Buena Vista, CA, United States
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Forero-Torres A.,University of Alabama at Birmingham | Holkova B.,Virginia Commonwealth University | Goldschmidt J.,Oncology and Hematology Assoc. of SW Virginia | Chen R.,City of Hope Medical Center | And 8 more authors.
Blood | Year: 2015

Outcomes in older patients with Hodgkin lymphoma (HL) tend to be poor following conventional chemotherapy regimens. Treatment-related toxicity is significant and comorbidities often limit therapeutic options. This phase 2, open-label study evaluated the efficacy and safety of brentuximab vedotin, a CD30-directed antibody-drug conjugate, as frontline therapy in 27 HL patients aged ≥60 years. The objective response rate (ORR) was 92%, with 73% achieving complete remission. All patients achieved stable disease or better, and had decreased tumor volume following treatment. At the time of this analysis, themedian duration of objective response for efficacy-evaluable patients (N5 26) was 9.1 months (range, 2.8 to 20.91 months), median progression-free survival was 10.5 months (range, 2.61 to 22.31 months), and median overall survival had not been reached (range, 4.61 to 24.91 months). The observed adverse events (AEs) were generally consistent withthe known safety profile of brentuximab vedotin. Themost common AEs were peripheral sensory neuropathy (78%), fatigue (44%), and nausea (44%), and were ≤ grade 2 formost patients. The incidence of grade 3 peripheral neuropathy events was relatively high (30% overall), particularly among patients with the knownrisk factors of diabetes and/or hypothyroidism (46% vs 14% for those without). However, these risk factors were not associated with delayed time to resolution/improvement of peripheral neuropathy. Preliminary data showed no substantial age-related changes in brentuximab vedotin pharmacokinetics. Brentuximab vedotin monotherapy may provide a frontline treatment option for older patients who cannot tolerate conventional combination chemotherapy. © 2015 by The American Society of Hematology.


Vacirca J.L.,North Shore Hematology and Oncology Associates | Acs P.I.,Florida Cancer Specialists | Tabbara I.A.,George Washington University | Rosen P.J.,Providence Saint Joseph Medical Center | And 2 more authors.
Annals of Hematology | Year: 2014

Patients with relapsed or refractory diffuse large B cell lymphoma (DLBCL) are treated with salvage regimens and may be considered for high-dose chemotherapy and autologous stem cell transplantation if disease is chemosensitive. Bendamustine is active in indolent B cell lymphomas and chronic lymphocytic leukemia but has not been extensively studied in aggressive lymphomas. This trial examines the combination of bendamustine and rituximab in patients with relapsed and refractory DLBCL. Patients received bendamustine at 90 mg/m2 (n = 2) or 120 mg/m2 (n = 57) on days 1 and 2 and rituximab at 375 mg/m2 on day 1 every 28 days for up to 6 cycles. The study evaluated objective response rate (ORR), duration of response (DOR), progression-free survival (PFS), and treatment safety. Fifty-nine patients were treated, and 48 were evaluable for response. Median age was 74; 89 % had stage III or IV disease, and 63 % had high revised International Prognostic Index scores; the median number of prior therapies was 1. Based on analysis using the intent-to-treat population, the ORR was 45.8 % (complete response, 15.3 %; partial response, 30.5 %). The median DOR was 17.3 months, and the median PFS was 3.6 months. Grade 3 or 4 hematological toxicities included neutropenia (36 %), leukopenia (29 %), thrombocytopenia (22 %), and anemia (12 %). The combination of bendamustine and rituximab showed modest activity in patients with relapsed and refractory DLBCL and has an acceptable toxicity profile. © 2013 The Author(s).


O'Sullivan Maillet J.,Rutgers University | Baird Schwartz D.,Providence Saint Joseph Medical Center | Posthauer M.E.,Healthcare Dietary Services Inc.
Journal of the Academy of Nutrition and Dietetics | Year: 2013

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published on the Academy website at: www.eatright.org/positions. © 2013 Academy of Nutrition and Dietetics.


