Risk of Ischemic Stroke in Patients With Gastric Cancer: A Nationwide Population-Based Cohort Study

Improvements in therapeutic modalities have prolonged the survival of gastric cancer patients. Comorbidities such as thromboembolic events that emerge as a result of disease complexities and/or treatments received have not been considered. The objectives of this study are to examine the relationship between gastric cancer and ischemic stroke, and to determine predictive risk factors.A nationwide population-based cohort study was conducted using data from the Taiwan National Health Insurance database. A total of 45,060 gastric cancer patients and non-cancer counterparts without antecedent stroke were recruited. Hazard ratios (HRs) and the cumulative incidence of ischemic stroke were calculated, and risk factors for ischemic stroke were assessed.Gastric cancer patients were associated with higher risk of ischemic stroke (HR 1.11, 95% confidence interval [CI] 1.03–1.19, P = 0.007), especially in participants younger than 65 years (HR 1.61, 95% CI 1.39–1.86, P < 0.001) and in female participants (HR 1.30, 95% CI 1.14–1.49; P < 0.001) when compared with the matched cohort. Independent risk factors of ischemic stroke in gastric cancer patients included age, hypertension, atrial fibrillation, dyslipidemia, and having received major surgery for gastric cancer.Our findings suggest the importance of stroke surveillance and prevention strategies in high-risk patients. Having received major surgery for gastric cancer is a significant risk factor in these patients.     

Risk factors of delayed recovery from general anesthesia in patients undergoing radical biliary surgery: What can we prevent

Delayed recovery (DR) is very commonly seen in the patients undergoing laparoscopic radical biliary surgery, we aimed to investigate the potential risk factors of DR in the patients undergoing radical biliary surgery, to provide evidences into the management of DR.Patients who underwent radical biliary surgery from January 1, 2018 to August 31, 2020 were identified. The clinical characteristics and treatment details of DR and no-DR patients were compared and analyzed. Multivariable logistic regression analyses were conducted to identify the potential influencing factors for DR in patients with laparoscopic radical biliary surgery.We included a total of 168 patients with laparoscopic radical biliary surgery, the incidence of postoperative DR was 25%. There were significant differences on the duration of surgery, duration of anesthesia, and use of intraoperative combined sevoflurane inhalation (all P < .05), and there were not significant differences on American Society of Anesthesiologists, New York Heart Association, tumor-lymph node- metastasis, and estimated blood loss between DR group and control group (all P > .05). Multivariable logistic regression analyses indicated that age ≥70 years (odd ratio [OR] 1.454, 95% confidence interval [CI] 1.146–1.904), body mass index ≥25 kg/m² (OR 1.303, 95% CI 1.102–1.912), alcohol drinking (OR 2.041, 95% CI 1.336–3.085), smoking (OR 1.128, 95% CI 1.007–2.261), duration of surgery ≥220 minutes (OR 1.239, 95% CI 1.039–1.735), duration of anesthesia ≥230 minutes (OR 1.223, 95% CI 1.013–1.926), intraoperative combined sevoflurane inhalation (OR 1.207, 95% CI 1.008–1.764) were the independent risk factors for DR in patients with radical biliary surgery (all P < .05).It is clinically necessary to take early countermeasures against various risk factors to reduce the occurrence of DR, and to improve the prognosis of patients.     

Efficacy and safety of ticagrelor monotherapy in patients following percutaneous coronary intervention: A systematic review and meta-analysis

