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Fisichella P.M.,Harvard University | Andolfi C.,University of Chicago | Orthopoulos G.,St Elizabeth Medical Center
World Journal of Surgery | Year: 2017

Introduction: Gastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing. Discussion: The evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient’s symptoms. Conclusions: The diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination. © 2017 Société Internationale de Chirurgie


Reddy C.,University of Utah | Ernst A.,St Elizabeth Medical Center | Lamb C.,Lahey Clinic | Feller-Kopman D.,Johns Hopkins University
Chest | Year: 2011

Background: Malignant pleural effusions (MPEs) affect > 150,000 people each year in the United States. Current palliative options include pleurodesis and placement of an indwelling catheter, each with its own associated benefits. This study was conducted to determine the safety, efficacy, and feasibility of a rapid pleurodesis protocol by combining medical thoracoscopy with talc pleurodesis and simultaneous placement of a tunneled pleural catheter (TPC) in patients with symptomatic MPE. Methods: Patients with recurrent, symptomatic MPEs underwent medical thoracoscopy with placement of a TPC and talc poudrage. The TPC was drained per protocol until the output was < 150 mL/d on two consecutive drainage attempts and then removed. Patients were followed for up to 6 months. Results: Between October 2005 and September 2009, 30 patients underwent the procedure. The median duration of hospitalization following the procedure was 1.79 days. All patients showed an improvement in dyspnea and quality of life. Pleurodesis was successful in 92% of patients, and the TPC was removed at a median of 7.54 days. Complications included fever (two patients), the need for TPC replacement (one patient), and empyema (one patient). Conclusion: Rapid pleurodesis can be achieved safely by combining medical thoracoscopy and talc poudrage with simultaneous TPC placement. Both hospital length of stay and duration of TPC use can be reduced significantly as compared with historical controls of either procedure alone. Future randomized trials are needed to confirm these results. © 2011 American College of Chest Physicians.


PubMed | St Elizabeth Medical Center, University of Barcelona and Beth Israel Deaconess Medical Center
Type: Journal Article | Journal: Current treatment options in gastroenterology | Year: 2016

Hyponatremia may occur in patients with cirrhosis and ascites mainly due to water retention and an inability of the kidney to excrete free water. The main reason for this abnormality is related to the fact that these patients have portal hypertension and this leads to systemic vasodilation that in turn activates sodium-retaining and water-retaining systems such as the renin-angiotensin-aldosterone system and arginine vasopressin (AVP). AVP increases solute-free water retention by acting on the V2 receptors of the kidney-collecting tubes. Hyponatremia in cirrhosis is defined as a serum sodium level less than 130meq/L. The appearance of hyponatremia in patients with advanced cirrhosis portends a poor prognosis before and after liver transplantation. Treatment of hyponatremia is difficult; fluid restriction rarely increases serum sodium levels and other therapies are associated with important drawbacks. A thorough discussion of the underlying mechanisms leading to hyponatremia and hypernatremia in cirrhosis and current treatment options including the use of vaptans (V2 receptor antagonists) are discussed in this review.


Ost D.E.,University of Houston | Ernst A.,St Elizabeth Medical Center | Lei X.,University of Houston | Feller-Kopman D.,Johns Hopkins University | And 4 more authors.
Chest | Year: 2011

Background: New transbronchial needle aspiration (TBNA) technologies have been developed, but their clinical effectiveness and determinants of diagnostic yield have not been quantified. Prospective data are needed to determine risk-adjusted diagnostic yield. Methods: We prospectively enrolled patients undergoing TBNA of mediastinal lymph nodes in the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE) multicenter database and recorded clinical, procedural, and provider information. All clinical decisions, including type of TBNA used (conventional vs endobronchial ultrasoundguided), were made by the attending bronchoscopist. The primary outcome was obtaining a specifi c diagnosis. Results: We enrolled 891 patients at six hospitals. Most procedures (95%) were performed with ultrasound guidance. A specific diagnosis was made in 447 cases. Unadjusted diagnostic yields were 37% to 54% for different hospitals, with significant between-hospital heterogeneity ( P =.0001). Diagnostic yield was associated with annual hospital TBNA volume (OR, 1.003; 95% CI, 1.000-1.006; P =.037), smoking (OR, 1.55; 95% CI, 1.02-2.34; P =.042), biopsy of more than two sites (OR, 0.57; 95% CI, 0.38-0.85; P =.015), lymph node size (reference > 1-2 cm, ≤ 1 cm: OR, 0.51; 95% CI, 0.34-0.77; P =.003; > 2-3 cm: OR, 2.49; 95% CI, 1.61-3.85; P<.001; and. 3 cm: OR, 3.61; 95% CI, 2.17-6.00; P<.001), and positive PET scan (OR, 3.12; 95% CI, 1.39-7.01; P =.018). Biopsy was performed on more and smaller nodes at high-volume hospitals(P<.0001). Conclusions: To our knowledge, this is the first bronchoscopy study of risk-adjusted diagnostic yields on a hospital-level basis. High-volume hospitals were associated with high diagnostic yields. This study also demonstrates the value of procedural registries as a quality improvement tool. A larger number and variety of participating hospitals is needed to verify these results and to further investigate other determinants of diagnostic yield. © 2011 American College of Chest Physicians.


