Franklin Michota

Publications of Franklin Michota

• Renin-angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice.

  Authors: Moises Auron, Brian Harte, Ajay Kumar, Franklin Michota

  Postgraduate medical journal. 03/2011; 87(1029):472-81.

  There are no existing guidelines supporting the withdrawal or continuation of renin-angiotensin-aldosterone system (RAAS) antagonists in the preoperative setting. RAAS antagonists include ACEThere are no existing guidelines supporting the withdrawal or continuation of renin-angiotensin-aldosterone system (RAAS) antagonists in the preoperative setting. RAAS antagonists include ACE inhibitors, angiotensin II receptor subtype 1 blockers and direct renin inhibitors (eg, aliskiren), as well as the aldosterone antagonists. The use of these agents before surgery has been associated with a variable incidence of hypotension during the initial 30 min after induction of anaesthesia; however, these hypotensive episodes have not been conclusively linked to any significant postoperative complications, although recent data suggest an increase in postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting. Further studies are required to be able to demonstrate if the organ-protective benefits of RAAS antagonists justify their continuation in the perioperative setting. Temporary withdrawal of RAAS antagonists in these patients may prevent or attenuate intraoperative hypotension and hypovolaemia. Alternatively, the increase in RAAS activity and blood pressure expected with cessation of RAAS antagonist therapy may impair regional circulation secondary to an increase in systemic vascular resistance. Full discussion of the potential implications of perioperative RAAS antagonist therapy with the surgical team is important, and strategies to ensure careful monitoring and maintenance of adequate intravenous volume before induction of anaesthesia are essential.

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• Intracerebral hemorrhage: Pick your poison.

  Authors: Franklin Michota

  Cleveland Clinic journal of medicine. 11/2010; 77(11):743-6.

• Managing diabetes in hemodialysis patients: observations and recommendations.

  Authors: Kumarpal Shrishrimal, Peter Hart, Franklin Michota

  Cleveland Clinic journal of medicine. 11/2009; 76(11):649-55.

  Diabetes is challenging to manage in patients who have end-stage renal disease (ESRD), as both uremia and dialysis can complicate glycemic control by affecting the secretion, clearance, andDiabetes is challenging to manage in patients who have end-stage renal disease (ESRD), as both uremia and dialysis can complicate glycemic control by affecting the secretion, clearance, and peripheral tissue sensitivity of insulin. The authors summarize the available evidence and make practical recommendations.

• Optimizing management of venous thromboembolism: diagnosis, treatment, and secondary prevention.

  Authors: Arthur Sasahara, Franklin Michota, Sylvia C McKean, Steven B Deitelzweig, Anne Jacobson

  Journal of hospital medicine (Online). 10/2009; 4(8 Suppl):S16-23.

• Assessing the risk of venous thromboembolism and identifying barriers to thromboprophylaxis in the hospitalized patient.

  Authors: Sylvia C McKean, Steven B Deitelzweig, Arthur Sasahara, Franklin Michota, Anne Jacobson

  Journal of hospital medicine (Online). 10/2009; 4(8 Suppl):S1-7.

• Guidelines-based use of thromboprophylaxis.

  Authors: Steven B Deitelzweig, Arthur Sasahara, Franklin Michota, Sylvia C McKean, Anne Jacobson

  Journal of hospital medicine (Online). 10/2009; 4(8 Suppl):S8-S15.

• Improving thromboprophylaxis: performance measures and practical strategies.

  Authors: Franklin Michota, Patrick J Connor, Sylvia C McKean, Steven B Deitelzweig, Arthur Sasahara, Anne Jacobson

  Journal of hospital medicine (Online). 10/2009; 4(8 Suppl):S24-30.

• Medical management of hip fracture.

  Authors: Moises Auron-Gomez, Franklin Michota

  Clinics in geriatric medicine. 12/2008; 24(4):701-19.

  The United States population at the greatest risk for hip fracture, those aged 65 years and older, is steadily increasing in size. Today, the incidence of hip fracture is approximately 250,000 perThe United States population at the greatest risk for hip fracture, those aged 65 years and older, is steadily increasing in size. Today, the incidence of hip fracture is approximately 250,000 per year and it is expected to double in the next 30 years. Hip fracture patients are comorbid at baseline, and there are complications inherent to hip fractures that can occur in almost a predictable fashion. Overall, one in four hip fracture patients will die within one year of injury. Medical comanagement of hip fracture patients offers the best chance for successful outcome.

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• Surgical comanagement: A natural evolution of hospitalist practice.

  Authors: Christopher Whinney, Franklin Michota

  Journal of hospital medicine (Online). 11/2008; 3(5):394-397.

• What are the disadvantages of sliding-scale insulin?

  Authors: Franklin Michota

  Journal of hospital medicine (Online). 02/2007; 2 Suppl 1:20-2.

• Avoiding complications in the hospitalized patient: the case for tight glycemic control.

  Authors: Franklin Michota, Susan S Braithwaite

  Journal of hospital medicine (Online). 02/2007; 2 Suppl 1:1-4.

• Unrecognized sleep apnea in the surgical patient: implications for the perioperative setting.

