Showing papers by "Lenox Hill Hospital published in 2003"

From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II.

Abstract: Atherosclerotic cardiovascular disease results in >19 million deaths annually, and coronary heart disease accounts for the majority of this toll. Despite major advances in treatment of coronary heart disease patients, a large number of victims of the disease who are apparently healthy die suddenly without prior symptoms. Available screening and diagnostic methods are insufficient to identify the victims before the event occurs. The recognition of the role of the vulnerable plaque has opened new avenues of opportunity in the field of cardiovascular medicine. This consensus document concludes the following. (1) Rupture-prone plaques are not the only vulnerable plaques. All types of atherosclerotic plaques with high likelihood of thrombotic complications and rapid progression should be considered as vulnerable plaques. We propose a classification for clinical as well as pathological evaluation of vulnerable plaques. (2) Vulnerable plaques are not the only culprit factors for the development of acute coronary syndromes, myocardial infarction, and sudden cardiac death. Vulnerable blood (prone to thrombosis) and vulnerable myocardium (prone to fatal arrhythmia) play an important role in the outcome. Therefore, the term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future. (3) A quantitative method for cumulative risk assessment of vulnerable patients needs to be developed that may include variables based on plaque, blood, and myocardial vulnerability. In Part I of this consensus document, we cover the new definition of vulnerable plaque and its relationship with vulnerable patients. Part II of this consensus document focuses on vulnerable blood and vulnerable myocardium and provide an outline of overall risk assessment of vulnerable patients. Parts I and II are meant to provide a general consensus and overviews the new field of vulnerable patient. Recently developed assays (eg, C-reactive protein), imaging techniques (eg, CT and MRI), noninvasive electrophysiological tests (for vulnerable myocardium), and emerging catheters (to localize and characterize vulnerable plaque) in combination with future genomic and proteomic techniques will guide us in the search for vulnerable patients. It will also lead to the development and deployment of new therapies and ultimately to reduce the incidence of acute coronary syndromes and sudden cardiac death. We encourage healthcare policy makers to promote translational research for screening and treatment of vulnerable patients.

Switching Patients to Aripiprazole From Other Antipsychotic Agents: A Multicenter Randomized Study

Abstract: Switching patients from one antipsychotic to another can lead to tolerability problems or transient symptom exacerbations. It is important to compare switching strategies to determine which methods produce the best possible patient outcomes. To investigate the efficacy, safety and tolerability of three dosing strategies for switching chronic, stable patients with schizophrenia from current oral antipsychotic monotherapy to once-daily oral aripiprazole monotherapy. Patients in this 8-week, open-label, outpatient study were randomized to: 1) immediate initiation of 30 mg/day aripiprazole with simultaneous immediate discontinuation of current antipsychotic; 2) immediate initiation of 30 mg/day aripiprazole while tapering off current antipsychotic over 2 weeks; or 3) up-titrating aripiprazole to 30 mg/day over 2 weeks, while simultaneously tapering off current antipsychotic. Efficacy assessments included PANSS, CGI-S, and CGI-I scores. Safety assessments included: adverse events (AEs) recording, evaluation of extrapyramidal symptoms (EPS), vital signs, ECG, and clinical laboratory tests. Efficacy with aripiprazole was maintained during the study with numerical improvements compared with baseline in all three groups. The overall incidence of AEs was broadly comparable across all groups, and AEs were generally mild to moderate in severity and time-limited. Discontinuations due to AEs were comparable across the groups. No deterioration in EPS occurred in any group. The reduction in body weight and plasma prolactin levels following switch to aripiprazole were comparable across the three groups. Any of the three strategies evaluated can be used safely for switching patients to aripiprazole from antipsychotic monotherapy. Furthermore, patients' symptoms may continue to improve after switching to aripiprazole.

Do Hospitals and Surgeons With Higher Coronary Artery Bypass Graft Surgery Volumes Still Have Lower Risk-Adjusted Mortality Rates?

Abstract: Background— Studies that are the basis of recommended volume thresholds for CABG surgery are outdated and not reflective of recent advances in the field. This study examines both hospital and surge...

Total knee arthroplasty rehabilitation protocol: what makes the difference?

