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1.
Hepatogastroenterology ; 60(124): 821-4, 2013 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-23282742

RESUMEN

BACKGROUND/AIM: Ultrasound marking by radiologists prior to percutaneous liver biopsy (PLB) results in biopsy site adjustment, decreased pain related complications and improved tissue yield. Minimal data exists on the impact of ultrasound marking by gastroenterologists on these parameters. The study aim was to evaluate whether ultrasound marking by gastroenterologists results in improved PLB tissue yield, fewer needle passes and decreased biopsy failure rates compared to blind biopsy, eliminating the need for a separate radiological evaluation. METHODOLOGY: All PLB performed by gastroenterologists from June 1999 to February 2003 at the University of Florida College of Medicine, Jacksonville, were reviewed retrospectively. Data collected included ultrasound marked or blind PLB, demographics, indication, number of passes performed, and specimen length, if obtained. RESULTS: Four hundred and eighty PLB were included: 328 performed with ultrasound marking and 152 blind. Ultrasound marking by gastroenterologists prior to PLB resulted in fewer passes and longer specimens as well as a decreased failure rate in ultrasound marked compared to blind PLB. CONCLUSIONS: Ultrasound marking by gastroenterologists prior to PLB provided significantly larger tissue samples, fewer needle passes and a decreased biopsy failure rate compared to blind PLB. This removes the need for a separate radiological evaluation on the procedure day.


Asunto(s)
Biopsia/métodos , Hepatopatías/patología , Ultrasonografía Intervencional , Femenino , Gastroenterología , Humanos , Hepatopatías/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
2.
South Med J ; 103(3): 207-11, 2010 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-20134378

RESUMEN

BACKGROUND: Acid suppression therapy (AST) is one of the most commonly prescribed classes of medications in hospitalized patients. Multiple studies have shown that AST is overused during inpatient admissions. However, minimal data is available regarding the frequency and patient characteristics of those discharged on unnecessary AST. The aims of the study were to examine administration of AST on admission, to characterize the patient population discharged on unnecessary AST and to determine predictive factors for inappropriate administration of AST in hospitalized patients. METHODS: A retrospective chart review of randomly selected patients admitted to the general medicine service at University of Florida Health Science Center/Jacksonville from August to October 2006 for appropriateness of AST was done. The admitting diagnosis, indications for starting AST, type of AST used, and discharge on these medications was recorded on a case by case basis. RESULTS: Seventy percent of patients were started on AST on admission. Of these, 73% were unnecessary. Stress ulcers prophylaxis in low risk patients or the concomitant use of ulcerogenic drugs motivated initiation of therapy most frequently. Sixty nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs did not predict continuation of unnecessary AST at discharge. CONCLUSION: AST is overused in hospitalized patients. This primarily occurred in low risk patients and was compounded by continuation at discharge. This significantly increases cost to the health care system and the risk of drug interactions.


Asunto(s)
Antiulcerosos/uso terapéutico , Auditoría Médica , Inhibidores de la Bomba de Protones/uso terapéutico , Centros Médicos Académicos , Antiácidos/uso terapéutico , Utilización de Medicamentos , Femenino , Florida , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Alta del Paciente
3.
J Health Care Finance ; 36(3): 1-12, 2010.
Artículo en Inglés | MEDLINE | ID: mdl-22329326

RESUMEN

This study is unique because it uses multiple regression and data envelopment analysis (DEA) to evaluate teaching hospital quality. The results support the premise that teaching hospital leadership through the effective allocation of resources can improve the quality of care. This study has managerial implications by demonstrating the positive correlation between HMO market penetration and improved clinical quality outcomes. This would suggest that improved efficiency caused by limited HMO reimbursement and tight utilization controls encourage hospitals to cut waste as well as improve their clinical care processes. Additionally, our research found that teaching hospitals with higher levels of long-term debt also had improved quality. This shows that increased investments in facilities and advanced technology at teaching hospitals can lead to enhanced quality.


