Foy A.J.,Pennsylvania State University |
Liu G.,Penn State Milton rshey Medical Center |
Davidson W.R.,Pennsylvania State University |
Sciamanna C.,Penn Medicine |
Leslie D.L.,Penn State Milton rshey Medical Center
JAMA Internal Medicine | Year: 2015
IMPORTANCE: Patients presenting to the emergency department (ED) with chest pain whose evaluation for ischemia demonstrates no abnormalities receive further functional or anatomical studies for coronary artery disease; however, comparative evidence for the various strategies is lacking and multiple testing options exist. OBJECTIVE: To compare chest pain evaluation pathways based on their association with downstream testing, interventions, and outcomes for patients in EDs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of health insurance claims data for a national sample of privately insured patients from January 1 to December 31, 2011. Individuals with a primary or secondary diagnosis of chest pain in the ED were selected and classified into 1 of 5 testing strategies: no noninvasive testing, exercise electrocardiography, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography. MAIN OUTCOMES ANDMEASURES: The proportion of patients in each group who received a cardiac catheterization, coronary revascularization procedure, or future noninvasive test as well as those who were hospitalized for an acute myocardial infarction (MI) during 7 and 190 days of follow-up. RESULTS: In 2011, there were 693 212 ED visits with a primary or secondary diagnosis of chest pain, accounting for 9.2% of all ED encounters. After application of the inclusion and exclusion criteria, 421 774 patients were included in the final analysis; 293 788 individuals did not receive an initial noninvasive test and 127 986 did, representing 1.7% of all ED encounters. Overall, the percentage of patients hospitalized with an MI was very low during both 7 and 190 days of follow-up (0.11% and 0.33%, respectively). Patients who did not undergo initial noninvasive testing were no more likely to experience an MI than were those who did receive testing. Compared with no testing, exercise electrocardiography, myocardial perfusion scintigraphy, and coronary computed tomography angiography were associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement inthe odds of experiencingan MI. CONCLUSIONS AND RELEVANCE: Patients with chest pain evaluated in the ED who do not have an MI are at very low risk of experiencing an MI during short- and longer-term follow-up in a cohort of privately insured patients. This low risk does not appear to be affected by the initial testing strategy. Deferral of early noninvasive testing appears to be reasonable. © 2015 American Medical Association. All rights reserved.
Survival after shock therapy in implantable cardioverter-defibrillator and cardiac resynchronization therapy-defibrillator recipients according to rhythm shocked: The altitude survival by rhythm study
Powell B.D.,Sanger Heart and Vascular Institute |
Saxon L.A.,University of Southern California |
Boehmer J.P.,Penn State Milton rshey Medical Center |
Day J.D.,Intermountain Medical Center |
And 5 more authors.
Journal of the American College of Cardiology | Year: 2013
Objectives This study sought to determine if the risk of mortality associated with inappropriate implantable cardioverter-defibrillator (ICD) shocks is due to the underlying arrhythmia or the shock itself. Background Shocks delivered from ICDs are associated with an increased risk of mortality. It is unknown if all patients who experience inappropriate ICD shocks have an increased risk of death. Methods We evaluated survival outcomes in patients with an ICD and a cardiac resynchronization therapy defibrillator enrolled in the LATITUDE remote monitoring system (Boston Scientific Corp., Natick, Massachusetts) through January 1, 2010. First shock episode rhythms from 3,809 patients who acutely survived the initial shock were adjudicated by 7 electrophysiologists. Patients with a shock were matched to patients without a shock (n = 3,630) by age at implant, implant year, sex, and device type. Results The mean age of the study group was 64 ± 13 years, and 78% were male. Compared with no shock, there was an increased rate of mortality in those who received their first shock for monomorphic ventricular tachycardia (hazard ratio [HR]: 1.65, p < 0.0001), ventricular fibrillation/polymorphic ventricular tachycardia (HR: 2.10, p < 0.0001), and atrial fibrillation/flutter (HR: 1.61, p = 0.003). In contrast, mortality after first shocks due to sinus tachycardia and supraventricular tachycardia (HR: 0.97, p = 0.86) and noise/artifact/oversensing (HR: 0.91, p = 0.76) was comparable to that in patients without a shock. Conclusions Compared with no shock, those who received their first shock for ventricular rhythms and atrial fibrillation had an increased risk of death. There was no significant difference in survival after inappropriate shocks for sinus tachycardia or noise/artifact/oversensing. In this study, the adverse prognosis after first shock appears to be more related to the underlying arrhythmia than to an adverse effect from the shock itself. © 2013 by the American College of Cardiology Foundation Published by Elsevier Inc.
