Carlos Estrada - Academia.edu (original) (raw)

Papers by Carlos Estrada

Research paper thumbnail of Outpatient Management of Cirrhosis: A Narrative Review

Southern Medical Journal, 2006

Cirrhosis is the 12th leading cause of death in the United States. Individuals with cirrhosis are... more Cirrhosis is the 12th leading cause of death in the United States. Individuals with cirrhosis are at risk for many potential complications. Complications can be managed or detected early with proper outpatient management. The most lethal of these complications is bleeding esophageal varices. All patients with cirrhosis should be screened for the presence of varices and treated when indicated. The most common complication seen in these patients is ascites. Ascites can be treated with dietary modifications and a diuretic regimen. Other potential complications include spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatic encephalopathy, hepatorenal syndrome, and hepatopulmonary syndrome. The outpatient management of these complications will be discussed in this paper, along with the use of vaccinations, educating patients about the avoidance of hepatotoxic drugs, and when to refer a patient for liver transplant.

Research paper thumbnail of Cultural Competencies Online for Medical Practice (CCOMP): A Clinician's Guide to Reduce Cardiovascular Disparities (Out of Print)

MedEdPORTAL Publications, 2009

Research paper thumbnail of The Chemokine System and Arthritis

The Receptors, 2007

Page 1. 10 The Chemokine System and Arthritis Marlon P. Quinones, Fabio Jimenez, Carlos A. Estrad... more Page 1. 10 The Chemokine System and Arthritis Marlon P. Quinones, Fabio Jimenez, Carlos A. Estrada, Hernan G. Martiniez, and Seema S. Ahuja Summary Rheumatoid arthritis (RA) affects 1% of the US population, or 3 million people. ...

Research paper thumbnail of Ultrasonography of the Pediatric Bladder

Research paper thumbnail of Nominal group technique: a tool for course evaluation

Research paper thumbnail of Critical Evaluation of Existing Methods for Accounting for Multiphase Effects Around Producers in Depleting Gas Condensate Reservoirs

SPE Gas Technology Symposium, 2006

Research paper thumbnail of Critical Evaluation of Existing Methods for Accounting for Multiphase Effects Around Producers in Depleting Gas/Condensate Reservoirs

Proceedings of SPE Gas Technology Symposium, 2006

Research paper thumbnail of Autoimmune Hemolytic Anemia and Rheumatoid Arthritis

Southern Medical Journal, 1990

The incidence of AIHA in patients with rheumatoid arthritis has not been shown to exceed that in ... more The incidence of AIHA in patients with rheumatoid arthritis has not been shown to exceed that in the general population. The prevalence of rheumatoid arthritis in patients with AIHA approximates that in the general population. On the basis of these data, it is extremely difficult to establish a relationship between AIHA and rheumatoid arthritis. The patient we have described had the unusual presentation of AIHA with rheumatoid arthritis. We believe the two remain distinct entities.

Research paper thumbnail of Acetaminophen and Risk Factors for Excess Anticoagulation With Warfarin

JAMA, 1998

To the Editor.—The article by Dr Hylek et al 1 brings a wealth of much-needed information to clin... more To the Editor.—The article by Dr Hylek et al 1 brings a wealth of much-needed information to clinicians managing individual patients (usual clinical practice) and to specialized anticoagulant therapy units. Even though no randomized trial data exist, anticoagulant ...

Research paper thumbnail of Positive Affect Facilitates Integration of Information and Decreases Anchoring in Reasoning among Physicians

Organizational Behavior and Human Decision Processes, 1997

The present study investigated the influence of positive affect on clinical reasoning among pract... more The present study investigated the influence of positive affect on clinical reasoning among practicing physicians using a simulated patient protocol. Forty-four internists were randomized to one of three groups; a control group, an affect-induction group, in which they received a small package of candy, or a group that was asked to read humanistic statements regarding the practice of medicine. Physicians “thought aloud” while they solved a case of a patient with liver disease. Two raters reviewed the transcripts to determine how soon the liver disease domain was considered, or at what point it was established, and the degree of anchoring displayed (distortion or inflexibility in thinking). The Affect group initially considered the diagnosis of liver disease significantly earlier in the protocol (20 vs 39%, or 19% earlier; 95% confidence interval; 6 to 32%,p= .008) and showed significantly less anchoring than did controls (means of 1.5 vs 3.9, or a difference of 2.4 in a scale of 1 to 10; 95% confidence interval; 0.3 to 4.5,p= .031). The Affect and Control groups established the diagnosis at similar points in the protocol. Ancillary analyses examined questions relevant to the amounts of heuristic processing, premature closure, jumping to a diagnosis without sufficient evidence, or other evidence of superficial or flawed processing. No other differences were found. Physicians in whom positive affect had been induced integrated information earlier (considered liver) and demonstrated less anchoring, but did not show evidence of premature closure or other superficial processing.

