Ochsner Medical Center

About: Ochsner Medical Center is a healthcare organization based out in New Orleans, Louisiana, United States. It is known for research contribution in the topics: Population & Heart failure. The organization has 980 authors who have published 1159 publications receiving 49961 citations. The organization is also known as: Ochsner Hospital & Ochsner Foundation Hospital.

Evaluating the impact of peer comparison on vancomycin dose order verification among pharmacists

Abstract: To evaluate the effect of blinded and unblinded peer comparison on appropriateness of vancomycin dose order verification.

Decompressive hemicraniectomy in the management of subcortical spontaneous intracerebral hemorrhage.

Abstract: Background: The benefit of decompressive hemicraniectomy in patients with malignant acute ischemic stroke is well established, however its role in supratentorial intracerebral hemorrhages is unclear and evolving. Prior studies combined cortical and subcortical hemorrhages in their analysis despite their different natural history. Subcortical hematoma is associated with worse outcomes due to mechanical compression of subcortical structures. We describe outcomes of a matched comparison of patients with spontaneous subcortical hemorrhage managed with hemicraniectomy versus medical management alone. Methods: Using our "Get-with-the-guideline stroke" database, patients with spontaneous subcortical hematoma managed with hemicraniectomy were identified. Using age, gender, and hematoma volume (categorized as 0-30, 30-60, >60ml), patients managed with hemicraniectomy were matched with medical management alone. Outcomes included hospital length of stay, discharge disposition, and Glasgow outcome score. Results: Eight patients with subcortical hematoma managed with hemicraniectomy were matched with 22 medically managed patients. Other than use of antithrombotics, clinical characteristics did not differ between groups. On comparing outcomes, hospital length of stay in the hemicraniectomy group (26.5 vs 12.5 days p = 0.006) was significantly longer. Discharge disposition did not differ between groups (75% vs 36.4% p = 0.101). Despite a higher frequency of Glasgow outcome score >= 3 at 90 days amongst hemicraniectomy cases, there was no significant difference between groups (71.3% vs 54.5% p = 0.535). Conclusion: Hemicraniectomy for subcortical hematoma was associated with a prolonged hospital stay. Despite improving survival and favorable discharge disposition, there was no statistically significant difference between groups. Further studies on the benefit of hemicraniectomy in subcortical hematoma are needed.

Cardiopulmonary stress testing in patients with pulmonary artery hypertension.

Abstract: To the Editor: We read with interest and applaud the recent article by Taichman et al1 that examined the limitations of subjectively determining functional class in patients with pulmonary artery hypertension (PAH). As with heart failure (HF), PAH often leads to a substantial reduction in exercise tolerance. Thus, assessing the degree to which functional capacity is limited becomes an important aspect of examination of patients with PAH. The authors appropriately state that the modified New York Heart Association (NYHA) functional classification system, adopted by the World Health Organization (WHO), is frequently used for the following: (1) to describe patients enrolled in clinical trials, (2) to gauge their treatment response to a given intervention, and (3) to guide treatment in clinical practice. Of the participating clinicians in the study by Taichman et al, 96% indicated that they “use the NYHA/WHO functional classification as part of their evaluation when selecting therapy for their patients.” Because an interclass correlation coefficient failed to reach 0.70 in any analytic scenario and often fell well below this value, the poor NYHA/WHO functional class agreement among experienced clinicians for an individual patient clearly illustrates the need for a more objective, reliable, and valid measure of physical capacity in patients with PAH. Cardiopulmonary exercise testing (CPX) is considered the criterion standard for determining both submaximal exercise tolerance (ie, ventilatory anaerobic threshold) and maximal aerobic capacity.2 This technique is well established in patients diagnosed as having HF and provides an objective quantification of disease severity that prognostically outperforms the NYHA classification.3-6 Moreover, several CPX variables favorably respond to numerous lifestyle, pharmacological, and surgical interventions in patients with HF.7 Our group has recently summarized the evidence (>20 original research investigations) that shows the potential clinical and research value of CPX in patients with PAH.8 Both peak oxygen consumption and measures of pulmonary gas exchange efficiency (Ve/Vco2 and Petco2) are highly reflective of disease severity (ie, the degree of PAH and functional limitation), favorably respond to several pharmacological interventions, and may provide valuable prognostic insight. The use of CPX in patients with PAH allows clinicians and researchers to eliminate interrater variation of functional classification, accurately quantify the effect of the disease state on maximal and submaximal exercise tolerance, and have more confidence in attributing improvements after a given intervention to a true physiologic adaptation as opposed to poor measurement reliability (ie, NYHA/WHO class). However, use of CPX to objectively quantify functional status requires an increased cost, additional equipment, and personnel properly trained in conducting this exercise assessment. Other scientific guideline statements provide a detailed description of the essential components required for conducting CPX in a safe, reliable, and valid manner.9 Given the attention functional classification is afforded in both the clinical and the research settings, the importance of its accurate quantification in patients with PAH supersedes the additional cost, equipment, and personnel requirements. Taichman et al1 eloquently illustrated the limitations of subjective functional classification in patients with PAH. The next step is to augment the implementation of a more objective, reliable, and valid measure of functional status in this patient population. On the basis of our recent literature review,8 there appears to be an evidence-based rationale for use of CPX in patients with PAH in both the clinical and the research settings.

