Stratton Veterans Affairs Medical Center

Albany, NY, United States

Stratton Veterans Affairs Medical Center

Albany, NY, United States
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Atkinson T.J.,Stratton Veterans Affairs Medical Center | Fudin J.,Stratton Veterans Affairs Medical Center | Fudin J.,The Academy of Management | Fudin J.,Albany College of Pharmacy and Health Sciences | And 4 more authors.
Clinical Therapeutics | Year: 2013

Background By 2030, the US population of adults aged ≥65 years will increase by >80%, and these adults will account for nearly 20% of the US population. In this population, the decline of multiple physiologic processes and diseases collectively influence treatment options. Physiologic changes, drug-drug interactions resulting from polypharmacy, and drug-disease interactions combine to make elderly patients more sensitive to the adverse events (AEs) associated with medications, all of which must be considered in drug selection. Objective This article focuses on select underutilized medication options for analgesia that may provide significant advantages in the elderly population above and beyond commonly prescribed conventional choices. Methods We performed a complete review of the literature using the search terms pain management, elderly, opioids, NSAIDs, topical NSAIDs, levorphanol, buprenorphine transdermal, and tapentadol. Databases searched included PubMed, Google Scholar, Ovid, and Athens. Package inserts were utilized for approval dates, indications, and formulations available. We looked at reviews of agents to identify important studies for consideration that searches may have missed. Pharmacology and pharmacokinetic data were taken from randomized trials focusing in this area. Pivotal Phase III trials were utilized for discussion of clinical trial experience and to summarize efficacy and AEs. For purposes of validity, only peer-reviewed literature was included. Results There were limited data that specifically outlined analgesic drug selection and highlighted safer alternatives for the elderly patient based on polypharmacy risks, end-organ deterioration, and/or drug choices that presented less risk. We focused on unique opioid alternatives: levorphanol, which offers several therapeutic advantages similar to methadone but without the pharmacokinetic and drug-interaction pitfalls associated with methadone; tapentadol, associated with significantly less gastrointestinal distress and constipation; and transdermal buprenorphine, an agonist/antagonist with less risk for the toxicities associated with conventional opioids and with compliance benefits. Topical NSAIDs are discussed as a viable therapeutic option. Specific attention to a more desirable tolerability profile, including avoidance of drug interactions, end-organ dysfunction, and gastrointestinal bleed with topical NSAID agents versus their oral counterparts is discussed, including the ability to achieve superior tissue levels for appropriately selected inflammatory conditions. Conclusion It is incumbent that providers consider these options as part of an analgesic armamentarium in an effort to maximize therapeutic benefit and minimize risks in the increasing elderly patient population. © 2013 The Authors.

PubMed | Albany Medical Center and Stratton Veterans Affairs Medical Center
Type: Journal Article | Journal: In vivo (Athens, Greece) | Year: 2016

Hypercalcemia due to malignancy is well described in the literature and a common paraneoplastic finding in certain solid tumors. Hematologic malignancies, however, are less frequently associated with hypercalcemia with the exception of myelomas and T-cell lymphomas.This case report describes a patient with B-cell chronic lymphocytic leukemia (B-CLL) who developed symptomatic hypercalcemia. None of the pathogenetic mechanisms of malignancy-associated hypercalcemia already described in the literature could explain the pathogenesis of hypercalcemia in our patient. Calcium levels were normalized after initial treatment and remained within normal limits following treatment of the underlying B-CLL. The follow-up period was 26 months. The normalization of calcium levels was closely associated with the drop in the absolute lymphocyte count.Symptomatic hypercalcemia in B-CLL is exceedingly rare and only documented a few times in the literature. Hypercalcemia, in the present case, was not caused by any of the mechanisms already described in the literature and responded well to treatment of the underlying B-CLL.

Mahrer A.,Stratton Veterans Affairs Medical Center | Ramchandani P.,University of Pennsylvania | Trerotola S.O.,University of Pennsylvania | Shlansky-Goldberg R.D.,University of Pennsylvania | Itkin M.,University of Pennsylvania
Journal of Vascular and Interventional Radiology | Year: 2010

Purpose: To describe a single-center experience with sclerotherapy of postoperative lymphocele and to determine the risk factors for failure of treatment. Materials and Methods: From 1999 to 2007, 43 patients with postsurgical lymphocele were treated with sclerotherapy with a combination of povidone iodine, alcohol, and doxycycline. The treatments were repeated at weekly intervals. The initial drainage volume of the lymphocele, the location of the lymphocele, the number of treatments, and the outcomes were retrospectively collected. Results: In 38 patients, the lymphocele was drained percutaneously, and in five patients, the treatment was initiated through an existing surgically placed drainage tube. Sclerotherapy was successful in 33 patients (77%). Complications that resulted in termination of the treatment were seen in five patients (12%): testicular pain, cellulitis, posttreatment increase in creatinine, acute renal tubular necrosis, and abdominal infection. In one of these patients the lymphocele resolved after resolution of the infection. The average number of treatments was four (range, 1-14). There was no difference in success rate between superficial intraabdominal and soft-tissue lymphoceles. There was a significant difference (P < .05) in the fluid volume at initial drainage between the failure group (1,708 mL ± 1,521) and the success group (206 mL ± 213). This assumes an attempt was made to drain the collection completely at the initial procedure. Conclusions: Sclerotherapy of postoperative lymphoceles is an effective treatment. Success of sclerotherapy is directly related to the size of the lymphocele cavity. © 2010 SIR.

