222 Piedmont Ave
Cincinnati OH 45219
Medical School: Other - 1994
Accepts Medicare: Yes
Participates In eRX: Yes
Participates In PQRS: Yes
Participates In EHR: Yes
License #: 35-084420
Taxonomy Codes:207R00000X 207RE0101X
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Gastric bypass alters both glucose-dependent and glucose-independent regulation of islet hormone secretion. - Obesity (Silver Spring, Md.)
Roux-en-Y gastric bypass surgery (GB) is characterized by accentuated but short-lived postprandial elevations of blood glucose and insulin. This profile has been attributed to effects of relative hyperglycemia to directly stimulate Î²-cells and an augmented incretin effect. An additional glucose-independent stimulation of insulin secretion in GB subjects was hypothesized.Fifteen subjects with prior GB, six matched obese non surgical controls, and seven lean individuals were recruited. Islet hormones were measured before and after meal ingestion during hyperinsulinemic hypoglycemic clamps to minimize the direct effects of glycemia and glucose-dependent gastrointestinal hormones on insulin secretion.The GB subjects had less suppression of fasting Î²-cell secretion during the insulin clamp compared to controls. In addition, meal-induced insulin secretion increased in the GB subjects but not controls during fixed sub-basal glycemia. In contrast, the glucagon responses to hypoglycemia and meal ingestion were lower in the GB subjects than controls.Among subjects with GB, the response of insulin and glucagon secretion to decreasing blood glucose is blunted, but meal-induced insulin secretion is stimulated even at fixed systemic sub-basal glycemia. These findings indicate that, following GB, islet hormone secretion is altered as a result of factors beyond circulatory glucose levels.Â© 2015 The Obesity Society.
Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis. - Surgery
Traditional decompressive and/or pancreatic resection procedures have been the cornerstone of operative therapy for refractory abdominal pain secondary to chronic pancreatitis. Management of patients that fail these traditional interventions represents a clinical dilemma. Salvage therapy with completion pancreatectomy and islet cell autotransplantation (CPIAT) is an emerging treatment option for this patient population; however, outcomes after this procedure have not been well-studied.All patients undergoing CPIAT after previous decompressive and/or pancreatic resection for the treatment of chronic pancreatitis at our institution were identified for inclusion in this single-center observational study. Study end points included islet yield, narcotic requirements, glycemic control, and quality of life (QOL). QOL was assessed using the Short Form (SF)-36 health questionnaire.Sixty-four patients underwent CPIAT as salvage therapy. The median age at time of CPIAT was 38Â years (interquartile range [IQR], 14.7-65.4). The most common etiology of chronic pancreatitis was idiopathic pancreatitis (66%; nÂ =Â 42) followed by genetically linked pancreatitis (9%; nÂ =Â 6) and alcoholic pancreatitis (8%; nÂ =Â 5). All of these patients had previously undergone prior limited pancreatic resection or decompressive procedure. The majority of patients (50%; nÂ =Â 32) underwent prior pancreaticoduodenectomy, whereas the remainder had undergone distal pancreatectomy (17%; nÂ =Â 11), Frey (13%; nÂ =Â 8), Puestow (13%; nÂ =Â 8), or Berne (8%; nÂ =Â 5) procedures. Median time from initial surgical intervention to CPIAT was 28.1Â months (IQR, 13.6-43.0). All of these patients underwent a successful CPIAT. Mean operative time was 502.2Â minutes with average hospital duration of stay of 13Â days. Islet cell isolation was feasible despite previous procedures with a mean islet yield of 331,304 islet cell equivalents, which totaled an islet cell autotransplantation of 4,737Â Â±Â 492 IEQ/kg body weight. Median patient follow-up was 21.2Â months (IQR, 7.9-36.8). Before CPIAT, all patients required a mean of 120.8 morphine equivalent milligrams per day (MEQ/d), which improved to 48.5 MEQ (PÂ <Â .001 compared with preoperative requirements) at most recent follow-up. Of these patients, 44% (nÂ =Â 28) achieved narcotic independence. All patients were able to achieve stable glycemic control with a mean insulin requirement of 16 units per day. Of these patients, 20% (nÂ =Â 13) were insulin independent after CPIAT. Mean postoperative glycosylated hemoglobin was 7.8% (range, 4.6-12.5). Islet cell viability was confirmed with endocrine testing and mean C-peptide levels 6Â months after CPIAT were 0.91Â ng/mL (range, 0.1-3.0). The SF-36 QOL survey administered postoperatively demonstrated improvement in all tested modules.This study is the first to examine the results of salvage therapy with CPIAT for patients with refractory chronic pancreatitis. Patients undergoing CPIAT achieved improved postoperative narcotic requirements, stable glycemic control, and improved QOL.