1613 Harrison Pkwy #200
Sunrise FL 33323
Medical School: Other - Unknown
Accepts Medicare: No
Participates In eRX: No
Participates In PQRS: No
Participates In EHR: No
License #: ME95197
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Awards & Recognitions
Medical Malpractice Cases
Dade County Florida
Case Number: *********
Incident Date: 07/15/2008
Settlemnt Date: 11/02/2011
Medical Board Sanctions
AKI in Children Hospitalized with Nephrotic Syndrome. - Clinical journal of the American Society of Nephrology : CJASN
Children with nephrotic syndrome can develop life-threatening complications, including infection and thrombosis. While AKI is associated with adverse outcomes in hospitalized children, little is known about the epidemiology of AKI in children with nephrotic syndrome. The main objectives of this study were to determine the incidence, epidemiology, and hospital outcomes associated with AKI in a modern cohort of children hospitalized with nephrotic syndrome.Records of children with nephrotic syndrome admitted to 17 pediatric nephrology centers across North America from 2010 to 2012 were reviewed. AKI was classified using the pediatric RIFLE definition.AKI occurred in 58.6% of 336 children and 50.9% of 615 hospitalizations (27.3% in stage R, 17.2% in stage I, and 6.3% in stage F). After adjustment for race, sex, age at admission, and clinical diagnosis, infection (odds ratio, 2.24; 95% confidence interval, 1.37 to 3.65; P=0.001), nephrotoxic medication exposure (odds ratio, 1.35; 95% confidence interval, 1.11 to 1.64; P=0.002), days of nephrotoxic medication exposure (odds ratio, 1.10; 95% confidence interval, 1.05 to 1.15; P<0.001), and intensity of medication exposure (odds ratio, 1.34; 95% confidence interval, 1.09 to 1.65; P=0.01) remained significantly associated with AKI in children with nephrotic syndrome. Nephrotoxic medication exposure was common in this population, and each additional nephrotoxic medication received during a hospitalization was associated with 38% higher risk of AKI. AKI was associated with longer hospital stay after adjustment for race, sex, age at admission, clinical diagnosis, and infection (difference, 0.45 [log]days; 95% confidence interval, 0.36 to 0.53 [log]days; P<0.001).AKI is common in children hospitalized with nephrotic syndrome and should be deemed the third major complication of nephrotic syndrome in children in addition to infection and venous thromboembolism. Risk factors for AKI include steroid-resistant nephrotic syndrome, infection, and nephrotoxic medication exposure. Children with AKI have longer hospital lengths of stay and increased need for intensive care unit admission.Copyright Â© 2015 by the American Society of Nephrology.
Current Trends, Evaluation, and Management of Pediatric Nephrolithiasis. - JAMA pediatrics
The incidence of pediatric nephrolithiasis has been steadily increasing for the past several decades, with a concomitant concerning increase in health care costs and burden to children with this disease. Recent population-based studies have also demonstrated a change in the current trends of pediatric nephrolithiasis that is characterized by a significant increase in the number of girls now being affected. While changes in diet and lifestyle, obesity prevalence, and even imaging practices have been proposed to contribute to the recent increase in pediatric nephrolithiasis, a definite underlying cause remains elusive. This situation is complicated by the fact that, unlike in adults, the trends occurring in pediatric nephrolithiasis have not been studied rigorously, which contributes to the paucity of data in children. The level of concern with the increasing incidence is raised by factors unique to pediatric nephrolithiasis that could expose an affected child to more complications. Factors such as variable clinical presentation, high recurrence of kidney stones associated with abnormalities of metabolism and the urinary tract, and the possible presence of rare genetic kidney stone diseases would require physicians to comprehensively evaluate patients presenting with kidney stones. The goal of evaluation is to identify modifiable risk factors and abnormalities for which targeted therapy can be prescribed. The goals of medical and surgical treatments are to eliminate the burden of kidney stones and prevent recurrence while simultaneously minimizing complications from interventions. Patients at high risk may benefit from a specialized kidney stone clinic staffed by a pediatric nephrologist, urologist, dietitian, and clinical nurse. Such a multidisciplinary clinic can help provide the medical and surgical support needed for patients at high risk and offer key opportunities to learn more about pediatric nephrolithiasis, thereby fueling the much-needed research in this field.
