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Miyara SJ, Becker LB, Guevara S, Lau L, Nair VV, Jandovitz N, Fahmy AE, Grodstein E, Winnick AM, Kirsch C, Rolston DM, Bhaskaran MC, Hayashida K, Shinozaki K, Takegawa R, Cho YM, Cagliani JA, Isa A, Al-Roubaie M, Krishnasastry KV, Teperman LW, Molmenti EP. Life-Threatening Hematuria as Initial Presentation of a Complicated Transplant Renal Artery Pseudoaneurysm. Int J Angiol 2023; 32:253-257. [PMID: 37927842 PMCID: PMC10624528 DOI: 10.1055/s-0040-1716327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
In this case report, we describe the clinical course of a complicated transplant renal artery (TRA) pseudoaneurysm, clinically featured by gross and massive hematuria one month after a kidney transplant was performed on a 50 year-old male patient. TRA pseudoaneurysm is a rare but potentially life-threatening complication that may result in bleeding, infection, graft dysfunction/loss, lower limb ischemia/loss, hemorrhagic shock, and death. TRA pseudoaneurysm treatment remains challenging as it needs to be tailored to the patient characteristics including hemodynamic stability, graft function, anatomy, presentation, and pseudoaneurysm features. This publication discusses the clinical scenario of massive gross hematuria that derived from a retroperitoneal hematoma which originated from an actively bleeding TRA pseudoaneurysm. This case highlights the combined approach of endovascular stent placement and subsequent transplant nephrectomy as a last resort in the management of intractable bleeding from a complicated TRA pseudoaneurysm. To the best of our knowledge, this is the first published case report of an actively bleeding TRA anastomotic pseudoaneurysm that caused a massive retroperitoneal bleed that in turn evacuated via the bladder after disrupting the ureter-to-bladder anastomosis. A temporizing hemostatic arterial stent placed percutaneously allowed for a safer and controlled emergency transplant nephrectomy.
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Affiliation(s)
- Santiago J Miyara
- Department of Surgery, Northwell Health, Manhasset, New York
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Lab. for Critical Care Physiology, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Lance B Becker
- Department of Surgery, Northwell Health, Manhasset, New York
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Lab. for Critical Care Physiology, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sara Guevara
- Department of Surgery, Northwell Health, Manhasset, New York
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
| | - Lawrence Lau
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Vinay V Nair
- Department of Medicine, Northwell Health, Manhasset, New York
| | | | - Ahmed E Fahmy
- Department of Surgery, Northwell Health, Manhasset, New York
| | | | - Aaron M Winnick
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Claudia Kirsch
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Daniel M Rolston
- Department of Surgery, Northwell Health, Manhasset, New York
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
| | - Madhu C Bhaskaran
- Department of Surgery, Northwell Health, Manhasset, New York
- Department of Medicine, Northwell Health, Manhasset, New York
| | - Kei Hayashida
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
- Lab. for Critical Care Physiology, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Koichiro Shinozaki
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
- Lab. for Critical Care Physiology, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Ryosuke Takegawa
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
- Lab. for Critical Care Physiology, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Young Min Cho
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Joaquin A Cagliani
- Department of Surgery, Northwell Health, Manhasset, New York
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
| | - Arton Isa
- Department of Interventional Radiology, Northwell Health, Manhasset, New York
| | - Mustafa Al-Roubaie
- Department of Interventional Radiology, Northwell Health, Manhasset, New York
| | | | | | - Ernesto P Molmenti
- Department of Surgery, Northwell Health, Manhasset, New York
- Department of Emergency Medicine, Northwell Health, Manhasset, New York
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Jandovitz N, George SJ, Abate M, Kressel AM, Bolognese AC, Lau L, Nair V, Grodstein E. A randomized trial of continuous glucose monitoring to improve post-transplant glycemic control. Clin Transplant 2023; 37:e15139. [PMID: 37725341 DOI: 10.1111/ctr.15139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/22/2023] [Accepted: 09/09/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION This study examines whether the use of inpatient Continuous Glucose Monitors provides improved glycemic control over finger-stick glucose monitoring post-transplant. METHODS This is a single-site, prospective randomized controlled trial of 40 patients receiving conventional finger-stick glucose monitoring or continuous monitoring using the Medtronic Guardian Sensor 3 during the first 5 days post-transplant. Included patients were adult renal transplant recipients with a diagnosis of diabetes. Assessed endpoints included post-transplant daily median glucose level, hyperglycemic (≥180 mg/dL) and hypoglycemic (≤80 mg/dL) episodes, number of post-transplant bacterial infections and length of stay. RESULTS Groups were well matched in demographic variables. Median daily glucose was significantly lower in the intervention group. There were also significantly less episodes of hyperglycemia on postoperative days 2, 3, 4, and 5. There were no differences in the incidences of hypoglycemia, postoperative bacterial infections, or length of stay. CONCLUSION In this randomized study, the use of a continuous glucose monitor to guide post-transplant glucose management significantly lowered the incidence of hyperglycemic episodes and median glucose levels through the first 5 days post-transplant without increasing the number of hypoglycemic episodes. The use of these devices can be considered in the immediate post-renal transplant setting.
