Premature Aging in Male Alcoholics: “Accelerated Aging” or “Increased Vulnerability”?

This study involved an evaluation of two versions of the "premature aging" theory of chronic alcoholism: the accelerated aging and increased vumerabHty versions. The major dependent measures used were the tests included in Reitan's brain age quotient (BAO), a series of neuropsychological tests known to be sensitive to the effects of alcoholism and aging. Subjects were 40 chronic alcoholic inpatients and 40 matched controls, divided into age groups by; decade, ranging from the 30s to the 60s. It was proposed that an j interaction between age and presence or absence of alcoholism, with BAO test differences between alcoholics and controls widening as age increases, would support the increased vulnerability version, while the absence of such aw interaction would support the accel-] erated aging version. The results dearty favored the accelerated aging version, with merited BAO test differences between alcoholics, and controls appearing even in the 30-year-old groups. It was concluded that chronic ateohoftcs tend to perform at levels found for nonalconoiics 10 years their senior, but the discrepancy between, alcoholics and nonalcohoics does not increase with age.     

“Valve‐in‐valve” for the treatment of paravalvular leaks following transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is commonly associated with some degree of aortic regurgitation (AR) secondary to the presence of paravalvular leaks. We present the case of an 86‐year‐old woman diagnosed with severe aortic stenosis who underwent TAVI with a 23‐mm Edwards‐SAPIEN valve. The procedure complicated with a severe paravalvular leak following TAVI that was unresponsive to balloon postdilation. This complication was successfully managed with the implantation of a second valve of the same diameter within the first one (“valve‐in‐valve”) resulting in trivial residual AR and the absence of significant transvalvular gradient at the end of the procedure. © 2009 Wiley‐Liss, Inc.     

The practice of Interventional Cardiovascular Medicine: “Evidence‐based” or “Judgment‐based”?

Evidence‐based medicine has emerged in response to empiric clinical decision‐making with the quest of infusing more “science” into the process of caring for the sick. Yet, evidence‐based medicine today is being applied to clinical practice in a rigid and, paradoxically, unscientific manner. The perception that evidence‐based medicine is the “ultimate and unquestionable biologic truth” that should supersede all other components of clinical decision‐making at the individual patient level needs to be critically reexamined. The practice of Interventional Cardiovascular Medicine should represent a bottom‐up approach that integrates the best external evidence—that has been critically analyzed—with individual clinical expertise and patient choice; it cannot result in cookbook approaches to patient care. External clinical evidence should inform, not replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. © 2008 Wiley‐Liss, Inc.     

Hepatitis C treatment from “response‐guided” to “resource‐guided” therapy in the transition era from interferon‐containing to interferon‐free regimens

Peginterferon/ribavirin has been the standard‐of‐care for chronic hepatitis C virus (HCV) infections: 48 weeks for genotype 1 or 4 (HCV‐1/4) and 24 weeks for HCV‐2/3. Response‐guided therapy recommended shorter 24‐ and 16‐week regimens for HCV‐1 with lower baseline viral loads (< 400 000–800 000 IU/mL) and rapid virological response (RVR, undetectable HCV RNA at week 4) and HCV‐2/3 with RVR, respectively; and extending to 72 and 48 weeks for HCV‐1 slower responders and HCV‐2 non‐RVR patients, respectively, to improve the efficacy. The progress of directly acting antivirals (DAA), moving from interferon‐containing regimens in 2011 to interferon‐free regimens in 2013, has greatly improved the treatment success. Interferon‐containing regimens include boceprevir or telaprevir or simeprevir or daclatasvir plus peginterferon/ribavirin, 24–48 weeks, for HCV‐1 or 4. However, adding these DAA has no benefit for HCV‐1 with lower baseline viral loads/RVR. Instead, 12‐week sofosbuvir plus peginterferon/ribavirin attained sustained virological response rates of > 90% for HCV‐1/3–6. Interferon‐free regimens include two main categories: NS5B nucleotide inhibitor (sofosbuvir)‐based regimens and NS3/4A inhibitor/NS5A inhibitor‐based regimens (daclatasvir/asunaprevir, paritaprevir/r/ombitasvir/dasabuvir and grazoprevir/elbasvir). About 8–24 weeks interferon‐free regimens could achieve sustained virological response rates of 82–99% for corresponding HCV genotypes. Although the newly DAA interferon‐free regimens have high efficacy and safety, the huge budget impact increases the treatment barriers. The current recommendation should, therefore, base on the availability, indication, and cost‐effectiveness in the transition era of DAA. Based on the concept of “resource‐guided therapy,” peginterferon/ribavirin might be applied for easy‐to‐treat interferon‐eligible patients in resource‐constrained areas. Prioritizing patients for interferon‐free regimens according to “time‐degenerative factors” (age and fibrosis) is justified before the regimens becoming available and affordable.