Research paper thumbnail of Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting

Annals of Thoracic Surgery, 2003

The association between perioperative hyperglycemia and outcomes in patients with and without dia... more The association between perioperative hyperglycemia and outcomes in patients with and without diabetes mellitus undergoing coronary artery bypass grafting is not well defined. We measured the association between perioperative hyperglycemia and outcomes among patients undergoing coronary artery bypass grafting.We report a historic cohort study of 1574 patients who had undergone coronary artery bypass grafting between 1998 and 1999, 545 (34.6%) with diabetes. Perioperative blood glucose level was defined as the average of all blood glucose tests obtained on the day of and the day after surgery. Outcomes were 30-day mortality, infection rates (sternum, harvest site, sepsis, pneumonia, urinary tract), and resource utilization.After adjusting for diabetes status and calculated preoperative mortality or mediastinitis risk scores, each 50 mg/dL (2.78 mmol/L) blood glucose increase was not statistically associated with higher mortality (odds ratio 1.37; 95% confidence interval, 0.98 to 1.92; p = 0.07), or higher infection rate (odds ratio 1.23, 95% confidence interval 0.94 to 1.60; p = 0.14). Each 50 mg/dL blood glucose increase was associated with longer postoperative days by 0.76 days (95% confidence interval 0.36 to 1.17 days; p < 0.001), increased hospitalization charges by 2824(952824 (95% confidence interval 2824(951599 to 4049;p<0.001),andincreasedhospitalizationcostby4049; p < 0.001), and increased hospitalization cost by 4049;p<0.001),andincreasedhospitalizationcostby1769 (95% confidence interval 928to928 to 928to2610; p < 0.001). In the unadjusted analysis, infections occurred more frequently in patients with diabetes (6.6% vs 4.1%, p = 0.03).Perioperative hyperglycemia is associated with increased resource utilization in patients undergoing coronary artery bypass grafting with and without diabetes.

Research paper thumbnail of Literacy and Numeracy Skills and Anticoagulation Control

American Journal of The Medical Sciences, 2004

The ability to use printed material to function in society (literacy) and to handle basic numeric... more The ability to use printed material to function in society (literacy) and to handle basic numerical concepts (numeracy) may have implications in patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; ability to follow dosing schedules. We examined literacy and numeracy skills among patients on warfarin and explored their association with anticoagulation control. Patients older than 50 years attending two anticoagulation management units were prospectively enrolled. We measured literacy, numeracy, and international normalized ratio (INR). During a 3-month follow-up period, we calculated the variability of the INR and the amount of time a patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s INR was within his or her therapeutic range, variables associated with bleeding and effectiveness. Among 143 patients, only 75 (52.4%) were able to read health-related words at the eighth grade level or less. Patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; self-reported grade completed was higher than the measured literacy grade level (kappa = 0.21). While 79.0% had completed at least eight grades, only 47.6% had a score at that grade level. Sixty-nine patients answered none or correctly answered fewer than two of the six numeracy questions (48.3%). The INR variability was higher among patients with lower literacy (P = 0.009) and lower numeracy skills (P = 0.004). The time in range was similar among patients at different literacy levels (P = 0.9). Patients with lower numeracy level spent more time above their therapeutic range (P = 0.04) and had a trend of less time spent in range (P = 0.10). Low literacy was prevalent among study patients taking warfarin. Low literacy and numeracy were associated with measures of poor anticoagulation control.

Research paper thumbnail of Hydroxyethyl starch in severe sepsis: end of starch era?

