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Voyce S.J.,The Wright Center for Graduate Medical Education
Texas Heart Institute Journal | Year: 2015

Interventional cardiologists have few data on which to base clinical decisions regarding optimal care for ST-segment‑elevation myocardial infarction patients who are taking therapeutic chronic oral anticoagulation. We present what we believe to be the first reported case of emergency coronary angiography and primary percutaneous coronary intervention in an ST-segment‑elevation myocardial infarction patient who was on a dabigatran regimen for atrial fibrillation. The patient tolerated the procedures well and had no observable bleeding sequelae. In addition to the patient’s case, we discuss the current evidence regarding the periprocedural management of oral anticoagulation in patients who need coronary angiography and percutaneous coronary intervention. © 2015 by the Texas Heart ® Institute, Houston.


PubMed | George Washington University, Johns Hopkins University, L V Prasad Eye Institute, The Wright Center for Graduate Medical Education and University of Iowa
Type: Journal Article | Journal: Biomedical journal | Year: 2016

We assessed the predictive accuracy of an empirically-derived score (weight loss, insulin resistance, and glycemic control: WIG) to predict patients who will be successful in reducing diabetes mellitus (DM) medication use with weight loss.Case records of 121 overweight and obese patients with DM at two outpatient weight management centers were analyzed.Mean period of follow-up was 12.53.5 months. To derive the WIG scoring algorithm, one point each was assigned to W (loss of 5% of initial body weight within the first 3 months of attempting weight loss), I (triglyceride [TGL]/highdensity lipoprotein ratio >3 [marker of insulin resistance] at baseline), and G (glycosylated hemoglobin [A1c%] >8.5 at baseline). WIG score showed moderate accuracy in discriminating anti-DM dose reductions at baseline, and after 3 months of weight loss efforts (likelihood ratios [LR] + >1, LR- <1, and area under the curve >0.7), and demonstrated good reproducibility.WIG score shows promise as a tool to predict success with dose reductions of antidiabetes medications.


PubMed | Duke Clinical Research Institute, Quebec Heart Lung Institute, The Wright Center for Graduate Medical Education and Hamilton Health Sciences
Type: Journal Article | Journal: The American journal of cardiology | Year: 2016

Bivalirudin is an alternative to unfractionated heparin (UFH) anticoagulation during percutaneous coronary intervention. Previously, we have reported clinical benefit on major bleeding in favor of bivalirudin compared with UFH monotherapy but inconclusive results on mortality. Controversial data have been reported in the last 2years. We conducted an updated meta-analysis including randomized trials and observational studies, which evaluated ischemic and bleeding outcomes for bivalirudin compared with UFH-only during percutaneous coronary intervention. We included 18 observational studies and 12 randomized trials published from 2003 to 2015. Primary outcomes were major adverse cardiovascular events within 30days including death, myocardial infarction, and urgent revascularization and stent thrombosis, major bleeding, and transfusion. Overall, we found a significant risk reduction with bivalirudin for major bleeding (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49 to 0.71, p <0.0001) and for transfusion (OR 0.79, 95% CI 0.66 to 0.95, p= 0.01) and similar risk for major adverse cardiovascular events (OR 0.98, 95% CI 0.86 to 1.12, p= 0.80). However, there was a substantial increased risk of stent thrombosis associated with bivalirudin (OR 1.52, 95% CI 1.11 to 2.08, p= 0.009). No impact on mortality was found. Meta-regression analyses on major bleeding suggested that bivalirudin was more effective than UFH at doses >60 IU/kg and independent of radial access. In conclusion, compared with UFH monotherapy, bivalirudin remains associated with less bleeding risk but higher stent thrombosis risk. Further study remains required to define its role in current antithrombotic armamentarium.


PubMed | Sunnybrook Health science Center, Li Ka Shing Knowledge Institute, Mount Sinai Hospital, The Wright Center for Graduate Medical Education and St Michaels Hospital
Type: Journal Article | Journal: Canadian geriatrics journal : CGJ | Year: 2017

