One-week quadruple therapy is an effective salvage regimen for Helicobacter pylori infection in patients after failure of standard triple therapy

Standard triple therapy remains an important option for eradicating Helicobacter pylori (Hp) in developing countries because of its relatively low cost. However, salvage therapies after failure of this regimen remain undefined. The authors therefore investigate the efficacy of 1-week quadruple therapy as a second-line treatment of Hp infection after failure of standard triple therapy. Seventy-eight patients who failed Hp eradication using a 2-week bismuth-based triple therapy were enrolled and received a course of 1-week quadruple therapy (lansoprazole, 30 mg twice daily; bismuth subcitrate, 120 mg four times daily; clarithromycin, 500 mg twice daily; and amoxicillin, 1,000 mg twice daily) as a salvage regimen. The Hp status was reassessed 7 weeks after cessation of therapy. Among the 78 patients, Hp eradication was achieved in 65 (83%, 95% confidence interval = 75-91%) by intention-to-treat analysis. Only five (6%) patients had side effects, and all (100%) showed good drug compliance. Multivariate analysis disclosed that coffee drinking was an independent factor for treatment failure (odds ratio = 5.3, 95% confidence interval = 1.2-23.6, p = 0.028). The authors therefore conclude that their 1-week quadruple therapy is an effective salvage regimen for Hp infection after failure of standard triple therapy in the population examined. The benefits of this regimen include the high eradication rate, the short duration of treatment, fewer side effects, and good drug compliance. Coffee consumption possibly is an important factor in failure of the rescue regimen. The mechanisms underlying the association between coffee drinking and eradication failure require further research.     

Outcomes of a 1-day nonmyeloablative salvage regimen for patients with primary graft failure after allogeneic hematopoietic cell transplantation

Primary graft failure after allogeneic hematopoietic cell transplantation is a life-threatening complication. A shortened conditioning regimen may reduce the risk of infection and increase the chance of survival. Here, we report the outcome of 11 patients with hematologic diseases (median age, 44; range, 25-67 years, seven males) who received a 1-day reduced-intensity preparative regimen given as a re-transplantation for primary graft failure. The salvage regimen consisted of fludarabine, cyclophosphamide, alemtuzumab and TBI, all administered 1 day before re-transplantation. All patients received T-cell replete PBSCs from the same or a different haploidentical donor (n=10) or from the same matched sibling donor (n=1). Neutrophil counts promptly increased to >500/μL for 10 of the 11 patients at a median of 13 days. Of these, none developed grade III/IV acute GVHD. At present, 8 of the 11 patients are alive with a median follow-up of 11.2 months from re-transplantation and 5 of the 8 are in remission. In conclusion, this series suggests that our 1-day preparative regimen is feasible, leads to successful engraftment in a high proportion of patients, and is appropriate for patients requiring immediate re-transplantation after primary graft failure following reduced-intensity transplantation.     

Mitral valve repair as an alternative treatment for heart failure patients

Heart failure is one of the leading causes of hospitalization worldwide. Mitral regurgitation (MR) is a known complication of end-stage cardiomyopathy and is associated with a poor prognosis. Historically, these patients were managed medically and frequently with mitral valve replacement, both of which have unfavorable long-term outcomes. Over a 10-year period, we studied 167 patients with cardiomyopathy and severe MR who underwent mitral valve repair. These patients with 4+ MR, a mean left ventricular ejection fraction (LVEF) of 14+/-6 and New York Heart Association (NYHA) class III or IV congestive heart failure (CHF) were prospectively studied. All patients underwent mitral valve repair with an undersized annuloplasty ring. There was one intra-operative death and eight 30-day mortalities. Intra-operative echocardiography revealed no MR in most patients and trivial to mild MR in seven patients. There were 26 late deaths; two of these patients had progression of CHF and underwent transplantation. The 1-, 2-, and 5-year actuarial survival rates were 82%, 71%, and 52%, respectively. NYHA class was improved for all patients from a pre-operative mean of 3.2+/-0.2 to 1.8+/-0.4 postoperatively. At 24-month follow-up, all patients demonstrated improvement in LVEF, cardiac output, and end-diastolic volume, with a reduction in sphericity index and regurgitant volume. Mitral valve repair utilizing an undersized annuloplasty ring is safe and effectively corrects MR in cardiomyopathic patients. All of the observed changes contribute to reverse remodeling and restoration of the normal LV geometric relationship. Mitral valve repair offers a new strategy for patients with MR and end-stage cardiomyopathy.     

