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Yochum C.,St John Medical Center | Utley R.,Missouri State University
Advanced Emergency Nursing Journal | Year: 2017

Therapeutic hypothermia (TH) postresuscitation has been recommended by the American Heart Association (AHA) since 2005. Early initiation of TH and fast achievement of goal temperatures have been associated with better neurological outcomes. The objective of this study was to evaluate the effectiveness of a specific TH protocol for the emergency department (ED) in increasing ED use of TH and decreasing the time from return of spontaneous circulation (ROSC) to initiation of cooling measures. An ED protocol for TH as recommended by the AHA was implemented. A random sample of 10 patients who received TH prior to the implementation of an ED protocol were analyzed and compared with the first 10 patients who received TH after the ED protocol was implemented. The time from ROSC to initiation of cooling measures and survival to discharge rates were analyzed. After implementation of the ED protocol, 7 of the 10 patients were treated with the ED protocol. The mean time to initiation of TH for the preimplementation group was 127.8 min (SD = 52.9) compared with 15.71 min (SD = 9.552) for the postimplementation group. The difference in initiation time between the pre- and postimplementation study groups was statistically significant, t(9.826) = 6.55, p < 0.05. Survival to discharge rates were 30% for the preimplementation group and 20% for the postimplementation group. The difference was not statistically significant, Χ2 (1, N = 20) = 0.73, p = 0.78. Implementation of an ED protocol for TH reduced mean time to initiation of therapy. Additional study is warranted to determine whether differences in survival and functional recovery for ED patients receiving TH were influenced by age, comorbidities, and total resuscitation time. © Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.


Starcher B.,University of Texas Health Science Center at Tyler | Sauter E.,University of Texas Health Science Center at Tyler | Ho C.,St John Medical Center
Connective Tissue Research | Year: 2013

Desmosine, a crosslinking amino acid unique to elastin, was investigated as a possible biomarker for cancer. Twenty-eight normal controls, median age 67 years, had a median value for urine desmosine of 43.5 picomoles desmosine/mg creatinine. The median for 19 untreated cancer subjects of similar age was significantly higher (175 picomoles desmosine/mg creatinine, p < 0.001). Urine desmosine levels in 55 subjects currently receiving chemotherapy, as well as 67 individuals who had survived cancer and were currently clinically disease free, were not significantly different from controls. Our findings indicate that elastin is being turned over in malignant solid tumors, releasing significantly elevated levels of desmosine in the urine. © 2013 Informa Healthcare USA, Inc.


Orlov M.V.,Caritas St Elizabeths Medical Center | Gardin J.M.,St John Medical Center | Slawsky M.,BayState Medical Center | Bess R.L.,St John Medical Center | And 5 more authors.
American Heart Journal | Year: 2010

Background: Randomized trials have demonstrated benefits of biventricular (BiV) pacing in patients with advanced heart failure, intraventricular conduction delay, and atrial fibrillation (AF) postatrioventricular (AV) node ablation. The AV Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF trial (AVAIL CLS/CRT) was designed to demonstrate superiority of BiV pacing in patients with AF after AV node ablation, to evaluate its effects on cardiac structure and function, and to investigate additional benefits of Closed Loop Stimulation ® (CLS) (BIOTRONIK, Berlin, Germany). Methods: Patients with refractory AF underwent AV node ablation and were randomized (2:2:1) to BiV pacing with CLS, BiV pacing with accelerometer, or right ventricular (RV) pacing. Echocardiography was performed at baseline and 6 months, with paired data available for 108 patients. Results: The RV pacing contributed to significant increase in left atrial volume, left ventricular (LV) end-systolic volume, and LV mass compared to BiV pacing. Ejection fraction decreased insignificantly with RV pacing compared to significant increase with BiV pacing. Interventricular dyssynchrony significantly decreased with BiV compared with RV pacing. Closed Loop Stimulation ® did not result in additional echocardiographic changes; heart rate distribution was significantly wider with CLS. All groups showed significant improvement in 6-minute walk distance, quality-of-life score, and New York Heart Association class. Conclusion: In conclusion, RV pacing results in significant increase in left atrial volume, LV mass, and worsening of LV contractility compared to patients receiving BiV pacing post-AV node ablation for refractory AF. Closed Loop Stimulation ® was not associated with additional structural changes but resulted in significantly wider heart rate distribution. © 2010 Mosby, Inc. All rights reserved.


Hagen J.W.,Cornell University | Magro C.M.,Cornell University | Crowson A.N.,University of Oklahoma | Crowson A.N.,St John Medical Center
Dermatologic Clinics | Year: 2012

The past several decades have seen the advent and rapidly expanding use of biological agents in the treatment of chronic disease states. As increasingly large pools of patients have been enrolled in treatment protocols using these agents, physicians have become acquainted with both desired and adverse events associated with their use. Dermatologists frequently encounter patients affected by cutaneous drug reactions associated with the use of biological agents, thereby becoming familiar with the full range of side effects reported in the literature. This review discusses these adverse cutaneous effects, their underlying mechanisms, and efforts to predict and minimize their occurrence. © 2012 Elsevier Inc.


