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1.
Giulia Renda Fabrizio Ricci Raffaele De Caterina 《The American journal of medicine》2017,130(4):457-461
Background
Non-vitamin K oral anticoagulants are now proven alternatives to vitamin K antagonists for stroke prevention in atrial fibrillation. However, there are few data on the efficacy and safety of their use for cardioversion, in which the risk of thromboembolic events is heightened.Methods
We performed a random-effects meta-analysis of patients undergoing both electrical and pharmacologic cardioversion for atrial fibrillation in the RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE AF-TIMI 48, X-VeRT, and ENSURE-AF trials. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% confidence intervals (CIs) for stroke/systemic embolism and major bleeding at ≤42 days of follow-up.Results
The analysis pooled 6148 patients in whom 6854 cardioversions for atrial fibrillation were performed. Compared with vitamin K antagonists, non-vitamin K antagonist oral anticoagulant therapy was associated with a similar risk of stroke/systemic embolism (RR, 0.82; 95% CI, 0.38-1.75) and major bleeding (RR, 0.98; 95% CI, 0.51-1.87). We found no significant statistical heterogeneity among studies (Cochrane Q P = .75, I2 = 0% for stroke/systemic embolism; P = .54; I2 = 0% for major bleeding).Conclusions
The short-term incidence of thromboembolism and major bleeding after cardioversion on non-vitamin K antagonist oral anticoagulants was comparable to the incidence observed on dose-adjusted vitamin K antagonist therapy. Non-vitamin K antagonist oral anticoagulants are a reasonable alternative to vitamin K antagonists in patients undergoing cardioversion. 相似文献2.
Terufumi Shimoda Hiroshi Odajima Arisa Okamasa Minako Kawase Masaki Komatsubara Bhabita Mayer Steven Yancey Hector Ortega 《Allergology international》2017,66(3):445-451
Background
The MENSA trial assessed the efficacy and safety of mepolizumab in patients with severe eosinophilic asthma. This report describes the efficacy and safety of mepolizumab in Japanese patients from MENSA.Methods
A post hoc analysis of the Japanese subgroup from the randomized, double-blind, placebo-controlled, double-dummy, Phase III MENSA trial (NCT01691521). Patients ≥12 years with severe eosinophilic asthma received mepolizumab 75 mg intravenously (IV), 100 mg subcutaneously (SC), or placebo, every 4 weeks for 32 weeks. The primary endpoint was the annualized rate of exacerbations. Secondary and other endpoints included annualized rate of exacerbations requiring emergency department (ED) visit/hospitalization, morning peak expiratory flow (PEF), St George's Respiratory Questionnaire (SGRQ) score and eosinophil counts. Adverse events (AEs) were monitored.Results
In the Japanese subgroup (N = 50), the rate of clinically significant exacerbations was reduced by 90% (rate ratio [RR]: 0.10; 95% confidence interval [CI]: 0.02–0.57; P = 0.010) with mepolizumab IV and 62% (RR: 0.38; 95% CI: 0.12–1.18; P = 0.094) with mepolizumab SC, versus placebo. No exacerbations requiring ED visit/hospitalization were reported with mepolizumab IV; exacerbations were reduced by 73% (RR: 0.27; 95% CI: 0.06–1.29; P = 0.102) with mepolizumab SC versus placebo. Compared with placebo, mepolizumab IV and SC numerically increased morning PEF from baseline by 40 L/min and 13 L/min, improved quality of life by greater than the minimal clinically important difference (SGRQ: 9.5 [P = 0.083] and 7.9 [P = 0.171] points) and reduced eosinophil counts. AE incidence was similar between treatments. Results were broadly consistent with the overall population.Conclusions
Mepolizumab was efficacious and well tolerated in Japanese patients with severe eosinophilic asthma, producing similar responses to the overall MENSA population. 相似文献3.
