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Cervical (Carotid and Vertebral) Artery Dissection
No full textCervical artery dissection (CAD) is a general term including both carotid and vertebral artery dissections. A dissection occurs when there is a tear in the intimal layer of a carotid or vertebral artery that leads to the development of an intramural hematoma. The hematoma can cause stenosis, occlusion, or aneurysmal dilation. Early detection is critical as the risk of recurrent stroke is highest during the first month following an inciting event. Management includes medical therapy, focused on antiplatelet medications, and in some cases surgical or endovascular intervention
Characteristics and Clinical Outcomes of Women with Polycystic Ovary Syndrome After Bariatric Surgery.
No full textBACKGROUND: Polycystic ovary syndrome (PCOS) commonly co-occurs with obesity, medical comorbidities, and psychiatric symptoms. Bariatric surgery is an effective treatment for co-occurring obesity and PCOS. While the incidence of PCOS declines substantially after bariatric surgery, the condition is still present for a subset of women. Examining characteristics and clinical outcomes of those with and without PCOS post-surgery may underscore potential risk factors or intervention targets.
METHODS: Individuals up to four years after bariatric surgery were invited to participate in this cross-sectional survey study, which included validated measures of depression, anxiety, eating disorder pathology, and quality of life. Post-surgical weight outcomes, medical comorbidities, and mental health treatment engagement were also assessed. Regression analyses were performed to examine differences in outcomes between those with and without a PCOS diagnosis after bariatric surgery.
RESULTS: Of the 657 female (sex assigned at birth) participants who underwent bariatric surgery, 7% (n = 46) reported having a current diagnosis of PCOS. All females identified as women. Women with PCOS were significantly younger (p \u3c 0.001) and were more likely to endorse migraines (p \u3c 0.007) and loss of control (LOC) eating episodes (\u3c 0.001) since undergoing surgery. Additionally, 47.8% of women with PCOS endorsed clinically significant anxiety, compared to 25.7% of women without PCOS (p = 0.03). There were no differences in other demographic, psychiatric, or medical characteristics.
CONCLUSION: Despite the low prevalence of PCOS diagnoses in the four years after bariatric surgery, this subpopulation may be particularly susceptible to migraines, disinhibited eating behavior, and anxiety, although weight and cardiometabolic outcomes were comparable to those without a diagnosis of PCOS post-surgically
Health Care Use and Expenditures Associated With Cardiac Rehabilitation Among Eligible Medicare Fee-for-Service Beneficiaries
No full textBACKGROUND: Cardiac rehabilitation (CR) can improve cardiovascular health. We identified whether CR participation was associated with fewer subsequent inpatient hospitalizations and emergency department visits and less Medicare and out-of-pocket expenditures, and whether outcomes varied by amount of participation.
METHODS: This retrospective study used Medicare fee-for-service claims data, including beneficiaries with a CR-qualifying event in 2016. Participants attended ≥2 sessions of CR within 365 days of the event. Propensity score matching was used to identify CR-eligible nonparticipants. Difference-in-differences analyses were used to compare differences in outcomes before (2014-2015) and after (2018-2019; 2-year CR period=2016-2017) the CR period between participants and nonparticipants.
RESULTS: We identified 57 668 CR-eligible beneficiaries after matching, with equal numbers of participants and nonparticipants. Nearly 65% of beneficiaries had a percutaneous coronary intervention, 33.5% had an acute myocardial infarction, 17.5% had a coronary artery bypass graft, and 16.8% had a heart valve repair/replacement. Compared with nonparticipants, participants had 47.6 fewer subsequent annual inpatient hospitalizations per 1000 beneficiaries (95% CI, -58.8 to -36.3) and 1352 to -$659). Compared with no participation, medium participation (12-23 sessions), high participation (24-35 sessions), and CR completion (≥36 sessions) were associated with fewer inpatient hospitalizations and lower Medicare expenditures per year.
CONCLUSIONS: CR was associated with fewer subsequent annual inpatient hospitalizations and lower subsequent annual Medicare expenditures. A higher amount of participation was associated with a further reduction in hospitalizations and expenditures. These findings can inform programs and policies that encourage CR participation
Lebrikizumab vs Other Systemic Monotherapies for Moderate-to-Severe Atopic Dermatitis: Network Meta-analysis of Efficacy.
