BACKGROUND There is increasing incidence of alcohol-associated liver disease in females.Despite this recent increased incidence,there is a paucity of research on the clinical course and outcomes of alcohol-associated ...BACKGROUND There is increasing incidence of alcohol-associated liver disease in females.Despite this recent increased incidence,there is a paucity of research on the clinical course and outcomes of alcohol-associated hepatitis(AH)in females compared to males.AIM To assess if there may be sex differences in severity,outcomes,and healthcare utilization for patients hospitalized for AH.METHODS This study used ICD-9-CM and ICD-10-CM codes to retrospectively identify inpatient encounters for AH at the University of Kentucky from 2012-2021 and obtained data on patient demographics and clinical outcomes.Encounters were cohorted by patient sex and differences in patient demographics and clinical outcomes were assessed.Multivariate logistic regression models were constructed to assess risk of mortality,sepsis,and mechanical ventilation during the encounter.RESULTS Of 1386 subjects,511(36.9%)were female and 875(63.1%)were male.Both sexes had similar baseline characteristics of race/ethnicity,discriminant function score,model of end-stage liver disease score,and length of hospital stay.However,the incidence of urinary tract infection,sepsis,and norepinephrine administration was significantly higher for females.Males had a significantly higher incidence of esophageal variceal bleed.On multivariate logistic regression analysis,females had higher odds of encounter sepsis(OR 1.41;95%CI:1.064-1.869)and mechanical ventilation(OR 1.352;95%CI:1.006-1.816).Odds of encounter mortality were significantly increased in encounters with sepsis(OR 2.309;95%CI:1.419-3.757)and mechanical ventilation(OR 9.301;95%CI:5.724-15.114).CONCLUSION This study shows sex-based differences in AH outcomes at the University of Kentucky.Future studies are warranted to assess whether tailoring treatments will improve clinical outcomes in females with AH.展开更多
BACKGROUND:BRASH syndrome(Bradycardia,Renal failure,AV nodal blockade,Shock,and Hyperkalemia)is a recently described clinical entity characterized by synergistic interaction between AV nodal blocking medications and h...BACKGROUND:BRASH syndrome(Bradycardia,Renal failure,AV nodal blockade,Shock,and Hyperkalemia)is a recently described clinical entity characterized by synergistic interaction between AV nodal blocking medications and hyperkalemia.Despite increasing recognition,its clinical characteristics,risk factors,and outcomes remain poorly defined.The rationale of this review is to provide clinicians an upto-date overview of the most commonly encountered risk factors,triggers,clinical pictures,usual lab values,complications and outcomes,via the systemic analysis of currently published cases.METHODS:A systematic review was conducted using MEDLINE,Web of Science,and Cochrane Library databases through December 2024.Case reports,case series,and conference abstracts involving adult patients with BRASH syndrome were included.Data extraction focused on demographics,clinical presentations,laboratory findings,management strategies,and outcomes.RESULTS:Analysis included 131 patients from 111 published cases.Mean age was(71±13)years,with female predominance(58.1%).Hypertension(77.0%),chronic kidney disease(48.4%),and diabetes mellitus(46.7%)were the most common comorbidities.Beta-blockers were the predominant medication(76.5%).Most common presenting symptoms were syncope(17.9%),generalized weakness(16.2%),and altered mental status(11.9%).Mean potassium level was 6.6 mEq/L,with more than half of cases presenting with non-severe hyperkalemia(<6.5 mEq/L).Management often required multimodal therapy,with 50.8% of patients requiring vasopressors and 31.6% requiring hemodialysis.CONCLUSION:This systematic review provides the most comprehensive analysis of BRASH syndrome to date,demonstrating that while potentially serious,outcomes are generally favorable with appropriate recognition and management.The syndrome can develop even with modest hyperkalemia,particularly in elderly patients with multiple comorbidities.Early recognition and systematic management addressing all components of the syndrome appear crucial for optimal outcomes.展开更多
BACKGROUND Liver imaging and transient elastography(TE)are both tools used to assess liver fibrosis and steatosis among people with hepatitis C virus(HCV)infection.However,the diagnostic accuracy of conventional imagi...BACKGROUND Liver imaging and transient elastography(TE)are both tools used to assess liver fibrosis and steatosis among people with hepatitis C virus(HCV)infection.However,the diagnostic accuracy of conventional imaging in detecting fibrosis and steatosis in this patient population remains unclear.AIM To investigate the correlation between steatosis and fibrosis and abnormal findings on liver imaging in patients with HCV.METHODS We conducted a retrospective cross-sectional analysis of patients with HCV at Grady Liver Clinic who had TE exams between 2018-2019.We analyzed the correlation of controlled attenuation parameter and liver stiffness measurement on TE and abnormal findings on liver imaging.Liver imaging findings(hepatic steatosis,increased echogenicity,cirrhosis,and chronic liver disease)were further evaluated for their diagnostic performance in detecting fibrosis(≥F2,≥F3,≥F4)and steatosis(≥S1,≥S2,≥S3).RESULTS Of 959 HCV patients who underwent TE,651 had liver imaging.Higher controlled attenuation parameter scores were observed in patients with abnormal liver findings(P=0.0050),hepatic steatosis(P<0.0001),and increased echogenicity(P<0.0001).Higher liver stiffness measurement values were also noted in those with abnormal liver(P<0.0001)and increased echogenicity(P=0.0026).Steatosis severity correlated with hepatic steatosis(r=0.195,P<0.001)and increased echogenicity(r=0.209,P<0.001).For fibrosis detection,abnormal liver imaging had moderate sensitivity(81.7%)and specificity(70.4%)for cirrhosis(≥F4),while cirrhosis on imaging had high specificity(99.2%)but low sensitivity(18.3%).Increased echogenicity showed high specificity(92.8%)but low sensitivity(20.9%)for steatosis detection.CONCLUSION Liver imaging detects advanced fibrosis and steatosis but lacks early-stage sensitivity.Integrating TE with imaging may improve evaluation in patients with HCV.展开更多
