Livingston, NJ, United States
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Weir M.R.,University of Maryland Baltimore County | Mulgaonkar S.,St Barnabas Medical Center | Chan L.,University of Colorado at Denver | Shidban H.,National Institute of Transplantation | And 4 more authors.
Kidney International | Year: 2011

As part of the Spare-the-Nephron trial, we evaluated the combination mycophenolate mofetil (MMF) and sirolimus (SRL) as a calcineurin inhibitor (CNI)-free regimen for the preservation of renal function in renal allograft recipients. This 2-year, open-label, multicenter trial randomized 299 patients of which 151 were maintained on MMF and a CNI, 148 on MMF plus SRL (n120, tacrolimus; n31, cyclosporine). Baseline characteristics including measured (iothalamate) glomerular filtration rate (GFR) were similar between groups. After 1 year, the mean percentage change from baseline in the primary end point of measured GFR was significantly higher in the MMF/SRL group compared with the MMF/CNI group. After 2 years, the change was indistinguishable. Calculated creatinine clearance and GFR were significantly greater with MMF/SRL at 2 years within which biopsy-proven acute rejection (BPAR) occurred in 14 MMF/SRL-treated patients (3 graft losses) and in 17 receiving the MMF/CNI (6 graft losses). Significantly, no patients receiving MMF/SRL but five treated with MMF/CNI died. Thus, compared with MMF/CNI treatment, a 2-year regimen of MMF/SRL resulted in similar measures of renal function but with fewer deaths and a trend to less BPAR and graft loss. © 2011 International Society of Nephrology.


Kulshrestha S.,University of Michigan | Barrantes F.,Presbyterian Kidney Transplant Center | Samaniego M.,University of Michigan | Luan F.L.,St Barnabas Medical Center
Clinical Transplantation | Year: 2014

Chronic opioid usage (COU) is common among patients with end-stage renal disease (ESRD) qualified for kidney transplantation and associated with inferior post-transplant outcomes. The magnitude of COU after kidney transplantation and its impact on transplant outcomes remain unknown. We performed a single-center retrospective study aimed to describe the prevalence of COU during the first year, to identify the predictors of COU and to determine the impact of COU on post-transplant outcomes including the rates of hospitalization and acute rejection during the first year, as well as long-term patient and graft survival. Among 1045 kidney transplant patients, 119 (11.4%) had required continued outpatient prescription of opioid analgesics during the first year after kidney transplantation, mostly for non-surgery-related pain (85%). A positive history of COU prior to transplantation was the strongest predictor of COU in the first year post-transplantation (adjusted odds ratio [AOR] 4.31, p<0.001). Patients with COU had more often hospital admission during the first year (AOR 2.48, p = 0.001, for 1 or 2 admissions, and AOR 6.03, p <0.001 for ≥3 admissions), but similar rate of acute rejection (19.3% vs. 15.7%, p=0.31). During long-term follow-up, however, the patient and/or death-censored kidney survival was not different. COU early post-kidney transplantation, when clinically indicated and properly supervised, does not appear to affect the risk of death and death-censored graft failure. © 2014 John Wiley & Sons A/S.


Woodle E.S.,University of Cincinnati | Peddi V.R.,California Pacific Medical Center | Tomlanovich S.,University of California at San Francisco | Mulgaonkar S.,St Barnabas Medical Center | Kuo P.C.,Duke University
Clinical Transplantation | Year: 2010

Background: This study compared the safety and efficacy of early corticosteroid withdrawal (ECSWD) with rabbit anti-thymocyte globulin (rATG) induction to chronic corticosteroid therapy (CCST) without antibody induction in primary, living-donor renal transplant recipients. Methods: Eligible subjects were randomized 2:1 to receive either an ECSWD (n = 103) or CCST (n = 48) regimen, with all subjects receiving tacrolimus and mycophenolate mofetil (MMF). Results: Results are reported as ECSWD vs. CCST. No significant differences were observed in the primary composite endpoint of freedom from biopsy-proven acute rejection (BPAR), graft loss, and death at six months (85.4% vs. 85.4%) or 12 months (84.4% vs. 74.4%). At 12 months, no difference was observed in BPAR (13.9% vs. 19.4%); however, ECSWD was associated with lower total cholesterol (159.7 ± 39.2 vs. 196.5 ± 56.7 mg/dL, p = 0.012), and trends toward significance were noted in serum triglycerides (151.9 ± 92.0 vs. 181.4 ± 78.8 mg/dL, p = 0.073) and weight gain (+3.6 ± 9.4 vs. +6.4 ± 9.3 kg, p = 0.069). No differences were observed in serious adverse events or infectious complications, with the exception of a higher incidence of leukopenia with ECSWD. Conclusions: rATG with tacrolimus and MMF therapy may allow early elimination of corticosteroids, is associated with trends toward lower lipid levels, less weight gain, and a safety profile comparable to CCST therapy. © 2009 John Wiley & Sons A/S.


