Fried L.F.,University of Pittsburgh |
Emanuele N.,Hines Veterans Administration Hospital |
Emanuele N.,Loyola University |
Zhang J.H.,Cooperative Studies Program Coordinating Center |
And 18 more authors.
New England Journal of Medicine | Year: 2013
BACKGROUND: Combination therapy with angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) decreases proteinuria; however, its safety and effect on the progression of kidney disease are uncertain. METHODS: We provided losartan (at a dose of 100 mg per day) to patients with type 2 diabetes, a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 300, and an estimated glomerular filtration rate (GFR) of 30.0 to 89.9 ml per minute per 1.73 m2 of body-surface area and then randomly assigned them to receive lisinopril (at a dose of 10 to 40 mg per day) or placebo. The primary end point was the first occurrence of a change in the estimated GFR (a decline of ≥30 ml per minute per 1.73 m2 if the initial estimated GFR was ?60 ml per minute per 1.73 m2 or a decline of ≥50% if the initial estimated GFR was <60 ml per minute per 1.73 m2), end-stage renal disease (ESRD), or death. The secondary renal end point was the first occurrence of a decline in the estimated GFR or ESRD. Safety outcomes included mortality, hyperkalemia, and acute kidney injury. RESULTS: The study was stopped early owing to safety concerns. Among 1448 randomly assigned patients with a median follow-up of 2.2 years, there were 152 primary endpoint events in the monotherapy group and 132 in the combination-therapy group (hazard ratio with combination therapy, 0.88; 95% confidence interval [CI], 0.70 to 1.12; P = 0.30). A trend toward a benefit from combination therapy with respect to the secondary end point (hazard ratio, 0.78; 95% CI, 0.58 to 1.05; P = 0.10) decreased with time (P = 0.02 for nonproportionality). There was no benefit with respect to mortality (hazard ratio for death, 1.04; 95% CI, 0.73 to 1.49; P = 0.75) or cardiovascular events. Combination therapy increased the risk of hyperkalemia (6.3 events per 100 person-years, vs. 2.6 events per 100 person-years with monotherapy; P<0.001) and acute kidney injury (12.2 vs. 6.7 events per 100 person-years, P<0.001). CONCLUSIONS: Combination therapy with an ACE inhibitor and an ARB was associated with an increased risk of adverse events among patients with diabetic nephropathy. (Funded by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development; VA NEPHRON-D ClinicalTrials.gov number, NCT00555217.) Copyright © 2013 Massachusetts Medical Society.
McCullough P.A.,St John Providence Health System |
McCullough P.A.,Providence Park Hospital |
Shaw A.D.,Duke University |
Haase M.,Otto Von Guericke University of Magdeburg |
And 6 more authors.
Contributions to Nephrology | Year: 2013
Acute kidney injury (AKI) commonly occurs in hospitalized patients and is independently and strongly associates with morbidity and mortality. The clinical benefits of a timely and definitive diagnosis of AKI have not been fully realized due to limitations imposed by the use of serum creatinine and urine output to fulfill diagnostic criteria. These restrictions often lead to diagnostic delays, potential misclassification of actual injury status, and provide little information regarding underlying cause. Novel biomarkers of damage have shown ability to reflect ongoing kidney injury and help further refine existing Risk, Injury, Failure, Loss, End-stage kidney disease (RIFLE) and Acute Kidney Injury Network (AKIN) diagnostic criteria. A comprehensive review of the published literature to date was performed using previously published methodology of the Acute Dialysis Quality Initiative (ADQI) working group to establish consensus statements regarding (i) the overall implementation of injury biomarkers in the concept of AKI diagnosis, (ii) their clinical use, and (iii) future research. On the basis of published data on the ability of novel damage biomarkers to provide diagnostic and prognostic information on AKI, we recommend that novel damage biomarkers may, in the appropriate clinical setting and context (situation consistent with AKI), be used to diagnose AKI even in the absence of changes in serum creatinine or the presence of oliguria as described in the existing RIFLE/AKIN criteria for diagnosis of AKI. Adding injury biomarkers as a criterion for AKI will complement the ability of RIFLE/AKIN to define AKI. Promising diagnostic injury markers include neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule 1 (KIM-1), interleukin 18 (IL-18) and liver-type fatty acid binding protein (L-FABP). However, there are currently insufficient data on damage biomarkers to support their use for AKI staging. Rigorous validation studies measuring the association between the novel damage biomarker(s) and clinically relevant outcomes are needed. Copyright © 2013 S. Karger AG, Basel.
