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Pawtucket, RI, United States

Bhatt V.R.,University of Nebraska Medical Center | Aryal M.R.,The Reading Health System | Shrestha R.,Memorial Hospital of Rhode Island | Armitage J.O.,University of Nebraska Medical Center
European Journal of Haematology | Year: 2013

Objectives: Large licensing trials did not find any association between the use of fondaparinux and the development of heparin-induced thrombocytopenia (HIT). Fondaparinux is in fact recommended as an option for the management of HIT. Since the first report of fondaparinux-associated HIT in 2007, additional reports have been published. However, the rarity of these cases, differences in case definition, and lack of larger case series have prevented better understanding of this disease. The objective of this study was to determine the clinical manifestations of fondaparinux-associated HIT, the predictive value of pretest probability (4Ts) scoring system, and the outcomes associated with current management. Methods: Using several search terms, we reviewed all cases of fondaparinux-associated HIT reported and indexed in PubMed till May 2013. All references were also checked for additional reports. We categorized the cases of fondaparinux-associated HIT as confirmed, probable, and possible based on our case definition. Results: A total of eight cases of fondaparinux-associated HIT were identified. Fondaparinux-associated HIT occurred in the setting of pro-inflammatory state, prior HIT, or exposure to heparin products. Bilateral adrenal hemorrhage or infarct, reflecting hypercoagulability or disseminated intravascular coagulation, was seen in 25% of patients. The pretest probability (4Ts) scoring system used for HIT appears to correctly risk stratify all the cases. Although functional assays can be used for the diagnosis, in the presence of recent exposure to heparin products, only the demonstration of fondaparinux-dependent platelet activation should be considered confirmatory. Non-heparin anticoagulants are effective therapy; however, one-third of the patients had poor outcomes. Conclusion: The risk of fondaparinux-associated HIT, although low is real, which along with documented cases of fondaparinux failure mandate its cautious use in the management of HIT. © 2013 John Wiley & Sons A/S.

Hotchkiss R.S.,University of Washington | Opal S.,Memorial Hospital of Rhode Island | Opal S.,Brown University
New England Journal of Medicine | Year: 2010

A pathway newly implicated in the immunosuppression observed in persons infected with the human immunodeficiency virus (HIV) may also be pertinent to immunosuppression associated with sepsis. Copyright © 2010 Massachusetts Medical Society. All rights reserved.

Carter S.J.,Brown University | Roberts M.B.,Memorial Hospital of Rhode Island | Salter J.,Brown University | Eaton C.B.,Brown University
Atherosclerosis | Year: 2010

Background: Mediterranean diet has been promoted as the preferred dietary model for cardiovascular disease prevention in the United States. Objective: We sought to evaluate the degree to which the Mediterranean diet is associated with reduced levels of atherothrombotic biomarkers in a population-based sample in the U.S. Design: Data from 13,197 adults between the ages of 18 and 90 were collected and atherothrombotic risk factors assessed as part of the NHANES III, 1988-1994. Adherence to the Mediterranean diet was evaluated using food frequency questionnaires, supplemented by the 24-h dietary recall data, to develop Mediterranean Diet Scores (MedDietScore) that were analyzed in tertiles. The cross-sectional relationship of MedDietScore to atherothrombotic factors were analyzed using multiple variable regression analysis adjusted for complex sampling design using SUDAAN. Results: The components of the Mediterranean diet and the dietary pattern's associations with atherothrombotic risk factors differed by age and gender. For men <45 years of age as MedDietScore increased: total cholesterol/HDL cholesterol (TC/HDL) ratio (p= 0.0390), serum insulin (p= 0.0414), and white blood cell (WBC) (p= 0.0246) decreased. For men ≥45 years as MedDietScore increased: TC/HDL ratio (p= 0.0008), Hemoglobin A1c (HgbA1c) (p= 0.0001), HOMA index (p= 0.0486), C-reactive protein (p= 0.0034), fibrinogen (p= 0.0028) decreased and HDL cholesterol (HDL-c) levels (p<. 0.0001) increased. For pre-menopausal women, as MedDietScore increased: TC/HDL ratio (p<. 0.0001), non-HDL cholesterol (p= 0.0012), apolipoprotein B (p= 0.0112), HgbA1c (p= 0.0001), decreased and HDL-c levels (p<. 0.0001) increased. For post-menopausal women, as MedDietScore increased: TC/HDL ratio (p= 0.0005), Triglycerides (p<. 0.0001), serum insulin (p= 0.0062), HOMA index (p= 0.0063) and Homocysteine (Hcy) (0.0046) levels decreased and HDL-c levels (p= 0.0005) increased. Conclusions: Mediterranean diet appears to be associated with selective measures of cardioprotective lipid profiles, glucose metabolism, and inflammation and coagulation levels. © 2010 Elsevier Ireland Ltd.