The Team Standardized Assessment of a Clinical Encounter Report (StACER) was designed for use in Geriatric Medicine residency programs to evaluate Communicator and Collaborator competencies.The Team StACER was completed by two geriatricians and interdisciplinary team members based on observations during a geriatric medicine team meeting. Postgraduate trainees were recruited from July 2010-November 2013. Inter-rater reliability between two geriatricians and between all team members was determined. Internal consistency of items for the constructs Communicator and Collaborator competencies was calculated. Raters completed a survey previously administered to Canadian geriatricians to assess face validity. Trainees completed a survey to determine the usefulness of this instrument as a feedback tool.Thirty postgraduate trainees participated. The prevalence-adjusted bias-adjusted kappa range inter-rater reliability for Communicator and Collaborator items were 0.87-1.00 and 0.86-1.00, respectively. The Cronbachs alpha coefficient for Communicator and Collaborator items was 0.997 (95% CI: 0.993-1.00) and 0.997 (95% CI: 0.997-1.00), respectively. The instrument lacked discriminatory power, as all trainees scored meets requirements in the overall assessment. Niney-three per cent and 86% of trainees found feedback useful for developing Communicator and Collaborator competencies, respectively.The Team StACER has adequate inter-rater reliability and internal consistency. Poor discriminatory power and face validity challenge the merit of using this evaluation tool. Trainees felt the tool provided useful feedback on Collaborator and Communicator competencies.


Sehgal V.,The Commonwealth Medical College | Bajwa S.J.S.,Gian Sagar Medical College | Sehgal R.,The Wright Center for Graduate Medical education | Bajaj A.,The Wright Center for Graduate Medical education
International Journal of Endocrinology and Metabolism | Year: 2014

Context: Articles in various international and national bibliographic indices were extensively searched with an emphasis on thyroid and hypothyroid disorders, hypothyroidism in elderly hospitalized patients, hypothyroidism in critically ill geriatric population, thyroxine in elderly hypothyroid, drug interactions and thyroid hormones, and thyroid functions in elderly. Evidence acquisition: Entrez (including PubMed), NIH.gov, Medscape.com, WebMD.com, MedHelp.org, Search Medica, MD consult, yahoo.com, and google.com were searched. Manual search was performed on various textbooks of medicine, critical care, pharmacology, and endocrinology. Results: Thyroid function tests in elderly hospitalized patients must be interpreted with circumspection. The elderly are often exposed to high iodide content and critical care settings. This may occur because of either decreased iodine excretion or very high intake of iodine. This is especially true for elderly population with underlying acute or chronic kidney diseases or both. Amiodarone, with a very high iodine content, is also often used in this set of population. Moreover, other medications including iodinated contrast are often used in the critical care settings. These may affect different steps of thyroid hormone metabolism, and thereby complicate the interpretation of thyroid function tests. Conclusions: The current review is aimed at analyzing and managing various clinical aspects of hypothyroidism in hospitalized elderly, and critically ill geriatric patients. © 2014, Research Institute For Endocrine Sciences and Iran Endocrine Society.


Bajaj A.,The Wright Center for Graduate Medical Education | Rathor P.,Zhengzhou University | Sehgal V.,The Common Wealth Medical College | Kabak B.,The Common Wealth Medical College | And 3 more authors.
Lung | Year: 2015

Background: Various biomarkers have been evaluated to risk stratify patients with acute pulmonary embolism (PE). We aimed to summarize the available evidence to compare the prognostic value of three most widely studied biomarkers in normotensive patients with acute PE. Method: A systematic literature review of database, including Pubmed, EMBASE and Cochrane, was done. Studies were included if those were done on patients with acute PE and serum troponin or brain natriuretic peptide and N-terminal proBNP (BNP/NT-proBNP) or Heart-type fatty acid-binding protein (H-FABP) assay was done. The primary end point was short-term all-cause mortality. The secondary end points were PE-related mortality and serious adverse events. Results: All three biomarkers were significantly associated with increased risk for short-term all-cause mortality, PE-related mortality and serious adverse events. All-cause mortality: troponin [odds ratio (OR) 4.80; 95 % CI 3.25–7.08, I2 = 54 %], BNP or NT-proBNP (OR 7.98; 95 % CI 4.34–14.67, I2 = 0 %); PE-related mortality: troponin (OR 3.80; 95 % CI 2.74–5.27, I2 = 0 %), BNP or NT-proBNP (OR 7.57; 95 % CI 2.89–19.81, I2 = 0 %) and H-FABP (OR 25.97; 95 % CI 6.63–101.66, I2 = 40 %). H-FABP has the lowest negative likelihood ratio (NLR) of 0.17 for mortality followed by high-sensitive cardiac troponin T (hs-cTnT) with NLR of 0.21. Conclusion: None of the biomarker identifies a subgroup of patients who can be managed as an outpatient versus patients who may get benefit from thrombolytics with certainty; however, H-FABP and hs-cTnT showed some promising results and should be investigated further. © 2015, Springer Science+Business Media New York.