Reza S.,Quaid e Azam Medical College |
Shaukat A.,Quaid e Azam Medical College |
Arain T.M.,Bahawal Victoria Hospital |
Riaz Q.S.,St John Providence Health System |
Mahmud M.,Carleton University
PLoS ONE | Year: 2013
Thyroid dysfunctions are common endocrine problems. They are often misdiagnosed, misunderstood, and frequently overlooked. These disorders affect almost every aspect of health. Most of them remain undetected because the clinical assessment alone lacks both sensitivity and specificity. As it is not sufficient enough we require the biochemical tests to confirm the diagnosis. As a consequence there is still great interest in new biomarkers that complement existing diagnostic tools. Osteopontin, a glycoprotein that can be detected in plasma, was found to be upregulated in several patients with hyperthyroidism and downregulated in hypothyroid patients so it may represent a new biomarker. 100 patients with thyroid dysfunctions (50 hyperthyroid, 50 hypothyroid) and 100 normal subjects were included in the study. Osteopontin and other clinical parameters for diagnosis of thyroid disorders were measured. Osteopontin is positively correlated with T3 and T4 (r = 0.62 and r = 0.75 respectively) while it is negatively correlated with thyroid stimulating hormone (r = -0.52) showing a significant correlation (p-value <0.001). Our findings suggest that osteopontin might be useful as a novel prognostic biomarker in patients with impaired thyroid function. © 2013 Reza et al.
Ronco C.,St Bortolo Hospital |
Ronco C.,International Renal Research Institute |
Cicoira M.,University of Verona |
McCullough P.A.,St John Providence Health System |
And 3 more authors.
Journal of the American College of Cardiology | Year: 2012
Cardiorenal syndrome (CRS) type 1 is characterized as the development of acute kidney injury (AKI) and dysfunction in the patient with acute cardiac illness, most commonly acute decompensated heart failure (ADHF). There is evidence in the literature supporting multiple pathophysiological mechanisms operating simultaneously and sequentially to result in the clinical syndrome characterized by a rise in serum creatinine, oliguria, diuretic resistance, and in many cases, worsening of ADHF symptoms. The milieu of chronic kidney disease has associated factors including obesity, cachexia, hypertension, diabetes, proteinuria, uremic solute retention, anemia, and repeated subclinical AKI events all work to escalate individual risk of CRS in the setting of ADHF. All of these conditions have been linked to cardiac and renal fibrosis. In the hospitalized patient, hemodynamic changes leading to venous renal congestion, neurohormonal activation, hypothalamic-pituitary stress reaction, inflammation and immune cell signaling, systemic endotoxemic exposure from the gut, superimposed infection, and iatrogenesis all contribute to CRS type 1. The final common pathway of bidirectional organ injury appears to be cellular, tissue, and systemic oxidative stress that exacerbate organ function. This review explores in detail the pathophysiological pathways that put a patient at risk and then effectuate the vicious cycle now recognized as CRS type 1. © 2012 American College of Cardiology Foundation.
Carlin A.M.,Ford Motor Company |
Zeni T.M.,St Mary Mercy Hospital |
English W.J.,Marquette General Hospital |
Hawasli A.A.,St John Providence Health System |
And 12 more authors.
Annals of Surgery | Year: 2013
OBJECTIVE: To evaluate the comparative effectiveness of sleeve gastrectomy (SG), laparoscopic gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) procedures. BACKGROUND: Citing limitations of published studies, payers have been reluctant to provide routine coverage for SG for the treatment of morbid obesity. METHODS: Using data from an externally audited, statewide clinical registry, we matched 2949 SG patients with equal numbers of RYGB and LAGB patients on 23 baseline characteristics. Outcomes assessed included complications occurring within 30 days, and weight loss, quality of life, and comorbidity remission at 1, 2, and 3 years after bariatric surgery. RESULTS: Matching resulted in cohorts of SG, RYGB, and LAGB patients that were well balanced on baseline characteristics. Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, P < 0.0001) but higher than for LAGB (2.4%, P < 0.0001). Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, P = 0.736) but higher than for LAGB (1.0%, P < 0.0001). Excess body weight loss at 1 year was 13% lower for SG (60%) than for RYGB (69%, P < 0.0001), but was 77% higher for SG than for LAGB (34%, P < 0.0001). SG was similarly closer to RYGB than LAGB with regard to remission of obesity-related comorbidities. CONCLUSIONS: With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers. Copyright © 2013 by Lippincott Williams & Wilkins.