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Affiliation(s)
- Nicholas Jandovitz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Sam J George
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Mersema Abate
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Adam M Kressel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Alexandra C Bolognese
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Lawrence Lau
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Vinay Nair
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Elliot Grodstein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
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3
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Abate M, Jandovitz N, Hirsch JS, Breslin N, Lau L, Fahmy AE, Jhaveri KD, Richardson S, Alsalmay Y, Baez A, Mishra A, Bolourani S, Miyara SJ, Winnick A, Nair G, Bhaskaran MC, Grodstein E, Kressel AM, Teperman LW, Molmenti EP, Nair V. OUP accepted manuscript. Clin Kidney J 2022; 15:942-950. [PMID: 35498880 PMCID: PMC9050544 DOI: 10.1093/ckj/sfab287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background Race coefficients of estimated glomerular filtration rate (eGFR) formulas may be partially responsible for racial inequality in preemptive listing for kidney transplantation. Methods We used the Scientific Registry of Transplant Recipients database to evaluate differences in racial distribution of preemptive listing before and after application of the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) race coefficients to all preemptively listed non-Black kidney transplant candidates (eGFR modulation). Odds of preemptive listing were calculated by race, with Black as the reference before and after eGFR modulation. Variables known to influence preemptive listing were included in the model. Results Among 385 087 kidney-alone transplant candidates from 1 January 2010 to 2 December 2020, 118 329 (30.7%) candidates were identified as preemptively listed (71.7% White, 19% Black, 7.8% Asian, 0.6% multi-racial, 0.6% Native American and 0.3% Pacific Islander). After eGFR modulation, non-Black patients with an eGFR ≥20 mL/min/1.73 m2 were removed. Compared with Black candidates, the adjusted odds of preemptive listing for White candidates decreased from 2.01 [95% confidence interval (95% CI) 1.78–2.26] before eGFR modulation to 1.18 (95% CI 1.0–1.39; P = 0.046) with the MDRD and 1.37 (95% CI 1.18–1.58) with the CKD-EPI equations after adjusting for race coefficients. Conclusions Removing race coefficients in GFR estimation formulas may result in a more equitable distribution of Black candidates listed earlier on a preemptive basis.
