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Wen X, Brothers T, Ward KE, Kogut S. Reducing the risks of prenatal opioid exposure in children. BMJ 2024; 385:q803. [PMID: 38658037 DOI: 10.1136/bmj.q803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Xuerong Wen
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Todd Brothers
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Kristina E Ward
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Stephen Kogut
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
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Vordenberg SE, Fusco NM, Ward KE, Darley A, Brady JH, Culhane NS, Habib MJ, Hernandez E, Moye PM, Munusamy S, Painter JT, Pope N, Stevenson TL, Vanderboll K, Chase PA, Matsumoto RR. An Integrative Review of Micro-Credentials and Digital Badges for Pharmacy Educators. Am J Pharm Educ 2024; 88:100660. [PMID: 38272238 DOI: 10.1016/j.ajpe.2024.100660] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024]
Abstract
Micro-credentials (MCs) and digital badges (DBs) have gained popularity in recent years as a means to supplement traditional degrees and certifications. MCs and DBs can play a significant role in supporting student-centered learning by offering personalized and flexible learning pathways, emphasizing real-world relevance and practical skills, and fostering a culture of continuous learning and growth. However, barriers currently exist within health professions education, including pharmacy education, that could limit the full adoption and implementation of MCs and DBs. Research on the use of MCs and DBs in Doctor of Pharmacy degree programs is sparse. In this integrative review, literature on the use of MCs and DBs in health professions education is reviewed, and perspectives on the benefits, issues, and potential future uses within Doctor of Pharmacy degree programs are presented.
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Affiliation(s)
| | - Nicholas M Fusco
- University at Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, NY, USA.
| | - Kristina E Ward
- University of Rhode Island, College of Pharmacy, Kingston, RI, USA
| | - Andrew Darley
- University of Georgia, College of Pharmacy, Athens, GA, USA
| | - Jessica H Brady
- University of Louisiana Monroe, College of Pharmacy, Monroe, LA, USA
| | - Nicole S Culhane
- Notre Dame of Maryland University, School of Pharmacy, Baltimore, MD, USA
| | | | - Eliud Hernandez
- University of Puerto Rico, School of Pharmacy, San Juan, PR, USA
| | - Pamela M Moye
- Mercer University, College of Pharmacy, Atlanta, GA, USA
| | - Shankar Munusamy
- Drake University, College of Pharmacy and Health Sciences, Des Moines, IA, USA
| | - Jacob T Painter
- University of Arkansas for Medical Sciences, College of Pharmacy, Little Rock, AR, USA
| | - Nathan Pope
- The University of Texas at Austin, College of Pharmacy, Austin, TX, USA
| | - T Lynn Stevenson
- Auburn University, Harrison College of Pharmacy, Auburn, AL, USA
| | - Kathryn Vanderboll
- University of Michigan, Taubman Health Sciences Library, Ann Arbor, MI, USA
| | - Patricia A Chase
- Oregon State University, College of Pharmacy, Corvallis, OR, USA
| | - Rae R Matsumoto
- University of the Pacific, Thomas J. Long School of Pharmacy, Stockton, CA, USA
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O'Toole R, Martinez KA, Rothberg MB, Diiorio G, Stenehjem EA, Ward KE, LaPlante KL. Antibiotics on Demand: Advances in Asynchronous Telemedicine Call for Increased Antibiotic Surveillance. Clin Infect Dis 2024; 78:308-311. [PMID: 37642218 DOI: 10.1093/cid/ciad472] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Indexed: 08/31/2023] Open
Abstract
The rapid growth of telehealth services has brought about direct-to-consumer telemedicine platforms, enabling patients to request antibiotics online without a virtual or face-to-face consultation. While telemedicine aims to enhance accessibility, this trend raises significant concerns regarding appropriate antimicrobial use and patient safety. In this viewpoint, we share our first-hand experience with 2 direct-to-consumer platforms, where we intentionally sought inappropriate antibiotic prescriptions for nonspecific symptoms strongly indicative of a viral upper respiratory infection. Despite the lack of clear necessity, requested antibiotic prescriptions were readily transmitted to our local pharmacy following a simple monetary transaction. The effortless acquisition of patient-selected antibiotics online, devoid of personal interactions or consultations, underscores the urgent imperative for intensified antimicrobial stewardship initiatives led by state and national public health organizations in telehealth settings. By augmenting oversight and regulation, we can ensure the responsible and judicious use of antibiotics, safeguard patient well-being, and preserve the efficacy of these vital medications.
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Affiliation(s)
- Rebecca O'Toole
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | | | | | - Gillian Diiorio
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kristina E Ward
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Kerry L LaPlante
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
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Wang S, Puggioni G, Wu J, Meador KJ, Caffrey A, Wyss R, Slaughter JL, Suzuki E, Ward KE, Lewkowitz AK, Wen X. Prenatal Exposure to Opioids and Neurodevelopmental Disorders in Children: A Bayesian Mediation Analysis. Am J Epidemiol 2024; 193:308-322. [PMID: 37671942 DOI: 10.1093/aje/kwad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/08/2023] [Accepted: 09/02/2023] [Indexed: 09/07/2023] Open
Abstract
This study explores natural direct and joint natural indirect effects (JNIE) of prenatal opioid exposure on neurodevelopmental disorders (NDDs) in children mediated through pregnancy complications, major and minor congenital malformations, and adverse neonatal outcomes, using Medicaid claims linked to vital statistics in Rhode Island, United States, 2008-2018. A Bayesian mediation analysis with elastic net shrinkage prior was developed to estimate mean time to NDD diagnosis ratio using posterior mean and 95% credible intervals (CrIs) from Markov chain Monte Carlo algorithms. Simulation studies showed desirable model performance. Of 11,176 eligible pregnancies, 332 had ≥2 dispensations of prescription opioids anytime during pregnancy, including 200 (1.8%) having ≥1 dispensation in the first trimester (T1), 169 (1.5%) in the second (T2), and 153 (1.4%) in the third (T3). A significant JNIE of opioid exposure was observed in each trimester (T1, JNIE = 0.97, 95% CrI: 0.95, 0.99; T2, JNIE = 0.97, 95% CrI: 0.95, 0.99; T3, JNIE = 0.96, 95% CrI: 0.94, 0.99). The proportion of JNIE in each trimester was 17.9% (T1), 22.4% (T2), and 56.3% (T3). In conclusion, adverse pregnancy and birth outcomes jointly mediated the association between prenatal opioid exposure and accelerated time to NDD diagnosis. The proportion of JNIE increased as the timing of opioid exposure approached delivery.
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Wang S, Meador KJ, Pawasauskas J, Lewkowitz AK, Ward KE, Brothers TN, Hartzema A, Quilliam BJ, Wen X. Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study. Drug Saf 2023; 46:257-271. [PMID: 36642778 PMCID: PMC10363992 DOI: 10.1007/s40264-022-01267-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Accepted: 11/24/2022] [Indexed: 01/17/2023]
Abstract
INTRODUCTION AND OBJECTIVE Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes. METHODS We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied. RESULTS Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone. CONCLUSIONS Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.
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Affiliation(s)
- Shuang Wang
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Kimford J Meador
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Jayne Pawasauskas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Adam K Lewkowitz
- Department of Obstetrics and Gynecology, Women and Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI, USA
| | - Kristina E Ward
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Todd N Brothers
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Abraham Hartzema
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Brian J Quilliam
- College of Health Sciences, University of Rhode Island, Kingston, RI, USA
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA.
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Wen X, Wang S, Lewkowitz AK, Ward KE, Brousseau EC, Meador KJ. Maternal Complications and Prescription Opioid Exposure During Pregnancy: Using Marginal Structural Models. Drug Saf 2021; 44:1297-1309. [PMID: 34609720 DOI: 10.1007/s40264-021-01115-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Prescription opioids are frequently used for pain management in pregnancy. Studies examining perinatal complications in mothers who received prescription opioids during pregnancy are still limited. OBJECTIVES The aim of this study was to assess the association of prescription opioid use and maternal pregnancy and obstetric complications. METHODS This retrospective cohort study with the Rhode Island (RI) Medicaid claims data linked to vital statistics throughout 2008-2015 included pregnant women aged 12-55 years with one or multiple live births. Women were excluded if they had cancer, opioid use disorder, or opioid dispensing prior to but not during pregnancy. Main outcomes included adverse pregnancy and obstetric complications. Marginal Structural Cox Models with time-varying exposure and covariates were applied to control for baseline and time-varying covariates. Analyses were conducted for outcomes that occurred 1 week after opioid exposure (primary) or within the same week as exposure (secondary). Sensitivity studies were conducted to assess the effects of different doses and individual opioids. RESULTS Of 9823 eligible mothers, 545 (5.5%) filled one or more prescription opioid during pregnancy. Compared with those unexposed, no significant risk was observed in primary analyses, while in secondary analyses opioid-exposed mothers were associated with an increased risk of cesarean antepartum depression (HR 3.19; 95% CI 1.22-8.33), and cardiac events (HR 9.44; 95% CI 1.19-74.83). In sensitivity analyses, results are more prominent in high dose exposure and are consistent for individual opioids. CONCLUSIONS Prescription opioid use during pregnancy is associated with an increased risk of maternal complications.