Birkmeyer N.J.O.,University of Michigan |
Finks J.F.,University of Michigan |
Carlin A.M.,Ford Motor Company |
Chengelis D.L.,William Beaumont Hospital |
And 6 more authors.
Archives of Surgery | Year: 2012
Objective: To evaluate the effectiveness and safety of 3 predominant venous thromboembolism (VTE) prophylaxis strategies among patients undergoing bariatric surgery. Design: Cohort study. Setting: The Michigan Bariatric Surgery Collaborative, a statewide clinical registry and quality improvement program. Patients: Twenty-four thousand seven hundred seventy-seven patients undergoing bariatric surgery between 2007 and 2012. Interventions: Unfractionated heparin preoperatively and postoperatively (UF/UF), UF heparin preoperatively and low-molecular-weight heparin postoperatively (UF/LMW), and LMW heparin preoperatively and postoperatively (LMW/LMW). Main Outcome Measures: Rates of VTE, hemorrhage, and serious hemorrhage (requiring >4 U of bloodproducts or reoperation) occurring within 30 days of surgery. Results: Overall, adjusted rates of VTE were significantly lower for the LMW/LMW (0.25%; P<.001) and UF/LMW (0.29%; P=.03) treatment groups compared with the UF/UF group (0.68%). While UF/LMW (0.22%; P=.006) and LMW/LMW (0.21%; P<.001) were similarly effective in patients at low risk of VTE (predicted risk <1%), LMW/LMW (1.46%; P=.10) seemed more effective than UF/LMW (2.36%; P=.90) for high-risk (predicted risk ≥1%) patients. There were no significant differences in rates of hemorrhage or serious hemorrhage among the treatment strategies. Conclusion: Low-molecular-weight heparin is more effective than UF heparin for the prevention of postoperative VTE among patients undergoing bariatric surgery and does not increase rates of bleeding. ©2012 American Medical Association. All rights reserved.
Shaikh W.,Wayne State University |
Morris D.,St John Providence Health System |
Morris S.,Mercer University
Journal of the American Board of Family Medicine | Year: 2016
Chronic bisphosphonate therapy is associated with atypical fractures of the subtrochanteric and proximal femoral diaphyseal regions. Various radiologic imaging signs can identify bisphosphonate-associated stress fractures before they progress to complete fractures. Identifying patients who are at risk and modifying treatment can prevent these fractures from occurring. We present a case study of a patient taking bisphosphonate with 2 years of chronic pain, and characteristic clinical signs of bisphosphonateassociated incomplete stress fractures that went untreated until the patient suffered from a right subtrochanteric complete fracture. Our goal is to make physicians aware of the signs of insufficiency fractures associated with chronic bisphosphonate therapy such that appropriate clinical decisions are made to optimize the quality of patient care.
Nagendran M.,Hammersmith Hospital |
Carlin A.M.,Wayne State University |
Bacal D.,Oakwood |
Genaw J.A.,Wayne State University |
And 3 more authors.