Does the addition of adjuvant intraoperative tumor bed chemotherapy during midgut neuroendocrine tumor debulking procedures benefit patients

Abstract: Background: Midgut neuroendocrine tumor (NET) patients are often diagnosed at advanced stages with extensive mesenteric nodal and hepatic metastasis. The only potentially curative treatment is surgical tumor eradication. Despite an aggressive resection, macro and microscopic residual disease still may remain in the resection bed. We hypothesize that the application of 5-fluorouracil (5-FU) within the tumor bed will help eliminate microscopic residual disease. Methods: Records of 189 patients who underwent extensive cytoreductive surgeries during 2003–2012 for advanced, midgut NETs with extensive mesenteric lymphadenopathy were reviewed. Eighty-six patients (46%) who had 5-FU saturated gel foam strips secured into their mesenteric resection sites served as the study group and a matching 103 patients (54%) who did not have such an intra-operative chemotherapy served as controls. Survival from the time of diagnosis and post-operative complications between the two groups were compared. Results: Mortality rates at 30, 60 and 90 days post-operatively were 4%, 0%, 0% versus 2%, 0%, 2% for study and control groups, respectively. Major complications (Grades III & IV) at the same intervals were 0, 0, 1 versus 2, 3, 2 for study and control groups, respectively. Median survival was 236 months versus 148 months for the study and control groups, respectively 24 (P=0.15). Conclusions: Intraoperative tumor resection bed chemotherapy is a safe adjuvant without discernible toxicity. This procedure may provide survival benefits to midgut NET patients with extensive mesenteric lymphadenopathy undergoing extensive cytoreductive surgery. Further study in prospective trials must be conducted to determine definitive benefit to the NET patient.

Cardiovascular Outcomes and Angiotensin Converting Enzyme Inhibitors: Beyond Blood Pressure Control

Abstract: Atherosclerosis and its complications, stroke, coronary artery disease and peripheral arterial disease, remain the leading cause of mortality and morbidity and are increasing in incidence in the developing world [1]. Multiple mechanisms are associated with the development of atherosclerosis but since the discovery of renin by Tigerstedt and Bergman [2] more that 100 years ago, the renin–angiotensin system (RAS) has been focus of intensive investigative efforts. Although our understanding of the RAS and the development of atherosclerosis has grown increasingly complex, inhibition of the RAS with an angiotensinconverting enzyme inhibitor (ACE-I) has become a firmly established therapeutic approach for reducing morbidity and the risk of death across a broad spectrum of cardiovascular diseases based on multiple, well-conducted, randomized clinical outcome trials (RCT) [3–6]. The benefits of ACE-I on clinical outcomes are due in part to blood pressure control but other mechanisms beyond blood pressure lowering, such as their anti-atherosclerotic properties has been postulated in recent clinical trials [7]. These clinical trials have broadened our knowledge of management of cardiovascular risk The Heart Outcome Prevention and Evaluation (HOPE) study [8] demonstrated the benefits of ACE-I on clinical outcomes in patients with established atherosclerosis or diabetes. The HOPE study by excluding patients with left ventricular systolic dysfunction and heart failure made obvious that the ACE-I ramipril not only reduced cardiovascular mortality, but also significantly reduced incidence of myocardial infarction and stroke. Similarly, the European Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA) [9] study demonstrated that inhibition of the RAS with an ACE-I perindopril will result in secondary prevention of coronary events in a much broader population, patients with stable coronary disease irrespective of risk profile. The ACE-I perindopril in EUROPA [9] significantly reduced the combined endpoint of cardiovascular death, non-fatal myocardial infarction, and resuscitated sudden cardiac death by 20%. However studies such as PEACE [10] failed to replicate the results of EUROPA and HOPE. In the PEACE trial, patients with coronary artery disease and with preserved left ventricular systolic function treated with ACE-I trandolapril in a dose of 4 mg for several years did not show any reduction in cardiovascular outcomes. The lack of benefits of trandolapril in PEACE may be due to a lower cardiovascular risk population included in the trial and that patients were optimally treated with other evidence based treatments such as statins, beta blockers, antiplatelets and revascularization therefore they do not benefit with additional ACE-I. Cardiovasc Drugs Ther (2009) 23:109–111 DOI 10.1007/s10557-008-6152-5