BACKGROUND Giant cell tumor of bone(GCTB)is a rare,locally aggressive neoplasm that should be treated surgically,whenever possible.This treatment approach may be linked with greater morbidity besides functional impair...BACKGROUND Giant cell tumor of bone(GCTB)is a rare,locally aggressive neoplasm that should be treated surgically,whenever possible.This treatment approach may be linked with greater morbidity besides functional impairment.Denosumab is a human monoclonal antibody.Its administration inhibits bone resorption and has become part of the therapeutic armamentarium against GCTB,as it allows local control with a view to downstaging for a more conservative surgical procedure.However,there is no consensus in the literature regarding the optimal denosumab regimen for GCTB.Therefore,a wide discussion of denosumab regimen is necessary.AIM To assess the effectiveness of various therapy protocols employing denosumab in individuals with GCTB.METHODS A broad and systematic literature search was carried out using the PRISMA guidelines.We analyzed studies that reported skeletally mature patients with GCTB regardless of sex or ethnicity treated with denosumab.Articles with fewer than five patients and in languages except Spanish,Portuguese and English were excluded.Statistical analysis with proportion meta-analysis was performed due to the dichotomous nature of the data.RESULTS 1005 articles were screened,of which 26 articles met the inclusion criteria and were selected,totaling 1742 patients,51.8%women and 48.2%men,with an average of 35 years of age.Treatment with denosumab was associated with high rates of clinical benefit(CB)and imaging response(IR),without changing local recurrence rates when compared to patients treated without denosumab,regardless of the therapeutic regimen adopted and the number of doses applied.The adverse events(AE)presented were mostly mild,with the exception of a malignant transformation to osteosarcoma.CONCLUSION Treatment of GCTB with denosumab is effective,showing high rates of CB and IR.The AE that occurred were mostly mild.We found no differences between the articles considering the researched outcomes regardless of the therapeutic regimen adopted.展开更多
Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]S...Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]Subtle cardiac signs may be overshadowed by systemic symptoms of the underlying infectious process.Fever,myalgias,lethargy,symptoms commonly associated with viral syndrome,can mask the life-threatening myocarditis that may be present.In fact,in the United States Myocarditis Treatment Trial,almost 90%of patients reported symptoms consistent with a viral prodrome.[2]Ammirati et al[3]reported that 27%of patients with myocarditis had either reduced left ventricular ejection fraction,ventricular arrhythmias,or low cardiac output.Here,we present a case report,in which handheld point-of-care ultrasound was utilized at the bedside to aid in the critical diagnosis of myocarditis.With the additional information provided through this imaging modality,this patient was able to be transferred to the appropriate tertiary care facility in an expeditious manner and receive possible defi nitive treatment.展开更多
Acetazolamide is the commonly prescribed oral and intravenous carbonic anhydrase inhibitor;over the years,its use in clinical practice has decreased in favor of more recent drugs.However,it is a rather handy drug,whic...Acetazolamide is the commonly prescribed oral and intravenous carbonic anhydrase inhibitor;over the years,its use in clinical practice has decreased in favor of more recent drugs.However,it is a rather handy drug,which can be useful in several clinical settings when managing critically ill patients.The objective of this review is the evaluation of the most recent evidence on the use of acetazolamide in emergency medicine and critical care medicine.Furthermore,the safety profile of this drug has been evaluated.This is a narrative review on the use of acetazolamide in the main contexts in which this drug can be useful in emergency situations for patients with potential critical issues.For the timeline 1999–2024,a search was conducted on the main scientific platforms;resources of greatest relevance for the use of acetazolamide in critical care and emergency medicine were selected.The most common emergency situations in which a critically ill patient could benefit from acetazolamide therapy are acute heart failure,acute mountain sickness,post hypercapnic metabolic alkalosis,idiopathic intracranial hypertension and acute angle-closure glaucoma.In a few cases,however,randomized controlled clinical trials have been conducted.There are also other less solid indications based mostly on experience or retrospective data.Acetazolamide seems to be an overall safe drug;serious side effects are rare and can be avoided by carefully selecting the patients to be treated.Acetazolamide represents a precious resource for emergency physicians and intensivists;critical patients with different conditions can in fact benefit from it;furthermore,acetazolamide is a safe drug if administered to correctly selected patients.展开更多
BACKGROUND Childhood obesity has emerged in the last decades as an important public health problem worldwide.Although relationships between obesity and flatfoot have been shown,no studies have investigated the influen...BACKGROUND Childhood obesity has emerged in the last decades as an important public health problem worldwide.Although relationships between obesity and flatfoot have been shown,no studies have investigated the influence of obesity on arthroereisis outcomes.AIM To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants.METHODS This retrospective study included one hundred and sixty-nine pediatric patients(10-14 years old)who underwent subtalar arthroereisis(PEEK PitStop®device)for severe flexible flatfoot.Exclusion criteria were additional procedures,revision of previous corrective surgeries,rigid flatfoot with severe deformity,and neurologi-cal or post-traumatic flatfoot.Preoperative/postoperative European Foot and Ankle Society(EFAS)and visual analogue scale(VAS)scores were determined;radiographic assessment was conducted on weight-bearing foot X-rays:Kite angle,first metatarsal-talus angle,Meary angle,calcaneal pitch angle and lateral talo-calcaneal angle were analyzed.RESULTS EFAS and VAS scores improved post-operatively in the whole population.Only seven cases with complications were reported.Radiographic assessment revealed an improvement in all angles.Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes:Relationships were reported between BMI and postoperative EFAS/VAS scores,postoperative calcaneal pitch angle,Kite angle,Meary angle and talo-first meta-tarsal angle.CONCLUSION Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children,obesity significantly influences clinical and radiographic outcomes of arthroereisis,and obese children tend to perceive more pain and discomfort.展开更多