Mechlin C.W.,Albany Medical College | Tanner M.J.,The Ordway Research Institute Inc. | Chen M.,The Ordway Research Institute Inc. | Buttyan R.,Albany Medical College | And 5 more authors.
Journal of Urology | Year: 2010

Purpose: Hedgehog signaling regulates Gli transcription factors. Aberrant hedgehog signaling can be oncogenic and drugs that block hedgehog are being tested as anticancer agents. We considered whether hedgehog/Gli signaling may be involved in human bladder transitional cell carcinoma proliferative or invasive behavior. Materials and Methods: We stratified the human bladder transitional cell carcinoma lines RT4 (ATCC®), 253JP, 253BV, UMUC6 and UMUC3 for relative growth rate by cell counting and for in vitro invasiveness by Matrigel™ invasion assay. Cells were tested for growth inhibition by the hedgehog blocking drug cyclopamine or the inactive mimic tomatidine. Cell RNA was characterized for hedgehog signaling component expression, including ligands, receptors and signaling mediators, by quantitative reverse transcriptase-polymerase chain reaction. Gli2 expression or activity was modified by Gli2 expression lentiviruses or the Gli inhibitor GANT61. We measured effects on proliferation and invasiveness. Results: Cell growth rates and invasiveness were stratified into an equivalent order (RT4 <243JP <253BV

Gosmanova E.O.,Stratton Veterans Affairs Medical Center | Gosmanova E.O.,Albany Medical College | Mikkelsen M.K.,University of Texas Health Science Center at San Antonio | Molnar M.Z.,University of Tennessee Health Science Center | And 5 more authors.
Journal of the American College of Cardiology | Year: 2016

Background Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes. Objectives This study investigated the association of increased visit-to-visit variability and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans. Methods From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. Systolic blood pressure variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use. Results Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and diastolic BP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared with the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher. Conclusions Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes. © 2016

Phelps K.R.,Stratton Veterans Affairs Medical Center | Lieberman R.L.,Albany Medical College
Clinical Nephrology | Year: 2012

The concepts of fractional excretion and reabsorption are often employed to elucidate the contribution of tubular transport to plasma concentrations. Fractional excretion of substance x, FEx, is the ratio of the urinary excretion rate to the filtration rate of x, or Ex/Fx. Fractional tubular reabsorption of x, FTRx, is the ratio of the reabsorption rate to the filtration rate of x, or TRx/Fx. When plasma is in equilibrium with respect to x, net influx (Ix) from gut and tissue determines Ex, and [x]p = Ex/GFR + TRx/GFR. In chronic kidney disease (CKD), Ex/GFR rises as GFR falls if Ix does not fall commensurately; at the same time, TRx/GFR may fall, remain unchanged, or rise. If TRx/GFR rises, a simultaneous, proportionately greater increment in Ex/GFR causes FEx to rise also and FTRx to fall secondarily. In this circumstance, FTRx is lower than normal even though reabsorption of x is increased per volume of filtrate. This paper reviews pertinent homeostatic principles, illustrates the potential for divergence of TRx/GFR and FTRx as GFR falls, and summarizes the conditions required for the divergence. Clinical examples show reduced FTRx despite increased TRx/GFR for phosphorus and urate, and analyses suggest that such discrepancies are often inevitable. Methods are described and arguments are advanced for using TRx/GFR to quantify tubular function in CKD. © 2012 Dustri-Verlag Dr. K. Feistle.

Phelps K.R.,Stratton Veterans Affairs Medical Center | Phelps K.R.,Albany Medical College | Stote K.S.,New York University | Mason D.,Stratton Veterans Affairs Medical Center | And 2 more authors.
Clinical Nephrology | Year: 2014

