Long-term safety and efficacy of a tamoxifen-based treatment strategy for idiopathic retroperitoneal fibrosis

BackgroundTamoxifen may be a viable treatment option for idiopathic retroperitoneal fibrosis (iRPF) but data are limited and its long-term safety and efficacy is unclear. We describe the long-term course and outcomes in a large group of patients with iRPF treated with tamoxifen monotherapy.MethodsThis is a single-center prospective, observational study of 55 patients with iRPF treated with tamoxifen for 2 years from April 1998 through April 2011. Measurements included clinical improvement, laboratory parameters and follow-up computed tomographic (CT) scanning. Treatment success was the composite endpoint of clinical improvement, mass regression and definite resolution of ureteral obstruction.ResultsForty-seven (85%) patients reported substantial resolution of symptoms after median treatment duration of 3.0 weeks (IQR 1.4–4.8 weeks). Repeated CT scanning showed mass regression in 39 (71%) patients at 4 months and 47 (85%) patients at 8 months of follow-up, respectively. Nineteen (34.5%) patients did not meet the composite endpoint of treatment success, 56% of whom responded satisfactorily to second-line immunosuppressive treatment. Recurrence-free survival in patients with treatment success after post-treatment follow-up of 21 months (IQR 9.0–35.0 months) was 68%. Tamoxifen was well tolerated. Pulmonary embolism occurred in 2 patients receiving tamoxifen and in one patient receiving second-line treatment.ConclusionTamoxifen is a safe and viable therapeutic option in the treatment of iRPF.     

Inflammation of unknown origin versus fever of unknown origin: Two of a kind

ObjectivesA vast literature exists on fever of unknown origin (FUO), characterized by prolonged and perplexing fevers > 38.3 °C. In contrast, no studies are available to guide the approach to inflammation of unknown origin (IUO), defined as prolonged and perplexing inflammation with temperatures < 38.3 °C. We aimed to determine the diagnostic yield, the case-mix, and the outcome of patients with IUO, relative to patients with FUO.MethodsWe matched 57 patients with IUO to 57 patients with FUO of the same gender (54% male) and a similar age (median: 67 years).ResultsA diagnosis was established in 35 patients with IUO (61%) and in 33 patients with FUO (58%) (p = .70). The case-mix did not differ significantly (p = .43). Non-infectious inflammatory disorders were the dominant diagnostic category in the IUO group (16 patients), while in the FUO group, similar numbers of malignancies [10], infections [9], and non-infectious inflammatory diseases [9] were diagnosed. ¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan contributed comparably to the diagnosis in both groups (in 18 of 50, 36%, patients with IUO and in 13 of 40, 33%, patients with FUO) (p = .83). In both groups, 7 patients (12%) died during an average follow-up of 1 year.ConclusionDiagnostic yield, case-mix, contribution of FDG-PET scan and vital outcome were similar in patients with IUO and FUO. These data suggest that the 38.3 °C boundary may be arbitrary and that the diagnostic approaches used in FUO can be applied to IUO.     

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.     

Recurrencia y mortalidad a largo plazo de los pacientes con síncope no cardiogénico

Introduction and objectivesThere are no in-depth studies of the long-term outcome of patients with syncope after exclusion of cardiac etiology. We therefore analyzed the long-term outcome of this population.MethodsFor 147 months, we included all patients with syncope referred to our syncope unit after exclusion of a cardiac cause.ResultsWe included 589 consecutive patients. There were 313 (53.1%) women, and the median age was 52 [34-66] years. Of these, 405 (68.8%) were diagnosed with vasovagal syncope (VVS), 65 (11%) with orthostatic hypotension syncope (OHS), and 119 (20.2%) with syncope of unknown etiology (SUE). During a median follow-up of 52 [28-89] months, 220 (37.4%) had recurrences (21.7% ≥ 2 recurrences), and 39 died (6.6%). Syncope recurred in 41% of patients with VVS, 35.4% with OHS, and 25.2% with SUE (P = .006). In the Cox multivariate analysis, recurrence was correlated with age (P = .002), female sex (P < .0001), and the number of previous episodes (< 5 vs ≥ 5; P < .0001). Death occurred in 15 (3.5%) patients with VVS, 11 (16.9%) with OHS, and 13 (10.9%) with SUE (P = .001). In the multivariate analysis, death was associated with age (P = .0001), diabetes (P = .007), and diagnosis of OHS (P = .026) and SUE (P = .020).ConclusionsIn patients with noncardiac syncope, the recurrence rate after 52 months of follow-up was 37.4% and mortality was 6.6% per year. Recurrence was higher in patients with a neuromedial profile and mortality was higher in patients with a nonneuromedial profile.Full English text available from:www.revespcardiol.org/en     

Orthostatic hypertension in normotensive type 2 diabetics: What characteristics?

