Dallas, TX, United States
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Metzger R.L.,Parkland Health and Hospital System
Nurse Practitioner | Year: 2016

Low back pain remains one of the most common patient complaints. It can exist alone or with the presence of lower extremity symptoms. Review of evidence-based guidelines will assist primary care providers in the identifi cation and treatment of various lumbar disorders in addition to ruling out specifi c lumbar spinal pathologies. © 2016 Wolters Kluwer Health, Inc.


News Article | May 18, 2017
Site: www.eurekalert.org

DALLAS - May 17, 2017 - One in three patients hospitalized for medical problems experienced a drop in their red blood cell count due to the hospitalization - a concept called hospital-acquired anemia, new research showed. Moreover, the worse the hospital-acquired anemia - or the more blood lost - the higher the risk of death or readmission, even after adjusting for other important factors, UT Southwestern Medical Center researchers reported in a study involving 11,000 patients cared for in six hospitals. "This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance. However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital so it needs to be taken more seriously," said senior author Dr. Ethan Halm, Director of UT Southwestern's Center for Patient-Centered Outcomes Research and Chief of the William T. and Gay F. Solomon Division of General Internal Medicine at UT Southwestern. Dr. Halm, Professor of Internal Medicine and Clinical Sciences, holds the Walter Family Distinguished Chair in Internal Medicine in Honor of Albert D. Roberts, M.D. Hospital-acquired anemia is defined as having a normal blood count on admission but developing anemia during the course of hospitalization. The most severe form of hospital-acquired anemia was independently associated with a 39 percent increase in the odds of being readmitted or dying within 30 days after hospital discharge compared with not developing hospital-acquired anemia. The most severe form was defined as a hematocrit of 27 percent or less at the time of discharge, occurring in 1.4 percent of all hospitalizations in the study, which appears in the Journal of Hospital Medicine. "This is the first study of post-discharge adverse outcomes of hospital-acquired anemia among a diverse group of patients who were hospitalized for different reasons," said lead author Dr. Anil Makam, Assistant Professor of Internal Medicine and Clinical Sciences and a member of the Center for Patient-Centered Outcomes Research. Other studies have examined post-discharge outcomes in patients hospitalized for heart attacks. While the study does not establish preventability, it points to several directly associated risk factors of developing hospital-acquired anemia. "Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient's risk of developing severe hospital-acquired anemia, and potentially improve their recovery," said Dr. Makam. In the current study, researchers found that the two strongest potentially modifiable predictors of developing moderate or severe hospital-acquired anemia are length of hospital stay and patients undergoing major surgery. In the future, researchers hope to examine other patient-centered outcomes that may be related to hospital-acquired anemia, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. Others involved in the study included Dr. Oanh Nguyen, Assistant Professor of Internal Medicine and Clinical Sciences, and analyst Christopher Clark in the Office of Research Administration at Parkland Health and Hospital System. The study was supported by UT Southwestern's Center for Patient-Centered Outcomes Research (PCOR) and the National Institute on Aging. PCOR helps facilitate studies designed to ensure delivery of high-quality, patient-centered, evidence-based, equitable care. The UT Southwestern PCOR Center is funded through a grant from the Agency for Healthcare Research and Quality (AHRQ), with a mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services and other partners to ensure that the evidence is understood and used. UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution's faculty includes many distinguished members, including six who have been awarded Nobel Prizes since 1985. The faculty of almost 2,800 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in about 80 specialties to more than 100,000 hospitalized patients and oversee approximately 2.2 million outpatient visits a year. This news release is available on our website at http://www. To automatically receive news releases from UT Southwestern via email, subscribe at http://www.


Ordonez J.E.,Parkland Health and Hospital System | Kleinschmidt K.C.,Parkland Health and Hospital System | Kleinschmidt K.C.,University of Texas Southwestern Medical Center
Nicotine and Tobacco Research | Year: 2015

Introduction: Exposure to the liquid nicotine solutions in electronic cigarettes (e-cigs) may be dangerous because they are highly concentrated. Little is known about the impact of exposure on public health. This study describes e-cig exposures reported to poison centers. Methods: All e-cig exposures reported to Texas poison centers during 2009 to February 2014 were identified. Exposures involving other substances in addition to e-cigs and exposures not followed to a final medical outcome were included. The distributions of exposures by demographic and clinical factors were determined. Results: Of 225 total exposures, 2 were reported in January 2009, 6 in 2010, 11 in 2011, 43 in 2012, 123 in 2013, and 40 through February 2014. Fifty-three percent (n = 119) occurred among individuals aged <5 years old, 41% (n = 93) occurred among individuals aged >20 years old, and 6% (n = 13) occurred among individuals aged 6-19 years. Fifty percent were female. The route of exposure was 78% ingestion. Eighty-seven percent of the exposures were unintentional, and 5% were intentional. The exposures occurred at patients' own residences in 95% of the cases. The clinical effects reported most often were vomiting (20%), nausea (10%), headache (4%), ocular irritation (5%), dizziness (5%), and lethargy (2%). Conclusion: E-cig exposures reported to poison centers are increasing. Most of the patients are young children, and the exposures most frequently occur through ingestion. Reported exposures often do not have serious outcomes. © The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.


