OBJECTIVE:Spontaneous spinal epidural hemorrhage (SSEH) warrants urgent surgical treatment in most cases. Which patients will benefit most from decompression is not known and the diseaseʼs rarity ...hampers the collection of large data series to ascertain this. Therefore, using an individual patient data (IPD) meta-analysis, we aimed to identify predictors for outcome and to obtain knowledge on the etiology of SSEH.
METHODS:The IPD meta-analysis is based on raw data from case reports across all studies concerning all variables of interest. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used. This led to a total of 741 unique pure SSEH patient cases from 487 journal articles. Data were extracted using a data extraction sheet and analyzed using a multivariable logistic regression model.
RESULTS:A preoperative Frankel score of C and higher, absence of use of anticoagulants, compression of the cauda equina only, and the extension of the hematoma over 3 or 4 vertebral segments were associated with good outcome. Operative interval was not invariably associated with outcome and hypertension was not a risk factor for developing SSEH.
CONCLUSIONS:Outcome is mainly determined by severity of preoperative neurologic deficit and use of anticoagulants. Evidence for a venous origin of SSEH is abundant in view of the observed anatomical distribution in different age categories and the absence of hypertension as an isolated risk factor.
Background The use of High-flow nasal cannula (HFNC) is increasing in admitted COPD-patients and could provide a step in between non-invasive ventilation (NIV) and standard oxygen supply. Recent ...studies demonstrated that HFNC is capable of facilitating secretion removal and reduce the work of breathing. Therefore, it might be of advantage in the treatment of acute exacerbations of COPD (AECOPD). No randomized trials have assessed this for admitted COPD-patients on a regular ward and only limited data from non-randomized studies is available. Objectives The aim of our study was to identify the reasons to initiate treatment with HFNC in a group of COPD-patients during an exacerbation, further identify those most likely to benefit from HFNC treatment and to find factors associated with treatment success on the pulmonary ward. Material and methods This retrospective study included COPD-patients admitted to the pulmonary ward and treated with HFNC from April 2016 until April 2019. Only patients admitted with severe acute exacerbations were included. Patients who had an indication for NIV-treatment where treated with NIV and were included only if they subsequently needed HFNC, e.g. when they did not tolerate NIV. Known asthma patients were excluded. Results A total of 173 patients were included. Stasis of sputum was the indication most reported to initiate HFNC-treatment. Treatment was well tolerated in 83% of the patients. Cardiac and vascular co-morbidities were significantly associated with a smaller chance of successful treatment (Respectively OR = 0.435; p = 0.013 and OR = 0.493;p = 0.035). Clinical assessment judged HFNC-treatment to be successful in 61% of the patients. Furthermore, in-hospital treatment with NIV was associated with a higher chance of HFNC failure afterwards (OR = 0.439; p = 0.045). Conclusion This large retrospective study showed that HFNC-treatment in patients with an AECOPD was initiated most often for sputum stasis as primary reason. Factors associated with improved outcomes of HFNC-treatment was the absence of vascular and/or cardiac co-morbidities and no need for in-hospital NIV-treatment.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
To evaluate the course of spinal radiographic progression for up to 8 years of followup in a large cohort of ankylosing spondylitis (AS) patients treated with tumor necrosis factor (TNF) ...inhibitors.
Methods
Consecutive patients from the Groningen Leeuwarden AS cohort starting TNF inhibitors between 2004 and 2012 were included. Baseline and biannual radiographs were randomized with radiographs of TNF‐naive AS patients and scored in chronologic order according to modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The course of radiographic progression (linear or nonlinear) was investigated using generalized estimating equations. Primary analysis was performed in patients with complete data over 4, 6, and 8 years of followup. Sensitivity analysis was performed after single linear imputation of missing radiographic data and after adjusting for patient characteristics with possible influence on radiographic progression.