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Affiliation(s)
- Mersema Abate
- Department of Medicine, Norwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Nicholas Jandovitz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- North Shore University Hospital, Department of Pharmacy, Northwell Health, Manhasset, NY, USA
| | - Jamie S Hirsch
- Department of Medicine, Norwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Nadine Breslin
- North Shore University Hospital, Department of Pharmacy, Northwell Health, Manhasset, NY, USA
| | - Lawrence Lau
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Ahmed E Fahmy
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Kenar D Jhaveri
- Department of Medicine, Norwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Safiya Richardson
- System-wide Division of Surgical Innovation, Northwell Health, New Hyde Park, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Yaser Alsalmay
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Anthony Baez
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Akash Mishra
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Siavash Bolourani
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Santiago J Miyara
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Aaron Winnick
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Gayatri Nair
- Department of Medicine, Norwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Madhu C Bhaskaran
- Department of Medicine, Norwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Elliot Grodstein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Adam M Kressel
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Lewis W Teperman
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - Ernesto P Molmenti
- Department of Medicine, Norwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
- System-wide Division of Surgical Innovation, Northwell Health, New Hyde Park, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
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4
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Breslin NT, Hedvat J, Salerno DM, Jandovitz N, Patel C, Lee S, Lange NW. Comparing weight-based dosing of tacrolimus XR in obese and non-obese renal transplant recipients. Clin Transplant 2021; 36:e14529. [PMID: 34757669 DOI: 10.1111/ctr.14529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/15/2021] [Accepted: 10/30/2021] [Indexed: 11/30/2022]
Abstract
The recommended initial weight-based dose of extended-release (XR) tacrolimus (Envarsus XR) in kidney transplant recipients (KTR) is 0.14 mg/kg/day. However, no data exist regarding dosing recommendations for obese patients specifically. The aim of this study was to evaluate weight-based dosing requirements in a cohort of obese KTR who were initiated on de novo tacrolimus XR post-transplantation. The primary outcome was weight-based dosing requirements (mg/kg/day) on post-operative day (POD) 7 and 14. Of the 254 KTR, 81 (31%) were obese. The median therapeutic dose on POD7 was 0.1 versus 0.12 vs. 0.14 mg/kg/day in the BMI > 30 kg/m2 , BMI 25-30 kg/m2 , and BMI < 25 kg/m2 , respectively, (p = .0001). This result was similar on POD14; median therapeutic dose was 0.09 versus 0.11 versus 0.15 mg/kg/day in the BMI > 30 kg/m2 , BMI 25-30 kg/m2 , and BMI < 25 kg/m2 , respectively, (p < .001). Therapeutic dose on POD7 and POD14 based on ideal body was similar in all cohorts (p = .238, p = .923, respectively). This finding was supported by a strong linear relationship between ideal body weight (IBW) and therapeutic dose (r = .929). In both obese and non-obese KTR, IBW had a stronger correlation with the therapeutic dose for tacrolimus XR.
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Affiliation(s)
- Nadine T Breslin
- Department of Pharmacy, North Shore University Hospital, Manhasset, New York, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Nicholas Jandovitz
- Department of Pharmacy, North Shore University Hospital, Manhasset, New York, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Chandni Patel
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Sara Lee
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Nicholas W Lange
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
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5
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Nair V, Jandovitz N, Hirsch JS, Abate M, Satapathy SK, Roth N, Miyara SJ, Guevara S, Kressel AM, Xiang A, Wu G, Butensky SD, Lin D, Williams S, Bhaskaran MC, Majure DT, Grodstein E, Lau L, Nair G, Fahmy AE, Winnick A, Breslin N, Berlinrut I, Molmenti C, Becker LB, Malhotra P, Gautam-Goyal P, Lima B, Maybaum S, Shah SK, Takegawa R, Hayashida K, Shinozaki K, Teperman LW, Molmenti EP. An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients. Am J Transplant 2021; 21:2522-2531. [PMID: 33443778 PMCID: PMC8206217 DOI: 10.1111/ajt.16460] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 01/25/2023]
Abstract
We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10 356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60 mL/min/1.73 m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p = .06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p = .027).
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Affiliation(s)
- Vinay Nair
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,Correspondence Vinay Nair, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY
| | | | - Jamie S. Hirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York,Department of Information Services, Northwell Health, New Hyde Park, New York
| | - Mersema Abate
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Sanjaya K. Satapathy
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Nitzan Roth
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Santiago J. Miyara
- North Shore University Hospital, Northwell Health, Manhasset, New York,Department of Surgery, Northwell Health, Manhasset, New York
| | - Sara Guevara
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Adam M. Kressel
- Department of Surgery, Northwell Health, Manhasset, New York
| | - Alec Xiang
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Grace Wu
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Samuel D. Butensky
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - David Lin
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Stephanie Williams
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Madhu C. Bhaskaran
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - David T. Majure
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Elliot Grodstein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Lawrence Lau
- North Shore University Hospital, Northwell Health, Manhasset, New York,Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Gayatri Nair
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Ahmed E. Fahmy
- North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Aaron Winnick
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,Department of Surgery, Northwell Health, Manhasset, New York
| | - Nadine Breslin
- North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Ilan Berlinrut