Tapan U.,Boston University | Bolla S.,St Elizabeth Medical Center | Daglilar E.S.,St Elizabeth Medical Center | Chang S.,Tufts University | Kozyreva O.,St Elizabeth Medical Center
Platelets | Year: 2015

Studies show increased mortality with positive heparin-platelet factor-4 (H-PF4) antibodies, especially in hemodialysis patients. We aimed to compare mortality and thrombosis in hospitalized patients with positive, equivocal and negative H-PF4 antibody results. Information was collected on these patients using a multi-institutional retrospective electronic medical record review. Patients tested for H-PF4 antibodies by commercial ELISA during the years 2006 to 2010 were identified. We compared 30-day, 90-day and 1-year mortality in patients with negative, equivocal and positive H-PF4 test and evaluated the relationship between H-PF4 status and rate of thrombosis. Four hundred and seventeen patients had ELISA testing for H-PF4 antibodies. Forty-four patients had equivocal (optical density value 0.4-0.9) and 21 had positive (value 1) H-PF4 antibody test. There were no statistically significant differences in mortality between patients with negative, equivocal and positive results at all three time points (p = 0.22, 0.27 and 0.38, respectively) even after excluding patients with thrombosis (p = 0.22, 0.24 and 0.31, respectively). Age and Charlson score were associated with increased 30-day, 90-day and 1 year mortality. Odds ratio of having thrombosis was 23.1 for positive vs. equivocal results (p < 0.001); however, there was no statistically significant difference between equivocal vs. negative results (p = 0.22). Our results revealed no association between H-PF4 status and mortality, as well as no difference in 1-year survival between the positive and negative groups. © 2014 Taylor & Francis Group, LLC.


Smith A.M.,University of Cincinnati | Smith A.M.,Cincinnati Veterans Affairs Medical Center | Villareal M.,University of Cincinnati | Bernstein D.I.,University of Cincinnati | Swikert D.J.,St Elizabeth Medical Center
Annals of Allergy, Asthma and Immunology | Year: 2012

Background: The incidence rate of asthma has increased in all age groups in the past 40 years. Asthma in older adults is underdiagnosed and undertreated, resulting in suboptimal asthma control. Objective: The objectives of the study are to evaluate differences in host characteristics between older patients with asthma and persons who do not have asthma and how these differences impact overall quality of life. Methods: Patients older than age 60 years were recruited from the general population for this case/control and nested cohort study. A complete medical history, physical examination, skin prick testing (SPT), spirometry, and exhaled nitric oxide (ENO) measurements were performed. Quality of life was assessed through the standardized SF-36v2 questionnaire. Quality of life scores, spirometry, ENO, and aeroallergen sensitization differences were compared between older patients with asthma and control patients. Results: The mean age of the 77 patients evaluated was 68.7 ± 7.2 years, with 59 (77%) being female. A higher rate of SPT positivity was found in patients with asthma (88.9%) compared with controls (51.2%) (P =.007). The mean percent predicted forced expiratory volume in 1 second (FEV1) at baseline was lower in the asthma group (73.7 ± 21.9%) compared with controls (89.6 ± 19.1%) (P =.007). For quality of life assessed by the SF-36v2 questionnaire, the asthma group had worse general health, increased bodily pain, and worse overall physical health compared with controls (P =.02;.021;.01). Conclusion: Older adults with asthma have a higher rate of allergic sensitization, decreased lung function, and significantly worse quality of life compared with controls. © 2012 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.


Thakor P.,St Elizabeth Medical Center | Padmanabhan M.,St Elizabeth Medical Center | Johnson A.,St Elizabeth Medical Center | Pararajasingam T.,St Elizabeth Medical Center | And 2 more authors.
American Journal of Therapeutics | Year: 2010