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Affiliation(s)
- Xuerong Wen
- Health Outcomes, Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA.
| | - Shuang Wang
- Health Outcomes, Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Adam K Lewkowitz
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Kristina E Ward
- Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Erin Christine Brousseau
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Kimford J Meador
- Department of Neurology, Stanford University, Palo Alto, CA, USA
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Kruszecki C, Cameron CR, Hume AL, Ward KE. A systematic review of integrative medicine for opioid withdrawal. J Subst Abuse Treat 2021; 125:108279. [PMID: 34016305 DOI: 10.1016/j.jsat.2021.108279] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/16/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The United States has been battling an opioid epidemic for decades. As substance use disorders have grown, so too has investigation into treatment options, including integrative medicine approaches, for managing opioid withdrawal symptoms (OWS). OBJECTIVES This systematic review sought to assess the use of integrative medicine approaches for the alleviation of OWS in patients dependent on opioids and to summarize the available data. METHODS The authors searched using synonyms for opioids, substance use disorder, and integrative medicine and standardized searches in Embase, PubMed, and Cochrane Library. We also hand searched references for systematic reviews. This review did not include articles that could not be obtained as full-text publications via interlibrary loan. The review also excluded studies with interventions involving acupuncture because multiple systematic reviews on this approach already exist. In addition, we also excluded studies of therapy for opioid maintenance. We evaluated studies for inclusion based on the Jadad criteria. We compared opioid withdrawal outcomes of the studies to determine the efficacy of integrative medicine approaches. RESULTS The authors identified a total of 382 unique publications initially for possible inclusion through systematic searches. After applying inclusion and exclusion criteria, five studies met Jadad criteria. The authors identified an additional two studies for inclusion via hand searching. A total of seven studies included interventions consisting of passionflower, weinicom, fu-yuan pellet, jinniu capsules, tai-kang-ning, dynorphin, and l-tetrahydropalmatine. Analyzing the articles was difficult given the varied scoring methods they used to quantify opioid withdrawal symptoms and the small sample sizes in the trials. Most showed evidence that supported integrative medicine approaches for OWS, although the strength of evidence was limited because of sample sizes. CONCLUSIONS This review found evidence of multiple integrative medicine approaches for opioid withdrawal symptoms. Well-designed randomized controlled trials should assess the efficacy of integrative medicine for improvement in OWS.
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Affiliation(s)
- Caroline Kruszecki
- The University of Rhode Island, College of Pharmacy, 7 Greenhouse Road, Kingston, RI 02881, United States
| | - Courtney R Cameron
- The University of Rhode Island, College of Pharmacy, 7 Greenhouse Road, Kingston, RI 02881, United States.
| | - Anne L Hume
- The University of Rhode Island, College of Pharmacy, 7 Greenhouse Road, Kingston, RI 02881, United States
| | - Kristina E Ward
- The University of Rhode Island, College of Pharmacy, 7 Greenhouse Road, Kingston, RI 02881, United States
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Abstract
IMPORTANCE The rapid increase of opioid-related overdoses and deaths has become a public health concern in the US. Use of prescription opioids in pregnant women has increased; results from teratogenicity studies remain controversial. OBJECTIVE To evaluate the association between maternal prescription opioid use (excluding opioid use disorders) during pregnancy and the incidence of congenital malformations. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study evaluated linked Rhode Island Medicaid claims and vital statistics data of live births from January 1, 2008, to December 31, 2016. Data analysis was conducted from May 1, 2019, to May 31, 2020. Women who had a live birth during the study period, but no cancer or opioid use disorder, were followed up from 3 months before pregnancy to the end of pregnancy. EXPOSURES Data on the mother's prescription opioid exposure were obtained through pharmacy claims and exposure was defined as dispensing of at least 1 prescription opioid during the first, second, or third trimester. MAIN OUTCOMES AND MEASURES The primary outcome was overall major or minor congenital malformations, defined as 1 or more major or minor congenital malformation. Secondary outcomes were defined as 10 specific categories of congenital malformations classified by organ systems using International Classification of Diseases diagnosis codes. RESULTS Of 12 424 included pregnancies, 891 mothers (7.2%) received prescription opioids during pregnancy and 3153 infants (25.4%) were diagnosed with major or minor congenital malformations. Comparing prescription opioid exposure vs nonexposure, no excess risk was observed for major birth defects in infants with opioid exposure in trimester 1 (adjusted relative risk [aRR], 1.40; 95% CI, 0.84-2.34), and higher risks were found for overall minor birth defects in trimester 3 (aRR, 1.26; 95% CI, 1.04-1.53) and minor birth defects in the musculoskeletal system in trimester 2 (aRR, 1.50; 95% CI, 1.10-2.03) and trimester 3 (aRR, 1.65; 95% CI, 1.23-2.22). Significant dose responses in selected minor malformations and effects of specific opioids were also identified. Hydrocodone in trimester 2 (aRR, 3.01; 95% CI, 1.80-5.03) and oxycodone in trimester 3 (aRR, 2.43; 95% CI, 1.37-4.02) were associated with plagiocephaly, polydactyly, and other specified congenital deformities of the hip. CONCLUSIONS AND RELEVANCE The findings of this study suggest a higher risk of minor congenital malformations associated with use of prenatal prescription opioids in trimester 3, which seems to be dose-dependent. Further investigation is needed to establish causality and explore the physiologic plausibility of the association.
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Affiliation(s)
- Xuerong Wen
- Health Outcomes, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston
| | - Nicholas Belviso
- Health Outcomes, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston
| | - Emily Murray
- Health Outcomes, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston
| | - Adam K. Lewkowitz
- Maternal Fetal Medicine, Women and Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence
| | - Kristina E. Ward
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston
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Abstract
OBJECTIVES The aim was to review current evidence regarding the off-label use of intranasal ketamine for acute pain presenting in the setting of the emergency department, and secondary to pediatric limb injuries, renal colic, digital nerve block, and migraines. RESULTS In all 5 indications reviewed, ketamine demonstrated efficacy in reducing pain. However, when compared with other agents, ketamine did not demonstrate superiority over opioids in pediatric limb injuries or renal colic and was not as efficacious as standard therapy for migraine relief. Ketamine was also associated with a greater incidence of transient adverse reactions, such as dizziness, bitter aftertaste, fatigue, and vomiting than opioid therapies. DISCUSSION The current body of evidence is insufficient to support the use of intranasal ketamine over other standard therapies for acute pain. However, current evidence can be used when developing dosing strategies, preparing for adverse reactions, and generating hypotheses for future, more robust research.
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Affiliation(s)
- Robert J Rocchio
- Department of Pharmacy Practice, University of Rhode Island, Kingston, RI
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Zeng YS, Wang C, Ward KE, Hume AL. Complementary and Alternative Medicine in Hospice and Palliative Care: A Systematic Review. J Pain Symptom Manage 2018; 56:781-794.e4. [PMID: 30076965 DOI: 10.1016/j.jpainsymman.2018.07.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT The aim of palliative care is to improve quality of life for patients with serious illnesses by treating their symptoms and adverse effects. Hospice care also aims for this for patients with a life expectancy of six months or less. When conventional therapies do not provide adequate symptom management or produce their own adverse effects, patients, families, and caregivers may prefer complementary or alternative approaches in their care. OBJECTIVES The objectives of this study were to evaluate the available evidence on the use of complementary or alternative medicine (CAM) in hospice and palliative care and to summarize their potential benefits. METHODS A defined search strategy was used in reviewing literature from major databases. Searches were conducted using base terms and the symptom in question. Symptoms included anxiety, pain, dyspnea, cough, fatigue, insomnia, nausea, and vomiting. Studies were selected for further evaluation based on relevancy and study type. References of systematic reviews were also assessed. After evaluation using quality assessment tools, findings were summarized and the review was structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Out of 4682 studies, 17 were identified for further evaluation. Therapies included acupressure, acupuncture, aromatherapy massage, breathing, hypnotherapy, massage, meditation, music therapy, reflexology, and reiki. Many studies demonstrated a short-term benefit in symptom improvement from baseline with CAM, although a significant benefit was not found between groups. CONCLUSION CAM may provide a limited short-term benefit in patients with symptom burden. Additional studies are needed to clarify the potential value of CAM in the hospice or palliative setting.
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Affiliation(s)
- Yvette S Zeng
- University of Rhode Island, Kingston, Rhode Island, USA
| | - Connie Wang
- University of Rhode Island, Kingston, Rhode Island, USA
| | | | - Anne L Hume
- University of Rhode Island, Kingston, Rhode Island, USA.
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Ryu R, Ward KE. Atezolizumab for the First-Line Treatment of Non-small Cell Lung Cancer (NSCLC): Current Status and Future Prospects. Front Oncol 2018; 8:277. [PMID: 30087855 PMCID: PMC6066722 DOI: 10.3389/fonc.2018.00277] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 03/26/2018] [Accepted: 07/03/2018] [Indexed: 12/31/2022] Open
Abstract
Purpose: Atezolizumab is a programmed death ligand 1 (PDL-1) blocking antibody that was approved for metastatic non-small cell lung cancer (NSCLC) in patients with disease progression. Various studies have been initiated to explore the effectiveness of atezolizumab among different patient cohorts and disease statuses, including as first-line therapy. The purpose of this paper is to identify and summarize the trials that use atezolizumab as a first-line agent in chemotherapy-naïve patients with NSCLC. Methods: A database search was performed on Pubmed, Embase, and Wiley Cochrane Library-Central Register of Controlled Trials to identify clinical trials using atezolizumab as first-line therapy in NSCLC. Additionally, ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) were searched to identify relevant clinical trials. Conference abstracts from the American Society of Clinical Oncology, the European Society for Medical Oncology, and the American Association for Cancer Research were hand-searched. Any trial in which atezolizumab was used as first-line therapy in chemotherapy-naive patients with NSCLC was included. Results: Fifteen studies were ultimately included, all of which are current and ongoing. Of the 15 studies, 5 have reported results. When given in the first-line setting, atezolizumab had higher rates of objective response, progression-free survival, and overall survival, compared to the second and third-line settings. Among the 15 studies, atezolizumab is used as monotherapy (n = 5), in combination with chemotherapy (n = 6), in combination with targeted therapy such as bevacizumab (n = 1), as neoadjuvant/adjuvant therapy (n = 3), in combination with stereotactic body radiation therapy (n = 1), and in combination with or following chemoradiation (n = 1). Conclusion: Available evidence shows promising safety and efficacy with the use of atezolizumab as first-line therapy in NSCLC. Atezolizumab is currently being studied in a variety of treatment settings. If clinical benefits are shown, atezolizumab may deem to be a useful first-line agent in NSCLC.