Schwartz D.B.,Providence Saint Joseph Medical Center | Posthauer M.E.,Healthcare Dietary Services Inc | O'Sullivan Maillet J.,Rutgers University
Journal of the Academy of Nutrition and Dietetics | Year: 2013

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians should work collaboratively as part of an interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. This practice paper provides a proactive, integrated, systematic process to implement the Academy's position. The position and practice papers should be used together to address the history and supporting information of ethical and legal issues of feeding and hydration identified by the Academy. Elements of collaborative ethical deliberation are provided for pediatrics and adults and in different conditions. The process of ethical deliberation is presented with the roles and responsibilities of the registered dietitian and the dietetic technician, registered. Understanding the importance and applying concepts dealing with cultural values and religious diversity is necessary to integrate clinical ethics into nutrition care. Incorporating screening for quality-of-life goals is essential before implementing the Nutrition Care Process and improving health literacy with individual interactions. Developing institution-specific policies and procedures is necessary to accelerate the practice change with artificial nutrition, clinical ethics, and quality improvement projects to determine best practice. This paper supports the "Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published in the June 2013 issue of the Journal of the Academy of Nutrition and Dietetics. © 2013 Academy of Nutrition and Dietetics.


Wright R.C.,Orthopaedic Surgery Specialists | Gillis C.T.,Orthopaedic Surgery Specialists | Gillis C.T.,Western University of Health Sciences | Yacoubian S.V.,Orthopaedic Surgery Specialists | And 5 more authors.
Journal of Arthroplasty | Year: 2012

Total knee arthroplasty (TKA) continues to advance as innovative devices become available. #2 PDO Quill SRS (Angiotech, Reading, Pa) bidirectional barbed suture was used for 161 primary TKAs at our facility. We report on 3 separate cases of extensor mechanism repair failure after primary TKA in which a barbed suture was used for extensor mechanism closure. Before the implementation of this device, there were no reported failures in 385 primary TKAs. We recommend that surgeons who use this device for extensor mechanism repair of a medial parapatellar arthrotomy in TKA exercise caution when operating on patients with morbid obesity, diabetes, and rheumatoid arthritis. We have discontinued use of the bidirectional barbed suture until more definitive large orthopedic studies establish its efficacy and safety. © 2012 Elsevier Inc.


Yacoubian S.V.,Providence Saint Joseph Medical Center
Orthopedics | Year: 2010

This article presents 2 cases of foot drop after joint replacement surgery that presented after sequential compression device application. In both cases, intact peroneal nerve function was documented by the surgeon in the recovery room prior to sequential compression device application. We believe that excessive pressure over the superficial aspect of the peroneal nerve in conjunction with decreased pain stimulus from analgesia may have contributed to these complications. We maintain sequential compression devices are the current mechanical thromboprophylaxis of choice; however, 4 recommendations are made to minimize the chances of this potential complication. First, precise attention should be given to patients who are short statured, as these patients can be more susceptible to having a sequential compression device improperly placed over the peroneal nerve at the fibular neck. Second, we recommend different size options become more widely available to accommodate varying patient sizes such that placement of the device is ensured to be distal to the fibular neck. Third, when using sequential compression device brands that have hook and look fastener straps, the straps should not be tight on application and frequent skin checks should be made to look for signs of over-compression. Lastly, we recommend considering delaying postoperative application of the sequential compression device until resolution of sensation following spinal or epidural anesthetic.


Schwartz D.B.,Providence Saint Joseph Medical Center
Nutrition in Clinical Practice | Year: 2013

The purpose of this article is to present the application of patient-centered care and clinical ethics into nutrition practice, illustrate the process in a case study, and promote change in the current healthcare clinical ethics model. Nutrition support clinicians have an opportunity to add another dimension to their practice with the incorporation of patient-centered care and clinical ethics. This represents a culture change for healthcare professionals, including nutrition support clinicians, patients and their family. All of these individuals are stakeholders in the process and have the ability to modify the current healthcare system to improve communication and facilitate a change by humanizing nutrition support practice. Nutrition support is a medical, life-sustaining treatment, and the use of this therapy requires knowledge by the nutrition support clinician of patient-centered care concepts, preventive clinical ethics, religion/spirituality and cultural diversity, palliative care team role, and advance care planning. Integrating these into the practice of nutrition support is an innovative approach and results in new knowledge that requires a change in the culture of care and engagement and empowerment of the patient and their family in the process. This is more than a healthcare issue; it involves a social/family conversation movement that will be enhanced by the nutrition support clinician's participation. © 2013 American Society for Parenteral and Enteral Nutrition.