- North Shore University Hospital, Northwell Health, Manhasset, New York,Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Christine Molmenti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Lance B. Becker
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,North Shore University Hospital, Northwell Health, Manhasset, New York,Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Prashant Malhotra
- North Shore University Hospital, Northwell Health, Manhasset, New York,Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Pranisha Gautam-Goyal
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Brian Lima
- North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Simon Maybaum
- North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Samit K. Shah
- North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Kei Hayashida
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Koichiro Shinozaki
- North Shore University Hospital, Northwell Health, Manhasset, New York,Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York,Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Lewis W. Teperman
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Ernesto P. Molmenti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York,Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
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6
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Miyara SJ, Becker LB, Guevara S, Kirsch C, Metz CN, Shoaib M, Grodstein E, Nair VV, Jandovitz N, McCann-Molmenti A, Hayashida K, Takegawa R, Shinozaki K, Yagi T, Aoki T, Nishikimi M, Choudhary RC, Cho YM, Zanos S, Zafeiropoulos S, Hoffman HB, Watt S, Lumermann CM, Aronsohn J, Shore-Lesserson L, Molmenti EP. Pneumatosis Intestinalis in the Setting of COVID-19: A Single Center Case Series From New York. Front Med (Lausanne) 2021; 8:638075. [PMID: 34150792 PMCID: PMC8212022 DOI: 10.3389/fmed.2021.638075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/08/2021] [Indexed: 12/18/2022] Open
Abstract
This case series reviews four critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [coronavirus disease 2019 (COVID-19)] suffering from pneumatosis intestinalis (PI) during their hospital admission. All patients received the biological agent tocilizumab (TCZ), an interleukin (IL)-6 antagonist, as an experimental treatment for COVID-19 before developing PI. COVID-19 and TCZ have been independently linked to PI risk, yet the cause of this relationship is unknown and under speculation. PI is a rare condition, defined as the presence of gas in the intestinal wall, and although its pathogenesis is poorly understood, intestinal ischemia is one of its causative agents. Based on COVID-19's association with vasculopathic and ischemic insults, and IL-6's protective role in intestinal epithelial ischemia-reperfusion injury, an adverse synergistic association of COVID-19 and TCZ can be proposed in the setting of PI. To our knowledge, this is the first published, single center, case series of pneumatosis intestinalis in COVID-19 patients who received tocilizumab therapy.
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Affiliation(s)
- Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Lance B. Becker
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Claudia Kirsch
- Department of Radiology, North Shore University Hospital, Manhasset, NY, United States
| | - Christine N. Metz
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Muhammad Shoaib
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Elliot Grodstein
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Vinay V. Nair
- Department of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Nicholas Jandovitz
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Pharmacy, North Shore University Hospital, Manhasset, NY, United States
| | | | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Tsukasa Yagi
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Tomoaki Aoki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Mitsuaki Nishikimi
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Young Min Cho
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Hannah B. Hoffman
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Stacey Watt
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Claudio M. Lumermann
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Judith Aronsohn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Linda Shore-Lesserson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Ernesto P. Molmenti
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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7
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Jandovitz N, Nair V, Grodstein E, Molmenti E, Fahmy A, Abate M, Bhaskaran M, Teperman L. Hepatitis C-positive donor to negative recipient kidney transplantation: A real-world experience. Transpl Infect Dis 2021; 23:e13540. [PMID: 33259125 DOI: 10.1111/tid.13540] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 11/03/2020] [Accepted: 11/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Several studies have shown that transplanting a hepatitis C virus (HCV)-negative recipients with a HCV-positive donor is feasible in a research setting. In February 2018, we began transplanting HCV-negative recipients with HCV-positive donors as standard of care. METHODS All patients, except those with previously cured HCV and those with cirrhosis, were consented for HCV NAT-positive donor kidneys. After transplantation, patients were tested for HCV RNA until viremic. A direct-acting antiviral (DAA) agent was prescribed based on genotype and insurance approval. Sustained virologic response (SVR) at weeks 4 and 12 was recorded. Renal function and death censored graft survival at 1 year were evaluated and compared to recipients of HCV NAT-negative kidneys. RESULTS A total of 25 HCV NAT-positive donor kidney transplants from February to October 2018 were performed. All patients received basiliximab and maintained with tacrolimus, mycophenolate mofetil, and prednisone. Median time from viremia to start of DAA was 13 (8-22) days. The most common genotype was 1a (60%), followed by 3a (28%). The most commonly prescribed DAA was ledipasvir/sofosbuvir (56%), followed by velpatasvir/sofosbuvir (32%), and then glecaprevir/pibrentasvir (12%). All patients achieved initial SVR12, except one. One patient had a mixed-genotype infection requiring retreatment to achieve SVR12. Death censored graft survival was 96%. Recipients of HCV NAT-positive organs compared to HCV NAT-negative organs received younger donors (mean 35 ± 8.9 vs 45.1 ± 15.7 years; P < .01) and spent less time on the waitlist (median 479 (93-582) vs 1808 (567-2263) days; P = .02). CONCLUSION HCV NAT-negative recipients can be safely and successfully transplanted with HCV NAT-positive donor kidneys outside of a research protocol. Access to DAA and timely administration of therapy is important and an insurance approval process within the transplant center can be beneficial to patients. A case of mixed-genotype infection was presented, and although not as common, can be successfully treated. HCV organs can expand the organ pool and should no longer be considered experimental. The use of these organs in HCV-negative recipient's decreases waiting time, have excellent outcomes, and should be considered standard of care.
