3181 Sw Sam Jackson Park Rd
Portland OR 97239
Medical School: Other - Unknown
Accepts Medicare: No
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License #: A103886
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Prevalence of Antibodies Against JC Virus in Patients With Refractory Crohn's Disease and Effects of Natalizumab Therapy. - Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association
Natalizumab, a humanized antibody against the Î±4 integrin subunit, effectively induces and maintains remission in patients with Crohn's disease (CD) refractory to conventional treatments. Progressive multifocal leukoencephalopathy is a rare but fatal brain infection caused by John Cunningham (JC) virus and has been associated with natalizumab use. We assessed the prevalence of and risk factors for antibodies to JC virus in serum of patients with refractory CD who were candidates for, or already were receiving, natalizumab. We also assessed the effects of natalizumab treatment of these patients.In a retrospective study, we analyzed clinical charts from 191 patients with CD (74 males; mean age, 38.7 y; mean duration of disease, 14.9 y) tested for serum JC virus antibody from December 2012 through May 2014 at 2 medical centers in the United States. We calculated JC virus antibody prevalence and compared the characteristics of patients who tested negative vs those who tested positive, to identify risk factors. We also assessed the rate of subsequent natalizumab use, surgery, and seroconversion during natalizumab therapy.A total of 129 of the patients (67.5%) tested positive for serum JC virus antibody. Multivariate analysis showed that past use of thiopurine was a risk factor for testing positive for JC virus antibody (odds ratio, 7.8; 95% confidence interval, 2.0-30.4; P = .003). Twenty-two of the patients who tested negative for JC virus antibody (35.5%) and 16 of the 129 patients who tested positive (12.4%) had been treated with natalizumab. Cox regression analysis determined that natalizumab use was the only factor associated with avoiding subsequent surgery (hazard ratio, 0.23; 95% confidence interval, 0.06-0.98). Seroconversion (from testing negative to positive for JC virus antibody) occurred in 1 of the 22 patients (4.5%) who initially tested negative during natalizumab therapy.The prevalence of CD patients exposed to JC virus is comparable with that of the general population. In this retrospective study, prior thiopurine use was associated with an increased risk for testing positive for JC virus antibody. Natalizumab use reduced the risk of subsequent surgery.Copyright Â© 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.
Strictureplasty for Treatment of Crohn's Disease: an ACS-NSQIP Database Analysis. - Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
Strictureplasty is an alternative to resection for treatment of Crohn's disease (CD) strictures. It preserves bowel length, and specialized centers report favorable outcomes. Strictureplasty rates, however, are thought to be low, and it was recently removed from required cases for colon and rectal surgery residents. We examined operative characteristics, and trends in its use using a large national database.We examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012, identifying patients with CD who underwent strictureplasty. We identified patient characteristics, outcome variables, and trends in utilization of strictureplasty.A total of 9172 patients underwent surgery for CD. Two hundred fifty-six (2.8 %) underwent strictureplasty. Median preoperative albumin was 3.6. Preoperative steroid use and weight loss rates were 39 and 8 %. Rates of wound infection and organ space infection were 11 and 4 %. Rate of reoperation was 6 %. Outcomes did not change significantly over time (all pâ€‰=â€‰NS). The proportion of CD operations that included a strictureplasty decreased from 5.1 to 1.7 % (OR 0.902 with each additional year, 95 % CI (0.852, 0.960), pâ€‰<â€‰0.001).Strictureplasty as treatment for CD is decreasing in the ACS-NSQIP database. Infectious complications and reoperation rates following strictureplasty are low and have not changed over time.
Initial surgical management of ulcerative colitis in the biologic era. - Diseases of the colon and rectum
The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically.We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras.We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database.This study was conducted at a single university.A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study.We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization.Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis.The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it.Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.
Natalizumab in Crohn's disease: results from a US tertiary inflammatory bowel disease center. - Inflammatory bowel diseases
Natalizumab is an efficacious agent for the induction and maintenance of remission in patients with Crohn's disease (CD) who have failed anti-tumor necrosis factor (TNF) agents. We aimed to assess the efficacy and safety of natalizumab outside of clinical trial at a US tertiary center.Retrospective case review of patients with CD receiving natalizumab.Forty-nine patients with CD (28 women; median age, 33 years) receiving natalizumab from April 2008 to November 2011 were identified. Median duration of disease was 180 months (range, 36-576 months); 40 patients had ileocolonic disease, 1 had ileal disease, and 8 had colonic disease. Twenty-one patients had penetrating disease, and 28 had a history of CD-related surgical treatment. Forty-seven patients previously failed treatment with at least 1 anti-TNF agent. Median duration of natalizumab treatment was 7 months (interquartile range, 3-21.5 months). Twenty-four patients (49%) were continuing natalizumab at the time of this review, and 25 discontinued treatment because of the lack of response, side effects, or positive JC virus antibody. Seventeen patients (35%) successfully continued treatment with natalizumab for longer than 12 months, and nonpenetrating disease phenotype was identified as a predictor of longer response (compared with penetrating phenotype; P = 0.013). Nine patients (18.4%) experienced adverse effects, 5 of which were serious, but no case of progressive multifocal leukoencephalopathy occurred.This is the largest series of natalizumab-treated patients with CD. Our results show that natalizumab is an efficacious and safe treatment agent for patients refractory to anti-TNF agents and that nonpenetrating disease phenotype has more durable response over time.
