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Roush G.C.,St Vincents Medical Center | Buddharaju V.,St Vincents Medical Center | Ernst M.E.,University of Iowa
Current Hypertension Reports | Year: 2013

How chlorthalidone (CTDN) reduces risk for cardiovascular events (CVEs) can be considered in light of its ability to lower blood pressure (BP) and its non-BP related, pleiotropic effects. The mechanism by which CTDN lowers BP is unclear but may include alterations in whole body regulation and vasodilatory actions on vasculature, possibly mediated via its inhibitory effects on carbonic anhydrase. Additionally, CTDN has potentially beneficial, non-BP related, pleiotropic effects that include improvements in endothelial function, anti-platelet activity, and oxidative status. CTDN reduces pulse wave velocity, predictor of CVEs and a measure of central aortic stiffness associated with endothelial dysfunction. On the other hand, CTDN fosters hypokalemia, hyperglycemia, sympathetic discharge, and the renin-angiotensin-aldosterone system, but these potentially harmful effects do not appear to materially reduce CTDN's ability to prevent CVEs. Further, CTDN reduces and regresses left ventricular hypertrophy (LVH), an important BP-dependent predictor of CVEs. Consistentwith this finding, CTDN was more effective than amlodipine in reducing congestive heart failure (CHF) in the Anti-hypertensive and Lipid-lowering Treatment to Prevent Heart Attach Trial (ALLHAT). In reducing CVEs, CTDN was superior to lisinopril in ALLHAT and superior to hydrochlorthiazide in observational cohort analyses and in network analyses of randomized trials. A statistical synthesis of randomized trials suggests that the reduction in cardiovascular risk from CTDN can be explained primarily on the basis of its ability to lower blood pressure rather than its influence upon non-BP related, pleiotropic effects. © Springer Science+Business Media New York 2013.


Heekin R.D.,St Vincents Medical Center | Fokin A.A.,Heekin Institute for Orthopedic Research
The journal of knee surgery | Year: 2014

We sought to determine the incidence of bicompartmental osteoarthritis among knee replacement patients for possible bone-sparing procedures. In 259 consecutive Knee Registry subjects undergoing total or unicondylar knee arthroplasty, all three compartments of the knee joint were evaluated. Radiographic images and preoperative cruciate ligaments assessment combined with intraoperative cartilage grading using Outerbridge classification was implemented for patients' evaluations. Among the candidates for knee replacement arthroplasty, 59% had osteoarthritis in all three compartments, 28% had bicompartmental disease, and 4% had unicompartmental disease. Nine percent of patients exhibited inconclusive osteoarthritis pattern. Only 5% of the patients were found to have cruciate ligaments impairment. Older patients ( > 65 years) were significantly more likely to have bi- and tricompartmental disease. We had found that 28% of our registry population had bicompartmental disease and infrequent impairment of cruciate ligaments, indicating that between one-fourth and one-third of patients undergoing total knee arthroplasty could be considered for bone preserving bicompartmental knee arthroplasty. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Roush G.C.,St Vincents Medical Center | Kaur R.,St Vincents Medical Center | Ernst M.E.,University of Iowa
Journal of Cardiovascular Pharmacology and Therapeutics | Year: 2014

Diuretics have been recommended as first-line treatment of hypertension and are also valuable in the management of hypervolemia and electrolyte disorders. This review summarizes the key features of the most commonly used diuretics. We then provide an update of clinical trials for diuretics during the past 5 years. Compared to other classes of medications, thiazide diuretics are at least as effective in reducing cardiovascular events (CVEs) in patients with hypertension and are more effective than β-blockers and angiotensin-converting enzyme inhibitors in reducing stroke. Observational cohort data and a network analysis have shown that CVEs are lowered by one-fifth from chlorthalidone when compared to the commonly used thiazide, hydrochlorothiazide. Relative to placebo, chlorthalidone increases life expectancy. In those aged 80 years and older, the diuretic, indapamide, lowers CVEs relative to placebo. The aldosterone antagonist, eplerenone, lowers total mortality in early congestive heart failure. The benefit of eplerenone following acute myocardial infarction (MI) is limited to administration within 3 to 6 days post-MI. Aldosterone antagonists have been shown to lower the incidence of sudden cardiac death and to reduce proteinuria. In the setting of heart failure, long acting loop diuretics azosemide and torasemide are more effective in improving heart failure outcomes than the far more commonly used short acting furosemide. Evening dosing of diuretics appears to lower CVEs relative to morning dosing. In conclusion, diuretics are a diverse class of drugs that remain extremely important in the management of hypertension and hypervolemic states.