Asunto(s)
Benchmarking , Hospitales de Enseñanza/organización & administración , Hospitales de Enseñanza/normas , Calidad de la Atención de Salud , Interpretación Estadística de Datos , Hospitales de Enseñanza/economía , Humanos , Análisis de Regresión , Asignación de Recursos , Estados Unidos
4.
Clin Gastroenterol Hepatol ; 7(2): 212-8, 2009 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-19061971

RESUMEN

BACKGROUND & AIMS: Pegylated interferon alfa-2a/2b is used in combination with ribavirin to treat patients with chronic hepatitis C (CHC), although many do not achieve a sustained virologic response (SVR). Albinterferon alfa-2b, a recombinant protein consisting of interferon alfa-2b fused to human albumin, may increase drug exposure. This phase 2 study evaluated the safety/efficacy of albinterferon in CHC patients who had not responded to interferon-based regimens. METHODS: A total of 115 patients were assigned to 5 groups given 1200 microg albinterferon every 4 weeks or 900, 1200, 1500, or 1800 microg every 2 weeks, plus oral ribavirin, for 48 weeks. The primary efficacy end point was achievement of an SVR after 24 weeks. Treatment was extended to 72 weeks for 6 slow responders who were negative for hepatitis C virus RNA after 24 weeks. RESULTS: The types of adverse events were similar across groups; the overall discontinuation rate as a result of adverse events was 10.4%. Reductions in absolute neutrophil counts were less frequent in the every 4 weeks group and comparable among the every 2 weeks groups. The overall SVR rate was 17% (11% for previous nonresponders to pegylated interferon-alfa/ribavirin with genotype 1 infection). An SVR occurred in 3 of 6 slow responders by 72 weeks. The greatest reductions in hepatitis C virus RNA in nonresponders to pegylated interferon-alfa/ribavirin with genotype 1 infection were observed in the 1800-microg group. CONCLUSIONS: In patients with CHC who did not respond to interferon-based regimens, higher doses of albinterferon had significant early antiviral activity and a low incidence of adverse events, with the types of adverse events similar to those observed with interferon.


Asunto(s)
Albúminas/efectos adversos , Albúminas/uso terapéutico , Antivirales/efectos adversos , Antivirales/uso terapéutico , Hepatitis C Crónica/tratamiento farmacológico , Interferón-alfa/efectos adversos , Interferón-alfa/uso terapéutico , Adulto , Albúminas/administración & dosificación , Antivirales/administración & dosificación , Femenino , Hepacivirus/efectos de los fármacos , Humanos , Interferón alfa-2 , Interferón-alfa/administración & dosificación , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Neutrófilos/efectos de los fármacos , ARN Viral/sangre , Proteínas Recombinantes , Carga Viral , Privación de Tratamiento
5.
J Gastroenterol Hepatol ; 24(4): 547-51, 2009 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-19220663

RESUMEN

BACKGROUND AND AIM: Various methods have been used to remove self expandable stents (SES) because of either malposition or migration. The main difficulties encountered in such situations are the anatomic obstacle of the lower and upper esophageal sphincters as well as risk of mucosal injury during removal. METHODS: We describe a modified approach using an esophagogastroduodenoscope (EGD) in combination with a foreign body hood protector, rat tooth forceps and snare allowing for successful SES removal from the upper gastrointestinal tract in four cases. RESULTS: In all cases, the SES were successfully removed from upper gastrointestinal tract using this technique. No complications were noted after extraction. CONCLUSION: The foreign body hood protector combined with rat tooth forceps/snare technique is a safe and effective alternative to previously described methods for extraction of SES from the upper gastrointestinal tract. This method may be applicable for the removal of other such objects within the endoscope's reach.