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Affiliation(s)
- Rachel Ryu
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, United States
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Caffrey AR, DeAngelis JM, Ward KE, Orr KK, Morrill HJ, Gosciminski M, LaPlante KL. A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination. J Am Pharm Assoc (2003) 2017; 58:303-310. [PMID: 28951137 DOI: 10.1016/j.japh.2017.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 07/24/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To describe our statewide, pharmacist-led education campaign to increase knowledge and awareness of pneumococcal immunization recommendations. SETTING Immunization providers and residents in the state of Rhode Island. PRACTICE DESCRIPTION A clinical pathway (i.e., decision-support tool) was developed to educate health professionals about appropriate indications, administration schedules, and frequently asked questions for the 2 different adult pneumococcal vaccines. Academic detailing and distribution of the clinical pathway to health professionals was conducted across Rhode Island. Community outreach activities included radio ads as well as distribution of patient handouts and wallet cards at community events. PRACTICE INNOVATION To our knowledge, this was the first statewide, pharmacist-driven academic detailing and community outreach campaign to promote adult pneumococcal vaccination. EVALUATION Academically detailed immunization providers received a 6-question survey. Pneumococcal disease rate differences between the study periods were evaluated with the use of Fisher exact tests, whereas changes in vaccination were assessed with the use of chi-square tests. RESULTS From November 2013 through July 2015, our academic detailers visited and distributed our vaccination pathway materials to more than 400 practice sites across Rhode Island, including 68% of community pharmacies and all adult acute care hospitals. Of the 413 surveys completed, 92% of respondents agreed that their knowledge of the pneumococcal conjugate vaccine, 13-valent and pneumococcal polysaccharide vaccine, 23-valent had improved. Pneumococcal vaccination increased significantly (absolute difference 3.9%, percentage change in proportion 5.4%; P = 0.01), and pneumococcal disease decreased significantly between the preintervention and intervention periods (-2.74/10,000 discharges [95% CI -5.15 to -0.32], P = 0.02). Invasive pneumococcal disease decreased by 21 cases per 1,000,000 population per year between the preintervention and postintervention periods (-42.25 to 0.14, P = 0.05). CONCLUSION Our statewide, pharmacist-driven pneumococcal vaccination educational outreach program resulted in favorable provider feedback relative to knowledge change and perceptions. Vaccination increased and pneumococcal disease decreased during the study period.
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Uppal P, LaPlante KL, Gaitanis MM, Jankowich MD, Ward KE. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control 2016; 5:55. [PMID: 27999664 PMCID: PMC5153904 DOI: 10.1186/s13756-016-0158-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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: 08/12/2016] [Accepted: 11/29/2016] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Eosinophilic pneumonia comprises a group of lung diseases in which eosinophils appear in increased numbers in the lungs and sometimes in the bloodstream. Several case reports link daptomycin use to this phenomenon. SUMMARY We performed a systematic literature review to identify cases of eosinophilic pneumonia associated with daptomycin use. Relevant studies were identified by searching Pubmed/Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Clin-Alert from inception to May 2016, and manual searches of reference lists. All case reports that include information regarding patient age, indication, clinical and objective findings, treatment and outcome were evaluated. Abstracts from conference proceedings as well as case reports not in English were excluded. Descriptive statistics were used to analyze the data. Thirty-five patient-cases were included in the final analysis. Patients most likely to be identified with daptomycin-induced eosinophilic pneumonia were male (83%) and elderly (mean age 65.4 ± 15 years). The dose for daptomycin ranged from 4 to 10 mg/kg/day, but included a large number of patients with renal dysfunction. The average duration of daptomycin therapy upon onset of EP symptoms was 2.8 ± 1.6 weeks. Majority of patients presented with dyspnea (94%), fever (57%) and were also found to have peripheral eosinophilia (77%) and infiltrates/opacities of CT/CXR (86%). Symptom improvement was seen after daptomycin discontinuation (24 h to 1 week). The majority of patients were also prescribed treatment with corticosteroids (66%). CONCLUSION Clinicians should be aware of daptomycin-induced eosinophilic pneumonia and its symptoms along with its presentation and treatment.
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Affiliation(s)
- Priyasha Uppal
- Providence Veterans Affairs Medical Center, Providence, RI USA
| | - Kerry L. LaPlante
- Providence Veterans Affairs Medical Center, Providence, RI USA
- Department of Pharmacy Practice, University of Rhode Island, 7 Greenhouse Rd, Suite 295 J, Kingston, RI 02881 USA
- Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Melissa M. Gaitanis
- Providence Veterans Affairs Medical Center, Providence, RI USA
- Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Matthew D. Jankowich
- Providence Veterans Affairs Medical Center, Providence, RI USA
- Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Kristina E. Ward
- Department of Pharmacy Practice, University of Rhode Island, 7 Greenhouse Rd, Suite 295 J, Kingston, RI 02881 USA
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Abstract
STUDY OBJECTIVES To assess whether pharmacist-provided medication education and counseling to Meals on Wheels (MOW) participants decreases medication-related preventable harm and improves adherence. DESIGN Prospective, quasi-experiment. SETTING Ambulatory congregrate dining centers. PATIENTS Persons 60 years of age and older participating in MOW receiving prescription, nonprescription, or complementary products were eligible. In total, 42 patients consented. Five patients did not complete the first visit, and 13 patients did not complete the six-month follow-up visit. INTERVENTIONS Pharmacists provided comprehensive medication education about prescription, nonprescription, and complementary products at baseline. Additional resources to enhance adherence and avoid medication-related preventable harm were provided and discussed. MAIN OUTCOME MEASURES Medication-related preventable harm and medication adherence were assessed before pharmacist intervention and six months after intervention. Adherence was assessed and compared with baseline using the Morisky scale and pill counts. RESULTS Women constituted the majority of participants (94.4%) with an average age of 74.5 ± 8.2 years. Mean difference in Morisky score from baseline to six months was 0.28 (-0.11 to 0.56). After adjustment for age and living situation, the change in Morisky score was associated with a 14% improvement in adherence. Mean differences in drug-drug and drug-supplement interactions, and medication-related harm were not significantly reduced from baseline to study end. CONCLUSION Pharmacist intervention with MOW participants appeared to improve medication adherence rates but had limited effect on medication-related preventable harm. No findings reached statistical significance as the sample size was inadequate. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Kristina E Ward
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
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15
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Abstract
Staphylococcus aureus (S. aureus) has proven to be a major pathogen with the emergence of methicillin-resistant S. aureus (MRSA) infections and recently with heteroresistant vancomycin-intermediate S. aureus (hVISA) and vancomycin-intermediate S. aureus (VISA) infections. Although vancomycin is traditionally a first-line and relatively effective antibiotic, its continued use is under question because reports of heteroresistance in S. aureus isolates are increasing. Both hVISA and VISA infections are associated with complicated clinical courses and treatment failures. The prevalence, mechanism of resistance, clinical significance, and laboratory detection of hVISA and VISA infections are not conclusive, making it difficult to apply research findings to clinical situations. We provide an evidence-based review of S. aureus isolates expressing heterogenic and reduced susceptibility to vancomycin.
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Affiliation(s)
- Diane M Gomes
- Department of Pharmacy Practice, University of Rhode Island, Kingston, Rhode Island; Veterans Affairs Medical Center, Providence, Rhode Island
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16
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Edwards KL, Salvo MC, Ward KE, Attridge RT, Kiser K, Pinner NA, Gallegos PJ, Kesteloot LL, Hylton A, Bookstaver PB. Assessment and revision of clinical pharmacy practice internet web sites. Ann Pharmacother 2013; 48:258-67. [PMID: 24259640 DOI: 10.1177/1060028013510899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/16/2022] Open
Abstract
BACKGROUND Health care professionals, trainees, and patients use the Internet extensively. Editable Web sites may contain inaccurate, incomplete, and/or outdated information that may mislead the public's perception of the topic. OBJECTIVE To evaluate the editable, online descriptions of clinical pharmacy and pharmacist and attempt to improve their accuracy. METHODS The authors identified key areas within clinical pharmacy to evaluate for accuracy and appropriateness on the Internet. Current descriptions that were reviewed on public domain Web sites included: (1) clinical pharmacy and the clinical pharmacist, (2) pharmacy education, (3) clinical pharmacy and development and provision for reimbursement, (4) clinical pharmacists and advanced specialty certifications/training opportunities, (5) pharmacists and advocacy, and (6) clinical pharmacists and interdisciplinary/interprofessional content. The authors assessed each content area to determine accuracy and prioritized the need for updating, when applicable, to achieve consistency in descriptions and relevancy. The authors found that Wikipedia, a public domain that allows users to update, was consistently the most common Web site produced in search results. RESULTS The authors' evaluation resulted in the creation or revision of 14 Wikipedia Web pages. However, rejection of 3 proposed newly created Web pages affected the authors' ability to address identified content areas with deficiencies and/or inaccuracies. CONCLUSIONS Through assessing and updating editable Web sites, the authors strengthened the online representation of clinical pharmacy in a clear, cohesive, and accurate manner. However, ongoing assessments of the Internet are continually needed to ensure accuracy and appropriateness.