Ferszt G.G.,University of Rhode Island | Clarke J.G.,Memorial Hospital of Rhode Island
Journal of Health Care for the Poor and Underserved | Year: 2012

Background. Although standards for pregnancy-related health care in correctional facilities have been established, there is no mandatory accreditation that requires adherence to these standards. Furthermore, this information has been difficult to access from correctional facilities across the country. Methods. To examine the health care practices of pregnant women in state prisons, a survey with 62 multiple choice questions and four open-ended questions was developed. Wardens of 50 women's state correctional facilities were contacted to describe the study and request participation. Nineteen facilities completed the survey, for a 38% response rate. Results. The findings of this study provide further evidence of the substandard care that pregnant incarcerated women receive in correctional facilities. In many state prisons, nutritional recommendations for a healthy pregnancy are not met, adequate rest is compromised and lower bunks are not required. Psychosocial support and education are minimal at best. The use of restraints, which can compromise the health and safety of the woman and her baby, continues as a matter of procedure in many facilities even during labor and delivery. Conclusions. The providers of health care for pregnant women fail to use best practices and established standards in many women's state prisons. A concerted effort is urgently needed to address the unmet health care needs of this marginalized population and support legislation to limit the use of restraints with pregnant incarcerated women in all states. © Meharry Medical College.

Olszewski A.J.,Memorial Hospital of Rhode Island | Olszewski A.J.,Brown University | Ali S.,Brown University
Annals of Hematology | Year: 2014

Despite diagnostic and therapeutic advances, the majority of patients with splenic marginal zone lymphoma (SMZL) are still treated with splenectomy. We analyzed survival outcomes after surgery or rituximab-based systemic therapy in the Surveillance Epidemiology and End Results-Medicare database, using inverse probability of treatment weighting to minimize treatment selection bias. From the 657 recorded cases diagnosed between 2000 and 2007, with a median age of 77 years, we selected 227 eligible patients treated with splenectomy (68 %), rituximab alone (23 %), or in combination with chemotherapy (9 %) within 2 years from diagnosis. No significant difference between the groups was observed in the cumulative incidence of lymphoma-related death (LRD) at 3 years (19.6 % with systemic therapy and 17.3 % with splenectomy; hazard ratio [HR], 1.04; 95 % confidence interval [CI], 0.56-1.92; P = 0.90) or in the overall survival (HR, 1.01; 95 % CI, 0.66-1.55; P = 0.95). The 90-day mortality after splenectomy was 7.1 %. The rates of hospitalizations, infections, transfusions, and cardiovascular or thromboembolic events were higher after combination chemoimmunotherapy than after splenectomy. Conversely, there was no significant difference in most complications between groups treated with splenectomy or rituximab alone. The cumulative incidence of LRD after single-agent rituximab at 3 years was 18.7 % (95 % CI, 8.6-31.7). In conclusion, in SMZL patients over the age of 65 years, the risk of LRD and overall survival are similar with systemic therapy or splenectomy as initial therapy. Single-agent rituximab may offer the most favorable risk/benefit ratio in this population. © 2013 Springer-Verlag Berlin Heidelberg.

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