L-DEP regimen salvage therapy for paediatric patients with refractory Epstein-Barr virus-associated haemophagocytic lymphohistiocytosis

Epstein–Barr virus-associated haemophagocytic lymphohistiocytosis (EBV-HLH) is one of the most common subtypes of secondary HLH. However, more than 30% of patients do not respond to traditional treatment. Here, we investigated the efficacy and safety of the L-DEP regimen as a salvage therapy for paediatric refractory EBV-HLH. We retrospectively analysed 26 paediatric patients with refractory EBV-HLH who received the L-DEP regimen at Beijing Children’s Hospital from 1 January 2016 to 31 March 2019. Five of the patients achieved complete response (CR) and 11 achieved partial response (PR), indicating an overall response rate of 61·5% (CR + PR). Ten of the 16 patients who achieved CR or PR received allogenic haematopoietic stem cell transplantation (allo-HSCT), and seven were still alive at the last follow-up on 30 April 2020. Two of the 10 patients who did not respond were alive after allo-HSCT. Major side effects included increased amylase, bone marrow suppression and coagulation disorders, though these could be controlled by supportive therapy in most cases. Thus, we conclude that the L-DEP regimen is an effective and relatively safe salvage therapy for children with refractory EBV-HLH. This regimen also provides a bridge to allo-HSCT.     

治疗心力衰竭的循证医学进展

心力衰竭(心衰)至今仍是心血管疾病重要致死的终极病变,为了让读者能了解这方面近年的进展,我们在2005年美国和欧洲的心衰治疗指南基础上,回顾关于心衰的临床试验和相关循证医学治疗概况.     

An interactive Internet site for the management of patients with congestive heart failure

BACKGROUND: The Internet is a useful tool for improving communication between patients and their health care providers. However, no study has examined an efficient use of the Internet to improve quality of care for these patients. The purpose of this pilot study is to determine the feasibility of using an Internet-based communication tool with heart failure patients and to assess the effect of this system on the patients' quality of life. METHODS AND RESULTS: A prospective study was conducted among patients (n=16) attending a university-based heart failure clinic. An Internet communication Web site (www.heartfunction.com) was developed for the pilot study. The system was designed to be an information resource for patients and a daily communication method between patients and health care providers. Quality of life scores based on the Minnesota Living with Heart Failure Questionnaire (MLHFQ) were obtained at baseline and at three months. The mean MLHFQ score was 59.75+/-1.5 at baseline and 49.87+/-1.3 at three months (P=0.093). Significant differences were found at three months in the scale items that measured relationships with friends and family (3.062 versus 2.06; P=0.03), working around the house and yard (3.68 versus 2.81; P=0.008) and side effects of medication (2.81 versus 1.93; P=0.048). All patients reported high levels of satisfaction with the Web site. CONCLUSIONS: Internet-based communication is a feasible tool for the management of heart failure patients, providing an effective medium through which health care professionals can interact with their patients. This approach may also improve patient quality of care and quality of life.     