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Affiliation(s)
- Krystal L Edwards
- Texas Tech School of Pharmacy-Dallas/Fort Worth Campus, Dallas, TX, USA
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17
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Phillips JA, Gabay MP, Ficzere C, Ward KE. Curriculum and Instructional Methods for Drug Information, Literature Evaluation, and Biostatistics: Survey of US Pharmacy Schools. Ann Pharmacother 2012; 46:793-801. [DOI: 10.1345/aph.1q813] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: The drug information curriculum in US colleges of pharmacy continues to evolve. The American College of Clinical Pharmacy (ACCP) Drug Information Practice and Research Network (DI PRN) published an opinion paper with specific recommendations regarding drug information education in 2009. Adoption of these recommendations has not been evaluated. OBJECTIVE: To assess which recommendations made in the ACCP DI PRN opinion paper are included in US pharmacy school curricula and characterize faculty qualifications, educational methods, and recent changes in drug information education. METHODS: An electronic survey was designed using the ACCP DI PRN opinion paper and the Accreditation Council for Pharmacy Education standards and guidelines for accreditation of PharmD programs in the US. Survey questions addressed curricular content within the following categories: drug information, literature evaluation, and biostatistics. A letter including the online survey link was sent via email to the dean of each US college/school of pharmacy (N = 128). Recipients were instructed to forward the email to the individual at their institution who was the most knowledgeable about the content and methodology used for didactic drug information education. RESULTS: Sixty-four responses were included in the final analysis. Of the 19 ACCP DI PRN minimum core concepts, 9 (47%) were included in curricula of all responding institutions; 14 of 19 (74%) were included in curricula for all but 1 institution. In contrast, 5 of 16 concepts (31%) were not formally taught by a number of institutions. Many respondents noted an increased focus on evidence-based medicine, medication safety, and informatics. CONCLUSIONS: Although a survey of drug information curricula documented substantial inclusion of the essential concepts presented in the ACCP DI PRN opinion paper, room for improvement remains in drug information curricula in US colleges of pharmacy.
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Affiliation(s)
- Jennifer A Phillips
- Jennifer A Phillips PharmD BCPS, Assistant Professor, Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, IL
| | - Michael P Gabay
- Michael P Gabay PharmD JD BCPS, Clinical Associate Professor, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago
| | - Cathy Ficzere
- Cathy Ficzere PharmD BCPS, Assistant Professor, Department of Pharmaceutical, Social, and Administrative Sciences, College of Pharmacy, Belmont University, Nashville, TN
| | - Kristina E Ward
- Kristina E Ward PharmD BCPS, Clinical Associate Professor, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston
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Ye Y, Ward KE. The depiction of illness and related matters in two top-ranked primetime network medical dramas in the United States: a content analysis. J Health Commun 2010; 15:555-70. [PMID: 20677058 DOI: 10.1080/10810730.2010.492564] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The effectiveness of entertainment-education is evidenced in previous research; nevertheless, content analytic research on the health content in such programs has been relatively meager in comparison to the large amount of content analyses of health content in news or ads in print media or on television. To address this issue, the current study content analyzed the portrayals of illnesses and related matters in 127 episodes aired from 2000 to 2007 of two top-ranked television medical dramas in the United States (Grey's Anatomy and ER). Results indicated that the two shows portrayed a wide range of illnesses and diseases, with injury, cardiovascular disease, and cancer being the top three most frequently portrayed. Moreover, equal numbers of men and women patient characters were portrayed, Caucasians and African Americans were the top two portrayed races, and the elderly were underrepresented. Last, the shows framed illness and health mainly from a medical perspective in references to the illness's causes, diagnosis, treatment, and prevention. Theoretical and practical implications are discussed.
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Affiliation(s)
- Yinjiao Ye
- Department of Communication Studies, University of Rhode Island, Kingston, Rhode Island 02881, USA.
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19
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Ward KE, Archambault R, Mersfelder TL. Severe adverse skin reactions to nonsteroidal antiinflammatory drugs: A review of the literature. Am J Health Syst Pharm 2010; 67:206-13. [DOI: 10.2146/ajhp080603] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Kristina E. Ward
- College of Pharmacy, University of Rhode Island, Kingston. LT USN MSC
| | - Raoul Archambault
- Department of Pharmacy, Robert E. Bush Naval Hospital, Twentynine Palms, CA; at the time of writing he was a student, College of Pharmacy, University of Rhode Island
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20
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Bernknopf AC, Karpinski JP, McKeever AL, Peak AS, Smith KM, Smith WD, Timpe EM, Ward KE. Drug information: from education to practice. Pharmacotherapy 2009; 29:331-46. [PMID: 19249951 DOI: 10.1592/phco.29.3.331] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Drug information is a specialty area within the realm of clinical pharmacy that has evolved as technology and clinical practice have changed. Drug information specialists are trained individuals who have clinical knowledge and skills that allow them to provide clear, concise, and accurate recommendations regarding drug use. The constant changing culture of drug information and health care in general has prompted the need for continual growth and refinement of the standards that govern drug information practice. This article outlines specific standards to help ensure that the education and practice of drug information will continue to meet the needs of the health care community. This opinion paper is divided into two sections: Education and Training, and Practice Areas. The Education and Training section is organized to describe the role of drug information and that of the drug information specialist in the training of all pharmacy students and advanced trainees, as well as to describe the role of focused training for those individuals wishing to specialize in drug information. This article also affirms the recommendations for the standards-based approach to drug information education and specialty training. The Practice Areas section is organized to describe the role of the drug information specialist within various practice settings, to identify some of the challenges faced by the drug information specialist within those settings, and to provide recommendations for the different practice areas. The areas found within this section include academia, institutional health systems, managed care, industry, medical writing, and informatics.
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Affiliation(s)
- Allison C Bernknopf
- Department of Pharmacy Practice, Ferris State University College of Pharmacy, Big Rapids, Michigan, USA
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21
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LaPlante KL, Mersfelder TL, Ward KE, Quilliam BJ. Prevalence of and risk factors for dysglycemia in patients receiving gatifloxacin and levofloxacin in an outpatient setting. Pharmacotherapy 2008; 28:82-9. [PMID: 18154478 DOI: 10.1592/phco.28.1.82] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To assess the prevalence of dysglycemia (hypoglycemia or hyperglycemia) associated with oral levofloxacin and gatifloxacin therapy in an outpatient setting, and to determine the characteristics of patients who developed dysglycemia while receiving either fluoroquinolone. DESIGN Retrospective medical record review. SETTING Outpatient clinic of a Veterans Affairs teaching hospital. PATIENTS A total of 1573 patients who received oral levofloxacin (343 patients), gatifloxacin (589 patients), or azithromycin (as a control, 641 patients) between June 1, 2004, and May 31, 2006. MEASUREMENTS AND MAIN RESULTS Dysglycemia occurred in 33 patients: 13 (2.2%), 9 (2.6%), and 11 (1.7%), respectively, of those in the gatifloxacin, levofloxacin, and azithromycin groups. Of 13 patients who experienced a hyperglycemic event, 11 (84.6%) had diabetes mellitus. After adjustment for confounding factors, neither levofloxacin nor gatifloxacin were associated with increased odds of developing a dysglycemic event compared with azithromycin. Multivariate analysis demonstrated that lack of downward dosage adjustment based on creatinine clearance (odds ratio [OR] 10.3, 95% confidence interval [CI] 3.8-27.6), presence of diabetes (OR 17.1, 95% CI 3.1-94.9), or treatment with insulin (OR 5.3, 95% CI 1.8-15.7) or sulfonylureas (OR 3.6, 95% CI 1.3-10.4) independently increased dysglycemia risk. Obesity (body mass index > or = 30 kg/m(2)) was independently protective (OR 0.22, 95% CI 0.09-0.55) against dysglycemic events. CONCLUSION Levofloxacin and gatifloxacin were not significantly associated with increased dysglycemic events compared with azithromycin. Lack of downward fluoroquinolone dosage adjustment for renal function, presence of diabetes, and treatment with insulin or sulfonylureas each independently increased the risk of dysglycemia. Obesity was independently protective against dysglycemia. More data are needed on the contributing effects of diabetes, fluoroquinolone dosage, and concomitant drug therapy so that an appropriate risk-management strategy can be developed.
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Affiliation(s)
- Kerry L LaPlante
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Providence, Rhode Island, USA.
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22
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Ward KE, Schucker JJ. Phosphate binders. Am J Health Syst Pharm 2006. [DOI: 10.2146/ajhp060053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Kristina E. Ward
- College of Pharmacy
University of Rhode Island
201A Fogarty Hall
Kingston, RI 02881
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23
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Abstract
Antibiotics save countless lives each year; however, increasing rates of drug-resistant bacteria have limited antibiotic selection. Currently, there are few available options for treating resistant Gram-positive organisms. Oritavancin, a novel glycopeptide antibiotic with bactericidal activity, has been developed and recently completed the first round of Phase III clinical trials for the treatment of complicated skin and skin structure infections. Investigations into oritavancin's efficacy will be explored in catheter-related bacteraemia and nosocomial pneumonia. Oritavancin demonstrates similar activity to vancomycin but possesses extended activity against vancomycin-resistant Staphylococcus and Enterococcus. The pharmacokinetics and pharmacodynamics of oritavancin appear to be favourable and once-daily dosing is likely. The incidence of multi-drug resistant bacteria is increasing and explorations into additional treatment options are essential. Further development of oritavancin is necessary to determine clinical efficacy.
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Affiliation(s)
- Kristina E Ward
- Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, RI, USA
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24
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Abstract
PURPOSE The pathophysiology of hyperphosphatemia associated with end-stage renal disease and treatment with phosphate binders are discussed. SUMMARY Phosphorus is an essential element necessary for the normal function of the human body, required for skeletal construction and synthesis of DNA, proteins, and adenosine triphosphate. In healthy individuals, serum phosphorus concentrations are maintained between 2.5 and 4.5 mg/dL through diet and renal excretion. In renal insufficiency, phosphorus excretion declines and hyperphosphatemia develops. The body's compensation mechanisms cause secondary hyperparathyroidism and renal osteodystrophy. Phosphate binders provide an effective means for managing serum phosphate. Commercially available phosphate binders include calcium carbonate, calcium acetate, sevelamer, lanthanum, and, rarely, aluminum hydroxide. Because of aluminum's known toxicities, aluminum-based phosphate binders have a limited place in therapy. Calcium carbonate's benefits are seen over a narrow gastric pH range, thereby limiting the drug's utility. Calcium acetate is effective over a wide pH range. Other phosphate binders, including sevelamer hydrochloride and lanthanum carbonate, have recently entered the market, but their use remains controversial. CONCLUSION If left untreated, hyperphosphatemia can result in secondary hyperparathyroidism, renal osteodystrophy, and metastatic calcification of blood vessels and soft tissue. The treatment of hyperphosphatemia in patients with chronic renal failure includes dialysis, dietary phosphorus restrictions, phosphate-binding medications, and vitamin D analogs. Selection of phosphate binders should be based on patient characteristics, including serum phosphate, serum calcium, and intact parathyroid hormone concentrations, and patient tolerability.
