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Evanston, IL, United States

Kudrna J.,North Shore University Health System
Current Orthopaedic Practice | Year: 2013

Patients who undergo total knee arthroplasty are at risk of developing venous thromboembolism. Thromboprophylaxis is widely accepted as standard of care in patients receiving total knee arthroplasty, but implementation of clinical practice guidelines is hampered by several barriers, including limitations of current agents. New anticoagulants in clinical development offer equivalent or superior efficacy and safety to existing anticoagulants and the added convenience of oral administration. To date, rivaroxaban is the only new oral anticoagulant with regulatory approval for total knee arthroplasty in the United States, although dabigatran and apixaban are approved in other countries. For total knee arthroplasty, neuraxial blockade offers advantages over general anesthesia and narcotic-based systemic analgesia, but it carries a risk of spinal hematoma if used in conjunction with antithrombotics. Clinical practice guidelines already exist for the use of neuraxial blockade with traditional antithrombotics, and similar evidence-based recommendations are required for the new oral anticoagulants. © 2013 Wolters Kluwer Health.

Eilers R.E.,Northwestern University | Gandhi M.,Northwestern University | Patel J.D.,Northwestern University | Mulcahy M.F.,Northwestern University | And 3 more authors.
Journal of the National Cancer Institute | Year: 2010

Background: Patients treated with epidermal growth factor receptor inhibitors (EGFRIs) frequently experience dermatologic toxic effects. Whereas the impact of these effects on quality of life and EGFRI dosing has been described, their impact on physical health has not been ascertained. We examined the prevalence of infections that complicate dermatologic toxic effects of EGFRIs.Methods:We used retrospective chart review methods to analyze 221 patients who were treated in the Skin and Eye Reactions to Inhibitors of EGFR and Kinases clinic, a referral clinic for dermatologic toxic effects of cancer therapies. We reviewed results of bacterial cultures, histopathologic assessment of biopsy samples, and immunohistochemical staining of skin specimens for viral pathogens that were recorded in the patients' medical records. Associations between patient demographic and treatment characteristics and the development of infections were examined using the Fisher exact test. All statistical tests were two-sided.ResultsEighty-four (38%) of the 221 patients showed evidence of infection at sites of dermatologic toxic effect. Fifty (22.6%) of the 221 patients had cultures positive for Staphylococcus aureus, and 12 (5.4%) of the 221 patients cultured positive for methicillin-resistant S aureus. Less frequent infections included herpes simplex (3.2%), herpes zoster (1.8%), and dermatophytes (10.4%). The seborrheic region was the most prevalent site of infection, and patients with leukopenia had higher risk for infection than patients who did not have leukopenia (P =. 005). Demographic factors and associated treatments were not associated with the occurrence of a dermatologic infection (P ≥. 05).ConclusionsPatients with dermatologic toxic effects following treatment with EGFRIs have a high prevalence of cutaneous infections. Most notably, bacterial infections developed at sites previously affected by dermatologic toxic effects, with leukopenic patients being at greater risk.

Ammirati M.,Ohio State University | Wei L.,Ohio State University | Ciric I.,North Shore University Health System
Journal of Neurology, Neurosurgery and Psychiatry | Year: 2013

Endoscopic transsphenoidal pituitary surgery has become increasingly more popular for the removal of pituitary adenomas. It is also widely recognised that transsphenoidal microscopic removal of pituitary adenomas is a well-established procedure with good outcomes. Our objective was to meta-analyse the short-term results of endoscopic and microscopic pituitary adenoma surgery. We undertook a systematic review of the English literature on results of transsphenoidal surgery, both microscopic and endoscopic from 1990 to 2011. Series with less than 10 patients were excluded. Pooled data were analysed using meta-analysis techniques to obtain estimate of death, complication rates and extent of tumour removal. Complications evaluated included cerebrospinal fluid leak, meningitis, vascular complications, visual complications, diabetes insipidus, hypopituitarism and cranial nerve injury. Data were also analysed for tumour size and sex. 38 studies met the inclusion criteria yielding 24 endoscopic and 22 microscopic datasets (eight studies included both endoscopic and microscopic series). Meta-analysis of the available literature showed that the endoscopic transsphenoidal technique was associated with a higher incidence of vascular complications (p<0.0001). No difference was found between the two techniques in all other variables examined. Meta-analysis of the available literature reveals that endoscopic removal of pituitary adenoma, in the short term, does not seem to confer any advantages over the microscopic technique and the incidence of reported vascular complications was higher with endoscopic than with microscopic removal of pituitary adenomas. While we recognise the limitations of meta-analysis, our study suggests that a multicentre, randomised, comparative effectiveness study of the microscopic and endoscopic transsphenoidal techniques may be a reasonable approach towards establishing a true valuation of these techniques.

Hess C.N.,Duke University | Peterson E.D.,Duke University | Peng S.A.,Duke University | De Lemos J.A.,University of Texas Southwestern Medical Center | And 5 more authors.
Journal of the American College of Cardiology | Year: 2015

Background Antithrombotic therapy for acute myocardial infarction (MI) with atrial fibrillation (AF) among higher risk older patients treated with percutaneous coronary intervention (PCI) remains unclear. Objectives This study sought to determine appropriate antithrombotic therapy for acute MI patients with AF treated with PCI. Methods We examined 4,959 patients ≥65 years of age with acute MI and AF who underwent coronary stenting (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines). The primary effectiveness outcome was 2-year major adverse cardiac events (MACE) comprising death, readmission for MI, or stroke; the primary safety outcome was bleeding readmission. Outcomes with dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus warfarin) were compared using Cox proportional hazard modeling with inverse probability-weighted propensity adjustment. Results Among 4,959 patients, 27.6% (n = 1,370) were discharged on triple therapy. Relative to DAPT, patients on triple therapy had a similar risk of MACE (adjusted hazard ratio [HR]: 0.99 [95% confidence interval (CI): 0.86 to 1.16]) but significantly greater risk of bleeding requiring hospitalization (adjusted HR: 1.61 [95% CI: 1.31 to 1.97]) and greater risk of intracranial hemorrhage (adjusted HR: 2.04 [95% CI: 1.25 to 3.34]). Of 1,591 Medicare Part D patients, 90-day post-discharge warfarin persistence among patients discharged on warfarin was 93.2% (n = 412). Results of 90-day landmark analyses comparing triple therapy versus DAPT in patients persistently on warfarin versus those not discharged on warfarin who had not filled a warfarin prescription were similar to our primary findings. Conclusions Approximately 1 in 4 older AF patients undergoing PCI for MI were discharged on triple therapy. Those receiving triple therapy versus DAPT had higher rates of major bleeding without a measurable difference in composite MI, death, or stroke. © 2015 American College of Cardiology Foundation.

Wong R.H.,University of Chicago | Bailes J.E.,North Shore University Health System
Seminars in Thrombosis and Hemostasis | Year: 2013

Intraventricular hemorrhage is a frequent complication of intracerebral hemorrhage and is independently associated with significant morbidity and mortality. Intraventricular fibrinolytic therapy is used with increasing frequency to accelerate clot clearance. We review the recent evidence and discuss the therapeutic benefits as well as the current concerns and limitations of fibrinolytic use in this setting. © 2013 by Thieme Medical Publishers, Inc.

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