Oh Chan Kwon Seokchan Hong Byeongzu Ghang Yong-Gil Kim Chang-Keun Lee Bin Yoo 《The American journal of medicine》2017,130(5):583-587
Objective
The purpose of this study was to investigate the risk of myopathy when statins are coadministered with colchicine in patients with gout.Methods
In gout patients who received colchicine with or without statin, clinical data collected included medications and history of hypertension, chronic kidney disease, and liver cirrhosis. Myopathy was defined as the presence of muscle symptoms with elevated creatine kinase or myoglobin. Multivariate analysis was performed to identify risk factors for myopathy. Inverse probability of treatment weighting (IPTW)-adjusted analysis was used to evaluate the influence of concomitant colchicine and statin use on myopathy.Results
Of 674 patients, 486 received colchicine alone and 188 also received statin. The incidence of myopathy was not significantly higher in those on both drugs than in those on colchicine alone (2.7% vs 1.4%, P = .330). On multivariate analysis, chronic kidney disease (hazard ratio [HR] 29.056; 95% confidence interval [CI], 4.387-192.450; P <.001), liver cirrhosis (HR 10.676; 95% CI, 1.279-89.126; P = .029), higher colchicine dose (HR 20.960; 95% CI, 1.835-239.481; P = .014), and concomitant CYP3A4 inhibitor (HR 12.027; 95% CI, 2.743-52.725; P = .001) were associated with increased risk of myopathy. Concomitant use of statins, however, was not, even after adjusting for confounders (HR 1.123; 95% CI, 0.262-4.814; P = .875; IPTW-adjusted HR 0.321; 95% CI, 0.077-1.345; P = .120).Conclusion
Concomitant use of statin and colchicine was not associated with increased risk of myopathy. Thus, concomitant use of statin with colchicine seems to be safe from myotoxicity in gout patients. 相似文献4.
Peter Kokkinos Charles Faselis Puneet Narayan Jonathan Myers Eric Nylen Xuemei Sui Jiajia Zhang Carl J. Lavie 《The American journal of medicine》2017,130(10):1192-1198
Background
Impact of cardiorespiratory fitness on statin-related incidence of type 2 diabetes has not been assessed. We assessed the cardiorespiratory fitness and diabetes incidence association in dyslipidemic patients on statins.Methods
We identified dyslipidemic patients with a normal exercise test performed during 1986 and 2014 at the Veterans Affairs Medical Centers in Washington, DC or Palo Alto, Calif. The statin-treated patients (n = 4092; age = 58.8 ± 10.9 years) consisted of 2701 Blacks and 1391 Whites. None had evidence of type 2 diabetes prior to statin therapy. We formed 4 fitness categories based on age and peak metabolic equivalents achieved: Least-fit (n = 954), Low-fit (n = 1201), Moderate-fit (n = 1242), and High-fit (n = 695). The non-statin-treated cohort (n = 3001; age = 57.2 ± 11.2 years) with no evidence of type 2 diabetes prior to the exercise test served as controls.Results
Diabetes incidence was 24% higher in statin-treated compared with non-statin-treated patients (P <.001). In the statin-treated cohort, 1075 (26.3%) developed diabetes (average annual incidence rate of 30.6 events/1000 person-years). Compared with the Least-fit, adjusted risk decreased progressively with increasing fitness and was 34% lower for High-fit patients (hazard ratio [HR] 0.66; 95% confidence interval [CI], 0.53-0.82; P <.001). Compared with the nonstatin cohort, elevated risk was evident only in the Least-fit (HR 1.50; 95% CI, 1.30-1.73; P <.001) and Low-fit patients (HR 1.22; 95% CI, 1.06-1.41; P = .006).Conclusions
Risk of diabetes in statin-treated dyslipidemic patients was inversely and independently associated with cardiorespiratory fitness. The increased risk was evident only in relatively low-fitness patients. Improving fitness may modulate the potential diabetogenic effects of statins. 相似文献5.
Yanming Zhou Bin Shi Lupeng Wu Xiaoying Si 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2017,19(1):10-15
Background
To assess the published evidence on clinical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma in the body or tail of the pancreas.Method
PubMed and Chinese Biomedical Literature databases were searched. The results of comparisons between RAMPS and standard retrograde pancreatosplenectomy (SRPS) were analyzed by meta-analytical techniques.Results
The literature search identified 13 observational studies involving 354 patients undergoing RAMPS. The overall morbidity and 30-day mortality was 40% and 0% respectively. The R0 resection rate was 88%; the median number of retrieved lymph nodes was 21; and the median 5-year overall survival rate was 37%. The result of meta-analysis showed that RAMPS was associated with a significantly less intraoperative bleeding [weighted mean difference ?195.2 (95% confidence interval (CI) ?223.27 to ?167.13); P < 0.001], a greater number of retrieved lymph nodes [odds ratio (OR) 6.19 (95% CI 3.72 to 8.67); P < 0.001] and a higher percentage of R0 resection [OR 2.46 (95% CI 1.13 to 5.35); P = 0.02] as compared with SRPS.Conclusion
The current literature provides supportive evidence that RAMPS is a safe and effective procedure for adenocarcinoma in the body or tail of the pancreas, and is oncologically superior to SRPS. 相似文献6.