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25
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Dimas VV, Dimasc VV, Taylor MD, Cunnyngham CB, Overholt ED, Bourne DWA, Stanely JR, Sheikh A, Wolf R, Valentine B, Ward KE. Transplacental pharmacokinetics of flecainide in the gravid baboon and fetus. Pediatr Cardiol 2005; 26:815-20. [PMID: 16132275 DOI: 10.1007/s00246-005-0974-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The objective of this study was to characterize the transfer of flecainide across the placenta and determine the fetal: maternal ratio of flecainide in the gravid baboon. Flecainide acetate has been especially successful for the treatment of fetal supraventricular tachycardia associated with hydrops fetalis. However, the degree of transplacental transmission remains unknown. In this study, all animals were placed under general anesthesia. Flecainide 2.5 mg/kg was administered intravenously. Percutaneous umbilical blood sampling was performed simultaneously with maternal sampling. Flecainide levels were measured using high-performance liquid chromatography with ultraviolet detection. A total of six gravid baboons were studied at an average gestational age of 132 days. The mean maternal volume of distribution at steady state was 5.1 +/- 1.8 L/kg. The mean combined elimination constant (k(el)) was 0.79 +/- 0.19 hr(-1) [95% confidence interval (CI), 0.64-0.93]. There was a linear relationship between maternal and fetal concentrations, with a ratio of fetal-to-maternal serum levels of 0.49 +/- 0.05 (95% CI, 0.39-0.59). At steady state, fetal flecainide levels are approximately 50% of maternal flecainide levels. Flecainide is rapidly distributed in the mother and fetus following a single intravenous dose with a maternal volume of distribution similar to that reported in normal healthy human adults. Since fetal levels correlate closely with maternal levels, we propose that it is possible to estimate fetal levels by monitoring maternal levels.
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Affiliation(s)
- V V Dimas
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC 19345-C, Houston, TX 77030, USA.
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26
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Kachur SG, Hannan CL, Ward KE. Antidepressant-induced weight gain. Med Health R I 2005; 88:359-61. [PMID: 16350939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Ward KE. Can Robitussin DM be used to treat cough during pregnancy? Med Health R I 2005; 88:99-100. [PMID: 15915786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Kristina E Ward
- Drug Information Services, University of Rhode Island College of Pharmacy, Kingston, RI 02881, USA.
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Abstract
BACKGROUND Ebstein's anomaly in the severely symptomatic neonate is usually fatal. Because the mortality for various surgical interventions has been prohibitively high, the indications for operation in these critically ill neonates are unclear. METHODS We reviewed our results with biventricular repair of three consecutive severely symptomatic neonates (2.8 to 3.2 kg) at our institution since 1994. Each had associated complex cardiac pathology, including multiple muscular ventricular septal defects (n = 1), pulmonary stenosis with functional pulmonary atresia (n = 1), and anatomic pulmonary atresia (n = 1). Preoperatively, all infants had severe tricuspid regurgitation, Great Ormond Street Ebstein echocardiogram scores greater than 1.3:1 (grade 3 or 4) and cardiothoracic ratio greater than 0.85. Two patients were severely cyanotic. Hepatic and renal insufficiency with diffuse coagulopathy was present preoperatively in two patients. Surgical repair consisted of (1) reconstruction of a competent monocuspid tricuspid valve, (2) right ventriculorrhaphy, (3) subtotal closure of atrial septal defect (ASD), (4) aggressive reduction atrioplasty, and (5) repair of all associated cardiac defects. RESULTS There were no early or late deaths. All patients are currently asymptomatic, without medications, and in sinus rhythm. At 5-year follow-up, trivial tricuspid regurgitation is present in 1 and mild regurgitation in 2 patients. On the basis of these results and review of the current literature, we propose new indications for surgical repair in the neonate with Ebstein's anomaly. CONCLUSIONS Biventricular repair of Ebstein's anomaly in the critically ill neonate is feasible and medium-term durability of the repair is excellent. Therefore, conventional management of these patients should be revised and early surgical repair encouraged.
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA.
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29
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Elkins RC, Lane MM, McCue C, Ward KE. Pulmonary autograft root replacement: mid-term results. J Heart Valve Dis 1999; 8:499-503; discussion 503-6. [PMID: 10517390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND AIMS OF THE STUDY The Ross operation was first performed as a root replacement in 1974, and only limited mid- and long-term results assessing durability and adaptation of the pulmonary root to systemic pressures are available. We reviewed our experience to assess function of the autograft valve and the autograft pulmonary root, and its adaptation to systemic pressures. METHODS A total of 244 operative survivors (median age 22 years; range: 1 week to 62 years) were reviewed. Clinical follow up (within one year) was available on 98% of cases, and echocardiographic assessment within one year on 93%. Autograft and homograft valve function, aortic annulus diameter, autograft root sinus diameter and ascending aortic diameter were determined on the most recent echocardiogram. RESULTS Actuarial freedom from autograft valve degeneration (non-endocarditis autograft valve reoperation or severe autograft valve insufficiency or valve-related death) was 95 +/- 3% at 5 years and 93 +/-4% at 10 years. Actuarial freedom from all valve-related complications (autograft valve degeneration, autograft valve reoperation, homograft valve reoperation or valve-related death) was 90 +/- 4% at 5 years and 83 +/-6% at 10 years. Actuarial freedom from autograft valve replacement was 98 +/- 2% at 5 years and 96 +/- 4% at 10 years. Actuarial survival rate was 98 +/- 2% at 5 years and 86 +/- 9% at 10 years. Aneurysmal dilation of the autograft root occurred in two patients; this was not associated with autograft valve degeneration, and these patients were followed closely. CONCLUSIONS At 10 years, the Ross root replacement has a low risk of valve degeneration, valve-related complications and autograft valve replacement, and patient survival is excellent. Autograft valve reoperation and homograft valve reoperation have been the only significant late valve-related complications. Techniques to reduce autograft reoperation have been introduced, and hopefully methods to mediate the immunological response to the homograft valve will reduce the incidence of failure. Significant aneurysmal dilation of the pulmonary autograft root is rare.
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Affiliation(s)
- R C Elkins
- Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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30
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Abstract
Successful surgical repair of an unusual case of blunt trauma to the chest and abdomen is presented. The injury resulted in rupture of the pericardium, avulsion and rupture of the right coronary artery into the right atrium, complete disruption of the tricuspid valve, and acute right heart failure with complete heart block.
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Affiliation(s)
- T H Trotter
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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31
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Adderson EE, Shikhman AR, Ward KE, Cunningham MW. Molecular analysis of polyreactive monoclonal antibodies from rheumatic carditis: human anti-N-acetylglucosamine/anti-myosin antibody V region genes. J Immunol 1998; 161:2020-31. [PMID: 9712075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Anti-myosin Abs are associated with inflammatory heart diseases such as rheumatic carditis and myocarditis. In this study, human cross-reactive anti-streptococcal/anti-myosin mAbs 1.C8, 1.H9, 5.G3, and 3.B6, produced from peripheral blood lymphocytes of patients with rheumatic carditis, and mAb 10.2.5, produced from a tonsil, were characterized, and the nucleotide sequences of their V(H) and V(H)L genes were analyzed. Human mAbs 1.C8, 1.H9, 10.2.5, and 3.B6 reacted with human cardiac myosin while mAb 5.G3 did not. The mAbs were strongly reactive with N-acetyl-beta-D-glucosamine, the dominant epitope of the group A streptococcal carbohydrate. mAb 1.H9 was moderately cytotoxic to rat heart cells in vitro in the presence of complement. The anti-myosin mAbs from rheumatic carditis were found to react with specific peptides from the light meromyosin region of the human cardiac myosin molecule. Anti-streptococcal/anti-myosin mAbs from normal individuals reacted with distinctly different light meromyosin peptides. The mAbs were encoded by V(H)3 gene segments V3-8, V3-23, and V3-30 and by the V(H)4 gene segment V4-59. The variable region genes encoding the anti-streptococcal/anti-myosin repertoire were heterogeneous and exhibited little evidence of Ag-driven somatic mutation.
