To Be or Not to Be Eisenmenger Cohen, Sarit S.; Nageshwaran, Sathiji Kathiresu; Murthy, Raghav ...
JACC. Case reports,
February 2021, 2021-02-00, 2021-02-01, Letnik:
3, Številka:
2
Journal Article
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Eisenmenger syndrome refers to any untreated congenital cardiac defect with an intracardiac communication that leads to pulmonary arterial hypertension, reversal of intracardiac shunting, and ...cyanosis. We describe a 40-year-old cyanotic patient with congenital heart disease with presumed Eisenmenger syndrome who was considered inoperable. Testing revealed a partial atrioventricular septal defect with no evidence of pulmonary arterial hypertension, and the patient underwent successful cardiac repair. (Level of Difficulty: Intermediate.)
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Increasing frequency of intermittent oral corticosteroid (OCS) prescription and cumulative OCS exposure increase the risk of OCS-related adverse outcomes.
We sought to describe the evolution and ...trajectory of intermittent OCS prescription patterns in patients with asthma and investigate risk factors independently associated with transitioning to a frequent prescription pattern.
This historical cohort study included patients with active asthma managed in UK primary care and included in the Optimum Patient Care Research Database (OPCRD; opcrd.co.uk). Intermittent OCS prescription patterns were categorized as sporadic, infrequent, moderately frequent, or frequent. Prescription pattern sequences were described for those who had a frequent sequence in their final year of prescribing. We examined associations between OCS prescription pattern and the hazard of transitioning into a frequent intermittent OCS prescription pattern using multivariable Cox regression with a 10-year look-back period.
Of 105,229 patients with intermittent OCS prescriptions, 57.1% (n = 60,083) had a frequent OCS prescription pattern at some point. Irrespective of baseline pattern, most patients transitioned to frequent prescription during the look back. The strongest risk factors were a more frequent prescription pattern at the start of look-back period, a lower percentage peak expiratory flow rate, and higher Global Initiative for Asthma treatment step. Older age, female sex, obesity, and active smoking were also associated with a higher risk of transitioning.
Our findings help identify those most at risk of transitioning to frequent intermittent OCS receipt and encourage earlier intervention with OCS-sparing treatments.
Background:
Inflammation during and after surgery can lead to organ damage including acute kidney injury. Colchicine, an established inexpensive anti-inflammatory medication, may help to protect the ...organs from pro-inflammatory damage. This protocol describes a kidney substudy of the colchicine for the prevention of perioperative atrial fibrillation (COP-AF) study, which is testing the effect of colchicine versus placebo on the risk of atrial fibrillation and myocardial injury among patients undergoing thoracic surgery.
Objective:
Our kidney substudy of COP-AF will determine whether colchicine reduces the risk of perioperative acute kidney injury compared with a placebo. We will also examine whether colchicine has a larger absolute benefit in patients with pre-existing chronic kidney disease, the most prominent risk factor for acute kidney injury.
Design and Setting:
Randomized, superiority clinical trial conducted in 40 centers in 11 countries from 2018 to 2023.
Patients:
Patients (~3200) aged 55 years and older having major thoracic surgery.
Intervention:
Patients are randomized 1:1 to receive oral colchicine (0.5 mg tablet) or a matching placebo, given twice daily starting 2 to 4 hours before surgery for a total of 10 days. Patients, health care providers, data collectors, and outcome adjudicators will be blinded to the randomized treatment allocation.
Methods:
Serum creatinine concentrations will be measured before surgery and on postoperative days 1, 2, and 3 (or until hospital discharge). The primary outcome of the substudy is perioperative acute kidney injury, defined as an increase (from the prerandomization value) in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of surgery or ≥50% within 7 days of surgery. The primary analysis (intention-to-treat) will examine the relative risk of acute kidney injury in patients allocated to receive colchicine versus placebo. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by pre-existing chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2.
Limitations:
The substudy will be underpowered to detect small effects on more severe forms of acute kidney injury treated with dialysis.
Results:
Substudy results will be reported in 2024.
Conclusions:
This substudy will estimate the effect of colchicine on the risk of perioperative acute kidney injury in older adults undergoing major thoracic surgery.
