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1.
J Thromb Haemost ; 12(7): 1044-53, 2014 Jul.
Article in English | MEDLINE | ID: mdl-24766902

ABSTRACT

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated response to unfractionated heparin and, less commonly, low molecular weight heparin. It is associated with a high thrombotic risk and the potential for limb and life-threatening complications. Argatroban is the only approved and currently available anticoagulant for HIT treatment in the USA. OBJECTIVES: To report safety and efficacy outcomes with bivalirudin for HIT treatment. METHODS: We retrospectively examined records from our registry of patients with a suspected, confirmed or previous history of HIT and who had received bivalirudin for anticoagulation in a single tertiary-care center over a 9-year period. RESULTS: We identified 461 patients who received bivalirudin: 220 (47.7%) were surgical patients, and 241 (52.3%) were medical patients. Of this population, 107 (23.2%) were critically ill, and 109 (23.6%) were dialysis-dependent. Suspected, confirmed and previous history of HIT were reported in 262, 124 and 75 patients, respectively. Of 386 patients with suspected or confirmed HIT, 223 patients (57.8%) had thrombosis at HIT diagnosis. New thrombosis was identified in 21 patients (4.6%) while they were on treatment with therapeutic doses of bivalirudin. No patient required HIT-related amputation. Major bleeding occurred in 35 patients (7.6%). We found a significant increase in major bleeding risk in the critically ill population (13.1%; odds ratio 2.4, 95% confidence interval 1.2-4.9, P = 0.014). The 30-day all-cause mortality rate was 14.5% (67 patients), and eight of 67 (1.7%) deaths were HIT-related. CONCLUSION: Bivalirudin may be an effective and safe alternative option for the treatment of both suspected and confirmed HIT, and appears to reduce the rate of HIT-related amputation.


Subject(s)
Antithrombins/therapeutic use , Heparin/adverse effects , Peptide Fragments/therapeutic use , Thrombocytopenia/chemically induced , Thrombocytopenia/drug therapy , Adult , Aged , Anticoagulants/therapeutic use , Arginine/analogs & derivatives , Female , Heparin, Low-Molecular-Weight/adverse effects , Hirudins , Humans , Male , Middle Aged , Odds Ratio , Pipecolic Acids/therapeutic use , Recombinant Proteins/therapeutic use , Registries , Retrospective Studies , Sulfonamides , Treatment Outcome
3.
Rheum Dis Clin North Am ; 25(3): 669-86, ix, 1999 Aug.
Article in English | MEDLINE | ID: mdl-10467634

ABSTRACT

Large artery occlusive disease is a common problem in the United States. It affects both the upper and lower extremities and is associated with significant morbidity and mortality. This article deals with the clinical recognition of this entity in hopes that the general internist and rheumatologist will more easily recognize it. In addition, the latest technology available to diagnose and treat large artery occlusive disease is discussed.


Subject(s)
Arterial Occlusive Diseases , Rheumatic Diseases/complications , Angioplasty , Arterial Occlusive Diseases/complications , Arterial Occlusive Diseases/diagnosis , Arterial Occlusive Diseases/therapy , Diagnosis, Differential , Exercise Therapy , Fibrinolytic Agents/therapeutic use , Humans , Life Style , Risk Assessment
4.
Cardiovasc Surg ; 7(4): 443-6, 1999 Jun.
Article in English | MEDLINE | ID: mdl-10430528

ABSTRACT

Diagnostic considerations in young patients presenting with coronary artery disease have conventionally included familial dyslipidemias, lipoprotein(a) elevation, hyperhomocysteinemia, cocaine toxicity, hypercoagulable states, connective tissue disorders, vasculitis and the presence of other established risk factors for coronary artery disease. The case of a young woman with unstable angina and a left main coronary artery ostial lesion on cardiac catheterization is discussed. She was subsequently diagnosed with Takayasu's arteritis 4 years later.


Subject(s)
Angina, Unstable/diagnosis , Coronary Disease/diagnosis , Takayasu Arteritis/diagnosis , Adrenal Cortex Hormones/therapeutic use , Adult , Cardiac Catheterization , Coronary Angiography , Diagnosis, Differential , Echocardiography, Doppler , Female , Humans , Magnetic Resonance Imaging , Methotrexate/therapeutic use , Takayasu Arteritis/drug therapy , Treatment Outcome
5.
Sci Context ; 11(3-4): 545-65, 1998.
Article in English | MEDLINE | ID: mdl-15168677

ABSTRACT

Japanese eugenic discourse and institution building contrast sharply with comparable movements elsewhere. As a social-intellectual phenomenon, Anglo-American eugenics considered the Japanese racially inferior to Western peoples; yet eugenic ideals and policies achieved a remarkable popularity in Japan. Most of mainstream Japanese genetics was derived from orthodox Mendelian roots in Germany and (to a lesser degree) the United States. But French-style Lamarckian notions of the inheritability of acquired characters held surprising popularity among enthusiasts of eugenics. Japanese eugenicists could condemn the actions of foreign eugenicists like Charles Davenport in the United States for their efforts to forbid Japanese immigration in the 1920s, yet appeal to these same eugenicists as a source of legitimacy in Japan. These paradoxes can partly be explained against a background of relative isolation in a period of profound social change. Few Japanese eugenicists had close personal contact with foreign eugenicists, and most of their knowledge was acquired through reading rather than direct exposure. The eugenic ideal of ethnic purity was attractive to a society long accustomed to monoracial self-imagery. The need to defend national independence in an era of high imperialism seemed to require the most up-to-date policies and ideas. And Japan's own acquisition of an overseas empire seemed to demand a population management philosophy ostensibly based on scientific principles. These and other forces supported the implementation of eugenic policies and prescriptions among the Japanese people in the first half of the twentieth century.