Mrs. M.S. is a 67-year-old African American woman with a history of rheumatoid arthritis and psoriatic arthritis who presented to the emergency room with complaint of new-onset rash, chills, and fatigue after she started taking ramipril (5 mg orally every day) for her hypertension. The rash involved entire upper chest, both arms, palms, and soles and was characterized as exfoliating with scattered small pustules of 1-2 mm in size. Patient was admitted with a differential diagnosis of exfoliative dermatitis versus adverse drug reaction for which her ramipril was stopped. After admission, the patient spiked a temperature of 102°F with chills, the entire workup for which was negative, including blood cultures, chest x-ray, and urine analysis. She underwent skin biopsy to find the cause of her rash. With her given clinical characteristics, she was presumed to have generalized pustular psoriasis (GPP), which was later confirmed by biopsy results. She was treated with methylprednisolone to which she responded dramatically with much improvement in her rash and her fever subsided. The flare of GPP was considered to be secondary to ramipril. After reviewing the published literature, there are no published cases of ramipril-induced GPP. Captopril, a different angiotensin converting enzyme (ACE) inhibitor, is known to cause flare of GPP. We presented this case as apart from being the first reported case of ramipril-induced GPP; clinicians and dermatologist should also be aware of this potentially serious complication of psoriasis when they start ramipril in patients with psoriasis. © 2010 Lippincott Williams & Wilkins.


Ernst A.,St Elizabeth Medical Center | Anantham D.,Singapore General Hospital
Pulmonary Medicine | Year: 2011

The application of lung volume reduction surgery in clinical practice is limited by high postoperative morbidity and stringent selection criteria. This has been the impetus for the development of bronchoscopic approaches to lung volume reduction. A range of different techniques such as endobronchial blockers, airway bypass, endobronchial valves, thermal vapor ablation, biological sealants, and airway implants have been employed on both homogeneous as well as heterogeneous emphysema. The currently available data on efficacy of bronchoscopic lung volume reduction are not conclusive and subjective benefit in dyspnoea scores is a more frequent finding than improvements on spirometry or exercise tolerance. Safety data are more promising with rare procedure-related mortality, few serious complications, and short hospital length of stay. The field of bronchoscopic lung volume reduction continues to evolve as ongoing prospective randomized trials build on earlier feasibility data to clarify the true efficacy of such techniques. © 2011 Armin Ernst and Devanand Anantham.


Wagner C.A.,St Elizabeth Medical Center | Oberoi N.,St Elizabeth Medical Center | Ahluwalia P.K.,St Elizabeth Medical Center
Journal of Minimally Invasive Gynecology | Year: 2013

Herein we present the case of a 71-year-old woman who had a severe postoperative ecchymotic reaction. Our patient had a history of atrial fibrillation, for which she was given dabigatran etexilate mesylate as an anticoagulant. She discontinued her anticoagulant therapy 2 days before undergoing total laparoscopic hysterectomy with pelvic and periaortic lymph node sampling for uterine endometrioid adenocarcinoma. Despite an uneventful surgical procedure, she had widespread ecchymosis, edema, and anemia. © 2013 AAGL.


Vyshedskiy A.,Brigham and Women's Hospital | Ishikawa S.,St Elizabeth Medical Center | Murphy Jr R.L.H.,Brigham and Women's Hospital
Respiratory Care | Year: 2011

OBJECTIVE: To determine the variability of crackle pitch and crackle rate during a single automated- auscultation session with a computerized 16-channel lung-sound analyzer. METHODS: Forty- nine patients with pneumonia, 52 with congestive heart failure (CHF), and 18 with interstitial pulmonary fibrosis (IPF) performed breathing maneuvers in the following sequence: normal breathing, deep breathing, cough several times; deep breathing, vital-capacity maneuver, and deep breathing. From the auscultation recordings we measured the crackle pitch and crackle rate. RESULTS: Crackle pitch variability, expressed as a percentage of the average crackle pitch, was small in all patients and in all maneuvers: pneumonia 11%, CHF 11%, pulmonary fibrosis 7%. Crackle rate variability was also small: pneumonia 31%, CHF 32%, IPF 24%. Compared to the first deepbreathing maneuver (100%), the average crackle pitch did not significantly change following coughing (pneumonia 100%, CHF 103%, IPF 100%), the vital-capacity maneuver (pneumonia 100%, CHF 92%, IPF 104%), or during quiet breathing (pneumonia 97%, CHF 100%, IPF 104%). Similarly, the average crackle rate did not change significantly following coughing (pneumonia 105%, CHF 110%, IPF 90%) or the vital-capacity maneuver (pneumonia 102%, CHF 101%, IPF 99%). However, during normal breathing the crackle rate was significantly lower in the patients with pneumonia (74%, P <.001) and significantly higher in the patients with IPF (147%, P <.05) than it was during deep breathing. In patients with CHF the average crackle rate during normal breathing was not significantly different from that during the first deep-breathing maneuver (108%). CONCLUSIONS: Crackle pitch and rate were surprisingly stable in all 3 conditions. Neither crackle pitch nor crackle rate changed significantly from breath to breath or from one deepbreathing maneuver to another, even when the maneuvers were separated by cough or the vitalcapacity maneuver. The observation that crackle rate is a reproducible measurement during one automated-auscultation session suggests that crackle rate can be used to follow the course of cardiopulmonary illnesses such as pneumonia, IPF, and CHF. © 2011 Daedalus Enterprises.

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