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Biomedical subjects

S M Gordon

Publications and source records attributed to S M Gordon.

At least 19 recordsLinked to original sources
PubMed2005

Psychosocial assessment by phone for high-scoring patients taking the Edinburgh Postnatal Depression Scale: communication pathways and strategies.

The well-documented risks associated with perinatal depression provide a strong argument for universal screening. However, uncertainty about what to do with findings is a significant barrier to implementing screenings where obstetric care is provided. Based on experience with a comprehensive screening program, we describe a protocol for those critical communication pathways that encourage a dynamic phone exchange between a mental health caller and the patient who has scored in the high range on the Edinburgh Postnatal Depression Scale. In addition, we present guidelines for developing an action plan for addressing intervention needs and closing the feedback loop to the original administrators of the scale.

Adult↗
PubMed2003

West Nile virus infection: a new acute paralytic illness.

OBJECTIVE: To determine the clinical, laboratory, electrodiagnostic, radiologic, and pathologic characteristics that define the spectrum of CNS disease caused by West Nile virus (WNV) infection. METHODS: The records of all patients hospitalized at the Cleveland Clinic from August 2002 to September 2002 with WNV infection were reviewed. RESULTS: Of 23 cases, the median age was 74 years old, and 74% were men. Symptoms included fever (100%), altered mental status (74%), gastrointestinal complaints (43%), back pain (35%), and rash (26%). In half, meningitis or encephalitis overlapped with flaccid weakness that progressed over 3 to 8 days, with a tendency to be proximal and asymmetric. Laboratory abnormalities included hyponatremia (30%) and initial CSF neutrophilic pleocytosis. Electrodiagnostic studies in two patients showed reduced motor amplitudes with normal conduction velocities and active denervation. In two other patients, reduced sensory amplitudes were also seen. MRI changes included cauda equina enhancement and parenchymal spinal cord signal abnormalities and parenchymal or leptomeningeal signal changes in the brain. Autopsy in three cases showed chronic perivascular inflammation in the brain and inflammatory changes with anterior horn cell loss in the spinal cord. CONCLUSION: An overlapping spectrum of meningitis, encephalitis, and myeloradiculitis occurs in CNS WNV infection. Fever, rash, abdominal and back pain, preceding a proximal, asymmetric flaccid weakness, with CSF pleocytosis help distinguish the motor syndrome from Guillain-Barré syndrome. Pathologic changes in the CNS resembled poliomyelitis.

Acute Disease↗
PubMed2002

Clinical characteristics of 13 solid organ transplant recipients with ganciclovir-resistant cytomegalovirus infection.

BACKGROUND: Ganciclovir-resistant (GCV-R) cytomegalovirus (CMV) is now being reported with increasing frequency in solid organ transplant recipients. OBJECTIVE: To describe the clinical characteristics and outcomes of all solid organ transplant patients with GCV-R CMV seen between 1990 and 2000 at a single center. METHODS: Patients with clinically suspected GCV resistance had viral isolates subjected to phenotypic analysis by plaque reduction assay, and also genotypic analysis. Medical records of the 13 patients with GCV-R CMV were reviewed for demographic, microbiologic, clinical, and pathologic data. RESULTS: Thirteen patients were identified, including 5 kidney, 1 heart, and 7 lung transplant recipients. All but one patient (92%) were CMV donor seropositive, recipient negative (D+/R-), and 11/13 (85%) had tissue-invasive CMV. CMV viremia was recurrent in 9/13 (69%); in 2 others, the first CMV episode was fatal. Overall, 9/13 (69%) of patients have died, all of CMV or its complications. Of the 10 who received foscarnet, only one survived. All patients had received GCV-based prophylactic regimens; 8/13 patients (62%) had received CMV hyperimmune globulin (CMVIG) as part of prophylaxis, 6/13 (46%) had received oral ganciclovir, and 5/13 (38%) had received intermittent (3 x/week) IV ganciclovir for prophylaxis. CONCLUSIONS: GCV-R CMV is associated with CMV D+/R- status, tissue-invasive disease, and high mortality even with foscarnet therapy. Exposure to less than fully therapeutic levels of GCV, in the form of oral or intermittent IV GCV, is common. The use of CMVIG in prophylaxis does not appear to prevent resistance. Further work remains to be done to elucidate the risk factors and optimal mode of prophylaxis and treatment for GCV-R CMV.

Cytomegalovirus↗
PubMed2002

The incidence of invasive aspergillosis among solid organ transplant recipients and implications for prophylaxis in lung transplants.

