4 2.6 with EBV; p = 0.192) with more patients within the therapeutic range after the second AF-Xa level (42.9% with WB vs. 33.3% with EBV; p = 0.897). There was one major and three minor bleeds in the WB dosing group versus one minor bleed for the EBV dosing cohort (p = 0.438 and p = 0.323, respectively).EBV dosing achieved quick therapeutic anticoagulation with less bleeding compared to WB dosing in a veteran population. Due to the studys limitations, larger, randomized, comparative trials are needed to confirm our findings.


Fitzmorris P.,University of Alabama at Birmingham | Shoreibah M.,University of Alabama at Birmingham | Anand B.S.,Michael key Medical Center | Singal A.K.,University of Alabama at Birmingham
Journal of Cancer Research and Clinical Oncology | Year: 2015

Purpose: Hepatocellular carcinoma (HCC), a common cause for cancer-related death, is increasing worldwide. Over the past decade, survival and quality of life of HCC patients have significantly improved due to better prevention strategies, early diagnosis, and improved treatment options. We performed this narrative review to synthesize current status on the HCC management. Methods: Literature search for publications especially over the last decade, which has changed the paradigm on the management of HCC. Results: Hepatitis B vaccination and treatment of chronic hepatitis B and C are important measures for HCC prevention. Screening and surveillance for HCC using ultrasonogram and alpha-fetoprotein estimation are directed toward cirrhotics and hepatitis B patients at high risk of HCC. If detected at an early stage, curative treatments for HCC can be used such as tumor resection, ablation and liver transplantation. HCC patients without curative options are managed by loco-regional therapies and systemic chemotherapy. Loco-regional treatments include trans-arterial chemoembolization, radioembolization and combinations of loco-regional plus systemic therapies. Currently, sorafenib is the only FDA-approved systemic therapy and newer better chemotherapeutic agents are being investigated. Palliative care for terminally ill patients with metastatic disease and/or poor functional status focusses on comfort care and symptom control. Conclusions: In spite of significant advancement in HCC management, its incidence continues to rise. There remains an urgent need to continue refining understanding of HCC and develop strategies to increase utilization of the available preventive measures and curative treatment modalities for HCC. © 2014, Springer-Verlag Berlin Heidelberg.


PubMed | Georgetown University, Michael key Medical Center, Houston Methodist Hospital and Baylor College of Medicine
Type: Journal Article | Journal: The American journal of cardiology | Year: 2016

The relation between the arterial and venous systems in patients with impaired lower extremity blood flow remains poorly described. The objective of this secondary analysis of the Effectiveness of Intensive Lipid Modification Medication in Preventing the Progression on Peripheral Artery Disease Trial was to determine the association between femoral vein (FV) volumes and measurements of peripheral artery disease. FV wall, lumen, and total volumes were quantified with fast spin-echo proton density-weighted magnetic resonance imaging scans in 79 patients with peripheral artery disease over 2 years. Reproducibility was excellent for FV total vessel (intraclass correlation coefficient 0.924, confidence interval 0.910 to 0.935) and lumen volumes (intraclass correlation coefficient 0.893, confidence interval 0.873 to 0.910). Baseline superficial femoral artery volumes were directly associatedwith FV wall (r= 0.46, p <0.0001), lumen (r= 0.42, p=0.0001),and totalvolumes (r=0.46, p <0.0001). The 2-year change in maximum walking time was inversely associated with the 24-month change in FV total volume (r=-0.45, p= 0.03). Inconclusion, FV volumes can be measured reliably with fast spin-echo proton density-weighted magnetic resonance imaging, and baseline superficial femoral artery plaque burden is positively associated with FV volumes, whereas the 2-year change in FV volumes and leg function show an inverse relation.


Gould-Suarez M.,Baylor College of Medicine | El-Serag H.B.,Baylor College of Medicine | El-Serag H.B.,Michael key Medical Center | El-Serag H.B.,Center for Innovations in Quality | And 3 more authors.
Digestive Diseases and Sciences | Year: 2014

Background and Aims: The optimal algorithm to identify Lynch syndrome (LS) among patients with colorectal cancer (CRC) is unclear. The definitive test for LS, germline testing, is too expensive to be applied in all cases. Initial screening with the revised Bethesda Guidelines (RBG) cannot be applied in a considerable number of cases due to missing information.Methods: We developed a model to evaluate the cost-effectiveness of 10 strategies for diagnosing LS. Three main issues are addressed: modeling estimates (20–40 %) of RBG applicability; comparing sequential or parallel use of microsatellite instability (MSI) and immunohistochemistry (IHC); and a threshold analysis of the charge value below which universal germline testing becomes the most cost-effective strategy.Results: LS detection rates in RBG-based strategies decreased to 64.1–70.6 % with 20 % inapplicable RBG. The strategy that uses MSI alone had lower yield, but also lower cost than strategies that use MSI sequentially or in parallel with IHC. The use of MSI and IHC in parallel was less affected by variations in the sensitivity and specificity of these tests. Universal germline testing had the highest yield and the highest cost of all strategies. The model estimated that if charges for germline testing drop to $633–1,518, universal testing of all newly diagnosed CRC cases becomes the most cost-effective strategy.Conclusions: The low applicability of RBG makes strategies employing initial laboratory-based testing more cost-effective. Of these strategies, parallel testing with MSI and IHC offers the most robust yield. With a considerable drop in cost, universal germline testing may become the most cost-effective strategy for the diagnosis of LS. © 2014, Springer Science+Business Media New York (Outside the USA).