Asunto(s)
Remoción de Dispositivos , Esofagoscopía , Esófago/cirugía , Migración de Cuerpo Extraño/cirugía , Gastroscopía , Stents/efectos adversos , Estómago/cirugía , Adulto , Anciano , Cateterismo , Diseño de Equipo , Esofagoscopios , Femenino , Migración de Cuerpo Extraño/etiología , Gastroscopios , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Reoperación , Instrumentos Quirúrgicos , Resultado del Tratamiento
6.
J Health Care Finance ; 34(1): 19-26, 2007.
Artículo en Inglés | MEDLINE | ID: mdl-18972982

RESUMEN

This quantitative research study assesses the efficiency of university teaching hospitals in providing hospital services and graduate medical education, identifying areas in which inefficient teaching hospitals differed from their efficient counterparts. The study analyzed American Hospital Association (AHA) data from 2002 in order to examine the efficiency of Council of Teaching Hospital (COTH) hospitals. An efficiency frontier was determined using Data Envelopment Analysis, an effective method of measuring efficiency widely accepted within the health care management literature. The study found that the performance of teaching hospitals increased approximately 6.6 percent when graduate medical education (GME) was included as a key measure of output. Additionally, average excess operating expenses per hospital went from $29,447,581 without residents to $8,321,407 with residents. The average excess full-time employees decreased by 24 percent from 187 without residents to 143 with residents. Conversely, the shortage of outpatient visits increased from an average of 29,461 per hospital without residents to 36,155 with residents. This study clearly documents the need to include GME when benchmarking teaching hospitals. It also shows inefficient COTH hospitals could save approximately $1.6 billion in excess overhead expenses if they emulate the practices of the most efficient members.


Asunto(s)
Educación de Postgrado en Medicina , Eficiencia Organizacional , Hospitales de Enseñanza/normas , Bases de Datos como Asunto , Encuestas de Atención de la Salud , Rol Profesional
7.
MedGenMed ; 9(2): 8, 2007 Apr 11.
Artículo en Inglés | MEDLINE | ID: mdl-17955064

RESUMEN

Pancreatic pseudocyst, a common complication of acute or chronic pancreatitis, in rare instances may also extend to the mediastinum. A case of 67-year-old woman presenting with a triad of chest pain, dysphagia, and dyspnea is presented. The patient had an episode of acute alcoholic pancreatitis 1 year before presentation. Chest radiography on admission showed a retrocardiac opacity. Two-dimensional echocardiography revealed an echolucent mass compressing the left atrium. A subsequent upper gastrointestinal series for her dysphagia showed extrinsic compression of the distal esophagus. Finally a definitive diagnosis was made with computed tomography (scan), which revealed a 19 x 12 cm pseudocyst extending from the body of pancreas into the thorax and compressing the esophagus and the cardiac chambers. A mediastinal pseudocyst can cause symptoms due to compression or invasion of surrounding structures. The fluid collection may enlarge slowly and hence the symptoms can be delayed as in our patient. The pseudocyst was successfully treated using endoscopic ultrasound-guided transesophageal drainage. Approximately 50 cases of mediastinal extension of the pancreatic pseudocyst in the world literature are reported. At this time, this is only the second time that successful drainage of a mediastinal pseudocyst using a transesophageal approach under endoscopic ultrasound guidance has been reported. The literature was reviewed for clinical presentation, complications, and available treatment options for mediastinal pancreatic pseudocysts.


Asunto(s)
Quiste Mediastínico/diagnóstico , Quiste Mediastínico/cirugía , Seudoquiste Pancreático/diagnóstico , Seudoquiste Pancreático/cirugía , Anciano , Diagnóstico Diferencial , Femenino , Humanos , Quiste Mediastínico/complicaciones , Seudoquiste Pancreático/complicaciones , Succión
8.
Antivir Ther ; 11(7): 901-8, 2006.
Artículo en Inglés | MEDLINE | ID: mdl-17302252

