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Association of Serum Phosphate Levels and Anemia in Critically Ill Surgical Patients. - JPEN. Journal of parenteral and enteral nutrition
Deranged serum phosphate (Phos) levels are associated with anemia in hospitalized patients, but their relevance to critical illness is unclear. Therefore, our goal was to investigate whether abnormal Phos on admission to the surgical intensive care unit (ICU) is associated with anemia.We performed a retrospective analysis of data from an ongoing study of nutrition in critical illness. Serum Phos and hemoglobin levels were obtained at ICU admission. Normal Phos was defined as 2.5-4.0 mg/dL. To investigate the association between Phos and anemia, we performed logistic regression analyses, while controlling for age, sex, race, body mass index, Nutrition Risk Screening score, Deyo-Charlson Comorbidity Index, creatinine, mean corpuscular volume, and serum albumin.In total, 510 patients comprised the analytic cohort; 62% were anemic, 30% had Phos >4.0 mg/dL, and 14% had levels <2.5 mg/dL. Logistic regression analysis demonstrated each unit increment in Phos was associated with a 25% higher likelihood of anemia (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.04-1.50). Moreover, patients with Phos >4.0 mg/dL had a 68% higher likelihood of anemia compared with those with normal levels (OR, 1.68; 95% CI, 1.02-2.80). Patients with Phos <2.5 mg/dL were not more likely to be anemic compared with those with normal levels.Surgical ICU patients with admission Phos >4.0 mg/dL are more likely to be anemic compared with those with normal levels. Our findings support the need for studies to determine whether globally maintaining optimal Phos reduces the likelihood of anemia and whether ideal Phos during acute care hospitalization influences clinical outcomes.Â© 2016 American Society for Parenteral and Enteral Nutrition.
Clustering analysis to identify distinct spectral components of encephalogram burst suppression in critically ill patients. - Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference
Millions of patients are admitted each year to intensive care units (ICUs) in the United States. A significant fraction of ICU survivors develop life-long cognitive impairment, incurring tremendous financial and societal costs. Delirium, a state of impaired awareness, attention and cognition that frequently develops during ICU care, is a major risk factor for post-ICU cognitive impairment. Recent studies suggest that patients experiencing electroencephalogram (EEG) burst suppression have higher rates of mortality and are more likely to develop delirium than patients who do not experience burst suppression. Burst suppression is typically associated with coma and deep levels of anesthesia or hypothermia, and is defined clinically as an alternating pattern of high-amplitude "burst" periods interrupted by sustained low-amplitude "suppression" periods. Here we describe a clustering method to analyze EEG spectra during burst and suppression periods. We used this method to identify a set of distinct spectral patterns in the EEG during burst and suppression periods in critically ill patients. These patterns correlate with level of patient sedation, quantified in terms of sedative infusion rates and clinical sedation scores. This analysis suggests that EEG burst suppression in critically ill patients may not be a single state, but instead may reflect a plurality of states whose specific dynamics relate to a patient's underlying brain function.
Vitamin D Status and the Risk of Anemia in Community-Dwelling Adults: Results from the National Health and Nutrition Examination Survey 2001-2006. - Medicine
Low vitamin D status has been implicated in several chronic medical conditions and unfavorable health outcomes. Our goal was to investigate whether serum 25-hydroxyvitamin D (25OHD) levels are a potentially modifiable risk factor for anemia in a nationally representative cohort of community-dwelling individuals in the United States.We performed a cross-sectional study of 5456 individuals (â‰¥17 years) from the National Health and Nutrition Examination Survey from 2001 to 2006. Locally weighted scatterplot smoothing (LOWESS) was used to graphically depict the relationship between serum 25OHD levels and the cumulative frequency of anemia. Multivariable logistic regression models were then used to assess the independent association of 25OHD levels with anemia, while controlling for age, sex, race, body mass index, chronic kidney disease, as well as serum levels of C-reactive protein, ferritin, iron, vitamin B12, and folic acid.The mean (standard error) 25OHD and hemoglobin levels in the analytic group were 23.5 (0.4) ng/mL and 14.4 (0.1) g/dL, respectively. Prevalence of anemia was 3.9%. Locally weighted scatterplot smoothing analysis demonstrated a near-linear relationship between vitamin D status and cumulative frequency of anemia up to 25OHD levels of approximately 20â€Šng/mL. With increasing 25OHD levels, the curve flattened out progressively. Multivariable regression analysis demonstrated an inverse association of 25OHD levels with the risk of anemia (adjusted odds ratio 0.97; 95% confidence interval 0.95-0.99 per 1â€Šng/mL change in 25OHD). Compared to individuals with â‰¥20â€Šng/mL, individuals with 25OHD levels <20â€Šng/mL were more likely to be anemic (adjusted odds ratio 1.64; 95% confidence interval 1.08-2.49).In a nationally representative sample of community-dwelling individuals in the United States, low 25OHD levels were associated with increased risk of anemia. Randomized controlled trials are needed to determine whether optimizing vitamin D status can reduce the burden of anemia in the general population.
Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates. - Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP.This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes.EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 Â± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%).In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.Â© 2015 American Society for Parenteral and Enteral Nutrition.
Serotonin Syndrome: The Potential for a Severe Reaction Between Common Perioperative Medications and Selective Serotonin Reuptake Inhibitors. - A & A case reports
Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed to patients of all ages. Although generally considered safe, therapy with SSRIs can be complicated by serotonin syndrome (SS), a life-threatening condition. We present a case of SS that developed in a young man who was receiving a stable dose of fluoxetine and then received several commonly used medications during an emergent appendectomy. Because polypharmacy in the perioperative setting may trigger SS, it is important for anesthesiologists to be cognizant of the interactions between SSRIs and common perioperative medications to formulate anesthetic plans that optimize patient safety.
Noise Levels in Surgical ICUs Are Consistently Above Recommended Standards. - Critical care medicine
The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient care areas in a hospital. Increased sound levels may contribute to worsened outcomes in these particularly vulnerable patients. Our objective was to determine whether ambient sound levels in surgical ICUs comply with recommendations established by the World Health Organization and Environmental Protection Agency, and whether implementation of an overnight "quiet time" intervention is associated with lower ambient sound levels.Prospective, observational cohort study.Two comparable 18-bed, surgical ICUs in a large, teaching hospital. Only one ICU had a formal overnight quiet time policy at the start of the study period.Sound levels were measured in 30-second blocks at preselected locations during the day and night over a period of 6 weeks using a simple, hand-held sound meter. All sound measurements in both units at all times exceeded recommended standards. Median minimum sound levels were lower at night in both units (50.8 and 50.3 vs 53.1 and 51.0 dB, p = 0.0003 and p = 0.009) and were similar between the two units (p = 0.52). The maximum overnight sound levels were statistically lower in the unit with the quiet time intervention implemented (62.5 vs 59.6 dB; p = 0.0040) and decreased overnight immediately after implementation of quiet time in the other unit (62.5 vs 56.1 dB; p < 0.0001). Maximum sound levels were lower inside patient rooms (52.2 vs 55.3 dB; p = 0.004), but minimum sound levels were similar (49.1 vs 49.2 dB; p = 0.23). Linear regression analysis showed that ICU census did not significantly influence sound levels.Ambient sound levels in the surgical ICUs were consistently above levels recommended by the World Health Organization and Environmental Protection Agency at all times. The use of a formal quiet time intervention was associated with a significant, but clinically irrelevant reduction in the median maximum sound level at night. Our results suggest that excessive ambient noise in the ICU is largely attributable to environmental factors, and behavior modifications are unlikely to have a meaningful impact. Future investigations, as well as hospital designs, should target interventions toward ubiquitous noise sources such as ventilation systems, which may not traditionally be associated with patient care.
