Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused

BackgroundData are sparse and inconsistent regarding whether thrombolytic therapy reduces case fatality rate in unstable patients with acute pulmonary embolism. We tested the hypothesis that thrombolytic therapy reduces case fatality rate in such patients.MethodsIn-hospital all-cause case fatality rate according to treatment was determined in unstable patients with pulmonary embolism who were discharged from short-stay hospitals throughout the United States from 1999 to 2008 by using data from the Nationwide Inpatient Sample. Unstable patients were in shock or ventilator dependent.ResultsAmong unstable patients with pulmonary embolism, 21,390 of 72,230 (30%) received thrombolytic therapy. In-hospital all-cause case fatality rate in unstable patients with thrombolytic therapy was 3105 of 21,390 (15%) versus 23,820 of 50,840 (47%) without thrombolytic therapy (P < .0001). All-cause case fatality rate in unstable patients with thrombolytic therapy plus a vena cava filter was 505 of 6630 (7.6%) versus 4260 of 12,850 (33%) with a filter alone (P < .0001). Case fatality rate attributable to pulmonary embolism in unstable patients was 820 of 9810 (8.4%) with thrombolytic therapy versus 1080 of 2600 (42%) with no thrombolytic therapy (P < .0001). Case fatality rate attributable to pulmonary embolism in unstable patients with thrombolytic therapy plus vena cava filter was 70 of 2590 (2.7%) versus 160 of 600 (27%) with a filter alone (P < .0001).ConclusionIn-hospital all-cause case fatality rate and case fatality rate attributable to pulmonary embolism in unstable patients was lower in those who received thrombolytic therapy. Thrombolytic therapy resulted in a lower case fatality rate than using vena cava filters alone, and the combination resulted in an even lower case fatality rate. Thrombolytic therapy in combination with a vena cava filter in unstable patients with acute pulmonary embolism seems indicated.     

Impact of vena cava filters on in-hospital case fatality rate from pulmonary embolism

BackgroundThe effects of vena cava filters on case fatality rate are not clear, although they are used increasingly in patients with pulmonary embolism. The purpose of this investigation is to determine categories of patients with pulmonary embolism in whom vena cava filters reduce in-hospital case fatality rate.MethodsIn-hospital all-cause case fatality rate according to the use of vena cava filters was determined in patients with pulmonary embolism discharged from short-stay hospitals throughout the United States using data from the Nationwide Inpatient Sample.ResultsIn-hospital case fatality rate was marginally lower in stable patients who received a vena cava filter: 21,420 of 297,700 (7.2%) versus 135,240 of 1,712,800 (7.9%) (P < .0001). Filters did not improve in-hospital case fatality rate if deep venous thrombosis was diagnosed in stable patients. A few stable patients (1.4%) received thrombolytic therapy. Such patients who received a vena cava filter had a lower case fatality rate than those who did not: 550 of 8550 (6.4%) versus 2950 of 19,050 (15%) (P < .0001). Unstable patients who received thrombolytic therapy had a lower in-hospital case fatality rate with vena cava filters than those who did not: 505 of 6630 (7.6%) versus 2600 of 14,760 (18%) (P < .0001). Unstable patients who did not receive thrombolytic therapy also had a lower in-hospital case fatality rate with a vena cava filter: 4260 of 12,850 (33%) versus 19,560 of 38,000 (51%) (P < .0001).ConclusionAt present, it seems prudent to consider a vena cava filter in patients with pulmonary embolism who are receiving thrombolytic therapy and in unstable patients who may not be candidates for thrombolytic therapy. Future prospective study is warranted to better define in which patients a filter is appropriate.     