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Affiliation(s)
- Nicholas Jandovitz
- Department of Pharmacy, North Shore University Hospital -Northwell Health, Manhasset, NY, USA.,Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Vinay Nair
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Elliot Grodstein
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Ernesto Molmenti
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Ahmed Fahmy
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Mersema Abate
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Madhu Bhaskaran
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Lewis Teperman
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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8
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Nair V, Jandovitz N, Jhaveri KD, Molmenti E. COVID-19 and solid organ transplant outcomes. Nephrol Dial Transplant 2020; 35:1444-1446. [PMID: 32871593 PMCID: PMC7499783 DOI: 10.1093/ndt/gfaa207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Vinay Nair
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Nicholas Jandovitz
- Department of Pharmacy, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Ernesto Molmenti
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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9
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Nair V, Jandovitz N, Hirsch JS, Nair G, Abate M, Bhaskaran M, Grodstein E, Berlinrut I, Hirschwerk D, Cohen SL, Davidson KW, Dominello AJ, Osorio GA, Richardson S, Teperman LW, Molmenti EP. COVID-19 in kidney transplant recipients. Am J Transplant 2020; 20:1819-1825. [PMID: 32351040 PMCID: PMC7267603 DOI: 10.1111/ajt.15967] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 01/25/2023]
Abstract
There is minimal information on coronavirus disease 2019 (COVID-19) in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction, and 9 were admitted. The median age was 57 (interquartile range [IQR] 47-67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID-19 testing was 2822 days (IQR 1272-4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X-ray and computed tomography abnormality was multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID-19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of nontransplant individuals.
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Affiliation(s)
- Vinay Nair
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Nicholas Jandovitz
- North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Jamie S. Hirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA,Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Gayatri Nair
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Mersema Abate
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Madhu Bhaskaran
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Elliot Grodstein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Ilan Berlinrut
- North Shore University Hospital, Northwell Health, Manhasset, New York, USA,Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York, USA
| | - David Hirschwerk
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Stuart L. Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Karina W. Davidson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Andrew J. Dominello
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Gabrielle A. Osorio
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Lewis W. Teperman
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Ernesto P. Molmenti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA,Correspondence Ernesto P. Molmenti
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10
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Tsapepas DS, Salerno D, Jandovitz N, Hammad S, Jordan P, Mohan S, Hardy M, Kotchoubey H, Vawdrey D, Fleischut PM. Using technology to enhance medication regimen education after solid organ transplantation. Am J Health Syst Pharm 2019; 75:1930-1937. [PMID: 30463868 DOI: 10.2146/ajhp170799] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The design and implementation of a tool that combines clinical teaching with cutting-edge, simplified technology for providing medication education to solid organ transplant (SOT) recipients are described. METHODS In a retrospective study of adults who received kidney transplants from February 2015 through May 2017, patients were educated about their medications using a tablet computer application, Medication Regimen Education (MRxEd), that presented concise videos describing the name, indication, dose, adverse effects, and associated interactions of all medications received, as well as special considerations applicable to each agent. Assessment questions were used to reinforce key concepts and identify knowledge gaps. RESULTS The digital educational intervention was provided to 282 kidney transplant recipients. Patients were predominantly white (48%) and/or male (63%), with a median age of 51 years (interquartile range, 37-61 years). Patients came from a variety of education backgrounds. Most patients (81%) were educated on dual maintenance immunosuppression (with tacrolimus and mycophenolate) and 3 infection prophylaxis agents (nystatin, sulfamethoxazole-trimethoprim, and valganciclovir). Most patients (90%) correctly answered questions related to medication indications, dosing, and special rules, but many (61%) had difficulty correctly answering questions about adverse effects. CONCLUSION An innovative approach for interactive and engaging medication teaching with the MRxEd application enhanced the education process for SOT recipients.