Aim of the studyWe aimed to determine the prevalence of orthostatic hypertension (OHT) in normotensive, newly diagnosed type 2 diabetics, to assess clinical, biological characteristics of those patients and evaluate the evolution of their blood pressure, after one year of follow-up.Materials and methodsIt is an observational, prospective, cohort study, on 108 normotensive, newly diagnosed diabetics, 40 men and 68 women aged from 40 to 70 ans. OHT was defined as an increase of systolic blood pressure (SBP) ≥ 20 mmHg and/or diastolic blood pressure (DBP) ≥ 10 mmHg, after 1 and 2 min of standing from supine position. Arterial hypertension and metabolic syndrome were respectively defined according to WHO and AHA 2009 guidelines. Clinical and biological data were collected for all patients. They had a screening for diabetic complications and a follow-up during one year. Statistical analysis was performed with Epi-Info 6.04.ResultsWe found OHT in 22 patients (20.4%). Patients with OHT had a higher SBP at lying position (P = 0.029), a higher waist circumference (P = 0.022) and LDL (P = 0.041). They had more frequently obesity (P = 0.036) left ventricular hypertrophy (P = 0.024), metabolic syndrome (P = 0.042) and cerebrovascular events (P = 0.050) when compared with those with normal blood pressure response to orthostasis. One year after follow-up, the prevalence of permanent hypertension was significantly higher in the OHT group (P = 0.0008).ConclusionOur study suggests that OHT is associated with insulin resistance syndrome and onset of sustained arterial hypertension in normotensive, newly diagnosed diabetics.     

Évaluation des acquis éducatifs de 73 patients hypertendus par enquête téléphonique à distance du programme HTA Vasc

HTA Vasc offers an approved educational program for hypertensive patients at high cardiovascular risk (CVR).MethodA telephone survey (December 2011–July 2012) evaluated the benefits of different workshops “my treatment”, “my blood pressure” and “my nutrition”, more than 6 months after the end of the program. The follow-up data (TS) were compared to inclusion data (T0) and to final data (TF) in 73 hypertensive patients.ResultsThe follow-up period was 6 to 31 months. The number of hypertensive controlled patients [blood pressure (BP) < 140/90 mmHg] increased from 55.4% to 75.4% (P = 0.0158) in TF, which remained over time. The practice of physical activity increased from 47.9% (T0) to 79.5% (TS) (P = 0.001). The follow-up period of 18 months or more was associated with a tendency to weight gain (P = 0.0059) and with a decline in physical activity [89.7% (< 18 months) to 67.5% (≥ 18 months) (P = 0.0198)]. The practice of self-measurement BP increased from 41.1% (T0) to 71.2% (TS) (P < 0.0001); knowledge of the “rule of three” increased from 6.8% (T0) to 74% (TS) (P < 0.0001).ConclusionAn educational support contributes to a better long-term BP control. The motivation for lifestyle rules decreases with time. The implementation of a structured motivational follow-up could maintain the lifestyle motivation at these CVR patients.     

Le spasme coronaire lié à la dobutamine chez les patients avec des échocardiographies de stress faussement positives : prévalence et facteurs prédictifs

Background and objectiveDobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobutamine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angiogram).MethodsThree thousand nine hundred and fifty-two patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm (“true” false positive DSE).ResultsTwenty-nine patients with DSE-related vasospasm (19.4% of positive DES without known CAD) were compared with 56 patients with no lesions and no spasm (“true” false positive DSE). They were more frequently smokers (72.4% vs 37.5%; P = 0.003); they had more frequently dyslipidemia (79.3% vs 43%; P = 0.001); they also had a larger ischemic area at peak DSE (3.4 segments vs 2.7 segments; P = 0.05). On multivariate analysis, dyslipidemia (HR = 10.7; 95% CI = [2.7–42.1]; P = 0.001) and active smoking (HR = 6.1; 95% CI = [1.7–21.1]; P = 0.004) were found to be independent predictors of spasm-related DSE rather than “true” false positive DSE.ConclusionDSE-related coronary spasm is present in a significant proportion of patients with erroneously labelled “false” positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independent predictors of spasm rather than “true” false positive DSE.     