Background:We aimed to systematically evaluate the efficacy and safety ticagrelor monotherapy following percutaneous coronary intervention.Methods:Online databases were searched for relevant studies (published between the years 2015 and 2020) comparing 1-month Dual antiplatelet therapy (DAPT) followed by 23-month ticagrelor monotherapy with 12-month DAPT followed by 12-month aspirin monotherapy following percutaneous coronary intervention. Primary outcomes assessed efficacy whereas secondary outcomes assessed safety. Odds ratios (OR) with 95% confidence intervals (CIs) based on a random effect model were calculated and the analysis was carried out by the RevMan 5.3 software.Results:Only 6 studies were selected for this meta-analytical research. The meta-analysis results: MI(OR:0.96, 95% CI:0.86–1.06, P = .40), stroke (OR:1.04, 95% CI: 0.87–1.25, P = .68), stent thrombosis (OR: 0.91,95% CI:0.76–1.10,P = .32),New-Q Wave (OR:0.85,95% CI: 0.72–1.00, P = .05), all cause death (OR:0.91, 95% CI: 0.87–0.96, P < .0001), death from cardiovascular (OR: 0.76, 95% CI: 0.58–0.99, P = .04), revascularization (OR: 0.93, 95% CI: 0.87–0.99, P = .03). Ticagrelor monotherapy was associated with a significantly lower rate of myocardial Infarction (MI), stroke, stent thrombosis, all cause death, death from cardiovascular and revascularization (OR:0.91,95% CI:0.87–0.96, P < .0001) when compared to DAPT. Besides, DAPT was associated with a significantly higher rate of BARC3 or 5 bleeding (OR:0.85, 95% CI: 0.68–1.06; P = .16) when compared to ticagrelor. When bleeding was further subdivided, minor or major bleeding was also significantly higher with DAPT (OR: 0.72, 95% CI: 0.41–1.27; P = .26). GUSTO moderate or severe bleeding was also significantly higher with DAPT (OR: 0.77, 95% CI: 0.39–1.52; P = .45).Conclusion:Ticagrelor monotherapy after short-term dual-antiplatelet therapy (DAPT) can optimize ischemic and bleeding risks. And, it can reduce the occurrence of events outcome (MI, revascularization, stroke, stent thrombosis).     

Effect of Different Antipsychotic Drugs on Short-Term Mortality in Stroke Patients

The safety, tolerability, and efficacy data for antipsychotic drugs used in the acute phase of stroke are limited. The primary aim of this study was to examine the effectiveness and safety of typical and atypical antipsychotics on acute ischemic stroke mortality.This observational study was conducted in a retrospective cohort of patients selected from the 2010–2011 National Health Research Institute database in Taiwan. Patients were tracked for 1 month from the time of their first hospitalization for acute ischemic stroke. A nested case–control analysis was used to estimate the odds ratio (OR) of 30-day mortality associated with antipsychotic drug, adjusted for age, gender, disease severity, and comorbidities.The study cohort included 47,225 subjects with ischemic stroke, including 9445 mortality cases and 37,780 matched controls. After adjustment for the covariates, antipsychotics users before ischemic stroke are associated with a 73% decrease in the rate of mortality (OR 0.27; 95% CI 0.23–0.31). After ischemic stroke, the use of antipsychotics is associated with 87% decrease in the rate of mortality (OR 0.13; 95% CI 0.1–0.16). The users of conventional antipsychotics are associated with a 78% decrease in the rate of mortality (OR 0.22; 95% CI 0.18–0.26). The users of atypical antipsychotics are also associated with a 86% decrease in the rate of mortality (OR 0.14; 95% CI 0.12–0.17).We found that 1-month mortality among acute stroke patients treated with antipsychotics is significantly lower. The benefit on lower mortality was found not only among ischemic stroke patients who had received antipsychotics previously but also among patients who start antipsychotics after their stroke.     

Warfarin Use and Risk of Stroke in Patients With Atrial Fibrillation Undergoing Hemodialysis: A Meta-Analysis

