Ronco C.,St Bortolo Hospital |
Ronco C.,International Renal Research Institute |
Cicoira M.,University of Verona |
McCullough P.A.,St John Providence Health System |
And 3 more authors.
Journal of the American College of Cardiology | Year: 2012
Cardiorenal syndrome (CRS) type 1 is characterized as the development of acute kidney injury (AKI) and dysfunction in the patient with acute cardiac illness, most commonly acute decompensated heart failure (ADHF). There is evidence in the literature supporting multiple pathophysiological mechanisms operating simultaneously and sequentially to result in the clinical syndrome characterized by a rise in serum creatinine, oliguria, diuretic resistance, and in many cases, worsening of ADHF symptoms. The milieu of chronic kidney disease has associated factors including obesity, cachexia, hypertension, diabetes, proteinuria, uremic solute retention, anemia, and repeated subclinical AKI events all work to escalate individual risk of CRS in the setting of ADHF. All of these conditions have been linked to cardiac and renal fibrosis. In the hospitalized patient, hemodynamic changes leading to venous renal congestion, neurohormonal activation, hypothalamic-pituitary stress reaction, inflammation and immune cell signaling, systemic endotoxemic exposure from the gut, superimposed infection, and iatrogenesis all contribute to CRS type 1. The final common pathway of bidirectional organ injury appears to be cellular, tissue, and systemic oxidative stress that exacerbate organ function. This review explores in detail the pathophysiological pathways that put a patient at risk and then effectuate the vicious cycle now recognized as CRS type 1. © 2012 American College of Cardiology Foundation.
Sweeney M.O.,Brigham and Women's Hospital |
Sakaguchi S.,University of Minnesota |
Simons G.,Englewood Hospital and Medical Center |
Machado C.,Providence Hospital and Medical Centers |
And 2 more authors.
Heart Rhythm | Year: 2012
BACKGROUND: The Center for Medicare & Medicaid Services expanded coverage for primary prevention (PP) implantable cardioverter-defibrillators (ICDs) included a request for outcome comparisons between 3 Group B subgroup patients (left ventricular ejection fraction [LVEF] 31%-35%, nonischemic dilated cardiomyopathy [NDCM] duration of <9 months, and New York Heart Association class IV heart failure (HF) treated with cardiac resynchronization therapy/defibrillator [CRT/D]) and non-Group B patients (LVEF ≤30%, NDCM duration of <9 months, and New York Heart Association class III HF treated with CRT/D) using real-world observational studies. OBJECTIVE: To compare outcomes in Center for Medicare & Medicaid Services Group B and non-Group B PP ICD patients. METHODS: OMNI was a 4-year prospective observational study that enrolled 1464 PP ICD patients with a mean LVEF of 25%; 72% were men, 78% had class II-IV HF, and 66% had coronary disease. A total of 795 (54.3%) received ICDs, and 669 (45.7%) received CRT/Ds. Ventricular tachyarrhythmia therapy rates and mortality were compared over 39 ± 18.4 months. RESULTS: Twenty-five percent received ventricular tachyarrhythmia therapies, and 21.2% died within 4 years. Patient-year therapy rates were not significantly different for LVEF of 31%-35% (0.36 per year) vs ≤30% (0.51/y) and CRT/D for class IV HF (0.21/y) vs class III HF (0.43 per year) but were lower for NDCM <9 months (0.3/y) vs <9 months (0.85/y; P = .02). Four-year mortality was similar for LVEF 30%-35% (22.6%) vs <30% (24.4%) and NDCM <9 months (14.2%) vs <9 months (12.3%) but was higher for CRT/D for class IV HF (48.6%) vs class III HF (27.4%) (P = .01). CONCLUSION: Patient-year ventricular tachyarrhythmia therapy rates did not differ between non-Group B and Group B PP ICD patients, though NDCM <9 months was significantly lower. Survival at 4 years was lowest in patients with New York Heart Association class IV HF treated with CRT/D and similar between all other non-Group B and Group B patients. © 2012 Heart Rhythm Society. All rights reserved.