RESUMEN

Albumin-interferon-alpha (alb-IFN) is a novel recombinant protein derived from IFN-alpha2b genetically fused to human albumin. The resulting single polypeptide combines in one molecule the antiviral properties of IFN-alpha with the long serum half-life of albumin. IFN-mediated biological responses stem from the engagement of IFN-alpha with its target receptor and subsequent modulation of IFN-specific gene (ISG) expression. To evaluate the pharmacodynamics of alb-IFN during the Phase I/II study conducted in patients with chronic hepatitis C (CHC) who had previously failed IFN-alpha-containing regimens, ISG induction was evaluated in peripheral blood and compared with antiviral response. Whole blood was obtained at day 0, day 7 and day 28 from 21 patients enrolled in the higher dose (500-900 microg) alb-IFN cohort, who received two injections on day 0 and day 14. Taqman real-time PCR was used to assess candidate ISG expression. There was sustained induction on day 7 and day 28 of the ISG's OAS1, IRF-7, IFI44 and IFI27. Although all patients showed a molecular response to alb-IFN, individual variability in pretreatment gene expression levels and fold of modulation during treatment was observed. At day 28, induction of OAS1, IFI44 and IRF7 showed pairwise correlation in individual patients (P < 0.05). Moreover, the induction of expression at day 28, and pretreatment levels of OAS1 and IFI44 correlated with hepatitis C virus RNA reduction at day 28 (P < 0.05). In conclusion, alb-IFN demonstrated robust induction of ISG that was consistent with the response associated with an IFN-alpha.


Asunto(s)
Regulación de la Expresión Génica , Hepacivirus , Hepatitis C Crónica/tratamiento farmacológico , Interferón-alfa/uso terapéutico , Albúmina Sérica/uso terapéutico , 2',5'-Oligoadenilato Sintetasa/genética , 2',5'-Oligoadenilato Sintetasa/metabolismo , Antígenos/genética , Antígenos/metabolismo , Estudios de Cohortes , Proteínas del Citoesqueleto/genética , Proteínas del Citoesqueleto/metabolismo , Femenino , Hepatitis C Crónica/genética , Hepatitis C Crónica/virología , Humanos , Inyecciones Subcutáneas , Factor 7 Regulador del Interferón/genética , Factor 7 Regulador del Interferón/metabolismo , Interferón alfa-2 , Interferón-alfa/administración & dosificación , Interferones , Leucocitos Mononucleares/inmunología , Leucocitos Mononucleares/metabolismo , Masculino , Proteínas de la Membrana/genética , Proteínas de la Membrana/metabolismo , Persona de Mediana Edad , Proteínas Recombinantes , Albúmina Sérica/administración & dosificación , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Carga Viral
9.
Antivir Ther ; 11(1): 35-45, 2006.
Artículo en Inglés | MEDLINE | ID: mdl-16518958

RESUMEN

Albumin-interferon-alpha (IFN-alpha) is a novel 85.7-kDa recombinant protein consisting of IFN-alpha that is genetically fused to human serum albumin. In this Phase I/II, multicentre, open-label study, we evaluated the safety and tolerability, pharmacokinetics and pharmacodynamics of albumin-IFN-alpha in IFN-alpha-experienced patients with chronic hepatitis C. Albumin-IFN-alpha was administered in 22 escalating doses (7-900 microg) in a single injection or in two injections 14 days apart. In the 119 patients studied, there were no discontinuations because of adverse events, and albumin-IFN-alpha had a favourable safety profile at doses up to 900 microg. The most common adverse events were headache (56%), fatigue (52%), injection site erythema (38%), arthralgias (32%) and pyrexia (27%). Reduced clearance resulted in a mean elimination half-life of 159 h, which supports dosing at 2- to 4-week intervals. Induction of the IFN-specific gene OAS1 was maintained for > or = 28 days following a single injection of albumin-IFN-alpha at doses of > or = 40 microg. Dose-dependent antiviral activity was observed in this IFN-alpha-experienced study population. Antiviral activity of > or = 1.0-log reductions in HCV RNA was observed in 47% (37/78) of patients in the 120- to 900-microg cohorts and in 59% (16/27) in the 400- to 900-microg double-injection cohorts. These results support further clinical studies of albumin-IFN-alpha for the treatment of patients with chronic hepatitis C.


