Prevalence, Predictors, and Outcomes of Prolonged Mechanical Ventilation After Endovascular Stroke Therapy.

BACKGROUND: To investigate the rates, predictors, and outcomes of prolonged mechanical ventilation (≥ 96 h) following endovascular treatment (EVT) of ischemic stroke. METHODS: Hospitalizations with acute ischemic stroke and EVT were identified using validated codes in the National Inpatient Sample (2010-2015). The primary outcome was prolonged mechanical ventilation defined as ventilation ≥ 96 consecutive hours. We compared hospitalizations involving prolonged ventilation following EVT with those that did not involve prolonged ventilation. Propensity score matching was used to adjust for differences between groups. Clinical predictors of prolonged ventilation were assessed using multivariable conditional logistic regression analyses. RESULTS: Among the 34,184 hospitalizations with EVT, 5087 (14.9%) required prolonged mechanical ventilation. There was a decline in overall intubation and prolonged ventilation during the study period. On multivariable analysis, history of heart failure [OR 1.28 (95% CI 1.05-1.57)] and diabetes [OR 1.22 (95% CI 1-1.50)] was independent predictors of prolonged ventilation following EVT. In a sensitivity analysis of anterior circulation stroke only, heart failure [OR 1.3 (95% CI 1.10-1.61)], diabetes [OR 1.25 (95% CI 1.01-1.57)], and chronic lung disease [OR 1.31 (95% CI 1.03-1.66)] were independent predictors of prolonged ventilation. The weighted proportions of in-hospital mortality, post-procedural shock, acute renal failure, and intracerebral hemorrhage were higher in the prolonged ventilation group. CONCLUSIONS: Among a nationally representative sample of hospitalizations, nearly one-in-six patients had prolonged mechanical ventilation after EVT. Heart failure and diabetes were significantly associated with prolonged mechanical ventilation following EVT. Prolonged ventilation was associated with significant increase in in-hospital mortality and morbidity.

Oral Anticoagulants With Dual Antiplatelet Therapy Versus Clopidogrel in Patients After Percutaneous Coronary Intervention: A Meta-Analysis.

BACKGROUND: In patients on oral anticoagulation (OAC), dual antiplatelet therapy (DAPT) is often indicated after percutaneous coronary intervention (PCI). AREAS OF UNCERTAINTY: We sought to investigate the effects of triple antithrombotic therapy (TT) versus dual therapy (DT) with OAC and clopidogrel on all-cause mortality, cardiovascular death, major bleeding, myocardial infarction (MI), stroke, and stent thrombosis. DATA SOURCES: We systematically searched on MEDLINE, EMBASE, and CENTRAL for randomized controlled or cohort studies, which investigated the comparative effects of TT versus DT. We performed a meta-analysis of 6 studies (1 randomized control study and 5 cohort studies). RESULTS: The included studies enrolled 7259 patients; 4630 (63.8%) were on TT and 2629 (36.2%) were on DT. The average follow-up time was 1.4 years. No significant differences were found between TT and DT in all-cause mortality (P = 0.70; I = 64%), stent thrombosis (P = 0.41), myocardial infarction (P = 0.43; I = 0%), stroke (P = 0.36; I = 0%), and major bleeding (P = 0.43; I = 0%). CONCLUSIONS: In patients who are on OAC with vitamin K antagonist and underwent percutaneous coronary intervention, no significant differences were found in mortality, ischemic, and hemorrhagic complications between the patients treated with TT and DT. Thus, tailored treatment based on individual thromboembolic and bleeding risk might be the most reasonable approach in these patients.

Efficacy of Cilostazol in Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis.

OBJECTIVES: Cilostazol, a selective inhibitor of phosphodiesterase 3, may reduce symptomatic vasospasm and improve outcome in patients with aneurysmal subarachnoid hemorrhage considering its anti-platelet and vasodilatory effects. We aimed to analyze the effects of cilostazol on symptomatic vasospasm and clinical outcome among patients with aneurysmal subarachnoid hemorrhage (aSAH). PATIENTS AND METHODS: We searched PubMed and Embase databases to identify 1) prospective randomized trials, and 2) retrospective trials, between May 2009 and May 2017, that investigated the effect of cilostazol in patients with aneurysmal aSAH. All patients were enrolled after repair of a ruptured aneurysm by clipping or endovascular coiling within 72hours of aSAH. fixed-effect models were used to pool data. We used the I2 statistic to measure heterogeneity between trials. RESULTS: Five studies were included in our meta-analysis, comprised of 543 patients with aSAH (cilostazol [n=271]; placebo [n=272], mean age, 61.5years [SD, 13.1]; women, 64.0%). Overall, cilostazol was associated with a decreased risk of symptomatic vasospasm (0.31, 95% CI 0.20 to 0.48; P<0.001), cerebral infarction (0.32, 95% CI 0.20 to 0.52; P <0.001) and poor outcome (0.40, 95% CI 0.25 to 0.62; P<0.001). We observed no evidence for publication bias. Statistical heterogeneity was not present in any analysis. CONCLUSION: Cilostazol is associated with a decreased risk of symptomatic vasospasm and may be clinically useful in the treatment of delayed cerebral vasospasm in patients with aSAH. Our results highlight the need for a large multi-center trial to confirm the observed association.

Hospital teaching status and trascatheter aortic valve replacement outcomes in the United States: Analysis of the national inpatient sample.

