5366 research outputs found
Sort by
Myocardial Fibrosis as a Predictor of Sudden Death in Patients With Coronary Artery Disease.
No full textBACKGROUND
The "gray zone" of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs).
OBJECTIVES
The purpose of this study was to determine whether GZF predicts sudden cardiac death (SCD) and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of left ventricular ejection fractions (LVEFs).
METHODS
In this retrospective study of CAD patients, the presence of myocardial fibrosis on visual assessment (MF) and GZF mass in patients with MF were assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs.
RESULTS
Among 979 patients (mean age [± SD]: 65.8 ± 12.3 years), 29 (2.96%) experienced SCD and 80 (8.17%) met the arrhythmic endpoint over median 5.82 years (interquartile range: 4.1 to 7.3 years). In the whole cohort, MF was strongly associated with SCD (hazard ratio: 10.1; 95% confidence interval [CI]: 1.42 to 1,278.9) and the arrhythmic endpoint (hazard ratio: 28.0; 95% CI: 4.07 to 3,525.4). In competing risks analyses, associations between LVEF 5.0 g was strongly associated with SCD (sHR: 10.8; 95% CI: 3.74 to 30.9) and the arrhythmic endpoint (sHR: 7.40; 95% CI: 4.29 to 12.8). Associations between LVEF <35% and SCD (sHR: 2.62; 95% CI: 1.24 to 5.52) and the arrhythmic endpoint (sHR: 4.14; 95% CI: 2.61 to 6.57) were weaker.
CONCLUSIONS
In CAD patients, MF plus quantified GZF mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter-defibrillators, assessment of MF followed by quantification of GZF mass may be preferable to LVEF
Trajectory of Serum Bilirubin Predicts Spontaneous Recovery in a Real-World Cohort of Patients with Alcoholic Hepatitis.
No full textBACKGROUND AND AIMS
Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments.
METHODS
We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment.
RESULTS
data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin 0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p<0.001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores.
CONCLUSIONS
We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy
Critical care management of the patient with an acute ischaemic stroke.
No full textAcute ischaemic stroke is a leading cause of morbidity and mortality worldwide. In the UK alone, there are more than 100 000 strokes per year, causing 38 000 deaths. While the incidence remains high, there has been significant medical progress in reducing mortality following a stroke. Admission of patients to specialised stroke units has led to an improvement in clinical outcomes, but the role of intensive care is less well defined. This article reviews the current critical care management and neuro-therapeutic options after an acute ischaemic stroke
The challenge of offering potentially curative treatment to patients with esophageal cancer and a history of liver transplantation: A literature review and case report.
No full textBACKGROUND
With survival after liver transplantation continuing to improve, effective and evidence-based treatment of malignancies in this patient group is needed as a matter of urgency. Treatment outcomes for esophageal cancer, a challenging malignancy to treat in otherwise fit and well patients, after liver transplant are rarely reported.
METHODS
A systematic literature review was performed according to the PRISMA guidance to identify studies reporting outcomes of radical esophageal cancer treatment in patients with liver transplant. Management strategies and oncological outcomes were compared with a case managed at our institution.
RESULTS
Six studies were identified for review, and the outcomes of 13 patients were collated. The most common indication for liver transplant was alcohol-related liver disease (62%), and the most common tumor type was adenocarcinoma (54%). Neoadjuvant chemotherapy was delivered safely in 23% of cases in the literature and in the case managed at our institution. The median time from liver transplant to esophagectomy was 46 months, and the majority of patients underwent an Ivor-Lewis esophagectomy. The median follow-up from esophagectomy was 17 months, with a pooled 1-year survival of 77% and recurrence rate of 38%. This was comparable with corresponding rates reported for nontransplanted patients.
CONCLUSION
This case report and systematic review demonstrates that radical treatment of esophageal cancer after liver transplantation is not only technically feasible when managed by expert multidisciplinary teams but that it also improves survival. Routine surveillance of liver transplant patients with evidence of Barrett's preoperatively should be considered and close involvement of appropriate specialists in individual treatment planning is vital to acceptable outcomes
Reporting guidelines for clinical trials of artificial intelligence interventions: the SPIRIT-AI and CONSORT-AI guidelines.