Orzechowski K.M.,Thomas Jefferson University | Miller R.C.,St Barnabas Medical Center
Clinical Obstetrics and Gynecology | Year: 2012

This article reviews the diagnosis and management of the most common respiratory conditions complicating pregnancy-asthma and influenza. We also review strategies for smoking cessation in pregnancy as, in addition to exacerbating all other pulmonary conditions, smoking is the most modifiable risk factor for poor pregnancy outcome. Moreover, the obstetrician frequently encounters each of these conditions in the ambulatory setting. A thorough knowledge of the normal pregnancy-induced physiological respiratory changes combined with a comprehensive understanding of how to manage these conditions, will provide the obstetrician with the armamentarium needed to optimize health outcomes for mothers and their fetuses. © 2012, Lippincott Williams &Wilkins.


Ravin K.A.,DuPont Company | Ravin K.A.,Thomas Jefferson University | Loy M.,St Barnabas Medical Center
Clinical Reviews in Allergy and Immunology | Year: 2016

First described by Paul Ehrlich in 1879, who noted its characteristic staining by acidophilic dyes, for many years, the eosinophil was considered to be an end-effector cell associated with helminth infections and a cause of tissue damage. Over the past 30 years, research has helped to elucidate the complexity of the eosinophil’s function and establish its role in host defense and immunity. Eosinophils express an array of ligand receptors which play a role in cell growth, adhesion, chemotaxis, degranulation, and cell-to-cell interactions. They play a role in activation of complement via both classical and alternative pathways. Eosinophils synthesize, store and secrete cytokines, chemokines, and growth factors. They can process antigen, stimulate T cells, and promote humoral responses by interacting with B cells. Eosinophils can function as antigen presenting cells and can regulate processes associated with both T1 and T2 immunity. Although long known to play a role in defense against helminth organisms, the interactions of eosinophils with these parasites are now recognized to be much more complex. In addition, their interaction with other pathogens continues to be investigated. In this paper, we review the eosinophil’s unique biology and structure, including its characteristic granules and the effects of its proteins, our developing understanding of its role in innate and adaptive immunity and importance in immunomodulation, and the part it plays in defense against parasitic, viral, fungal and bacterial infections. Rather than our worst enemy, the eosinophil may, in fact, be one of the most essential components in host defense and immunity. © Springer Science+Business Media New York 2015.


Busque S.,Stanford University | Cantarovich M.,McGill University | Mulgaonkar S.,St Barnabas Medical Center | Gaston R.,University of Alabama at Birmingham | And 5 more authors.
American Journal of Transplantation | Year: 2011

Voclosporin (VCS, ISA247) is a novel calcineurin inhibitor being developed for organ transplantation. PROMISE was a 6-month, multicenter, randomized, open-label study of three ascending concentration-controlled groups of VCS (low, medium and high) compared to tacrolimus (TAC) in 334 low-risk renal transplant recipients. The primary endpoint was demonstration of noninferiority of biopsy proven acute rejection (BPAR) rates. Secondary objectives included renal function, new onset diabetes after transplantation (NODAT), hypertension, hyperlipidemia and pharmacokinetic-pharmacodynamic evaluation. The incidence of BPAR in the VCS groups (10.7%, 9.1% and 2.3%, respectively) was noninferior to TAC (5.8%). The incidence of NODAT for VCS was 1.6%, 5.7% and 17.7% versus 16.4% in TAC (low-dose VCS, p = 0.03). Nankivell estimated glomerular filtration rate was respectively: 71, 72, 68 and 69 mL/min, statistically lower in the high-dose group, p = 0.049. The incidence of hypertension and adverse events was not different between the VCS groups and TAC. VCS demonstrated an excellent correlation between trough and area under the curve (r2= 0.97) and no difference in mycophenolic acid exposure compared to TAC. This 6-month study shows VCS to be as efficacious as TAC in preventing acute rejection with similar renal function in the low- and medium-exposure groups, and potentially associated with a reduced incidence of NODAT. © Copyright 2011 The American Society of Transplantation and the American Society of Transplant Surgeons.