Safety of withholding anticoagulant therapy in patients with suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography

BackgroundTo assess the safety of withholding anticoagulant therapy in patients with clinically suspected pulmonary embolism with a negative multislice computed tomography pulmonary angiography (MCTPA).MethodsThree hundred and eighty six patients who were consecutively assessed in the emergency room of our institution for suspected pulmonary embolism were eligible for our study. Patients with either a low or an intermediate clinical probability of pulmonary embolism according to the Wells score and a negative MCTPA for pulmonary embolism were enrolled. Patients with anticoagulant therapy for other medical conditions were excluded from this study. We assessed the percentage of patients in whom venous thromboembolic events or death related to this condition within three months after the negative CT.ResultsTwo hundred and forty two patients were included in our series [mean age ± standard deviation (SD) (63.1 ± 18.1)]. Only one patient (0.41% [95% confidence interval ?0.4%–1.22%]) showed a non-fatal pulmonary embolism during the three-month follow-up period after an initial negative CT scan (negative predictive value, 99.58%). Eleven patients died during the follow-up period due to conditions unrelated to venous thromboembolic disease (pneumonia [n = 5], lung cancer [n = 2], wasting syndrome [n = 1], acute myocardial infarction [n = 1], leiomyosarcoma [n = 1], and severe pulmonary hypertension [n = 1]).ConclusionsWithholding anticoagulant therapy in patients with suspected venous thromboembolic disease with a negative result on MCTPA seems to be safe in our clinical setting.     

Role of echocardiography and cardiac biomarkers in prediction of in-hospital mortality and long-term risk of brain infarction in pulmonary embolism patients

IntroductionThe aim of prospective study was to evaluate the ability of echocardiography and cardiac biomarkers to predict in-hospital mortality and the risk of brain infarction during a 12-month follow-up period (FUP) with anticoagulation in pulmonary embolism (PE) patients.MethodsEighty-eight consecutive acute PE patients (39 men, mean age 63 years) were enrolled; 78 underwent baseline echocardiography and brain magnetic resonance imaging (MRI). After a 12-month FUP, 58 underwent brain MRI. In-hospital mortality and the rates of new ischemic brain lesions (IBL) on MRI with clinical ischemic stroke (IS) events were predicted based on echocardiography (patent foramen ovale presence with right-to-left shunt – PFO/RLS; right/left ventricle diameter ratio – RV/LD; tricuspid annulus plane systolic excursion – TAPSE; tricuspid annulus systolic velocity – S_T; pulmonary artery systolic pressure – PASP) and biomarkers results (amino-terminal fragment of brain natriuretic peptide – NT-proBNP and cardiac troponin T – cTnT).ResultsOur series involved 88 patients, of whom 11 (12.5%) presented high-risk PE, 24 (27.3%) intermediate-high risk PE, 19 (21.6%) intermediate-low risk PE and 34 (38.6%) patients had low risk PE.Nine patients (10.2%) died during hospitalization including high-risk PE [6/9 (66.6%)] and intermediate-high-risk PE [3/24 (12.5%)]. cTnT [odds ratio (OR) 4.3; 95% confidence interval 0.59–31.3, P = 0.014], NT-proBNP (OR 14.2 [1.5–133.4], P = 0.02), RV/LD ≥0.79 (OR 36.6 [4.2–316.4], P = 0.001), TAPSE (OR 0.55 [0.34–0.92, P = 0.022) and PASP ≥51.5 mmHg (OR 33.3 [3.8–292.6], P = 0.022) were predictors of in-hospital mortality.Seventeen patients (19.3%) experienced IS (n = 8) or new IBL (n = 9). On multivariate analysis, PFO/RLS (OR 27.1 [3.0–245.3], P = 0.003) and S_T ≤14.5 cm/s (OR 34.1 [CI 3.4–344.0], P = 0.003) were independent predictors of IS and IBL risk.ConclusionsHigh blood troponin T, NT-proBNP, RV dilatation/systolic dysfunction and pulmonary hypertension predicted in-hospital mortality. PFO/RLS presence and S_T were predictors of clinically apparent/silent brain infarction.     

Accuracy of computed tomography angiography in the detection of pulmonary embolism in patients with high body weight