Hasan R.A.,Mercy Childrens Hospital |
Thomas J.,Providence Hospital and Medical Centers |
Davidson B.,University of Toledo |
Barnes J.,Providence Hospital and Medical Center |
Reddy R.,Mercy Childrens Hospital
Pediatric Critical Care Medicine | Year: 2011
Objective: To evaluate the safety and feasibility of exhaled breath condensate (EBC) collection in children recovering from status asthmaticus (SA) in a pediatric intensive care unit (PICU); and to investigate whether 8-isoprostane (8-Iso) could be detected in the EBC of these children and to compare its concentration with that in the EBC collected from healthy children. Design: Prospective study. Setting: Multidisciplinary PICU in a teaching hospital. Patients: Sixteen consecutive patients (7-18 yrs of age) with SA and 16 age- and sex-matched controls. Interventions: The Wood clinical asthma score and the pulmonary index were used to assess the clinical severity of patients with SA upon admission to the PICU. EBC samples were collected within 24 hrs of admission to the PICU and were analyzed for the concentration of 8-Iso. Measurements and Main Results: Data are presented as mean ± sd values. There were no differences in age (12 ± 3.3 yrs vs.12 ± 2 yrs, p > .05) or sex (n = 10 males and n = 6 females in each group), between SA patients and controls. All patients with SA and the controls completed the EBC collection without complications. There was no statistically significant difference in the pulmonary index (3.2 ± 2.7 vs. 3.1 ± 2.8, p 0.9) post collection of EBC compared with the baseline values. There was a statistically significant correlation between Wood score and pulmonary index at the time of admission to the PICU in children with SA (r = .7, p < .01). The concentration of 8-Iso was significantly higher in the EBC of children with SA compared with controls (14.3 ± 1.8 pg/mL vs. 5.2 ± 0.7 pg/mL, p < .001). The correlation between the concentration 8-Iso and either the pulmonary index or Wood score at the time admission to the PICU was not statistically significant. Conclusions: EBC collection is well tolerated by children aged 7-18 yrs who are recovering from SA in a PICU. 8-Iso is elevated in the EBC from children with SA and may provide insight into the biochemical changes of oxidative stress in children in this clinical setting. Copyright © 2011 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Ronco C.,San Bortolo Hospital |
Stacul F.,Science Radiologia Ospedale Maggiore |
McCullough P.A.,St John Providence Health System |
McCullough P.A.,St John Hospital |
McCullough P.A.,Providence Hospital and Medical Centers
European Radiology | Year: 2013
Abstract: Contrast-induced acute kidney injury (CI-AKI), previously known as contrast-induced nephropathy (CIN), is a syndrome in which an acute renal dysfunction is diagnosed after the intravascular injection of contrast media. AKI implies an injury or damage but not necessarily a reduction in overall renal filtration function. The renal damage becomes evident only when more than 50 % of the renal mass is compromised. This typically occurs when AKI is diagnosed using creatinine as a marker; in fact, creatinine is a surrogate of glomerular filtration and it does not describe the whole spectrum of kidney function. Recent AKI classifications include even slight changes in serum creatinine (as low as 0.3 mg/dl), which are associated with worse outcomes. An early diagnosis of AKI using novel biomarkers has now become possible. These new biomarkers provide additional value, not only because they facilitate earlier diagnosis but also because they can diagnose AKI even in the absence of a change in subsequent filtration function. Thus, in this situation, these new criteria can reveal subclinical AKI. A new domain of AKI diagnosis could then include functional and structural criteria as indicated by laboratory testing. Key Points: • There is continuing concern about renal damage caused by radiological contrast agents • Acute kidney injury may be associated with minor changes in serum creatinine • AKI implies damage but not necessarily a reduction in overall renal filtration function. • Novel biomarkers facilitate earlier diagnosis, even if subsequent filtration function is unaltered. • AKI diagnosis could include functional and structural criteria as indicated by laboratory testing © 2012 European Society of Radiology.
Unawane A.,Providence Surgery Centers |
Kamyab A.,Providence Surgery Centers |
Patel M.,Providence Surgery Centers |
Flynn J.C.,Providence Hospital and Medical Centers |
Mittal V.K.,Providence Surgery Centers
American Journal of Surgery | Year: 2013
Background: Realizing the trends toward minimally invasive procedures, the Accreditation Council for Graduate Medical Education (ACGME) increased the requirements for laparoscopic procedures effective 2007 to 2008. Our purpose was to analyze the trend of laparoscopic versus open cases. Methods: We analyzed national ACGME general surgery operative log program data for basic and advanced open and laparoscopic procedures performed by graduating surgical residents between academic years 1996 to 1997 and 2009 to 2010. Results: From 1997 to 2010, the average number of procedures performed by graduating residents increased for appendectomies (36.5 to 59.3), cholecystectomies (90.9 to 112), hernia repairs (58.9 to 67.4), and colectomies (40.1 to 60.2). These increases have been accompanied by decreases in the percentage of open procedures for appendectomies (84% to 30%), cholecystectomies (24% to 9%), hernia repairs (90% to 70%), and colectomies (97% to 71%), which have resulted primarily from a decrease in open procedures (basic) or an increase in laparoscopic procedures (advanced). Conclusions: The rising number of laparoscopic procedures performed by surgical residents is associated with a drastic decrease in the number of basic open procedures. Although the number of open procedures is sufficient to meet ACGME requirements for now, this is an area of concern for the adequacy of training in the future. © 2013 Elsevier Inc. All rights reserved.