Critical Care, 2013

Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjæ... more Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP, Winkel P, Wetterslev J; 6S Trial Group; Scandinavian Critical Care Trials Group: Hydroxyethyl starch 130/0.42 versus Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate in severe sepsis. N Engl J Med 2012, 367:124-34. Hydroxyethyl starch (HES) is widely used for fluid resuscitation in ICUs, but its safety and efficacy have not been established in patients with severe sepsis. To assess the effects of HES 130/0.4 compared with a balanced crystalloid solution on mortality and end-stage kidney failure in patients with severe sepsis. Multicenter, parallel-group, blinded, randomized clinical trial, in patients with severe sepsis. Patients with severe sepsis admitted to the ICU received fluid resuscitation with either 6% HES 130/0.42 (Tetraspan) or Ringer’s acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate (relative risk, 1.17; 95% confidence interval (CI), 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal replacement therapy versus 65 patients (16%) assigned to Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline. Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal replacement therapy compared with those receiving Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate.

Research paper thumbnail of Zafirlukast in Asthma

Annals of Internal Medicine, 1998

... Samy Suissa, PhD Pierre Ernst, MD McGill University Montreal, Quebec H3A 1A3, Canada Rodolfo ... more ... Samy Suissa, PhD Pierre Ernst, MD McGill University Montreal, Quebec H3A 1A3, Canada Rodolfo Dennis, MD Universidad Javeriana Bogota, Colombia ... Sanyal and coworkers reported a higher percentage of patients with Child-Pugh class C cirrhosis (49%) (1) than were ...

Research paper thumbnail of Mechanical stretch is a highly selective regulator of

Am. J. Respir. Cell Mol. Biol, Apr 1, 2006

Research paper thumbnail of Clinical prediction rule for stratifying risk of pulmonary multidrug-resistant tuberculosis

Research paper thumbnail of Mechanical stretch is a highly selective regulator of gene expression in human bladder smooth muscle cells

Physiological genomics, Jan 15, 2004

Research paper thumbnail of Implementation Research: Beyond the Traditional Randomized Controlled Trial

Essentials of Clinical Research, 2014

... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report ... more ... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report from the Institute of Medicine drew attention to patient safety and the concept of preventable injury.14 Studies of patient safety have focused on “medical error resulting in an inappropri-ate ...

Research paper thumbnail of Implementation Research: Beyond the Traditional Randomized Controlled Trial

Essentials of Clinical Research, 2008

... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report ... more ... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report from the Institute of Medicine drew attention to patient safety and the concept of preventable injury.14 Studies of patient safety have focused on “medical error resulting in an inappropri-ate ...

Research paper thumbnail of HER2/neu protein overexpression and gene amplification in human transitional cell carcinoma of the bladder

Urology, 2004

To assess HER-2/neu gene status by fluorescence in situ hybridization and protein expression by i... more To assess HER-2/neu gene status by fluorescence in situ hybridization and protein expression by immunohistochemistry in human bladder transitional cell carcinoma (TCC). In breast carcinoma, HER-2/neu gene amplification and receptor protein overexpression are tightly correlated and have prognostic and therapeutic implications.We used 54 randomly selected TCC specimens obtained from 1998 to 2000. Each specimen was fixated in 10% neutral-buffered formalin and embedded in paraffin. Of the 54 specimens, 7 were grade 1 (13%), 26 were grade 2 (48%), and 21 were grade 3 (39%); 36 (67%) were superficial (Stage Ta or T1) and 18 (33%) were invasive (Stage T2 or T3). The specimens were analyzed for HER-2/neu protein overexpression by immunohistochemistry and for gene amplification using fluorescence in situ hybridization.Of the 54 specimens, 14 (26%) were positive for protein overexpression. One (14%) of the 7 grade 1 tumors was positive for protein overexpression, 3 (12%) of 26 grade 2 tumors were positive, and 10 (48%) of 21 grade 3 tumors were positive (P = 0.0195). Six (17%) of 36 Stage Ta or T1 specimens and 8 (44%) of 18 Stage T2 or T3 specimens were positive for protein overexpression (P = 0.01). None of the 54 TCC specimens showed amplification of the HER-2/neu gene using fluorescence in situ hybridization.HER-2/neu protein overexpression is present in human bladder TCC, with a statistically significant increase in overexpression in grade 3, and invasive specimens. Gene amplification does not appear to be the mechanism of protein overexpression. The prognostic significance of these findings and the application of HER-2/neu in treatment needs additional investigation.

