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OBJECTIVES: To synthesize the available evidence regarding the outcomes associated with nonoperative management, open repair, and endovascular repair of thoracic aortic transection. METHODS: We searched electronic databases (MEDLINE, EMBASE Cochrane, Web of Science, and Scopus) for studies that enrolled patients with aortic transection and measured the outcomes of interest. Two reviewers determined study eligibility and extracted data. We estimated the event rate associated with the different approaches from case series and the relative risk from comparative studies. Estimates from each study were pooled using the random effects model. RESULTS: We found 139 studies that fulfilled the inclusion criteria, the majority of which were noncomparative surgical case series, retrospective, and none were randomized. Studies included 7768 patients, the majority of which were males. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair and nonoperative management (9%, 19%, and 46%, respectively, P < .01). No significant difference in event rate across the three groups was noted for the outcomes of anterior stroke, posterior stroke, or any stroke. The risk of spinal cord ischemia and end-stage renal disease were higher in open repair compared with the other 2 groups (9% vs 3% and 3%, P = .01 for spinal cord ischemia and 8% vs 5% and 3%, P = .01 for end-stage renal disease). Compared with endovascular repair, open repair was associated with an increased risk of graft infection and systemic infections. Meta-analyses of comparative studies demonstrated that compared with open repair, endovascular repair is associated with reduced mortality and spinal cord ischemia (relative risk, 0.61; 95% confidence interval, 0.46-0.80; and relative risk, 0.34; 95% confidence interval, 0.16-0.74; respectively). Inferences are limited by methodological quality, survival, and publication biases. CONCLUSIONS: Very low-quality evidence suggests that, compared with open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, and graft and systemic infections. Nonoperative management is associated with the least favorable outcomes.
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Aorta Torácica/lesiones , Investigación sobre la Eficacia Comparativa , Evaluación de Resultado en la Atención de Salud , Procedimientos Quirúrgicos Vasculares , Heridas no Penetrantes/terapia , Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Femenino , Humanos , Fallo Renal Crónico/epidemiología , Masculino , Traumatismo Múltiple/terapia , Complicaciones Posoperatorias/epidemiología , Isquemia de la Médula Espinal/epidemiología , Heridas no Penetrantes/cirugíaRESUMEN
Background: Classic Takotsubo cardiomyopathy has been described as transient apical dyskinesia following major stress that is believed to be related to catecholamine surges. Atypical variants have been described, including the rarer reverse Takotsubo cardiomyopathy. Discrepant gradients of the beta-2 adrenoceptors are thought to determine the different anatomic variants. Case Report: A 43-year-old female presented with chest pain and a mild troponin elevation. Echocardiography and coronary angiography were consistent with stress-induced apical Takotsubo cardiomyopathy. Eight months later, the patient was admitted with a similar presentation; however, workup revealed stress-induced reverse Takotsubo cardiomyopathy. Conclusion: Recurrent Takotsubo cardiomyopathy involving different anatomic regions of the left ventricle is a rare phenomenon yet appears to be similar to typical Takotsubo cardiomyopathy in presentation and hospital course. Chronic therapy with beta blockers and angiotensin-converting enzyme inhibitors did not prevent a recurrence in this patient, suggesting that optimum treatment needs to be determined. Takotsubo cardiomyopathy affecting different myocardial segments may recur in the same patient, implying that the adrenoceptor distribution theory needs further refinement.
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BACKGROUND: Thirty-day readmission rates have become a publicly reported quality performance measure for congestive heart failure, acute myocardial infarction, and percutaneous coronary intervention (PCI). However, little is known regarding the factors associated with 30-day readmission after PCI. METHODS: To assess the demographic, clinical, and procedural factors associated with 30-day readmission rates after PCI, we identified 15, 498 PCI hospitalizations (elective or for acute coronary syndromes) from January 1998 through June 2008 at Saint Marys Hospital, Rochester, Minnesota. All were included in this analysis. Multivariate logistic regression models were used to estimate the adjusted association between demographic, clinical, and procedural variables and 30-day readmission. The association between 30-day readmission and 1-year mortality was estimated using Cox proportional hazards models with readmission as a time-dependent covariate and by using landmark analysis. The main outcome measures were all-cause 30-day readmission to any hospital following PCI and 1-year mortality. RESULTS: Overall, 9.4% of PCIs (n = 1459) were readmitted, and 0.68% of PCIs (n = 106) resulted in death within 30 days after discharge. After multivariate analysis, female sex, Medicare insurance, having less than a high school education, unstable angina, cerebrovascular accident or transient ischemic attack, moderate to severe renal disease, chronic obstructive pulmonary disease, peptic ulcer disease, metastatic cancer, and a length of stay of more than 3 days were associated with an increased risk of 30-day readmission after PCI. Thirty-day readmission after PCI was associated with a higher risk of 1-year mortality (adjusted hazard ratio, 1.38; 95% CI, 1.08-1.75; P = .009). CONCLUSIONS: Nearly 1 in 10 patients undergoing PCI were readmitted within 30 days. Thirty-day readmission after PCI was associated with a higher risk of 1-year mortality.