Subject(s)
Eugenics/history , Asian People/ethnology , Education/history , History, 19th Century , History, 20th Century , Humans , Japan , Public Policy , Societies/history
9.
Chest ; 99(1): 54-9, 1991 Jan.
Article in English | MEDLINE | ID: mdl-1984986

ABSTRACT

The experience at the Cleveland Clinic from 1982 to 1990 using thrombolytic therapy for superior vena cava (SVC) syndrome was retrospectively reviewed. Sixteen patients, 11 of whom had indwelling central venous catheters, were treated with either urokinase (n = 11) or streptokinase (n = 5). Either urokinase (4,400 U/kg bolus followed by 4,400 U/kg/h) or streptokinase (250,000 U bolus followed by 100,000 U/h) was used, and venograms were performed before and after. Overall, 56 percent of patients had complete clot lysis and relief of symptoms. Thrombolytic therapy was effective in eight (73 percent) of 11 patients receiving urokinase and one (20 percent) of five patients receiving streptokinase. Of those with a central venous catheter, eight (73 percent) of 11 patients were successfully lysed, whereas only one (20 percent) of five patients was successfully lysed if no catheter was present. If thrombolytic therapy was performed less than or equal to five days of symptom onset, seven (88 percent) of eight patients were successful, if thrombolytic therapy was performed greater than five days after symptom onset, two (25 percent) of eight patients were successful. Symptoms were relieved and the catheter was preserved in patients in whom thrombolytic therapy was effective. Factors predicting success were as follows: (1) the use of urokinase compared with streptokinase; (2) the presence of a central venous catheter; and (3) a duration of symptoms less than or equal to five days.


Subject(s)
Streptokinase/therapeutic use , Superior Vena Cava Syndrome/drug therapy , Thrombolytic Therapy , Urokinase-Type Plasminogen Activator/therapeutic use , Catheterization, Central Venous , Female , Humans , Infusions, Intravenous , Male , Middle Aged , Radiography , Retrospective Studies , Streptokinase/administration & dosage , Superior Vena Cava Syndrome/diagnostic imaging , Superior Vena Cava Syndrome/epidemiology , Time Factors , Urokinase-Type Plasminogen Activator/administration & dosage
10.
Circulation ; 82(5 Suppl): IV3-8, 1990 Nov.
Article in English | MEDLINE | ID: mdl-2225420

ABSTRACT

Between 1970 and 1987, 112 patients were diagnosed as having thromboangiitis obliterans (TAO). The age was 42 +/- 11 years (mean +/- SD; range, 20-75 years); 23% were women, and 7% were more than 60 years old when they were first diagnosed. Ischemic ulcerations were present in 85 (76%) patients: 24 (28%) patients with upper-extremity, 39 (46%) patients with lower-extremity, and 22 (26%) patients with both upper- and lower-extremity lesions. Ninety-one (81%) patients had rest pain, 49 (44%) patients had Raynaud's phenomenon, and 43 (38%) patients had superficial thrombophlebitis. We were able to follow up 89 of the 112 (79%) patients for 1-460 months (mean follow-up time, 91.6 +/- 84 months). Sixty-five (73%) patients had no amputations, while 24 (27%) had one or more of the following amputations: finger, six (15%) patients; toe, 13 (33%) patients; transmetatarsal, four (10%) patients; below knee, 14 (36%) patients; and above knee, two (5%) patients. Forty-three (48%) patients stopped smoking for a mean of 80 +/- 105 months (median, 46.5 months; range, 1-420 months), and only two (5%) patients had amputations after they stopped smoking, while 22 (42%) patients had amputations while continuing to smoke (p less than 0.0001). The spectrum of patients with TAO is changing in that the male-to-female ratio is decreasing (3:1), more older patients are being diagnosed, and upper-extremity involvement is commonly present. In the 48% of patients who stopped smoking, amputations and continued disease activity were uncommon.


