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Cohen M.,Newark Beth Israel Medical Center
Journal of Interventional Cardiology

Acute coronary syndrome (ACS) is a major health burden, resulting in increased hospital admissions and significant morbidity and mortality. Platelet activation, which leads to thrombin generation, is highly implicated in ACS, and antiplatelet agents represent the current standard of care. Established antiplatelet agents include acetylsalicylic acid (ASA), thienopyridines (clopidogrel, ticlopidine), and glycoprotein IIb/IIIa inhibitors. Recently, antiplatelet therapy for ACS has evolved to include more potent inhibitors (e.g., prasugrel, cangrelor, and ticagrelor). During the acute phase of an acute coronary event, both anticoagulation and dual antiplatelet therapy with aspirin and a thienopyridine are guideline recommended as first-line treatment. While anticoagulation is usually limited to the acute in-patient phase, dual antiplatelet therapy is recommended for 12 months. Despite the efficacy of antiplatelet agents in ACS, in many patients the residual risk of death from cardiac events, myocardial infarction, stroke, and refractory ischemia remains high. Dual therapy (i.e., ASA or clopidogrel plus a vitamin K antagonist [VKA]), and triple therapy (two antiplatelets plus a VKA) are associated with increases in bleeding complications. New oral anticoagulants that offer a novel mechanism of action may, when added to the current standard of care, provide a more comprehensive response to thrombin generation. In this review, we examine the pathology of ACS, investigate antiplatelet therapies and describe emerging anticoagulants that may be of benefit when used as combination therapy with antiplatelet agents for secondary prevention in ACS patients. (J Interven Cardiol 2012;25:425-432) ©2012, Wiley Periodicals, Inc. Source

Baran D.A.,Newark Beth Israel Medical Center
Nature Reviews Cardiology

Heart transplantation has evolved into the treatment of choice for eligible patients with end-stage heart failure. Effective immunosuppression is critical to the success of this treatment, with the modern era beginning with the advent of cyclosporin A in the 1980s. In this Perspectives article, the major prospective, randomized trials of immunosuppression after heart transplantation are briefly reviewed. These trials provided the setting for the 2011 TICTAC trial, in which combined immunosuppression was compared with monotherapy. The results of the study are discussed, as are the implications of these data for future research, including the importance of frameworks, the risks and benefits of changes in immunosuppression regimen, the future of funding for such research, and the selection of appropriate end points in trials of heart transplantation. The presupposed need for multidrug immunosuppression is challenged, and the potential efficacy and benefits of monotherapy are explored. © 2013 Macmillan Publishers Limited. Source

Cohen M.,Newark Beth Israel Medical Center
Journal of Thrombosis and Thrombolysis

Greater use of evidence-based therapies has improved outcomes for patients with acute coronary syndromes (ACS) in recent decades. Consequently, more ACS patients are surviving beyond 12 months; however, limited data exist to guide treatment in these patients. Long-term outcomes have not improved in non-ST-segment elevation myocardial infarction (NSTEMI) patients at the same rate seen in ST-segment elevation myocardial infarction patients, possibly reflecting NSTEMI patients’ more complex clinical phenotype, including older age, greater burden of comorbidities and higher likelihood of a previous myocardial infarction (MI). This complexity impacts clinical decision-making, particularly in high-risk NSTEMI patients, in whom risk–benefit assessments are problematical. This review examines the need for more effective long-term management of NSTEMI patients who survive ≥12 months after MI. Ongoing risk assessment using objective measures of risk (for bleeding and ischemia) should be used in all post-MI patients. While 12 months appears to be the optimal duration of dual antiplatelet therapy for most patients, this may not be the case for high-risk patients, and more research is urgently needed in this population. A recent subgroup analysis from the DAPT study in patients with or without MI who had undergone coronary stenting (31 % presented with MI; 53 % had NSTEMI) and the prospective PEGASUS-TIMI 54 trial in patients with a prior MI and at least one other risk factor (40 % had NSTEMI) demonstrated that long-term dual antiplatelet therapy improved cardiovascular outcomes but increased bleeding. Further studies will help clarify the role of dual antiplatelet therapy in stable post-NSTEMI patients. © 2015, The Author(s). Source

Cohen E.,Newark Beth Israel Medical Center
Journal of general internal medicine

INTRODUCTION: Medical-legal partnerships (MLPs) bring together medical professionals and lawyers to address social causes of health disparities, including access to adequate food, housing and income. SETTING: Eighty-one MLPs offer legal services for patients whose basic needs are not being met. PROGRAM DESCRIPTION: Besides providing legal help to patients and working on policy advocacy, MLPs educate residents (29 residency programs), health care providers (160 clinics and hospitals) and medical students (25 medical schools) about how social conditions affect health and screening for unmet basic needs, and how these needs can often be impacted by enforcing federal and state laws. These curricula include medical school courses, noon conferences, advocacy electives and CME courses. PROGRAM EVALUATION: Four example programs are described in this paper. Established MLPs have changed knowledge (MLP | Boston-97% reported screening for two unmet needs), attitudes (Stanford reported reduced concern about making patients "nervous" with legal questions from 38% to 21%) and behavior (NY LegalHealth reported increasing resident referrals from 15% to 54%) after trainings. One developing MLP found doctors experienced difficulty addressing social issues (NJ LAMP-67% of residents felt uncomfortable). DISCUSSION: MLPs train residents, students and other health care providers to tackle socially caused health disparities. Source

Pitter M.C.,Newark Beth Israel Medical Center | Gargiulo A.R.,Harvard University | Bonaventura L.M.,Indiana University | Stefano Lehman J.,Newark Beth Israel Medical Center | Srouji S.S.,Harvard University
Human Reproduction

Study Question What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? Summary Answer Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. What is Known Already Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy. Study Design, Size, Duration This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011. Participants/Material, Setting, Methods Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed. Main Results And Role of Chancemean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion. Bias, Confounding and Other Reasons for Cautiongiven the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery. Generalizability to Other Populationsprospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome. Study Funding/Competing Interest (S)There was no funding source for this study. © 2012 The Author. Source

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