BackgroundThe accuracy of CT pulmonary angiography (CTPA) in detecting or excluding pulmonary embolism has not yet been assessed in patients with high body weight (BW).MethodsThis retrospective study involved CTPAs of 114 patients weighing 75–99 kg and those of 123 consecutive patients weighing 100–150 kg. Three independent blinded radiologists analyzed all examinations in randomized order. Readers' data on pulmonary emboli were compared with a composite reference standard, comprising clinical probability, reference CTPA result, additional imaging when performed and 90-day follow-up. Results in both BW groups and in two body mass index (BMI) groups (BMI < 30 kg/m² and BMI ≥ 30 kg/m², i.e., non-obese and obese patients) were compared.ResultsThe prevalence of pulmonary embolism was not significantly different in the BW groups (P = 1.0). The reference CTPA result was positive in 23 of 114 patients in the 75–99 kg group and in 25 of 123 patients in the ≥ 100 kg group, respectively (odds ratio, 0.991; 95% confidence interval, 0.501 to 1.957; P = 1.0). No pulmonary embolism-related death or venous thromboembolism occurred during follow-up. The mean accuracy of three readers was 91.5% in the 75–99 kg group and 89.9% in the ≥ 100 kg group (odds ratio, 1.207; 95% confidence interval, 0.451 to 3.255; P = 0.495), and 89.9% in non-obese patients and 91.2% in obese patients (odds ratio, 0.853; 95% confidence interval, 0.317 to 2.319; P = 0.816).ConclusionThe diagnostic accuracy of CTPA in patients weighing 75–99 kg or 100–150 kg proved not to be significantly different.     

Venous Thromboembolism in Patients with Chronic Obstructive Pulmonary Disease

ObjectiveOur aim was to compare the clinical characteristics, prophylaxis, treatment, and outcomes of venous thromboembolism in patients with and without previously diagnosed chronic obstructive pulmonary disease.MethodsWe analyzed the population-based Worcester Venous Thromboembolism Study of 2488 consecutive patients with validated venous thromboembolism to compare clinical characteristics, prophylaxis, treatment, and outcomes in patients with and without chronic obstructive pulmonary disease.ResultsOf 2488 patients with venous thromboembolism, 484 (19.5%) had a history of clinical chronic obstructive pulmonary disease and 2004 (80.5%) did not. Patients with chronic obstructive pulmonary disease were older (mean age 68 vs 63 years) and had a higher frequency of heart failure (35.5% vs 12.9%) and immobility (53.5% vs 43.3%) than patients without chronic obstructive pulmonary disease (all P < .0001). Patients with chronic obstructive pulmonary disease were more likely to die in hospital (6.8% vs 4%, P = .01) and within 30 days of venous thromboembolism diagnosis (12.6% vs 6.5%, P < .0001). Patients with chronic obstructive pulmonary disease demonstrated increased mortality despite a higher frequency of venous thromboembolism prophylaxis. Immobility doubled the risk of in-hospital death (adjusted odds ratio, 2.21; 95% confidence interval, 1.35-3.62) and death within 30 days of venous thromboembolism diagnosis (adjusted odds ratio, 2.04; 95% confidence interval, 1.43-2.91).ConclusionPatients with chronic obstructive pulmonary disease have an increased risk of dying during hospitalization and within 30 days of venous thromboembolism diagnosis. Immobility in patients with chronic obstructive pulmonary disease is an ominous risk factor for adverse outcomes.     

Case fatality rate with pulmonary embolectomy for acute pulmonary embolism

BackgroundThere are insufficient data to assess the potential role of pulmonary embolectomy in patients with acute pulmonary embolism.MethodsIn-hospital all-cause case fatality rate with pulmonary embolectomy was assessed from the Nationwide Inpatient Sample from 1999 through 2008.ResultsAmong unstable patients (in shock or ventilator-dependent), case fatality rate with embolectomy was 380 of 950 (40%). Among stable patients, case fatality rate was lower: 690 of 2820 (24%) (P <.0001). Case fatality rate in unstable patients was 39% in 1999-2003 and 40% in 2004-2008 (not significant), and in stable patients it was 27% in 1999-2003 and 23% in 2004-2008 (P = .01). Case fatality rates were lower in patients with a primary diagnosis of pulmonary embolism and even lower in patients with a primary diagnosis who had none of the comorbid conditions listed in the Charlson Index. Within each stratified group, patients with vena cava filters had a lower case fatality rate.ConclusionsCase fatality rate in unstable patients who underwent pulmonary embolectomy remained at 39%-40% from 1999-2003 to 2004-2008, and in stable patients it decreased only from 27% to 23%. Case fatality rates were lower in those with fewer comorbid conditions and in those who received a vena cava filter. Our data reflect average outcome in the US. It may be that experienced surgeons and an aggressive multidisciplinary team could obtain a lower case fatality rate.     