Renin Angiotensin System Blocker Fetopathy: A Midwest Pediatric Nephrology Consortium Report. - The Journal of pediatrics
Fetuses continue to be exposed to renin angiotensin system (RAS) blockers despite their known teratogenicity and a black box warning. We hypothesized that fetopathy from in utero exposure to RAS blockers has a broader spectrum of clinical manifestations than described previously and that there are a variety of clinical scenarios leading to such exposures.This was a retrospective study performed through the Midwest Pediatric Nephrology Consortium. Cases of RAS blocker fetopathy were identified, with determination of renal and extrarenal manifestations, timing of exposure, and the explanation for the fetal exposure.Twenty-four cases were identified. RAS blocker exposure after the first trimester was associated with more severe renal manifestations. Chronic dialysis or kidney transplantation was required in 8 of 17 (47%) patients with RAS blocker exposure after the first trimester and 0 of 7 patients with exposure restricted to the first trimester (P = .05). Extrarenal manifestations, some not previously noted in the literature, included central nervous system anomalies (cystic encephalomalacia, cortical blindness, sensorineural hearing loss, arachnoid cysts) and pulmonary complications (pneumothorax, pneumomediastinum). RAS blocker exposure usually was secondary to absent or poor prenatal care or undiagnosed pregnancy.RAS blocker fetopathy continues to be a cause of considerable morbidity, with more severe renal manifestations associated with exposure after the first trimester. A variety of significant extrarenal manifestations occur in these patients. Clinicians should emphasize the risk of fetopathy when prescribing RAS blockers to women of childbearing age.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Rotational atherectomy: if you do not do it before, you can do it after stenting. - The Journal of invasive cardiology
We report the treatment of three severely underexpanded freshly deployed stent layers in the proximal left anterior descending artery, despite 24 atm inflation pressure, due to heavily calcified plaque. Rotational atherectomy, using a high rpm and a stepped burr strategy, successfully ablated the stent layers and the protruding calcified plaque. Subsequently, balloon angioplasty resulted in stent expansion and the treated segment was scaffolded with another stent, finally obtaining an excellent angiographic result. The patient's evolution was satisfactory. This case shows that rotational atherectomy can be a useful tool in a compromising situation, such as severely underexpanded implanted stents.
Percutaneous closure of patent foramen ovale: "Closed" door after the last randomized trials? - World journal of cardiology
Patent foramen ovale (PFO) percutaneous closure has previously been an accepted intervention for the prevention of recurrent cryptogenic stroke on the basis of observational studies. However, randomized trials have been lacking until now. Three recently published randomized trials (CLOSURE I, PC and RESPECT) do not demonstrate the superiority of this intervention versus optimal medical therapy, therefore making this practice questionable. Nonetheless, these trials have had certain pitfalls, mainly a lower than initially estimated number of patients recruited, therefore lacking sufficient statistical power. On the other hand, different closure devices were used in the three trials. In two of them (PC and RESPECT), the Amplatzer PFO Occluder was used and the STARflex device was used in the other one (CLOSURE I). Taken altogether, a meta-analysis of these three trials does not demonstrate a statistically significant benefit of percutaneous PFO closure (1.9% vs 2.9%; P = 0.11). However, if we analyze only the PC and RESPECT trials together, in which the Amplatzer PFO Occluder was used, a statistically significant benefit of percutaneous PFO closure is observed (1.4% vs 3.0%, P = 0.04). In conclusion, our interpretation of these trials is that the use of a dedicated, specifically designed Amplatzer PFO device could possibly reduce the risk of stroke in patients with PFO and cryptogenic stroke. This consideration equally applies to patients who have no contraindications for anticoagulant or antithrombotic therapy.
Design of the Nephrotic Syndrome Study Network (NEPTUNE) to evaluate primary glomerular nephropathy by a multidisciplinary approach. - Kidney international
The Nephrotic Syndrome Study Network (NEPTUNE) is a North American multicenter collaborative consortium established to develop a translational research infrastructure for nephrotic syndrome. This includes a longitudinal observational cohort study, a pilot and ancillary study program, a training program, and a patient contact registry. NEPTUNE will enroll 450 adults and children with minimal change disease, focal segmental glomerulosclerosis, and membranous nephropathy for detailed clinical, histopathological, and molecular phenotyping at the time of clinically indicated renal biopsy. Initial visits will include an extensive clinical history, physical examination, collection of urine, blood and renal tissue samples, and assessments of quality of life and patient-reported outcomes. Follow-up history, physical measures, urine and blood samples, and questionnaires will be obtained every 4 months in the first year and biannually, thereafter. Molecular profiles and gene expression data will be linked to phenotypic, genetic, and digitalized histological data for comprehensive analyses using systems biology approaches. Analytical strategies were designed to transform descriptive information to mechanistic disease classification for nephrotic syndrome and to identify clinical, histological, and genomic disease predictors. Thus, understanding the complexity of the disease pathogenesis will guide further investigation for targeted therapeutic strategies.