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Angioplastia Coronaria con Balón/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/terapia , Anciano , Angina Inestable/epidemiología , Angioplastia Coronaria con Balón/mortalidad , Puente de Arteria Coronaria , Escolaridad , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Humanos , Ataque Isquémico Transitorio/epidemiología , Enfermedades Renales/epidemiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Medicare , Análisis Multivariante , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Metástasis de la Neoplasia , Úlcera Péptica/epidemiología , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Sistema de Registros , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Estados Unidos/epidemiologíaRESUMEN
CONTEXT: Vitamin D affects bone and muscle health and likely reduces the risk of falls in the elderly. OBJECTIVE: The aim of this systematic review is to summarize the existing evidence on vitamin D use and the risk of falls. DATA SOURCES: We searched electronic databases from inception through August 2010. STUDY SELECTION: Eligible studies were randomized controlled trials in which the intervention was vitamin D and the incidence of falls was reported. DATA EXTRACTION: Reviewers working in duplicate and independently extracted study characteristics, quality, and outcomes data. DATA SYNTHESIS: Odds ratio and associated 95% confidence interval were estimated from each study and pooled using the random effects model. RESULTS: We found 26 eligible trials of moderate quality that enrolled 45,782 participants, the majority of which were elderly and female. Vitamin D use was associated with statistically significant reduction in the risk of falls (odds ratio for suffering at least one fall, 0.86; 95% confidence interval, 0.77-0.96). This effect was more prominent in patients who were vitamin D deficient at baseline and in studies in which calcium was coadministered with vitamin D. The quality of evidence was low to moderate because of heterogeneity and publication bias. CONCLUSIONS: Vitamin D combined with calcium reduces the risk of falls. The reduction in studies without calcium coadministration did not reach statistical significance. The majority of the evidence is derived from trials enrolling elderly women.
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Accidentes por Caídas/estadística & datos numéricos , Vitamina D/fisiología , Vitamina D/uso terapéutico , Anciano , Anciano de 80 o más Años , Calcio de la Dieta/uso terapéutico , Análisis por Conglomerados , Intervalos de Confianza , Femenino , Humanos , Masculino , Estado Nutricional , Oportunidad Relativa , Sesgo de Publicación , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Deficiencia de Vitamina D/complicaciones , Deficiencia de Vitamina D/tratamiento farmacológicoRESUMEN
CONTEXT: Several studies found association between vitamin D levels and hypertension, coronary artery calcification, and heart disease. OBJECTIVE: The aim of this study was to summarize the evidence on the effect of vitamin D on cardiovascular outcomes. DESIGN AND METHODS: We searched electronic databases from inception through August 2010 for randomized trials. Reviewers working in duplicate and independently extracted study characteristics, quality, and the outcomes of interest. Random-effects meta-analysis was used to pool the relative risks (RR) and the weighted mean differences across trials. RESULTS: We found 51 eligible trials with moderate quality. Vitamin D was associated with nonsignificant effects on the patient-important outcomes of death [RR, 0.96; 95% confidence interval (CI), 0.93, 1.00; P = 0.08], myocardial infarction (RR, 1.02; 95% CI, 0.93, 1.13; P = 0.64), and stroke (RR, 1.05; 95% CI, 0.88, 1.25; P = 0.59). These analyses were associated with minimal heterogeneity. There were no significant changes in the surrogate outcomes of lipid fractions, glucose, or diastolic or systolic blood pressure. The latter analyses were associated with significant heterogeneity, and the pooled estimates were trivial in absolute terms. CONCLUSIONS: Trial data available to date are unable to demonstrate a statistically significant reduction in mortality and cardiovascular risk associated with vitamin D. The quality of the available evidence is low to moderate at best.