Cystatin-C as a predictor for major adverse cardiac events in patients with acute coronary syndrome

Cystatin-C (CYS-C) has emerged as a highly sensitive marker of even a mildly impaired glomerular filtration rate. Experimental studies have suggested that its inhibitory effects on cysteine protease may help to prevent plaque destabilisation. We aimed to evaluate the predictive value of CYS-C level for major adverse cardiac events (MACE) including mortality and morbidity during the hospital stay and 3-month follow-up period.MethodsSeventy-five patients were hospitalised for acute coronary syndrome (ACS). Another control group consisted of patients who were presented with chest pain but no evidence of ischaemic heart disease documented by laboratory markers and angiography. Serum CYS-C levels were measured during the first 24 h of admission. Patients with an abnormal creatinine-derived glomerular filtration rate (GFR) were excluded. Coronary angiography was performed for the entire study population.ResultsIn group I, the mean CYS-C was 1.836 ± 0.782 mg/l vs. 0.991 ± 0.163 mg/l in the control group (P < 0.000). Cystatin-C showed a moderate correlation with total cholesterol in group I (r = 0.5) and with LDL (r = 0.367, P < 0.01). CYS-C showed a moderate positive correlation with the number of diseased vessels (r = 0.419, P < 0.01) and a moderate significant positive correlation with Killip classification (r = 0.349). Smoking was the only predictor associated with a high CYS-C level in the multivariate regression analysis (P = 0.033). CYS-C was an independent predictor of MACE and heart failure complications either in-hospital or during follow-up (P < 0.05).ConclusionsCYS-C could be a useful marker for diagnosing coronary arteriosclerosis. An elevated CYS-C in patients with ACS is an independent predictor of MACE either in-hospital or during follow-up.     

Clinical analysis of fulminant type 1 diabetes in China and comparison with a nationwide survey in Japan

ObjectivesTo report 26 cases of fulminant type 1 diabetes found in Guangdong Medical College Futian Hospital and Central South University Second Xiangya Hospital in China and to study the difference between Chinese and Japanese patients.MethodsThe clinical and biochemical characteristics of 26 patients who had been diagnosed with fulminant type 1 diabetes mellitus in China were analyzed retrospectively and then compared with those characteristics of 161 patients from a nationwide survey in Japan at the time of diagnosis and follow-up 6 months.ResultsThe mean values of the characteristics from these two data sets, including fasting and postprandial serum C-peptide concentration, serum sodium and potassium level, positive for GADAb were significantly different (P = 0.003, P = 0.005, P = 0.035, P = 0.030, P < 0.001, respectively).ConclusionsThe clinical and biochemical characteristics of Chinese patients did not largely differ from those of Japanese patients. Further studies are needed for some unique characteristics found in our group.     

The effects of paroxetine and amitriptyline on the upper esophageal sphincter (UES) pressure and its natural history in globus pharyngeus

BackgroundAntidepressant agents have been shown to be an effective and safe treatment method for patients with globus. However, there are few clinical trials dedicated to studying the effects of antidepressant agents on the natural history and upper oesophageal sphincter (UES) pressure of treated globus patients.AimsTo evaluate the effect of paroxetine and amitriptyline to prevent relapses in patients with globus, the simultaneous relationship between changes in UES pressure and improvement of globus symptoms were measured.MethodsGlobus patients were randomised into amitriptyline, paroxetine and lansoprazole groups for a 6-week treatment period, and follow-up was extended to 12 additional months. Efficacy was evaluated in terms of the Glasgow-Edinburgh Throat Scale (GETS), and UES pressure was measured by standard oesophageal manometry.ResultsParoxetine therapy resulted in a higher withdrawal rate due to symptom relapse (15.9% vs 44.1%, P = 0.01; 15.9% vs 64.7, P = 0.001) than amitriptyline and lansoprazole. Furthermore, globus symptoms were alleviated with the decrease of UES pressure after paroxetine and amitriptyline treatment (r = 0.620, P = 0.02; r = 0.575, P = 0.03)ConclusionsThis follow-up study indicates that paroxetine may alter the natural history of globus and can effectively be used for the long-term management of patients with the disease. Apart from the clinical benefits, paroxetine and amitriptyline can potentially decrease UES pressure.     

