Youngstown, OH, United States
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DiDomenico L.A.,St Elizabeth Health Center | Sann P.,Heritage Valley Health Systems
Journal of Foot and Ankle Surgery | Year: 2011

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated. © 2011 American College of Foot and Ankle Surgeons.


Marnejon T.,St Elizabeth Health Center | Angelo D.,St Elizabeth Health Center | Abdou A.A.,St Elizabeth Health Center | Gemmel D.,St Elizabeth Health Center
Journal of Vascular Access | Year: 2012

Purpose: To identify clinically important risk factors associated with upper extremity venous thrombosis following peripherally inserted central venous catheters (PICC). Methods: A retrospective case control study of 400 consecutive patients with and without upper extremity venous thrombosis post-PICC insertion was performed. Patient data included demographics, body mass index (BMI), ethnicity, site of insertion, size and lumen of catheter, internal length, infusate, and co-morbidities, such as diabetes mellitus, congestive heart failure, and renal failure. Additional risk factors analyzed were active cancer, any history of cancer, recent trauma, smoking, a history of prior deep vein thrombosis, and recent surgery, defined as surgery within three months prior to PICC insertion. Results: The prevalence of trauma, renal failure, and infusion with antibiotics and total parenteral nutrition (TPN) was higher among patients exhibiting upper extremity venous thrombosis (UEVT), when compared to controls. Patients developing UEVT were also more likely to have PICC line placement in a basilic vein and less likely to have brachial vein placement (P<.001). Left-sided PICC line sites also posed a greater risk (P=.026). The rate of standard DVT prophylaxis with low molecular weight heparin and unfractionated heparin and the use of warfarin was similar in both groups. Average length of hospital stay was almost double among patients developing UEVT, 19.5 days, when compared to patients undergoing PICC line insertion without thrombosis, 10.8 days (t=6.98, P<.001). Conclusions: In multivariate analysis, trauma, renal failure, left-sided catheters, basilic placement, TPN, and infusion with antibiotics, specifically vancomycin, were significant risk factors for UEVT associated with PICC insertion. Prophylaxis with low molecular weight heparin, unfractionated heparin or use of warfarin did not prevent the development of venous thrombosis in patients with PICCs. Length of hospital stay and cost are markedly increased in patients who develop PICCassociated upper extremity venous thrombosis. © 2011 Wichtig Editore.


Turjanica M.A.,St Elizabeth Health Center
Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses | Year: 2011

Skin prevalence audits revealed annual increases in incidence of pressure ulcers of the ear. A research study was conducted to assess correlates of the problem. Study results guided clinical practice changes that reduced the incidence to zero.


Tran H.,St Elizabeth Health Center | Tan D.,St Elizabeth Health Center | Marnejon T.P.,St Elizabeth Health Center | Marnejon T.P.,Northeast Ohio Medical University
Clinical Medicine and Research | Year: 2013

We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocainelevamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis. ©2013 Marshfield Clinic.


DiDomenico L.A.,St Elizabeth Health Center | DiDomenico L.A.,The Ankle and Foot Care Centers | Wargo-Dorsey M.,The Ankle and Foot Care Centers
Journal of Foot and Ankle Surgery | Year: 2012

The goal of a tibiotalocalcaneal arthrodesis is to create a pain-free, stable hindfoot and ankle. Although a reserved procedure, it is useful when simultaneous ankle and subtalar joint pathology exists. Numerous complications have been reported after tibiotalocalcaneal arthrodesis, most importantly nonunion. Locking plates have proved to be a more stable construct than alternative forms of arthrodesis. In the inverted positions, the hybrid plating of the femoral locking plate structurally aligns with the anatomy of the hindfoot. This provides an anatomically sound construct, while allowing for both locking and lag screw insertion. We describe a new technique using a 4.5-mm condylar plate for tibiotalocalcaneal arthrodesis. © 2012 American College of Foot and Ankle Surgeons.