Results
At baseline, median mSASSS of 210 included AS patients was 2.8 (interquartile range 0.0–12.0), mean ± SD mSASSS 10.0 ± 15.5. During the first 4 years, radiographic progression followed a linear course (estimated mean progression rate was 1.7 for 0–2 and 2–4 years). A deflection from a linear course was found in patients with complete and imputed data over 6 and 8 years. The estimated mean 2‐year progression rate reduced from 2.3 to 0.8 in patients with complete 8‐year data. The same pattern was found after adjustment for baseline mSASSS scores, presence of syndesmophytes, sex, HLA–B27 status, age, symptom duration, smoking duration, body mass index, disease activity, and nonsteroidal antiinflammatory drug use.
Conclusion
This observational cohort study in AS patients receiving long‐term TNF inhibitors showed a reduction in spinal radiographic progression after more than 4 years of followup.
Summary
The efficacy of azacitidine in the treatment of high‐risk myelodysplastic syndromes (MDS), chronic myelomonocytic leukaemia (CMML) and acute myeloid leukaemia (AML) (20–30% blasts) has been ...demonstrated. To investigate the efficacy of azacitidine in daily clinical practice and to identify predictors for response, we analysed a cohort of 90 MDS, CMML and AML patients who have been treated in a Dutch compassionate named patient programme. Patients received azacitidine for a median of five cycles (range 1–19). The overall response rate (complete/partial/haematological improvement) was 57% in low risk MDS, 53% in high risk MDS, 50% in CMML, and 39% in AML patients. Median overall survival (OS) was 13·0 (9·8–16·2) months. Multivariate analysis confirmed circulating blasts Hazard Ratio (HR) 0·48, 95% confidence interval (CI) 0·24–0·99; P = 0·05 and poor risk cytogenetics (HR 0·45, 95% CI 0·22–0·91; P = 0·03) as independent predictors for OS. Interestingly, this analysis also identified platelet doubling after the first cycle of azacitidine as a simple and independent positive predictor for OS (HR 5·4, 95% CI 0·73–39·9; P = 0·10). In conclusion, routine administration of azacitidine to patients with variable risk groups of MDS, CMML and AML is feasible, and subgroups with distinct efficacy of azacitidine treatment can be identified.
Evaluation of 1025 fetal deaths: proposed diagnostic workup Korteweg, Fleurisca J., MD, PhD; Erwich, Jan Jaap H.M., MD, PhD; Timmer, Albertus, MD, PhD ...
American journal of obstetrics and gynecology,
2012, 2012-Jan, 2012-01-00, 20120101, Letnik:
206, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Objective We sought to evaluate the contribution of different diagnostic tests for determining cause of fetal death. Our goal was to propose a workup guideline. Study Design In a multicenter ...prospective cohort study from 2002 through 2008, for 1025 couples with fetal death ≥20 weeks' gestation, an extensive nonselective diagnostic workup was performed. A panel classified cause and determined contribution of diagnostics for allocating cause. Results A Kleihauer-Betke, autopsy, placental examination, and cytogenetic analysis were abnormal in 11.9% (95% confidence interval CI, 9.8–14.2), 51.5% (95% CI, 47.4–55.2), 89.2% (95% CI, 87.2–91.1), and 11.9% (95% CI, 8.7–15.7), respectively. The most valuable tests for determination of cause were placental examination (95.7%; 95% CI, 94.2–96.8), autopsy (72.6%; 95% CI, 69.2–75.9), and cytogenetic analysis (29.0%; 95% CI, 24.4–34.0). Conclusion Autopsy, placental examination, cytogenetic analysis, and testing for fetal maternal hemorrhage are basic tests for workup after fetal death. Based on the results of these tests or on specific clinical characteristics, further sequential testing is indicated.