Daee S.S.,Providence Surgery Centers |
Flynn J.C.,Providence Hospital and Medical Centers |
Jacobs M.J.,Providence Surgery Centers |
Mittal V.K.,Providence Surgery Centers
HPB | Year: 2013
Objective This study was conducted to determine whether residents are receiving enough hepatopancreatobiliary (HPB) training during general surgery residencies to exclude the necessity of pursuing formal fellowships in HPB surgery. Methods Trends in HPB surgery training were examined using Accreditation Council for Graduate Medical Education (ACGME) operative log data for the academic years 1999/2000 to 2009/2010. Results Of 800 000 HPB operations performed annually in the USA, the proportion of HPB procedures performed by general surgery residents increased from 15% (122 007) to 18% (143 000) between the periods under study. Numbers of pancreatic, liver and biliary procedures performed by graduating general surgery residents increased by 47% (from 8185 to 12 006), 31% (from 7468 to 9765), and 14% (from 106 354 to 121 239), respectively. The mean number of operations undertaken by a graduating resident increased from 8.3 to 11.5 (38% increase) for pancreatic surgeries, from 7.6 to 9.4 (24% increase) for liver surgeries, and from 107.5 to 116.6 (8% increase) for biliary surgeries. Total numbers of complex pancreatic, liver and biliary procedures increased by 91% (from 4768 to 9129) and 24% (from 6649 to 8233), and decreased by 29% (from 6581 to 4648), respectively. Conclusions The overall trend shows an increase in the number of HPB procedures undertaken by graduating general surgery residents. The mean number of procedures exceeds ACGME requirements, but falls short of association guidelines. However, certain residents exceed International Hepato-Pancreato-Biliary Association (IHPBA) fellowship requirements for total and complex procedures during residency. Consideration should be given to those residents to allow them to bypass fellowship training provided that they meet other IHPBA standards. © 2013 International Hepato-Pancreato-Biliary Association.
Bhullar J.S.,Providence Surgery Centers |
Makarawo T.,Providence Surgery Centers |
Subhas G.,Providence Surgery Centers |
Alomari A.,Providence Surgery Centers |
And 4 more authors.
Journal of the American College of Surgeons | Year: 2013
Background: Orthotopic mouse models of human gastric cancer represent an important in vivo tool for testing chemotherapeutic agents and for studying intraluminal factors. Currently, orthotopic mouse models of gastric cancer require an operative procedure involving either injection or implantation of tumor cells in stomach layers. The resultant tumor does not grow from the stomach's mucosal surface, so it does not mimic the human disease process. Study Design: A low-dose gastric mucosal coagulation was done transorally in the body of stomach using a specially designed polyethylene catheter in 16 female severe combined immunodeficient mice. This was followed by the instillation of SNU-16 human gastric cancer tumor cells (1 × 106 cells). Five mice each were euthanized at 1 and 2 months, and 6 mice were euthanized at 3 months. Three control mice underwent electrocoagulation alone and 3 mice underwent cell line instillation alone. Results: Tumors were detected in 11 of 16 experimental mice, but not in the control mice. Tumors were noted in mice at 1 month. Over time, there was an increase in tumor growth and metastasis to lymph nodes and surrounding organs. Histopathologic evaluation showed that the tumors grew from the gastric mucosa. Conclusions: Our model is easy to create and overcomes the limitations of the existing models, as the tumor arises from the stomach's mucosal layer and mimics the human disease in terms of morphology and biologic behavior. This is the first report of a true orthotopic gastric cancer murine model. This model opens new doors for additional studies that were not possible earlier. © 2013 by the American College of Surgeons.