Magro C.M.,Cornell University | Crowson A.N.,University of Oklahoma | Crowson A.N.,St John Medical Center | Desman G.,Laboratory of Dermatopathology | Zippin J.H.,Cornell University
Archives of Dermatology | Year: 2012

Objective: To investigate the usefulness of a novel marker for melanocytic proliferations. Design: Using a novel monoclonal antibody against soluble adenylyl cyclase (sAC), various benign and malignant melanocytic proliferations were immunostained. Setting: Weill Medical College of Cornell University dermatopathology laboratory. Main Outcome Measures: The results were qualitative, not quantifiable. Results: The sAC immunostaining produced distinctive patterns that paralleled melanomagenesis. At one pole of the spectrum were benign nevi, including atypical nevi of special sites and recurrent nevi showing a distinct pattern of dotlike Golgi staining, while at the opposite pole was melanoma, in which many cells demonstrated an intense pannuclear expression pattern, often accompanied by loss of the Golgi expression pattern. Melanomas of lentigo maligna and acral lentiginous subtypes exhibited the most striking pannuclear expression, while nodular melanomas showed the least, although with supervening enhanced diffuse cytoplasmic expression. Loss of the Golgi expression pattern was a feature of malignant melanoma. Conclusion: The sAC expression pattern is complex but seems discriminatory, with distinctive and variable staining patterns according to the nature of the lesion biopsied. ©2012 American Medical Association. All rights reserved.


White D.,St John Medical Center | Kaplan L.,American Nurses Association | Eddy L.,Washington State University
Advanced Emergency Nursing Journal | Year: 2011

This study identifies characteristics of patients who return to the emergency department (ED) within 72 hr after an initial visit. An exploratory quantitative descriptive study was conducted to identify characteristics of patients with unscheduled 72 hr ED returns. The sample consisted of all patients with 72 hr ED return visits for the month of January 2009 at the study facility. Data were collected from electronic patient records utilizing the National Hospital Ambulatory Medical Care Survey instrument modified to eliminate patient identifiers. There were 169 individuals who had at least one 72 hr return visit to the ED for a total of 393 initial and return ED visits. The most common diagnoses were for gastrointestinal complaints. Over a third of the patients who returned had chronic health conditions. There were more emergency department return visits in individuals who lacked access to primary care. Copyright © 2011 LippincottWilliams & Wilkins.


Bindlish S.,Heritage University | Bindlish S.,Camden Clark Medical Center | Presswala L.S.,St John Medical Center | Schwartz F.,Camden Clark Memorial Hospital
Postgraduate Medicine | Year: 2015

Context: Lipodystrophy (LD) is a relatively rare complex collection of diseases that can be congenital or acquired. It is commonly missed in the clinical setting. Thus, the spectrum of disease presentation mandates clinician expertise in the pathophysiology and management of all forms of LD, obesity, and insulin resistance. Methods and materials: An extensive literature search of clinical trials, systematic reviews, and narrative reviews was completed in PubMed for the years 1970 to 2013. The search terms were lipodystrophy, congenital LD, acquired LD, HIV-associated LD, severe insulin resistance, adiposity, obesity, and dyslipidemia. Evidence synthesis: Lipodystrophies are a heterogeneous group of disorders with abnormal adipose tissue distribution, utilization, and metabolism. Adipose tissue can undergo significant changes in composition (hypertrophy and atrophy) in response to a nutritional state. Paradoxically, both excess and deficient adipose tissue is associated with insulin resistance and the metabolic syndrome. Bone density scan (DEXA) for body fat composition analysis or magnetic resonance imaging are optimal modalities for the assessment of abnormal adipose tissue distribution. Ongoing clinical studies suggest thiazolidinediones, insulin like growth factor-1, leptin, and growth hormone–releasing hormone as possible treatment for LPD; however, none of them is approved to reverse fat loss or treat severe insulin resistance due to LPD. Conclusion: The underlying mechanisms for LPD causing insulin resistance may be lipotoxicity and derangements in adipose tissue-derived proteins (adipocytokines). However, the lack of evidence to support this model means that clinicians are on their own as they navigate through the phenotypic presentation of lipodystrophies, obesity, insulin resistance, and the metabolic syndrome. © 2015 Informa UK Ltd.