Manish P. Shrestha Mark Borgstrom Eugene Trowers 《The American journal of medicine》2017,130(7):819-825
Background
Although digital rectal examination is an established part of physical examinations in patients with acute gastrointestinal bleeding, clinicians are reluctant to perform a rectal examination. We intended to assess whether rectal examination affects the clinical management decision in these patients.Methods
We performed a single-center, retrospective, cross-sectional study using data from electronic health records of patients aged ≥18 years presenting to the emergency department with acute gastrointestinal bleeding. Hospital admissions, intensive care unit admissions, gastroenterology consultation, initiation of medical therapy (proton pump inhibitor or octreotide), and inpatient endoscopy (upper endoscopy or colonoscopy) were assessed as outcomes. Univariate and multivariate logistic regression analyses were performed.Results
Of 1237 patients with acute gastrointestinal bleeding, 549 (44.4%) did not have a rectal examination. Patients who had a rectal examination were less likely to be admitted than patients who did not have a rectal examination (adjusted odds ratio [AOR], 0.49; 95% confidence interval [CI], 0.30-0.79; P = .004). Patients who had a rectal examination were less likely to be started on medical therapy (AOR, 0.64; 95% CI, 0.41-0.98; P = .04) and to have endoscopy (AOR, 0.64; 95% CI, 0.44-0.94; P = .02) than patients who did not have a rectal examination.Conclusions
Rectal examination in patients with acute gastrointestinal bleeding can assist clinicians with clinical management decision and reduce admissions, endoscopies, and medical therapy in these patients. 相似文献7.
Amber B. Moore J. Elyse Krupp Alyssa B. Dufour Mousumi Sircar Thomas G. Travison Alan Abrams Grace Farris Melissa L.P. Mattison Lewis A. Lipsitz 《The American journal of medicine》2017,130(10):1199-1204
Purpose
Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.Methods
We undertook a prospective cohort study comparing cost and health care utilization outcomes between ECHO-CT facilities and matched comparisons from January 2014-December 2014.Results
Thirty-day readmission rates were significantly lower in the intervention group (odds ratio 0.57; 95% CI, 0.34-0.96; P-value .04), as were the 30-day total health care cost ($2602.19 lower; 95% CI, ?$4133.90 to ?$1070.48; P-value <.001) and the average length of stay at the skilled nursing facility (?5.52 days; 95% CI, ?9.61 to ?1.43; P = .001). The 30-day mortality rate was not significantly lower in the intervention group (odds ratio 0.38; 95% CI, 0.11-1.24; P = .11).Conclusion
Patients discharged to skilled nursing facilities participating in the ECHO-CT program had shorter lengths of stay, lower 30-day rehospitalization rates, and lower 30-day health care costs compared with those in matched skilled nursing facilities delivering usual care. ECHO-CT may improve patient transitions to postacute care at lower overall cost. 相似文献8.
Avi Sabbag Shlomi Matetzky Avital Porter Zaza Iakobishvili Mady Moriel Donna Zwas Paul Fefer Elad Asher Roy Beigel Shmuel Gottlieb Ilan Goldenberg Amit Segev 《The American journal of medicine》2017,130(11):1324.e15-1324.e22
Background
Young women are usually protected against coronary artery disease due to hormonal and risk-factor profile. Previous studies have suggested poorer outcome in women hospitalized with acute coronary syndrome as compared with men. However, when adjusted for age and other risk factors, this difference does not remain significant. We compared the risk profile and outcome between young (≤55 years) women and men admitted with acute coronary syndrome.Methods
We analyzed clinical characteristics, management strategies, and outcomes of men and women ≤55 years of age enrolled in the biennial Acute Coronary Syndrome Israeli Surveys between 2000 and 2013.Results
Among 11,536 patients enrolled, 3949 (34%) were ≤55 years old (407 women, 3542 men). Women were slightly older (48.9 ± 5.7 vs 48.3 ± 5.5, P = .007) and suffered more from diabetes (34% vs 24%) and hypertension (47% vs 37%, P <.001 for both). Rates of prior myocardial infarction were high in both sexes (18% vs 21%). Women presented less often with ST-elevation myocardial infarction (50% vs 57%, P = .007) and with typical chest pain (73% vs 80%, P = .004), and had higher rates of Global Registry of Acute Coronary Events (GRACE) score ≥140 (19% vs 12%, P = .007). After adjustment for GRACE score, diabetes, and enrollment year, women had a lower likelihood to undergo coronary angiography during hospitalization (odds ratio 0.6, P = .007). Female sex was independently associated with higher risk of in-hospital mortality (hazard ratio [HR] 4.1; 95% confidence interval [CI], 1.15-14.0), 30-day major adverse cardiac and cerebral events (HR 2.1; 95% CI, 1.31-3.36), and 5-year mortality (HR 1.96; 95% CI, 1.3-2.8).Conclusions
Young women admitted with acute coronary syndrome are a unique high-risk group that presents a diagnostic challenge for clinicians. Women receive less invasive therapy during hospitalization and have worse in-hospital and long-term outcomes. 相似文献9.