Background: The differential diagnosis for intracavitary cardiac masses is limited, typically including vegetations, tumors, or thrombi. Cardiac thrombi can often mimic cardiac tumors on imaging, creating a diagnostic...Background: The differential diagnosis for intracavitary cardiac masses is limited, typically including vegetations, tumors, or thrombi. Cardiac thrombi can often mimic cardiac tumors on imaging, creating a diagnostic challenge. Primary cardiac tumors are rare and usually benign, whereas most cardiac tumors result from metastases, commonly originating from malignancies in the breast, lung, or melanoma. Aim: This report highlights the importance of distinguishing various cardiac masses based on clinical presentations, clinical courses, and radiological features. Case Presentation: We describe two cases of cardiac masses with unique and diverse clinical features. Each case posed significant diagnostic challenges due to their distinct presentations and clinical progressions. Conclusion: These cases underscore the importance of considering both benign and metastatic origins in the differential diagnosis of intracavitary cardiac masses. Accurate differentiation between thrombi and tumors is crucial for appropriate management and treatment.展开更多
Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago.The definition,diagnosis,and management have evolved with new published consensus guidelines and newly approved treatment avail...Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago.The definition,diagnosis,and management have evolved with new published consensus guidelines and newly approved treatment available to pediatricians,enabling a better understanding of this disease and more targeted treatment for patients.We describe the definition,presentation,and diagnosis of eosinophilic esophagitis including management,challenges,and future directions in children.The definition,diagnosis,and management of eosinophilic esophagitis have evolved over the last 50 years.Consensus guidelines and newly approved biologic treatment have enabled pediatricians to better understand this disease and allow for more targeted treatment for patients.We describe the definition,presentation,diagnosis,management,and treatment in addition to the challenges and future directions of eosinophilic esophagitis management in children.展开更多
Takotsubo cardiomyopathy is a heart condition that is widely known to be caused by stress. It presents with symptoms that are similar to a myocardial infarction even though the coronary arteries are clear. This case r...Takotsubo cardiomyopathy is a heart condition that is widely known to be caused by stress. It presents with symptoms that are similar to a myocardial infarction even though the coronary arteries are clear. This case report details the clinical characteristics, diagnostic assessment, and management plan of a 55-year-old male patient with a past medical history of alcoholism who arrived at the emergency department with the typical symptoms of acute pancreatitis. The case demonstrates the progression of Takotsubo cardiomyopathy, which was triggered by acute pancreatitis in the context of alcoholism, and underlines the significance of early detection and management to enhance the patient’s outcomes.展开更多
Background:Hodgkin lymphoma refers to a malignancy of the lymphatic tissue.Extra-nodal Hodgkin lymphoma(ENHL)is a rare variant consisting of Hodgkin lymphoma occurring outside the lymphatic system.Studies investigatin...Background:Hodgkin lymphoma refers to a malignancy of the lymphatic tissue.Extra-nodal Hodgkin lymphoma(ENHL)is a rare variant consisting of Hodgkin lymphoma occurring outside the lymphatic system.Studies investigating the epidemiology associated with ENHL are rare.Methods:618 ENHL cases were analyzed using the National Cancer Institute’s Surveillance,Epidemiology,and End Results(SEER)database(2000–2020).Demographics including sex,race/ethnicity,rural-urban continuum,age group(categorized as adolescent and young adult(AYA)if between years of 15 and 39,and adult if over the age of 40),and living status(alive/deceased)were examined,with survival status as the main outcome.Results:This study included 335 males(54.2%)and 283 females(45.8%).Of this total,47.9%were in the AYA group.In terms of ethnicity the distribution was 12.5%non-Hispanic Black,67.5%non-Hispanic White,5.2%non-Hispanic Asian/Pacific Islander,and 14.9%Hispanic.Bivariate analyses evidenced significant differences in survival by age group with 91.6%in AYA vs.72.4%in adults(P<0.001)alive by the end of the study period.Multivariable analyses identified age as a key predictor of survival,as the AYA patients had a lower odds ratio for death(odds ratio=0.25,P<0.001).In addition,survival outcomes were also impacted by race,with non-Hispanic Blacks showing higher survival probabilities.Regarding treatment,27.0%of patients underwent surgery,with 10.2%receiving post-surgery radiation,reducing odds of mortality(odds ratio=0.32,P=0.046).Conclusion:The background research as such,tends to affirm that these two factors–age and race are quite crucial in the prognosis as well as management of ENHL.Compared to adults,AYA patients had significantly lower odds of death,while non-Hispanic Black individuals exhibited reduced survival probabilities.It should be noted that 27.0%of patients underwent surgery with 10.2%receiving post-operative radiation which led to decrease in mortality rates.Thus,these results reiterate the necessity for tailor-made treatment methods according to demographic characteristics to boost patient outcomes effectively.For better ENHL care,future studies could shed light on these disparities and improve treatment regimens as needed.展开更多
Hepatocellular carcinoma(HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with...Hepatocellular carcinoma(HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with 80%-90% of new cases occurring in the background of cirrhosis. Studies have shown that early diagnosis of HCC through surveillance programs improve prognosis and availability of curative therapies. All patients with cirrhosis and high-risk hepatitis B patients are at risk for HCC and should undergo surveillance. The recommended surveillance modality is abdominal ultrasound(US) given that it is cost effective and noninvasive with good sensitivity. However, US is limited in obese patients and those with non-alcoholic fatty liver disease(NAFLD). With the current obesity epidemic and rise in the prevalence of NAFLD, abdominal computed tomography or magnetic resonance imaging may be indicated as the primary screening modality in these patients. The addition of alpha-fetoprotein to a surveillance regimen is thought to improve the sensitivity of HCC detection.Further investigation of serum biomarkers is needed. Semiannual screening is the suggested surveillance interval. Surveillance for HCC is underutilized and low adherence disproportionately affects certain demographics such as nonCaucasian race and low socioeconomic status.展开更多
Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course ...Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course can be variable,most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly,PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma,hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.展开更多
Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta...Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction(AMI)in the elderly.Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019.The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included.Data from each study were combined using the random-effects,generic inverse variance method of Der Simonian and Laird to calculate hazard ratio(HR),and 95%confidence interval(CI).Results Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects(mean age 75.33-year-old,60.0%male).Frailty status was evaluated using different methods such as Fried Frailty Index.Frailty was statistically associated with increased early mortality in nine studies(pooled HR=2.07,95%CI:1.67-2.56,P<0.001,I^2=41.2%)and late mortality in 11 studies(pooled HR=2.30,95%CI:1.70-3.11,P<0.001,I^2=65.8%).Moreover,frailty was also statistically associated with higher bleeding in 7 studies(pooled HR=1.34,95%CI:1.12-1.59,P<0.001,I^2=4.7%).Conclusion Frailty is strongly and independently associated with bleeding,early and late mortality in elderly with AMI.Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.展开更多
Inflammatory fibroid polyp(IFP) is a rare,idiopathic pseudotumorous lesion of the gastrointestinal tract.While mostly reported as solitary gastric lesions,multiple cases of small bowel IFPs are also reported.It is a d...Inflammatory fibroid polyp(IFP) is a rare,idiopathic pseudotumorous lesion of the gastrointestinal tract.While mostly reported as solitary gastric lesions,multiple cases of small bowel IFPs are also reported.It is a documented cause of intussusception in adults.In the case reports of ileal inflammatory fibroid polyps with intussusception,an emergent presentation with small bowel obstruction has been most often described.Here we depict a case of ileal inflammatory fibroid polyp presenting with chronic intermittent ileocolic intussusception,anemia and weight loss with an endoscopic appearance mimicking necrotic cecal carcinoma.展开更多
BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulat...BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulation treatment have an associated increase rate.GICA-VTE remains a challenging clinical scenario with MB concerns for utilization of direct oral anticoagulants(DOAC),especially with active cancer therapies.AIM To evaluate patient risk factors,effectiveness(VTE)and safety(MB)of DOACs and low molecular weight heparin(LMWH)in patients with active GICA-VTE.METHODS A retrospective chart review of patients receiving DOACs and LMWH with GICA and symptomatic or incidental VTE treated at comprehensive cancer center from November 2013 to February 2017 was performed.Inclusion criteria included active GI cancer diagnosed at any stage or treatment+/-6 mo of VTE diagnosis,whom were prescribed 6 mo or more of DOACs or LMWH.The Chi-squared test was used for overall and the Fisher exact test for pairwise comparisons of the proportions of patients experiencing recurrent VTE and MB events.Odds ratios were used to compare the relative odds of the occurrence of the outcome given exposure to the risk factor.RESULTS A total of 144 patients were prescribed anticoagulation,in which 106 fulfilled inclusion criteria apixaban(27.3%),rivaroxaban(34.9%)and enoxaparin(37.7%),and 38 were excluded.Patients median age was 66.5 years at GICA diagnosis and 67 years at CAVTE event,with 62%males,80%Caucasian,70%stage IV,pancreatic cancer(40.5%),30%Khorana Score(≥3 points),and 43.5%on active chemotherapy.Sixty-four percent of patients completed anticoagulation therapy(range 1 to 43 mo).Recurrent VTE at 6 mo was noted in 7.5%(n=3),6.8%(n=2)and 2.7%(n=1)of patients on enoxaparin,apixaban and rivaroxaban,respectively(all P=NS).MB at 6 mo were 5%(n=2)for enoxaparin,6.8%(n=2)for apixaban and 21.6%(n=8)for rivaroxaban(overall P=0.048;vs LMWH P=0.0423;all other P=NS).Significant predictors of a primary or secondary outcome for all anticoagulation therapies included:Active systemic treatment(OR=5.1,95%CI:1.3-19.3),high Khorana Score[≥3 points](OR=5.5,95%CI:1.7-17.1),active smoker(OR=6.7,95%CI:2.1-21.0),pancreatic cancer(OR=6.8,95%CI:1.9-23.2),and stage IV disease(OR=9.9,95%CI:1.2-79.1).CONCLUSION Rivaroxaban compared to apixaban and enoxaparin had a significantly higher risk of MB on GICA-VTE patients with equivocal efficacy.展开更多
AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus(HCV)/human immunodeficiency virus(HIV) co-infection in an urban HIV clinic.METHODS A retro...AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus(HCV)/human immunodeficiency virus(HIV) co-infection in an urban HIV clinic.METHODS A retrospective cohort study of 40 subjects co-infected with HIV-1 and HCV treated with the fixed-dose combination of ledipasvir and sofosbuvir for 12 wk from 2014 to 2016.All patients included were receiving antiretroviral therapy(ART) with HIV RNA values of 100 copies/m L or fewer regardless of baseline HCV RNA level.The primary end point was a sustained virologic response of HCV at 12 wk(SVR12) after the end of therapy.RESULTS Of the 40 patients enrolled,55% were black,22.5% had been previously treated for HCV,and 25% hadcirrhosis.The patients were on a wide range of ART.Overall,39 patients(97.5%) had a SVR 12 after the end of therapy,including rates of 97.1% in patients with HCV genotype 1 a and 100% in those with HCV genotype 1 b.One patient with HCV genotype 3 a was included and achieved SVR12.Rates of SVR12 were similar regardless of previous treatment or the presence of compensated cirrhosis.Only 1 patient experienced relapse at week 12 following treatment and deep sequencing didn't reveal any resistance associated mutation in the NS5A or NS5B region.Interestingly,7(17.5%) patients who were adherent to ART experienced HIV viral breakthrough which resolved after continuing the same ART regimen.Two(5%) patients experienced HIV-1 virologic rebound due to noncompliance with HIV therapy,which resolved after resuming the same ART regimen.No severe adverse events were observed and no patient discontinued treatment because of adverse events.The most common adverse events included headache(12.5%),fatigue(10%),and diarrhea(2.5%).CONCLUSION This retrospective study demonstrated the high rates of SVR12 of ledipasvir/sofosbuvir on HCV eradication in patients co-infected with HCV and HIV,regardless of HCV baseline levels,HCV treatment history or cirrhosis condition.The oral combination of ledipasvir/sofosbuvir represents a safe and well tolerated HCV treatment option that does not require modification for many of the common HIV ART.Occasional HIV virologic rebound occurred but later resolved without the need to change ART.展开更多
BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital comp...BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services(EMS),ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5minutes(interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes(IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes(IQR=1.30, 22.13); between arrival-at- and departurefrom-patient-location was 13.12 minutes(IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes(IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulancedispatch and arrival-at-patient-location was shorter(5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter(10.78 vs.14.37 minutes, P<0.01).CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.展开更多
文摘BACKGROUND There is increasing incidence of alcohol-associated liver disease in females.Despite this recent increased incidence,there is a paucity of research on the clinical course and outcomes of alcohol-associated hepatitis(AH)in females compared to males.AIM To assess if there may be sex differences in severity,outcomes,and healthcare utilization for patients hospitalized for AH.METHODS This study used ICD-9-CM and ICD-10-CM codes to retrospectively identify inpatient encounters for AH at the University of Kentucky from 2012-2021 and obtained data on patient demographics and clinical outcomes.Encounters were cohorted by patient sex and differences in patient demographics and clinical outcomes were assessed.Multivariate logistic regression models were constructed to assess risk of mortality,sepsis,and mechanical ventilation during the encounter.RESULTS Of 1386 subjects,511(36.9%)were female and 875(63.1%)were male.Both sexes had similar baseline characteristics of race/ethnicity,discriminant function score,model of end-stage liver disease score,and length of hospital stay.However,the incidence of urinary tract infection,sepsis,and norepinephrine administration was significantly higher for females.Males had a significantly higher incidence of esophageal variceal bleed.On multivariate logistic regression analysis,females had higher odds of encounter sepsis(OR 1.41;95%CI:1.064-1.869)and mechanical ventilation(OR 1.352;95%CI:1.006-1.816).Odds of encounter mortality were significantly increased in encounters with sepsis(OR 2.309;95%CI:1.419-3.757)and mechanical ventilation(OR 9.301;95%CI:5.724-15.114).CONCLUSION This study shows sex-based differences in AH outcomes at the University of Kentucky.Future studies are warranted to assess whether tailoring treatments will improve clinical outcomes in females with AH.
文摘BACKGROUND:BRASH syndrome(Bradycardia,Renal failure,AV nodal blockade,Shock,and Hyperkalemia)is a recently described clinical entity characterized by synergistic interaction between AV nodal blocking medications and hyperkalemia.Despite increasing recognition,its clinical characteristics,risk factors,and outcomes remain poorly defined.The rationale of this review is to provide clinicians an upto-date overview of the most commonly encountered risk factors,triggers,clinical pictures,usual lab values,complications and outcomes,via the systemic analysis of currently published cases.METHODS:A systematic review was conducted using MEDLINE,Web of Science,and Cochrane Library databases through December 2024.Case reports,case series,and conference abstracts involving adult patients with BRASH syndrome were included.Data extraction focused on demographics,clinical presentations,laboratory findings,management strategies,and outcomes.RESULTS:Analysis included 131 patients from 111 published cases.Mean age was(71±13)years,with female predominance(58.1%).Hypertension(77.0%),chronic kidney disease(48.4%),and diabetes mellitus(46.7%)were the most common comorbidities.Beta-blockers were the predominant medication(76.5%).Most common presenting symptoms were syncope(17.9%),generalized weakness(16.2%),and altered mental status(11.9%).Mean potassium level was 6.6 mEq/L,with more than half of cases presenting with non-severe hyperkalemia(<6.5 mEq/L).Management often required multimodal therapy,with 50.8% of patients requiring vasopressors and 31.6% requiring hemodialysis.CONCLUSION:This systematic review provides the most comprehensive analysis of BRASH syndrome to date,demonstrating that while potentially serious,outcomes are generally favorable with appropriate recognition and management.The syndrome can develop even with modest hyperkalemia,particularly in elderly patients with multiple comorbidities.Early recognition and systematic management addressing all components of the syndrome appear crucial for optimal outcomes.
文摘BACKGROUND Liver imaging and transient elastography(TE)are both tools used to assess liver fibrosis and steatosis among people with hepatitis C virus(HCV)infection.However,the diagnostic accuracy of conventional imaging in detecting fibrosis and steatosis in this patient population remains unclear.AIM To investigate the correlation between steatosis and fibrosis and abnormal findings on liver imaging in patients with HCV.METHODS We conducted a retrospective cross-sectional analysis of patients with HCV at Grady Liver Clinic who had TE exams between 2018-2019.We analyzed the correlation of controlled attenuation parameter and liver stiffness measurement on TE and abnormal findings on liver imaging.Liver imaging findings(hepatic steatosis,increased echogenicity,cirrhosis,and chronic liver disease)were further evaluated for their diagnostic performance in detecting fibrosis(≥F2,≥F3,≥F4)and steatosis(≥S1,≥S2,≥S3).RESULTS Of 959 HCV patients who underwent TE,651 had liver imaging.Higher controlled attenuation parameter scores were observed in patients with abnormal liver findings(P=0.0050),hepatic steatosis(P<0.0001),and increased echogenicity(P<0.0001).Higher liver stiffness measurement values were also noted in those with abnormal liver(P<0.0001)and increased echogenicity(P=0.0026).Steatosis severity correlated with hepatic steatosis(r=0.195,P<0.001)and increased echogenicity(r=0.209,P<0.001).For fibrosis detection,abnormal liver imaging had moderate sensitivity(81.7%)and specificity(70.4%)for cirrhosis(≥F4),while cirrhosis on imaging had high specificity(99.2%)but low sensitivity(18.3%).Increased echogenicity showed high specificity(92.8%)but low sensitivity(20.9%)for steatosis detection.CONCLUSION Liver imaging detects advanced fibrosis and steatosis but lacks early-stage sensitivity.Integrating TE with imaging may improve evaluation in patients with HCV.
