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What is the optimal approach to a non- culprit stenosis after ST-elevation myocardial infarction - Conservative therapy or upfront revascularization? An updated meta-analysis of randomized trials. - International journal of cardiology
Non-culprit percutaneous coronary intervention (PCI) during a ST-segment elevation myocardial infarction (STEMI) remains controversial. We performed a meta-analysis of the published literature comparing a strategy of complete revascularization (CR) with culprit or target vessel revascularization (TVR)-only after STEMI in patients with multi-vessel disease.We searched PubMed/Medline, Cochrane, EMBASE, Web of Science, CINAHL, Scopus and Google-scholar databases from inception to March-2016 for clinical trials comparing CR with TVR during PCI for STEMI. Mantel-Haenszel risk ratio (MH-RR) with 95% confidence intervals (CI) for individual outcomes was calculated using random-effects model.A total of 7 randomized trials with 2004 patients were included in the final analysis. Mean follow-up was 25.4months. Major adverse cardiac events (MACE) (MH-RR: 0.58, 95% CI: 0.43-0.78, P<0.001), cardiac deaths (MH-RR: 0.42, 95% CI: 0.24-0.74, P=0.003) and repeat revascularization (MH-RR: 0.36, 95% CI: 0.27-0.48, P<0.001) were much lower in the CR group when compared to TVR. However, there was no significant difference in the risk of all-cause mortality (0.84, 95% CI: 0.57-1.25, P=0.394) or recurrent MI (MH-RR: 0.66, 95% CI: 0.34-1.26, P=0.205) between the two groups. CR appeared to be safe with no significant increase in adverse events including stroke rates (MH-RR: 2.19, 95% CI: 0.59-8.12, P=0.241), contrast induced nephropathy (MH-RR: 0.73, 95% CI: 0.34-1.57, P=0.423) or major bleeding episodes (MH-RR: 0.72, 95% CI: 0.34-1.54, P=0.399).CR strategy in STEMI patients with multivessel coronary artery disease is associated with reduction in MACE, cardiac mortality and need for repeat revascularization but with no decrease in the risk of subsequent MI or all-cause mortality. CR was safe however, with no increase in adverse events including stroke, stent thrombosis or contrast nephropathy when compared to TVR.Copyright Â© 2016 Elsevier Ireland Ltd. All rights reserved.
Transcatheter Aortic Valve Replacement Complication Rates in Teaching Vs Non-Teaching Centers in the United States. - The Journal of invasive cardiology
The objective of our study is to compare transcatheter aortic valve replacement (TAVR) complication rates among teaching vs non-teaching centers in the United States.Using National Inpatient Sample (NIS) data, the largest all-payer database of hospital inpatient stay available in the United States, we identified patients (age â‰¥18 years) who underwent TAVR from January-December 2012. We constructed multivariable models to determine independent predictors (age, sex, race, Charlson's comorbidity index, hospital size, hospital location, and TAVR approach) of TAVR-associated complications.We identified 7405 TAVR procedures performed in the United States in 2012. In all, 88% of TAVRs were performed in teaching centers. There was no difference in mortality following TAVR between teaching and non-teaching centers. In-hospital complication rate was lower in teaching centers vs non-teaching centers (42% vs. 50%, respectively; P<.001). In adjusted analysis, hemorrhage requiring transfusion (13.2% vs. 20.8%; P<.001), renal complications requiring dialysis (1.2% vs. 2.3%; P<.01), respiratory complications (7.5% vs. 11%; P<.001), and complications requiring open-heart surgery (2% vs. 4.6%; P<.001) were lower in teaching centers vs non-teaching centers. Vascular access-site, pacemaker insertion, pericardial, and neurological complications were similar between teaching and non-teaching centers.Institutional design impacts TAVR complications, albeit with no difference in mortality. In general, complication rates are lower in teaching centers compared with non-teaching centers.
Narrow QRS tachycardia with RR alternans and 2:1 VA relation. - Journal of cardiovascular electrophysiology
A 50-year-old female underwent electrophysiology study for paroxysmal palpitation. Panel A represents surface electrocardiogram showing narrow QRS tachycardia with RR alternans and 2:1 VA relation. Panel B represents intracardiac electrogram showing AV nodal reentrant tachycardia with alternation between two antegrade conduction times with retrograde conduction to atrium occurring only after longer antegrade conduction. The underlying morphological substrate behind this interesting phenomenon is not known. There may be potential mechanisms possible like antegrade conduction alternating between anatomically or functionally distinct antegrade pathways and retrograde conduction to atrium occurring only after longer antegrade conduction probably due to longer preceding HH interval or two antegrade conducting pathways with separate turn around points with one not retrogradely conducting to the atrium or multiple potential exits of the circuit with one not retrogradely conducting to the atrium. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved.