Mikhael M.,University of Texas at Dallas | Brown L.S.,Parkland Health and Hospital System | Rosenfeld C.R.,University of Texas at Dallas
Journal of Pediatrics | Year: 2014

Objective To validate established neonatal neutrophil reference ranges (RRs) and determine the utility of serial measurements of neutrophil values in the first 24 hours to predict the absence of neonatal early-onset sepsis (EOS). Study design Retrospective study of 2073 admissions to the neonatal intensive care unit (2009-2011). Neonates were classified as blood culture-positive, proven EOS (n = 9), blood culture-negative but clinically suspect EOS (n = 292), and not infected (n = 1292). Neutrophil values from 745 not-infected neonates without perinatal complications were selected to validate RR distributions. Positive and negative predictive values were calculated; area under receiver operating characteristic curves (AUCs) were constructed to predict the presence or absence of EOS. Neutrophil value scores were established to determine whether serial neutrophil values predict the absence of EOS. Results Seventy-seven percent of admissions to the neonatal intensive care unit were evaluated for EOS: 9 (0.56%) had proven EOS with positive blood culture ≤37 hours; 18% had clinically suspect EOS. Neutropenia occurred in preterm neonates, and nonspecific neutrophilia was common in uninfected neonates. The distribution of neutrophil values differed significantly between study groups. The specificity for absolute total immature neutrophils and immature to total neutrophil proportions was 91% and 94%, respectively, with negative predictive value of 99% for proven and 78% for proven plus suspect EOS. Absolute total immature neutrophils and immature to total neutrophil proportions had the best predictability for EOS >6 hours postnatal with an AUC ∼0.8. Neutrophil value scores predicted the absence of EOS with AUC of 0.9 and 0.81 for proven and proven plus suspect EOS, respectively. Conclusion Age-dependent neutrophil RRs remain valid. Serial neutrophil values at 0, 12, and 24 hours plus blood culture and clinical evaluation can be used to discontinue antimicrobial therapy at 36-48 hours. © 2014 Mosby Inc.


Clarke C.F.,Dynamis | Glowicz J.,Parkland Health and Hospital System
American Journal of Tropical Medicine and Hygiene | Year: 2013

Autochthonous human cases of leishmaniasis in the United States are uncommon. We report three new cases of cutaneous leishmaniasis and details of a previously reported case, all outside the known endemic range in Texas. Surveys for enzootic rodent reservoirs and sand fly vectors were conducted around the residences of three of the casepatients during the summer of 2006; female Lutzomyia anthophora sand flies were collected at a north Texas and southeast Oklahoma residence of a case-patient, indicating proximity of a suitable vector. Urban sprawl, climatologic variability, or natural expansion of Leishmania mexicana are possible explanations for the apparent spread to the north and east. Enhanced awareness among healthcare providers in the south central region of the United States is important to ensure clinical suspicion of leishmaniasis, diagnosis, and appropriate patient management. Copyright © 2013 by The American Society of Tropical Medicine and Hygiene.


Boyd N.,Parkland Health and Hospital System | Nailor M.D.,University of Connecticut | Nailor M.D.,Hartford Hospital
Pharmacotherapy | Year: 2011

The widespread emergence of antibiotic-resistant gram-negative organisms has compromised the utility of current treatment options for severe infections caused by these pathogens. The rate of gram-negative multidrug resistance is worsening, threatening the effectiveness of newer broad-spectrum antibiotic agents. Infections associated with multidrug-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae are having a substantial impact on hospital costs and mortality rates. The potential for these resistant gram-negative nosocomial pathogens must always be a primary consideration when selecting antibiotic therapy for critically ill patients. Empiric combination therapy directed at gram-negative pathogens is a logical approach for patients with suspected health care-associated infections, particularly those with risk factors for infections caused by multidrug-resistant pathogens. Although in vitro synergy tests have shown potential benefits of continued combination therapy, convincing clinical data that demonstrate a need for combination therapy once susceptibilities are known are lacking. Thus, deescalation to a single agent once susceptibilities are known is recommended for most patients and pathogens. Use of polymyxins, often in combination with other antimicrobials, may be necessary for salvage therapy.


Stumpf K.A.,Southwestern University | Thompson T.,Parkland Health and Hospital System | Sanchez P.J.,Southwestern University
Pediatrics | Year: 2013

OBJECTIVE: Preterm infants are at increased risk of severe rotavirus gastroenteritis. Although immunization with rotavirus vaccine is safe and effective, age restrictions limit the number of infants eligible for vaccination at discharge from the NICU. The objectives of this study were to assess the implementation of the rotavirus vaccine program in our NICU, recognize missed opportunities for vaccination, and document how often very low birth weight (VLBW; birth weight ≤1500 g) and extremely low birth weight (ELBW; birth weight <1000 g) infants were eligible to receive rotavirus vaccine at the time of NICU discharge. METHODS: This study reports on a prospective, observational cohort of all VLBW infants who were discharged from the NICU at Parkland Memorial Hospital from May 2008 to April 2010. Medical records were reviewed and data collected regarding the number of infants who were eligible for and received rotavirus vaccination at discharge. RESULTS: A total of 63% (135 of 213) of VLBW infants did not receive rotavirus vaccine. The reasons for not providing vaccine included the following: <42 days of age at discharge (56 of 213;26%), >84 or 104 days of age at discharge (48 of 213;23%), or missed (35 of 213;16%). The majority (75%) who were too old for vaccination at the time of discharge were ELBW. CONCLUSIONS: The current age restrictions for rotavirus immunization resulted in more than half of ELBW infants being ineligible for vaccination at the time of discharge from the NICU. Alternative strategies for rotavirus immunization in this population are needed. Copyright © 2013 by the American Academy of Pediatrics.