Abstract: The goals of any rehabilitation protocol should be to control pain, improve ambulation, maximize range of motion,develop muscle strength, and provide emotional support. Over 85% of total knee arthroplasty (TKA) patients will recover knee function regardless of which rehabilitation protocol is adopted. However, the remaining 15% of patients will have difficulty obtaining proper knee function secondary to significant pain, limited preoperative motion, or the development of arthrofibrosis. This subset will require a special, individualized rehabilitation program that may involve prolonged oral analgesia, continued physical therapy, additional diagnostic studies, and occasionally manipulation. Controlling pain is the mainstay of any treatment plan. The program described herein has been used at the Ranawat Orthopaedic Center over the past 10 years in more than 2,000 TKAs.

Diagnostic value of cytokines and C-reactive protein in the first 24 hours of neonatal sepsis.

Abstract: The first objective of this article was to determine the diagnostic accuracy of tumor necrosis factor-alpha, interleukin-6 (IL-6), and interleukin-8 (IL-8) in differentiating infected from noninfected neonates during the first 24 hours of suspected sepsis and to compare them to the currently used laboratory parameters: C-reactive protein (CRP), immature-to-total neutrophil ratio, and leukocyte and platelet count. The secondary objective was to compare the cytokine levels in subpopulations of neonates. Seventy-five premature and 30 term infants were enrolled. Blood samples for the "currently used laboratory tests" and the cytokine levels were obtained at the first suspicion of sepsis ("0-hour") and 18 to 30 hours later ("24-hours"). Patients were classified as septic (48) or nonseptic (57). Thirty-two septic patients had positive blood cultures and 16 showed clinical signs of sepsis. Twenty septic patients had early-onset and 28 had late-onset sepsis. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated for each test. Receiver-operating characteristic curves were analyzed to determine the optimal thresholds. A combination of CRP > 10 pg/mL plus IL-6 > 18 pg/mL (sensitivity = 89%, specificity = 73%, PPV = 70%, NPV = 90%) was the best "0-hour" test, and CRP (sensitivity = 78%, specificity = 94%) was the best "24-hours" test. Lower IL-6 at 0-hour (p = 0.018) and IL-8 at 24 hours (p = 0.023) were detected among the patients infected with coagulase-negative staphylococci then with other bacteria. In conclusion, a combination of CRP + IL-6 provided additional diagnostic accuracy for differentiation between septic and nonseptic patients during the first 24 hours of suspected sepsis.

Drug-eluting stents: costs versus clinical benefit.

Abstract: Although coronary stenting improves angiographic and clinical outcome of patients with coronary stenosis compared to balloon angioplasty, in-stent restenosis (ISR) still represents a major limitation

Comparison of outcomes of diabetic and nondiabetic patients undergoing primary angioplasty for acute myocardial infarction

Abstract: We sought to determine whether diabetes mellitus independently conferred poor prognosis in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). In 3,742 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) studies with the intention of undergoing primary PCI, we compared in-hospital mortality, 6-month mortality, and 6-month major adverse cardiovascular events (MACEs), i.e., composite of death, reinfarction, or ischemic target vessel revascularization (TVR), between diabetics (n = 626, 17%) and nondiabetics (n = 3,116, 83%). We evaluated the independent impact of diabetes on outcomes after adjustment for baseline clinical and angiographic differences. Diabetics had worse baseline clinical characteristics, longer pain onset-to-hospital arrival time, and longer door-to-balloon time. They had more multivessel coronary disease and lower left ventricular ejection fractions, but better baseline Thrombolysis In Myocardial Infarction (TIMI) flow. Diabetics underwent primary PCI less often (88% vs 91%, p = 0.01). During the index hospitalization, diabetics were more likely to die (4.6% vs 2.6%, p = 0.005). During 6-month follow-up, diabetics had higher incidences of death (8.1% vs 4.2%, p <0.0001) and MACEs (18% vs 14%, p = 0.036). In multivariate analysis, diabetes was independently associated with 6-month mortality (hazard ratio 1.53, 95% confidence interval 1.03 to 2.26, p = 0.03), but not with in-hospital mortality or 6-month MACEs. We conclude that diabetics with AMI have less favorable baseline characteristics and are less likely to undergo primary PCI than nondiabetics. Despite excellent angiographic results, diabetics had significantly worse 6-month mortality.

Design may be counterproductive for optimizing flexion after TKR.