No full textINTRODUCTION: A systematic literature review and network meta-analysis (NMA) were conducted to compare the short-term efficacy of lebrikizumab to other biologic and Janus kinase (JAK) inhibitor monotherapies approved for moderate-to-severe atopic dermatitis in adults and adolescents.
METHODS: The NMA included randomized, double-blind, placebo-controlled monotherapy phase 2 and 3 trials of biologics (lebrikizumab 250 mg every 2 weeks [Q2W], dupilumab 300 mg Q2W, and tralokinumab 300 mg Q2W) and JAK inhibitors (abrocitinib 100/200 mg daily, baricitinib 2/4 mg daily, and upadacitinib 15/30 mg daily) at approved doses. Efficacy outcomes included the proportions of patients achieving Eczema Area and Severity Index (EASI) improvement, an Investigator Global Assessment of 0 or 1 (IGA 0/1), and a ≥ 4-point improvement in pruritus/itch numeric rating scale score at 12 weeks (abrocitinib) or 16 weeks (other treatments). Itch was also assessed at week 4. A Bayesian NMA employing baseline risk-adjusted random effects models was used to estimate treatment differences.
RESULTS: Twenty-two monotherapy studies involving 8531 patients were included in the NMA. By week 12/16, lebrikizumab had superior odds of achieving IGA 0/1 and itch improvement compared to baricitinib and tralokinumab; similar odds to dupilumab, abrocitinib, and upadacitinib 15 mg; and inferior odds to upadacitinib 30 mg. Additionally, lebrikizumab had a higher probability of improving EASI than baricitinib 2 mg; similar probability to baricitinib 4 mg, tralokinumab, dupilumab, abrocitinib, and upadacitinib 15 mg; and lower probability than upadacitinib 30 mg daily. At week 4, lebrikizumab had superior odds of improving itch compared to tralokinumab; similar odds to baricitinib, dupilumab, and abrocitinib 100 mg; and inferior odds to abrocitinib 200 mg and upadacitinib.
CONCLUSION: Among biologics, lebrikizumab was comparable to dupilumab and superior to tralokinumab in improving response rates at week 16. Upadacitinib 30 mg was the only JAK inhibitor with superior response rates compared to lebrikizumab
The Impact of Percutaneous Coronary Intervention on Echocardiographic Parameters in Patients with Chronic Total Occlusion of the Coronary Arteries with Diverse Left Ventricular Ejection Fractions: A Single-Center Retrospective Study
Get PDFClinical Characteristics and Outcomes of Patients With Rome IV Functional Dyspepsia Who Consume Opioids: A Real-World Study
No full textINTRODUCTION: The prevalence of opioid use and its impact on healthcare outcomes among patients with Rome IV functional dyspepsia (FD) has not been reported in real-world clinical practice in the United Kingdom (UK). The primary aim of this study was to study the prevalence of opioid intake among outpatients diagnosed with Rome IV FD. Secondary aims were to determine (A) the differences in phenotype and healthcare resource utilization between patients who consumed opioids versus non-users, and (B) whether a combination of opioid cessation and a neuromodulator prescription could improve gastrointestinal (GI) symptoms.
METHODOLOGY: Data were collected from consecutive patients diagnosed with FD according to the Rome IV clinical criteria in a single tertiary care neurogastroenterology outpatient clinic in the UK between January 2016 and December 2021. Patients who consumed opioids were provided with opioid cessation advice and prescribed a neuromodulator (the intervention).
RESULTS: One hundred and fifty-six patients were diagnosed with FD and 48 (31%) were taking opioids. In a multivariate logistic regression model (OR, [95% CI]), older age (1.03 [1.004-1.059], p = 0.03), depression and/or anxiety (4.2 [1.4-12.5], p = 0.01), and chronic pain (4.0 [1.8-8.9], p \u3c 0.001) were independently associated with opioid consumption at baseline. At least 44% of patients adhered to opioid cessation advice and, among these persons, 29% reported symptom improvement in response to a neuromodulator. The intervention had a number needed to treat of 5.7 to achieve an improvement in clinical symptoms.
CONCLUSION: Opioid intake in FD is independently associated with older age, depression and/or anxiety, and chronic pain. Encouraging opioid cessation may be an important strategy in the management of FD
Patterns of recurrence among adults diagnosed with screen-detected lung cancer
No full textBACKGROUND: With the recent shift in lung cancer staging towards early-stage disease coinciding with the introduction of lung cancer screening (LCS), little is known if LCS has affected the rate of recurrence and survival in community settings. Our objective was to evaluate variation in the detection and outcomes of recurrent lung cancer stratified by receipt of LCS.