BACKGROUND: Invasive aspergillosis (IA) is associated with significant morbidity and mortality in solid organ transplant recipients but data on the incidence rates stratified by type of solid organ are limited. OBJECTIVE: To describe the attack rates and incidence of IA in solid organ transplant recipients, and the impact of universal Aspergillus prophylaxis (aerosolized amphotericin B or oral itraconazole) in lung transplant recipients. PATIENTS: The 2,046 patients who received solid organ transplants at the Cleveland Clinic Foundation from January 1990 through 1999 were studied. METHODS: Cases were ascertained through computerized records of microbiology, cytology, and pathology reports. Definite IA was defined as a positive culture and pathology showing septate hyphae. Probable IA was clinical disease and either a positive culture or histopathology. Disseminated IA was defined as involvement of two or more noncontiguous anatomic sites. RESULTS: We identified 33 cases of IA (28% disseminated) in 2,046 patients (attack rate = 1.6%) for an incidence of 4.8 cases per 1,000 patient-years (33 cases/6,813 pt-years). Both the attack and the incidence rates were significantly higher for lung transplant recipients vs. other transplant recipients: lung 12.8% (24 cases/188 patients) or 40.5 cases/1,000-pt year vs. heart 0.4% (3/686) or 1.4 per 1,000-pt year vs. liver 0.7% (3/439) or 2.1 per 1,000-pt year vs. renal 0.4% (3/733) or 1.2 per 1,000-pt year (P < 0.01). The incidence of IA was highest during the first year after transplantation for all categories, but cases occurred after the first year of transplantation only in lung transplant recipients. The attack rate of IA in lung transplant recipients was significantly lower after institution of routine Aspergillus prophylaxis (4.9% vs. 18.2%, P < 0.05). CONCLUSIONS: The highest incidence and attack rate of invasive aspergillosis among solid organ transplant recipients occurs in lung transplant recipients and supports the routine use of Aspergillus prophylaxis for at least one year after transplantation in this group.

Adult↗
PubMed2001

Single-lumen subcutaneous ports inserted by interventional radiologists in patients undergoing chemotherapy: incidence of infection and outcome of attempted catheter salvage.

BACKGROUND: Subcutaneous ports are commonly used for vascular access in patients with cancer undergoing chemotherapy. OBJECTIVES: To determine the incidence of catheter-related infection and to assess the efficacy of catheter salvage in subcutaneous ports. METHODS: We retrospectively reviewed 300 subcutaneous single-lumen chest ports inserted by interventional radiologists in 294 patients between December 1, 1995, and November 15, 1997, at the Cleveland Clinic Foundation, Cleveland, Ohio. The number of days that the catheter remained in situ, infection rate, treatment, and outcome of infection were determined. RESULTS: Two hundred ninety-four patients had a total of 79 748 catheter-days. Vascular access for chemotherapy was the indication for 95% of the subcutaneous ports placed. Seventeen catheters (5.7%) developed 20 episodes of noninfectious complications resulting in the removal of 6 ports. Seventeen patients (5.7%) developed catheter-related infections (2.1/10 000 catheter-days) including 10 episodes of catheter-related bacteremia (1.2/10 000 catheter-days). The most common organism isolated was Staphylococcus aureus. A total of 15 of the 17 infected catheters were removed. Salvage was attempted in 6 patients in whom 4 catheters were eventually removed due to recurrent bacteremia (2 patients) and persistent local infection (2 patients). One of the 10 patients with catheter-related bacteremia developed septic arthritis. There were no complications associated with attempted catheter salvage. CONCLUSIONS: Subcutaneous single-lumen ports inserted by interventional radiologists in patients undergoing chemotherapy have low complication rates but infections remain the leading cause of catheter loss. Antibiotic therapy without catheter removal is unlikely to eradicate catheter-related bacteremia.

Antineoplastic Agents↗
PubMed2001

Hypogammaglobulinemia in lung transplant recipients.