In spite of the substantial burden of atrial fibrillation and associated elevated ischemic stroke risk in patients undergoing hemodialysis, the role of warfarin in these high-risk patients remains uncertain. Our objective was to clarify the association between warfarin use and risk of stroke for patients with atrial fibrillation undergoing dialysis.PubMed and Embase from January 1966 to January 2015 were searched to identify relevant studies. Inclusion criteria were cohort studies, patients with atrial fibrillation undergoing hemodialysis, and reported quantitative estimates of the multivariate adjusted relative risk (RR) and 95% confidence interval (CI) for future stroke associated with warfarin use. We identified 8 studies, with a total of 9539 participants and 706 stroke events. Three studies reported total stroke as primary endpoint and other studies reported ischemic stroke as primary endpoint. Pooling the results showed that warfarin use was associated with higher risk of any stroke (RR 1.50, 95% CI: 1.13–1.99). By stroke type, warfarin was not significantly linked to risk of ischemic stroke (RR 1.01, 95% CI: 0.65–1.57, P = 0.97), but was related to greater hemorrhagic stroke risk (RR 2.30, 95% CI: 1.62–3.27). Warfarin heightened overall bleeding risk (RR 1.27, 95% CI: 1.03–1.56), but not death (RR 0.67, 95% CI: 0.37–1.21).Among patients with atrial fibrillation undergoing hemodialysis, use of warfarin is associated with a higher risk of hemorrhagic stroke, but did not increase overall mortality.     

The Efficacy of Surgical Treatment for the Secondary Prevention of Stroke in Symptomatic Moyamoya Disease: A Meta-Analysis

The treatment of moyamoya disease (MMD) is controversial and often depends on the doctor''s experience. In addition, the choice of surgical procedure to treat MMD can differ in many ways. In this study, we performed a meta-analysis to determine whether surgical treatment of MMD is superior to conservative treatment and to provide evidence for the selection of an appropriate surgical treatment.The human case–control studies regarding the association of MMD treatment were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized.This meta-analysis included 16 studies. Surgical treatment significantly reduced the risk of stroke (odds ratio (OR) of 0.17, 95% confidence interval (CI), 0.12–0.26, P < 0.01). A subgroup analysis showed that surgical treatment was more beneficial to hemorrhagic MMD (OR of 0.23, 95% CI, 0.15–0.38, P < 0.01), but there was no significant difference between surgical treatment and conservative treatment on ischemic MMD treatment (OR of 0.45, 95% CI, 0.15–1.29, P = 0.14). Further analysis indicated that compared to direct bypass surgery, indirect bypass surgery had a lower efficacy on secondary stroke risk reduction (OR of 1.79, 95% CI, 1.14–2.82, P = 0.01), while no significant difference was detected for perioperative complications.Surgery is an effective treatment for symptomatic MMD patients, and direct bypass surgery may bring more benefits for these patients.     

High-dose statin pretreatment decreases periprocedural myocardial infarction and cardiovascular events in East Asian patients undergoing percutaneous coronary intervention: A meta-analysis of fifteen randomized controlled trials

Background:Numerous studies have shown that high-dose statin pretreatment may reduce the risk of periprocedural myocardial infarction (PMI) and short-term major adverse cardiac events (MACE) in western people undergoing percutaneous coronary intervention (PCI). However, the effects in East Asian patients are still controversial. The objective was to evaluate the effects of short-term high-dose statin (all types) pretreatment compared with the control (low-dose or no statin) on the reduction of the rate of MACE and PMI in East Asian patients.Methods:PubMed/Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) in East Asian patients up to December 2019, in which short-term high-dose statin pretreatment was compared with control for patients undergoing PCI. The primary outcome measure was the incidence of MACE at 30 days. The secondary outcome measure was the incidence of PMI. The meta-analysis was performed with the fixed-effect model or random-effects model according to the heterogeneity. The meta-analysis was performed using RevMan 5.3 software (Cochrane Collaboration).Results:Fifteen RCTs that enrolled 4313 East Asian patients were identified. High-dose statin pretreatment was associated with a 54% relative reduction in 30-day MACE (OR, 0.46; 95% CI, 0.31–0.67; P < .001) and a 50% relative reduction in PMI (OR, 0.50; 95% CI, 0.34–0.76; P = .001).Conclusions:High-dose statin pretreatment can significantly reduce 30-day MACE and PMI for East Asian patients undergoing PCI.     