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Risk factors and the outcome of therapy in patients with seizure after Carbamazepine poisoning: A two-year cross-sectional study. - Journal of research in pharmacy practice
We aimed to investigate the frequency of seizure after acute carbamazepine poisoning and the important risk factors related to the outcomes of therapy.In this two-year cross-sectional study conducted in a University Hospital in Iran, 114 patients with acute carbamazepine poisoning were divided into two groups of with seizure (n = 8) and without seizure (n = 106) after intoxication. Demographic data, average amount of drug ingestion, time elapsed from ingestion to hospital admission, history of seizure before poisoning, mental status, visual disturbances and nystagmus, duration of hospitalization, the outcomes of therapy, arterial blood gas values and serum biochemical indices were compared between the two groups.Patients with seizure had an estimated (Mean Â± SD) ingestion of 14,300 Â± 570 mg carbamazepine, which was significantly higher (P < 0.0001) than the seizure-free group (4600 Â± 420 mg). The estimated average time between drug ingestion and hospital admission in patients with seizure and the seizure-free group were 515 Â± 275 and 370 Â± 46 minutes, respectively (P < 0.0001). In this study, 104 out of the total number of patients had recovered without any complication. Need for respiratory support, including airway support or intubation were the most recorded complication. One patient died after status epilepticus and aspiration pneumonia.The ingested amount of carbamazepine and the time elapsed from the ingestion of drug to hospital admission may influence the occurrence of seizure after acute carbamazepine poisoning; however, the outcome of supportive care in these patients seems to be positive.
Total pancreatectomy with islet cell autotransplantation as the initial treatment for minimal-change chronic pancreatitis. - HPB : the official journal of the International Hepato Pancreato Biliary Association
Patients with minimal-change chronic pancreatitis (MCCP) are traditionally managed medically with poor results. This study was conducted to review outcomes following total pancreatectomy with islet cell autotransplantation (TP/IAT) as the initial surgical procedure in the treatment of MCCP.All patients submitted to TP/IAT for MCCP were identified for inclusion in a single-centre observational study. A retrospective chart review was performed to identify pertinent preoperative, perioperative and postoperative data.A total of 84 patients with a mean age of 36.5 years (range: 15-60 years) underwent TP/IAT as the initial treatment for MCCP. The most common aetiology of chronic pancreatitis in this cohort was idiopathic (69.0%, n = 58), followed by aetiologies associated with genetic mutations (16.7%, n = 14), pancreatic divisum (9.5%, n = 8), and alcohol (4.8%, n = 4). The most common genetic mutations pertained to CFTR (n = 9), SPINK1 (n = 3) and PRSS1 (n = 2). Mean Â± standard error of the mean preoperative narcotic requirements were 129.3 Â± 18.7 morphine-equivalent milligrams (MEQ)/day. Overall, 58.3% (n = 49) of patients achieved narcotic independence and the remaining patients required 59.4 Â± 10.6â€‰MEQ/day (P < 0.05). Postoperative insulin independence was achieved by 36.9% (n = 31) of patients. The Short-Form 36-Item Health Survey administered postoperatively demonstrated improvement in all tested quality of life subscales.The present report represents one of the largest series demonstrating the benefits of TP/IAT in the subset of patients with MCCP.Â© 2014 International Hepato-Pancreato-Biliary Association.