  Authors: Roop Kaw, Franklin Michota, Amir Jaffer, Shekhar Ghamande, Dennis Auckley, Joseph Golish

  Chest. 02/2006; 129(1):198-205.

  Anesthesia and surgery both affect the architecture of sleep. Aside from the postoperative effects of anesthesia and surgery, sleep deprivation and fragmentation have been shown to produce apneas orAnesthesia and surgery both affect the architecture of sleep. Aside from the postoperative effects of anesthesia and surgery, sleep deprivation and fragmentation have been shown to produce apneas or desaturations even in patients without presumed sleep apnea. Recent epidemiologic data have placed the prevalence of obstructive sleep apnea syndrome (OSAS) at about 5% among Western countries. The problem is further hindered by the difficulty in diagnosing OSAS, as patients with OSAS may present for surgery without a prior diagnosis. Clinical suspicion for OSAS may first be recognized intraoperatively. Adverse surgical outcomes appear to be more frequent in OSAS patients. Immediate postoperative complications may intuitively be attributed to the negative effects of sedative, analgesic, and anesthetic agents, which can worsen OSAS by decreasing pharyngeal tone, and the arousal responses to hypoxia, hypercarbia, and obstruction. Later events are, however, more likely to be related to postoperative rapid eye movement (REM) sleep rebound. In the severe OSAS patient, REM sleep rebound could conceivably act in conjunction with opioid administration and supine posture to aggravate sleep-disordered breathing. REM sleep rebound has also been suggested to contribute to mental confusion and postoperative delirium, myocardial ischemia/infarction, stroke, and wound breakdown. Although the data to guide the perioperative management of patients with moderate-to-severe OSAS is scarce, heightened awareness is recommended. The selected use of therapy with nasal continuous positive airway pressure before surgery and after extubation may be beneficial.Learning OBJECTIVES: 1. Identify common sleep architectures affected by anesthesia and surgery in the perioperative period. 2. State a perioperative complication in Obstructive Sleep Apnea Syndrome patients. 3. Identify perioperative interventions and management techniques that best facilitate improved obstructive sleep apnea syndrome patient care.

• Current and emerging options in the management of venous thromboembolism.

  Authors: Amir K Jaffer, Daniel J Brotman, Franklin Michota

  Cleveland Clinic journal of medicine. 05/2005; 72 Suppl 1:S14-23.

  Venous thromboembolism (VTE) is a common disease whose diagnosis is challenging. The best diagnostic approaches combine the patient's pretest clinical probability of disease with D-dimer testingVenous thromboembolism (VTE) is a common disease whose diagnosis is challenging. The best diagnostic approaches combine the patient's pretest clinical probability of disease with D-dimer testing and/or diagnostic imaging. In light of several advantages, low-molecular-weight heparins are now recommended over unfractionated heparin for most patients with acute VTE. Newer anticoagulants such as the factor Xa inhibitor fondaparinux also show promise for acute VTE. For chronic management, the duration and intensity of warfarin therapy should be tailored to the individual patient.

• Anticoagulation in special patient populations: are special dosing considerations required?

  Authors: Franklin Michota, Geno Merli

  Cleveland Clinic journal of medicine. 05/2005; 72 Suppl 1:S37-42.

  Optimal dosing of low-molecular-weight heparin (LMWH) therapy has not yet been established for patients with morbid obesity or renal insufficiency or for pregnant women. Monitoring of anti-Xa levelsOptimal dosing of low-molecular-weight heparin (LMWH) therapy has not yet been established for patients with morbid obesity or renal insufficiency or for pregnant women. Monitoring of anti-Xa levels appears to be helpful in guiding LMWH dosing in all of these patient groups. Use of fondaparinux in these populations has yet to be defined. Cancer patients are at particular risk of venous thromboembolism and generally require escalated and/or prolonged anticoagulation with intense monitoring of therapy.

• Venous thromboembolism: epidemiology, characteristics, and consequences.

  Authors: Franklin Michota

  Clinical cornerstone. 02/2005; 7(4):8-15.

  Venous thromboembolism (VTE) and its manifestations, including deep vein thrombosis (DVT) and pulmonary embolism (PE), pose a life-threatening health problem for thousands of people each year. TheVenous thromboembolism (VTE) and its manifestations, including deep vein thrombosis (DVT) and pulmonary embolism (PE), pose a life-threatening health problem for thousands of people each year. The diagnosis of VTE is frequently missed, however, because few signs and symptoms are recognized. Symptoms of DVT may include pain, erythema, tenderness, and swelling of the affected limb, whereas PE often presents as sudden breathlessness with chest pain, or collapse with shock in the absence of other causes. Greater awareness of the epidemiology of VTE, the consequences of VTE, and the risk factors for VTE can help health care providers take appropriate preventive measures to reduce the incidence of VTE.

• Testing for B-type natriuretic peptide in the diagnosis and assessment of heart failure: what are the nuances?

  Authors: James B Young, Natalie G Correia, Gary S Francis, Alan Maisel, Franklin Michota

  Cleveland Clinic journal of medicine. 07/2004; 71 Suppl 5:S1-17.