Person: Oh, Daniel
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Oh, Daniel
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Publication Treatment Failure Among Infected Periprosthetic Patients at a Highly Specialized Revision TKA Referral Practice(Bentham Open, 2013) Schwarzkopf, Ran; Oh, Daniel; Wright, Elizabeth; Estok, Daniel; Katz, Jeffery NDeep infection is a serious and costly complication of total knee arthroplasty (TKA), which can increase patient morbidity and compromise functional outcome and satisfaction. Two-stage revision with an interval of parental antibiotics has been shown to be the most successful treatment in eradicating deep infection following TKA. We report a large series by a single surgeon with a highly specialized revision TKA referral practice. We identified 84 patients treated by a two-stage revision. We defined “successful two-stage revision” as negative intraoperative cultures and no further infection-related procedure. We defined “eradication of infection” on the basis of negative cultures and clinical diagnosis. After a mean follow up of 25 months, eradication of the infection was documented in 90.5% of the patients; some had undergone further surgical intervention after the index two-stage procedure. Successful two-stage revision (e.g. no I&D, fusion, amputation) was documented only in 63.5% of the patients. We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision. Factors affecting the high failure rate included multiple surgeries prior to the two-stage revision done at our institution, and high prevalence of MRSA present among failed cases. The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice. Thus increasing the prevalence of patients with previous failed attempts at infection eradication and delayed care as well as more fragile and immune compromised hosts.Publication Refractory Lactic Acidosis in Small Cell Carcinoma of the Lung(Hindawi Publishing Corporation, 2017) Oh, Daniel; Dinerman, Ellen; Matthews, Andrew; Aron, Abraham; Berg, KatherineBackground. Elevated lactate levels in critically ill patients are most often thought to be indicative of relative tissue hypoxia or type A lactic acidosis. Shock, severe anemia, and thromboembolic events can all cause elevated lactate due to tissue hypoperfusion, as well as the mitochondrial dysfunction thought to occur in sepsis and other critically ill states. Malignancy can also lead to elevation in lactate, a phenomenon described as type B lactic acidosis, which is much less commonly encountered in the critically ill. Case Presentation. We present the case of a 73-year-old Caucasian woman with type 2 diabetes and hypertension who presented with abdominal pain, nausea, vomiting, nonbloody diarrhea, and weight loss over five weeks and was found to have unexplained refractory lactic acidosis despite fluids and antibiotics. She was later diagnosed with small cell carcinoma of the lung. Conclusions. In this case report, we describe a critically ill patient whose elevated lactate was incorrectly attributed to her acute illness, when in truth it was an indicator of an underlying, as yet undiagnosed, malignancy. We believe this case is instructive to the critical care clinician as a reminder of the importance of considering malignancy on the differential diagnosis of a patient presenting with elevated lactate out of proportion to their critical illness.Publication Contrast-Enhanced CT Imaging as a Non-Destructive Tool for Ex Vivo Examination of the Biochemical Content and Structure of the Human Meniscus(2016-05-17) Oh, DanielObjective: Biochemical and biomechanical changes occur in the meniscus before osteoarthritis (OA) is clinically diagnosed through symptoms. However, existing techniques to characterize such changes are destructive and time-consuming. This study evaluated the ability of contrast-enhanced computed tomography (CECT) and contrast agent flux using the contrast agents Ioxaglate (ioxaglate) and CA4+ to correlate with the glycosaminoglycan (GAG) distribution and water content in ex vivo human menisci using microCT imaging. Methods: A diffusion-in kinetics study for CA4+ was conducted to determine the equilibrium time for the contrast agents by subregion. Subsequently, the optimal concentrations of Ioxaglate and CA4+ to map the native GAG distribution were determined. Then, these optimal concentrations were used to examine correlations between CECT attenuation and GAG content at various time points, including equilibrium time. Using microCECT imaging, imaged zones were excised, rinsed, and analyzed for GAG content by subregion using the dimethylmethylene blue (DMMB) assay. Depth-wise analysis was performed through each of the native surfaces to examine differences in contrast agent diffusion kinetics and calculate flux. Finally, correlations between CECT attenuation and GAG content, CECT attenuation and water content, and flux and water content were calculated by subregion and whole meniscus. Results: The equilibrium time was 48 hr with tau values ranging from 7.09 hr (posterior), 9.64 hr (anterior), and 12.32 hr (center). The optimal concentrations for native GAG mapping for ioxaglate and CA4+ were ≥80 mgI/mL and 12 mgI/mL, respectively. Using these optimal concentrations, weak to moderate correlations were found between ioxaglate CECT and GAG content at all diffusion time points, while strong correlations existed between CA4+ attenuation and GAG content as early as 7 hr (R2=0.67), strengthening by equilibrium (R2=0.81). CECT attenuation for both contrast agents did not significantly correlate with water content but CA4+ flux for the entire meniscus correlated moderately to strongly with water content (R2=0.56-0.64). Conclusions: CECT attenuation is a rapid, effective, non-destructive imaging technique to evaluate meniscal GAG distribution and water content. With CA4+ CECT, GAG content and distribution can be mapped in the human meniscus with high resolution. Consequently, CA4+ CECT is a useful tool for determining the biochemical health of human meniscal tissue, and further developments in quantitative imaging techniques will aid in understanding meniscal biology, diagnosis, and monitoring treatment outcomes.