Heekin R.D.,St Vincents Medical Center | Fokin A.A.,Heekin Institute for Orthopedic Research
Journal of Arthroplasty | Year: 2014

Comparisons between mini-midvastus (mMV) and mini-medial parapatellar approach (mMPP) for total knee arthroplasty (TKA) have reported variable results. We compared two approaches with minimum two year follow up. Forty consecutive patients who underwent staged bilateral TKA were prospectively randomized for mMPP approach in one knee and mMV approach in the other. Clinical parameters (muscle strength, pain, ROM, Knee Society Score) and surgic.l parameters (duration of surgery, blood loss, lateral releases) were assessed at 2, 6, 12. weeks and 6, 12, 24. months postoperatively. Clinical outcomes revealed inconsistent pattern of differences at various intervals. Surgical outcomes were not different. There were no major differences in outcomes between the two approaches. We recommend someone use surgical approach with which they are most familiar. © 2014 The Authors.


Li Z.,St Vincents Medical Center | Vaziri H.,University of Connecticut Health Center
Best Practice and Research: Clinical Gastroenterology | Year: 2012

The treatment of chronic diarrhoea can be challenging. While Oral Rehydration Solution is an important step in treating diarrhoeal illnesses, various medications can be used to alleviate the symptoms while the patient is undergoing diagnostic work up or to target the underlying mechanism responsible for their diarrhoea. Medications are also being prescribed in cases when there is a strong suspicious about a diagnosis or when there is no specific treatment for an underlying aetiology. This chapter discusses the treatment options for diarrhoeal disorders.© 2012 Elsevier Ltd. All rights reserved.


Crick B.C.,St Vincents Medical Center
Journal of surgical orthopaedic advances | Year: 2011

Litigation involving Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS), because of its complexities, is often difficult to prove or defend. In our review of 56 verdicts and settlements in the state of Florida, in cases involving a diagnosis or misdiagnosis of RSD or CRPS, over half resulted in a substantial verdict or settlement for the plaintiff.


Roush G.C.,St Vincents Medical Center | Holford T.R.,Yale University | Guddati A.K.,St Vincents Medical Center
Hypertension | Year: 2012

Hydrochlorothiazide (HCTZ) is widely used for hypertension, and prescriptions for HCTZ outnumber those for chlorthalidone (CTDN) by >20-fold in 2 recent surveys. Some have recently expressed a preference for CTDN. However, head-to-head trials testing the effect of the 2 drugs on cardiovascular events (CVEs) are lacking. We conducted a systematic review of randomized trials in which 1 arm was based on either HCTZ or CTDN followed by 2 types of network meta-analyses, a drug-adjusted analysis and an office systolic blood pressure-adjusted analysis. Nine trials were identified: 3 based on HCTZ and 6 based on CTDN. In the drug-adjusted analysis (n=50946), the percentage of risk reduction in congestive heart failure for CTDN versus HCTZ was 23 (95% CI, 2-39; P=0.032); and in all CVEs was 21 (95% CI, 12-28; P<0.0001). In the office systolic blood pressure-adjusted analysis (n=78350), the percentage of risk reduction in CVEs for CTDN versus HCTZ was 18 (95% CI, 3-30; P=0.024). When the reduction in office systolic blood pressure was identical in the 2 arms, the risk for CVEs in HCTZ arms was 19% higher than in its nondiuretic comparator arms (P=0.021). Relative to HCTZ, the number needed to treat with CTDN to prevent 1 CVE over 5 years was 27. In conclusion, CTDN is superior to HCTZ in preventing cardiovascular events. This cannot be attributed entirely to the lesser effect of HCTZ on office systolic blood pressure but may be attributed to the pleomorphic effects of alternative medications or to the short duration of action of HCTZ. © 2012 American Heart Association, Inc.