Dunham C.M.,St Elizabeth Health Center | Chirichella T.J.,St Elizabeth Health Center
PLoS ONE | Year: 2012

Background: Statistics from the National Trauma Data Bank imply that discretionary blood alcohol and urine drug testing is common. However, there is little evidence to determine which patients are appropriate for routine testing, based on information available at trauma center arrival. In 2002, Langdorf reported alcohol and illicit drug rates in Trauma Activation Patients. Methodology/Principal Findings: This is a retrospective investigation of alcohol and illicit drug rates in consecutive St. Elizabeth Health Center (SEHC) trauma patients. SEHC Trauma Activation Patients are compared with the Langdorf Activation Patients and with the SEHC Trauma Nonactivation Patients. Minimum Rates are positive tests divided by total patients (tested and not tested). Activation patients The minimum alcohol rates were: SEHC 23.1%, Langdorf 28.2%, combined 24.8%. The minimum illicit drug rates were: SEHC 15.7%, Langdorf 23.5, combined 18.3%. The minimum alcohol and/or illicit drug rates were: SEHC 33.4%, Langdorf 41.8%, combined 36.2%. Nonactivation patients The SEHC minimum alcohol rate was 4.7% and the minimum illicit drug rate was 6.0%. Conclusions: Alcohol and illicit drug rates were significantly greater for Trauma Activation Patients, when compared to Nonactivation Patients. At minimum, Trauma Activation Patients are likely to have a 1-in-3 positive test for alcohol and/or an illicit drug. This substantial rate suggests that Trauma Activation Patients, a readily discernible group at trauma center arrival, are appropriate for routine alcohol and illicit drug testing. However, discretionary testing is more reasonable for Trauma Nonactivation Patients, because minimum rates are low. © 2012 Dunham, Chirichella.


Dunham C.M.,St Elizabeth Health Center | Chirichella T.J.,St Elizabeth Health Center
Lipids in Health and Disease | Year: 2011

Background: Post-traumatic ventilator-associated pneumonia (VAP) is a substantial clinical problem that increases hospital costs and typically adds to the duration of mechanical ventilation. We evaluated the impact of VAP on ventilator days. We also assessed 48-hour total blood cholesterol (TC) and other potential risk factors for the development of VAP. Methods. We performed a retrospective study of consecutive trauma patients requiring emergency tracheal intubation and evaluated TC, age, gender, ethanol status, smoker status, injury mechanism, chest injury, brain injury, Injury Severity Score (ISS), shock, day-one hypoxemia, and RBC transfusion as potential risks for VAP. Results: The 152 patients had ISS 28.1, brain injury 68.4%, VAP 50.0%, ventilator days 14.3, and death 9.9%. Ventilator days were increased with late VAP (p < 0.0001). TC was 110.7 mg/dL with expected TC 197.5 mg/dL. TC was lower with chest injury, shock, and RBC transfusion but, higher with brain injury (p 0.01). TC decreased as ISS increased (p = 0.01). However, one patient subset (ISS ≥ 20-&-TC ≥ 90 mg/dL) had a relative increase in TC despite an increase in ISS. ISS ≥ 20-&-TC ≥ 90 mg/dL, but not ISS alone, was the only independent predictor of late VAP (OR 3.0; p = 0.002). ISS ≥ 20-&-TC ≥ 90 mg/dL and day-one hypoxemia were the only independent predictors for increased ventilator days (p = 0.01). ISS ≥ 20-&-TC ≥90 mg/dL, but not ISS alone, was the only predictor of death (OR 3.8; p = 0.03). Conclusions: Severe traumatic injury produced substantial hypocholesterolemia that is greater with chest injury, shock, and RBC transfusion, but less with brain injury. Total blood cholesterol tended to decrease with increasing injury severity. However, attenuated hypocholesterolemia (ISS ≥ 20-&-TC ≥ 90 mg/dL) represents a unique response that can occur with critical injury. Attenuated hypocholesterolemia signals early risk for late VAP, ventilator dependency, and death. © 2011 Dunham and Chirichella; licensee BioMed Central Ltd.