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MESH Headings
- Acetylglucosamine/immunology
- Amino Acid Sequence
- Antibodies, Bacterial/chemistry
- Antibodies, Bacterial/genetics
- Antibodies, Bacterial/metabolism
- Antibodies, Monoclonal/chemistry
- Antibodies, Monoclonal/genetics
- Antibodies, Monoclonal/metabolism
- Autoantibodies/chemistry
- Autoantibodies/genetics
- Autoantibodies/metabolism
- Base Sequence
- Binding Sites, Antibody
- Cross Reactions
- Endocarditis, Bacterial/genetics
- Endocarditis, Bacterial/immunology
- Genes, Immunoglobulin
- Humans
- Immunoglobulin Variable Region/chemistry
- Immunoglobulin Variable Region/genetics
- Immunoglobulin Variable Region/metabolism
- Molecular Sequence Data
- Myosins/immunology
- Rheumatic Heart Disease/genetics
- Rheumatic Heart Disease/immunology
- Streptococcus pyogenes/immunology
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Affiliation(s)
- E E Adderson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City 84132, USA
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Knott-Craig CJ, Elkins RC, Lane MM, Holz J, McCue C, Ward KE. A 26-year experience with surgical management of tetralogy of Fallot: risk analysis for mortality or late reintervention. Ann Thorac Surg 1998; 66:506-11. [PMID: 9725393 DOI: 10.1016/s0003-4975(98)00493-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Over the past decade repair of tetralogy of Fallot (TOF) in infancy has gained favor. It is still uncertain what effect early complete repair will have on survival or late reoperation on the right ventricular outflow tract. METHODS To assess these outcomes, we reviewed our experience (1971-1997) with 294 patients undergoing operation at one institution. Median follow-up was 10.6 years (range, 0.1 to 26 years), and was complete for 90.2% patients. RESULTS Primary complete repair was done in 199 patients (68%), and a staged repair in 62 patients (21%). Thirty-three patients had only a palliative procedure. Sixty-eight patients (23.1%) had complex pathologic processes, including pulmonary atresia in 53. Hospital mortality for primary repair was 11.1% (22/199), for staged repair was 17.7% (11/62), and for palliative procedures was 15.5% (16/103 procedures). Since 1990 mortality has been 2.1%, 11.8%, and 0% respectively (p < 0.001), despite younger age at repair (0.6+/-0.1 versus 2.1+/-0.2 years; p < 0.001). Multivariate analysis identified longer period of hypothermic circulatory arrest, pulmonary artery patch angioplasty, earlier year of operation, and closure of the foramen ovale as risk factors for hospital death. For hospital survivors 20-year survival was 98%+/-3% for TOF with pulmonary stenosis and 88%+/-9% for TOF with pulmonary atresia (p=0.09). Reintervention on the right ventricular outflow tract was needed in 14.1% (37/261) patients. Freedom from reintervention on the right ventricular outflow tract at 20 years was 86%+/-4% for TOF with pulmonary stenosis and 43%+/-16% for TOF with pulmonary atresia (p=0.001). For the subgroup TOF with pulmonary stenosis, this was 85%+/-5% after primary repair and 91%+/-8% after staged repair (not significant). At 15-year follow-up, this was 78%+/-10% for patients not older than 1 year at operation compared with 88%+/-4% for older patients (not significant). CONCLUSIONS Early mortality after primary repair of TOF has significantly improved and late survival is excellent. Primary repair in infancy does not increase risk for reintervention on the right ventricular outflow tract.
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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Abstract
OBJECTIVE To report a case of methemoglobinemia in a patient receiving dapsone for prophylaxis of Pneumocystis carinii pneumonia (PCP). CASE SUMMARY A 69-year-old white woman was hospitalized to rule out sepsis. Two years prior to this admission, the patient received an orthotopic liver transplant after which she required hemodialysis three times weekly. Because of intolerance to trimethoprim/ sulfamethoxazole and aerosolized pentamidine, she was prescribed dapsone therapy on hospital day 13, that was continued for 11 days. On hospital day 45 the patient received a cadaveric kidney transplant, and dialysis treatments were scheduled only as needed. One week after the transplant, dapsone therapy was resumed. Nine days into this course of dapsone, the patient developed dyspnea and oxygen desaturation of unknown etiology. The patient was evaluated for and diagnosed with methemoglobinemia. She received two doses of intravenous methylene blue and one dose of oral activated charcoal due to fluctuating methemoglobin concentrations. DISCUSSION The elimination of dapsone is not completely understood. Several case reports of dapsone-induced methemoglobinemia are present in the literature. Most have occurred in patients who have accidentally or deliberately overdosed. Cases of methemoglobinemia in patients receiving therapeutic doses of dapsone are discussed. CONCLUSIONS The growing numbers of immunosuppressed patients due to transplantation of HIV may result in increased dapsone use for the prevention of PCP. Clinicians should be aware of the adverse effects associated with dapsone therapy, and patients with dyspnea and hypoxemia of unclear etiology should be evaluated for methemoglobinemia.
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Affiliation(s)
- K E Ward
- School of Pharmacy, University of Pittsburgh, PA, USA
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34
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Abstract
BACKGROUND The Ross operation, first performed in children in 1968, may be the ideal aortic valve replacement. Technical demands of the operation and two valves at risk have delayed acceptance. A review of our experience to assess midterm and long-term results with the Ross operation is presented. METHODS The records of 150 consecutive patients, aged 7 days to 21 years (median age, 12 years, 75% less than 15 years) were reviewed. Follow-up was complete within the last 12 months (median, 2.8 years; range, 1 month to 10 years). Echocardiographic assessment was available on 116 (71%) within 1 year of closure and in 136 (91%) within 2 years. RESULTS Survival was 97.3% at 8 years. Late autograft valve dysfunction required replacement in 2 and reoperation with restitution of autograft function in 6. Freedom from reoperation for autograft dysfunction is 90% +/- 4% at 8 years. Freedom from reoperation for homograft obstruction is 94% +/- 3% at 8 years. Pulmonary homograft dysfunction (gradient > 40 mm Hg) was present in 4 additional patients. Freedom from reoperation on the homograft or a gradient of 40 mm Hg is 89% +/- 4% at 8 years. All patients have a normal, active lifestyle, without anticoagulants for their aortic valve replacement. CONCLUSIONS The Ross operation is the preferred operative replacement in children requiring aortic valve replacement.
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Affiliation(s)
- R C Elkins
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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Fox NW, Johnstone EM, Ward KE, Schrementi J, Little SP. APP gene promoter constructs are preferentially expressed in the CNS and testis of transgenic mice. Biochem Biophys Res Commun 1997; 240:759-62. [PMID: 9398640 DOI: 10.1006/bbrc.1997.7728] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Transgenic animals were used to examine the spatial and temporal regulation of the human beta amyloid precursor protein (APP) gene promoter region in vivo. A 2.9 kb DNA fragment encompassing the APP gene promoter was fused to the chloramphenical acetyltransferase (CAT) reporter gene (pAMY-CAT) or a partial cDNA encoding the potentially amyloidogenic C-terminal 100 amino acid region of APP (pAMY-C100). Expression of these transgenes occurred primarily, but not exclusively, in the central nervous system (CNS) and testis in multiple independent lineages of transgenic mice. Temporal expression of the CAT reporter gene during development paralleled that reported for the endogenous APP gene. These studies suggest that a CNS-responsive cis-acting element(s) may exist in the promoter/5'-flanking region of the APP gene.
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Affiliation(s)
- N W Fox
- Central Nervous System Research, Lilly Research Laboratories, Indianapolis, Indiana 46285, USA
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36
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Ward KE, Elkins RC, Overholt ED, Knott-Craig CJ, Razook JD, Lane MM, Gilliland SS. Evaluation of cryopreserved homografts in the right ventricular outflow tract after the Ross procedure: intermediate-term follow up. J Heart Valve Dis 1997; 6:130-3. [PMID: 9130119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS OF THE STUDY The Ross procedure involves replacing a transplanted pulmonary valve with a cryopreserved homograft in order to re-establish right ventricle-pulmonary artery continuity. This study reviews mid-term results of such surgery in children and young adults. METHODS Since November 1986, 114 patients have undergone the Ross procedure at the Children's Hospital of Oklahoma using cryopreserved pulmonary homografts (n = 113) and aortic homograft (n = 1) to reconstruct the right ventricular outflow tract. Graft size ranged from 16 to 32 mm. Ninety-three patients (mean age at implant 10.4 years (range: 0.8-22 years) have had complete mean follow up of 3.2 years (range: 5 months to 8.4 years) after surgery. Homograft evaluation included clinical reports and comparison of early post-implant and latest echocardiography. Measurements of homograft valve annulus and peak instantaneous Doppler gradient were compared; quality of valve leaflets, location of obstruction, and the degree of pulmonary regurgitation were assessed. RESULTS Compared with early postoperative data, mean homograft annulus size decreased by 15% (p < 0.0001); in 88% of patients, the decrease ranged from one to nine millimeter. Peak Doppler gradient increased significantly (from 10 to 17 mmHg, p < 0.0001); 25% of patients developed gradients > 25 mmHg, and four had gradients > 50 mmHg. Significant obstruction developed most often at the supravalvular level or in the homograft conduit itself. This usually occurred within one year of implant, and was associated with calcification and contracture of the homograft wall. Significant pulmonary regurgitation developed in 19 cases (20%), but was more than mild in only three. Leaflet integrity was maintained except in those who developed severe stenosis or regurgitation. Two patients have undergone re-operation for homograft stenosis 2.8 and 5.4 years respectively after the Ross procedure; one has developed recurrent severe stenosis in the homograft four months later. CONCLUSIONS After the Ross procedure: (i) Pulmonary homografts undergo significant annular reduction in most patients, though this is usually not associated with the development of significant obstruction. (ii) Peak Doppler gradients across the homograft increase in most patients, though only 4% develop more than mild obstruction. (iii) Mild pulmonary regurgitation is common (20%); moderate or severe regurgitation is rare and usually develops in concert with severe stenosis. (iv) Severe homograft valve degeneration usually occurs within one year of implant, and may reflect an immune-mediated response.
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Affiliation(s)
- K E Ward
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, USA
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Abstract
Several meta-analyses are presented that address the issue of brain and/or cranial size reductions in schizophrenia. Separate meta-analyses were conducted for brain size (n = 27 studies), intracranial size (n = 18) or extracranial size (n = 8). For each meta-analysis, the weighted composite effect size (d) was tested for statistical significance (the direction of the effect size was negative if patients with schizophrenia had smaller structure size than controls). The influence of several potential modifiers of effect size (age, methods, region, gender) was individually evaluated. The composite effect sizes for studies of brain, intracranial and extracranial measures were d = -0.26, (p < 0.0001), d = -0.18, (p = 0.0012), and d = +0.14, (p = 0.16), respectively. Thus, the review found evidence for a small, but statistically significant reduction in brain and intracranial size in schizophrenia, but no evidence for a reduction in extracranial size. Studies based on axial image slices had significantly larger effects (d = -0.60) than the studies based on sagittal images (d = -0.09) (chi(2) = 14.0, p = 0.0002). In summary, the findings clearly support a small yet highly significant reduction of brain and intracranial size in schizophrenia.
