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Grand Rapids, MI, United States

Poor H.D.,Columbia University | Girgis R.,Spectrum Health | Studer S.M.,Newark Beth Israel Medical Center
Progress in Cardiovascular Diseases | Year: 2012

Pulmonary hypertension in the setting of parenchymal lung disease and conditions associated with chronic hypoxemia is commonly encountered in clinical practice and may adversely affect patients' function and mortality. Diagnosis of this subgroup of pulmonary hypertension has evolved but still requires right heart catheterization for confirmation. The primary treatment goal is optimization of the underlying parenchymal lung or hypoxemia-associated condition prior to consideration of pharmacologic therapy. Limited published experience with pulmonary hypertension-specific medications for treatment of WHO Group 3 pulmonary hypertension suggests symptomatic and functional benefit in selected individuals. The potential for worsening ventilation-perfusion matching must be considered in these cases, however, since there is a paucity of data regarding the optimal approach to treatment selection. Ongoing medication trials and further investigation of mechanisms of hypoxic pulmonary vasoconstriction provide hope for these patients who in the past often had only lung transplantation as a potential treatment option. © 2012 Elsevier Inc.

Barletta J.F.,Spectrum Health | Cooper B.,Hamot Medical Center | Ohlinger M.J.,University of Toledo
Critical Care Medicine | Year: 2010

Disorders of coagulation are common adverse drug events encountered in critically ill patients and present a serious concern for intensive care unit (ICU) clinicians. Dosing strategies for medications used in the ICU are typically developed for use in noncritically ill patients and, therefore, do not account for the altered pharmacokinetic and pharmacodynamic properties encountered in the critically ill as well as the increased potential for drug-drug interactions, given the far greater number of medications ordered. This substantially increases the risk for coagulation-related adverse reactions, such as a bleeding or prothrombotic events. Although many medications used in the ICU have the potential to cause coagulation disorders, the exact incidence will vary based on the specific medication, dose, concomitant drug therapy, ICU setting, and patient-specific comorbidities. Clinicians must strongly consider these factors when evaluating the risk/benefit ratio for a particular therapy. This review surveys recent literature documenting the risk for adverse drug reactions specific to bleeding and/or clotting with commonly used medications in the ICU. Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

Ross J.R.,University of Michigan | Larson C.M.,Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics | Adeoyo O.,Spectrum Health | Kelly B.T.,Hospital for Special Surgery | Bedi A.,University of Michigan
Clinical Orthopaedics and Related Research | Year: 2015

Background: Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. An awareness of the most frequent locations of the residual deformities may be critical to minimize these failures. Questions/purposes: The purposes of this study were to (1) define the three-dimensional (3-D) morphology of hips with residual symptoms before revision femoroacetabular impingement (FAI) surgery; (2) determine the limitation in range of motion (ROM) in these patients using dynamic, computer-assisted, 3-D analysis; and (3) compare these measures with a cohort of patients who underwent successful arthroscopic surgery for FAI by a high-volume hip arthroscopist. Methods: Between 2008 and 2013, one senior surgeon (BTK) performed revision arthroscopic FAI procedures on patients with residual FAI deformity and symptoms after prior unsuccessful arthroscopic surgery; all of these 47 patients (50 hips) had preoperative CT scans. Mean patient age was 29 ± 9 years (range, 16–52 years). Three-dimensional models of the hips were created to allow measurements of femoral and acetabular morphology and ROM to bony impingement using a validated, computer-based dynamic imaging software. During the same time period, 65 patients with successful primary arthroscopic treatment of FAI by the same surgeon underwent preoperative CT scans for the symptomatic contralateral hip; this group of 65 patients thus fortuitously provided postoperative evaluation of the originally operated hip and served as a control group. A comparison of the virtual correction with the actual correction in the primary successful FAI treatment cohort was performed. Correspondingly, a comparison of the recommended virtual correction with the correction evident at the time of presentation after failed primary surgery in the revision cohort was performed. Analysis was performed by two independent observers (JRR, OA) and a paired t-test was used for comparison of continuous variables, whereas chi-square testing was used for categorical variables with p < 0.05 defined as significant. Results: Ninety percent (45 of 50) of patients undergoing revision surgery for symptomatic FAI had residual deformities; the mean maximal alpha angle in revision hips was 68° ± 16° and was most often located at 1:15, considering the acetabulum as a clockface and 1 to 5 o’clock as anterior independent of side. Twenty-six percent (13 of 50) of hips had signs of overcoverage with a lateral center-edge angle greater than or equal to 40°. Dynamic analysis revealed mean direct hip flexion of 114° ± 11° to osseous impingement. Internal rotation in 90° of hip flexion and flexion, adduction, internal rotation to osseous contact were 28° ± 12° and 20° ± 10°, respectively, which were less than those in hips that had underwent hip arthroscopy by a high-volume hip arthroscopist (all p < 0.001). Conclusions: We found marked radiographic evidence of incomplete correction of deformity in patients with residual symptoms compared with patients with successful results with residual deformity present in the large majority of patients (45 of 50 [90%]) undergoing residual FAI surgery. We recommend careful attention to full 3-D resection of impinging structures. Level of Evidence: Level III, retrospective study, case series. © 2014, The Association of Bone and Joint Surgeons®.