Rahman S.,Michael key Medical Center | Bhargava P.,Michael key Medical Center
Clinical Nuclear Medicine | Year: 2010

A 65-year-old asymptomatic male who tested positive for fecal occult blood was found to have a rectal mass on colonoscopy. Staging workup included a CT scan of the abdomen which showed a neoplasm in the liver, with neuroendocrine features on fine needle aspiration. Planar 24 hours whole body In-111 octreotide scan showed a small focus of mildly increased activity in the lateral left lower chest, a very large focus of intense uptake in the liver, and 4 distinct foci of mild to moderately increased uptake in the lower abdomen and pelvis. SPECT-CT images localized these abnormalities to: focal uptake in the rectal wall thickening, 2 presacral lymph nodes, the liver mass, and multiple bone metastases (left ilium, L5 pedicle, and the left 6th rib). This rare case highlights the importance of SPECT-CT in staging carcinoid tumors with In-111 octreotide imaging. Copyright © 2010 by Lippincott Williams & Wilkins.


Marschall J.,University of Washington | Marschall J.,University of Bern | Carpenter C.R.,University of Washington | Fowler S.,Washington University in St. Louis | And 2 more authors.
BMJ (Online) | Year: 2013

Objective: To determine whether antibiotic prophylaxis at the time of removal of a urinary catheter reduces the risk of subsequent symptomatic urinary tract infection. Design: Systematic review and meta-analysis of studies published before November 2012 identified through PubMed, Embase, Scopus, and the Cochrane Library; conference abstracts for 2006-12 were also reviewed. Inclusion criteria: Studies were included if they examined antibiotic prophylaxis administered to prevent symptomatic urinary tract infection after removal of a short term (≤14 days) urinary catheter. Results: Seven controlled studies had symptomatic urinary tract infection after catheter removal as an endpoint; six were randomized controlled trials (five published; one in abstract form) and one was a non-randomized controlled intervention study. Five of these seven studies were in surgical patients. Studies were heterogeneous in the type and duration of antimicrobial prophylaxis and the period of observation. Overall, antibiotic prophylaxis was associated with benefit to the patient, with an absolute reduction in risk of urinary tract infection of 5.8% between intervention and control groups. The risk ratio was 0.45 (95% confidence interval 0.28 to 0.72). The number needed to treat to prevent one urinary tract infection was 17 (12 to 30). Conclusions: Patients admitted to hospital who undergo short term urinary catheterization might benefit from antimicrobial prophylaxis when the catheter is removed as they experience fewer subsequent urinary tract infections. Potential disadvantages of more widespread antimicrobial prophylaxis (side effects and cost of antibiotics, development of antimicrobial resistance) might be mitigated by the identification of which patients are most likely to benefit from this approach.


Tan R.S.,Michael key Medical Center | Tan R.S.,Baylor College of Medicine | Tan R.S.,University of Houston | Tan R.S.,Low T Institute | And 2 more authors.
American Journal of Men's Health | Year: 2015

Testosterone replacement improves quality of life and is aromatized in men in adipose tissues to estrogen. Hyperestrogenism is believed to be harmful to male sexuality. This is a description of our experience of screening 34,016 men in the Low T Centers, of which approximately 50% were converted to treatment. Men were treated with injectable testosterone, and we have available data from 2009 to 2014. The data were extracted from our electronic health record (AdvancedMD) of 35 Low T Centers across the United States. In all, 7,215 (20.2%) out of the 34,016 patients had high estradiol levels defined as ≥42.6 pg/ml. Estradiol was measured using electro-chemiluminescence immunoassay. Of the patients who had high estradiol levels, the age distribution was as follows: 132/989 (13.3%) were older than 65 years, 3,753/16,955 (22.1%) were between 45 and 65 years; 2,968/15,857 (18.7%) were between 25 and 44 years, 7/215 (3.3%) were younger than 25 years. The difference between extreme age groups (<25 and ≥65) was statistically significant using a chi-square test (p =.013). The correlation coefficient of serum estradiol to age was.53, SD = 8.21. It was observed that practitioners used aromatase inhibitor and selective estrogen receptor modulator to treat symptoms of hyperestrogenism, irrespective of blood estradiol levels. Gynecomastia was rarely documented as a reason for the prescription. Our finding was that high estradiol levels were not associated with higher rates of low libido but established higher rates of documented low libido with those with normal or lower estradiol levels. The difference was statistically significant (p <.05). © The Author(s) 2014.