Research paper thumbnail of Outpatient Management of Cirrhosis: A Narrative Review

Southern Medical Journal, 2006

Cirrhosis is the 12th leading cause of death in the United States. Individuals with cirrhosis are... more Cirrhosis is the 12th leading cause of death in the United States. Individuals with cirrhosis are at risk for many potential complications. Complications can be managed or detected early with proper outpatient management. The most lethal of these complications is bleeding esophageal varices. All patients with cirrhosis should be screened for the presence of varices and treated when indicated. The most common complication seen in these patients is ascites. Ascites can be treated with dietary modifications and a diuretic regimen. Other potential complications include spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatic encephalopathy, hepatorenal syndrome, and hepatopulmonary syndrome. The outpatient management of these complications will be discussed in this paper, along with the use of vaccinations, educating patients about the avoidance of hepatotoxic drugs, and when to refer a patient for liver transplant.

Research paper thumbnail of Cultural Competencies Online for Medical Practice (CCOMP): A Clinician's Guide to Reduce Cardiovascular Disparities (Out of Print)

MedEdPORTAL Publications, 2009

Research paper thumbnail of The Chemokine System and Arthritis

The Receptors, 2007

Page 1. 10 The Chemokine System and Arthritis Marlon P. Quinones, Fabio Jimenez, Carlos A. Estrad... more Page 1. 10 The Chemokine System and Arthritis Marlon P. Quinones, Fabio Jimenez, Carlos A. Estrada, Hernan G. Martiniez, and Seema S. Ahuja Summary Rheumatoid arthritis (RA) affects 1% of the US population, or 3 million people. ...

Research paper thumbnail of Ultrasonography of the Pediatric Bladder

Research paper thumbnail of Nominal group technique: a tool for course evaluation

Research paper thumbnail of Critical Evaluation of Existing Methods for Accounting for Multiphase Effects Around Producers in Depleting Gas Condensate Reservoirs

SPE Gas Technology Symposium, 2006

Research paper thumbnail of Critical Evaluation of Existing Methods for Accounting for Multiphase Effects Around Producers in Depleting Gas/Condensate Reservoirs

Proceedings of SPE Gas Technology Symposium, 2006

Research paper thumbnail of Autoimmune Hemolytic Anemia and Rheumatoid Arthritis

Southern Medical Journal, 1990

The incidence of AIHA in patients with rheumatoid arthritis has not been shown to exceed that in ... more The incidence of AIHA in patients with rheumatoid arthritis has not been shown to exceed that in the general population. The prevalence of rheumatoid arthritis in patients with AIHA approximates that in the general population. On the basis of these data, it is extremely difficult to establish a relationship between AIHA and rheumatoid arthritis. The patient we have described had the unusual presentation of AIHA with rheumatoid arthritis. We believe the two remain distinct entities.

Research paper thumbnail of Acetaminophen and Risk Factors for Excess Anticoagulation With Warfarin

JAMA, 1998

To the Editor.—The article by Dr Hylek et al 1 brings a wealth of much-needed information to clin... more To the Editor.—The article by Dr Hylek et al 1 brings a wealth of much-needed information to clinicians managing individual patients (usual clinical practice) and to specialized anticoagulant therapy units. Even though no randomized trial data exist, anticoagulant ...

Research paper thumbnail of Positive Affect Facilitates Integration of Information and Decreases Anchoring in Reasoning among Physicians

Organizational Behavior and Human Decision Processes, 1997

The present study investigated the influence of positive affect on clinical reasoning among pract... more The present study investigated the influence of positive affect on clinical reasoning among practicing physicians using a simulated patient protocol. Forty-four internists were randomized to one of three groups; a control group, an affect-induction group, in which they received a small package of candy, or a group that was asked to read humanistic statements regarding the practice of medicine. Physicians “thought aloud” while they solved a case of a patient with liver disease. Two raters reviewed the transcripts to determine how soon the liver disease domain was considered, or at what point it was established, and the degree of anchoring displayed (distortion or inflexibility in thinking). The Affect group initially considered the diagnosis of liver disease significantly earlier in the protocol (20 vs 39%, or 19% earlier; 95% confidence interval; 6 to 32%,p= .008) and showed significantly less anchoring than did controls (means of 1.5 vs 3.9, or a difference of 2.4 in a scale of 1 to 10; 95% confidence interval; 0.3 to 4.5,p= .031). The Affect and Control groups established the diagnosis at similar points in the protocol. Ancillary analyses examined questions relevant to the amounts of heuristic processing, premature closure, jumping to a diagnosis without sufficient evidence, or other evidence of superficial or flawed processing. No other differences were found. Physicians in whom positive affect had been induced integrated information earlier (considered liver) and demonstrated less anchoring, but did not show evidence of premature closure or other superficial processing.

