BackgroundAlthough direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF.MethodsWe conducted a study of subjects with AF who had a clinical indication for stroke prophylaxis (with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 47 years, sex category [CHA2DS2-VASc] of 2 or greater) and were prescribed 1 of the 4 clinically approved DOACs (apixaban, rivaroxaban, dabigatran, or edoxaban). We compared all-cause mortality, composite of stroke and systemic embolism, composite of myocardial infarction (MI), acute coronary syndromes (ACS), and coronary revascularization, and major bleeding between patients appropriately dosed and inappropriately underdosed.ResultsA total of 8125 patients met inclusion criteria, with a mean follow up of 2.2 ± 2 years. Of those, 1724 patients (21.2%) were inappropriately dosed. After adjusting for baseline variables, there was no difference in all-cause mortality, risk of stroke or systemic embolism, International Society on Thrombosis and Haemostasis (ISTH) major bleeding, or composite of myocardial infarction, acute coronary syndromes, or coronary revascularization between patients appropriately dosed and inappropriately underdosed. In subgroup analysis, only apixaban demonstrated an increased incidence all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.03-1.49) with inappropriate underdosing. There was no difference in the remaining clinical outcomes noted on subgroup analysis.ConclusionUnderdosing of DOACs did not minimize risk of bleeding, systemic embolization or all-cause mortality in patients with AF. Inappropriate underdosing with apixaban in particular was associated with increased all-cause mortality. 相似文献
Obesity is an important component of metabolic syndrome X and predisposes to the development of type 2 diabetes mellitus.
The incidence of obesity, type 2 diabetes mellitus and metabolic syndrome X is increasing, and the cause(s) for this increasing
incidence is not clear. Although genetics could play an important role in the higher prevalence of these diseases, it is not
clear how genetic factors interact with environmental and dietary factors to increase their incidence. We performed gene expression
profile in subjects with obesity and type 2 diabetes mellitus with and without family history of these diseases. It was noted
that genes involved in carbohydrate, lipid and amino acid metabolism pathways, glycan of biosynthesis, metabolism of cofactors
and vitamin pathways, ubiquitin mediated proteolysis, signal transduction pathways, neuroactive ligand-receptor interaction,
nervous system pathways, neurodegenerative disorders pathways are upregulated in obesity compared to healthy subjects. In
contrast genes involved in cell adhesion molecules, cytokine-cytokine receptor interaction, insulin signaling and immune system
pathways are downregulated in obese. Genes involved in signal transduction, regulation of actin cytoskeleton, antigen processing
and presentation, complement and coagulation cascades, axon guidance and neurodegenerative disorders pathways are upregulated
in subjects with type 2 diabetes with family history of diabetes compared to those who are diabetic but with no family history.
Genes involved in oxidative phosphorylation, immune, nervous system, and metabolic disorders pathways are upregulated in those
with diabetes with family history of diabetes compared to those with diabetes but with no family history. In contrast, genes
involved in lipid and amino acid pathways, ubiquitin mediated proteolysis, signal transduction, insulin signaling and PPAR
signaling pathways are downregulated in subjects with diabetes with family history of diabetes. It was noted that genes involved
in inflammatory pathway are differentially expressed both in obesity and type 2 diabetes. These results suggest that genes
concerned with carbohydrate, lipid and amino acid metabolic pathways, neuronal function and inflammation play a significant
role in the pathobiology of obesity and type 2 diabetes. 相似文献
Three recent publications have reported the development of erythema multiforme and Stevens-Johnson syndrome in patients receiving cranial irradiation and sodium phenytoin. Some authors have recommended that patients receiving whole brain radiation therapy and who have had seizures should not be prescribed phenytoin but an alternative anticonvulsant. This article reviews the current literature pertaining to the development of this potentially lethal complication in patients receiving whole brain radiation and phenytoin, with reference to the single recorded case of Stevens-Johnson syndrome in a patient receiving cranial irradiation and phenytoin in Auckland, New Zealand. While the clinical picture in the 16 patients reported in the literature and the current case report differed from the classical form of erythema multiforme, a similar pattern of presentation and outcome appeared in all patients reviewed, suggesting that the combination of phenytoin, cranial irradiation and the gradual reduction of concomitant steroids seem to lead to the development of erythema multiforme and/or Stevens-Johnson syndrome. The data presented, although sparse, suggest that phenytoin should not be prescribed in patients receiving cranial irradiation. 相似文献
Passive intestinal permeability in 33 newborn babies was studied using feeds containing lactulose and mannitol. Each marker is thought to pass across the gut wall by a different route; lactulose by a paracellular and mannitol by a transcellular pathway. Neither is metabolised and both are wholly and solely excreted by the kidney; urinary recovery is a measure of the intestinal uptake. Babies born before 34 weeks' gestation exhibited a higher intestinal permeability to lactulose than more mature babies, and all preterm babies showed an appreciable decline in lactulose absorption during the first week of oral feeds. Babies of 34 to 37 weeks' gestation achieved a 'mature' intestinal permeability to lactulose within four days of starting oral feeds. These findings may reflect the immaturity of the gut of the preterm baby rather than a process essential to adaptation to enteral nutrition. 相似文献
A previous study from this laboratory demonstrated that treatment of
pregnant mice with 3-methylcholanthrene (MC) caused lung tumors in the
offspring at 1 year after birth, the incidence of which correlated with
fetal inducibility of Cyp1a1. Analysis by PCR amplification and allele-
specific hybridization (ASO) of paraffin-embedded tumors generated from
that study revealed the presence of point mutations in exon 1 of the Ki-
ras gene. This work has now been expanded by PCR amplification and ASO
analysis of 31 additional lesions. Point mutations were found in 37 of the
47 (79%) lesions analyzed in this and the previous study, the majority of
which were G-->T transversions in the first or second base of codon 12.