Liang A.,Baylor College of Medicine | Liang A.,Chongqing Medical University | Wang Y.,Baylor College of Medicine | Woodard L.E.,Baylor College of Medicine | And 7 more authors.
Journal of Pathology | Year: 2012

Glutathione transferase isozyme A4 (GSTA4) exhibits high catalytic efficiency to metabolize 4-hydroxynonenal (4-HNE), a highly reactive lipid peroxidation product that has been implicated in the pathogenesis of various chronic diseases. We investigated the role of 4-HNE in the mechanisms of unilateral ureteral obstruction (UUO)- induced fibrosis and its modulation by GSTA4-4 in a mouse model. Our data indicate that after UUO, accumulation of 4-HNE and its adducts were increased in renal tissues, with a concomitant decrease in the expression of GSTA4-4 in mice. As compared to wild-type (WT) mice, UUO caused an increased expression of fibroblast markers in the interstitium of GSTA4 KO mice. Additionally, increased autophagy and tubular cell damage were more severe in UUO-treated GSTA4 KO mice than in WT mice. Furthermore, GSK-3β phosphorylation and expression of Snail, a regulator of E-cadherin and Occludin, was found to be significantly higher in UUO-inflicted GSTA4 KO mice. GSTA4 over-expression prevented 4-HNE-induced autophagy activation, tubular cell damage and Snail nuclear translocation in vitro. The effects of long-term expression of GSTA4 in restoration of UUO-induced damage in mice with the GSTA4 inducible transposon system indicated that release of obstruction after 3 days of UUO resulted in the attenuation of interstitial SMAa and collagen I expression. This transposon-delivered GSTA4 expression also suppressed UUO-induced loss of tubular cell junction markers and autophagy activation. Together, these results indicate that 4-HNE significantly contributes to the mechanisms of tubule injury and fibrosis and that these effects can be inhibited by the enhanced expression of GSTA4-4. Copyright © 2012 Pathological Society of Great Britain and Ireland.


Mandava P.,Baylor College of Medicine | Dalmeida W.,Baylor College of Medicine | Anderson J.A.,Baylor College of Medicine | Thiagarajan P.,Baylor College of Medicine | And 3 more authors.
Translational Stroke Research | Year: 2010

Thrombolysis remains a mainstay in the treatment of ischemic stroke. While not usually considered in the spectrum of clot lysis, experimental data show that inhibition of the platelet glycoprotein (GP) IIb/IIIa receptor can reduce as well as reverse thrombus formation and improve microvascular flow in stroke models. However, a recent clinical trial of GP IIb/IIIa inhibition in stroke did not demonstrate clinical benefit and was associated with increased hemorrhage. Based on an understanding of the relationship between GP IIb/IIIa receptor inhibition, efficacy and hemorrhage, we hypothesized that a lower dose of abciximab would achieve a favorable range of platelet inhibition and potentially good clinical outcomes. Forty-four patients with suspected large vessel occlusion, who were not eligible for rt-PA were offered treatment with approximately 30% lower total dose of intravenous abciximab if within 6 h for anterior circulation or 24 h for posterior circulation stroke (later modified to 12 h). Concomitant anticoagulation, usually with unfractionated heparin was employed. The extent of platelet inhibition was measured in 21 patients. Hemorrhage rate and 90-day functional outcomes and mortality were obtained. A matching algorithm involving finding the nearest neighbor from individual subjects in the control arm of the NINDS rt-PA database was used to compare outcomes at similar baseline characteristics and gender. Mean platelet inhibition was 92.1 ± 6.7% vs inhibition reported with percutaneous coronary intervention (PCI) of 96 ± 10; p = 0.08. Successful matching to NINDS controls was accomplished: after outlier elimination, median and mean NIHSS of the abciximab subjects compared to NINDS controls was 16.5 vs 15.5 (p = 0.92) and 16.3 vs 16.0 (p = 0.86). Mean age was 67.2 vs 67.1 (p = 0.97). Mean glucose was 141 vs 142 (p = 0.92). There was one symptomatic hemorrhage; minor hemorrhages occurred in 9%. The percent of patients who achieved an mRS 0-2 or died in the treated vs matched NINDS control patients was 63 vs 38 (p =.02) and 23 vs 23 (p = 1.0). Our pilot results indicated that a lower dose of abciximab results in platelet inhibition similar to that achieved in the coronary vascular bed during PCI. Comparison to matched historical controls suggests that this lower dose in combination therapy may be safe and effective therapy for thrombotic stroke and a randomized trial is warranted. © 2010 U.S. Department of Veterans Affairs.


PubMed | Michael key Medical Center, University of Houston and Baylor College of Medicine
Type: Journal Article | Journal: Journal of surgical oncology | Year: 2016

Over the last decade, the use of neoadjuvant chemo-radiation has been an integral part of the care of patients with locally advanced rectal cancer. However, emerging data are beginning to challenge the current treatment paradigm of neoadjuvant chemo-radiation followed by radical resection and subsequent adjuvant chemotherapy. Going forward, the challenge will be to identify patients for whom radiation can be safely omitted and those for whom it can potentially provide added oncologic value. J. Surg. Oncol. 2016;114:304-310. 2016 Wiley Periodicals, Inc.

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