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Affiliation(s)
- K E Ward
- Department of Neuroscience, Case Western Reserve University, Cleveland, OH 44106, USA
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Knott-Craig CJ, Fryar-Dragg T, Overholt ED, Razook JD, Ward KE, Elkins RC. Modified hemi-Fontan operation: an alternative definitive palliation for high-risk patients. Ann Thorac Surg 1995; 60:S554-7. [PMID: 8604934 DOI: 10.1016/0003-4975(95)00655-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We conceptualized that by adding small amounts of prograde pulmonary blood flow to the hemi-Fontan operation, or bidirectional Glenn procedure, this modified hemi-Fontan operation could be safely done at an early age, with better oxygenation, and with less potential for pulmonary arteriovenous fistulae. METHODS Since April 1992 the hemi-Fontan operation was modified by adding some prograde flow through the native pulmonary artery in 10 high-risk infants, either by leaving the critical subpulmonary stenosis untreated (n = 6) or by tightening a previously placed pulmonary artery band (n = 4). All other sources of pulmonary blood flow were interrupted. Patients were 4 to 23 months old (3.8 to 10.3 kg). Diagnoses included isolated dextrocardia with single ventricle (3) and polysplenia syndrome (2). Cardiopulmonary bypass was needed in 5 patients. RESULTS There were no hospital deaths. Mean postoperative intensive care unit stay was 2 days, and 9 of 10 patients were discharged within 7 days of operation. One 4-month-old infant with Down's syndrome survived postoperative takedown of the hemi-Fontan repair after pneumonia and caval thrombosis developed. Eight patients are currently asymptomatic receiving minimal modification, and oxygen saturations range from 84% to 93%. CONCLUSIONS Adding small volumes of prograde pulmonary blood flow to the hemi-Fontan operation is safe, provides improved oxygenation, may encourage growth of central pulmonary arteries, and represent an alternative definitive palliation for high-risk Fontan candidates.
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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39
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Abstract
A 16-month-old boy suffered a cardiac arrest as a result of acute myocarditis, and venoarterial extracorporeal membrane oxygenation was instituted. Twelve hours later, acute left heart distention developed with cessation of left ventricular ejection. Under transesophageal echocardiographic guidance, a long introducer was placed into the left atrium through a transseptal puncture and connected in-line to the venous circuit. Within hours, left ventricular function improved and ejection returned. Left heart decompression was continued for 5 days, and the patient was weaned from extracorporeal membrane oxygenation after 6 days with normal cardiac and neurologic function.
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Affiliation(s)
- K E Ward
- Department of Pediatrics, Childrens Hospital of Oklahoma, University of Oklahoma Health Sciences Center, Oklahoma City
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40
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Knott-Craig CJ, Elkins RC, Ramakrishnan K, Hartnett DA, Lane MM, Overholt ED, Ward KE, Razook JR. Associated atrial septal defects increase perioperative morbidity after ventricular septal defect repair in infancy. Ann Thorac Surg 1995; 59:573-8. [PMID: 7887692 DOI: 10.1016/0003-4975(94)01005-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Although closure of ventricular septal defects (VSDs) is currently associated with a relatively low risk, infants with associated atrial septal defects (ASDs) seem to have a higher perioperative morbidity. To clarify this impression, we reviewed our entire experience (since 1977) with closure of simple VSDs in 163 infants (age, < or = 12 months). Of these, 57 had significant ASDs (ASD-VSD subgroup). Hospital mortality was 3.7% (6/163) overall and 1.4% (2/145) since 1980. Actuarial survival at 10 years was 92% +/- 5%. Significant morbidity occurred in 15.5% (16/103) of the VSD subgroup versus 48.1% (26/54) of the ASD-VSD subgroup (p < or = 0.001). Multivariate analysis identified the presence of multiple VSDs and early date of operation as risk factors for hospital death, and younger age, an associated ASD, the size of the VSD, and use of hypothermic circulatory arrest as risk factors for significant perioperative morbidity. Compared with the VSD subgroup, the ASD-VSD subgroup had a higher hospital mortality (5.3% [3/57] versus 2.8% [3/106]), were younger (5.1 +/- 2.9 versus 7.2 +/- 2.9 months; p = 0.001), had a higher preoperative pulmonary artery pressure (70.2 +/- 19.0 versus 62.7 +/- 21.8 mm Hg; p = 0.08), needed more inotropic support (12.3% versus 3.7%; p = 0.07), needed more prolonged ventilation (3.3 versus 1.8 days; p = 0.02), and had longer postoperative hospital stays (11 versus 8 days; p = 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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41
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Abstract
Pulmonary autograft replacement of the aortic valve has the potential to remain viable and grow in proportion to the somatic growth of the child. Changes in aortic annulus and sinotubular dimensions were compared early and late postoperatively, and related to normal. Eighty-six children, 0.9 to 21 years, were operated on between 1986 and 1993: 42 had a root replacement, 24 an inclusion cylinder, and 20 a scalloped subcoronary implant. Actuarial survival at 7 years was 96.5% +/- 2.0%. Freedom from reoperation for the pulmonary autograft or the homograft reconstruction of the right ventricular outflow tract was 92% +/- 4%. Freedom from reoperation on the autograft in root replacements was 96% +/- 4%, in the inclusion cylinder was 100%, and in the scalloped subcoronary was 90% +/- 7% (not significant). Aortic annulus and sinotubular junction diameters were compared with normal values predicted by body surface area. In 22 intraaortic implants, early and late postoperative annulus diameter mean Z values are in the normal range. In the 23 root replacements, early annulus diameter was within the normal range, but late Z values were larger than normal (p < 0.02). Intraaortic implant annulus diameter increased proportionally to somatic growth, but the sinotubular junction, which was small, remained small but increased toward normal. In the root replacements, the annulus increased in diameter and became dilated. The sinotubular junction, which was small early, increased and was within the normal range late. Lower operative risk and valve durability without failure suggest improved results with inclusion cylinder technique.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R C Elkins
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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Mizumori SJ, Miya DY, Ward KE. Reversible inactivation of the lateral dorsal thalamus disrupts hippocampal place representation and impairs spatial learning. Brain Res 1994; 644:168-74. [PMID: 8032944 DOI: 10.1016/0006-8993(94)90361-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Place-specific discharge of hippocampal cells was monitored while rats performed daily 15 trials of a spatial memory task. During the intertrial interval between trials 5 and 6, the lateral dorsal nucleus of the thalamus (LDN) was reversibly inactivated. Choice accuracy on the maze became impaired, and many hippocampal place fields became disrupted. These data support the proposition that the LDN passes onto hippocampus important (spatial) information that is used for accurate maze navigation.
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Affiliation(s)
- S J Mizumori
- Department of Psychology, University of Utah, Salt Lake City 84112
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43
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Elkins RC, Knott-Craig CJ, Ahn JH, Murray CK, Overholt ED, Ward KE, Razook JD. Ventricular function after the arterial switch operation for transposition of the great arteries. Ann Thorac Surg 1994; 57:826-31. [PMID: 8166526 DOI: 10.1016/0003-4975(94)90183-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The theoretical advantages of anatomical repair have resulted in the widespread use of the arterial switch operation for transposition of the great arteries. However, preservation of systemic ventricular performance and late functional results have not been well documented. To evaluate late postoperative ventricular function, we reviewed 53 consecutive patients undergoing arterial switch operation for transposition of the great arteries with or without a ventricular septal defect over the 8-year period from March 1985 to 1993. Forty-two patients had simple transposition of the great arteries and 11 patients had associated ventricular septal defects that were closed at operation. Mean age at operation was 1.8 months (range, 1 day to 36 months), and mean patient weight was 3.8 kg (range, 1.8 to 15.6 kg). All but 8 patients were neonates. There were six operative deaths (11.3%, 6/53) and two late deaths during a median follow-up of 23 months (range, 0.1 to 99.5 months). Actuarial survival at 8 years was 83% +/- 6%. Left ventricular outflow tract obstruction has not been identified, and 9 patients (20%, 9/45) have right ventricular outflow tract gradients exceeding 20 mm Hg, 3 of whom have required reoperation. Eighteen patients have mild neo-aortic valve regurgitation. All survivors are currently in New York Heart Association class I, and are in sinus rhythm. Systolic left ventricular function is well preserved with ejection fractions greater than 0.60 in all survivors followed up for more than 4 months (41 patients). Left ventricular end-diastolic volume index is elevated in only 1 patient, a patient who had pulmonary artery banding as a neonate.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R C Elkins
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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44
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Abstract
Aortic valve replacement in the child and young adult is often delayed, and multiple operations or invasive procedures are performed to avoid valve replacements. Prosthetic valves, bioprosthetic valves, or allograft valves have been associated with significant complications or early failure and have been a disappointing solution for the patient requiring aortic valve replacement. The pulmonary autograft replacement (PAR) of the aortic valve in children has been shown to be safe and effective with a low incidence of late valve dysfunction. The absence of thromboembolism, the avoidance of anticoagulants, and its viability with the potential for growth and repair strongly support its use for the potential parent, patients of age 35 or less. The experience with 112 patients, 32 females and 80 males, ages 1.5 to 35 years (average 16.1) are reviewed. Twenty-four had aortic insufficiency, 34 had aortic stenosis, and 54 had both aortic stenosis and insufficiency. Actuarial survival was 95.4% +/- 2.0% at 7 years and freedom from reoperation or significant aortic insufficiency of the autograft valve was 92.7% +/- 3.7%. Freedom from all valve related complications of the autograft valve and the homograft replacement of the pulmonary valve was 90.0% +/- 4.0%. Reoperation for the autograft valve was related to limited experience in one, leaflet prolapse and adherence to a VSD patch in one, associated lupus erythematosus in one, and annular and sinotubular dilatation in one. Reoperation of the homograft valve in two patients was secondary to early homograft stenosis, probably due to rejection.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R C Elkins
