N-Acetylcysteine to Reduce Mortality for Patients Requiring Cardiac Catheterization or Cardiac Surgery: A Systematic Review and Meta-analysis.

ABSTRACT: Multimers of von Willebrand factor play a critical role in various processes inducing morbidity and mortality in cardiovascular-risk patients. With the ability to reduce von Willebrand factor multimers, N-acetylcysteine (NAC) could reduce mortality in patients undergoing coronary catheterization or cardiac surgery. However, its impact in perioperative period has never been studied so far in regard of its potential cardiovascular benefits. Then, 4 databases were searched for randomized controlled trials that compared in-hospital mortality between an experimental group, with NAC, and a control group without NAC, in patients undergoing coronary catheterization or cardiac surgery. The primary efficacy outcome was in-hospital mortality. Secondary outcomes were the occurrence of thrombotic events, major cardiovascular events, myocardial infarction, and contrast-induced nephropathy. The safety outcome was occurrence of hemorrhagic events. Nineteen studies totaling 3718 patients were included. Pooled analysis demonstrated a reduction of in-hospital mortality associated with NAC: odds ratio, 0.60; 95% confidence interval, 0.39-0.92; P = 0.02. The occurrence of secondary outcomes was not significantly reduced with NAC except for contrast-induced nephropathy. No difference was reported for hemorrhagic events. Subgroup analyses revealed a life-saving effect of NAC in a dose-dependent manner with reduction of in-hospital mortality for the NAC high-dose group, but not for the NAC standard-dose (<3500-mg) group. In conclusion, without being able to conclude on the nature of the mechanism involved, our review suggests a benefit of NAC in cardiovascular-risk patients in perioperative period in terms of mortality and supports prospective confirmatory studies.

Pulmonary Artery Embolization in the Management of Hemoptysis Related to Lung Tumors.

(1) Background: Bronchial artery embolization has been shown to be effective in the management of neoplastic hemoptysis. However, knowledge of pulmonary artery embolization is lacking. The aim of this study was to evaluate the safety and efficacy of pulmonary artery embolization in patients presenting with hemoptysis related to lung tumors. (2) Methods: This retrospective study reviewed all consecutive patients with cancer and at least one episode of hemoptysis that required pulmonary artery embolization from December 2008 to December 2020. The endpoints of the study were technical success, clinical success, recurrence of hemoptysis and complications. (3) Results: A total of 92 patients were treated with pulmonary artery embolization (63.1 years ± 9.9; 70 men). Most patients had stage III or IV advanced disease. Pulmonary artery embolization was technically successful in 82 (89%) patients and clinically successful in 77 (84%) patients. Recurrence occurred in 49% of patients. Infectious complications occurred in 15 patients (16%). The 30-day mortality rate was 31%. At 3 years, the survival rate was 3.6%. Tumor size, tumor cavitation and necrosis and pulmonary artery pseudoaneurysm were significantly associated with recurrence and higher mortality. (4) Conclusions: Pulmonary artery embolization is an effective treatment to initially control hemoptysis in patients with lung carcinoma, but the recurrence rate remains high and overall survival remains poor.

New Histoprognostic Factors to Consider for the Staging of Colon Cancers: Tumor Deposits, Invasive Tumor Infiltration and High-Grade Budding.

Colorectal cancer is a major public health issue due to its high incidence and mortality. It is, therefore, essential to identify histological markers for prognostic purposes and to optimize the therapeutic management of patients. The main objective of our study was to analyze the impact of new histoprognostic factors, such as tumor deposits, budding, poorly differentiated clusters, mode of infiltration, the intensity of inflammatory infiltrate and the type of tumor stroma, on the survival of patients with colon cancer. Two hundred and twenty-nine resected colon cancers were fully histologically reviewed, and survival and recurrence data were collected. Survival was analyzed using Kaplan-Meier curves. A univariate and multivariate Cox model was constructed to identify prognostic factors for overall survival and recurrence-free survival. The median overall survival of the patients was 60.2 months and the median recurrence-free survival was 46.9 months. Overall survival and recurrence-free survival were significantly worse in the presence of isolated tumor deposits (log rank = 0.003 and 0.001, respectively) and for an infiltrative type of tumor invasion (log rank = 0.008 and 0.02, respectively). High-grade budding was associated with a poor prognosis, with no significant difference. We did not find a significant prognostic impact of the presence of poorly differentiated clusters, the intensity of the inflammatory infiltrate or the stromal type. In conclusion, the analysis of these recent histoprognostic factors, such as tumor deposits, mode of infiltration, and budding, could be integrated into the results of pathological reports of colon cancers. Thus, the therapeutic management of patients could be adjusted by providing more aggressive treatments in the presence of some of these factors.