Sripal Bangalore Barry R. Davis William C. Cushman Sara L. Pressel Paul M. Muntner David A. Calhoun John B. Kostis Paul K. Whelton Jeffrey L. Probstfield Mahboob Rahman Henry R. Black 《The American journal of medicine》2017,130(4):439-448.e9
Background
Although hypertension guidelines define treatment-resistant hypertension as blood pressure uncontrolled by ≥3 antihypertensive medications, including a diuretic, it is unknown whether patient prognosis differs when a diuretic is included.Methods
Participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) were randomly assigned to first-step therapy with chlorthalidone, amlodipine, or lisinopril. At a Year 2 follow-up visit, those with average blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic on ≥3 antihypertensive medications, or blood pressure <140/90 mm Hg on ≥4 antihypertensive medications were identified as having apparent treatment-resistant hypertension. The prevalence of treatment-resistant hypertension and its association with ALLHAT primary (combined fatal coronary heart disease or nonfatal myocardial infarction) and secondary (all-cause mortality, stroke, heart failure, combined coronary heart disease, and combined cardiovascular disease) outcomes were identified for each treatment group.Results
Of participants assigned to chlorthalidone, amlodipine, or lisinopril, 9.6%, 11.4%, and 19.7%, respectively, had treatment-resistant hypertension. During mean follow-up of 2.9 years, primary outcome incidence was similar for those assigned to chlorthalidone compared with amlodipine or lisinopril (amlodipine- vs chlorthalidone-adjusted hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.53-1.39; P = .53; lisinopril- vs chlorthalidone-adjusted HR = 1.06; 95% CI, 0.70-1.60; P = .78). Secondary outcome risks were similar for most comparisons except coronary revascularization, which was higher with amlodipine than with chlorthalidone (HR 1.86; 95% CI, 1.11-3.11; P = .02). An as-treated analysis based on diuretic use produced similar results.Conclusions
In this study, which titrated medications to a goal, participants assigned to chlorthalidone were less likely to develop treatment-resistant hypertension. However, prognoses in those with treatment-resistant hypertension were similar across treatment groups. 相似文献10.
Chirag Bavishi Vrinda Trivedi Mandeep Singh Edward Katz Franz H. Messerli Sripal Bangalore 《The American journal of medicine》2017,130(11):1325.e1-1325.e12
Background
The recent American Heart Association/American College of Cardiology guidelines on duration of dual antiplatelet therapy (DAPT) recommend DAPT for 1 year in patients presenting with an acute coronary syndrome, with a Class IIb recommendation for continuation. We aim to assess the evidence for these recommendations using a meta-analytic approach.Methods
We searched electronic databases for randomized trials comparing short-term (≤6 months) vs 12-month vs extended (>12 months) DAPT in patients with an acute coronary syndrome undergoing percutaneous coronary intervention. We evaluated all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis, and major bleeding. A random-effects model was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI).Results
We included 8 trials comprising 12,917 patients with an acute coronary syndrome; 5 trials compared short-term vs 12-month/extended DAPT, whereas 3 trials compared 12-month vs extended DAPT. There was no significant difference in cardiovascular mortality (RR 1.04; 95% CI, 0.67-1.60), myocardial infarction (RR 1.08; 95% CI, 0.79-1.47), or major bleeding (RR 0.91; 95% CI, 0.49-1.69) between short-term and 12-month/extended DAPT. However, compared with extended DAPT, 12-month DAPT showed significantly higher risk of myocardial infarction (RR 2.00; 95% CI, 1.47-2.73), but reduced risk of major bleeding (RR 0.58; 95% CI, 0.34-0.98). All-cause mortality was found to be similar between 12-month and extended DAPT.Conclusions
In acute coronary syndrome, short-term DAPT may be reasonable for some patients, whereas extended DAPT may be appropriate in select others. An individualized approach is needed, taking into account the competing risks of bleeding and ischemic events. 相似文献11.