Association of Vitamin D Status and Acute Rhinosinusitis: Results From the United States National Health and Nutrition Examination Survey 2001-2006. - Medicine
Although vitamin D status may be a modifiable risk factor for various respiratory ailments, limited data exists regarding its role in sinonasal infections. Our goal was to investigate the association of 25-hydroxyvitamin D (25OHD) levels with acute rhinosinusitis (ARS) in a large, nationally representative sample of non-institutionalized individuals from the United States. In this cross-sectional study of individuals â‰¥ 17 years from the National Health and Nutrition Examination Survey 2001-2006, we used multivariable regression analysis to investigate the association of 25OHD levels with ARS, while adjusting for season, demographics (age, sex, race, and poverty-to-income ratio), and clinical data (smoking, asthma, chronic obstructive pulmonary disease, diabetes mellitus, and neutropenia). A total of 3921 individuals were included in our analyses. Median 25OHD level was 22 (interquartile range 16-28) ng/mL. Overall, 15.8% (95% confidence interval [CI] 14.4-17.7) of participants reported ARS within the 24 hours leading up to their survey participation. After adjusting for season, demographics, and clinical data, 25OHD levels were associated with ARS (odds ratio 0.88, 95% CI 0.78-0.99 per 10 ng/mL). When vitamin D status was dichotomized, 25OHD levels < 20 ng/mL were associated with 33% higher odds of ARS (odds ratio 1.33, 95% CI 1.03-1.72) compared with levels â‰¥ 20 ng/mL. Our analyses suggest that 25OHD levels are inversely associated with ARS. Randomized, controlled trials are warranted to determine the effect of optimizing vitamin D status on the risk of sinonasal infections.
Admission vitamin D status is associated with discharge destination in critically ill surgical patients. - Annals of intensive care
Discharge destination after critical illness is increasingly recognized as a valuable patient-centered outcome. Recently, vitamin D status has been shown to be associated with important outcomes such as length of stay (LOS) and mortality in intensive care unit (ICU) patients. Our goal was to investigate whether vitamin D status on ICU admission is associated with discharge destination.We performed a retrospective analysis from an ongoing prospective cohort study of vitamin D status in critical illness. Patients were recruited from two surgical ICUs at a single teaching hospital in Boston, Massachusetts. All patients had 25-hydroxyvitamin D (25OHD) levels measured within 24Â h of ICU admission. Discharge destination was dichotomized as non-home or home. Locally weighted scatterplot smoothing (LOWESS) was used to graph the relationship between 25OHD levels and discharge destination. To investigate the association between 25OHD level and discharge destination, we performed logistic regression analyses, controlling for age, sex, race, body mass index, socioeconomic status, acute physiology and chronic health evaluation II score, need for emergent vs. non-emergent surgery, vitamin D supplementation status, and hospital LOS.300 patients comprised the analytic cohort. Mean 25OHD level was 19 (standard deviation 8) ng/mL and 41Â % of patients had a non-home discharge destination. LOWESS analysis demonstrated a near-inverse linear relationship between vitamin D status and non-home discharge destination to 25OHD levels around 10Â ng/mL, with rapid flattening of the curve between levels of 10 and 20Â ng/mL. Overall, 25OHD level at the outset of critical illness was inversely associated with non-home discharge destination (adjusted OR, 0.88; 95Â % CI 0.82-0.95). When vitamin D status was dichotomized, patients with 25OHD levels <20Â ng/mL had an almost 3-fold risk of a non-home discharge destination (adjusted OR, 2.74; 95Â % CI 1.23-6.14) compared to patients with 25OHD levels â‰¥20Â ng/mL.Our results suggest that vitamin D status may be a modifiable risk factor for non-home discharge destination in surgical ICU patients. Future randomized, controlled trials are needed to determine whether vitamin D supplementation in surgical ICU patients can improve clinical outcomes such as the successful rate of discharge to home after critical illness.