Rehder C.W.,Duke University | David K.L.,Metropolitan Hospital Center | Hirsch B.,University of Minnesota | Toriello H.V.,Spectrum Health | And 2 more authors.
Genetics in Medicine | Year: 2013

Genomic testing, including single-nucleotide polymorphism-based microarrays and whole-genome sequencing, can detect long stretches of the genome that display homozygosity. The presence of these segments, when distributed across multiple chromosomes, can indicate a familial relationship between the proband's parents. This article describes the detection of possible consanguinity by genomic testing and the factors confounding the inference of a specific parental relationship. It is designed to guide the documentation of suspected consanguinity by clinical laboratory professionals and to alert laboratories to the need to establish a reporting policy in conjunction with their ethics review committee and legal counsel. © American College of Medical Genetics and Genomics.

Barletta J.F.,Midwestern University | Asgeirsson T.,Spectrum Health | Senagore A.J.,University of Southern California
Annals of Pharmacotherapy | Year: 2011

BACKGROUND: Intravenous opioids represent a major component in the pathophysiology of postoperative ileus (POI). However, the most appropriate measure and threshold to quantify the association between opioid dose (eg, average daily, cumulative, maximum daily) and POI remains unknown. OBJECTIVE: To evaluate the relationship between opioid dose, POI, and length of stay (LOS) and identify the opioid measure that was most strongly associated with POI. METHODS: Consecutive patients admitted to a community teaching hospital who underwent elective colorectal surgery by any technique with an enhanced-recovery protocol postoperatively were retrospectively identified. Patients were excluded if they received epidural analgesia, developed a major intraabdominal complication or medical complication, or had a prolonged workup prior to surgery. Intravenous opioid doses were quantified and converted to hydromorphone equivalents. Classification and regression tree (CART) analysis was used to determine the dosing threshold for the opioid measure most associated with POI and define high versus low use of opioids. Risk factors for POI and prolonged LOS were determined through multivariate analysis. RESULTS: The incidence of POI in 279 patients was 8.6%. CART analysis identified a maximum daily intravenous hydromorphone dose of 2 mg or more as the opioid measure most associated with POI. Multivariate analysis revealed maximum daily hydromorphone dose of 2 mg or more (p = 0.034), open surgical technique (p = 0.045), and days of intravenous narcotic therapy (p = 0.003) as significant risk factors for POI. Variables associated with increased LOS were POI (p < 0.001), maximum daily hydromorphone dose of 2 mg or more (p < 0.001), and age (p = 0.005); laparoscopy (p < 0.001) was associated with a decreased LOS. CONCLUSIONS: Intravenous opioid therapy is significantly associated with POI and prolonged LOS, particularly when the maximum hydromorphone dose per day exceeds 2 mg. Clinicians should consider alternative, nonopioid-based pain management options when this occurs.

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