Asunto(s)
Antivirales/efectos adversos , Antivirales/farmacocinética , Hepatitis C Crónica/tratamiento farmacológico , Interferón-alfa/administración & dosificación , Interferón-alfa/efectos adversos , Interferón-alfa/farmacocinética , Albúmina Sérica/administración & dosificación , Albúmina Sérica/efectos adversos , Albúmina Sérica/farmacocinética , Adulto , Anciano , Antivirales/administración & dosificación , Antivirales/uso terapéutico , Relación Dosis-Respuesta a Droga , Femenino , Hepatitis C Crónica/virología , Humanos , Interferón-alfa/uso terapéutico , Masculino , Persona de Mediana Edad , Albúmina Sérica/uso terapéutico , Albúmina Sérica Humana , Resultado del Tratamiento
10.
Chest ; 130(4): 1096-101, 2006 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-17035443

RESUMEN

BACKGROUND AND AIMS: The impact of gastroesophageal reflux disease (GERD) on exacerbations of COPD has never been evaluated. The aims of this investigation were to determine the prevalence of gastroesophageal reflux (GER) symptoms in COPD patients and the effect of GER on the rate of exacerbations of COPD per year. METHODS: A questionnaire-based, cross sectional survey was performed. Subjects were recruited from the outpatient pulmonary clinics at the University of Florida Health Science Center/Jacksonville. Included patients had an established diagnosis of COPD. Exclusion criteria were respiratory disorders other than COPD, known esophageal disease, active peptic ulcer disease, Zollinger-Ellison syndrome, mastocytosis, scleroderma, and current alcohol abuse. Those meeting criteria and agreeing to participate were asked to complete the Mayo Clinic GERD questionnaire by either personal/telephone interview. Clinically significant reflux was defined as heartburn and/or acid regurgitation weekly. Other outcome measures noted were frequency and type of COPD exacerbations. Statistical analysis was performed using the Fisher exact test for categorical data and the independent t test for interval data. RESULTS: Eighty-six patients were enrolled and interviewed (mean age, 67.5 years). Male patients accounted for 55% of the study group. Overall, 37% of patients reported GER symptoms. The mean FEV(1) percentage of predicted was similar in those with or without GER. The rate of exacerbations of COPD was twice as high in patients with GER symptoms compared to those without GER symptoms (3.2/yr vs 1.6/yr, p = 0.02). CONCLUSIONS: The presence of GER symptoms appears to be associated with increased exacerbations of COPD.


Asunto(s)
Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/etiología , Anciano , Antiácidos/administración & dosificación , Antiulcerosos/administración & dosificación , Comorbilidad , Progresión de la Enfermedad , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Reflujo Gastroesofágico/tratamiento farmacológico , Antagonistas de los Receptores H2 de la Histamina/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de la Bomba de Protones , Fumar/efectos adversos , Fumar/epidemiología , Estadística como Asunto , Resultado del Tratamiento
11.
Gastrointest Endosc ; 67(3): 519-21, 2008 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-18294515

RESUMEN

BACKGROUND: Various methods have been used to remove foreign bodies; hollow foreign bodies deserve special consideration. The main difficulty encountered in such situations is the anatomic obstacle of the lower and upper esophageal sphincters along with a risk of perforation. OBJECTIVE: We describe a unique approach by using an esophageal balloon dilator to anchor a hollow foreign body onto an endoscope, which allows for the successful extraction of such objects with minimal risk. DESIGN: Case series. SETTING: Shands Jacksonville and University of Florida/Jacksonville, Jacksonville, Florida. PATIENTS: Two consecutive patients with hollow foreign bodies in the stomach that required removal. INTERVENTIONS: A combined approach by using an endoscope and a 20-mm by 8-cm esophageal balloon dilator to remove hollow foreign bodies from the stomach. MAIN OUTCOME MEASUREMENTS: Nonsurgical removal of hollow gastric foreign bodies. RESULTS: Both foreign bodies were successfully removed from the stomach and extracted by mouth with this technique. There were no complications after both procedures. CONCLUSIONS: The inflated esophageal balloon that anchors a hollow foreign body onto a flexible endoscopic technique is a safe and effective alternative to previously described methods for removal of such foreign bodies in the gastric cavity. This method may be applicable to the removal of other hollow objects within the gastric lumen.


Asunto(s)
Cateterismo/instrumentación , Endoscopía Gastrointestinal/métodos , Cuerpos Extraños/cirugía , Estómago , Humanos , Masculino , Persona de Mediana Edad
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