Prostate specific antigen screening for prostate cancer: knowledge of, attitudes towards, and utilization among primary care physicians. - Urologic oncology
Prostate specific antigen (PSA) screening for prostate cancer screening is not uniformly recommended by national organizations or primary care physicians (PCPs). Given this lack of consensus, we sought to identify patterns in physician knowledge of and attitudes towards PSA screening and to determine how these patterns along with patient and provider demographics influence PSA screening practices.A self-administered questionnaire, which assessed provider's knowledge of prostate cancer, confidence in his/her knowledge, and PSA screening practices, was mailed to PCPs at an academic medical center. Frequencies of responses were summarized and 3 outcome variables (knowledge, confidence, and propensity to screen) were derived. Association of covariates with the outcome variables was determined using multivariable logistic regression.Eight-two (30.4%) physicians completed the survey; 98% identified African-American race as a prostate cancer risk factor, 42% identified digital rectal exam and PSA as the accepted screening method, and 59% underestimated the likelihood of prostate cancer in a man with a PSA level > 4 ng/ml; 19% were confident in their knowledge of prostate cancer; 86% screened fewer than 60% of their male patients over 50. A knowledge score above the median was not associated with a higher propensity to screen (r = 0.06, P = 0.61). Confidence in one's knowledge was correlated with ordering PSA testing (r = 0.33, P < 0.01). Physician (e.g., ethnicity) and patient (e.g., request for PSA testing) related factors, as well as practice guidelines, particularly those of the US Preventative Services Task Force, influenced providers' decision to offer PSA screening.Respondents correctly identified prostate cancer risk factors but were less knowledgeable about prostate cancer screening tests and overall prostate cancer risk. Most respondents were not confident in their knowledge and did not screen men over 50. Multiple patient- and provider-specific factors influence the decision to offer or not offer PSA screening.Copyright Ã‚Â© 2012 Elsevier Inc. All rights reserved.
Endophthalmitis associated with intravenous drug use. - Southern medical journal
Infectious complications related to i.v. drug use represent an important source of morbidity and mortality among this population. We report an informative case of endogenous endophthalmitis related to injection of cocaine mixed with lemon juice. Clinicians should remember that any visual change among patients using injection drugs warrants aggressive workup, including empiric antifungal therapy. Once the disease is identified, early vitrectomy should be considered.
Effect of alvimopan and codeine on gastrointestinal transit: a randomized controlled study. - Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association
background & aims: Opiate bowel dysfunction is a significant clinical problem. Our aim was to evaluate the ability of a peripheral mu-opioid antagonist, alvimopan, to reverse the effect of codeine on gastric, small-bowel, and colonic transit time in healthy volunteers.Seventy-four healthy participants (43 women) were randomized in a double-blind, placebo-controlled manner to 1 of 4 groups: alvimopan 12 mg twice daily in the presence and absence of codeine sulfate 30 mg 4 times/day, or codeine or placebo alone. Gastric emptying, small-bowel, and colonic transit were measured by scintigraphy using a 99m-labeled technetium egg meal and 111-labeled indium charcoal delivered to the proximal colon via a delayed-release capsule. The primary end points for colonic transit were geometric center of the colonic counts at 24 hours and time for 50% ascending colon emptying. Analysis of covariance was used to assess the significance of the primary and secondary end points.Codeine delayed gastric, small-bowel, proximal, and overall colonic transit (P < .05). Alvimopan reversed codeine's effect on small bowel and colon (ascending colon and overall colonic transit). Alvimopan also accelerated overall colonic transit compared with placebo. Thus, the mean colonic geometric center at 24 hours was 2.33 with placebo/placebo, 3.25 with alvimopan/placebo (P < .05), 1.5 with placebo/codeine (P < .05), and 2.63 with alvimopan/codeine. Alvimopan did not reverse codeine's delay of gastric emptying.Alvimopan reverses codeine's inhibitory effect on small-bowel and colon transit and has potential for treatment of opiate bowel dysfunction. Alvimopan alone accelerates colonic transit, suggesting that mu-opiate mechanisms participate in the physiologic control of colonic transit.
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