Bajaj A.,The Wright Center for Graduate Medical Education | Rathor P.,Zhengzhou University | Sehgal V.,The Common Wealth Medical College | Shetty A.,The Common Wealth Medical College
Heart and Lung: Journal of Acute and Critical Care | Year: 2015

The objective our meta-analysis is to update the evidence on the efficacy of noninvasive ventilation (NIV) compared with conventional oxygen therapy after planned extubation. We did a systematic literature review of database, including Pubmed, EMBASE, and Cochrane. We included randomized controlled trials comparing NIV with conventional oxygen therapy after planned extubation in medical intensive care unit (ICU) in our analysis. The results of our meta-analysis is consistent with the results of previous reviews and show that NIV decreased reintubation rate significantly as compared to conventional oxygen therapy in chronic obstructive pulmonary disease (COPD) and patients at high risk for extubation failure; COPD (RR, 0.33; 95% CI, 0.16-0.69; I2 = 0), high risk (RR, 0.47; 95% CI, 0.32-0.70; I2 = 0). However, in a mixed medical ICU population, there was no statistical difference of reintubation rate between the two groups (RR, 0.66; 95% CI, 0.25-1.73; I2 = 68%). Our study suggests that use of NIV after planned extubation significantly decreases the reintubation rate in COPD patients and patients at high risk for extubation failure, confirming the findings of previous reviews. There is no difference in the reintubation rate between the two groups in the mixed medical ICU population. © 2015 Elsevier Inc..


Shantha G.P.S.,The Wright Center for Graduate Medical Education | Pancholy S.B.,The Wright Center for Graduate Medical Education | Pancholy S.B.,The Commonwealth Medical College
Sleep and Breathing | Year: 2015

Purpose: Recent evidence associates sympathetic tone with severity of obstructive sleep apnea (OSA). Renal sympathetic denervation (RDN), by decreasing sympathetic tone, has the potential to decrease OSA severity. Small observational studies that assessed this hypothesis lacked precision. Hence, in this meta-analysis, we have attempted to pool available data from studies that have assessed the effect of RDN on OSA severity in patients with OSA. Methods: Medline, Embase, Cochrane central, Ovid, Cinahl, web of science, and conference abstracts were searched for eligible citations by two independent reviewers using key words “renal denervation,” “hypertension,” and “obstructive sleep apnea.” From a total of 2,863 identified citations, using meta-analysis of observational studies in epidemiology method, five studies were assessed eligible and included in the meta-analysis. Results: All five studies followed an observational study design, involved patients with OSA and HTN, and reported an apnea-hypopnea index (AHI) 6 months post-RDN. Four were “before and after” studies and one compared continuous positive airway pressure with RDN. In the pooled analysis, involving 49 patients, RDN was associated with a significant reduction in mean AHI [weighted mean difference −9.61 (95 % CI −15.43 to −3.79, P = 0.001)] 6 months post-RDN. One study also reported improvement in oxygen desaturation index and Epworth sleepiness scale score 6 months post-RDN. Conclusions: RDN is associated with significant improvement in OSA severity. However, our results need validation in RCTs that assess effect of RDN in patients with OSA, which can potentially broaden the clinical applicability of RDN. © 2014, Springer-Verlag Berlin Heidelberg.


PubMed | The Wright Center for Graduate Medical Education
Type: | Journal: Case reports in genetics | Year: 2017

Interstitial deletions of the distal 7q region are considered a rare entity. In this report, we describe a seven-year-old male with a heterozygous interstitial deletion at 7q33-36.1 with characteristic dysmorphic facial features, intellectual disability, severe microcephaly, and significant language delay. The primary focus of our report is to compare our case with the few others in the literature describing interstitial deletions at the long arm of chromosome 7. Based on the various breakpoints in prior studies, a number of phenotypic variations have been identified that are unique to each of the reports. However, there are also a number of similarities among these cases as well. We hope to provide a concise review of the literature and genes involved within our deletion sequence in the hope that it will contribute to creating a phenotypic profile for this patient population.


PubMed | The Wright Center for Graduate Medical Education
Type: Case Reports | Journal: The Journal of invasive cardiology | Year: 2016

Right heart catheter advancement from right atrium (RA) to right ventricle (RV) is frequently difficult in patients with large and geometrically deformed RAs. We describe a simple technique, using no additional equipment, that significantly improves the probability of successful passage of right heart catheter from RA to RV.

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