Prise en charge du rétrécissement mitral durant la grossesse au centre hospitalo-universitaire d’Oran : à propos de 83 cas

IntroductionThe management of pregnancy in patients with mitral valve stenosis disease continues to pose a challenge to the clinician.ObjectiveThe aim of study was to evaluate the association between mitral valve stenosis and maternal and fetal out come.Materiel and methodEighty-three pregnant women with mitral valve disease, followed-up from 2009 to 2012, were prospectively evaluated medical history, NYHA class assessment, ECG and echocardiography were performed during pregnancy and after delivery.ResultsWomen with mitral stenosis had significantly clinical higher incidence of complications deterioration of clinical status was observed (44.57%, P = 0.0001) congestive heart failure had observed (27.71%, P = 0.0001), hospitalization (33.73%, P = 0.0001), need of cardiac medications (53.75%, P = 0.009), arrhythmias (16%, P < 0.05), New born outcome, mitral stenosis had an effect on fetal outcome. We had increasing preterm, delivery (17.50%, P = 0.018), hypotrophy (20.48%, P = 0.001), intra-uterine growth retardation (12.04%, P = 0.011) new born hospitalizations (13.25%, P = 0.03) Increased maternal morbidity and unfavorable fetal outcome was seen mostly in patients with moderate and severe mitral stenosis.ConclusionPregnant with critical mitral stenosis form a high-risk groups of life-threatening complications. There is need for close maternal follow-up and fetal surveillance and repair of mitral stenosis should be performed before pregnancy.     

Resultado del tratamiento percutáneo de la reestenosis de stents farmacoactivos: ¿depende de si el stent tenía o no recubrimiento polimérico?

Introduction and objectivesOutcomes of patients undergoing percutaneous intervention for drug-eluting stent (DES) restenosis are poorer than those in patients with bare-metal stent restenosis. It is unknown if this is related to the presence of polymer coating. We sought to compare outcomes after interventions for in-stent restenosis (ISR) of polymer-free DES vs durable polymer DES.MethodsPatients enrolled in the ISAR-TEST 5 randomized trial who underwent repeat percutaneous intervention for ISR during follow-up were included. Angiographic outcomes at 6 to 8 months and clinical outcomes at 2 years were analyzed and compared between 2 groups according to whether the restenosed stent was a polymer-free or a durable polymer DES. Multivariate analysis was used to adjust for differences between groups.ResultsA total of 326 patients with ISR were included: 220 with ISR in polymer-free DES and 106 with ISR in durable polymer DES. Angiographic follow-up was available for 83.4% of patients. No difference was observed in recurrent binary restenosis between the 2 groups (31.7% vs 27.0%; P = .38; P_adjusted = .29). At 2 years, the composite of death, myocardial infarction, or repeat target lesion revascularization were similar between the 2 groups (35.7% vs 34.0%; HR = 1.04, 95%CI, 0.70-1.55; P = .83; P_adjusted = .79). The rate of repeat target lesion revascularization was also similar in the 2 groups (29.8% vs 31.5%; HR = 0.91, 95%CI, 0.60-1.39; P = .68; P_adjusted = .62).ConclusionsIn patients undergoing reintervention for DES-ISR, we found no evidence of differences in outcomes according to whether the restenosed stent was a polymer-free or durable polymer DES.     

Volumen renal total y función renal en pacientes nefrectomizados por neoplasias renales

IntroductionThe reduction of renal mass after radical nephrectomy (RN) for renal neoplasm, could be associated with compensatory hypertrophy of the contralateral kidney. The capacity of compensation will determine the renal function (RF) evolution. Measuring of total renal volume (TRV) of the remaining kidney pre and post RN can help assess the RF evolution.ObjectivesTo determine the correlation between TRV pre and post nephrectomy (a year of follow-up) with RF.Materials and methodsA retrospective cohort study was carried out in 47 patients who had undergone RN from 2014 to 2018, due to renal cell carcinoma (confirmed by histopathology).The TRV was calculated, pre and post (a year of follow-up) RN, using ellipsoid formula equation, which were compared with clinical and analytical data. The results were analyzed by multivariate linear logistic models.ResultsThe median age at the time of RN was 70 years old (range, 40-88 years). Most of them were men, 66%. The estimated glomerular filtration rate (eGFR) pre and post nephrectomy was 78 (40-100) and 53.3 ml/min/ m² (30-90) respectively (P = .01). The TRV pre and post-nephrectomy was 168.2 ml (100.4-257.2) and 187.8 ml (115.5-273.1) respectively (P = .001).The pre-nephrectomy eGFR (β = 0.62; P = .034) and the TRV (β = 1.08; P < .0001) were positively correlated with the post-nephrectomy TRV, while the eGFR at year of follow-up was correlated negatively (β = –1.18; P = .047)ConclusionsThe measurement of pre and post nephrectomy TRV can help to predict renal function evolution at a year of follow-up.     