Chen T.-Y.,Chi Mei Medical Center | Chiu L.,Providence Saint Joseph Medical Center | Wu T.-C.,Chi Mei Medical Center | Lin C.-J.,Chi Mei Medical Center | And 2 more authors.
Clinical Imaging | Year: 2012

We described our experience with a heterogeneous collection of 200 arterial spin-labeling (ASL) perfusion cases. ASL imaging was performed on a 1.5-T magnetic resonance imaging unit with a receive head coil using a second version of quantitative perfusion imaging. Sixty-four (32%) patients exhibited normal perfusion, 107 (53.5%) patients exhibited hypoperfusion, and 29 (14.5%) exhibited hyperperfusion. This ASL study illustrates the usefulness of ASL perfusion studies in a number of pathological conditions and that perfusion imaging can be implemented successfully in a routine clinical neuroimaging protocol. © 2012 Elsevier Inc.


Seltzer J.,University of Southern California | Lucas J.,University of Southern California | Commins D.,University of Southern California | Lerner O.,Providence Saint Joseph Medical Center | And 3 more authors.
Neurosurgical Focus | Year: 2015

Ectopic pituitary adenomas are exceedingly rare entities that are often misdiagnosed. The resulting delay in diagnosis may be particularly concerning in the case of Cushing syndrome caused by an ectopic adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma. Although the total resection of ectopic adenomas results in rapid and durable remission, persistent Cushing syndrome is often associated with permanently damaging invasive procedures and significantly higher risk of mortality. The authors report the case of a 48-year-old man with ACTH-dependent Cushing syndrome. On the morning before surgery, his serum cortisol measured 51 μg/dl, his ACTH level was 195.7 pg/ml, and his urinary free cortisol level was 2109 μg/day. Serum cortisol was not suppressed with the administration of high-dose dexamethasone. Imaging showed separate masses in both the sphenoid sinus and the pituitary gland, complicating the diagnostic process and requiring pathological assessment of both masses. No other abnormalities were found on thoracic, abdominal, or pelvic scans. Gross-total resection of both lesions was accomplished via an endoscopic endonasal transsphenoidal approach. Pathology confirmed an ectopic ACTH pituitary adenoma of the sphenoid sinus and a Crooke hyaline change of the pituitary gland. The patient achieved stable hormonal remission without significant postoperative complications, returned to full activity within 3 months, and remained disease free nearly 1 year after tumor resection. In a systematic literature review, the authors identified 41 cases of ectopic ACTH-secreting pituitary adenomas, including 18 arising in the sphenoid sinus without direct involvement of the sella. Including the case described here, the total number of ectopic ACTH pituitary adenomas arising in the sphenoid sinus was 19, and the total number of ectopic ACTH pituitary adenomas without regard to location was 42. For the 19 patients with adenomas found in the sphenoid sinus, ages ranged from 16 to 76 years, and there were 15 women and 4 men. The mean and median diameters of the resected sphenoid masses were 13.9 and 8 mm, respectively, with a range of 3-55 mm. Seven were microadenomas (< 1 cm). Fifteen of the 19 cases reported serum ACTH and morning cortisol levels, the means of which were 106.7 pg/ml and 32.5 μg/dl, respectively. Gross-total tumor resection was achieved in all patients except one, and in all of them durable hormonal remission of Cushing syndrome was achieved (mean follow-up time 20 months). Ectopic pituitary adenomas are rare but important causes of Cushing syndrome and related endocrinopathies, particularly because of the rapid onset and severity of symptoms with atypical presentation. Ectopic pituitary adenomas, especially those in the nasal cavity, nasopharynx, or paranasal sinuses, are easily misidentified. Any patient presenting with signs and symptoms of Cushing syndrome without any obvious pituitary adenoma or other sources of hypercortisolemia should be thoroughly screened for an ectopic adenoma. However, as with the case presented here, the coincident existence of a sellar mass should not preclude the possibility of an ectopic source. There should be a high degree of clinical suspicion for any mass in the general area surrounding the sella when evaluating Cushing syndrome. © AANS, 2015.


Schwartz D.B.,Providence Saint Joseph Medical Center | DiTucci A.,VA Boston Healthcare System | Goldman B.,Providence Saint Joseph Medical Center | Gramigna G.D.,VA Boston Healthcare System | Cummings B.,VA Boston Healthcare System
Nutrition in Clinical Practice | Year: 2014

This case study illustrates the interdisciplinary approach of a hospital's proactive and systematic process in caring for a patient with advanced dementia, using patient-centered care, the role of the surrogate decision maker, and application of ethical principles to nutrition support practice. © 2014 American Society.

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