Kapadia V.S.,University of Texas Southwestern Medical Center | Chalak L.F.,University of Texas Southwestern Medical Center | Sparks J.E.,University of Texas Southwestern Medical Center | Allen J.R.,Parkland Health and Hospital System | And 2 more authors.
Pediatrics | Year: 2013

OBJECTIVE: To determine whether a limited oxygen strategy (LOX) versus a high oxygen strategy (HOX) during delivery room resuscitation decreases oxidative stress in preterm neonates. METHODS: A randomized trial of neonates of 24 to 34 weeks' gestational age (GA) who received resuscitation was performed. LOX neonates received room air as the initial resuscitation gas, and fraction of inspired oxygen (FIO2) was adjusted by 10% every 30 seconds to achieve target preductal oxygen saturations (SpO2) as described by the 2010 Neonatal Resuscitation Program guidelines. HOX neonates received 100% O2 as initial resuscitation gas, and FIO2 was adjusted by 10% to keep preductal SpO2 at 85% to 94%. Total hydroperoxide (TH), biological antioxidant potential (BAP), and the oxidative balance ratio (BAP/TH) were analyzed in cord blood and the first hour of life. Secondary outcomes included delivery room interventions, respiratory support on NICU admission, and short-term morbidities. RESULTS: Forty-four LOX (GA: 306 3 weeks; birth weight: 1678 ± 634 g) and 44 HOX (GA: 30 ± 3 weeks; birth weight: 1463 ± 606 g) neonates were included. LOX decreased integrated excess oxygen (∑FIO2 3 time [min]) in the delivery room compared with HOX (401 ± 151 vs 662 ± 249; P < .01). At 1 hour of life, BAP/TH was 60% higher for LOX versus HOX neonates (13 [9-16] vs 8 [6-9]) μM/U.CARR, P < .01). LOX decreased ventilator days (3 [0-64] vs 8 [0-96]; P < .05) and reduced the incidence of bronchopulmonary dysplasia (7% vs 25%; P < .05). CONCLUSIONS: LOX is feasible and results in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities and thus is a reasonable alternative for resuscitation of preterm neonates in the delivery room. © 2013 by the American Academy of Pediatrics.


Carter S.L.,Parkland Health and Hospital System | Attel S.,Parkland Health and Hospital System
Nurse Practitioner | Year: 2013

Approximately 70% of the world's population is lactase deficient. This article reviews the evolutionary history of lactase deficiency, recent recommendations to establish screening, and clinical practice guidelines for increased diagnosis of this important, yet often misunderstood condition of malabsorption. © 2013 Lippincott Williams &: Wilkins.


Shah J.P.,University of Texas Southwestern Medical Center | Valdes M.,Parkland Health and Hospital System | Rockey D.C.,University of Texas Southwestern Medical Center
Journal of General Internal Medicine | Year: 2012

BACKGROUND: Safety-net hospital systems provide care to a large proportion of United States' under- and uninsured population. We have witnessed delayed colorectal cancer (CRC) care in this population and sought to identify demographic and systemic differences in these patients compared to those in an insured health-care system. DESIGN, PATIENTS, AND APPROACH/MEASUREMENTS: We collected demographic, socioeconomic, and clinical data from 2005-2007 on all patients with CRC seen at Parkland Health and Hospital System (PHHS), a safety-net health system and at Presbyterian Hospital Dallas System (Presbyterian), a community health system, and compared characteristics among the two health-care systems. Variables associated with advanced stage were identified with multivariate logistic regression analysis and odds ratios were calculated. RESULTS: Three hundred and eighteen patients at PHHS and 397 patients at Presbyterian with CRC were identified. An overwhelming majority (75 %) of patients seen at the safety-net were diagnosed after being seen in the emergency department or at an outside facility. These patients had a higher percentage of stage 4 disease compared to the community. Patients within the safety-net with Medicare/private insurance had lower rates of advanced disease than uninsured patients (25 % vs. 68 %, p<0.001). Insurance status and physician encounter resulting in diagnosis were independent predictors of disease stage at diagnosis. CONCLUSIONS: A large proportion of patients seen in the safety-net health system were transferred from outside systems after diagnosis, thus leading to delayed care. This delay in care drove advanced stage at diagnosis. The data point to a pervasive and systematic issue in patients with CRC and have fundamental health policy implications for population-based CRC screening. © Society of General Internal Medicine 2012.

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