Successful removal of a floating thrombus in ascending aorta. - The Annals of thoracic surgery
Free-floating thrombus in ascending aorta is a rare cause of peripheral embolism with potentially fatal consequences. We report the case of a young patient with syncope and sudden lumbar pain. Computed tomographic scan revealed a large pedunculated floating mass attached to the posterior wall of the ascending aorta, probably responsible of renal embolic infarction; transthoracic echocardiography confirmed the diagnosis. Surgery was urgently performed. The thrombus was excised, and was not related to atherosclerotic disease of the aortic wall. We conclude that once diagnosis is clear, urgent surgery must be considered to avoid any further embolic complications.Copyright Â© 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Technical approach to iliac crest biopsy. - Clinical journal of the American Society of Nephrology : CJASN
Bone histomorphometry has been the gold standard in the evaluation and diagnosis of renal osteodystrophy. The recent new definition of renal osteodystrophy as chronic kidney disease-mineral and bone disorder has once again highlighted the use of bone biopsy as a powerful and diagnostic tool to determine skeletal abnormalities in chronic kidney disease. The procedure of iliac crest bone biopsy has been proved safe and associated with very minimal morbidity. In this review, the clinical indications, preparation, instrumentation, and potential complications are discussed. Because current biochemical markers are poor predictors of bone turnover, volume, and mineralization, a wider use of bone biopsy and histomorphometry will lead to a better understanding of the bone and mineral disorders that are associated with chronic kidney disease.
Osteomalacia in a hemodialysis patient receiving an active vitamin D sterol. - Nature clinical practice. Nephrology
A 17-year-old Filipino male hemodialysis patient presented for renal transplant evaluation. He had significant skeletal abnormalities characterized by bone pain, an inability to walk, and secondary hyperparathyroidism despite therapy with an active vitamin D sterol (paricalcitol).The patient underwent a physical examination, and his serum levels of calcium, phosphorus, alkaline phosphatase, parathyroid hormone, aluminum and 25-hydroxycholecalciferol (25OH-vitamin D) were determined. X-rays of hips and lower extremities, MRI, and bone histomorphometry after double tetracycline labeling were performed.Osteomalacia associated with low 25OH-vitamin D levels.Monthly therapy with ergocalciferol (vitamin D2) and discontinuation of paricalcitol.
Fatty acid ethyl esters in meconium: are they biomarkers of fetal alcohol exposure and effect? - Alcoholism, clinical and experimental research
Biomarkers of fetal exposure to alcohol are important to establish so that early detection and intervention can be made on these infants to prevent undesirable outcomes. The aim of this study was to analyze long-chain fatty acid ethyl esters (FAEEs) in meconium as potential biomarkers of fetal alcohol exposure and effect.Fatty acid ethyl esters were analyzed in the meconium of 124 singleton infants by positive chemical ionization gas chromatography/mass spectrometry (GC/MS) and correlated to maternal ethanol use.A total of 124 mother/infant dyads were enrolled in the study: 31 were in the control group and 93 were in the alcohol-exposed group. The incidence (28% vs 9.7%, p = 0.037) of ethyl linoleate detected in meconium was significantly higher in the alcohol-exposed groups than the control groups. Similarly, when the concentrations of ethyl linoleate in meconium were grouped (trichotomized), there was a significant linear by linear association between alcohol exposure and group concentrations of ethyl linoleate (p = 0.013). Furthermore, only alcohol-exposed infants were found in the group with the highest ethyl linoleate concentration. The sensitivity of ethyl linoleate in detecting prenatal alcohol exposure was only 26.9%, and its specificity and positive predictive value were 96.8 and 96.2%, respectively. There was no significant correlation between the concentration of ethyl linoleate in meconium and absolute alcohol consumed (oz) per drinking day across pregnancy, although a trend toward a positive correlation is seen at lower amounts of alcohol consumed. Among the polyunsaturated, long-chain FAEEs, there was weak evidence that the incidence (21.5% vs 6.5%, p = 0.057) and concentration (p = 0.064) of ethyl arachidonate (AA) were significantly higher in the alcohol-exposed groups than the control groups. Ethyl linolenate and ethyl docosahexanoate (DHA) in meconium were found only in the alcohol group, although not at statistically significant levels. Highly significant correlations were found among the concentrations of ethyl linoleate, ethyl linolenate, ethyl AA, and ethyl DHA in meconium (correlations ranged between rs = 0.203, p = 0.024; and rs = 0.594, p < 0.001).We conclude that FAEEs in meconium, particularly ethyl linoleate and ethyl AA, are biomarkers of high specificity for prenatal exposure to alcohol in newborn infants. We also propose that ethyl AA and DHA could be potential biomarkers of fetal alcohol effects on the developing fetal brain and should be investigated further.
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1613 Harrison Pkwy #200 Sunrise, FL 33323
1613 N Harrison Parkway Bldg. C, Suite 200
14050 Nw 14Th St Suite 190
1613 Harrison Pkwy #200