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Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment.
Get PDFBACKGROUND:
Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR).
OBJECTIVES:
The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial.
METHODS:
MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex.
RESULTS:
A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06).
CONCLUSIONS:
iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.info:eu-repo/semantics/publishedVersio
Outcomes of Single-Operator Cholangioscopy-Guided Lithotripsy in Patients with Difficult Biliary and Pancreatic Stones
Get PDFBACKGROUND AND AIMS:
Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones.
METHODS:
This is a prospective clinical study - conducted at two affiliated university hospitals - of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications.
RESULTS:
Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.info:eu-repo/semantics/publishedVersio
Astenopia Digital: Estudo do Grupo Português de Ergoftalmologia
Get PDFINTRODUCTION:
Given the increasing use of electronic devices, and the increasing number of complaints with its use, we intend to evaluate the prevalence of manifestations of dry eye and ocular fatigue in a population of individuals, who use the computer daily to perform all their professional tasks, as well as to correlate these complaints with the number of hours of digital use as well as their possible improvement with behavioural measures and use of tear drops.
MATERIAL AND METHODS:
A total of 77 individuals (154 eyes) were evaluated on two separate days with a 1-month interval. They completed two questionnaires: OSDI and PEG Eye Fatigue. An objective ocular surface assessment was performed: Schirmer test without anesthetic, DR-1a Dry Eye Monitor™, hyperemia evaluation, lacrimal break up, presence of keratitis and lesions in the conjunctiva, as well as near accommodation point and near convergence point. After the first evaluation, the subjects were divided into two groups: group A ( 2 hours of computer working). Some environmental measures to reduce complaints and recommendation of use of artificial tears were explained to the latter.
RESULTS:
There was a statistically significant difference in the majority of the parameters evaluated in the group B, in relation to the morning period (group A) - tear film (p = 0.032), hyperemia (p < 0.001), BUT (p < 0.001), keratitis (p < 0.001), conjunctival lesion (p = 0.002) and accommodation point (p < 0.001). In the evaluation - one month later - there were no statistically significant differences in any of the parameters analysed in the group A, and in group B there was a decrease in most parameters at the end of that period - Schirmer test (p = 0.005), lacrimal film (p = 0.022), keratitis (p < 0.001), conjunctival lesion (p = 0.005) and fatigue score (p < 0.001).
DISCUSSION:
It was thus possible to show the appearance of ocular fatigue and ocular surface changes with prolonged use of computers (> 2 hours) as well as a significant improvement in symptomatology (subjective assessment) as well as of ocular surface changes (objective evaluation) with the implementation of postural measures, regular breaks and use of lubricants. This is the first study, to the best of our knowledge, of digital asthenopia in which, in addition to the subjective evaluation, the presence of ocular surface modifications (objective assessment) were evaluated and the respective improvement with the aforementioned ergophthalmological measures were evaluated.
CONCLUSION:
This survey highlights the increased overall level of awareness that we need to have to face the rapid and wide-scale changes driven by the emergence of digital technology and, more particularly, its impact on user's vision and posture. We concluded that the longer we use the electronic devices (more than two hours) the more severe the complaints and rates of ocular surface changes are. Environmental and ocular strategies can attenuate or even eliminate the discomfort caused by this syndrome, and increase professional performance and quality of life.info:eu-repo/semantics/publishedVersio
Drug-Induced Aseptic Meningitis Following Spinal Anesthesia.
Get PDFMeningitis is a very uncommon complication of spinal anesthesia, and drug-induced aseptic meningitis (DIAM) is even rarer. We present two cases of DIAM following spinal anesthesia with bupivacaine and ropivacaine, respectively. The patients presented shortly after the procedure with typical meningitis symptoms. Since CSF (cerebrospinal fluid) analysis could not initially exclude bacterial meningitis, they were started on empirical antibiotics. CSF was subsequently found to be negative for viruses and bacteria in both cases, and antibiotics were promptly stopped. Both patients improved rapidly and without neurological sequelae. While it remains a diagnosis of exclusion, it is important to be aware of DIAM as recognition of the condition can lead to shorter admission times and avoid unnecessary use of antibiotics.
LEARNING POINTS:
A diagnosis of DIAM should be considered when a patient who recently underwent spinal anesthesia is admitted with symptoms and CSF compatible with meningitis.Clinical and laboratory findings (including CSF analysis) cannot distinguish between bacterial meningitis and DIAM.A negative CSF culture and rapid recovery confirm the diagnosis and stopping antibiotics at this point is effective.info:eu-repo/semantics/publishedVersio
Reactivation of hepatitis B virus infection during treatment of hepatitis C with direct-acting antivirals
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Urachal Adenocarcinoma: A Case Report with Key Imaging Findings and Radiologic-Pathologic Correlation.
Get PDFUrachal pathologies are rare and can mimic numerous abdominal and pelvic diseases. Differential diagnosis of urachal anomalies can be narrowed down by proper assessment of lesion location, morphology, imaging findings, patient demographics, and clinical history. We report a case of a 60-year-old male, with a history of unintentional weight loss without associated symptoms, who was diagnosed with locally invasive urachal adenocarcinoma. With this article, we pretend to emphasize urachal adenocarcinoma clinical features along with its key imaging findings with radiologic-pathologic correlation.info:eu-repo/semantics/publishedVersio