Beating heart valve surgery using stentless xenografts as a surgical alternative for patients with end-stage renal failure

Patients suffering from end-stage renal disease are an inhomogeneous high-risk group with a substantial perioperative mortality and morbidity when undergoing cardiac surgical procedures[1-3]. Myocardial ischemia, reperfusion injury and myocardial edema are a few of the deleterious consequences of the traditional use of cardioplegic arrest when performing valve surgery,irrespective of the type of cardioplegia used [4-7]. Novel operative techniques are required to reduce these induced perioperative risks. Clinical studies in the past have demonstrated the efficacy of beating heart valve surgery in the high-risk patient using retrograde, antegrade or combined coronary perfusion with warm oxygenated blood [8, 9]. We chose to combine the superior hemodynamic profile of stentless xenografts with the concept of performing valve replacement on the empty beating heart with continuous antegrade application of oxygenated blood in 2 chronic hemodialysis patients.     

An alternative approach to understanding the pathophysiological mechanisms of chronic heart failure

No single well established hypothesis for the mechanisms of heart failure currently exists. Those definitions that do exist are either not universally applicable or are not exclusive to heart failure. The pathogenesis of heart failure has been considered by some to be too complex to define with multiple pathophysiological processes being implicated. The many clinical and neurohumoral features of heart failure may be more dependent on the severity of the condition and its speed of onset rather than its etiology. This suggests a potential single common pathway or pathogenic mechanism in all forms of heart failure regardless of cause.This viewpoint uses the framework of myocardial mechanics and energetics to propose an alternative, simplified definition and unifying hypothesis for the pathogenesis of chronic heart failure. Chronic heart failure may be understood as follows. Cardiac output and stroke volume are determined by the tissues' requirements; the ejection fraction is determined by both myocardial shortening and degree of end-diastolic wall thickness; the end-diastolic volume is determined by the requirement to normalize stroke volume. We will argue that chronic heart failure can be viewed as a condition where the dominant compensatory mechanism is through regulation of ventricular end-diastolic volume. Consequently, in conditions where there is a fall in tissue perfusion, stroke volume and tissue perfusion are returned toward normal predominantly via this feedback mechanism.It is important for researchers, clinicians and their patients that we strive for a comprehensive, inclusive and unambiguous unifying hypothesis for pathophysiological mechanisms of heart failure.     

The relationship of medication regimen to hospital readmissions for older adults with heart failure

The purpose of this part of a longitudinal study was to examine whether medication therapy for older adults with heart failure predicted days to readmission post-hospital discharge. Using a prospective, predictive design, a convenience sample included 127 older adults with heart failure who had been recently discharged from two hospitals in northeastern Ohio. One hundred five patients were prescribed diuretics, 49 angiotensin-converting enzyme inhibitors, 23 b blockers, and 47 digoxin. There were no significant differences between readmitted and non-readmitted patients with regard to the use of the specific classes of cardiac medications. None of the specific classes of cardiac medications predicted the number of days between the initial hospital discharge and readmission 3 months later. The use of a small, non-probability sample and exclusion of variables limit the results of the study. Effective case management with teaching about heart failure must address changes involved with heart failure and the use of medication therapy. More research is needed about treatment protocols in various regions of the United States.     

End-of-life care for elderly patients with heart failure

The mortality rate of elderly persons with heart failure is high despite the introduction of several effective therapeutic interventions during the past decade. The management of end of life, often associated with distressing symptoms and multiple hospitalizations, is a significant clinical problem. Skillful and effective management requires expert knowledge of the heart failure syndrome, but the critical dimension of care relates to detailed knowledge about a patient's comorbidities, extent of debility, values, and desires. Discussing end-of-life issues early in the course of illness is essential for determining the appropriate levels of intensity of care and for defining the circumstances in which patients wish to be hospitalized and when hospital care offers little potential for increased comfort or longevity. Early and repeated discussions are needed to consider matters such as living wills, do-not-resuscitate orders, and power of attorney. In light of the complexity of the health care system, including involvement of multiple caregivers, end-of-life issues are among the most demanding of a physician's time, but when end-of-life care is managed effectively, health care providers often are rewarded with the gratitude of patients and their families for minimizing suffering and providing optimal opportunities for patients to participate in the affairs of family and the community.