Abstract: Pain-free flexion of as much as 155° with stability is the ultimate goal of total knee replacement (TKR). Achieving this amount of flexion depends on implant design, surgical technique, preoperative range of motion (ROM), and patient cooperation. Current design trends are focusing on shortening the radii of curvature; such shortening, in turn, thickens the posterior femoral condyle and increases the height of the posterior-stabilized box, both of which require removal of more bone. The end results may be excessive wear, increased patellofemoral complications, and difficult revisions. Several studies have indicated preoperative ROM is more predictive of postoperative ROM than any other criteria, including implant design. Based on currently available information, if full or almost full preoperative ROM is required for the high flex total knee design, few patients would qualify for the high flex TKA.

Cumulative experience with short- and long-term toxicity to 6-mercaptopurine in the treatment of Crohn's disease and ulcerative colitis.

Abstract: Background and Aims: The efficacy of 6-mercaptopurine (6-MP) in the treatment and long-term maintenance of remission of inflammatory bowel disease and prevention of recurrence after resection in Crohn's disease have been established. Concern about 6-MP toxicity remains, especially the development of neoplasm. The aim of this study is to determine the incidence of all short- and long-term toxicity by follow-up of all patients with inflammatory bowel disease treated with 6-MP over a 20-year period. Materials and Methods: We reviewed the office and hospital records and also determined the recent status of 410 patients with inflammatory bowel disease treated with 6-MP from 1980 to 1999. All toxicity was recorded. Results: There was a low incidence of early drug-related allergic reactions (3.9%) and pancreatitis (1.2%). Desensitization to either 6-MP or azathioprine is often successful with the same or the other drug. Significant leukopenia (≤3,500) was observed in 11.5%. In some cases, this was caused purposefully. Infectious complications occurred at different times during treatment with 6-MP in 14%, including pneumonia in 3.9% and herpes zoster in 3%. We now establish diabetes as a 6-MP-related complication. No significant difference in the incidence of neoplasm was seen from our earlier study or from patients not treated with 6-MP. We have now seen three lymphomas and two leukemias, again not greater in incidence than the overall inflammatory bowel disease population. Conclusions: Our data support the long-term safety of 6-MP in the management of patients with inflammatory bowel disease. Earlier development of a neoplasm in a patient predisposed, without a change in incidence, remains possible.

The ethnic nose.

Abstract: There are distinctive anatomical differences between the non-Caucasian (platyrrhine, mesorrhine) nose and the Caucasian (leptorrhine) nose. In general, non-Caucasian patients requesting aesthetic rhinoplasty desire improvement and refinement of their noses with preservation of defining ethnic characteristics. Surgeons who perform rhinoplasty in this patient population must be familiar with the variations in nasal anatomy and implement augmentation rather than reduction techniques to achieve the desired aesthetic and functional outcomes. We provide a brief review of recent historical trends in ethnic rhinoplasty, highlight relevant anatomical differences, and describe our strategy for addressing the challenges of ethnic rhinoplasty.

Improvement in driving reaction time after total hip arthroplasty.

Abstract: Decisions made regarding resumption of driving after total hip arthroplasty may be determined by a combination of factors including driving reaction time and when postsurgical precautions need no longer be adhered to. Ninety patients, ranging in age from 34 to 85 years old were recruited after total hip arthroplasty to measure driving reaction time preoperatively and from 1 to 52 weeks postoperatively. Driving reaction time worsened 1 week postoperatively for patients who had a right hip arthroplasty. The driving reaction time then improved up to 1 year postoperatively. Patients who had a left arthroplasty improved from 1 week postoperative. In general, patients reach their preoperative driving reaction time 4 to 6 weeks postoperatively and continue to improve.

Biochemical Properties of a Newly Described Escherichia Species, Escherichia albertii

Abstract: Five strains of a newly described Escherichia species, Escherichia albertii, were extensively characterized by conventional biochemical methods and by commercial identification panels. E. albertii is an indole-negative species that ferments D-mannitol but not D-xylose. Because these strains are not included in the databases of commercial systems at present, they were most often identified as Hafnia, Salmonella, Escherichia coli, or, on one system (MicroScan dried overnight panels), Yersinia ruckeri.

Immunohistochemical staining of cytologic smears with MIB-1 helps distinguish low-grade from high-grade neuroendocrine neoplasms.