Low-site versus traditional peritoneal dialysis catheterization: A meta-analysis

Background:The objective of this study was to compare the complications of low-site peritoneal dialysis (PD) catheter placement and traditional open surgery in peritoneal dialysis catheter insertion.Methods:The following databases were searched from inception to September 6, 2019: PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang. Eligible studies comparing low-site PD catheter placement and traditional open surgery in peritoneal dialysis catheter insertion were included. The data were analyzed using Review Manager Version 5.3.Results:Seven studies were included in the meta-analysis. A total of 504 patients were included in the low-site PD catheter placement group, and 325 patients were included in the traditional open surgery group. Compared with traditional open surgery, low-site PD catheter placement had a lower incidence rate of catheter displacement (odds ratios [OR] 0.11, 95% CI 0.05–0.22, P < .01) and noncatheter displacement dysfunction (OR 0.11, 95% CI 0.04–0.31, P < .01). However, there was no difference between the 2 catheter insertion methods concerning bleeding (OR 0.53, 95% CI 0.23–1.22, P = .13), PD fluid leakage (OR 0.40, 95% CI 0.15–1.10, P = .07), hypogastralgia (OR 0.95, 95% CI 0.32–2.80, P = .93), peritonitis (OR 0.70, 95% CI 0.32–1.54, P = .38), or exit-site and tunnel infections (OR 0.39, 95% CI 0.14–1.03, P = .06).Conclusion:Low-site PD catheter placement reduced the risk of catheter displacement and noncatheter displacement dysfunction and did not increase the risk of bleeding, PD fluid leakage, hypogastralgia, peritonitis, or exit site and tunnel infections. Additional large multicenter randomized controlled trials are needed to confirm these conclusions.     

Impact of Previous Stroke on Short-Term Myocardial Reinfarction in Patients With Acute ST Segment Elevation Myocardial Infarction: An Observational Multicenter Study

Myocardial reinfarction is frequent after ST-elevation myocardial infarction (STEMI). The incidence of previous stroke in STEMI patients is also high. We aim to evaluate the risk factors for short-term myocardial reinfarction in STEMI patients in a multicenter study.STEMI patients with chest pain onset within 12 hours in 247 hospitals in China were enrolled. Seven and 30-day follow-ups from admission to hospitals were performed. The primary outcome of our study was myocardial reinfarction at 30 days after STEMI. The study population was stratified into 2 groups: STEMI patients with mayocardial reinfarction and without mayocardial reinfarction. Survival curve was constructed using Kaplan–Meier survival methods with log-rank statistics. Multivariable Cox regression model was performed to determine the risk factors for myocardial reinfarction events in STEMI patients.A total of 6876 STEMI patients were enrolled. The proportion of STEMI patients with previous stroke was 9.4%. Rate of 30-day myocardial reinfarction was 2.0% among all STEMI patients. Rate of 30-day myocardial reinfarction was 4.2% in STEMI patients with previous stroke which was statistically higher than that in STEMI patients without previous stroke (P < 0.001). Multivariable Cox regression analysis showed that previous stroke (HR, 3.673; 95% CI, 1.180–11.43) and statin use (HR, 0.230; 95% CI, 0.080–0.664) were independent predictors for 30-day myocardial reinfarction.A large proportion of STEMI patients had previous stroke history. Short-term myocardial reinfarction after STEMI is not infrequent. STEMI patients with previous stroke confronted higher rates of short-term myocardial reinfarction and statin could decline the risk of short-term myocardial reinfarction.     