METHODS: Patients aged 55-80 years old diagnosed with stage I-IIIA non-small cell lung cancer (NSCLC) between 1/1/2014 and 12/31/2020 who completed definitive therapy and were considered disease-free were identified. Rates of recurrence were calculated in discrete 12-month intervals and by cumulative incidence. Survival was evaluated by multivariable adjusted Restricted Mean Survival Time (aRMST). Factors associated with recurrence were evaluated by Poisson models.
RESULTS: Among 916 patients meeting study criteria, 708 (77 %) were non-screen-detected and 208 (23 %) were considered screen-detected. The proportion of recurrence between non-screen-detected (22 %) and screen-detected (17 %) was similar (P = 0.11). Recurrence rates during the first and second years after definitive therapy were 10.1 and 4.1 per 100 person-years for the non-screen-detected and 6.0 and 4.5 per 100 person-years for screen-detected, respectively. Two-year cumulative incidence of recurrence was 16.5 % (95 % CI, 13.9 %-19.4 %) for non-screen-detected patients and 13.8 % (95 % CI, 9.3 %-19.0 %) in the screen-detected group. Recurrence-free survival and survival after recurrence were similar between the two groups. Screening status was not associated with the likelihood of recurrence (RR=0.94, 95 % CI, 0.59-1.50).
CONCLUSION: These findings provide evidence of recurrence being a part of the intrinsic nature of disease progression despite mode of detection. Our findings emphasize the need for all patients to receive surveillance and survivorship care after treatment for early-stage NSCLC regardless of mode of detection. Further study with longer follow-up is warranted
Clinical Outcomes With Normothermic Pulsatile Organ Perfusion in Heart Transplantation: A Report From the OCS Heart Perfusion Registry.
No full textBACKGROUND: A preservation system, the Organ Care System (OCS; TransMedics) uses normothermic pulsatile perfusion during organ transport for heart transplantation. This system has demonstrated favorable outcomes in hearts recovered from extended-criteria donors after brain death (DBD) and donors after circulatory death (DCD).
METHODS: The OCS Heart Perfusion Registry collects data on US heart transplantations using the OCS, static cold storage (SCS), or thoracoabdominal normothermic regional perfusion (NRP) and donor hearts recovered from DBD or DCD donors. We analyzed donor and recipient characteristics and posttransplantation outcomes in patients transplanted with OCS donor hearts (either DBD or DCD) compared with SCS hearts, and with OCS hearts from DCD donors compared with those recovered with NRP followed by SCS. Propensity score matching was used in survival analyses to adjust for differences among recipient characteristics.
RESULTS: Between 2021 and 2023, 3225 consecutive heart transplantations enrolled from 56 centers were analyzed in the Heart Perfusion Registry. The OCS was used in 854 of 3225 heart transplantations (26.4%), among which 340 (39.8%) were DBD and 514 (60.2%) were DCD donors, whereas 2174 DBD donors were recovered with SCS and another 197 DCD donors with NRP techniques. The OCS-DBD group experienced a greater number of organ offer refusals before final acceptance (13 versus 6; Wilcoxon rank sum, P\u3c 0.001) and a longer transport distance (667 miles versus 232 miles; Wilcoxon rank sum, P\u3c 0.001) compared with SCS-DBD. Survival at 12 months was similar between the 2 groups (89.9% for OCS-DBD versus 90.6% for SCS-DBD; marginal Cox model, P=0.54). Among the OCS-DCD and SCS-DBD groups, survival at 12 months was also similar (91.0% versus 92.5%, respectively; marginal Cox model, P=0.32). The OCS-DCD and NRP-DCD groups demonstrated similar survival (91.0% versus 91.7%, respectively; log rank, P=0.63), although the transport distance was longer in OCS-DCD compared with DCD with NRP followed by SCS (400 miles versus 223 miles; Wilcoxon rank sum, P\u3c 0.001). By 2023, 90% of all OCS donor management and recovery was performed with dedicated organ recovery teams.