No full textBACKGROUND
The application of artificial intelligence (AI) in healthcare is an area of immense interest. The high profile of 'AI in health' means that there are unusually strong drivers to accelerate the introduction and implementation of innovative AI interventions, which may not be supported by the available evidence, and for which the usual systems of appraisal may not yet be sufficient.
MAIN TEXT
We are beginning to see the emergence of randomised clinical trials evaluating AI interventions in real-world settings. It is imperative that these studies are conducted and reported to the highest standards to enable effective evaluation because they will potentially be a key part of the evidence that is used when deciding whether an AI intervention is sufficiently safe and effective to be approved and commissioned. Minimum reporting guidelines for clinical trial protocols and reports have been instrumental in improving the quality of clinical trials and promoting completeness and transparency of reporting for the evaluation of new health interventions. The current guidelines-SPIRIT and CONSORT-are suited to traditional health interventions but research has revealed that they do not adequately address potential sources of bias specific to AI systems. Examples of elements that require specific reporting include algorithm version and the procedure for acquiring input data. In response, the SPIRIT-AI and CONSORT-AI guidelines were developed by a multidisciplinary group of international experts using a consensus building methodological process. The extensions include a number of new items that should be reported in addition to the core items. Each item, where possible, was informed by challenges identified in existing studies of AI systems in health settings.
CONCLUSION
The SPIRIT-AI and CONSORT-AI guidelines provide the first international standards for clinical trials of AI systems. The guidelines are designed to ensure complete and transparent reporting of clinical trial protocols and reports involving AI interventions and have the potential to improve the quality of these clinical trials through improvements in their design and delivery. Their use will help to efficiently identify the safest and most effective AI interventions and commission them with confidence for the benefit of patients and the public
Systematic Review and Meta-Analysis of Wound Adjuncts for the Prevention of Groin Wound Surgical Site Infection in Arterial Surgery.
No full textOBJECTIVE
Groin incision surgical site infections (SSIs) following arterial surgery are common and are a source of considerable morbidity. This review evaluates interventions and adjuncts delivered immediately before, during, or after skin closure, to prevent SSIs in patients undergoing arterial interventions involving a groin incision.
DATA SOURCES
MEDLINE, EMBASE, and CENTRAL databases were searched.
REVIEW METHODS
This review was undertaken according to established international reporting guidelines and was registered prospectively with the International prospective register of systematic reviews (CRD42020185170). The MEDLINE, EMBASE, and CENTRAL databases were searched using pre-defined search terms without date restriction. Randomised controlled trials (RCTs) and observational studies recruiting patients with non-infected groin incisions for arterial exposure were included; SSI rates and other outcomes were captured. Interventions reported in two or more studies were subjected to meta-analysis.
RESULTS
The search identified 1 532 articles. Seventeen RCTs and seven observational studies, reporting on 3 747 patients undergoing 4 130 groin incisions were included. A total of seven interventions and nine outcomes were reported upon. Prophylactic closed incision negative pressure wound therapy (ciNPWT) reduced groin SSIs compared with standard dressings (odds ratio [OR] 0.34, 95% CI 0.23 - 0.51; p < .001, GRADE strength of evidence: moderate). Local antibiotics did not reduce groin SSIs (OR 0.60 95% CI 0.30 - 1.21 p = .15, GRADE strength: low). Subcuticular sutures (vs. transdermal sutures or clips) reduced groin SSI rates (OR 0.33, 95% CI 0.17 - 0.65, p = .001, GRADE strength: low). Wound drains, platelet rich plasma, fibrin glue, and silver alginate dressings did not show any significant effect on SSI rates.
CONCLUSION
There is evidence that ciNPWT and subcuticular sutures reduce groin SSI in patients undergoing arterial vascular interventions involving a groin incision. Local antibiotics did not reduce groin wound SSI, although the strength of this evidence is lower. No other interventions demonstrated a significant effect
PD-1 is imprinted on cytomegalovirus-specific CD4+ T cells and attenuates Th1 cytokine production whilst maintaining cytotoxicity.