BACKGROUND: Infectious complications continue to represent a significant source of morbidity and mortality in lung transplant recipients. Identifying specific, remediable immune defects is of potential value. After one lung transplant patient with recurrent infections was noted to be severely hypogammaglobulinemic, a screening program for humoral immune defects was instituted. The objectives were to define the prevalence of hypogammaglobulinemia in lung transplant recipients, assess levels of antibody to specific pathogens, and correlate infectious disease outcomes and survival with immunoglobulin levels. METHODS: All lung transplant recipients followed at a single center between October 1996 and June 1999 underwent a posttransplant humoral immune status survey as part of routine posttransplant follow-up. This survey consists of total immunoglobulin levels (IgG, IgM, IgA), IgG subclasses (IgG1-4), and antibody titers to Pneumococcus, diphtheria, and tetanus. Since February 1997, this survey has been incorporated into the pretransplant evaluation as well. Humoral survey results for October 1996 through July 1999 were recorded, and clinical information on major infectious disease outcomes was obtained from chart reviews, discharge summaries, the Cleveland Clinic Unified Transplant Database, and review of all microbiological studies and pathology results for each patient. RESULTS: Of 67 patients with humoral immune surveys drawn posttransplant, 47 (70%) had IgG levels less than 600 mg/dl (normal 717-1410 mg/dl), of which 25 (37%) had IgG levels less than 400 mg/dl ("lowest IgG group") and 22 (33%) had IgG levels between 400 and 600 mg/dl ("moderately low IgG group"). A total of 20 patients (30%) had IgG levels of more than 600 mg/dl ("normal IgG group"). Infections that were significantly more common in the lowest IgG group, and more common in the moderately low IgG group than the normal IgG group, included: number of pneumonias (P=0.0006), bacteremias (P=0.02), total bacterial infections (P=0.002), tissue-invasive cytomegalovirus (P=0.01), invasive aspergillosis (P=0.001), total fungal infections (P=0.001), and total infections (P=0.006). Median hospital days per posttransplant year was significantly different in the three groups (11.0 vs. 7.4 vs. 2.8 days, P=0.0003.) Invasive aspergillosis occurred in 44% of the lowest IgG group, 9% of the moderately low IgG group, and 0% of the normal IgG group (P<0.001). Survival was poorest in the lowest IgG group and intermediate in the moderately low IgG group. IgG subclass deficiencies occurred in a variety of patterns. Hypogammaglobulinemic patients lacked protective responses to Pneumococcus in 14/47 (30%), diphtheria in 15%, and tetanus in 19%. In a group of 48 patients screened pretransplant, 90% had normal immunoglobulin levels. CONCLUSIONS: Hypogammaglobulinemia in lung transplant recipients is more common than has been previously recognized. An IgG level of less than 400 mg/dl identifies a group at extremely high risk of bacterial and fungal infections, tissue-invasive cytomegalovirus, and poorer survival. Immunoglobulin monitoring may offer an opportunity for intensive surveillance, tapering of immunosuppression, and preemptive therapy for infection.

Adolescent↗
PubMed2001

Nosocomial bloodstream infections in patients with implantable left ventricular assist devices.

BACKGROUND: Implantable left ventricular assist devices (LVAD) are used as a bridge to transplantation but are associated with a high risk of infection including nosocomial bloodstream infections (BSI). METHODS: We retrospectively reviewed the medical records of all patients with implantable LVAD at the Cleveland Clinic with 72 hours or longer of LVAD support from January 1992 through June 2000, to determine the attack rate, incidence, and impact of nosocomial BSI in patients with LVAD. A nosocomial BSI was defined using Centers for Disease Control and Prevention definition. An LVAD-related BSI was defined as one where the same pathogen is cultured from the device and the blood with no other obvious source. Two hundred fourteen patients were included in the study (17,831 LVAD-days). RESULTS: One hundred forty BSI were identified in 104 patients for an attack rate of 49% and incidence of 7.9 BSI per 1000 LVAD-days. Thirty-eight percent of the BSI were LVAD associated. The most common pathogens causing BSI were coagulase-negative staphylococci (n = 33), Staphylococcus aureus, and Candida spp. (19 each), and Pseudomonas aeruginosa (16 each). A Cox proportional hazard model found BSI in patients with LVAD to be significantly associated with death (hazard ratio = 4.02, p < 0.001). Fungemia had the highest hazard ratio (10.9), followed by gram-negative bacteremia (5.1), and gram-positive bacteremia (2.2). CONCLUSIONS: Patients with implantable LVAD have a high incidence of BSI, which are associated with a significantly increased mortality. Strategies for prevention of infection in LVAD recipients should focus on the drive line exit site until technical advances can achieve a totally implantable device.

Bacteremia↗
PubMed2001

Enhanced cyclosporine-itraconazole interaction with cola in lung transplant recipients.