CONCLUSIONS: We demonstrate that real-world implementation of the OCS for DBD donors (using predominantly a dedicated recovery team) is associated with expanded donor criteria, longer transport distance, and excellent posttransplantation outcomes. In OCS-DCD donors, outcomes parallel those of donors recovered with NRP-DCD and compare favorably with DBD donor organs
Cardiac Biomarkers in Patients with Asymptomatic Severe Aortic Stenosis: Analysis from the EARLY TAVR Trial
No full textBACKGROUND: The EARLY TAVR trial demonstrated that early transcatheter aortic valve replacement (TAVR) intervention was superior to clinical surveillance (CS) with delayed TAVR in patients with asymptomatic, severe aortic stenosis (AS). Cardiac biomarkers are associated with maladaptive remodeling, symptom onset, and worse outcomes after TAVR. Whether elevated biomarkers identify asymptomatic patients more likely to benefit from early intervention is unknown.
METHODS: A core laboratory measured N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high sensitivity cardiac troponin T (hs-cTnT). Associations between biomarker levels and risk of the trial primary endpoint (death, stroke, or unplanned cardiovascular hospitalization) and other secondary endpoints were examined with Kaplan-Meier curves and Cox proportional hazard models. Interaction tests were performed to assess whether the treatment effect of early TAVR, compared with CS, differed according to biomarker levels.
RESULTS: Among 901 patients randomized in EARLY TAVR, 798 (89%) had biospecimens measured (median NT-proBNP 287 [145, 601]; median hs-cTnT 14.6 [10.5, 21.0]). Higher levels of NT-proBNP and hs-cTnT were broadly associated with higher event rates for multiple endpoints. In general, there was no significant interaction between baseline biomarkers and treatment group with respect to any composite or individual endpoint examined, although trends broadly demonstrated a greater relative benefit of early TAVR at lower biomarker levels. There was a significant interaction between hs-cTnT and treatment group with respect to death or heart failure hospitalization (HFH) (interaction p=0.04) and HFH alone (interaction p=0.03) such that the relative benefit of early TAVR was greater for patients with normal, rather than elevated, levels of hs-cTnT at baseline. For some endpoints, higher baseline NT-proBNP was associated with numerically greater absolute risk reduction with early TAVR than lower NT-proBNP levels.
CONCLUSIONS: In patients with asymptomatic severe high gradient AS, higher NT-proBNP and hs-cTnT levels were broadly associated with higher event rates as expected. However, the relative benefit of an early TAVR strategy was consistent regardless of baseline biomarker levels and, contrary to our hypothesis, tended to be more pronounced in those with the lowest biomarker levels. These findings suggest limited value for single measurements of these biomarkers to guide the timing of TAVR in asymptomatic patients
Acute Myocardial Infarction and Stage E Shock: Insights From the RECOVER III Study
No full textBACKGROUND: The present analysis reports characteristics and outcomes of Society of Cardiovascular Angiography & Interventions (SCAI) stage E shock patients with acute myocardial infarction with cardiogenic shock (AMICS) undergoing percutaneous coronary intervention (PCI) who improved to stage C or D within 24 hours of Impella support ( responders ) vs those patients who remained in stage E ( nonresponders ).
METHODS: The SCAI shock stage was assigned prior to initiation of Impella, and a second SCAI shock classification was performed within 24 hours of Impella support. SCAI shock stage was assigned independently by 2 reviewers; in cases where there was a discrepancy, a third reviewer adjudicated the stage assignment. Criteria such as a low pH (≤7.1), the need for multiple vasopressors/mechanical circulatory support devices, or the need for cardiopulmonary resuscitation were used to define stage E shock.
RESULTS: Of the 415 RECOVER III patients, 298 presented in stage E shock; 152 (51.1%) were responders and 145 (48.8%) were nonresponders. Kaplan-Meier 30-day survival estimates were 56.9% and 28.6% in responders and nonresponders, respectively (P \u3c .001). In multivariate analysis, fewer inotropic medications during Impella support (P \u3c .0001), more lesions treated (P = .01), Impella support initiated pre-PCI (P = .03), and baseline white blood cell (P = .048) were all significant predictors for responsiveness to therapy.
CONCLUSIONS: Stage E patients who improved to stage C/D within 24 hours of Impella support had significantly better survival than those who remained in stage E. Predictors of responsiveness to therapy were mostly related to shock treatment strategy, and not baseline characteristics. This suggests that whether stage E patients will improve with Impella support is difficult to determine at the time support is initiated, and the SCAI shock stage should be repeated within 24 hours to more accurately determine the prognosis