Research paper thumbnail of Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting

Annals of Thoracic Surgery, 2003

The association between perioperative hyperglycemia and outcomes in patients with and without dia... more The association between perioperative hyperglycemia and outcomes in patients with and without diabetes mellitus undergoing coronary artery bypass grafting is not well defined. We measured the association between perioperative hyperglycemia and outcomes among patients undergoing coronary artery bypass grafting.We report a historic cohort study of 1574 patients who had undergone coronary artery bypass grafting between 1998 and 1999, 545 (34.6%) with diabetes. Perioperative blood glucose level was defined as the average of all blood glucose tests obtained on the day of and the day after surgery. Outcomes were 30-day mortality, infection rates (sternum, harvest site, sepsis, pneumonia, urinary tract), and resource utilization.After adjusting for diabetes status and calculated preoperative mortality or mediastinitis risk scores, each 50 mg/dL (2.78 mmol/L) blood glucose increase was not statistically associated with higher mortality (odds ratio 1.37; 95% confidence interval, 0.98 to 1.92; p = 0.07), or higher infection rate (odds ratio 1.23, 95% confidence interval 0.94 to 1.60; p = 0.14). Each 50 mg/dL blood glucose increase was associated with longer postoperative days by 0.76 days (95% confidence interval 0.36 to 1.17 days; p < 0.001), increased hospitalization charges by 2824(952824 (95% confidence interval 2824(951599 to 4049;p<0.001),andincreasedhospitalizationcostby4049; p < 0.001), and increased hospitalization cost by 4049;p<0.001),andincreasedhospitalizationcostby1769 (95% confidence interval 928to928 to 928to2610; p < 0.001). In the unadjusted analysis, infections occurred more frequently in patients with diabetes (6.6% vs 4.1%, p = 0.03).Perioperative hyperglycemia is associated with increased resource utilization in patients undergoing coronary artery bypass grafting with and without diabetes.

Research paper thumbnail of Literacy and Numeracy Skills and Anticoagulation Control

American Journal of The Medical Sciences, 2004

The ability to use printed material to function in society (literacy) and to handle basic numeric... more The ability to use printed material to function in society (literacy) and to handle basic numerical concepts (numeracy) may have implications in patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; ability to follow dosing schedules. We examined literacy and numeracy skills among patients on warfarin and explored their association with anticoagulation control. Patients older than 50 years attending two anticoagulation management units were prospectively enrolled. We measured literacy, numeracy, and international normalized ratio (INR). During a 3-month follow-up period, we calculated the variability of the INR and the amount of time a patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s INR was within his or her therapeutic range, variables associated with bleeding and effectiveness. Among 143 patients, only 75 (52.4%) were able to read health-related words at the eighth grade level or less. Patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; self-reported grade completed was higher than the measured literacy grade level (kappa = 0.21). While 79.0% had completed at least eight grades, only 47.6% had a score at that grade level. Sixty-nine patients answered none or correctly answered fewer than two of the six numeracy questions (48.3%). The INR variability was higher among patients with lower literacy (P = 0.009) and lower numeracy skills (P = 0.004). The time in range was similar among patients at different literacy levels (P = 0.9). Patients with lower numeracy level spent more time above their therapeutic range (P = 0.04) and had a trend of less time spent in range (P = 0.10). Low literacy was prevalent among study patients taking warfarin. Low literacy and numeracy were associated with measures of poor anticoagulation control.

Research paper thumbnail of Hydroxyethyl starch in severe sepsis: end of starch era?