Risk factors for postoperative pneumonia and prognosis in lung cancer patients after surgery: A retrospective study

Postoperative pneumonia (POP) is one of the most frequent complications following lung surgery. The aim of this study was to identify the risk factors for developing POP and the prognostic factors in lung cancer patients after lung resection.We performed a retrospective review of 726 patients who underwent surgery for stages I–III lung cancer at a single institution between August 2017 and July 2018 by conducting logistic regression analysis of the risk factors for POP. The Cox risk model was used to analyze the factors influencing the survival of patients with lung cancer.We identified 112 patients with POP. Important risk factors for POP included smoking (odds ratio [OR], 2.672; 95% confidence interval [CI], 1.586–4.503; P < .001), diffusing capacity for carbon monoxide (DLCO) (40–59 vs ≥80%, 4.328; 95% CI, 1.976–9.481; P < .001, <40 vs ≥80%, 4.725; 95% CI, 1.352–16.514; P = .015), and the acute physiology and chronic health evaluation (APACHE) II score (OR, 2.304; 95% CI, 1.382–3.842; P = .001). In the Cox risk model, we observed that age (hazard ratios (HR), 1.633; 95% CI, 1.062–2.513; P = .026), smoking (HR, 1.670; 95% CI, 1.027–2.716; P = .039), POP (HR, 1.637; 95% CI, 1.030–2.600; P = .037), etc were predictor variables for patient survival among the factors examined in this study.The risk factors for POP and the predictive factors affecting overall survival (OS) should be taken into account for effective management of patients with lung cancer undergoing surgery.     

Imaging-Based Patient Selection and Endovascular Therapy of Ischemic Stroke: A Stratified Meta-Analysis

The positive results of recent trials for the treatment of acute ischemic stroke have highlighted the importance of imaging selection before endovascular therapy. We performed a stratified meta-analysis to confirm this new understanding.We searched EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov in April 2015 for randomized controlled trials evaluating the effect of endovascular treatment in patients with acute ischemic stroke. The meta-analysis was stratified by whether computed tomographic angiography (CTA) was used to select patients. Outcome data were pooled using fixed-effects models.Seven randomized controlled trials with 2217 patients were included in this study. Endovascular therapy significantly increased the rate of 90-day functional independence (a modified Rankin score of 0–2) in patients with a CTA-confirmed large-vessel occlusion (relative risk [RR] = 1.75, 95% confidence interval [CI]: 1.48–2.06, I² = 0.0%), and reduced 90-day mortality in patients with occlusion stroke with a small ischemic core (RR = 0.58, 95% CI: 0.37–0.89, I² = 0.0%). The functional benefit was significantly greater in patients with CTA-based selection than in those without (Z = 5.04, P < 0.001). The mortality benefit was significantly greater in patients with a large-vessel occlusion and a small ischemic core than in those without CTA-based selection (Z = 2.04, P = 0.041). There was no evidence of between-study heterogeneity or publication bias.This meta-analysis showed the effect of vascular imaging on identifying patients with acute ischemic stroke with a proximal vessel occlusion and a small ischemic core, who would benefit from endovascular therapy.     

Sitagliptin After Ischemic Stroke in Type 2 Diabetic Patients: A Nationwide Cohort Study

The cerebrovascular safety and efficacy of sitagliptin, a dipeptidyl peptidase-4 inhibitor, in patients with type 2 diabetes mellitus (T2DM) with ischemic stroke remains uncertain. The aim of this study was to assess the efficacy and safety of sitagliptin in patients with T2DM with recent ischemic stroke.We analyzed data from the Taiwan National Health Insurance Research Database between March 1, 2009, and December 31, 2011. Ischemic stroke patients were identified from individuals with T2DM. Patients who received sitagliptin were compared with those who did not to evaluate the cardiovascular safety and efficacy of sitagliptin. The primary outcome was a composite of ischemic stroke, myocardial infarction, or cardiovascular death.A total of 5145 type 2 diabetic patients with ischemic stroke met our inclusion criteria and were followed for up to 2.83 years (mean, 1.17 years). Overall, 1715 patients (33.3%) received sitagliptin and 3430 patients (66.7%) did not. The primary composite outcome occurred in 190 patients in the sitagliptin group (11.1%) and in 370 patients in the comparison group (10.8%) (hazard ratio [HR] = 1.02; 95% confidence interval [CI], 0.85–1.21). Patients treated with sitagliptin had a similar risk of ischemic stroke, hemorrhagic stroke, and all-cause mortality with an HR of 0.95 (95% CI, 0.78–1.16, P = 0.612), 1.07 (95% CI, 0.55–2.11, P = 0.834), and 1.00 (95% CI, 0.82–1.22, P = 0.989), respectively, compared with patients not treated with sitagliptin.Treatment with sitagliptin in type 2 diabetic patients with recent ischemic stroke was not associated with increased or decreased risks of adverse cerebrovascular outcomes.     