Clinical trial registration number:
NCT03310125
Objective. To describe changes in oral health behaviors following implementation of a nursing intervention targeting children at risk for early childhood caries at an urban 2-site primary care ...practice. Methods. Nurses used a proprietary Nursing Caries Assessment Tool (N-CAT) to identify behaviors associated with early childhood caries risk, then provided brief focused dental education, fluoride varnish applications, and dental referrals to children without a dental home. We used generalized estimating equation logistic regression models, adjusted for age at visit, to analyze changes in oral health behaviors over time including the following: (1) tooth brushing frequency, (2) use of fluoride toothpaste, and (3) adult help with brushing among children younger than 5 years of age who had at least 2 N-CATs documented during well care visits between April 2013 and June 2015. We also evaluated dietary habits including going to bed with a bottle or sippy cup and sugar-sweetened beverage consumption, as secondary study outcomes during the same time frame. Results. A total of 2097 children with a mean age of 15.8 (SD 7.6) months at the initial visit were included in the analysis; 51% were boys; 28% were black, 36% Hispanic/Latino, 5% white, 2% Asian, and 19% other; 75% were publicly insured. During the study period, significant (P < .05) improvements were noted across the 3 oral health behaviors studied among children younger than 18 months. Conclusion. Nursing interventions show promise for promoting preventive dental care in primary care settings and deserve further study.
Objective To assess the influence of gender on mortality after aortic valve replacement for aortic stenosis. Methods A retrospective analysis was performed on data prospectively collected from all ...patients undergoing aortic valve replacement for aortic stenosis. Multivariate regression analysis was performed to evaluate the effect of 22 preoperative and operative variables on early, late, and overall mortality. Results Aortic valve replacement was performed in 3343 patients with aortic stenosis between 1982 and 2003. The female patients were older, with a smaller body mass index. The women were less likely to have diabetes, chronic obstructive pulmonary disease, previous myocardial infarction, or left ventricular ejection fraction <35% but were more likely to have hypertension or a New York Heart Association III-IV classification. The female patients received a smaller prosthetic valve, with a smaller effective orifice area index (EOAI). The mean follow-up period was 6.18 ± 4.96 years, with a total of 2066.142 years of follow-up. The independent predictors of early mortality for the male patients included age, concomitant surgical revascularization, congestive heart failure, and valve size of ≤21 mm. The independent predictors of late mortality for the male patients included age, concomitant surgical revascularization, diabetes, renal failure, chronic obstructive pulmonary disease, congestive heart failure, and a bioprosthetic valve. The independent predictors of overall mortality for the male patients included age, concomitant surgical revascularization, diabetes, renal failure, heart failure, and valve size of ≤21 mm. For the female patients, the risk factors for early mortality included body mass index <25 kg/m2 ; for late mortality included age, concomitant surgical revascularization, New York Heart Association class III-IV, and diabetes; and for overall mortality included age, concomitant surgical revascularization, New York Heart Association class III-IV, and renal failure. Furthermore, male gender was an independent predictor of late (but not early or overall) mortality. Conclusions The independent predictors of mortality after aortic valve replacement for aortic stenosis differed between the male and female patients. Male gender increased the risk of late mortality, and a valve size of ≤21 mm increased the risk of early and overall mortality among the male patients only. These differences need to be taken into consideration preoperatively and require consideration during operative management.
Infectious diseases acquired by survivors of large-scale natural disasters complicate the recovery process. During events such as tsunamis, hurricanes, earthquakes, and tornados and well into the ...recovery period, victims often are exposed to water-soil mixtures that have relocated with indigenous microbes. Because nontuberculous mycobacteria (NTM) are ubiquitous in water and soil, there is potential for increased exposure to these organisms during natural disasters. In this hypothesis-driven commentary, we discuss the rise in NTM lung disease and natural disasters and examine the geographic overlap of NTM infections and disaster frequencies in the United States. Moreover, we show an increased number of positive NTM cultures from Louisiana residents in the years following three of the relatively recent epic hurricanes and posit that such natural disasters may help to drive the increased number of NTM infections. Finally, we advocate for increased environmental studies and surveillance of NTM infections before and after natural disasters.
Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all ...subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.
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