Aspiration Thrombectomy in Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction: An Updated Meta-Analysis. - Journal of interventional cardiology
The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI).We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data.Clinical trials (nâ€‰=â€‰20) that randomized patients (nâ€‰=â€‰21,281) with STEMI between Routine AT (nâ€‰=â€‰10,619) and PPCI (nâ€‰=â€‰10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, Pâ€‰=â€‰0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, Pâ€‰=â€‰0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, Pâ€‰=â€‰0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, Pâ€‰=â€‰0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, Pâ€‰=â€‰0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, Pâ€‰=â€‰0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, Pâ€‰=â€‰0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, Pâ€‰=â€‰0.11), early (0.59, 95%CI: 0.23-1.50, Pâ€‰=â€‰0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, Pâ€‰=â€‰0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, Pâ€‰=â€‰0.76).Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone.Â© 2015, Wiley Periodicals, Inc.
Quadrivalent Human Papillomavirus Vaccine Initiation in Boys Before and Since Routine Use: Southern California, 2009-2013. - American journal of public health
We examined the trends and correlates of quadrivalent human papillomavirus vaccine (HPV4) initiation in insured boys during the periods before and after routine use recommendation.We grouped data from electronic medical records of boys aged 9 to 17 years from the Kaiser Permanente Southern California prepaid health plan into 3 open cohorts: permissive use: 2009 to 2010; anal cancer indication added: 2010 to 2011; and routine use: 2011 to 2013. We estimated adjusted risk ratios (ARRs) between demographics and vaccination initiation using Poisson regression.HPV4 initiation increased across cohorts--1.6%, 3.4%, and 18.5%--with the greatest increase among boys aged 11 to 12 years in cohort 3. Initiation was associated with receiving influenza vaccination in the previous year in all cohorts (cohort 3: ARRâ€‰=â€‰1.48; 95% confidence interval [CI]â€‰=â€‰1.46, 1.51) and with non-White race/ethnicity following routine recommendation (cohort 3, non-Hispanic Black: ARRâ€‰=â€‰1.18; 95% CIâ€‰=â€‰1.08, 1.30; Hispanic: ARRâ€‰=â€‰1.23; 95% CIâ€‰=â€‰1.17, 1.29; Asian/Pacific Islanders: ARRâ€‰=â€‰1.16; 95% CIâ€‰=â€‰1.11, 1.20).Routine use recommendation increased the uptake of HPV4 in boys. System-level interventions to encourage providers to routinely recommend HPV4 vaccination may help increase HPV4 uptake in boys.
Derivation and preliminary validation of a risk score to predict 30-day ED revisits for sickle cell pain. - The American journal of emergency medicine
Emergency department (ED) revisits and 30-day readmissions have been proposed as markers for quality of ED care for sickle cell disease (SCD).To create a scoring system that quantifies the risk of 30-day revisit after ED discharge for SCD vaso-occlusive painThis was a dual-center retrospective derivation and validation cohort study. The derivation was performed at an academic, tertiary care center and the validation at an urban community hospital. The primary outcome was revisit to the ED within 30 days after an ED discharge for SCD pain. Recursive partitioning was used to derive a scoring system to predict 30-day revisits.Of a total of 1456 ED visits for SCD pain, there were 680 ED discharges (admission rate of 53%) in 193 unique individuals included in the derivation cohort. There were 240 (35.3%) 30-day revisits. Of a total of 126 ED visits for SCD, there were 79 ED discharges in 41 unique individuals in the validation cohort. The final risk score included 4 variables: (1) age, (2) insurance status, (3) triage pain score, and (4) amount of opioids administered during the ED visit. Possible scores range from 0 to 6. The areas under the receiver operating characteristic curves were 0.746 (95% confidence interval, 0.71-0.78-derivation cohort) and 0.753 (95% confidence interval, 0.65-0.86-validation cohort). A cutoff of 4 or greater identified 60% of 30-day ED revisits in the derivation cohort and 80% of revisits in the validation cohort.A risk score can identify ED visits for SCD pain with high risk of 30-day revisit.Copyright Â© 2015 Elsevier Inc. All rights reserved.
"Natural Amphetamine" Khat: A Cultural Tradition or a Drug of Abuse? - International review of neurobiology
Khat, Catha edulis Forsk, is among the most widely used plant-based psychoactive substance in the world. Grown in Eastern Africa, Horn of Africa, and southwestern part of the Arabian Peninsula, its fresh young leaves and twigs are used daily by over 20 million people for the psychostimulatory effects it produces in the user, a practice deeply rooted in the history, tradition, and culture of the indigenous population. Once hardly known outside the regions where it is grown and used, khat use has now spread to other countries. This review will cover the, phytochemistry, pharmacokinetics of the active ingredients-cathinone, cathine, norephedrine, neurochemistry, effects on cognitive and executive functions as well as its ability to produce dependency in the user. Whether it is an innocuous cultural practice or a drug of abuse is debatable as the preclinical and clinical data needed to arrive at an authoritative conclusion is lacking.Â© 2015 Elsevier Inc. All rights reserved.