Risk Factors and Clinical Outcomes for Patients With Acinetobacter baumannii Bacteremia

Acinetobacter (A.) baumannii, an opportunistic nosocomial pathogen that can cause significant morbidity and mortality, has emerged as a worldwide problem. This study aimed to analyze the clinical features and outcomes of patients with A. baumannii bacteremia and determine the factors influencing survival by using 14-day mortality as the primary endpoint.A 6-year retrospective study of 122 cases with monomicrobial A. baumannii bacteremia was conducted in Chinese People''s Liberation Army (PLA) General Hospital from January 2008 to April 2014. Predictors of 14-day mortality were identified by logistic regression analysis.The overall 14-day mortality rate was 40.2% (49 of 122 patients). Multivariable analysis revealed that independent predictors of 14-day mortality included severity of illness defined by Pitt Bacteremia Score (PBS) (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.340–0.619; P < 0.001), neutropenia (OR, 18.02; 95% CI, 1.667–194.67; P = 0.017), and malignancy (OR, 4.63; 95% CI, 1.292–16.588; P = 0.019). The effect of malignancy was influenced by neutropenia (OR for interaction term, 1.60; 95% CI, 1.15–2.22; P = 0.005). A subgroup analysis revealed that 14-day mortality rate for patients with underlying hematological malignancies and solid tumors was 75% (12/16) and 40% (12/30), respectively. Survival analysis revealed that mortality in patients with hematological malignancies was higher than that in patients with solid tumors (P = 0.032).The outcomes of patients with A. baumannii bacteremia were related to PBS, neutropenia, and malignancy. Compared with solid tumors, patients with hematological malignancies had a higher mortality in the setting of A. baumannii bacteremia.     

Diameter-Axial-Polar Nephrometry is Predictive of Surgical Outcomes Following Partial Nephrectomy

This study sought to evaluate the predictive value of the DAP (diameter-axial-polar) nephrometry system on surgical outcomes following partial nephrectomy (PN).This was a retrospective study of 237 patients who underwent open or minimally invasive PN for renal tumors at a single tertiary care center between 2009 and 2013. The primary outcomes included ischemia time >20 minutes and percentage of estimated glomerular filtration rate (eGFR) decline >10%. Statistical analysis was performed to study associations and predictions.The DAP sum score exhibited a statistically significant correlation with ischemia time, operative time (OT), estimated blood loss (EBL), length of hospital stay (LOS), and percent change in eGFR. The DAP sum score (odds ratio [OR]: 1.749; 95% confidence interval [CI] 1.379–2.220; P < 0.001) and conventional laparoscopy and laparo-endoscopic single-site (CL&LESS) surgery versus the open surgical approach (OR: 5.736; 95% CI: 2.529–13.011; P < 0.001) independently predicted an ischemia time >20 minutes. Similarly, the DAP sum score (OR: 1.297; 95% CI 1.051–1.602; P = 0.016), age-weighted Charlson comorbidity index (CCI) (OR: 4.730; 95% CI 1.463–15.291; P = 0.009), EBL (OR 2.433; 95% CI 1.095–5.407; P = 0.029), and ischemia time (OR 3.332; 95% CI 1.777–6.249; P < 0.001) were identified as independent predictors of eGFR decline >10%. Furthermore, the DAP score × ischemia time interactions were statistically significant (P < 0.001).We confirmed the predictive value of the DAP nephrometry score with respect to ischemia time and renal functional decline in an independent external cohort of patients undergoing PN. The effect of the DAP score on renal functional decline partially depends on that of ischemia time, and the individual component DAP scores may have different effects on clinical outcomes.     

Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study

There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32–1.74, P < 0.001) for overall, 1.50 (95% CI 1.14–1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35–1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27–1.99, P < 0.001) in North America, 1.50 (95% CI 1.24–1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31–2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20–1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50–2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28–3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55–0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04–1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39–3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.     

Risk factors for and impact of poststroke pneumonia in patients with acute ischemic stroke

Poststroke pneumonia (PSP) is a common complication of stroke and an important cause of death following stroke. However, the treatment of PSP remains inadequate due to severe impairment to the respiratory system by PSP. Thus, it is crucial to focus on preventing PSP to improve the prognosis of patients with stroke.This prospective single-center Cohort study aimed to investigate the risk factors for pulmonary infection following an ischemic stroke and identify whether PSP significantly influences the prognosis of patients after stroke.Altogether, 451 patients who were treated for acute ischemic stroke in the First Affiliated Hospital of Chongqing Medical University in China between April 2017 and April 2018 were enrolled. Clinical data from the patients from admission to 3 months after discharge were collected. PSP was the primary outcome and poor prognosis or death at 3 months following discharge was the secondary outcome observed in this study. We performed logistic regression analyses to identify the risk factors for PSP and test an association between pneumonia and poor prognosis or death after stroke.Our findings revealed the following risk factors for PSP: atrial fibrillation odds ratio (OR) = 2.884, 95% confidence intervals (CI) = 1.316–6.322), being bedridden (OR = 2.797, 95%CI = 1.322–5.921), subject to an invasive procedure (OR = 12.838, 95%CI = 6.296–26.178), massive cerebral infarction (OR = 3.994, 95%CI = 1.496–10.666), and dysphagia (OR = 2.441, 95%CI = 1.114–5.351). Pneumonia was a risk factor for poor prognosis (OR = 2.967, 95%CI = 1.273–6.915) and death (OR = 5.493, 95%CI = 1.825–16.53) after stroke.Hence, since pneumonia increases the risk of poor prognosis and death following acute ischemic stroke, preventing, and managing the risk factors for PSP may improve the prognosis and reduce the mortality after stroke.     

A meta-analysis of the association of atrial septal abnormalities and atrial vulnerability

Background:The mechanism of cryptogenic stroke (CS) in patients with atrial septal abnormalities remains unclear, and the increased incidence of atrial vulnerability may be one of the reasons. We performed this meta-analysis to clarify the association between atrial septal abnormalities and atrial vulnerability, and to provide evidence-based basis for the prevention and mechanism of CS.Methods:We systematically searched for studies on the association between atrial septal abnormalities and atrial vulnerability, and pooled available data on types of atrial septal abnormalities, types of atrial vulnerability, and methods of atrial vulnerability detection. The primary endpoints were the occurrence of atrial arrhythmias or P wave abnormalities. Random-effects models were used to calculate odds ratios (OR) and 95% confidence intervals (CI).Results:Twelve case-control studies were eligible. Compared with the control group, patients with atrial septal abnormalities had a higher risk of atrial vulnerability (OR: 1.93; 95% CI: 1.13-3.30, P = .02). Data based on stroke patients showed that the group with atrial septal abnormalities had a higher risk of atrial vulnerability than the control group (OR: 2.00; 95% CI: 1.13–3.53, P = .02). However, there was no significant difference in the incidence of atrial vulnerability between the 2 groups of nonstroke patients. Subgroup analysis showed that although atrial septal abnormality increased the risk of atrial vulnerability in the subgroup of atrial septal aneurysm (OR: 1.68; 95% CI: 0.47–5.95, P = .42), the subgroup of atrial fibrillation (AF)/atrial fluster (OR: 1.81; 95% CI: 0.94–3.46, P = .07) and the subgroup of subcutaneous recording system (OR: 1.33; 95% CI: 0.68–2.61, P = .41), the difference was not statistically significant.Conclusions:Atrial septal abnormalities can increase the risk of atrial vulnerability, and atrial arrhythmia caused by atrial septal abnormalities may be one of the mechanisms of CS.     