Aims The aim of this prospective study was to investigate the association between compliance with non-pharmacological recommendations (diet, fluid restriction, weighing, exercise) and outcome in ...patients with heart failure (HF). Methods and results In total 830 patients after an HF hospitalization participated in the study (age 70 ± 11; left ventricular ejection fraction 34%). Compliance was measured 1 month after discharge; patients were followed for 18 months. Primary outcomes were the composite of death or HF readmission and the number of unfavourable days. Cox regression analysis was used to determine the association between primary outcome and compliance. Adjustments were made for those variables that were identified as confounders in the association between compliance and outcome. Patients who were non-compliant with at least one of the recommendations had a higher risk of mortality or HF readmission (HR 1.40; P = 0.01). Non-compliance with exercise was associated with an increased risk for mortality or HF readmission (HR 1.48; P < 0.01), while non-compliance with daily weighing was associated with an increased risk of mortality (HR 1.57; P = 0.02). Non-compliance (overall) and non-compliance with exercise were both associated with a higher risk for HF readmission HR 1.38; P < 0.05(overall) and HR 1.55; P < 0.01(exercise). Patients who were overall non-compliant or with weighing and exercise had more unfavourable days than compliant patients. Conclusion Non-compliance with non-pharmacological recommendations in HF patients is associated with adverse outcome.
Recent years have seen major changes in clinical practice which may have affected the incidence rates of pheochromocytoma(PCC)/sympathetic paraganglioma(sPGL). There is, however, a lack of up-to-date ...information describing trends in these incidence rates.
We searched the Dutch pathology registry to identify all histopathologically confirmed cases of PCC/sPGL diagnosed between 1995 and 2015. We calculated incidence rates according to age category as well as age-standardized incidence rates (ASR). We also searched Medline and Embase to find data on nationwide incidence rates of PCC/sPGL.
The nationwide pathology study revealed a total of 1493 patients with either PCC or sPGL. The ASR for PCC increased from 0.29 (95% CI: 0.24–0.33) to 0.46 (95% CI: 0.39–0.53) per 100,000 person-years in the periods 1995–1999 and 2011–2015, respectively. For sPGL the ASR in these same periods were 0.08 (95% CI: 0.06–0.10) and 0.11 (95% CI: 0.09–0.13) per 100,000 person-years, respectively. Concomitantly, PCC size decreased (β −0.17; P < .001) and age at diagnosis increased (β 0.13; P = .001). Our systematic search yielded 3 papers reporting on a total of 530 PCC/sPGL cases, showing a combined annual incidence rate varying from 0.04 to 0.21 per 100,000 person-years.
Incidence rates of PCC/sPGL have increased significantly over the past two decades. This trend coincides with a higher age and a smaller tumor size at diagnosis. Most likely these observations are at least in part the result of changes in clinical practice during the study period, with a more intensified use of both imaging studies and biochemical tests for detecting PCC/sPGL.
•Up-to-date epidemiological data on PCC/sPGL are lacking.•The incidence rate of PCC/sPGL has increased significantly during the past two decades.•This rise in incidence rate is accompanied by a reduction in tumor size and a higher age at diagnosis.•The observed epidemiological changes are most likely the result of more intensified use of better diagnostics.
BACKGROUND AND PURPOSE—Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating type of stroke associated with high morbidity and mortality. One of the most feared complications is an early ...rebleeding before aneurysm repair. Predictors for such an often fatal rebleeding are largely unknown. We therefore aimed to determine predictors for an early rebleeding after aSAH in relation with time after ictus.
METHODS—This observational prospective cohort study included all consecutive patients admitted with aSAH between January 1998 and December 2014 (n=1337) at our University Neurovascular Center. Clinical predictors for rebleeding ≤24 hours were identified using multivariable Cox regression analyses. Kaplan–Meier analyses were applied to evaluate the time of rebleeding ≤72 hours after aSAH.