Abstract: Neuroendocrine neoplasms (NENs) of the lung and gastrointestinal tract constitute a pathologic and biologic spectrum of tumors. Accurate cytologic diagnosis of a neuroendocrine neoplasm is important since definitive treatment frequently is based on lowand high-grade categories without histologic sampling. In many instances, however, low- and high-grade NENs share cytologic features, hindering a precise classification. Since the histologic diagnostic criteria for separation of low- from high-grade categories can be based on the proliferation rate, we proposed to evaluate the usefulness of the immunocytochemical stain for the proliferation marker MIB-1 in the grading of NENs. Cytologic preparations of 63 NENs were retrieved from the files of Memorial Sloan-Kettering Cancer Center, New York, NY. One representative alcohol-fixed slide from each case was destained and restained immunocytochemically for MIB-1. When MIB-1 immunoreactivity was considered, all low-grade NENs showed immunoreactivity in fewer than 25% of the neoplastic cells, and all high-grade NENs demonstrated immunoreactivity in more than 50% of neoplastic cells. Our study demonstrates that MIB-1 dramatically stratifies NENs as low-grade or highgrade. Therefore, the proliferation index also correlates with grade of NEN in cytology specimens. Neuroendocrine neoplasms (NENs) of the lung and gastrointestinal tract constitute a pathologic and biologic spectrum of tumors. They encompass a range of tumors varying from low to high grade that includes typical carcinoids, atypical carcinoids, pancreatic endocrine neoplasms, small cell carcinomas (SCC), and large cell neuroendocrine carcinomas. The diagnostic criteria and terminology for NEN vary somewhat in different anatomic locations, but the separation into low- (or intermediate-) and high-grade categories can be based on the proliferation rate, a useful parameter, particularly in difficult cases. The low- and intermediategrade NENs include typical and atypical carcinoid tumors of the lung, pancreatic endocrine neoplasms, and carcinoid tumors of the tubular gastrointestinal tract. They are characterized by a relatively uniform population of cells with a low mitotic rate, and, although exact criteria for classification vary, they have fewer than 10 mitoses per 10 high-power fields (HPF). The high-grade NENs (SCCs and large cell neuroendocrine carcinomas), in contrast, show more pleomorphism, with more than 10 mitoses per 10 HPF and actually average almost 75 mitoses per 10 HPF. 1 The distinction of the low- and intermediate-grade

The Effect of Bolus Consistency on Dysphagia in Unilateral Vocal Cord Paralysis

Abstract: Objective To examine the risk of aspiration for liquid versus paste bolus consistencies in patients with unilateral vocal cord paralysis (UVCP). Methods The swallowing function of adult patients with UVCP was prospectively studied videofluorographically to examine the incidence of laryngeal penetration and aspiration for both liquid and paste boluses. The degree of penetration or aspiration was quantified using the penetration-aspiration scale (PAS). The presence and location of pharyngeal bolus residue were also documented for each consistency. Results were compared between liquid and paste bolus consistencies. Results Fifty-five patients with UVCP were studied with a mean age of 60.2 years. Intrathoracic surgery or malignancy accounted for 38 (69.1%) of cases. The mean PAS scores for liquid and paste bolus consistency were 3.1 vs. 1.5, respectively (P Conclusions A significant percentage of patients with UVCP will aspirate thin liquids. Paste bolus consistencies are safer for patients with UVCP as they are much less likely to lead to penetration or aspiration despite a higher prevalence of pharyngeal residue.

Prognostic significance of transient no-reflow during primary percutaneous coronary intervention for ST-elevation acute myocardial infarction.

Abstract: We found that of 1,192 patients who underwent primary percutaneous coronary intervention and who had final Thrombolysis In Myocardial Infarction grade 3 flow at the conclusion of the procedure, transient no-reflow occurred in 16 patients (1.3%). Compared with patients without transient no-reflow during the procedure, those with transient no-reflow had higher in-hospital (2% vs 13%, p = 0.04) and 6-month mortality (3% vs 31%, adjusted odds ratio 5.4, 95% confidence interval 1.01 to 29.0, p = 0.0001).