Mustafa Raoof Aaron Lewis Leanne Goldstein Sinziana Dumitra Susanne G. Warner Gagandeep Singh Yuman Fong Laleh Melstrom 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2017,19(4):371-377
Background
In order to decrease cost and increase healthcare quality there is an ongoing effort to reduce readmissions after complex operations. The timing and severity of post-discharge complications after hepatectomy need to be better defined.Methods
All patients undergoing liver resection at a single institution from Jan 2009–Jun 2015 were included. Complications were scored using the comprehensive complication index (CCI). Multivariate analysis is performed using logistic regression. Receiver operating characteristics (ROCs) were analyzed to optimize the Readmission Risk Index (RRI).Results
Of the 258 patients that met the inclusion criteria, 26 (10%) were readmitted within 30 days of discharge after hepatectomy. On multivariate analysis age ≥68 years (OR 3.76; 95% CI 1.47–9.63, p = 0.006), CCI ≥ 15 (OR 3.65; 95% CI 1.39–9.56, p = 0.008), maximum temperature within 48 h of discharge (OR 3.02; 95% CI 1.17–7.75, p = 0.022) and white blood cell count ≥10.2 billion cells/L within 48 h of discharge (OR 2.88; 95% CI 1.04–8, p = 0.043) were independent predictors of 30-day readmission. These variables were used to develop the RRI (ROC area 0.80; 95% CI 0.70–0.9, p < 0.001).Conclusion
The CCI and pre-discharge variables can help identify individuals at risk of readmission. Readmission risk reduction efforts should focus on this subset of patients. 相似文献12.
Elena F. Wurster Solveig Tenckhoff Pascal Probst Katrin Jensen Eva Dölger Phillip Knebel Markus K. Diener Markus W. Büchler Alexis Ulrich 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2017,19(6):491-497
Background
Recurrence of colorectal liver metastases after a first hepatectomy is common (4–48% of patients). This review investigates the utility of repeated hepatic resection of colorectal liver metastases.Methods
A systematic search of the literature was performed in the Cochrane Library, MEDLINE, EMBASE, and trial registers. All studies comparing repeated hepatic resection for colorectal liver metastases with patients who underwent only one hepatectomy were eligible. Outcome criteria were safety parameters and survival rates. Data were analyzed using the random-effects model.Results
In eight observational clinical studies, 450 patients with repeated hepatic resection were compared with 2669 single hepatic resections. Morbidity such as hepatic insufficiency (OR [95% CI] 1.46 [0.69; 3.08], p = 0.32) and biliary leakage and fistula (OR [95% CI] 1.22 [0.80; 1.85], p = 0.35) was comparable between the two groups. Mortality (OR [95% CI] 1.13 [0.46; 2.74], p = 0.79) and overall survival (HR [95% CI] 1.00 [0.63; 1.60], p = 0.99) were not significantly different between the two groups.Discussion
Repeated hepatic resection for colorectal liver metastases is safe in selected patients. A prospective, multicenter high-quality trial or register study of repeated hepatic resection will be required to clarify patient-oriented outcomes such as overall survival and quality of life. 相似文献13.