文摘BACKGROUND Giant cell tumor of bone(GCTB)is a rare,locally aggressive neoplasm that should be treated surgically,whenever possible.This treatment approach may be linked with greater morbidity besides functional impairment.Denosumab is a human monoclonal antibody.Its administration inhibits bone resorption and has become part of the therapeutic armamentarium against GCTB,as it allows local control with a view to downstaging for a more conservative surgical procedure.However,there is no consensus in the literature regarding the optimal denosumab regimen for GCTB.Therefore,a wide discussion of denosumab regimen is necessary.AIM To assess the effectiveness of various therapy protocols employing denosumab in individuals with GCTB.METHODS A broad and systematic literature search was carried out using the PRISMA guidelines.We analyzed studies that reported skeletally mature patients with GCTB regardless of sex or ethnicity treated with denosumab.Articles with fewer than five patients and in languages except Spanish,Portuguese and English were excluded.Statistical analysis with proportion meta-analysis was performed due to the dichotomous nature of the data.RESULTS 1005 articles were screened,of which 26 articles met the inclusion criteria and were selected,totaling 1742 patients,51.8%women and 48.2%men,with an average of 35 years of age.Treatment with denosumab was associated with high rates of clinical benefit(CB)and imaging response(IR),without changing local recurrence rates when compared to patients treated without denosumab,regardless of the therapeutic regimen adopted and the number of doses applied.The adverse events(AE)presented were mostly mild,with the exception of a malignant transformation to osteosarcoma.CONCLUSION Treatment of GCTB with denosumab is effective,showing high rates of CB and IR.The AE that occurred were mostly mild.We found no differences between the articles considering the researched outcomes regardless of the therapeutic regimen adopted.
文摘Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]Subtle cardiac signs may be overshadowed by systemic symptoms of the underlying infectious process.Fever,myalgias,lethargy,symptoms commonly associated with viral syndrome,can mask the life-threatening myocarditis that may be present.In fact,in the United States Myocarditis Treatment Trial,almost 90%of patients reported symptoms consistent with a viral prodrome.[2]Ammirati et al[3]reported that 27%of patients with myocarditis had either reduced left ventricular ejection fraction,ventricular arrhythmias,or low cardiac output.Here,we present a case report,in which handheld point-of-care ultrasound was utilized at the bedside to aid in the critical diagnosis of myocarditis.With the additional information provided through this imaging modality,this patient was able to be transferred to the appropriate tertiary care facility in an expeditious manner and receive possible defi nitive treatment.
文摘Acetazolamide is the commonly prescribed oral and intravenous carbonic anhydrase inhibitor;over the years,its use in clinical practice has decreased in favor of more recent drugs.However,it is a rather handy drug,which can be useful in several clinical settings when managing critically ill patients.The objective of this review is the evaluation of the most recent evidence on the use of acetazolamide in emergency medicine and critical care medicine.Furthermore,the safety profile of this drug has been evaluated.This is a narrative review on the use of acetazolamide in the main contexts in which this drug can be useful in emergency situations for patients with potential critical issues.For the timeline 1999–2024,a search was conducted on the main scientific platforms;resources of greatest relevance for the use of acetazolamide in critical care and emergency medicine were selected.The most common emergency situations in which a critically ill patient could benefit from acetazolamide therapy are acute heart failure,acute mountain sickness,post hypercapnic metabolic alkalosis,idiopathic intracranial hypertension and acute angle-closure glaucoma.In a few cases,however,randomized controlled clinical trials have been conducted.There are also other less solid indications based mostly on experience or retrospective data.Acetazolamide seems to be an overall safe drug;serious side effects are rare and can be avoided by carefully selecting the patients to be treated.Acetazolamide represents a precious resource for emergency physicians and intensivists;critical patients with different conditions can in fact benefit from it;furthermore,acetazolamide is a safe drug if administered to correctly selected patients.
文摘BACKGROUND Childhood obesity has emerged in the last decades as an important public health problem worldwide.Although relationships between obesity and flatfoot have been shown,no studies have investigated the influence of obesity on arthroereisis outcomes.AIM To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants.METHODS This retrospective study included one hundred and sixty-nine pediatric patients(10-14 years old)who underwent subtalar arthroereisis(PEEK PitStop®device)for severe flexible flatfoot.Exclusion criteria were additional procedures,revision of previous corrective surgeries,rigid flatfoot with severe deformity,and neurologi-cal or post-traumatic flatfoot.Preoperative/postoperative European Foot and Ankle Society(EFAS)and visual analogue scale(VAS)scores were determined;radiographic assessment was conducted on weight-bearing foot X-rays:Kite angle,first metatarsal-talus angle,Meary angle,calcaneal pitch angle and lateral talo-calcaneal angle were analyzed.RESULTS EFAS and VAS scores improved post-operatively in the whole population.Only seven cases with complications were reported.Radiographic assessment revealed an improvement in all angles.Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes:Relationships were reported between BMI and postoperative EFAS/VAS scores,postoperative calcaneal pitch angle,Kite angle,Meary angle and talo-first meta-tarsal angle.CONCLUSION Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children,obesity significantly influences clinical and radiographic outcomes of arthroereisis,and obese children tend to perceive more pain and discomfort.