Long-term outcomes after total pancreatectomy and islet cell autotransplantation: is it a durable operation? - Annals of surgery
Total pancreatectomy and islet cell autotransplantation (TPIAT) has been increasingly utilized for the management of chronic pancreatitis (CP) with early success. However, the long-term durability of this operation remains unclear.All patients undergoing TPIAT for the treatment of CP with 5-year or greater follow-up were identified for inclusion in this single-center observational study. End points included narcotic requirements, glycemic control, islet function, quality of life (QOL), and survival.Between 2000 and 2013, 166 patients underwent TPIAT; 112 of these patients had 5-year follow-up data to analyze. All patients underwent successful IAT with a mean of 6027 Â± 595 islet equivalents per body weight. There was no perioperative mortality and actuarial survival at 5 years was 94.6%. The narcotic independence rate at 1 year was 55% and continued to improve to 73% at 5-year follow-up (P < 0.05). The insulin independence rate declined over time (38% at 1 year vs 27% at more than 5 years), but insulin requirements remained similar (21.4 vs 24.3 units per day, P = 0.6). All patients achieved stable glycemic control with a median hemoglobin A1C (HgA1C) of 6.9% (range: 5.85%-8.3%). The short form 36-item QOL assessment of a subset of patients available for contact demonstrated continued improvements in all tested modules in patients with at least 5-year follow-up. Two patients developed diabetic complications requiring whole organ pancreas transplant for salvage.This represents one of the largest series examining long-term outcomes after TPIAT. This operation produces durable pain relief and improvement in QOL parameters. Insulin independence rates decline over time, but most patients maintain stable glycemic control.
Comparison of the effect of surgical and medical therapy for the treatment of idiopathic granulomatous mastitis. - Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences
Idiopathic granulomatous mastitis (IGM) is defined as a rare, inflammatory, chronic and benign disease mimicking malignant hyperplasia of mammary glands. There is no definitive therapeutic strategy for IGM; nevertheless, some approaches can be exploited as beneficial strategies. In this study, the surgery strategy was compared with coincident treatment with azithromycin and corticosteroid in IGM patients.This study was implemented as clinical trial during 2011-2013 in Isfahan, Iran. The target population comprised women whose IGM was substantiated. The medical group consisted of 20 patients, which were compared with a historical control group treated through surgical approach. Surgical group comprised 39 patients. Partial mastectomy was implemented in the surgical group whereas treatment protocol comprising azithromycin and prednisolone administered in medical group. Recurrence of mass was followed for 12 months. Fischer exact test, Chi-square test, Mann-Whitney and regression tests were applied for statistical analysis. This study was registered in Iranian Registry of clinical trial (IRCT number: IRCT 2013123015999N1).No significant differences were recognized in side of lesions, lymphadenopathy, fever and pain; however, number of abscesses, number of lesions and size of lesions were significantly higher in the surgical group (P < 0.0001). Furthermore, probability of relapse correlated with the number of lesions, (odds ratio = 24.67 confidence interval [CI] = 2.2-269.3), whereas methods of IGM treatment did not contribute to the likelihood of relapse (odds ratio = 12.5 CI = 0.52-299).This clinical trial demonstrated that pharmaceutical treatment has appropriate efficacy, in treatment and prevention of IGM relapse. Moreover, this study presented hazf gardad number of the lesions as the most appropriate criteria for IGM prognosis, thus the probability of relapse decreases whether earlier IGM recognizing could be implemented.
Effects of glucagon like peptide-1 to mediate glycemic effects of weight loss surgery. - Reviews in endocrine & metabolic disorders
To date, weight loss surgeries are the most effective treatment for obesity and glycemic control in patients with type 2 diabetes. Roux-en-Y gastric bypass surgery (RYGB) and sleeve gastrectomy (SG), two widely used bariatric procedures for the treatment of obesity, induce diabetes remission independent of weight loss while glucose improvement after adjustable gastric banding (AGB) is proportional to the amount of weight loss. The immediate, weight-loss independent glycemic effect of gastric bypass has been attributed to postprandial hyperinsulinemia and an enhanced incretin effect. The rapid passage of nutrients into the intestine likely accounts for significantly enhanced glucagon like-peptide 1 (GLP-1) secretion, and postprandial hyperinsulinemia after GB is typically attributed to the combined effects of elevated glucose and GLP-1. For this review we focus on the beneficial effects of the three most commonly performed bariatric procedures, RYGB, SG, and AGB, on glucose metabolism and diabetes remission. Central to this discussion will be the extent to which the effects of surgery are mediated by GLP-1. Better understanding of these mechanisms could provide insight to development of novel therapeutic strategies for treatment of diabetes as well as refinement of surgical techniques.