A comparison of results with eversion versus conventional carotid endarterectomy from the Vascular Quality Initiative and the Mid-America Vascular Study Group. - Journal of vascular surgery
Carotid endarterectomy (CEA) is usually performed with eversion (ECEA) or conventional (CCEA) technique. Previous studies report conflicting results with respect to outcomes for ECEA and CCEA. We compared patient characteristics and outcomes for ECEA and CCEA.Deidentified data for CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) database for years 2003 to 2013. Second (contralateral) CEA, reoperative CEA, CEA after previous carotid stenting, or CEA concurrent with cardiac surgery were excluded, leaving 2365 ECEA and 17,155 CCEA for comparison. Univariate analysis compared patients, procedures, and outcomes. Survival analysis was also performed for mortality. Multivariate analysis was used selectively to examine the possible independent predictive value of variables on outcomes.Groups were similar with respect to sex, demographics, comorbidities, and preoperative neurologic symptoms, except that ECEA patients tended to be older (71.3 vs 69.8 years; P < .001). CCEA was more often performed with general anesthesia (92% vs 80%; P < .001) and with a shunt (59% vs 24%; P < .001). Immediate perioperative ipsilateral neurologic events (ECEA, 1.3% vs CCEA, 1.2%; P = .86) and any ipsilateral stroke (ECEA, 0.8% vs CCEA, 0.9%; P = .84) were uncommon in both groups. ECEA tended to take less time (median 99 vs 114 minutes; P < .001). However, ECEA more often required a return to the operating room for bleeding (1.4% vs 0.8%; P = .002), a difference that logistic regression analysis showed was only partly explained by differential use of protamine. Life-table estimated 1-year freedom from any cortical neurologic event was similar (96.7% vs 96.7%). Estimated survival was similar comparing ECEA with CCEA at 1 year (96.7% vs 95.9%); however, estimated survival tended to decline more rapidly in ECEA patients after âˆ¼2 years. Cox proportional hazards modeling confirmed that independent predictors of mortality included age, coronary artery disease, chronic obstructive pulmonary disease, and smoking, but also demonstrated that CEA type was not an independent predictor of mortality. The 1-year freedom from recurrent stenosis >50% was lower for ECEA (88.8% vs 94.3%, P < .001). However, ECEA and CCEA both had a very high rate of freedom from reoperation at 1 year (99.5% vs 99.6%; P = .67).ECEA and CCEA appear to provide similar freedom from neurologic morbidity, death, and reintervention. ECEA was associated with significantly shorter procedure times. Furthermore, ECEA obviates the expenses, including increased operative time, associated with use of a patch in CCEA, and a shunt, more often used in CCEA in this database. These potential benefits may be reduced by a slightly greater requirement for early return to the operating room for bleeding.Copyright Â© 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Use of 4-factor prothrombin complex concentrate in the treatment of a gastrointestinal hemorrhage complicated by dabigatran. - International journal of emergency medicine
Target-specific oral anticoagulants (TSOACs) provide patients and healthcare providers with an alternative to vitamin K antagonists (VKA). The TSOACs are of similar or superior efficacy to warfarin, but unlike VKAs, there are no approved 'antidotes' for rapid reversal of life-threatening bleeding on therapy. We report here the case of an 83-year-old gentleman, who presented to the emergency department with severe gastrointestinal hemorrhage and coagulopathy (hemoglobin: 5.3Â g/dL and INR: 2.2) while on the direct thrombin inhibitor dabigatran. His coagulopathy reversed rapidly after administration of 4-factor prothrombin complex concentrate (4Â F-PCC), and after initial administration of 2 units of packed red blood cells, no further product transfusions were required. He was discharged 4Â days later without further complications.
Arterial blood pressure is inversely associated with vascular sympathetic reactivity (isometric handgrip exercise) in Gujarati Indian adolescents. - Indian journal of physiology and pharmacology
Studies conducted earlier have found that vascular sympathetic reactivity to isometric handgrip exercise is either low or high in adolescents with higher blood pressure (Hypertensives) as compared to adolescents with relatively lower blood pressure (Normotensive). The current study was conducted to determine the correlation of vascular sympathetic reactivity to isometric handgrip exercise with blood pressure in Gujarati Indian adolescents so as to understand the pathogenesis and/consequences of Hypertension in this population. A cross-sectional study was conducted on 651 Gujarati Indian adolescents (285 girls, 366 boys) of age group 13-19 years. Blood pressure was measured by oscillometry and vascular sympathetic reactivity (Percentage rise in Diastolic Blood Pressure, %RDBP) was assessed using isometric handgrip test. Pearson's correlation coefficient was determined to study the correlation between %RDBP and blood pressure. In both girls and boys, %RDBP showed significant negative correlation with resting SBP, DBP and MAP. The study thus indicates that an inverse association exist between arterial blood pressure and vascular sympathetic reactivity to isometric handgrip exercise in Gujarati Indian adolescents.
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