The mutational spectrum appeared to be dependent on the relative stage of
differentiation of the lesion, as both the incidence of mutation and type
of mutation produced correlated with malignant progression. Mutations
occurred in 60% of the hyperplasias, 80% of the adenomas and 100% of the
adenocarcinomas. In the lesions with mutations, GLY12-->CYS12
transversions occurred in 100% of the hyperplasias, 42% of the adenomas and
14% of the adenocarcinomas. The GLY12-->VAL12 transversions occurred in
none of the hyperplasias, 42% of the adenomas and 57% of the
adenocarcinomas. The remaining mutations, which consisted of ASP12
transitions and ARG13 transversions, occurred only in adenomas (17%) and
adenocarcinomas (29%). Between this study and our previous analyses, the
identity of the mutations obtained by ASO were confirmed by sequence
analysis of eight of the 37 lesions that harbored mutations at the Ki-ras
gene locus. There were no differences in the type or incidence of mutations
relative to the metabolic phenotype or sex of the mice. These data suggest
that mutational activation of the Ki-ras gene locus is an early event in
transplacental lung tumorigenesis, and that the type of mutations produced
by exposure to chemical carcinogens can influence the carcinogenic
potential of the tumor. This may have prognostic significance in
determining the malignant progression of the neoplasm.
相似文献
The prevalence of dyslipidaemia in children with insulin dependent diabetes mellitus (IDDM) and its relation to glycaemic control was studied in a group of 51 diabetic children and a control population of 132 schoolchildren. The prevalence of dyslipidaemia in the fasting state was increased in the diabetic group (39%) compared with control subjects (17%). Serum cholesterol concentration alone was raised in 25% of diabetic subjects while serum cholesterol and triglycerides were raised in 14%, compared with 16% and 0.7% respectively in control subjects. Serum total cholesterol (5.1 v 4.5 mmol/l), low density lipoprotein cholesterol (3.2 v 2.6 mmol/l), non-esterified fatty acids (0.91 v 0.50 mmol/l), and triglycerides (0.94 v 0.76 mmol/l) were higher in diabetic children. Serum total cholesterol, triglycerides, and apolipoprotein (apo)B concentrations increased with worsening control, while serum high density lipoprotein cholesterol and apoA-I concentrations were unaltered. There were also positive correlations between glycated haemoglobin and total cholesterol, triglycerides, and apoB in diabetic children. Thus, abnormalities in circulating lipids are common in young subjects with IDDM but largely disappear if blood glucose concentrations are reasonably controlled. 相似文献
Objective: The aim of the study was to assess whether vaginal administration of misoprostol before copper intrauterine device (IUD) insertion increased the success of the procedure among parous women with previous insertion failure.
Methods: A single-centre, parallel-group, double-blind, placebo-controlled, randomised clinical trial was conducted at Ain Shams University Maternity Hospital, Cairo, Egypt, between October 2015 and August 2016. The study comprised 90 parous women undergoing TCu380A IUD insertion after a failed attempt. A computer-generated list of random numbers was used to assign participants to receive either misoprostol 200?μg or a placebo tablet, applied vaginally 10?h and 4?h prior to the second attempted IUD insertion, without ultrasound guidance. The primary outcome was the success of IUD insertion. Secondary outcomes were to establish the effect on insertion success of cervical dilation, cervical softening and previous mode of delivery.
Results: Forty-two women (93.3%) in the misoprostol group and 24 women (53.3%) in the placebo group had a successful IUD insertion (p?<?.001). Cervical dilation was required in 24 women in the misoprostol group and 44 women in the placebo group. Misoprostol application significantly increased insertion success in women with previous caesarean delivery (p?<?.001) but did not affect insertion success in women with previous vaginal delivery (p?=?.481).
Conclusion: Vaginal misoprostol before IUD insertion in parous women with previous insertion failure increased the rate of successful insertion, particularly in women with previous caesarean delivery. 相似文献