Association between the ratio of insulin-like growth factor-I to insulin-like growth factor binding protein-3 and inflammation in incident automated peritoneal dialysis patients

BackgroundThe insulin-like growth factor (IGF) system is known to be associated with inflammation in various populations. However, the association between the IGF system and inflammation has not previously been investigated in automated peritoneal dialysis (APD) patients. Therefore, the aim of this study was to investigate whether the IGF system correlates with inflammation in APD patients.MethodsWe prospectively determined IGF-I activity, the ratio of serum IGF-I concentrations to those of IGF binding protein-3 (IGFBP-3), and inflammatory markers at initiation of APD and after 6 months of follow-up in 21 incident APD patients.ResultsThe mean age was 55.2 ± 13.1 years, and 11 patients (52.3%) were male. Continuous cyclic PD (CCPD) was performed in 11 patients, and nocturnal intermittent PD (NIPD) in 10 patients. The mean value of IGF-I/IGFBP-3 was 0.21 ± 0.13. At baseline, IGF-I/IGFBP-3 was negatively correlated with high-sensitivity C-reactive protein (hs-CRP) (r = ? 0.27, P = 0.032) and interleukin-6 (IL-6) (r = ? 0.19, P = 0.046) concentrations. After 6 months, IGF-I/IGFBP-3 (P = 0.048) had decreased significantly, while the hs-CRP (P = 0.036) increased significantly in the CCPD group. However, there were no significant changes in IGF-I/IGFBP-3 (P = 0.59) and hs-CRP (P = 0.14) during 6 months in the NIPD group. Furthermore, compared with the NIPD group, IGF-I/IGFBP-3 (P = 0.041) decreased greater, whereas hs-CRP (P = 0.048) concentrations increased greater in the CCPD group.ConclusionsThe IGF system was significantly associated with inflammatory markers in incident APD patients, and different APD modalities modulate the IGF system and inflammation.     

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.     

Facteurs de risque de progression des calcifications des artères coronaires après 5 ans d’évolution en dialyse

BackgroundAlthough progression of coronary artery calcification (CAC) has been established as an important marker for cardiovascular morbidity, very few studies have studied it in end-stage renal disease patients. Thus we examined and evaluate risk factors of calcification changes in dialysis patients.MethodAmong 28 hemodialysis (HD) patients, CAC was measured in Agatston units at baseline and after five years using the 64 multi-slice ultra-fast CT. The HD patients were classified as progressors or no progressors according to the change in the CAC score across these 2 measurements.ResultsOver an average 63 months follow-up, participants without CAC at baseline had no incident CAC. The progression of CAC was slow and was found only in 6 patients (21.4%). It was significantly associated with several cardiovascular risk factors, namely, older age (P = 0.03), diabetes (P = 0.05), male sex (P = 0.02), hypercholesterolemia (P = 0.05), anemia (P = 0.017), inflammation (P = 0.05), and hyperphosphataemia (P = 0.012). However, calcemia, parathormone levels, dialysis duration, tobacco, high blood pressure and dialysis dose did not seem to influence the progression of CAC in our series. A strong association was found between basal calcification scores and Delta increment at 5 years.ConclusionsOur study suggests that CAC progression in dialysis is a complex phenomenon, associated with several risk factors with special regard to elevated basal scores. This progression can be avoided or slowed with appropriate management, which must begin in the early stages of chronic kidney disease.     

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.     

One-year outcome of patients with diabetes mellitus after percutaneous coronary intervention with three different revascularization strategies: Results from the DiabEtic Argentina Registry (DEAR)