A Prospective, Observational Pilot Study of the Use of Urinary Antimicrobial Peptides in Diagnosing Emergency Department Patients With Positive Urine Cultures. - Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
Urinary tract infection (UTI) often represents a diagnostic challenge in the emergency department (ED) where urine culture results are generally not available and other tests demonstrate limited sensitivity and specificity. Antimicrobial peptides (AMPs) are components of the innate immune system that have demonstrated increased urinary levels in response to infection both in children and in adults with chronic UTI. The objective of this study was to determine the relationship between urinary AMP levels and positive urine cultures in adult ED patients with suspected UTI.This was a prospective, observational study of adult ED patients with suspected UTI. Enzyme-linked immunosorbent assays were performed to measure urine levels of AMPs: human neutrophil peptides 1-3 (HNP1-3), human Î±-defensin 5 (HD5), human beta defensin 2 (hBD-2), and cathelicidin (LL-37). Comparisons between positive and negative cultures were performed using Wilcoxon rank sum tests and receiver operating characteristic curves, with calculation of area under the curve (AUC). Data were also analyzed for the older adult subgroup.Of 40 patients enrolled, 23 (58%) were â‰¥ 65 years, 25 were female (64%), and seven (17%) were nonwhite. Cultures were positive in 13 (32%), including seven in those â‰¥ 65 years old. HNP1-3, HD5, and hBD-2 levels were significantly higher in those with positive than negative urine cultures. Median HNP1-3 was 5.39 ng/mg (interquartile range [IQR] = 2.74 to 11.09) in positive vs. 0.81 ng/mg (IQR = 0.06 to 3.87) in negative cultures. Median HD5 was 4.75 pg/mg (IQR = 1.6 to 22.7) in positive versus 0.00 pg/mg (IQR = 0 to 2.60) in negative cultures, and median hBD-2 was 0.13 pg/mg (IQR = 0.08 to 0.17) in positive versus 0.02 pg/mg (IQR = 0 to 0.04) in negative cultures (p < 0.05 for all). Findings were similar for adults â‰¥ 65 years. The AUC was â‰¥ 0.75 for all three AMPs, both overall and in the older adult subgroup. LL-37 was not significantly higher in patients with positive urine culture. However, LL-37 expression is vitamin D dependent, and inadequate serum levels (< 30 ng/mL) were present in 72% of those tested.Urinary levels of HNP1-3, HD5, and hBD-2 are significantly greater in the presence of positive urine cultures in ED patients with suspected UTI. These findings are maintained in the high-risk subgroup of older adults.Â© 2015 by the Society for Academic Emergency Medicine.
The Deyo-Charlson and Elixhauser-van Walraven Comorbidity Indices as predictors of mortality in critically ill patients. - BMJ open
Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) and Elixhauser-van Walraven Comorbidity Index (EVCI) to predict mortality in intensive care unit (ICU) patients.Observational study of 2 tertiary academic centres located in Boston, Massachusetts.The study cohort consisted of 59,816 patients from admitted to 12 ICUs between January 2007 and December 2012.For the primary analysis, receiver operator characteristic curves were constructed for mortality at 30, 90, 180, and 365â€…days using the DCCI as well as EVCI, and the areas under the curve (AUCs) were compared. Subgroup analyses were performed within different types of ICUs. Logistic regression was used to add age, race and sex into the model to determine if there was any improvement in discrimination.At 30â€…days, the AUC for DCCI versus EVCI was 0.65 (95% CI 0.65 to 0.67) vs 0.66 (95% CI 0.65 to 0.66), p=0.02. Discrimination improved at 365â€…days for both indices (AUC for DCCI 0.72 (95% CI 0.71 to 0.72) vs AUC for EVCI 0.72 (95% CI 0.72 to 0.72), p=0.46). The DCCI and EVCI performed similarly across ICUs at all time points, with the exception of the neurosciences ICU, where the DCCI was superior to EVCI at all time points (1-year mortality: AUC 0.73 (95% CI 0.72 to 0.74) vs 0.68 (95% CI 0.67 to 0.70), p=0.005). The addition of basic demographic information did not change the results at any of the assessed time points.The DCCI and EVCI were comparable at predicting mortality in critically ill patients. The predictive ability of both indices increased when assessing long-term outcomes. Addition of demographic data to both indices did not affect the predictive utility of these indices. Further studies are needed to validate our findings and to determine the utility of these indices in clinical practice.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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