BACKGROUND: Invasive aspergillosis is a major cause of morbidity and mortality in lung transplant recipients (LTR), occurring in up to 15% of patients post-transplant. The 14% aspergillus incidence at the Cleveland Clinic Foundation prompted institution of universal prophylaxis with oral itraconazole (ICZ) in 1997. We report our experience with two protocols of ICZ administration in non-cystic fibrosis LTR and the interaction with cyclosporine (CSA). METHODS: Group 1 patients (n=12) were administered ICZ capsules in a fasting or fed state, with or without a histamine-2 (H-2) receptor antagonist or proton pump inhibitor. Group 2 patients (n=12) received the same protocol as group I, but in a fed state with a carbonated beverage (cola) to increase acidity in the stomach to enhance absorption of ICZ. The ICZ dose was 200 mg/d, given as one daily dose. A historical control group (n=10) did not receive chemoprophylaxis with ICZ. CSA daily doses, dose intervals, concentration, cost, and random ICZ levels were documented over a 4-month period of time and compared using generalized estimating equations. RESULTS: The daily CSA mg/kg/d dose decreased over time in all three groups, but no differences were found between the three groups. The CSA dosing interval over time was significantly prolonged in group 2 compared to group 1 or the control group (p< or =0.003). Over time, there was no difference in CSA concentration between all groups. There was no difference in cost over time between the three groups; however, the mean cost of CSA therapy was significantly lower in group 2 compared to the control group (p=0.025). Group 2 administered ICZ with cola had greater random blood concentrations of ICZ (p=0.019). CONCLUSIONS: ICZ capsules administered in a fed state with a cola resulted in greater random levels of ICZ, a decrease in cost/d of CSA, and a prolongation of CSA dosing interval. Although daily CSA dosage trended lower in group 2, it did not reach statistical significance. We believe these changes in CSA dosing over time reflect increased absorption of ICZ and recommend verifying ICZ absorption with an itraconazole level, especially when CSA intervals are not prolonged.

Antifungal Agents↗
PubMed2001

Aspergillosis in lung transplantation: incidence, risk factors, and prophylactic strategies.

Invasive aspergillosis remains a significant cause of morbidity and mortality in transplantation, especially lung and allogeneic bone marrow transplant recipients. The epidemiology, classic and newly recognized risk factors, and incidence of aspergillosis are reviewed. Risk factors include environmental exposures, airway colonization, profound immunosuppression, neutropenia, prior cytomegalovirus infection, and renal dysfunction. Clinical and radiographic presentations of invasive aspergillosis are discussed, including some unusual manifestations in lung transplant recipients. Early and accurate diagnosis of aspergillosis remains a challenge, and diagnostic strategies are reviewed, with an emphasis on the chest computerized tomography scan and on transbronchial or open lung biopsy. Recent advances include prophylactic and pre-emptive antifungal strategies, newer therapeutic agents, and improved risk stratification.

Antibiotic Prophylaxis↗
PubMed2001

Relapsing Exophiala jeanselmei phaeohyphomycosis in a lung-transplant patient.

Dematiaceous fungi are a cause of a variety of human infections, including phaeohyphomycosis, that may affect patients with solid organ or bone marrow transplants. Exophiala jeanselmei, the most common cause of the pheomycotic cyst/subcutaneous phaeohyphomycosis in the United States, has been shown to cause disease in transplant recipients. We report a lung-transplant patient with relapsing and invasive E. jeanselmei phaeohyphomycosis, who previously had a pheomycotic cyst excised and treated with oral fluconazole. The patient was subsequently treated with re-excision and an 8-month course of oral itraconazole without relapse as to date.

Adult↗
PubMed2001

Coccidioidomycosis in non-endemic areas: a case series.

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.

Adult↗
PubMed2001

Analgesic effects of peripherally administered opioids in clinical models of acute and chronic inflammation.

A series of double-blind, placebo-controlled clinical trials demonstrated that low doses of morphine (0.4, 1.2, and 3.6 mg) administered into the intraligamentary space of a chronically inflamed hyperalgesic tooth produced a dose-related naloxone-reversible analgesia. This analgesic effect is mediated by a local mechanism in the inflamed tissue, because subcutaneous administration of a 1.2 mg dose of morphine failed to elicit an analgesic response. In contrast, submucosal administration of 1.2 mg morphine or 50 microg fentanyl to the site of extraction of an impacted third molar after the onset of acute pain failed to elicit an analgesic response despite demonstration of a sensitive bioassay. These data indicate that peripheral opioid analgesia can be evoked in a model of chronic, but not acute, inflammatory pain, suggesting a temporal dependent mechanism needed for the expression of peripheral opiate analgesia during inflammation in humans.

Acute Disease↗
PubMed2001

Training pathways for careers in dental, oral, and craniofacial research.

There are virtually unlimited opportunities for biomedical research training through either extramural or intramural training mechanisms, with programs designed for both the pre- and postdoctoral educational levels. The only difficulty is selecting from the vast array of research topic areas.