Matsushima K.,Penn State Milton rshey Medical Center |
Frankel H.L.,University of Maryland, Baltimore
Current Opinion in Critical Care | Year: 2011
Purpose of review: The use of ultrasound for the management of the injured patient has expanded dramatically in the last decade. The focused assessment with sonography for trauma (FAST) has become one of the fundamental skills incorporated into the initial evaluation of the trauma patient. However, there are significant limitations of this diagnostic modality as initially described. Novel ultrasound examinations of the injured patient, although useful, must also be considered carefully. Recent findings: Increasing evidence supports the high specificity of FAST for detecting a pericardial effusion and intra-abdominal free fluid (hemorrhage) in the patient with blunt injury. On the other hand, a so-called negative FAST result still requires further diagnostic work up given its low sensitivity. Similarly, the role of FAST in penetrating abdominal trauma appears to be limited because of lower sensitivity for visceral injury compared to other modalities. Extended FAST (EFAST), that adds a focused thoracic examination, has high accuracy for the detection of pneumothorax comparable to computed tomographic scan, the significance of which is not currently known. Finally, the utility of intensivist-performed ultrasound in the ICU is expanding to limited hemodynamic assessment and facilitation of central venous catheter placement. Summary: The indications for FAST and additional ultrasound studies in the injured patient continue to evolve. Application of sound clinical evidence will avoid unsubstantiated indications for ultrasound to creep into our clinical practice. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Connelly T.M.,Penn State Milton rshey Medical Center |
Koltun W.A.,Penn State Milton rshey Medical Center
Expert Review of Gastroenterology and Hepatology | Year: 2013
Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is controversial. Total proctocolectomy (TPC) is the most definitive treatment for the eradication of undiagnosed synchronous dysplasias and/or carcinomas and the prevention of subsequent metachronous lesions in both Crohn's disease (CD) and ulcerative colitis (UC). However, TPC is not always an attractive option owing to patient comorbidities and patient preference. Historically, dysplasia has been most studied in patients with UC, where the option of reconstruction without a stoma makes TPC more acceptable. Due to a relative lack of research on CD-related dysplasia, surveillance and treatment of CD dysplasia has followed paradigms based on UC data. However, due to pathophysiological differences in CD versus UC, options for surgical management in CD may be more varied than simple TPC, particularly in the less healthy surgical candidate and those who refuse end ileostomy. © 2013 Expert Reviews Ltd.
Frankenfield D.C.,Penn State Milton rshey Medical Center |
Ashcraft C.M.,Penn State Milton rshey Medical Center
Nutrition | Year: 2012
Objective: To compare the effect of stroke on the metabolic rate compared with the effect of traumatic brain injury and to determine whether the metabolic rate is predictable in both types of brain injury. Methods: Indirect calorimetry was conducted prospectively in mechanically ventilated patients within the first 6 d of admission to a critical care unit owing to ischemic stroke, hemorrhagic stroke, isolated traumatic brain injury, or traumatic brain injury with collateral injuries. Clinical data were collected simultaneously and a predicted value of the resting metabolic rate was calculated using the Penn State equation (using body size, body temperature, and minute ventilation). Results: One hundred thirty patients were measured. Ischemic stroke showed a lower incidence of fever, a lower body temperature, and a lower resting metabolic rate than the other groups; whereas in hemorrhagic stroke, these variables were similar to the trauma groups. Sedation decreased the resting metabolic rate, but this effect seemed particular to the trauma patients. The Penn State equation predicted the resting metabolic rate accurately 72% of the time, and when its component variables of body temperature and minute ventilation were controlled in an analysis of variance, all the differences among the brain injury and sedation groups were eliminated. Conclusion: Stroke is a hypermetabolic event most of the time. Body size, temperature, and minute ventilation explain most of the variation in the resting metabolic rate after traumatic and non-traumatic brain injuries. The Penn State equation therefore predicts the resting metabolic rate in brain-injured patients no matter the mechanism of injury. © 2012 Elsevier Inc.
Frankenfield D.C.,Penn State Milton rshey Medical Center
Nutrition | Year: 2010
The technique of indirect calorimetry developed with the sciences of nutrition and physiology over the course of hundreds of years. It was in fact fundamental to the establishment of these disciplines. This review describes the development of the technology and the principles of body function it has revealed. © 2010 Elsevier Inc.
Zaenglein A.L.,Penn State Milton rshey Medical Center
Clinical Pediatrics | Year: 2010
Early acne can be defined as the occurrence of acne at its onset, primarily in preteens, or as acne at its earliest severity (ie, mild to moderate). Although the majority of patients with acne are treated by dermatologists, most, particularly mild to moderate cases, could be successfully managed by primary care physicians. Therefore, it is important for physicians to understand the benefits of treating all types of acne, not just the most severe. Awareness of the emotional impact of acne, particularly in adolescence, as well as recognition of possible scarring are important considerations. To achieve optimal results, physicians should be familiar with classification and severity grading of acne. Also, in-depth knowledge of available acne medications will streamline and optimize treatment regimens. Recognizing, treating, and monitoring the progress of early acne may lead to quicker, better clinical outcomes and improved quality of life.