Subject(s)
Smoking/adverse effects , Thromboangiitis Obliterans , Adult , Age Factors , Aged , Amputation, Surgical , Female , Follow-Up Studies , Humans , Male , Middle Aged , Ohio/epidemiology , Retrospective Studies , Sex Factors , Thromboangiitis Obliterans/diagnosis , Thromboangiitis Obliterans/epidemiology , Thromboangiitis Obliterans/surgery
11.
Arch Intern Med ; 149(9): 1959-61, 1989 Sep.
Article in English | MEDLINE | ID: mdl-2774776

ABSTRACT

Patients with thrombocytopenia have an increased risk of bleeding. We have used 18 courses of aminocaproic acid in 17 patients with either immune or nonimmune thrombocytopenia to successfully control hemorrhage associated with reduced platelet counts. The types of hemorrhage controlled included the following: vaginal, gastrointestinal, intracerebral, cutaneous, mucous membrane, subconjunctival, and renal, as well as that associated with dental extractions, tracheostomy, and sites of Penrose drains. The number of platelet and red blood cell transfusions administered decreased substantially following institution of aminocaproic acid therapy. We conclude that therapy with aminocaproic acid is safe and useful in the management of bleeding in patients with both immune and nonimmune thrombocytopenia.


Subject(s)
Aminocaproates/therapeutic use , Autoimmune Diseases/complications , Hemorrhage/drug therapy , Thrombocytopenia/complications , Adult , Aged , Erythrocyte Transfusion , Female , Humans , Male , Platelet Transfusion , Prospective Studies , Purpura, Thrombocytopenic/complications
12.
J Reprod Med ; 34(3): 234-6, 1989 Mar.
Article in English | MEDLINE | ID: mdl-2724238

ABSTRACT

Autoimmune thrombocytopenia purpura frequently is first noted during pregnancy. The severity of the disorder varies, but when the patient presents with active bleeding from any site, therapy is mandatory. Treatment generally consists of corticosteroids and/or splenectomy. A woman developed severe autoimmune thrombocytopenia purpura during pregnancy that proved refractory to corticosteroids and splenectomy. Six days after delivery her platelet count returned to normal. The etiology of autoimmune thrombocytopenia purpura remains unknown, but this experience suggests that in this patient the thrombocytopenia was related to her pregnancy.


Subject(s)
Autoimmune Diseases/physiopathology , Pregnancy Complications, Hematologic/physiopathology , Thrombocytopenia/physiopathology , Adrenal Cortex Hormones/therapeutic use , Adult , Autoimmune Diseases/drug therapy , Autoimmune Diseases/surgery , Female , Humans , Postpartum Period , Pregnancy , Pregnancy Complications, Hematologic/drug therapy , Pregnancy Complications, Hematologic/surgery , Splenectomy , Thrombocytopenia/drug therapy , Thrombocytopenia/surgery
14.
Transfusion ; 26(5): 431-3, 1986.
Article in English | MEDLINE | ID: mdl-2429410

ABSTRACT

The effects of dextran therapy on pretransfusion compatibility testing were evaluated in 24 patients with a variety of vascular disorders. Specimens were drawn before, during, and after the administration of low-molecular-weight dextran (average molecular weight, 40 kd). Forty-three specimens were studied extensively with several immunohematologic techniques. Dextran levels were measured to determine whether the concentration influenced the results of serologic tests. In no instance could we demonstrate any interference by dextran with pretransfusion tests, even at high serum levels of dextran.


Subject(s)
Blood Grouping and Crossmatching , Dextrans/administration & dosage , Blood Banks , Humans , Prospective Studies
15.
Curr Probl Cardiol ; 10(9): 1-70, 1985 Sep.
Article in English | MEDLINE | ID: mdl-3905273

ABSTRACT

PIP: This monograph includes a state-of-the-art discussion of pulmonary embolism, including its pathogenesis, predisposing factors, clinical presentation, diagnosis, and medical and surgical treatment. This remains one of the most common yet most difficult problems in medical practice. The disease affects 650,000 patients each year in the US, with over 200,000 fatalities. 40-60% of patients who die because of pulmonary emboli arrive at autopsy without the correct diagnosis and treatment. The major source of pulmonary embolism is the deep venous system of the legs and pelvis. Its frequency is greatest in patients ages 50-65 years, with no significant difference between men and women. An association has been identified with oral contraceptives. Figures in the monograph schematize an appropriate diagnostic plan of approach to the patient with suspected pulmonary embolism as well as a combined approach to both diagnosis and treatment. Elements of the latter include a history taking and physical examination for suspicion of pulmonary embolism, arterial blood gas, chest x-ray, electrocardiogram, ventilation-perfusion lung scan, pulmonary angiography, Doppler ultrasound, and thrombolytic therapy followed by heparin. A total of 572 references are cited.^ieng


Subject(s)
Pulmonary Embolism/diagnosis , Aged , Angiography , Contraceptives, Oral/adverse effects , Female , Heart Diseases/complications , Hematologic Diseases/complications , Heparin/therapeutic use , Humans , Immobilization , Middle Aged , Neoplasms/complications , Obesity/complications , Phlebography , Postpartum Period , Pregnancy , Pulmonary Circulation , Pulmonary Embolism/etiology , Pulmonary Embolism/prevention & control , Pulmonary Embolism/therapy , Risk , Wounds and Injuries/complications
17.
Science ; 224(4650): 714-5, 1984 May 18.
Article in English | MEDLINE | ID: mdl-17780595
18.
Science ; 220(4599): 822-4, 1983 May 20.
Article in English | MEDLINE | ID: mdl-17834175
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