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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Elkins RC, Knott-Craig CJ, Randolph JD, Razook JR, Ward KE, Overholt ED, Lane MM. Medium-term follow-up of pulmonary autograft replacement of aortic valves in children. Eur J Cardiothorac Surg 1994; 8:379-83. [PMID: 7946416 DOI: 10.1016/1010-7940(94)90032-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Pulmonary autograft replacement (PAG) of the aortic valve in children has been shown to be safe and effective with a low incidence of late valve dysfunction. Relief of all types of left ventricular outflow tract obstruction using the pulmonary root has been possible. Concern about the durability of the pulmonary root in the aortic position, and the potential for growth of the pulmonary autograft used either as a root replacement or intraaortic implant, has been questioned. Sixty-five consecutive patients, aged 1.8 to 21 years (mean 12 years) operated on between September 1986 and January 1993, 35 with an intra-aortic implant (IA) and 30 with root replacement (RR), were evaluated by clinical and serial echocardiographic studies (ECHO) up to 6.5 years post-operatively. The hospital mortality rate was 3.0% (70% CL 2.1-5.1%). Two patients required reoperation for PAG insufficiency (AI), one for technical malalignment necessitating replacement at 6 months, and one with progressive leaflet prolapse due to adherence of the valve leaflet to a ventricular septal defect (VSD) patch. Freedom from significant aortic regurgitation at 6-year follow-up was 100% for RR and 91 +/- 6% for IA, and freedom from all valve-related complications including reoperation was 92 +/- 5% at 6 years. Significant enlargement of the aortic annulus which parallels somatic growth has been measured by ECHO in 17 IA implants (P < 0.001) and 17 RR patients (P < 0.01) by 1 year, and in 10 IA (P = 0.007) and 6 RR (P < 0.05) by 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R C Elkins
- Dept. of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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46
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Knott-Craig CJ, Elkins RC, Ward KE, Overholt ED, Razook JD, McCue CA, Lane MM. Neonatal coarctation repair. Influence of technique on late results. Circulation 1993; 88:II198-204. [PMID: 8222154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Coarctation repair in the neonate (< or = 28 days) is associated with higher mortality and increased incidence of restenosis compared with older infants. It has been suggested that resection of pericoarctation ductal tissue may reduce this risk of restenosis. METHODS AND RESULTS To further clarify these issues, we reviewed our experience with 111 consecutive neonates undergoing primary repair between 1973 and 1991. Hospital mortality was 14.4% (16 of 111) and was not significantly different for the type of repair:resection and end-to-end anastomosis (RETE) 10.7% (6 of 56), subclavian flap angioplasty (SFA) 16.7% (6 of 36), and patch angioplasty (PA) 16.7% (3 of 18). Associated complex cardiac pathology was associated with higher operative risk: 25% (10 of 40) versus 8.4% (6 of 71) (P = .02). Median follow-up of 4.2 years (range, 0.1 to 18.5 years) was 99% complete. Late mortality was 13.6% (13 of 95), of which 92% occurred within 1 year of repair. Twenty percent (19 of 95) needed reintervention for restenosis, RETE 16% (8 of 50), SFA 13% (4 of 30), and PA 47% (7 of 15) (P = .02). Of these, 84.2% (16 of 19) required reintervention within 1 year of repair. Freedom from reintervention 1 and 8 years after operation was 80 +/- 4% and 77 +/- 5%, respectively. Actuarial survival 8 years after operation was 73 +/- 4%; for simple coarctation, this was 90 +/- 4%. By multivariate analysis, survival was negatively influenced only by presence of associated cardiac pathology (P = .002) and reintervention only by patch angioplasty technique of repair (P = .007). CONCLUSIONS In the neonate, resection of coarctation (RETE) does not diminish the risk for reintervention compared with SFA. The risk for both late death and recurrent coarctation are highest within the first year after repair, and follow-up should be particularly vigilant during this period.
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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47
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Bobele GB, Ward KE, Bodensteiner JB. Hypertrophic cardiomyopathy during corticotropin therapy for infantile spasms. A clinical and echocardiographic study. Am J Dis Child 1993; 147:223-5. [PMID: 8381257 DOI: 10.1001/archpedi.1993.02160260113037] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To evaluate the incidence and clinical features of abnormal cardiac hypertrophy during treatment of infantile spasms with corticotropin. DESIGN A prospective, echocardiographic study. PARTICIPANTS Eighteen children treated for infantile spasms with high-dose corticotropin at a large tertiary children's hospital. INTERVENTIONS None. MEASUREMENTS AND RESULTS Abnormal cardiac hypertrophy was seen in 13 (72%) of 18 patients. Five of 18 patients (group 1) developed hypertrophic cardiomyopathy with asymmetric septal hypertrophy; none developed significant left ventricular outflow obstruction. Concentric left ventricular hypertrophy was seen in eight patients (group 2), whereas no changes were observed in five (group 3). CONCLUSION Abnormal ventricular hypertrophy occurs in the majority of patients treated with corticotropin for infantile spasms. In our study, many of these patients developed hypertrophic cardiomyopathy with dramatic asymmetric septal hypertrophy; however, none developed significant obstruction to left ventricular outflow. All changes were reversible, and did not require premature discontinuation of therapy.
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Affiliation(s)
- G B Bobele
- Department of Neurology, University of Oklahoma Health Science Center, Oklahoma City 73126
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Elkins RC, Santangelo K, Randolph JD, Knott-Craig CJ, Stelzer P, Thompson WM, Razook JD, Ward KE, Overholt ED. Pulmonary autograft replacement in children. The ideal solution? Ann Surg 1992; 216:363-70; discussion 370-1. [PMID: 1417185 PMCID: PMC1242626 DOI: 10.1097/00000658-199209000-00016] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fifty-one children, aged 1.8 to 21 years (mean, 11.4) with aortic valve replacement using a pulmonary autograft are reviewed. Twenty-nine were intra-aortic implants and 22 were root replacements. There was one operative death, no late deaths, and two have required reoperation. Actuarial freedom from reoperation was 93% +/- 5.5 at 5.6 years. Freedom from progression of aortic insufficiency (AI) was 81% +/- 9 at 5.6 years in the intra-aortic implants and 86% +/- 10 in the root replacement. Enlargement of the pulmonary autograft was seen echocardiographically in both groups. This enlargement was consistent with somatic growth and not associated with progression of AI. Ten of 19 patients with aortic stenosis had an LV mass index suggestive of LV hypertrophy before operation. At 1 year, 18 of 25 had a normal LV mass index. Thirteen of 16 patients with AI had preoperative abnormal LV mass index. All but four returned to normal by 1 year. Low operative risk, excellent function, resolution of abnormal LV hemodynamics, and enlargement consistent with somatic growth suggest that the pulmonary autograft is the ideal replacement for the malfunctioning aortic valve.
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Affiliation(s)
- R C Elkins
- University of Oklahoma Health Sciences Center, Oklahoma City 73190
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Abstract
Reversible inactivation of the medial septal area results in a spatial memory impairment and selective disruption of hilar/CA3, but not CA1, location-specific discharge. The present study examined the possibility that such septal deafferentation produces effects on hippocampal function by altering physiological properties of the primary input and output structures for hippocampus, the entorhinal cortex and the subiculum, respectively. Single unit activity of hippocampal, entorhinal, and subicular cells was recorded before, during, and after septal injection of lidocaine in anesthetized rats. When compared to hippocampal cells, relatively few subicular and entorhinal cells showed a change in mean firing rate following septal inactivation. Entorhinal unit responses to septal inactivation (via tetracaine injection) were also examined in freely moving rats performing a spatial maze task. About one-third of entorhinal cells showed enhanced or reduced firing rates of 40% or more. Also, the spatial distribution of cells found in the superficial, but not deep, entorhinal layers became less clear following septal inactivation. Together, these data are consistent with the hypothesis that manipulation of the medial septum affects hippocampal function via its septosubicular and septo-entorhinal projections in addition to the more direct septohippocampal pathway. Since entorhinal cortical function was affected by tetracaine injection into the septum, it does not appear that direct entorhinal-CA1 afferents were primarily responsible for the maintenance of CA1 location-specific neural activity in previous septal inactivation experiments. Rather, these data are consistent with the hypothesis that the persistence of CA1 place fields was accomplished by intrahippocampal neural network operations.
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Affiliation(s)
- S J Mizumori
- Department of Psychology, University of Utah, Salt Lake City 84112
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Santangelo K, Elkins RC, Stelzer P, Randolph JD, Ward KE, Overholt ED, Thompson WM, Razook JD, Lane M. Normal left ventricular function following pulmonary autograft replacement of the aortic valve in children. J Card Surg 1991; 6:633-7. [PMID: 1810559 DOI: 10.1111/jocs.1991.6.4s.633] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To assess growth potential and hemodynamic sequelae of pulmonary autograft valves implanted into aortic outflow tracts of children, we reviewed our experience with 37 patients (2-21 years) from August 1986 to December 1990. Twenty patients had predominantly aortic stenosis (AS), and 17 had aortic insufficiency (AI). Operative mortality was 3%. Two technical failures required reoperation. Of survivors, six (18%) have moderate AI. Pre- and postoperative echocardiograms were reviewed. The AS group showed increased left ventricular (LV) cavity size by greater than 1-year follow-up, and decreased LV wall and interventricular septal thickness. In the AI group, wall and septal thickness increased by 10 days and LV cavity decreased by 10 days, 60 days, and greater than 1 year. Root replacements (n = 14) showed mean increases of 4.3 mm and 5.3 mm, respectively, in diameters of the aortic annulus and aortic sinuses at greater than 1 year. Intraaortic implants increased 3.1 mm (annulus) and 3.9 mm (sinuses) at greater than 1 year. The pulmonary autograft procedure is safe, and successful implantation normalizes LV dimensions and function rapidly. The autograft valve shows evidence of growth at greater than 1 year postoperative. The pulmonary autograft may be the ideal valve replacement in children.
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Affiliation(s)
- K Santangelo
- The Department of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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