Career Choice↗
PubMed2000

Diagnosis and management of infections involving implantable electrophysiologic cardiac devices.

BACKGROUND: Optimal treatment of infections related to implantable electrophysiologic cardiac devices is poorly defined. OBJECTIVE: To describe the clinical presentation, treatment, and outcome of patients with such infections. DESIGN: Retrospective case series. SETTING: The Cleveland Clinic Foundation, Cleveland, Ohio. PATIENTS: 123 patients with infections involving implantable cardiac electrophysiologic devices. MEASUREMENTS: Demographic characteristics, clinical manifestations, time to diagnosis, management, and outcome. RESULTS: 87 patients with permanent pacemakers and 36 patients with implantable cardioverter defibrillators had infections. The most common signs and symptoms were pocket erythema and local pain. The most common pathogens were coagulase-negative staphylococci (68%) and Staphylococcus aureus (23%). In 117 patients (95%), all equipment was extracted and antibiotic therapy lasted a median of 28 days. Operative mortality was zero. Follow-up showed crude mortality and relapse rates of 8% and 3%, respectively. CONCLUSION: For infections related to implantable electrophysiologic devices, complete device removal and antimicrobial therapy allow timely, successful reimplantation at a remote anatomic site without substantial risk for operative mortality or recurrent infection.

Adolescent↗
PubMed2000

Early onset prosthetic valve endocarditis: the Cleveland Clinic experience 1992-1997.

BACKGROUND: We reviewed all cases of early onset prosthetic valve endocarditis (EO-PVE) occurring less than 12 months after valve operation among 7,043 patients undergoing heart valve replacements or repairs at The Cleveland Clinic between 1992 and 1997. METHODS: Cases were defined by the Duke criteria and identified through prospective surveillance. RESULTS: Seventy-seven cases of EO-PVE were identified (1 per 100 procedures), and during the study period the incidence of EO-PVE decreased from 1.5% (1992 to 1994) to 0.7% (1995 to 1997) (p < 0.01). The incidence of EO-PVE for rings (0.2%; 4 of 1,992) was significantly lower than for mechanical (1.6%; 28 of 1,731) and bioprosthetic valves (1.1%; 41 of 3,320) (p < 0.001). The incidence of EO-PVE was also significantly lower for mitral valve versus aortic valve surgeries (0.6% versus 1.4%, p < 0.001). The most common pathogens causing EO-PVE were coagulase-negative staphylococci (52%), fungi (13%), Staphylococcus aureus (10%), and enterococci (8%). Patients undergoing combined surgical and medical treatment of EO-PVE had a significantly higher 30-day, 2-year, and 3-year survival than medically treated patients, although patients judged to be too ill to survive surgery accounted for two-thirds of the patients treated medically. CONCLUSIONS: There is a 1% incidence rate of EO-PVE among patients undergoing valve operations at our institution, usually caused by coagulase-negative staphylococci, and combined surgical and medical treatment is associated with improved survival compared with medical treatment alone.

Adolescent↗
PubMed2000

Should all patients with candidaemia have an ophthalmic examination to rule out ocular candidiasis?

PURPOSE: To determine the incidence of ocular candidiasis and length of ophthalmic follow-up required to rule out ocular candidiasis in candidemia patients. METHODS: We prospectively studied patients with candidemia at our institution. Eligibility criteria included a dilated ophthalmological examination within 72 h of fungemia. Patients without ocular candidiasis on initial examination had follow-up dilated ophthalmoscopy performed at 1, 2, 4, 12 and 24 weeks. RESULTS: Between May 1996 and March 1997 a total of 50 patients with fungemia were identified of whom 31 were included in the study; 15 excluded patients died before an initial examination was performed. The overall incidence of ocular candidiasis was 26% (8/31 patients), all manifested as chorioretinitis. Five patients (16%) had ocular candidiasis on their initial examination. One of 21 patients (5%) without ocular candidiasis on initial examination developed ocular candidiasis within 1 week. Two of 16 patients (13%) without ocular candidiasis on initial examination or at 1 week follow-up developed ocular candidiasis within 2 weeks. No evidence of ocular candidiasis occurred in the 12 patients with follow-up at 4 weeks, the 8 patients with follow-up at 12 weeks and the 4 patients with follow-up at 24 weeks. CONCLUSION: The incidence of ocular candidiasis among hospitalized patients is clinically significant. We recommend ophthalmological follow-up for development of ocular candidiasis for at least 2 weeks after an initial negative eye examination.

Aged↗