Shi C.,St Vincents Medical Center
Journal of applied clinical medical physics / American College of Medical Physics | Year: 2012

Novalis Tx ExacTrac X-ray system has the 6D adjustment ability for patient setup. Limited studies exist about the setup uncertainty with ExacTrac X-ray system for IMRT prostate treatment with fiducial markers implanted. The purpose of this study is to investigate the marker-based prostate IMRT treatment setup uncertainty using ExacTrac 6D IGRT ability for patient setup. Forty-three patients with prostate cancers and markers implanted have been treated on the Novalis Tx machine. The ExacTrac X-ray system has been used for the patient pretreatment setup and intratreatment verification. In total, the shifts data for 1261 fractions and 3504 correction times (the numbers of X-ray images were taken from tube 1 and tube 2) have been analyzed. The setup uncertainty has been separated into uncertainties in 6D. Marker matching uncertainty was also analyzed. Correction frequency probability density function was plotted, and the radiation dose for imaging was calculated. The minimum, average, and maximum translation shifts were: -5.12 ± 3.89 mm, 0.20 ± 2.21 mm, and 6.07 ± 4.44 mm, respectively, in the lateral direction; -6.80 ± 3.21 mm, -1.09 ± 2.21 mm, and 3.12 ± 2.62 mm, respectively, in the longitudinal direction; and -7.33 ± 3.46 mm, -0.93 ± 2.70 mm, and 5.93 ± 4.85mm, respectively, in the vertical direction. The minimum, average, and maximum rotation shifts were: -1.23° ± 1.95°, 0.25° ± 1.30°, and 2.38° ± 2.91°, respectively, along lateral direction; -0.67° ± 0.91°, 0.10° ± 0.61°, and 1.51° ± 2.04°, respectively, along longitudinal direction; and -0.75° ± 1.01°, 0.02° ± 0.50°, and 0.82° ± 1.13°, respectively, along vertical direction. On average, each patient had three correction times during one fraction treatment. The radiation dose is about 3 mSv per fraction. With the ExacTrac 6D X-ray system, the prostate IMRT treatment with marker implanted can achieve less than 2 mm setup uncertainty in translations, and less than 0.25° in rotations as overall interfraction mean error. The imaging dose is less than kV (CBCT) for setup verification.


Guddati A.K.,St Vincents Medical Center
Medical Oncology | Year: 2012

Ovarian cancer is one of the major causes of death in women with gynecologic malignancy. Most patients respond favorably to platinum therapy, but relapses are common. There is emerging evidence that a special subset of cells that is highly tumorigenic is responsible for recurrence of the disease. This subset of cells has been characterized by several groups and has been found to have the properties of cancer stem cells. They have been isolated from tumor samples obtained during surgical cytoreduction and also from the ascitic fluid of ovarian cancer patients. Currently, there are no known unique markers to define these cells, but several groups have used different approaches to purify them. Although some heterogeneity has been observed in these cells, most of them satisfy the functional definition of a stem cell. Advances in characterization of ovarian cancer stem cells are instrumental in developing therapies that specifically target them. This review describes the advances made in characterization of these cells, basis of their resistance to conventional chemotherapeutic agents and the prognostic implications of utilizing mechanisms specific to ovarian cancer stem cell for therapeutic interventions. Eliminating ovarian cancer stem cells could possibly lead to a prolongation of the disease-free survival period and hopefully a definitive cure. © 2012 Springer Science+Business Media, LLC.


Leder S.B.,Yale University | Ross D.A.,St Vincents Medical Center
Dysphagia | Year: 2010

Debate continues regarding an association between tracheotomy and aspiration status. The aim of this research was to perform a direct replication study to investigate further the causal relationship, if any, between tracheotomy and aspiration. Twenty-five consecutive adult hospitalized patients participated. Inclusion criteria were a pretracheotomy dysphagia evaluation, subsequent tracheotomy and tracheotomy tube placement, then a post-tracheotomy dysphagia reevaluation prior to decannulation. Twenty-two (88%) participants exhibited the same aspiration status or resolved aspiration pre- versus post-tracheotomy. Three participants exhibited new aspiration posttracheotomy due to worsening medical conditions. Conversely, four participants exhibited resolved aspiration post-tracheotomy due to improved medical conditions. Excluding these seven participants, all nine participants who aspirated pretracheotomy also aspirated post-tracheotomy and all nine participants who did not aspirate pretracheotomy also did not aspirate post-tracheotomy (P>0.05). No statistically significant differences were found between aspiration status and days since tracheotomy x2 = 0.08, P<0.05) or between age and aspiration status (P>0.05). The absence of a causal relationship between tracheotomy and aspiration status was confirmed. © Springer Science+Business Media, LLC 2009.

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