Hirshey Dirksen S.J.,Malignant Hyperthermia Association of the United States | Larach M.G.,North American Malignant Hyperthermia Registry of MHAUS | Rosenberg H.,St Barnabas Medical Center | Brandom B.W.,University of Pittsburgh | And 4 more authors.
Anesthesia and Analgesia | Year: 2011

Malignant hyperthermia (MH) is a complex pharmacogenetic disorder of muscle metabolism. To more closely examine the complexities of MH and other related muscle disorders, the Malignant Hyperthermia Association of the United States (MHAUS) recently sponsored a scientific conference at which an interdisciplinary group of experts gathered to share new information and ideas. In this Special Article, we highlight key concepts and theories presented at the conference along with exciting new trends and challenges in MH research and patient care. Copyright © 2011 International Anesthesia Research Society.


Adamczak J.E.,St Barnabas Medical Center | Wolf E.J.,St Barnabas Medical Center
American Journal of Perinatology | Year: 2010

Normal changes in blood pressure during pregnancy are well documented in the second and third trimesters. Little is known about first-trimester changes, particularly compared with preconceptional values. This knowledge might allow for early prediction of conditions such as preeclampsia or intrauterine growth restriction. Prior studies utilized a laboratory setting. We conducted this retrospective study to compare blood pressure readings in early pregnancy with preconceptional values in the clinical setting. The records of 44 healthy normotensive nonsmoking women with a body mass index <30 and an uncomplicated appropriately grown singleton term delivery were reviewed. Preconceptional blood pressures values were compared with values at five periods (weeks 1 to 8, 9 to 16, 17 to 23, 24 to 32, 33 to 40). There was no difference in blood pressure parameters when comparing preconceptional values with period 1. The mean and systolic arterial pressures decreased significantly in periods 2 and 3. We were unable to demonstrate significant change in any blood pressure parameter in the first 8 weeks of pregnancy. This work should be repeated in patients who subsequently develop preeclampsia, spontaneous abortion, or intrauterine growth restriction to determine if early changes might be evident in early pregnancy to identify patients destined to develop pregnancy complications. Copyright © 2010 by Thieme Medical Publishers, Inc.


Lacz N.L.,St Barnabas Medical Center | Zurlo J.V.,St Barnabas Medical Center
Emergency Radiology | Year: 2010

We present 3 cases of small bowel diverticulitis ultimately presenting to our Emergency Department over a span of 2 years. Though the final diagnosis was the same, each patient's symptomatology was different, mimicking more common pathologies. Thus, it is important to consider this entity when confronted with signs and symptoms of acute abdomen, especially in the elderly. A missed or delayed diagnosis can lead to costly erroneous studies, incorrect treatments and delay in proper management, resulting in significant morbidity and even mortality. The variety of presentations can often be misleading; therefore, a high index of suspicion is needed on the part of the Emergency Department physician and Radiologist. © 2010 Am Soc Emergency Radiol.


Wu G.,St Barnabas Medical Center
BMJ case reports | Year: 2013

Tacrolimus is an immunosuppressant frequently used following solid organ transplantation, including renal transplantation. Peripheral neuropathy is an uncommon neurological side effect of tacrolimus and has rarely been reported in renal transplantation. We report a patient who received a living-related donor kidney transplant and presented with altered mental status and new-onset bilateral foot drop. Laboratory tests including cerebrospinal fluid tests excluded infection, and MRI of the brain showed chronic microvascular ischaemic changes. Electromyography and nerve conduction study confirmed bilateral common peroneal nerve demyelination. He was also found to have inadvertently overdosed on tacrolimus at home. After switching from tacrolimus to cyclosporine, the patient's symptoms improved within 5 months. His renal function was maintained with an immunosuppressant regimen of cyclosporine, prednisone and mycophenolic acid. The prompt recognition of tacrolimus as a potential neurotoxic drug in a patient with renal transplant and substituting tacrolimus with a different immunosuppressant may prevent permanent neurological damage.

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