Delay and misdiagnosis in sub-massive and non-massive acute pulmonary embolism

BackgroundThere is limited information about the extent and clinical importance of the delay in the diagnosis of acute pulmonary embolism.Patients and methodsBetween 1998 and 2009, all consecutive patients diagnosed of acute pulmonary embolism from a registry of a single department were evaluated. We recorded the start or shift in symptoms as the beginning of pulmonary embolism and the mistaken diagnosis for which the patients had been treated. We evaluated the factors associated with the delay and misdiagnosis and their relation with mortality.ResultsOverall 375 patients were evaluated. Median age was 75 years, interquartile range (IQR) 15, and female 186 (49%). Median delay was 6 (IQR 12) days. Median Wells score was 4.5 (IQR 3).Delay in diagnosis was longer than 6 days in 50% (95% CI 44–55) of patients, longer than 14 days in 25% (95% CI 21–30) and longer than 21 days in 10% (95% CI 7–13). Misdiagnosis occurred in 50% (95% CI 44–55) of patients. Higher age, more days of delay and the absence of syncope or sudden onset dyspnea were factors associated with misdiagnosis.Follow-up was carried out in 331 patients during a median of 31 (IQR 45) months. 36% (95% CI 33–43) of patients died [median 8 (IQR 29) months]. Higher age, misdiagnosis and a history of cancer were factors associated with mortality. Days of delay were not associated with mortality.ConclusionsDelay and misdiagnosis of pulmonary embolism is frequent. Elderly patients and the absence of syncope or sudden onset dyspnea favour the misdiagnosis. Delay in diagnosis does not participate in mortality.     

Cinética del lactato para el pronóstico en el shock cardiogénico asistido con oxigenador extracorpóreo de membrana venoarterial

Introduction and objectivesLactate and its evolution are associated with the prognosis of patients in shock, although there is little evidence in those assisted with an extracorporeal venoarterial oxygenation membrane (VA-ECMO). Our objective was to evaluate its prognostic value in cardiogenic shock assisted with VA-ECMO.MethodsStudy of patients with cardiogenic shock treated with VA-ECMO for medical indication between July 2013 and April 2021. Lactate clearance was calculated: [(initial lactate ? 6 h lactate) / initial lactate × exact time between both determinations].ResultsFrom 121 patients, 44 had acute myocardial infarction (36.4%), 42 implant during cardiopulmonary resuscitation (34.7%), 14 pulmonary embolism (11.6%), 14 arrhythmic storm (11.6%), and 6 fulminant myocarditis (5.0%). After 30 days, 60 patients (49.6%) died, mortality was higher for implant during cardiopulmonary resuscitation than for implant in spontaneous circulation (30 of 42 [71.4%] vs 30 of 79 [38.0%], P = .030). Preimplantation GPT and lactate (both baseline, at 6 hours, and clearance) were independently associated with 30-day mortality. The regression models that included lactate clearance had a better predictive capacity for survival than the ENCOURAGE and ECMO-ACCEPTS scores, with the area under the ROC curve being greater in the model with lactate at 6 h.ConclusionsLactate (at baseline, 6 h, and clearance) is an independent predictor of prognosis in patients in cardiogenic shock supported by VA-ECMO, allowing better risk stratification and predictive capacity.     

Incidencia e historia natural de la enfermedad inflamatoria intestinal en Castilla y León: estudio prospectivo,multicéntrico y poblacional

IntroductionThe incidence of inflammatory bowel disease (IBD) is increasing worldwide.ObjectivesTo evaluate the incidence of IBD in Castilla y León describing clinical characteristics of the patients at diagnosis, the type of treatment received and their clinical course during the first year.Materials and methodsProspective, multicenter and population-based incidence cohort study. Patients aged >18 years diagnosed during 2017 with IBD (Crohn's disease [CD], ulcerative colitis [UC] and indeterminate colitis [IC]) were included from 8 hospitals in Castilla y León. Epidemiological, clinical, and therapeutic variables were registered. The global incidence and disease incidence were calculated.Results290 patients were diagnosed with IBD (54.5% UC, 45.2% CD, and 0.3% IC), with a median follow-up of 9 months (range 8?11). The incidence rate of IBD in Castilla y Leon in 2017 was 16.6 cases per 10,000 inhabitants-year (9/10⁵ UC cases and 7.5/10⁵ CD cases), with a UC/CD ratio of 1.2:1. Use of systemic corticosteroids (47% vs 30%; P = .002), immunomodulatory therapy (81% vs 19%; P = .000), biological therapy (29% vs 8%; P = .000), and surgery (11% vs 2%; p = .000) were significatively higher among patients with CD comparing with those with UC.ConclusionsThe incidence of patients with UC in our population increases while the incidence of patients with CD remains stable. Patients with CD present a worse natural history of the disease (use of corticosteroids, immunomodulatory therapy, biological therapy and surgery) compared to patients with UC in the first year of follow-up.     