Aims: Primary hyperparathyroidism (PHPT) causes hypercalcemia by increasing tubular calcium reabsorption. Because chronic kidney disease (CKD) is associated with normocalcemia, we inferred that calcium reabsorption is also normal, and hypothesized that normal reabsorption requires excessive parathyroid hormone (PTH) in CKD. Methods: The following were obtained in controls and patients with CKD or PHPT: estimated GFR (eGFR); concentrations of PTH 1-84, 1,25-dihydroxyvitamin D, and ultrafilterable and ionized calcium ([PTH], [1,25(OH)2D], [Ca]uf, [Ca]i); and ratios of calcium excreted or reabsorbed per volume of filtrate (ECa/Ccr, TRCa/Ccr). Pertinent linear regressions were examined. Results: In CKD, [PTH] was increased, but ECa/Ccr, TRCa/Ccr, [Ca]uf, and [Ca]i equaled control values. [PTH] was inversely related to eGFR but unrelated to [1,25(OH)2D]. TRCa/Ccr was constant at all [PTH]. In PHPT, [PTH] was no higher than in CKD, but TRCa/Ccr, [Ca]uf, and [Ca]i were increased. [1,25(OH)2D] correlated with [PTH]. In controls, TRCa/Ccr varied directly with [1,25(OH)2D] and inversely with [PTH]. Conclusions: In controls, calcium reabsorption rose with [1,25(OH)2D], and [PTH] fell in response. In PHPT, [PTH] determined [1,25(OH)2D]; together, the hormones increased calcium reabsorption and caused hypercalcemia. In CKD, normal calcium reabsorption required high [PTH]. © 2014 Dustri-Verlag Dr. K. Feistle.

Phelps K.R.,Stratton Veterans Affairs Medical Center | Phelps K.R.,Albany Medical College | Stote K.S.,Albany State University | Mason D.,Albany Medical College | Mason D.,Albany College of Pharmacy and Health Sciences
Clinical Nephrology | Year: 2014

Aims: Parathyroid hormone (PTH) promotes calcium reabsorption in the cortical distal nephron (CDN). The phosphate concentration ([P]f) rises in that segment in chronic kidney disease (CKD); in theory, high [P]f could reduce availability of calcium for reabsorption and necessitate a compensatory rise in [PTH]. With assumptions, [P]f is proportional to phosphate excreted/volume of filtrate (EP/GFR). We therefore hypothesized that [PTH] would correlate with EP/GFR in CKD, and δ[PTH] would correlate with δEP/GFR after sevelamer therapy. Methods: We conducted a 4-week, placebo-controlled trial of sevelamer carbonate in patients with CKD. [PTH]1-84 and parameters of phosphate homeostasis were measured before and after treatment. GFR was assumed to equal creatinine clearance (Ccr). Pertinent linear regressions were performed. Results: Phosphate excretion fell in the sevelamer group only. Decrements in [PTH] with sevelamer differed from increments with placebo. With either treatment, [PTH] correlated with EP/Ccr and δ[PTH] correlated with δEP/Ccr. Changes in [PTH] were minimal in some sevelamer recipients despite reductions in EP/Ccr; calcium excreted/volume of filtrate was low in these subjects. Conclusions: Phosphate influx affected [PTH] in CKD by determining [P]f in the CDN. In some patients, low calcium influx may have blunted the effect of sevelamer on [PTH]. © 2014 Dustri-Verlag Dr. K. Feistle.

PubMed | William Jennings Bryan Dorn Veterans Affairs Medical Center, Albany Research Center, Albany Medical College, Meridian and Stratton Veterans Affairs Medical Center
Type: Journal Article | Journal: Nephrology (Carlton, Vic.) | Year: 2016

Community-acquired acute kidney injury (CA-AKI) has been found to be a common event in the population. Current incidence estimates are not available, but evaluations of severe elevations in serum creatinine indicate that incidence can be as high as 989 cases per million population in those older than 80years. Data on risk factors are limited, but older age and higher comorbid illness burden, especially diabetes and cardiovascular disease, seem to be more common in patients who suffer CA-AKI. In addition to being more common than hospital-acquired AKI, the long-term sequelae of CA-AKI seem to be just as severe, including renal disease progression and mortality. Efforts to better understand the aetiology of CA-AKI and how ultimately to prevent the development of this condition will need to be taken. In the meantime, a concerted effort by general internists and nephrologists will be needed to prevent CA-AKI in the highest risk patients and thus limit the poor outcomes associated with this entity.

PubMed | Stratton Veterans Affairs Medical Center and Albany Medical College
Type: Journal Article | Journal: Journal of investigative medicine high impact case reports | Year: 2016

A 68-year-old man with end-stage renal disease was hospitalized because of radicular pain and weakness in the left arm and hand. Sonography and computed tomography had recently shown a large right renal mass. On admission, magnetic resonance imaging demonstrated vertebral metastases with epidural extension, and radiotherapy was directed to the spine and kidney. Hypocalcemia was first noted on the fourth hospital day. A second computed tomography scan showed bleeding into and around the kidney, and arterial embolization was required to halt the bleeding. Hypocalcemia persisted for at least 27 days at values between 6.0 and 7.7 mg/dL and was consistently associated with ionized calcium concentrations less than or equal to 4.44 mg/dL. After an unrevealing search for a recognized cause, we attributed hypocalcemia to persistent sequestration of calcium in the right retroperitoneum. Exogenous supplementation eventually restored the concentration to normal. In the absence of renal and intestinal loss, hypocalcemia reflects abnormal flux of calcium from the extracellular compartment into tissue. Our patients repository appears to have been a necrotic and hemorrhagic cancer. Tumor-induced sequestration of calcium should be included in the differential diagnosis of hypocalcemia.

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