AimsPercutaneous coronary interventions (PCI) in patients with diabetes mellitus (DM) are associated with a high incidence of coronary restenosis, myocardial infarction (MI) and death. This study was to assess the potential role of a paclitaxel-eluting balloon (PEB) treatment in patients with DM with coronary lesions compared to those treated either with bare-metal stents (BMS) or drug-eluting stents (DES).Methods and ResultsThe Diabetic Argentina Registry (DEAR) was an observational, prospective, non-randomised, open-label study that enrolled 92 patients with diabetes mellitus in three centers from Buenos Aires, Argentina, between April 2009 and March 2011, to be treated with PEB. Results were compared with previous outcome data in all patients with DM treated with DES (n = 129 pts) or BMS (n = 96 pts) in clinical studies conducted at our institutions. At one-year follow-up, patients with DM who received PEB followed by BMS implantation (96%) had a significantly lower incidence of major adverse cardiac events (MACE) compared to the BMS group (BMS 32.3%, PEB 13.2%; P = .003). The incidence of target-vessel failure (TVF) was 30.2% (BMS) and 11% (PEB) (P = .003), that of target-vessel revascularization (TVR) was 22.9% (BMS) and 8.3% (PEB) (P = .005) and the composite of death/MI occurred in 13.5% (BMS) and in 2.2% for PEB (P = .05). These positive results are persistent even after subgroups analysis. When comparing with previous DES patients, TVF was 18.6% in DES vs. 11.0% in PEB (P = .13), MACE was 18.6% in DES vs. 13.2% in PEB (P = .29), TVR rate was 14.0% in DES vs. 8.3% in PEB (P = .14) and the composite death/MI was 9.3% in DES vs. 4.4% in PEB (0.18)ConclusionsDiabetic patients treated with PEB followed by BMS resulted in a significantly better outcome than BMS alone and appeared to be comparable to DES treatment.     

HEPACONTROL. A program that reduces early readmissions,mortality at 60 days,and healthcare costs in decompensated cirrhosis

Background & aimsDecompensated cirrhosis patients have an elevated incidence of early readmission, mortality and economic burden. The aims of HEPACONTROL were to reduce early readmission and to evaluate its impact on mortality and emergency department visits.Patients and methodsQuasi-experimental study with control group which compared two cohorts of patients discharged after being admitted for cirrhosis-related complications. A prospective cohort (n = 80), who followed the HEPACONTROL program, which began with a follow-up examination seven days after discharge at the Hepatology Unit Day Hospital and a retrospective cohort of patients (n = 112), who had been given a standard follow-up. Outcome variables that were compared between both groups were early readmission rates, the number of emergency department visits post-discharge, financial costs and mortality.ResultsThe rate of early readmission was lower in the group with HEPACONTROL (11.3% vs 29.5%; P = .003). Also, the mean number of visits to the emergency department post-discharge (1.10 ± 1.64 vs 1.71 ± 2.36; P = .035), mortality at 60 days (3.8% vs 14.3%; P = .016), and the cost of early readmission were all lower compared with the group with standard follow-up (P = .029).ConclusionsHEPACONTROL decreases the incidence of early readmission the rate of emergency department visits and mortality at 60 days in patients with decompensated cirrhosis, and it is cost-effective.     

Influencia de la neoateroesclerosis en el pronóstico y la respuesta al tratamiento de los pacientes con reestenosis en el stent

Introduction and objectivesNeoatherosclerosis is one of the causes of in-stent restenosis (ISR). Our objective was to evaluate the influence of neoatherosclerosis on prognosis and treatment response in patients with ISR.MethodsThis is a pooled analysis of the optical coherence tomography (OCT)-substudies of 2 multicenter, randomized clinical trials, RIBS IV and V, comparing treatment with paclitaxel-coated balloon vs everolimus-eluting stent in patients with ISR. OCT evaluation was performed at baseline and at 6 to 9 months. Neoatherosclerosis was defined in baseline OCT as neointima with calcified or lipid content. We evaluated the angiographic and OCT results at 6 to 9 months and the occurrence of major adverse cardiovascular events at 3 years of follow-up in patients with and without neoatherosclerosis treated with paclitaxel-coated balloon or everolimus-eluting stents.ResultsSixty-four patients underwent OCT at the time of the index procedure. Neoatherosclerosis was documented in 23 (36%) lesions. Angiographic follow-up at 6 to 9 months showed no differences in restenosis [5 (24%) vs 6 (15%) P = .49], minimum lumen diameter (1.79 ± 0.7 vs 1.94 ± 0.6 mm; P = .41) or late loss (0.33 ± 0.7 vs 0.15 ± 0.5; P = .34) in patients with and without neoatherosclerosis, respectively. Follow-up OCT confirmed the absence of differences in quantitative parameters and the characteristics of tissue coverage between the 2 groups. At 3 years of follow-up, the major adverse cardiovascular events rate was 3 (13%) vs 5 (12%) in the neoatherosclerosis and nonneoatherosclerosis groups (HR, 0.94; 95%CI, 0.22-3.93; P = .93).ConclusionsIn this limited study population, OCT-defined neoatherosclerosis did not seem to influence acute and long-term outcomes in patients randomized to paclitaxel-coated balloon or everolimus-eluting stents for ISR.