Lung ultrasound in internal medicine: A bedside help to increase accuracy in the diagnosis of dyspnea

BackgroundDyspnea is one of the most frequent causes of admission in Internal Medicine wards, leading to a sizeable utilization of medical resources.Study design and methodsThe role of bedside lung ultrasound (LUS) was evaluated in 130 consecutive patients (age: 81 ± 9 years), in whom blindly collected LUS results were compared with data obtained by clinical examination, medical history, blood analysis, and chest X-ray. Dyspnea etiology was classified as “cardiac” (n = 80), “respiratory” (n = 36) or “mixed” (n = 14), according to the discharge diagnosis (congestive heart failure either alone [n = 80] or associated with pneumonia [n = 14], pneumonia [n = 24], and obstructive disventilatory syndrome [n = 12]). An 8-window LUS protocol was applied to evaluate B-line distribution, “interstitial syndrome” pattern, pleural effusion and images of static or dynamic air bronchogram/focal parenchymal consolidation.ResultsThe presence of a generalized “interstitial syndrome” at the initial LUS evaluation allowed to discriminate “cardiac” from “pulmonary” Dyspnea with high sensitivity (93.75%; confidence intervals: 86.01%–97.94%) and specificity (86.11%; 70.50%–95.33%). Positive and negative predictive values were 93.76% (86.03%–97.94%) and 86.09% (70.47%–95.32%), respectively. Moreover, LUS diagnostic accuracy for the diagnosis of pneumonia was not inferior to that of chest X-ray.ConclusionsBedside LUS evaluation contributes with high sensitivity and specificity to the differential diagnosis of Dyspnea. This holds true not only in the emergency setting, but also in the sub-acute Internal Medicine arena. A wider use of this portable technique in our wards is warranted.     

Insuffisance cardiaque congestive : place de l’ultrafiltration

IntroductionThe prevalence rate of congestive heart failure is approximately 2% in high-income countries. The aim of this study was to assess the overall benefit of ultrafiltration therapy in patients with acute or persistent congestive heart failure.MethodsWe conducted a health technology assessment following the EUnetHTA guidelines, with systematic literature review from bibliographic medical databases, independent experts and manufacturer interviews.ResultsThirteen clinical trials and five meta-analyses were examined. In the most recent one, 608 patients were included, of which 304 received ultrafiltration therapy and 304 received intravenous loop diuretics. Ultrafiltration therapy seems to be more beneficial regarding the fluid removal and the body weight reduction, (mean difference respectively 1.44 kg, IC95% [0.29; 2.59], P-value = 0.01 and 1.28 L [0.43; 2.12], P-value = 0.003). No difference has been showed in overall mortality, renal function, hospital readmission or safety. Medico-economic studies are incomplete and contradictory.ConclusionUltrafiltration therapy seems to be effective, most likely for patients ineligible or resistant to intravenous diuretics. But most topics remain uncertain, mainly impact on overall mortality, safety and cost-effectiveness. Given these knowledge-gaps, the generalization of ultrafiltration therapy should be examined cautiously, and conditional upon a large-scale systematic evaluation.     