Aakash Garg Abhishek Sharma Parasuram Krishnamoorthy Jalaj Garg Deepti Virmani Toishi Sharma Giulio Stefanini John B. Kostis Debabrata Mukherjee Ekaterina Sikorskaya 《The American journal of medicine》2017,130(2):173-187
Background
Niacin, a potent high-density lipoprotein cholesterol-raising drug, seems an attractive approach to reduce cardiac events in patients with or at risk of atherosclerotic cardiovascular disease. However, previous evidence for niacin has been challenged recently by negative outcomes in 2 large, randomized, controlled trials comparing niacin to placebo with background statin therapy. We studied the currently available evidence for the role of niacin treatment for reducing the risk of cardiovascular events in current practice.Methods
A systematic review of randomized controlled trials in the MEDLINE, EMBASE, CINAHL, and Cochrane databases comparing niacin alone or combined with statin therapy was performed. We extracted trial level data, including basic characteristics and number of patients enrolled, duration of follow up, occurrence of adverse events, and cardiovascular-related outcomes. Random effects meta-analysis was conducted to estimate the risk ratio (RR) for individual trial endpoints.Results
Thirteen trials (N = 35,206) were selected for final analysis. The mean follow-up duration was 32.8 months. Overall, niacin led to significant increases in serum high-density lipoprotein cholesterol levels from baseline trial enrolment by 21.4%, 9.31 (95% confidence interval [CI] 5.11-13.51) mg/dL. However, we did not observe any differences in all-cause mortality rates (RR 0.99; 95% CI 0.88-1.12) between niacin and control arms. Further, niacin treatment was associated with a trend toward lower risk of cardiovascular mortality (RR 0.91; 95% CI 0.81-1.02), coronary death (RR 0.93; 95% CI 0.78-1.10), nonfatal myocardial infarction (RR 0.85; 95% CI 0.73-1.0), revascularization (coronary and noncoronary) (RR 0.83; 95% CI 0.65-1.06), and stroke (RR 0.89; 95% CI 0.72-1.10), compared with control.Conclusion
Niacin therapy does not lead to significant reductions in total or cause-specific mortality or recurrent cardiovascular events among persons with or at risk of atherosclerotic cardiovascular disease. 相似文献14.
Deisy Barrios Jeremy Chavant David Jiménez Laurent Bertoletti Vladimir Rosa-Salazar Alfonso Muriel Alain Viallon Carmen Fernández-Capitán Roger D. Yusen Manuel Monreal 《The American journal of medicine》2017,130(5):588-595
Background
Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism.Methods
This study included patients who had acute pulmonary embolism associated with right heart thrombi and participated in the Registro Informatizado de la Enfermedad TromboEmbólica registry. We assessed the effectiveness of anticoagulation versus reperfusion treatment for the outcomes of all-cause mortality, pulmonary embolism–related mortality, recurrent venous thromboembolism, and major bleeding rates through 30 days after initiation of pulmonary embolism treatment. We used propensity score matching to adjust for the likelihood of receiving reperfusion treatment.Results
Of 325 patients with pulmonary embolism and right heart thrombi, 255 (78%; 95% confidence interval, 74-83) received anticoagulation and 70 (22%; 95% confidence interval, 17-26) also received reperfusion treatment. Propensity score–matched pairs analyses did not detect a statistically lower risk of all-cause death (6.2% vs 14%, P = .15) or pulmonary embolism–related mortality (4.7% vs 7.8%; P = .47) for reperfusion compared with anticoagulation. Of the patients who received reperfusion treatment, 6.2% had a recurrence during the study follow-up period, compared with 0% of those who received anticoagulation (P = .049). The incidence of major bleeding events was not statistically different between the 2 treatment groups (3.1% vs 3.1%; P = 1.00).Conclusions
In patients with pulmonary embolism and right heart thrombi, no significant difference was found between reperfusion therapy and anticoagulant therapy for mortality and bleeding. The risk of recurrences was significantly higher for reperfusion therapy compared with anticoagulation. Right heart thrombi may not warrant riskier interventions than standard anticoagulation. 相似文献15.
Georgios A. Margonis Kazunari Sasaki Nikolaos Andreatos Manijeh Zargham Pour Nannan Shao Mounes Aliyari Ghasebeh Stefan Buettner Efstathios Antoniou Christopher L. Wolfgang Matthew Weiss Ihab R. Kamel Timothy M. Pawlik 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2017,19(9):808-817
Background
Although experimental data strongly support the pro-tumorigenic role of postoperative liver regeneration, this hypothesis has not been clinically investigated. We aimed to examine the impact of liver regeneration determined by volumetric imaging on recurrence following resection of colorectal liver metastasis (CRLM).Methods
Resected liver volume was subtracted from total liver volume (TLV) to define postoperative remnant liver volume (RLVp). Early and late kinetic growth rates (KGR) were defined as the postoperative increases in liver volume within 2–3 and 8–10 months from surgery, respectively, divided by the corresponding time interval.Results
Median early and late KGR was 2.6%/month (IQR: ?0.9 to 12.3) and 1.0%/month (IQR: ?0.64 to 2.91), respectively. Late KGR predicted intrahepatic recurrence after 1 year from surgery (AUC 0.677, P = 0.011). Specifically, patients with a late KGR ≥1% had a higher cumulative risk of recurrence compared with patients with a KGR <1% (P = 0.038). In multivariate analysis, KGR ≥1% independently predicted recurrence (P = 0.027).Discussion
A KGR ≥1% during the late regeneration phase was associated with increased risk of intrahepatic recurrence. These data may inform the timing of adjuvant therapy administration and focus surveillance strategies for high-risk patients. 相似文献16.