No full textPD-1 is expressed on exhausted T cells in cancer patients but its physiological role remains uncertain. We determined the phenotype, function and transcriptional correlates of PD-1 expression on cytomegalovirus-specific CD4+ T cells during latent infection. PD-1 expression ranged from 10-85% and remained stable over time within individual donors. This 'setpoint' was correlated with viral load at primary infection. PD-1+ CD4+ T cells display strong cytotoxic function but generate low levels of Th1 cytokines which is only partially reversed by PD-1 blockade. TCR clonotypes showed variable sharing between PD-1+ and PD-1- CMV-specific cells indicating that PD-1 status is defined either during T cell priming or subsequent clonal expansion. Physiological PD-1+ CD4+ T cells therefore display a unique 'high cytotoxicity-low cytokine' phenotype and may act to suppress viral reactivation whilst minimizing tissue inflammation. Improved understanding of the physiological role of PD-1 will help to delineate the mechanisms, and potential reversal, of PD-1+ CD4+ T cell exhaustion in patients with malignant disease
Palliative care in pulmonary hypertension associated with congenital heart disease: systematic review and expert opinion.
No full textAIMS
Pulmonary arterial hypertension (PAH) is common amongst patients with congenital heart disease (CHD). It is a severe and complex condition that adversely affects quality of life and prognosis. While quality of life questionnaires are routinely used in clinical pulmonary hypertension practice, little is known on how to interpret their results and manage PAH-CHD patients with evidence of impaired health-related quality of life, especially those with advanced disease and palliative care needs.
METHODS AND RESULTS
We performed a systematic review of studies concerning palliative care for people with PAH-CHD, also reviewing the health-related quality of life literature pertaining to these patients. Of 330 papers identified through initial screening, 17 were selected for inclusion. Underutilization of advance care planning and palliative care resources was common. Where palliative care input was sought, this was frequently late in the course of the disease. No studies provided evidence-based clinical criteria for triggering referral to palliative care, a framework for providing tailored care in this patient group, or how to manage the risk of sudden cardiac death and implantable cardioverter defibrillators in advanced PAH-CHD. We synthesize this information into eight important areas, including the impact of PAH-CHD on quality of life, barriers to and benefits of palliative care involvement, advance care planning discussions, and end-of-life care issues in this complex patient group, and provide expert consensus on best practice in this field.
CONCLUSIONS
This paper presents the results of a systematic review and expert statements on the preferred palliative care strategy for patients with PAH-CHD
History of sunscreen: An updated view.
No full textBACKGROUND
With the global sunscreen market expected to reach $24.4 billion worldwide by 2029, this demonstrates the increasing awareness of the damaging effects of sunlight. Sunscreen has been gradually evolving, and new photoprotective ingredients are continuing to be produced in response to growing scientific evidence on the effect of solar radiation on the skin.
AIMS
This literature review aims to provide an updated view of the history of sunscreens.
METHODS
A literature search was conducted with the keywords "Sunscreen, history, regulation, ultraviolet A, ultraviolet B, visible light" from PubMed, Medline, and online search engines.
RESULTS
Humankind has always found ways to provide photoprotection since 4000BC. Only in the last century, evidence-based sunscreens have existed. The first ultraviolet B filters were produced in 1928, its evidence of efficacy and safety discovered in 1956 and development of sun protection factor in 1974. Similarly, sunscreen containing ultraviolet A filters was released in 1980 and the ultraviolet A star rating system developed in 1992. Regulatory bodies for sunscreen were introduced in the 1970s and have sought to review the safety and efficacy of ingredients. With the rising number of researches on the effects of visible light on hyperpigmentation over the past decade, the need for photoprotection beyond ultraviolet has been increasing.
CONCLUSION
To provide consumers with evidence-based sunscreen, challenges remain in acquiring further evidence, regulation, and rating systems