文摘Background: The differential diagnosis for intracavitary cardiac masses is limited, typically including vegetations, tumors, or thrombi. Cardiac thrombi can often mimic cardiac tumors on imaging, creating a diagnostic challenge. Primary cardiac tumors are rare and usually benign, whereas most cardiac tumors result from metastases, commonly originating from malignancies in the breast, lung, or melanoma. Aim: This report highlights the importance of distinguishing various cardiac masses based on clinical presentations, clinical courses, and radiological features. Case Presentation: We describe two cases of cardiac masses with unique and diverse clinical features. Each case posed significant diagnostic challenges due to their distinct presentations and clinical progressions. Conclusion: These cases underscore the importance of considering both benign and metastatic origins in the differential diagnosis of intracavitary cardiac masses. Accurate differentiation between thrombi and tumors is crucial for appropriate management and treatment.
文摘Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago.The definition,diagnosis,and management have evolved with new published consensus guidelines and newly approved treatment available to pediatricians,enabling a better understanding of this disease and more targeted treatment for patients.We describe the definition,presentation,and diagnosis of eosinophilic esophagitis including management,challenges,and future directions in children.The definition,diagnosis,and management of eosinophilic esophagitis have evolved over the last 50 years.Consensus guidelines and newly approved biologic treatment have enabled pediatricians to better understand this disease and allow for more targeted treatment for patients.We describe the definition,presentation,diagnosis,management,and treatment in addition to the challenges and future directions of eosinophilic esophagitis management in children.
文摘Takotsubo cardiomyopathy is a heart condition that is widely known to be caused by stress. It presents with symptoms that are similar to a myocardial infarction even though the coronary arteries are clear. This case report details the clinical characteristics, diagnostic assessment, and management plan of a 55-year-old male patient with a past medical history of alcoholism who arrived at the emergency department with the typical symptoms of acute pancreatitis. The case demonstrates the progression of Takotsubo cardiomyopathy, which was triggered by acute pancreatitis in the context of alcoholism, and underlines the significance of early detection and management to enhance the patient’s outcomes.
文摘Background:Hodgkin lymphoma refers to a malignancy of the lymphatic tissue.Extra-nodal Hodgkin lymphoma(ENHL)is a rare variant consisting of Hodgkin lymphoma occurring outside the lymphatic system.Studies investigating the epidemiology associated with ENHL are rare.Methods:618 ENHL cases were analyzed using the National Cancer Institute’s Surveillance,Epidemiology,and End Results(SEER)database(2000–2020).Demographics including sex,race/ethnicity,rural-urban continuum,age group(categorized as adolescent and young adult(AYA)if between years of 15 and 39,and adult if over the age of 40),and living status(alive/deceased)were examined,with survival status as the main outcome.Results:This study included 335 males(54.2%)and 283 females(45.8%).Of this total,47.9%were in the AYA group.In terms of ethnicity the distribution was 12.5%non-Hispanic Black,67.5%non-Hispanic White,5.2%non-Hispanic Asian/Pacific Islander,and 14.9%Hispanic.Bivariate analyses evidenced significant differences in survival by age group with 91.6%in AYA vs.72.4%in adults(P<0.001)alive by the end of the study period.Multivariable analyses identified age as a key predictor of survival,as the AYA patients had a lower odds ratio for death(odds ratio=0.25,P<0.001).In addition,survival outcomes were also impacted by race,with non-Hispanic Blacks showing higher survival probabilities.Regarding treatment,27.0%of patients underwent surgery,with 10.2%receiving post-surgery radiation,reducing odds of mortality(odds ratio=0.32,P=0.046).Conclusion:The background research as such,tends to affirm that these two factors–age and race are quite crucial in the prognosis as well as management of ENHL.Compared to adults,AYA patients had significantly lower odds of death,while non-Hispanic Black individuals exhibited reduced survival probabilities.It should be noted that 27.0%of patients underwent surgery with 10.2%receiving post-operative radiation which led to decrease in mortality rates.Thus,these results reiterate the necessity for tailor-made treatment methods according to demographic characteristics to boost patient outcomes effectively.For better ENHL care,future studies could shed light on these disparities and improve treatment regimens as needed.
文摘Hepatocellular carcinoma(HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with 80%-90% of new cases occurring in the background of cirrhosis. Studies have shown that early diagnosis of HCC through surveillance programs improve prognosis and availability of curative therapies. All patients with cirrhosis and high-risk hepatitis B patients are at risk for HCC and should undergo surveillance. The recommended surveillance modality is abdominal ultrasound(US) given that it is cost effective and noninvasive with good sensitivity. However, US is limited in obese patients and those with non-alcoholic fatty liver disease(NAFLD). With the current obesity epidemic and rise in the prevalence of NAFLD, abdominal computed tomography or magnetic resonance imaging may be indicated as the primary screening modality in these patients. The addition of alpha-fetoprotein to a surveillance regimen is thought to improve the sensitivity of HCC detection.Further investigation of serum biomarkers is needed. Semiannual screening is the suggested surveillance interval. Surveillance for HCC is underutilized and low adherence disproportionately affects certain demographics such as nonCaucasian race and low socioeconomic status.
文摘Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course can be variable,most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly,PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma,hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.
文摘Background Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly.It is related to unfavorable outcomes in various cardiovascular conditions.We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction(AMI)in the elderly.Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019.The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included.Data from each study were combined using the random-effects,generic inverse variance method of Der Simonian and Laird to calculate hazard ratio(HR),and 95%confidence interval(CI).Results Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects(mean age 75.33-year-old,60.0%male).Frailty status was evaluated using different methods such as Fried Frailty Index.Frailty was statistically associated with increased early mortality in nine studies(pooled HR=2.07,95%CI:1.67-2.56,P<0.001,I^2=41.2%)and late mortality in 11 studies(pooled HR=2.30,95%CI:1.70-3.11,P<0.001,I^2=65.8%).Moreover,frailty was also statistically associated with higher bleeding in 7 studies(pooled HR=1.34,95%CI:1.12-1.59,P<0.001,I^2=4.7%).Conclusion Frailty is strongly and independently associated with bleeding,early and late mortality in elderly with AMI.Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.