Diabetic kidney disease versus non-diabetic kidney disease in type 2 diabetic patients on dialysis: An observational cohort.

BACKGROUND: All chronic kidney diseases in diabetic patients are not diabetic kidney diseases. The objective was to compare the clinical characteristics, survival and access to transplantation in diabetic patients starting dialysis and classified either as diabetic kidney disease (DKD) or non-diabetic kidney disease in diabetic patients (NDKD). METHODS: We used the nationwide French REIN registry to analyse baseline clinical characteristics at dialysis inception and outcomes defined as kidney transplantation, deaths and their causes. The probability of death or transplantation was analysed using a multivariate Cox model and the Fine and Gray competing for risk model (sdHT). RESULTS: We included 65,136 patients from January 2009 to December 2015 with a median follow-up of 31 months. The cumulative incidence of kidney transplantation over eight years was 46.9% (44.8-48.9) in non-diabetic patients (ND), higher than the 19.3% (17.5-21.2) in the DKD group and 22.2% (18.4-26.7) in the NDKD group. The risk of death was significantly higher in the NDKD group than in the DKD group, even after accounting for the competing risk of transplantation (NDKD/sdHR 1.22; 95%CI 1.18-1.27; p < 0.005 vs. DKD/sdHR 1.12; 95%CI 1.08-1.16; p < 0.005 with adjustment for age, sex, major adverse cardiovascular events, cancer and chronic respiratory failure, compared to ND). CONCLUSIONS: In diabetic patients starting dialysis, patients in the DKD group had reduced access to kidney transplantation. NDKD patients had a higher risk of mortality than DKD. The distinction between DKD and NDKD should be accounted for in the plan of care of diabetic patients starting dialysis.

Evaluation of the 3-minute chair rise test as part of preoperative evaluation for patients with non-small cell lung cancer.

BACKGROUND: Peak oxygen uptake ( V˙O2peak ) measured by a cardiopulmonary exercise test (CPX) is the gold-standard for predicting surgical risk in patients with non-small cell lung cancer (NSCLC). The 3-minute chair rise test (3CRT) is a simple test requiring minimal resources. This study aimed to determine the ability of 3CRT to predict V˙O2peak in patients with NSCLC. METHODS: Retrospective data from CPX and 3CRT carried out in 36 patients with NSCLC between March 2018 and February 2019 were included. A multivariate analysis was undertaken to derive a predictive V˙O2peak equation based on performance on the 3CRT. In addition, sensitivity-specificity analysis was carried out to estimate a threshold 3CRT value for the prediction of V˙O2peak ≥ 15 mL/kg/minute. RESULTS: The following equation was obtained: V˙O2peak predicted = (0.04765 × FEV1) - (0.207 59 × BMI) - (0.115 89 × age) + (0.386 09 × vertical distance) + 16.628 69; r2 = 0.75, P < 0.01. The bias between the V˙O2peak values predicted and measured during CPX was 0.0 ± 1.7 mL/kg/minute (95% limits of agreement [-3.5 to 3.5]). A performance ≥49 chair rises predicted V˙O2peak ≥ 15 mL/kg/minute with a sensitivity of 0.75 and a specificity of 0.81. CONCLUSIONS: The level of error in the prediction of V˙O2peak from 3CRT performance was too great to recommend that 3CRT should replace CPX as the sole measurement of V˙O2peak . Nevertheless, the 3CRT could help to identify those patients that require CPX prior to lung resection surgery for NSCLC, larger prospective study is needed to confirm this hypothesis. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Cardiopulmonary exercise tests can stratify the surgical risk. Prediction of the peak oxygen uptake ( V˙O2peak ) value from the 3CRT yields an unacceptable level of error. However, a performance of 49 chair rises or more during the 3CRT could indicate a V˙O2peak ≥ 15 mL / kg / minute. WHAT THIS STUDY ADDS: The 3CRT is a useful screening tool to determine the necessity for a comprehensive cardiopulmonary exercise test, whose access is limited in clinical practice. It could also allow early screening of patients requiring specific prehabilitation programs.