Mundra V.,St John Medical Center
American Journal of Case Reports | Year: 2012

Background: Lung cancer accounts for more deaths than any other cancer in the country for both men and women. Here we describe a case of rectus abdominis muscle, small bowel and mesenteric metastasis with poorly differentiated lung adenocarcinoma at the time of diagnosis. Case Report: This is a case of 51 year old male patient who came with complains of severe abdominal pain for 3 days. He had a workup done for hemoptysis (over 2 months) including a CT chest which showed a 3.1×2.7cm cavitary lesion but the following bronchoscopy for malignancy was negative. He had a 30 pack year smoking history and had quit 10 years back. CT abdomen showed dense lobular mesenteric mass likely representing hemorrhagic mass seen in the right aspect of the mesentery. A second lesion was seen at inferior lateral aspect of the right rectus muscle which likely represents hemorrhagic lesion with hemoperitonuem. Pathology result came back as most consistent with metastatic poorly differentiated pulmonary adenocarcinoma. The patient is undergoing radiation treatment at present. Conclusions: There are very few case reports of lung cancer presenting with small bowel obstruction or perforation as the initial presentation. Skeletal muscle metastasis although rare, has been described to forearm, gluteal and psoas muscle. Our case presented as a hemorrhage resulting in overlying bruise which is not described before. Treatment options for such cases are not clear but as the patients usually have advanced disease at the time of diagnosis. Multimodality treatment options including surgical excision, chemotherapy and radiotherapy have been tried with mixed results. © Am J Case Rep, 2012.


Jennings W.C.,University of Tulsa | Miller G.A.,Columbia University | Zachary Coburn M.,University of Tulsa | Anthony Howard C.,University of Tulsa | Lawless M.A.,St John Medical Center
Journal of Vascular Access | Year: 2012

Purpose: Vascular access patients with central vein (CV) stenosis or occlusion may have significant symptoms. Treatment is generally by balloon angioplasty, with or without stenting. However, CV lesions may not be correctable and when treated, tend to recur. Surgical bypass of CV obstruction is a major procedure and ligation of the access may leave the patient dependent on catheter dialysis. We review a precision inflow banding procedure to limit vascular access flow and pressure for symptomatic patients with CV obstruction while preserving access functionality. Materials and Methods: All individuals with symptomatic CV occlusive disease who underwent an autogenous vascular access inflow restriction procedure by the two senior authors were identified. All had failed attempts to correct CV lesions by angioplasty and stent placement. A precision banding procedure was used for access inflow reduction with the addition of real-time intravascular flow monitoring. Results: Twenty-two patients were identified. Ages were 22-72 years (mean=43 years). Nine patients (40.9%) were women, and 8 (36.4%) obese. Mean access flow was 1640 mL/minute before banding decreased to 820 mL/minute after banding (P<.01). All patients had access salvage. Swelling resolved promptly in 20 patients and was markedly improved in two individuals. Three patients underwent aneurysm repair with simultaneous inflow banding and decreased intra-access pressure after flow restriction. Two fistulas failed at eight and 13 months. Mean follow-up was 8 months. Conclusions: The symptoms of hemodialysis vascular access patients associated with non-correctable central venous lesions resolved successfully and their access was maintained using a precision inflow banding procedure. © 2011 Wichtig Editore.


Crowson A.N.,St John Medical Center
American Journal of Dermatopathology | Year: 2016

BACKGROUND:: The cutaneous manifestations of herpes infection are primarily in the context of active infection and of the post-herpetic zosteriform eruption. The former manifests cytopathic alterations diagnostic of herpes. The latter includes lichen planus–like and granuloma annulare–like eruptions and lymphocytoma cutis. METHODS:: We encountered skin biopsies from 28 patients whose acute or chronic herpetic or post-herpetic zosteriform lesions manifested folliculocentricity. The clinical appearance of the lesions was correlated with the histopathologic and immunohistochemical features of paraffin-embedded skin biopsies to determine the specific viral etiology. A history of underlying medical disease was noted if present. RESULTS:: There were 16 men and 12 women with a folliculocentric eruption occurring after a known herpetic eruption or manifesting cytopathic changes and/or immunohistochemical findings compatible with herpes virus in lesional skin biopsies. Underlying immune dysregulatory states were present in most cases, namely, malignancy, anticonvulsant or antidepressant therapy, diabetes mellitus, psoriasis, Crohn disease, and other conditions. All biopsies demonstrated dense lymphohistiocytic infiltrates in or around hair follicles with variable necrosis, while active infections also showed cytopathic and/or immunohistochemical evidence of herpetic alterations, most commonly varicella zoster. Other features included interfollicular interface dermatitis, lymphocytic eccrine hidradenitis, neuritis, and folliculocentric vasculitis. CONCLUSIONS:: Cutaneous herpetic eruptions can evoke a predominantly folliculocentric mononuclear cell reaction and vasculitis; there is an association with underlying endogenous and/or iatrogenic immune dysregulation. Most cases are secondary to reactivation of varicella zoster. The histomorphology suggests a role for cell-mediated immunity. Antigenic homology of an endogenous 72-kd heat shock protein in follicles with that of a herpetic heat shock protein, in concert with an intrafollicular proliferative response of γ-δ T lymphocytes, may explain the follicular localization and composition of the infiltrate. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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