文摘Inflammatory fibroid polyp(IFP) is a rare,idiopathic pseudotumorous lesion of the gastrointestinal tract.While mostly reported as solitary gastric lesions,multiple cases of small bowel IFPs are also reported.It is a documented cause of intussusception in adults.In the case reports of ileal inflammatory fibroid polyps with intussusception,an emergent presentation with small bowel obstruction has been most often described.Here we depict a case of ileal inflammatory fibroid polyp presenting with chronic intermittent ileocolic intussusception,anemia and weight loss with an endoscopic appearance mimicking necrotic cecal carcinoma.
基金The University of Arizona Hematology and Medical Oncology Fellowship program
文摘BACKGROUND Gastrointestinal cancer(GICA)is associated with a higher incidence of venous thromboembolism(VTE)compared to other solid tumors,moreover,recurrent VTE and major bleeding(MB)complications during anticoagulation treatment have an associated increase rate.GICA-VTE remains a challenging clinical scenario with MB concerns for utilization of direct oral anticoagulants(DOAC),especially with active cancer therapies.AIM To evaluate patient risk factors,effectiveness(VTE)and safety(MB)of DOACs and low molecular weight heparin(LMWH)in patients with active GICA-VTE.METHODS A retrospective chart review of patients receiving DOACs and LMWH with GICA and symptomatic or incidental VTE treated at comprehensive cancer center from November 2013 to February 2017 was performed.Inclusion criteria included active GI cancer diagnosed at any stage or treatment+/-6 mo of VTE diagnosis,whom were prescribed 6 mo or more of DOACs or LMWH.The Chi-squared test was used for overall and the Fisher exact test for pairwise comparisons of the proportions of patients experiencing recurrent VTE and MB events.Odds ratios were used to compare the relative odds of the occurrence of the outcome given exposure to the risk factor.RESULTS A total of 144 patients were prescribed anticoagulation,in which 106 fulfilled inclusion criteria apixaban(27.3%),rivaroxaban(34.9%)and enoxaparin(37.7%),and 38 were excluded.Patients median age was 66.5 years at GICA diagnosis and 67 years at CAVTE event,with 62%males,80%Caucasian,70%stage IV,pancreatic cancer(40.5%),30%Khorana Score(≥3 points),and 43.5%on active chemotherapy.Sixty-four percent of patients completed anticoagulation therapy(range 1 to 43 mo).Recurrent VTE at 6 mo was noted in 7.5%(n=3),6.8%(n=2)and 2.7%(n=1)of patients on enoxaparin,apixaban and rivaroxaban,respectively(all P=NS).MB at 6 mo were 5%(n=2)for enoxaparin,6.8%(n=2)for apixaban and 21.6%(n=8)for rivaroxaban(overall P=0.048;vs LMWH P=0.0423;all other P=NS).Significant predictors of a primary or secondary outcome for all anticoagulation therapies included:Active systemic treatment(OR=5.1,95%CI:1.3-19.3),high Khorana Score[≥3 points](OR=5.5,95%CI:1.7-17.1),active smoker(OR=6.7,95%CI:2.1-21.0),pancreatic cancer(OR=6.8,95%CI:1.9-23.2),and stage IV disease(OR=9.9,95%CI:1.2-79.1).CONCLUSION Rivaroxaban compared to apixaban and enoxaparin had a significantly higher risk of MB on GICA-VTE patients with equivocal efficacy.
文摘AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus(HCV)/human immunodeficiency virus(HIV) co-infection in an urban HIV clinic.METHODS A retrospective cohort study of 40 subjects co-infected with HIV-1 and HCV treated with the fixed-dose combination of ledipasvir and sofosbuvir for 12 wk from 2014 to 2016.All patients included were receiving antiretroviral therapy(ART) with HIV RNA values of 100 copies/m L or fewer regardless of baseline HCV RNA level.The primary end point was a sustained virologic response of HCV at 12 wk(SVR12) after the end of therapy.RESULTS Of the 40 patients enrolled,55% were black,22.5% had been previously treated for HCV,and 25% hadcirrhosis.The patients were on a wide range of ART.Overall,39 patients(97.5%) had a SVR 12 after the end of therapy,including rates of 97.1% in patients with HCV genotype 1 a and 100% in those with HCV genotype 1 b.One patient with HCV genotype 3 a was included and achieved SVR12.Rates of SVR12 were similar regardless of previous treatment or the presence of compensated cirrhosis.Only 1 patient experienced relapse at week 12 following treatment and deep sequencing didn't reveal any resistance associated mutation in the NS5A or NS5B region.Interestingly,7(17.5%) patients who were adherent to ART experienced HIV viral breakthrough which resolved after continuing the same ART regimen.Two(5%) patients experienced HIV-1 virologic rebound due to noncompliance with HIV therapy,which resolved after resuming the same ART regimen.No severe adverse events were observed and no patient discontinued treatment because of adverse events.The most common adverse events included headache(12.5%),fatigue(10%),and diarrhea(2.5%).CONCLUSION This retrospective study demonstrated the high rates of SVR12 of ledipasvir/sofosbuvir on HCV eradication in patients co-infected with HCV and HIV,regardless of HCV baseline levels,HCV treatment history or cirrhosis condition.The oral combination of ledipasvir/sofosbuvir represents a safe and well tolerated HCV treatment option that does not require modification for many of the common HIV ART.Occasional HIV virologic rebound occurred but later resolved without the need to change ART.
文摘BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services(EMS),ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5minutes(interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes(IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes(IQR=1.30, 22.13); between arrival-at- and departurefrom-patient-location was 13.12 minutes(IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes(IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulancedispatch and arrival-at-patient-location was shorter(5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter(10.78 vs.14.37 minutes, P<0.01).CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.