Altered islet function and insulin clearance cause hyperinsulinemia in gastric bypass patients with symptoms of postprandial hypoglycemia. - The Journal of clinical endocrinology and metabolism
Postprandial hypoglycemia, a late complication of gastric bypass (GB) surgery, is associated with an exaggerated insulin response to meal ingestion.The purpose of this study was to characterize insulin secretion and other glucoregulatory hormone responses to meal ingestion after GB based on hypoglycemia and clinical symptoms.We conducted a cross-sectional analysis of insulin secretion rate and islet and gastrointestinal hormone responses to liquid mixed meal ingestion in 65 subjects with GB and 11 body mass index-matched controls without surgery. The GB subjects were stratified by clinical history for analysis of their responses to the test meal.The glucose and insulin responses to meal ingestion were shifted upward and to the left after GB, with the largest early insulin response and the lowest nadir glucose levels in patients with a history of hypoglycemia, particularly those with neuroglycopenic symptoms. Hypoglycemic GB subjects had lower postprandial insulin clearance rates and higher insulin secretion rates during the glucose decline after the test meal. Meal-induced glucagon was enhanced in all GB subjects but did not differ between subjects who did and did not develop hypoglycemia. Plasma gastric inhibitory polypeptide and glucagon-like peptide-1 concentrations did not differ between asymptomatic and neuroglycopenic GB subjects.Among GB subjects with a clinical history of hypoglycemia, hyperinsulinemia is the result of inappropriate insulin secretion and reduced insulin clearance. In subjects with symptoms of postprandial hypoglycemia, insulin secretion is higher in the latter stages of meal glucose clearance, and despite elevated meal-induced glucagon, there is no further response to hypoglycemia. These abnormalities in islet function are most pronounced in subjects who report neuroglycopenic symptoms.
Blockade of glucagon-like peptide 1 receptor corrects postprandial hypoglycemia after gastric bypass. - Gastroenterology
Postprandial glycemia excursions increase after gastric bypass surgery; this effect is even greater among patients with recurrent hypoglycemia. These patients also have increased postprandial levels of insulin and glucagon-like peptide 1 (GLP-1). We performed a clinical trial to determine the role of GLP-1 in postprandial glycemia in patients with hyperinsulinemic hypoglycemia syndrome after gastric bypass.Nine patients with recurrent hypoglycemia after gastric bypass (H-GB), 7 patients who were asymptomatic after gastric bypass (A-GB), and 8 healthy control subjects underwent a mixed-meal tolerance test (350 kcal) using a dual glucose tracer method on 2 separate days. On 1 day they received continuous infusion of the GLP-1 receptor antagonist exendin (9-39) (Ex-9), and on the other day they received a saline control. Glucose kinetics and islet and gut hormone responses were measured before and after the meal.Infusion of Ex-9 corrected hypoglycemia in all patients with H-GB. The reduction in postprandial insulin secretion by Ex-9 was greater in the H-GB group than in the other groups (H-GB, 50% Â± 8%; A-GB, 13% Â± 10%; controls, 14% Â± 10%) (P < .05). The meal-derived glucose appearance was significantly greater in subjects who had undergone gastric bypass compared to the controls and in the H-GB group compared to the A-GB group. Ex-9 shortened the time to reach peak meal-derived glucose appearance in all groups without a significant effect on overall glucose flux. Postprandial glucagon levels were higher among patients who had undergone gastric bypass than controls and increased with administration of Ex-9.Hypoglycemia after gastric bypass can be corrected by administration of a GLP-1 receptor antagonist, which might be used to treat this disorder. These findings are consistent with reports that increased GLP-1 activity contributes to hypoglycemia after gastric bypass. ClinicalTrials.gov, Number: NCT01803451.Copyright Â© 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.
Complications of diabetes therapy. - Endocrinology and metabolism clinics of North America
Current strategies for the treatment of type 2 diabetes mellitus promote individualized plans to achieve target glucose levels on a patient-by-patient basis while minimizing treatment related risks. Maintaining glycemic control over time is a significant challenge because of the progressive nature of diabetes as a result of declining Î²-cell function. This article identifies complications of non-insulin treatments for diabetes. The major classes of medications are reviewed with special focus on target population, mechanism of action, effect on weight, cardiovascular outcomes and additional class-specific side effects including effects on bone. Effects on Î²-cell function are also highlighted.Copyright Â© 2013 Elsevier Inc. All rights reserved.
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