Holmes J.W.,St Elizabeth Health Center | Williams M.D.,St Elizabeth Health Center
American Journal of Surgery | Year: 2010

Background: The problem of intensive care unit methicillin-resistant Staphylococcus aureus (MRSA) infections has led to routine surveillance and eradication strategies. Methods Our surgical intensive care unit (SICU) admissions receive MRSA nares cultures and if positive are isolated followed by eradication treatment. This strategy was retrospectively reviewed. Results Our nares-positive culture rate was 21% (30/145), and the sputum positive (sputum+) rate was 18% (26/145). Positive nares culture (Nares+) was eradicated in 63%. The rate of sputum+ in Nares+ patients was 36% (9/25). The rate of sputum+ in Nares- was 10% (12/115; P = .003). The sputum+ SICU length of stay (LOS) (18 ± 12 days in 23 S+ patients) is longer than in sputum- (10 ± 9 days in 69 S-patients, P = .0002). Conclusions This SICU has high rates of both nares and sputum MRSA cultures. Our data suggest eradicating nares colonization may prevent pneumonia and might decrease SICU LOS. © 2010 Elsevier Inc. All rights reserved.


Ghattas C.,St Elizabeth Health Center | Dai A.,Northeast Ohio Medical University | Gemmel D.J.,St Elizabeth Health Center | Awad M.H.,Northeast Ohio Medical University
International Journal of COPD | Year: 2013

Introduction: While cross-national studies have documented rates of chronic obstructive pulmonary disease (COPD) misdiagnosis among patients in primary care, US studies are scarce. Studies investigating diagnosis among uninsured patients are lacking. Objective: The purpose of this study is to identify patients who are over diagnosed and thus, mistreated, for COPD in a federally qualified health center. Methods: A descriptive study was conducted for a retrospective cohort from February 2011 to June 2012. Spirometry was performed by trained personnel following American Thoracic Society recommendations. Patients were referred for spirometry to confirm previous COPD diagnosis or to assess uncontrolled COPD symptoms. Airway obstruction was defined as a forced expiratory volume in the first second of expiration (FEV1) to forced vital capacity ratio less than 0.7. Reversibility was defined as a postbronchodilator increase in FEV1 greater than 200 mL and greater than 12%. Results: Eighty patients treated for a previous diagnosis of COPD (n = 72) or on anticholinergic inhalers (n = 8) with no COPD diagnosis were evaluated. The average age was 52.9 years; 71% were uninsured. Only 17.5% (14/80) of patients reported previous spirometry. Spirometry revealed that 42.5% had no obstruction, 22.5% had reversible obstruction, and 35% had nonreversible obstruction. Conclusion: Symptoms and smoking history are insufficient to diagnose COPD. Prevalence of COPD over diagnosis among uninsured patient populations may be higher than previously reported. Confirming previous COPD diagnosis with spirometry is essential to avoid unnecessary and potentially harmful treatment. © 2013 Ghattas et al.


Moreno F.A.,University of Arizona | Chong J.,University of Arizona | Dumbauld J.,St Elizabeth Health Center | Humke M.,St Elizabeth Health Center | Byreddy S.,University of Arizona
Psychiatric Services | Year: 2012

Objective: Depression affects nearly one in five Americans at some time in their life, causing individual suffering and financial cost. The Internet has made it possible to deliver telemedicine care economically to areas and populations with limited access to specialist or culturally and linguistically congruent care. Methods: This study compared the effectiveness for Hispanic patients of depression treatment provided by a psychiatrist through Internet videoconferencing (Webcam intervention) and treatment as usual by a primary care provider. Adults (N=167) with a diagnosis of depression were recruited from a community clinic and were randomly assigned to treatment condition. Webcam participants met remotely each month with the psychiatrist, and treatment-as-usual patients received customary care from their primary care providers, all for six months. At baseline and three and six months, analyses of variance tested differences between conditions in scores on depression rating scales and quality-of-life and functional ability measures. Results: All participants experienced an improvement in depression symptoms. Ratings on the Montgomery-Asberg Depression Rating Scale by clinicians blind to treatment group and self-ratings on the nine-item Patient Health Questionnaire, Quality of Life Enjoyment and Satisfaction Questionnaire, and Sheehan Disability Scale showed a significant main effect of time. On all four measures, a significant interaction of time by intervention favoring the Webcam group was noted. Discussion: Results suggest that telepsychiatry delivered through the Internet utilizing commercially available domestic Webcams and standard Internet and computer equipment is effective and acceptable. Use of this technology may help close the gap in access to culturally and linguistically congruent specialists. Copyright © American Psychiatric Association.

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