Refusal of cancer-directed surgery in male breast cancer

It has been reported that some male breast cancer patients may refuse the recommended surgery, but the incidence rate in the United States is not clear. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with the rejection of such cancer-directed surgery.We collected data on 5860 patients with male breast cancer (MBC) from the Surveillance, Epidemiology, and End Results database, including 50 patients refusing surgery as recommended. Kaplan–Meier survival analysis and Cox proportional hazard regression were used to identify the effects of refusing surgery on cancer-specific survival (CSS) and overall survival (OS). The association between acceptance or rejection of surgery and mortality were estimated by nested Cox proportional hazards regression models with adjustment for age, race, clinical characteristics, and radiation.Of the 5860 patients identified, 50 (0.9%) refused surgery. Old age (≥65: hazard ratio [HR]: 3.056, 95% confidence interval [CI]: 1.738–5.374, P < .0001), higher AJCC stage (III: HR: 3.283, 95% CI: 2.134–5.050, P < .0001, IV: HR: 14.237, 95% CI: 8.367–24.226, P < .0001), progesterone receptor status (negative: HR: 1.633, 95% CI: 1.007–2.648, P = .047) were considered risk factors. Compared with the surgery group, the refusal group was associated with a poorer prognosis in both OS and CSS (χ² = 94.81, P < .001, χ² = 140.4, P < .001). Moreover, significant differences were also observed in OS and CSS among 1:3 matched groups (P = .0002, P < .001).Compared with the patients undergoing surgery, the patients who refused the cancer-directed surgery had poor prognosis in the total survival period, particularly in stage II and III. The survival benefit for undergoing surgery remained even after adjustment, which indicates the importance of surgical treatment before an advanced stage for male breast cancer patients.     

Blood Pressure Reduction in the Acute Phase of an Ischemic Stroke Does Not Improve Short- or Long-Term Dependency or Mortality: A Meta-Analysis of Current Literature

The purpose of this study was to perform a meta-analysis of current literature to determine whether lowering blood pressure (BP) during the acute phase of an ischemic stroke improves short- and long-term outcomes.PubMed, Cochrane, and Embase were searched until September 5, 2014 using combinations of the search terms: blood pressure reduction, reduced blood pressure, lowering blood pressure, ischemic stroke, acute stroke, and intra-cerebral hemorrhage. Inclusion criteria were randomized controlled trial and patients with acute stroke (ischemic or hemorrhagic) treated with an antihypertensive agent or placebo. Outcome measures were change in systolic and diastolic BP (SBP, DBP) after treatment, and short- and long-term dependency and mortality rates.A total of 459 studies were identified, and ultimately 22 studies were included in the meta-analysis. The total number of participants in the treatment groups was 5672 (range, 6–2308), and in the control groups was 5416 (range, 6–2033). In most studies, more than 50% of the participants were males and the mean age was more than 60 years. The mean follow-up time ranged from 5 days to 12 months. As expected, treatment groups had a greater decrease in BP than control groups, and this effect was seen with different classes of antihypertensive drugs. Short-term and long-term dependency rates were similar between treatment and control groups (short-term dependency: pooled odds ratio [OR] = 1.041, 95% confidence interval [CI]: 0.936–1.159, P = 0.457; long-term dependency: pooled OR = 1.013, 95% CI: 0.915–1.120, P = 0.806). Short-term or long-term mortality was similar between the treatment and control groups (short-term mortality: pooled OR = 1.020, 95% CI: 0.749–1.388, P = .902; long-term mortality: pooled OR = 1.039, 95% CI: 0.883–1.222, P = 0.644).Antihypertensive agents effectively reduce BP during the acute phase of an ischemic stroke, but provide no benefit with respect to short- and long-term dependency and mortality.