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Affiliation(s)
- Demetra S Tsapepas
- NewYork-Presbyterian Hospital, New York, NY, and Department of Surgery, Columbia University, New York, NY
| | | | | | | | | | - Sumit Mohan
- NewYork-Presbyterian Hospital, New York, NY, and Department of Medicine, Columbia University, New York, NY
| | - Mark Hardy
- Department of Surgery, Columbia University, New York, NY
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11
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Jandovitz N, Li H, Watts B, Monteiro J, Kohlberg D, Tsapepas D. Telemedicine pharmacy services implementation in organ transplantation at a metropolitan academic medical center. Digit Health 2018; 4:2055207618789322. [PMID: 30083373 PMCID: PMC6073825 DOI: 10.1177/2055207618789322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 06/25/2018] [Indexed: 11/16/2022] Open
Abstract
Transplant patients represent a complex patient population for which telemedicine may allow enhanced access to the healthcare team and promote active engagement in health improvement. This retrospective study summarizes a multi-pronged approach that was instituted to implement a pharmacy telemedicine practice at our institution. Telemedicine visits included the provision of six key elements for our patients: (1) medication reconciliation, (2) vaccination history, (3) medication teaching, (4) pharmacotherapy review, (5) medication adherence, and (6) triage to other providers. From January through June 2017, 46 patients were registered for a visit (recipients n = 32 and living donors n = 14). Three-fourths of the patients who completed a visit connected using a mobile device. Time from discharge to the visit was 5.4 days. The average visit duration was 11.6 ± 8 minutes. Medication reconciliation was performed for 24 patients where 6 (25%) required medication list adjustments. An average of 1.2 ± 0.4 medication changes were updated in the medical record. During visits, patients were asked questions to assess adherence to their regimen, all patients responded favorably indicating that they were following instructions provided by the healthcare team. Telemedicine has the potential to improve the healthcare delivery model by providing increased patient-to-healthcare team interactions and access, which optimize engagement and outcomes.
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Affiliation(s)
- Nicholas Jandovitz
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University, Irving Medical Center, New York, USA
| | - Hanlin Li
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University, Irving Medical Center, New York, USA
| | - Brady Watts
- Department of Information Technology - Innovation Team, NewYork-Presbyterian Hospital, New York, USA
| | - Jonathan Monteiro
- Department of Information Technology - Innovation Team, NewYork-Presbyterian Hospital, New York, USA
| | - Diana Kohlberg
- Department of Information Technology - Innovation Team, NewYork-Presbyterian Hospital, New York, USA
| | - Demetra Tsapepas
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University, Irving Medical Center, New York, USA.,Department of Transplantation, NewYork-Presbyterian Hospital, Columbia University, Irving Medical Center, New York, USA.,Department of Surgery, Columbia University, New York, USA
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12
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Abstract
Institutions with established clinical pharmacy services have the ability to offer focused patient care learning experiences, often led by a clinical specialist, for pharmacy residents and pharmacy students. Since all parties are continually involved in professional development and lifelong learning, the aforementioned groups can all be considered “pharmacy learners.” By utilizing the dynamic interplay and collaboration between pharmacy learners through direct and nondirect patient care activities, experiential and educational opportunities may be improved and enhanced for each learner. A tiered learning approach engages individuals in areas such as direct patient care, patient education, presentations, research projects, career development, and the feedback process. We describe our experience during a solid organ transplantation learning experience using a layered learning practice model that included a clinical pharmacy specialist, a postgraduate year 2 specialty pharmacy resident, a postgraduate year 1 pharmacy resident, and a pharmacy student.
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Affiliation(s)
- Jonathan H. Sin
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Hanlin Li
- Department of Pharmacy, NewYork–Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Nicholas Jandovitz
- Department of Pharmacy, NewYork–Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Madeline King
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
| | - Demetra S. Tsapepas
- Department of Pharmacy, NewYork–Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
- Division of Abdominal Transplantation, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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