RESULTS—A modified Fisher grade of 3 to 4 was a predictor for an in-hospital rebleeding ≤24 hours after ictus (adjusted hazard ratio, 4.4; 95% confidence interval, 2.1–10.6; P<0.001). The numbers needed to treat to prevent 1 rebleeding ≤24 hours was calculated 15 (95% confidence interval, 10–25). Also, the initiation of external cerebrospinal fluid-drainage (adjusted hazard ratio, 1.9; 95% confidence interval, 1.4–2.5; P<0.001) was independently associated with a rebleeding ≤24 hours. Cumulative in-hospital rebleeding rates were 5.8% ≤24 hours, and 1.2% in the time frame 24–72 hours after ictus.
CONCLUSIONS—In our opinion, timing of treatment of aSAH patients, especially those with an modified Fisher grade of 3 or 4 in a good clinical condition, should be reconsidered. These aSAH patients might be regarded a medical emergency, requiring aneurysm repair as soon as possible. In this respect, our findings should provoke the debate on timing of aneurysm repair, especially in patients considered to be at high risk for rebleeding.
Background Low levels of vitamin D are associated with asthma severity, airway remodeling, and exacerbation rate increase, especially in nonatopic asthma. Reduced steroid responsiveness or impaired ...antimicrobial defense might be underlying mechanisms. Objective We sought to evaluate the effect of vitamin D supplementation on eosinophilic and neutrophilic airway inflammation in patients with nonatopic asthma. Methods In a double-blind, randomized, placebo-controlled trial, we investigated the effect of long-acting vitamin D3 (400,000 IU) on sputum neutrophils and eosinophils in 44 patients with nonatopic asthma with neutrophilic (≥53%) and/or eosinophilic (≥3%) airway inflammation. Sputum induction was performed at baseline and after 9 weeks. Other measurements included questionnaires, blood samples, and pulmonary function. Results Treatment with vitamin D did not significantly affect sputum neutrophils or eosinophils compared with treatment with placebo in the total group. Regarding sputum eosinophils, the effect of vitamin D appeared to be dependent on baseline sputum eosinophil levels (interaction P = .015). In patients with eosinophil levels of 26.2% or more (median in patients with sputum eosinophilia, >3%), eosinophils decreased from a median of 41.0% to 11.8% after vitamin D treatment as compared with an increase from 51.8% to 63.3% in patients receiving placebo ( P = .034). Vitamin D treatment also resulted in slightly better Asthma Control Questionnaire scores ( P = .08). Conclusions Vitamin D supplementation reduced eosinophilic airway inflammation in patients with nonatopic asthma with severe eosinophilic airway inflammation, but did not affect sputum neutrophils. Also, a small effect on asthma control was observed. These findings suggest that vitamin D might have potential as an add-on treatment option in eosinophilic asthma.
Summary
An observational population‐based cohort study was performed to investigate the role of comorbidity on outcome and treatment‐related toxicity in patients with newly diagnosed advanced‐stage ...diffuse large B‐cell lymphoma (DLBCL) treated with R‐CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). Data for the clinical characteristics of 154 patients (median age 69 years), including Charlson Comorbidity Index (CCI), treatment, toxicity and outcome were evaluated. Forty‐five percent of the patients had an International Prognistic index ≥3 and 16% had a CCI ≥2. The planned R‐CHOP schedule was completed by 84% and 75% reached complete remission (CR). In those with CCI ≥2, 67% completed treatment with 46% CR. In patients with a CCI <2, overall survival (OS) after 1, 2 and 5 years was 84%, 79% and 65% respectively and it was 64%, 48% and 48% for those with CCI ≥2. Grade III/IV toxicity was documented in 53%, most frequently febrile neutropenia (27%) and infections (23%). In multivariate analysis CCI ≥2 and IPI ≥3 were independent risk indicators for OS and grade III/IV toxicity. In conclusion, comorbidity is an independent risk indicator for worse OS in patients with advanced DLBCL treated with R‐CHOP by interference with intensive treatment schedules and more grade III/IV toxicity. Future studies are warranted to determine the optimal treatment approach in patients with significant comorbidities.
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