Vikas Singh Alex P. Rodriguez Badal Thakkar Ghanshyambhai T. Savani Nileshkumar J. Patel Apurva O. Badheka Mauricio G. Cohen Carlos E. Alfonso Raul D. Mitrani Juan Viles-Gonzalez Jeffrey J. Goldberger 《The American journal of medicine》2017,130(6):688-698
Background
The outcomes related to chest pain associated with cocaine use and its burden on the healthcare system are not well studied.Methods
Data were collected from the Nationwide Inpatient Sample (2001-2012). Subjects were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcome was a composite of mortality, myocardial infarction, stroke, and cardiac arrest.Results
We identified 363,143 admissions for cocaine-induced chest pain. Mean age was 44.9 (±21.1) years with male predominance. Left heart catheterizations were performed in 6.7%, whereas the frequency of acute myocardial infarction and percutaneous coronary interventions were 0.69% and 0.22%, respectively. The in-hospital mortality was 0.09%, and the primary outcome occurred in 1.19% of patients. Statistically significant predictors of primary outcome included female sex (odds ratio [OR], 1.16; confidence interval [CI], 1.00-1.35; P = .046), age >50 years (OR, 1.24, CI, 1.07-1.43; P = .004), history of heart failure (OR, 1.63, CI, 1.37-1.93; P <.001), supraventricular tachycardia (OR, 2.94, CI, 1.34-6.42; P = .007), endocarditis (OR, 3.5, CI, 1.50-8.18, P = .004), tobacco use (OR, 1.3, CI, 1.13-1.49; P <.001), dyslipidemia (OR, 1.5, CI, 1.29-1.77; P <.001), coronary artery disease (OR, 2.37, CI, 2.03-2.76; P <.001), and renal failure (OR, 1.27, CI, 1.08-1.50; P = .005). The total annual projected economic burden ranged from $155 to $226 million with a cumulative accruement of more than $2 billion over a decade.Conclusion
Hospital admissions due to chest pain and concomitant cocaine use are associated with low rates of adverse outcomes. For the low-risk cohort in whom acute coronary syndrome has been ruled out, hospitalization may not be beneficial and may result in unnecessary cardiac procedures. 相似文献17.
Stefano Partelli Nicolò Pecorelli Francesca Muffatti Giulio Belfiori Stefano Crippa Francesco Piazzai Renato Castoldi Cristina Marmorale Gianpaolo Balzano Massimo Falconi 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2017,19(7):580-586
Background
An early recognition of clinically relevant pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is essential.Methods
All consecutive patients who underwent PD in two institutions were included (2013–2015). In all patients amylase value in drains (AVD) was evaluated in postoperative day 1 (POD1). White-blood cell count (WBC), serum pancreatic amylase (SPA) and C-reactive protein (CRP) were routinely evaluated in POD1, POD2, and POD3. Receiver operator characteristic (ROC) curves were performed. Significant diagnostic cut-offs were tested in a multivariate model.Results
Overall, 463 patients underwent PD. Postoperative morbidity and mortality were 58% and 4%, respectively. Sixty-four patients (14%) had a clinically relevant PF (grade B or C). ROC curve analyses revealed that AVD on POD1 had the greatest area under the curve value (0.881, P < 0.0001) followed by CRP on POD3 (0.796, P < 0.0001). Multivariable analysis identified male gender (OR 2.29 95%CI: 1.12–4.70, P = 0.023), AVD on POD1>500 U/l (OR 21.72, 95%CI: 7.41–63.67, P < 0.0001), CRP on POD2 > 150 mg/l (OR 3.480, 95%CI: 1.21–9.99, P = 0.021), and CRP on POD3 > 185 mg/l (OR 6.738, 95%CI: 1.91–23.78, P = 0.003) as independent predictors of clinically relevant PF.Conclusion
The combination of CRP and AVD was effective in the early prediction of clinically relevant POPF after PD. 相似文献18.