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Enfermedades Cardiovasculares/sangre , Vitamina D/sangre , Humanos , RiesgoRESUMEN
CONTEXT: Women with primary or secondary adrenal insufficiency report a decreased health-related quality of life (HRQOL) despite traditional adrenal replacement therapy. Dehydroepiandrosterone (DHEA) has been studied as an agent to improve HRQOL in these patients. OBJECTIVE: We sought to conduct a systematic review and meta-analysis of randomized controlled trials of DHEA effects on HRQOL in women with adrenal insufficiency. DATA SOURCES: We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, CINAHL, and PsycInfo) and reference lists of eligible studies through July 2008. STUDY SELECTION: Eligible trials randomly assigned women with primary or secondary adrenal insufficiency to either DHEA or control and measured the effect of treatment on HRQOL. DATA EXTRACTION: Reviewers working independently and in duplicate assessed the methodological quality of trials and collected data on patient characteristics, interventions, and outcomes. DATA SYNTHESIS: We found 10 eligible trials that measured HRQOL and depression, anxiety, and sexual function. Random-effects meta-analysis showed a small improvement in HRQOL in women treated with DHEA compared with placebo [effect size of 0.21; 95% confidence interval, 0.08 to 0.33; inconsistency (I(2)) = 32%]. There was a small beneficial effect of DHEA on depression; effects on anxiety and sexual well-being were also small and not statistically significant. CONCLUSIONS: DHEA may improve, in a small and perhaps trivial manner, HRQOL and depression in women with adrenal insufficiency. There was no significant effect of DHEA on anxiety and sexual well-being. The evidence appears insufficient to support the routine use of DHEA in women with adrenal insufficiency.
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Insuficiencia Suprarrenal/tratamiento farmacológico , Deshidroepiandrosterona/uso terapéutico , Calidad de Vida , Ansiedad/prevención & control , Deshidroepiandrosterona/farmacología , Depresión/prevención & control , Estado de Salud , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Proyectos de Investigación , Conducta Sexual/efectos de los fármacos , Resultado del TratamientoRESUMEN
It has been suggested that certain placental histopathological changes may be useful in predicting the time of death in stillborn fetuses. We retrospectively evaluated 36 placentas from therapeutic terminations in which the time interval between fetal death and delivery was relatively short and well-documented to determine the earliest stillbirth-associated changes and the utility of placental examination in timing death in the second trimester. In each case, termination had been initiated by creating fetal asystole with intracardiac KCl injections. The gestational age ranged from 18-23 wk. The time from asystole to placental delivery range was 2.8-52.0 h. Placental groups were categorized by time intervals from asystole to delivery: I, <12 h [n = 4 (11%)]; II, 12-24 h [n = 15 (42%)]; III, 24-36 h [n = 14 (39%)]; IV, > 36 h [n = 3 (8%)]. Among eight histopathologic changes involving the umbilical cord or chorionic villi evaluated, only three were present in a significant number of cases and also appeared to be the result of stillbirth. Degeneration of cord vascular smooth muscle was present in 33% of umbilical cords in group I, but was seen in 100% of cords in groups II-IV; the extent of these changes increased significantly with increasing time intervals. Intravascular karyorrhexis was present in villous blood vessels in 75, 73, 64, and 100%, respectively, for groups I-IV. Villous blood vessel luminal abnormalities were seen in 25, 7, 21, and 67%, respectively, for groups I-IV. These findings indicate that these are the earliest morphological changes in stillbirth in second trimester placentas, but they cannot be used to accurately predict time of death in the relatively short time intervals evaluated in this study.
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Muerte Fetal/patología , Placenta/patología , Aborto Eugénico , Adulto , Femenino , Humanos , Embarazo , Segundo Trimestre del Embarazo , Estudios Retrospectivos , Factores de TiempoRESUMEN
Ring chromosomes are thought to be the result of breakage in both arms of a chromosome, with fusion of the points of fracture and loss of the distal fragments. Another mechanism of ring formation is believed to be the simple fusion of chromosome ends with preservation of telomeric and subtelomeric sequences. Ring chromosome 13 was first described in 1968 and its incidence estimated at 1 in 58,000 live births. Severe phenotypes associated with large deletions of 13q have been described as "ring chromosome 13 syndrome." Features of the "ring chromosome 13 syndrome" include mental retardation (often severe), growth retardation, microcephaly, facial dysmorphism, and hand, foot or toe abnormalities. We report on a case of a mother and daughter with r(13) and mild phenotypes. Our patient, IA, had chromosome analysis performed at about 4(1/2) years of age due to some developmental delay. This revealed 46,XX, r(13)(p13q34) karyotype with no loss of any chromosomal band. Her mother, EA, was subsequently found to have the same ring 13. IA's maternal grandmother had a normal karyotype while her maternal grandfather was unavailable for testing. Fluorescence in situ hybridization (FISH) analysis showed loss of a specific subtelomeric 13q region in r(13) in the mother. Clinically, IA had macular hyperpigmentation on the chin and mild delay in speech and fine motor skills. EA, 22 years of age, had mild short stature and borderline mental retardation. To our knowledge, this is the first report of a case of familial transmission of r(13). We compare phenotypes of our cases with those from other reported cases of r(13) and discuss the possible mechanism of formation of this ring chromosome.