Predictive factors of renal impairment in HIV-infected patients on antiretroviral therapy: Results from the VACH longitudinal cohort study

BackgroundThe use of combination antiretroviral therapy has led to dramatic improvements in the life expectancy of HIV-infected persons. As result, the HIV population is aging and increasingly facing illnesses typically seen in the elderly, such as chronic kidney disease (CKD).MethodsA retrospective longitudinal study was conducted using data from years 2010 and 2014 in all HIV-infected persons enrolled at the Spanish VACH cohort. We analyzed the prevalence and the predictive factors for developing CKD (estimated glomerular filtration rate, eGFR < 60 mL/min/1.73 m²).ResultsThe CKD prevalence at baseline was 456/8968, 5.1% [4.6–5.6%]. Of 8512 HIV-positive individuals examined without CKD at baseline (73.7% male, median age 44 years-old), 2.15% developed CKD (eGFR < 60 mL/min/1.73 m²). The odds ratios [95%CI] for the independent predictive factors identified were gender (male) 0.54 [0.39–0.75], age (per year) 1.08 [1.07–1.10], AIDS diagnosis 1.40 [1.03–1.91], protease inhibitor-based regimens 1.49 [1.10–2.02], hypertension 1.37 [0.94–1.99], diabetes 1.84 [1.33–2.55] and history of cardiovascular events 1.66 [0.96–2.86].ConclusionThe prevalence and risk factors for CKD and its progression are high in the VACH cohort. Thus, preventive measures such as control of hypertension, diabetes and obesity, as well as efforts for avoiding exposure to nephrotoxic drugs, including some antiretrovirals, are warranted in this aging HIV population.     

Prevalence of renal artery stenosis in flash pulmonary oedema: Determination using gadolinium-enhanced MRA

PurposeThe primary purpose was to determine the prevalence of renal artery stenosis (RAS) in patients presenting with acute (“flash”) pulmonary oedema (FPE), without identifiable cause using contrast-enhanced magnetic resonance angiography (CE-MRA) of renal arteries. A secondary goal was to correlate clinical parameters at presentation with the presence or absence of RAS.Materials and methodsPatients presenting with acute pulmonary oedema without identifiable cause prospectively underwent CE-MRA. > 50% renal artery stenosis was considered significant. Clinical parameters (blood pressure, serum creatinine, history of hypertension/hyperlipidaemia) were compared in patients with and without RAS using an unpaired t-test. Results expressed; mean (+/?SD).Results20 patients (4 male, 16 female, age 78.5+/?11 years) underwent CE-MRA. 9 patients (45%) had significant RAS (6 (30%) bilateral, 3 (15%) unilateral). Systolic BP was higher in patients with RAS (192+/?38 mm Hg) than those without (134+/?30 mm Hg) (p < .005). Diastolic BP was higher in patients with RAS (102+/?23 mm Hg) than those without (76+/?17 mm Hg) (p < .01). All patients with RAS and 6/11(55%) patients without RAS had a history of hypertension. No significant difference in creatinine or hyperlipidaemia history was observed.ConclusionThe prevalence of RAS in patients presenting with FPE is 45%. The diagnosis should be considered in patients presenting with unexplained acute pulmonary oedema, particularly if hypertensive at presentation.     

Probucol therapy improves long-term (>10-year) survival after complete revascularization: a propensity analysis

ObjectiveProbucol has anti-atherosclerotic properties and has been shown to reduce post-angioplasty coronary restenosis. However, the effect of probucol therapy on long-term (>10 years) outcome following coronary revascularization is less well established. Accordingly, we sought to determine if probucol therapy at the time of complete coronary revascularization reduces mortality in patients with coronary artery disease (CAD).MethodsWe collected data from 1694 consecutive patients who underwent complete revascularization (PCI and/or bypass surgery). Mortality data were compared between patients administered probucol and those not administered probucol at the time of revascularization. A propensity score (PS) was calculated to evaluate the effects of variables related to decisions regarding probucol administration. The association of probucol use and mortality was assessed using 3 Cox regression models, namely, conventional adjustment, covariate adjustment using PS, and matching patients in the probucol and no-probucol groups using PS.ResultsIn the pre-match patients, 231 patients were administered probucol (13.6%). During follow-up [10.2 (SD, 3.2) years], 352 patients died (including 113 patients who died of cardiac-related issues). Probucol use was associated with significant decrease in all-cause death (hazard ratio [HR], 0.65; P = 0.036 [conventional adjustment model] and HR, 0.57; P = 0.008 [PS adjusted model]). In post-match patients (N = 450, 225 matched pair), the risk of all-cause mortality was significantly lower in the probucol group than in the no-probucol group (HR, 0.45; P = 0.002).ConclusionIn CAD patients who had undergone complete revascularization, probucol therapy was associated with a significantly reduced risk of all-cause mortality.     