Sathyendra V.,Penn State Milton rshey Medical Center |
Darowish M.,Penn State Milton rshey Medical Center
Hand Clinics | Year: 2013
Bone healing is a complex process that can be influenced by both host and environmental factors. In this article, we review the biology involved in the regeneration of new bone after fracture, and factors influencing bone healing, including diabetes, smoking, NSAID use, and bisphosphonates. © 2013 Elsevier Inc.
Allahverdian S.,University of British Columbia |
Chehroudi A.C.,University of British Columbia |
McManus B.M.,University of British Columbia |
Abraham T.,Penn State Milton rshey Medical Center |
Francis G.A.,University of British Columbia
Circulation | Year: 2014
Background: Intimal smooth muscle cells (SMCs) contribute to the foam cell population in arterial plaque, and express lower levels of the cholesterol exporter ATP-binding cassette transporter A1 (ABCA1) in comparison with medial arterial SMCs. The relative contribution of SMCs to the total foam cell population and their expression of ABCA1 in comparison with intimal monocyte-derived macrophages, however, are unknown. Although the expression of macrophage markers by SMCs following lipid loading has been described, the relevance of this phenotypic switch by SMCs in human coronary atherosclerosis has not been determined. Methods and results: Human coronary artery sections from hearts explanted at the time of transplantation were processed to clearly delineate intracellular and extracellular lipids and allow costaining for cell-specific markers. Costaining for oil red O and the SMC-specific marker SM α-actin of foam cell-rich lesions revealed that 50±7% (average±standard error of the mean, n=14 subjects) of total foam cells were SMC derived. ABCA1 expression by intimal SMCs was significantly reduced between early and advanced atherosclerotic lesions, with no loss in ABCA1 expression by myeloid lineage cells. Costaining with the macrophage marker CD68 and SM α-actin revealed that 40±6% (n=15) of CD68-positive cells originated as SMCs in advanced human coronary atherosclerosis. Conclusions: These findings suggest SMCs contain a much larger burden of the excess cholesterol in human coronary atherosclerosis than previously known, in part, because of their relative inability to release excess cholesterol via ABCA1 in comparison with myeloid lineage cells. Our results also indicate that many cells identified as monocyte-derived macrophages in human atherosclerosis are in fact SMC derived. © 2014 American Heart Association, Inc.
Barbour M.L.,Penn State Milton rshey Medical Center |
Raman J.D.,Penn State Milton rshey Medical Center
Urology | Year: 2015
Objective To review our experience in using ureteroscopy (URS) with lithotripsy for renal or ureteral calculi to determine the incidence and predictors of postprocedural ipsilateral hydronephrosis. Patients and Methods Records of 324 URS cases for renal or ureteral calculi with imaging performed 4-12 weeks postprocedure were reviewed. Ipsilateral hydronephrosis was determined by computed tomography scan or renal ultrasound. Univariate and multivariate analyses determined the factors associated with hydronephrosis. Results 176 men and 148 women with a median age of 50 years were included. Median stone size was 6 mm and operative duration was 60 minutes; 30% of patients had multiple calculi; and 35% had undergone a prior ipsilateral URS. Overall, 49 of 324 patients (15%) had evidence of hydronephrosis, with 65% of these patients having symptoms and 40% requiring ancillary procedures. On multivariate analysis, increasing stone diameter (odds ratio [OR] 8.9, 95% confidence interval [CI] 1.9-23.8, P =.03), prior ipsilateral URS (OR 7.7, 95% CI 1.8-28.2, P =.006), longer operative duration (OR 6.5, 95% CI 1.8-16.3, P =.02), and renal colic symptoms (OR 48.3, 95% CI 14.7-71.4, P <.001) independently predicted hydronephrosis. Conversely, other factors including stone impaction at procedure, ureteral dilation, use of an access sheath, intraoperative perforation, or use of a stent did not associate with ipsilateral hydronephrosis. Conclusion In this contemporary cohort study, 15% of patients undergoing URS had evidence of ipsilateral hydronephrosis. Larger stone size, longer OR duration, prior ipsilateral URS, and recurrent colic were associated with an increased likelihood for this observation. Patients and stone cases with such characteristics likely warrant imaging modalities beyond plain radiography. © 2015 Elsevier Inc. All Rights Reserved.