Targeting higher ferritin concentrations with intravenous iron dextran lowers erythropoietin requirement in hemodialysis patients

Abstract: INTRODUCTION Although clinical use of recombinant human erythropoietin (rHuEPO) since 1989 has improved anemia in most end-stage renal disease patients, there are still many hemodialysis patients unable to maintain an adequate hematocrit (HCT) without large doses of rHuEPO. This suggests that anemia is not solely a consequence of rHuEPO deficiency, but may be due to other factors including functional iron deficiency. Since the optimal prescription for iron replacement is not yet known, we evaluated the effect of intravenous iron dextran (IVFe) infusion on serum ferritin (SFer) concentration and rHuEPO dose. Our objective was to raise and maintain serum ferritin concentrations to 2 different levels above the National Kidney Foundation Dialysis Outcome Quality Initiative standard of 100 ng/ml to determine whether, and by what degree rHuEPO dose could be lowered. METHODS HD patients on i.v. rHuEPO with a SFer concentration > or = 70 ng/ml and an HCT of < or = 33% were enrolled. Subjects were divided as follows: Group 1: target SFer of 200 ng/ml, Group 2: target SFer of 400 ng/ml. Each subject below the target level received IVFe in up to 10 divided doses during consecutive dialysis sessions as needed to reach the target. HCT was maintained between 32.5% and 36% by adjusting rHuEPO dosage. RESULTS Mean SFer concentration at the study conclusion in Group 1: 261 ng/ml; Group 2: 387 ng/ml. The mean decrease in rHuEPO dose for Group 1 was 31 U/kg body weight/week (250 - 219 U/kg bw/wk) while in Group 2 it was 154 U/kg body weight/week (312 - 158 U/kg bw/wk) (p < 0.001). There was no difference in HCT between groups. Our results suggest that higher target serum ferritin concentrations can be well tolerated and lower rHuEPO requirements.

Effects of prior beta-blocker therapy on clinical outcomes after primary coronary angioplasty for acute myocardial infarction

Abstract: We hypothesized that pretreatment with beta blockers may improve clinical outcomes after primary angioplasty for acute myocardial infarction. We pooled clinical, angiographic, and outcomes data on 2,537 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI), PAMI-2, and Stent PAMI trials. We classified patients into a beta group (n = 1,132) if they received beta-blocker therapy before primary angioplasty or a no-beta group (n = 1,405) if they did not. We evaluated procedural complications and in-hospital and 1-year outcomes (death and major adverse cardiac events [death, reinfarction, target vessel revascularization, or stroke]) between groups. Beta patients were younger, had higher systolic blood pressure and heart rate, and were more likely to be in Killip class I at admission. They had lower left ventricular ejection fraction, greater door-to-balloon time, greater likelihood of having a left anterior descending artery culprit lesion, but a similar incidence of Thrombolysis In Myocardial Infarction 3 flow after angioplasty (92.6% vs 92.7%, p = 0.91). The beta group had less procedural complications (23% vs 34%, p <0.0001) and a lower incidence of death (1.8% vs 3.7%, p = 0.0035) and major adverse cardiac events (5.5% vs 7.8%, p = 0.027) during hospitalization. At 1 year, mortality remained lower in beta patients (4.9% vs 6.7%, log-rank p = 0.055). After adjustment for baseline differences, beta patients had significantly lower in-hospital mortality (odds ratio 0.41; 95% confidence interval 0.20 to 0.84; p <0.0148) and nonsignificantly lower 1-year mortality (odds ratio 0.72; 95% confidence interval 0.47 to 1.08; p = 0.11). Thus, pretreatment with beta blockers has an independent beneficial effect on short-term clinical outcomes in patients undergoing primary angioplasty for acute myocardial infarction.

Fifteen-year survivorship of a collarless, cemented, normalized femoral stem in primary hybrid total hip arthroplasty with a modified third-generation cement technique

Abstract: This prospective review aimed to evaluate 15-year survivorship of the collarless, third-generation cemented, normalized, Omnifit (Osteonics, Allendale, NJ) femoral stem in hybrid total hip arthroplasty (THA). Between January 1986 and June 1990, a single surgeon prospectively implanted 250 consecutive hybrid THAs (215 patients) using a modified third-generation cement technique in selected patients. A Harris-Galante (I or II) (Zimmer, Warsaw, IN) cementless shell with modular polyethylene (4150 resin) liners gamma-sterilized in air were implanted. Kaplan-Meier survivorship of the femoral or acetabular component with mechanical failure (revision for aseptic loosening) as the end-point was 100% ± 0% at 15 years. Wear couple exchange and bone grafting was performed in 1 case (0.4%) for progressive acetabular osteolysis. This report supports femoral component centralization and good cement mantle to ensure durability of the collarless, cemented, normalized femoral stem with a surface roughness of 30–40 microinches.