Statin use and musculoskeletal pain among adults with and without arthritis

BackgroundMusculoskeletal symptoms are common adverse effects of statins, yet little is known about the prevalence of musculoskeletal pain and statin use in the general population.MethodsWe conducted a cross-sectional study of the National Health and Nutrition Examination Survey 1999-2004. We estimated the prevalence of self-reported musculoskeletal pain according to statin use and calculated prevalence ratio estimates of musculoskeletal pain obtained from adjusted multiple logistic regression modeling.ResultsAmong 5170 participants without arthritis, the unadjusted prevalence of musculoskeletal pain was significantly higher for statin users reporting pain in any region (23% among statin users, 95% confidence interval [CI], 19-27, compared with 18% among those not using statins, 95% CI, 17-20; P = .02) and in the lower extremities (12% among statin users, 95% CI, 8-16, compared with 8% among those not using statins, 95% CI, 7-9; P = .02). Conversely, among 3058 participants with arthritis, statin use was not associated with higher musculoskeletal pain in any region. After controlling for confounders, among those without arthritis, statin use was associated with a significantly higher prevalence of musculoskeletal pain in any region, the lower back, and the lower extremities (adjusted prevalence ratios: 1.33 [CI, 1.06-1.67]; 1.47 [CI, 1.02-2.13]; 1.59 [CI, 1.12-2.22], respectively). Among participants with arthritis, no association was observed between musculoskeletal pain and statin use on adjusted analyses.ConclusionIn this population-based study, statin use was associated with a higher prevalence of musculoskeletal pain, particularly in the lower extremities, among individuals without arthritis. Evidence that statin use was associated with musculoskeletal pain among those with arthritis was lacking.     

Facteurs de risque de mortalité hospitalière au cours de l’embolie pulmonaire en milieu de pneumologie

ObjectivesThe objective of our work is to identify the risk factors for hospital mortality during pulmonary embolism in a pneumology department.Material and methodAll patients admitted to the pneumology department of Habib-Bourguiba hospital between 2014 and 2019, with a final diagnosis of PE are analyzed.ResultsOne hundred patients were included, 62% of whom were female, with an average age of 63 ± 16 years. Pulmonary fibrosis was noted in eight patients. On admission, the mean Simplified Pulmonary Embolism Severity Index score was 1.46 ± 1.05. The mean duration of hospitalization was 10.6 ± 7 days. The hospital mortality rate was 12%. The independent risk factors for intra-hospital mortality were arterial hypotension (OR: 6.13; 95% CI: 2.88–14.35; p = 0.001), cancer (OR: 2.66; 95% CI: 1.22–9.54; p = 0.026), a VD/LV ratio at echocardiography > 0.9 (OR: 1.84; 95% CI: 1.06–7.69; p = 0.039) and severe hypoxemia (OR: 4.86; 95% CI: 2.19–11,34; p = 0.006).ConclusionPulmonary embolism mortality remains high despite improvements in diagnostic and therapeutic management. It is important for our country to take these results into consideration for a better management of patients admitted for pulmonary embolism, and to improve survival.     

Riesgo de eventos tromboembólicos en función del manejo de la terapia anticoagulante y antiagregante en pacientes sometidos a colangiopancreatografía retrógrada endoscópica

Background and objectivesThe main clinical practice guidelines recommend adequate periprocedural withdrawal and reintroduction of antithrombotic drugs in case of invasive techniques. The main objective of this study was to assess whether, in patients receiving anticoagulant or antiplatelet therapy, the suppression or reduction of the pharmacological dose for the performance of endoscopic retrograde cholangiopancreatography (ERCP) implies a greater risk of thromboembolic events.Patients and methodsA prospective observational study was carried out, which included 644 ERCP performed with therapeutic intention during 2019 at the Reina Sofía University Hospital with follow-up during the 30 days after the endoscopic intervention.ResultsSix patients presented a thromboembolic event, finding no differences between the incorrect withdrawal/reintroduction of antithrombotic treatment and a higher proportion of thromboembolic or hemorrhagic events after the procedure (P > .05). The incidence of thrombotic events was significantly higher in patients treated with heparin or apixaban (P = .001), as well as with a history of atrial fibrillation (P = .05), rheumatic valve disease (P = .037) and recurrent pulmonary embolism (P = .035), this being also an independent risk factor. Likewise, the incidence of hemorrhage in the 30 days post-sphincterotomy was significantly lower in those with implantation of a biliary prosthesis (P = .04).ConclusionsInadequate periprocedural management of antithrombotic therapy is not associated with a significant increase in the incidence of thromboembolic events in the 30 days after ERCP. However, close follow-up and surveillance during the days after this is essential in those patients with a condition that significantly increases the risk of thrombosis.     