Critical Care, 2013

Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjæ... more Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP, Winkel P, Wetterslev J; 6S Trial Group; Scandinavian Critical Care Trials Group: Hydroxyethyl starch 130/0.42 versus Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate in severe sepsis. N Engl J Med 2012, 367:124-34. Hydroxyethyl starch (HES) is widely used for fluid resuscitation in ICUs, but its safety and efficacy have not been established in patients with severe sepsis. To assess the effects of HES 130/0.4 compared with a balanced crystalloid solution on mortality and end-stage kidney failure in patients with severe sepsis. Multicenter, parallel-group, blinded, randomized clinical trial, in patients with severe sepsis. Patients with severe sepsis admitted to the ICU received fluid resuscitation with either 6% HES 130/0.42 (Tetraspan) or Ringer’s acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate (relative risk, 1.17; 95% confidence interval (CI), 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal replacement therapy versus 65 patients (16%) assigned to Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline. Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal replacement therapy compared with those receiving Ringer&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acetate.

Research paper thumbnail of Zafirlukast in Asthma

Annals of Internal Medicine, 1998

... Samy Suissa, PhD Pierre Ernst, MD McGill University Montreal, Quebec H3A 1A3, Canada Rodolfo ... more ... Samy Suissa, PhD Pierre Ernst, MD McGill University Montreal, Quebec H3A 1A3, Canada Rodolfo Dennis, MD Universidad Javeriana Bogota, Colombia ... Sanyal and coworkers reported a higher percentage of patients with Child-Pugh class C cirrhosis (49%) (1) than were ...

Research paper thumbnail of Mechanical stretch is a highly selective regulator of

Am. J. Respir. Cell Mol. Biol, Apr 1, 2006

Research paper thumbnail of Clinical prediction rule for stratifying risk of pulmonary multidrug-resistant tuberculosis

Research paper thumbnail of Mechanical stretch is a highly selective regulator of gene expression in human bladder smooth muscle cells

Physiological genomics, Jan 15, 2004

Research paper thumbnail of Implementation Research: Beyond the Traditional Randomized Controlled Trial

Essentials of Clinical Research, 2014

... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report ... more ... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report from the Institute of Medicine drew attention to patient safety and the concept of preventable injury.14 Studies of patient safety have focused on “medical error resulting in an inappropri-ate ...

Research paper thumbnail of Implementation Research: Beyond the Traditional Randomized Controlled Trial

Essentials of Clinical Research, 2008

... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report ... more ... Amanda H. Salanitro, Carlos A. Estrada, and Jeroan J. Allison ... In 1999, a landmark report from the Institute of Medicine drew attention to patient safety and the concept of preventable injury.14 Studies of patient safety have focused on “medical error resulting in an inappropri-ate ...

Research paper thumbnail of HER2/neu protein overexpression and gene amplification in human transitional cell carcinoma of the bladder

Urology, 2004

To assess HER-2/neu gene status by fluorescence in situ hybridization and protein expression by i... more To assess HER-2/neu gene status by fluorescence in situ hybridization and protein expression by immunohistochemistry in human bladder transitional cell carcinoma (TCC). In breast carcinoma, HER-2/neu gene amplification and receptor protein overexpression are tightly correlated and have prognostic and therapeutic implications.We used 54 randomly selected TCC specimens obtained from 1998 to 2000. Each specimen was fixated in 10% neutral-buffered formalin and embedded in paraffin. Of the 54 specimens, 7 were grade 1 (13%), 26 were grade 2 (48%), and 21 were grade 3 (39%); 36 (67%) were superficial (Stage Ta or T1) and 18 (33%) were invasive (Stage T2 or T3). The specimens were analyzed for HER-2/neu protein overexpression by immunohistochemistry and for gene amplification using fluorescence in situ hybridization.Of the 54 specimens, 14 (26%) were positive for protein overexpression. One (14%) of the 7 grade 1 tumors was positive for protein overexpression, 3 (12%) of 26 grade 2 tumors were positive, and 10 (48%) of 21 grade 3 tumors were positive (P = 0.0195). Six (17%) of 36 Stage Ta or T1 specimens and 8 (44%) of 18 Stage T2 or T3 specimens were positive for protein overexpression (P = 0.01). None of the 54 TCC specimens showed amplification of the HER-2/neu gene using fluorescence in situ hybridization.HER-2/neu protein overexpression is present in human bladder TCC, with a statistically significant increase in overexpression in grade 3, and invasive specimens. Gene amplification does not appear to be the mechanism of protein overexpression. The prognostic significance of these findings and the application of HER-2/neu in treatment needs additional investigation.