Surgery for Obesity and Related Diseases | Year: 2015
Background Evidence on remission of obstructive sleep apnea (OSA) after bariatric surgery and its relation to weight loss is conflicting. We sought to identify factors associated with successful self-reported OSA remission in a large cohort of bariatric surgery patients. Methods We analyzed data from the statewide, prospective clinical registry of the Michigan Bariatric Surgery Collaborative and identified 3,550 patients with OSA who underwent a primary bariatric procedure between June 2006 and October 2011 and had at least 1 year of follow-up data. We used multivariate logistic regression to identify preoperative factors associated with successful self-reported OSA remission, defined as discontinuation of continuous positive airway pressure or bilevel positive airway pressure at 1 year. Our regression model also included procedure type and weight loss at 1 year, divided into equal quintiles, as covariates. Results The overall 1-year self-reported OSA remission rate was 60%. Significant predictors of remission included age category (per 10 yr) (OR.73, CI.69-.78), body mass index category (per 10 units) (OR.57, CI.54-.62), male gender (OR.58, CI.52-.69), hypertension (OR.83, CI.74-.99), depression (OR.78, CI.69-.88), pulmonary disease (OR.88, CI.78-.98), and baseline Health and Activities Limitations Index score (OR 1.70, CI 1.32-2.23). Relative to gastric banding, the adjusted odds of OSA remission were greater with gastric bypass (OR 2.38, CI 1.89-3.08), sleeve gastrectomy (OR 2.01, CI 1.44-2.55), and duodenal switch (OR 2.57, CI 1.02-7.26). The odds ratio of OSA remission increased stepwise through quintiles of 1-year weight loss. Relative to the lowest quintile, the odds ratios of remission in the 2nd through 5th quintiles were 1.44 (CI 1.11-1.84), 2.03 (CI 1.48-2.57), 2.47 (1.85-3.40), and 3.53 (CI 2.56-4.85). Conclusions Weight loss is an important predictor of self-reported OSA remission after bariatric surgery. However, independent of weight loss, there remain significant differences in the likelihood of remission between gastric banding and other bariatric procedures. This suggests that there may be metabolic, weight-independent effects of procedure type on self-reported OSA remission. © 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Ronco C.,San Bortolo Hospital |
Stacul F.,Science Radiologia Ospedale Maggiore |
McCullough P.A.,St John Providence Health System |
McCullough P.A.,St John Hospital |
McCullough P.A.,Providence Hospital and Medical Centers
European Radiology | Year: 2013
Abstract: Contrast-induced acute kidney injury (CI-AKI), previously known as contrast-induced nephropathy (CIN), is a syndrome in which an acute renal dysfunction is diagnosed after the intravascular injection of contrast media. AKI implies an injury or damage but not necessarily a reduction in overall renal filtration function. The renal damage becomes evident only when more than 50 % of the renal mass is compromised. This typically occurs when AKI is diagnosed using creatinine as a marker; in fact, creatinine is a surrogate of glomerular filtration and it does not describe the whole spectrum of kidney function. Recent AKI classifications include even slight changes in serum creatinine (as low as 0.3 mg/dl), which are associated with worse outcomes. An early diagnosis of AKI using novel biomarkers has now become possible. These new biomarkers provide additional value, not only because they facilitate earlier diagnosis but also because they can diagnose AKI even in the absence of a change in subsequent filtration function. Thus, in this situation, these new criteria can reveal subclinical AKI. A new domain of AKI diagnosis could then include functional and structural criteria as indicated by laboratory testing. Key Points: • There is continuing concern about renal damage caused by radiological contrast agents • Acute kidney injury may be associated with minor changes in serum creatinine • AKI implies damage but not necessarily a reduction in overall renal filtration function. • Novel biomarkers facilitate earlier diagnosis, even if subsequent filtration function is unaltered. • AKI diagnosis could include functional and structural criteria as indicated by laboratory testing © 2012 European Society of Radiology.
Hallman I.S.,University of Michigan |
O'Connor N.,Madonna University of Schoolcraft |
Hasenau S.,Madonna University of Schoolcraft |
Brady S.,St John Providence Health System
Journal of Child and Adolescent Psychiatric Nursing | Year: 2014
Problem: The purpose of this study was to reduce perceived levels of interprofessional staff stress and to improve patient and staff safety by implementing a brief mindfulness-based stress reduction (MBSR) training program on a high-acuity psychiatric inpatient unit. Methods: A one-group repeated measure design was utilized to measure the impact of the (MBSR) training program on staff stress and safety immediately post-training and at 2 months. Two instruments were utilized in the study: the Toronto Mindfulness Scale and the Perceived Stress Scale. Findings: The MBSR program reduced staff stress across the 2-month post-training period and increased staff mindfulness immediately following the brief training period of 8 days, and across the 2-month post-training period. A trend toward positive impact on patient and staff safety was also seen in a decreased number of staff call-ins, decreased need for 1:1 staffing episodes, and decreased restraint use 2 months following the training period. Conclusions: A brief MBSR training program offered to an interprofessional staff of a high-acuity inpatient adolescent psychiatric unit was effective in decreasing their stress, increasing their mindfulness, and improving staff and patient safety. © 2014 Wiley Periodicals, Inc.