Kevin Chang Chio Yokose Craig Tenner Cheongeun Oh Robert Donnino Alana Choy-Shan Virginia C. Pike Binita D. Shah Jeffrey D. Lorin Svetlana Krasnokutsky Steven P. Sedlis Michael H. Pillinger 《The American journal of medicine》2017,130(2):230.e1-230.e8
Background
An independent association between gout and coronary artery disease is well established. The relationship between gout and valvular heart disease, however, is unclear. The aim of this study was to assess the association between gout and aortic stenosis.Methods
We performed a retrospective case-control study. Aortic stenosis cases were identified through a review of outpatient transthoracic echocardiography (TTE) reports. Age-matched controls were randomly selected from patients who had undergone TTE and did not have aortic stenosis. Charts were reviewed to identify diagnoses of gout and the earliest dates of gout and aortic stenosis diagnosis.Results
Among 1085 patients who underwent TTE, 112 aortic stenosis cases were identified. Cases and nonaortic stenosis controls (n = 224) were similar in age and cardiovascular comorbidities. A history of gout was present in 21.4% (n = 24) of aortic stenosis subjects compared with 12.5% (n = 28) of controls (unadjusted odds ratio 1.90, 95% confidence interval 1.05-3.48, P = .038). Multivariate analysis retained significance only for gout (adjusted odds ratio 2.08, 95% confidence interval 1.00-4.32, P = .049). Among subjects with aortic stenosis and gout, gout diagnosis preceded aortic stenosis diagnosis by 5.8 ± 1.6 years. The age at onset of aortic stenosis was similar among patients with and without gout (78.7 ± 1.8 vs 75.8 ± 1.0 years old, P = .16).Conclusions
Aortic stenosis patients had a markedly higher prevalence of precedent gout than age-matched controls. Whether gout is a marker of, or a risk factor for, the development of aortic stenosis remains uncertain. Studies investigating the potential role of gout in the pathophysiology of aortic stenosis are warranted and could have therapeutic implications. 相似文献19.
Paul R. Kalra Nicola Greenlaw Roberto Ferrari Ian Ford Jean-Claude Tardif Michal Tendera Christopher M. Reid Nicolas Danchin Janina Stepinska Ph. Gabriel Steg Kim M. Fox 《The American journal of medicine》2017,130(6):720-730
Background
Anemia is a predictor of adverse outcomes in acute myocardial infarction. We studied the relationship of hemoglobin, or its change over time, and outcomes in patients with stable coronary artery disease.Methods
The ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease is a prospective, cohort study of outpatients with stable coronary artery disease (32,901 in 45 countries 2009-2010): 21,829 with baseline hemoglobin levels. They were divided into hemoglobin quintiles and anemia status (anemic or normal at baseline/follow-up: normal/normal; anemic/normal; normal/anemic; anemic/anemic. All-cause mortality, cardiovascular events, and major bleeding at 4-year follow-up were assessed.Results
Low baseline hemoglobin was an independent predictor of all-cause, cardiovascular, and noncardiovascular mortality, the composite of cardiovascular death/myocardial infarction or stroke and major bleeds (all P <.001; unadjusted models). Anemia at follow-up was independently associated with all-cause mortality (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.55-2.33 for anemic/anemic; 1.87; 1.54-2.28 for normal/anemic; both P <.001), noncardiovascular mortality (P <.001), and cardiovascular mortality (P = .001). Patients whose baseline anemia normalized (anemic/normal) were not at increased risk of death (HR, 1.02; 95% CI, 0.77-1.35), although the risk of major bleeding was greater (HR, 2.06; 95% CI, 1.23-3.44; P = .013) than in those with normal hemoglobin throughout. Sensitivity analyses excluding patients with heart failure and chronic kidney disease at baseline yielded qualitatively similar results.Conclusions
In this large population with stable coronary artery disease, low hemoglobin was an independent predictor of mortality, cardiovascular events, and major bleeds. Persisting or new-onset anemia is a powerful predictor of cardiovascular and noncardiovascular mortality. 相似文献20.
Pulmonary Hypertension with Left Heart Disease: Prevalence,Temporal Shifts in Etiologies and Outcome
Tatyana Weitsman Giora Weisz Rivka Farkash Marc Klutstein Adi Butnaru David Rosenmann Tal Hasin 《The American journal of medicine》2017,130(11):1272-1279