Hasan R.A.,Providence Hospital and Medical Centers |
O'Brien E.,University of Michigan |
Mancuso P.,University of Michigan
Pediatric Critical Care Medicine | Year: 2012
OBJECTIVE: To measure levels of 8-isoprostane and Lipoxin A4 in the exhaled breath condensate of children (7-17 yrs old) recovering from status asthmaticus in a pediatric intensive care unit and to compare their respective levels in the exhaled breath condensate collected from age-matched "healthy" children enrolled from an ambulatory pediatric clinic during well-child visits. DESIGN: Prospective case-controlled study. SETTING: Teaching hospitals and a research laboratory. PATIENTS: Children recovering from status asthmaticus and age-matched controls. INTERVENTIONS: Collection of exhaled breath condensate from patients recovering from status asthmaticus and controls for purpose of measurement of 8-isoprostane and Lipoxin A4. MEASUREMENTS AND MAIN RESULTS: There was no difference in age (11.9 ± 3.0 vs. 12.0 ± 3.3 yrs, p = .9) between patients and control subjects. All participants completed the exhaled breath condensate collection without complications. There was no difference in the pulmonary index (3.3 ± 2.2 vs. 3.1 ± 1.9, p = 1.0) after collection of exhaled breath condensate compared with baseline values in patients with status asthmaticus. The level of 8-isoprostane was significantly higher (63 ± 9 vs. 41 ± 13 pg/mL, p < .001), whereas the level of Lipoxin A4 was significantly lower (5.6 ± 2.9 vs. 10.5 ± 3.1 ng/mL, p < .001) in the exhaled breath condensate from children recovering from status asthmaticus compared with control subjects. CONCLUSIONS: 8-Isoprostane was elevated and Lipoxin A4 is decreased in the exhaled breath condensate of children recovering from status asthmaticus in a pediatric intensive care unit. These data may provide new insight into the pathophysiology of asthma in children in this clinical setting. © 2012 The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Bhullar J.S.,Providence Hospital and Medical Centers |
Varshney N.,Providence Hospital and Medical Centers |
Bhullar A.K.,Providence Hospital and Medical Centers |
Mittal V.K.,Providence Hospital and Medical Centers
International Journal of Surgical Pathology | Year: 2014
In 2004, A new peculiar subtype of renal cell carcinoma, which later received the name of tubulocystic carcinoma (TCCRC), was recognized. Though the tumor has distinct macroscopic, microscopic and immunohistochemical features, the tumor was previously considered to have some similarities to various other renal cancers. We did an extensive review of literature using PubMed and CrossRef, which yielded more than 80 cases reported from various parts of the world. We evaluated the epidemiology, tumor presentations, pathological characteristics, treatment, and outcome of TCC-RC. © The Author(s) 2013.
High-grade undifferentiated small round cell sarcoma with t(4;19)(q35;q13.1) CIC-DUX4 fusion: Emerging entities of soft tissue tumors with unique histopathologic features – A case report and literature review
Haidar A.,Providence Hospital and Medical Centers |
Arekapudi S.,Providence Hospital and Medical Centers |
DeMattia F.,Providence Hospital and Medical Centers |
Abu-Isa E.,University of Michigan |
Kraut M.,Providence Hospital and Medical Centers
American Journal of Case Reports | Year: 2015
Objective: Rare disease. Background: A subset of undifferentiated small round cell sarcomas (USRCSs) is currently being recognized as emerging entities with unique gene fusions: CIC-DUX4 (the area of focus in this article), BCOR-CCNB3, or CIC-FOXO4 gene fusions. CIC-DUX4 and CIC-FOXO4 fusions have been reported in soft tissue tumors, while BCOR-CCNB3 fusion with an X chromosomal inversion was described in both bone and soft tissue tumors. CIC-DUX4 fusion can either harbor t(4;19)(q35;q13.1) or t(10;19)(q26.3;q13), while t(4;19)(q35;q13.1) is reported more commonly. Case Report: The aim of this study is to share a new case report of a 36-year-old woman who had a rapidly growing mass in her right upper thigh, which was found to be an undifferentiated small round cell sarcoma with t(4;19) (q35;q13.1) CIC-DUX4 fusion was confirmed by cytogenetic testing. Combined modality treatment with surgery, radiation, and chemotherapy was used and achieved a good response. A review of the literature of the reported cases with CIC-DUX4 fusions including both t(4;19) and t(10;19) translocations revealed a total of 44 cases reported. Out of these 44 cases, 33 showed t(4;19)(q35;q13.1) translocation compared to 11 cases with t(10;19)(q26.3;q13). Conclusions: Undifferentiated small round cell sarcomas are aggressive tumors. Their treatment includes surgery, chemotherapy, and radiation. Resistance to chemotherapy is common. Lung and brain are common sites of metastasis, with associated poor prognosis. Generally, median survival is less than 2 years. Newer techniques have been developed recently which helped identify a subset of previously unclassifiable sarcomas, with promising prognostic value. © 2015 Am J Case Rep.