Development of pouchitis following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis: A role for serological markers and microbial pattern recognition receptor genes

Background and AimsPouchitis, the most common complication after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, has been attributed to altered composition of faecal flora. We investigated the role of antimicrobial and antiglycan antibodies and polymorphisms in microbial pattern recognition receptor genes.MethodsClinical charts of all 184 patients with ulcerative colitis who underwent IPAA between 1990–2004 were reviewed for pre- and post-operative disease course.ResultsFollow-up data were available in 172 patients [67 female, median age at proctocolectomy 39.1 years]. During a median follow-up of 6.7 (interquartile range 3.7–10.5) years, 80 patients (47%) developed at least one episode of pouchitis. Cox proportional-hazard regression identified extra-intestinal manifestations [HR 1.78 (95%CI 1.10–2.88), p = 0.020], a GT/TT genotype at Toll-like-receptor-1 S87I [HR 1.64 (1.01–2.66), p = 0.047], anti-chitobioside carbohydrate antibodies [HR 2.03 (1.11–3.70), p = 0.021] and young age at diagnosis [p = 0.003] to be independently associated with pouchitis. Factors associated with chronic pouchitis, diagnosed in 33 patients (19%), were extra-intestinal manifestations [HR 2.45 (1.07–5.62), p = 0.034], backwash ileitis [HR 3.15 (1.10–9.00), p = 0.032], outer-membrane porin antibodies [HR 2.67 (1.20–5.94), p = 0.016] and young age at proctocolectomy [p = 0.008].Conclusions:The reported association with antibodies and Toll-like-receptor-1 supports the pathophysiological role of the faecal flora in the development of pouchitis.     

Adenosine improves post-procedural coronary flow but not clinical outcomes in patients with acute coronary syndrome: a meta-analysis of randomized trials

AimsAdjunctive therapy with adenosine has been shown to improve coronary flow in patients with acute coronary syndromes (ACS); it is unclear, however, whether adenosine can effectively reduce adverse clinical events. The aim of our study was to perform a meta-analysis of all randomized controlled trials (RCTs) investigating angiographic and clinical outcomes in ACS patients undergoing PCI or thrombolysis and receiving adjunctive adenosine therapy vs. placebo.MethodsMedline/CENTRAL/EMBASE and Google Scholar database were scanned. The meta-analysis included ten RCTs (N = 3821). All-cause mortality was chosen as primary endpoint. Secondary endpoints were re-infarction (MI), heart failure (HF) symptoms (NYHA class III/IV), no-reflow (defined as TIMI 0 flow) and >50% ST-resolution.ResultsAdenosine compared to placebo was associated with a significant reduction of post-procedural no-reflow (OR [95% CI] = 0.25 [0.08–0.73], p = 0.01); however, at a median follow-up of 6 months, prior treatment with adenosine did not confer significant benefits in terms of reduction of mortality (OR_Fixed [95% CI] = 0.87 [0.69–1.09], p = 0.23), as well as re-MI (p = 0.80), HF symptoms (p = 0.44) and ST-resolution (p = 0.09). Separate analyses conducted in the subgroups of ST-elevation MI patients treated with either PCI or thrombolysis confirmed the findings found in the overall population.ConclusionsThis meta-analysis shows that adenosine adjunctive therapy does not improve survival nor reduce the rates of re-MI and HF symptoms in patients with ACS treated with PCI or thrombolysis. The beneficial effect on post-procedural coronary flow was not associated with consistent advantages on clinical outcomes.