BACKGROUND: Evidence suggests that medical service offerings vary by hospital teaching status. However, little is known about how these translate to patient outcomes. We therefore sought to evaluate this gap in knowledge in patients undergoing Transcatheter aortic valve replacement (TAVR) in the United States. METHODS: This study was conducted using the National Inpatient Sample (NIS) in the United States from 2011 to 2014. Teaching status was classified, as teaching vs. nonteaching and endpoints were clinical outcomes, length of stay and cost. Procedure-related complications were identified via ICD-9 coding and analysis was performed via mixed effect model. RESULTS: An estimated 33,790 TAVR procedures were performed in the U.S between 2011 and 2014, out of which 89.3% were in teaching hospitals. Mean (SD) age was 81.4 (8.5) and 47% were females. There was no significant difference between teaching versus nonteaching hospitals in regards to the primary outcome of in-hospital mortality and secondary outcomes of several cardiovascular and other end points except for a high rates of acute kidney injury (AKI) (OR: 1.34 [95% CI, 1.04-1.72]) and lower rate for use of mechanical circulatory support devices in teaching vs. nonteaching centers. The mean length of stay was significantly higher in teaching hospitals (7.7 days) vs. nonteaching hospitals (6.8 days) (P = 0.002) and so was the median cost of hospitalization (USD 50,814 vs. USD 48, 787, P = 0.02) for teaching vs. nonteaching centers. CONCLUSION: Most TAVR related short-term outcomes including all cause in-hospital mortality are about the same in teaching and nonteaching hospitals. However, AKI, length of hospital stay and TAVR related cost were significantly higher in teaching than nonteaching hospitals. There was more use of mechanical circulatory support in nonteaching than teaching hospitals.

Long (>12 Months) and Short (<6 Months) Versus Standard Duration of Dual Antiplatelet Therapy After Coronary Stenting: A Systematic Review and Meta-Analysis.

Dual antiplatelet therapy (DAPT) is recommended for 6-12 months after drug-eluting stent (DES) implantation to prevent ischemic events and late stent thrombosis. The optimal duration of DAPT has not been established. We performed a meta-analysis of the comparative effects of short and long versus standard duration DAPT duration on adverse cardiovascular and major bleeding. We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with a different duration of DAPT. We included studies that provided data on DES selection, DAPT regimen and duration, and incidence of the selected endpoints at the end of the follow-up period. We identified 5 prospective randomized studies comparing short versus standard duration DAPT and 3 comparing long versus standard duration DAPT with a total of 28,343 patients. Short-term DAPT has similar incidence of stent thrombosis, MI, and death compared to standard duration DAPT, whereas major bleeding was significantly lower in short duration DAPT. Long-term DAPT was associated with lower rates of stent thrombosis and MI but significantly increased major bleeding and all-cause mortality compared to standard duration DAPT. In this meta-analysis of prospective controlled studies we found that short duration DAPT is safer and as effective as standard duration DAPT in patients with second-generation DES. Extended DAPT is associated with less ischemic events at the expense of high bleeding and mortality rates.

US Medical Schools' Awareness of Their Students Who Smoke, Cessation Programs Available, and the Potential Impact on Residency Match.

INTRODUCTION: Hospital systems are adopting strict nicotine-free policies excluding hiring individuals who smoke, including residents for graduate medical training. This study was conducted to (1) determine medical schools' awareness of these policies, (2) awareness of their students' smoking behaviors, and (3) the smoking cessation programs that they provide. METHODS: A survey was developed to learn about the smoking policies of medical schools in the United States: how school leadership estimates smoking prevalence among their students, what those estimates are, and what programs are in place to help students quit smoking. Questions were asked about awareness of policies restricting hiring smokers including applicants for residency training. Opinions were solicited on including smoking status in medical school applications. The online survey was sent to the Deans of student affairs at US medical schools. RESULTS: Of the 160 schools invited to participate, 84 (53%) responded. Most medical schools (92%) are smoke-free and 97% have policies specifically prohibiting tobacco use on campus. Estimates of student smoking prevalence varied from 0% to 34% with a mean of 6%. More than half of schools (52%) had no smoking-cessation programs to help students. Despite recent trends in policies that prohibit smokers from being hired into residency training programs, only 22% were aware of such policies. There were no statistically significant differences by school size, location or category (allopathic, osteopathic, public or private). CONCLUSIONS: Medical schools need to be aware of new hiring policies and take steps to identify and help their students quit smoking to ensure all students can secure residency training upon graduation. IMPLICATIONS: This study draws attention to recent policies that preclude hiring medical students who smoke for post graduate (residency) training. Our study demonstrates a lack of appreciation of these policies by medical school administration in the United States. Our study also provides information on smoking rates of medical students, as well as the prevalence and use of smoking cessation programs available through schools of medicine. The study supports the need for medical schools to identify and aid students who smoke to become nicotine-free so that they can secure residency training positions.

Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases.

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and disability worldwide, yet ASCVD risk factor control and secondary prevention rates remain low. A fixed-dose combination of blood pressure- and cholesterol-lowering and antiplatelet treatments into a single pill, or polypill, has been proposed as one strategy to reduce the global burden of ASCVD. OBJECTIVES: To determine the effect of fixed-dose combination therapy on all-cause mortality, fatal and non-fatal ASCVD events, and adverse events. We also sought to determine the effect of fixed-dose combination therapy on blood pressure, lipids, adherence, discontinuation rates, health-related quality of life, and costs. SEARCH METHODS: We updated our previous searches in September 2016 of CENTRAL, MEDLINE, Embase, ISI Web of Science, and DARE, HTA, and HEED. We also searched two clinical trials registers in September 2016. We used no language restrictions. SELECTION CRITERIA: We included randomised controlled trials of a fixed-dose combination therapy including at least one blood pressure-lowering and one lipid-lowering component versus usual care, placebo, or an active drug comparator for any treatment duration in adults 18 years old or older, with no restrictions on presence or absence of pre-existing ASCVD. DATA COLLECTION AND ANALYSIS: Three review authors independently selected studies for inclusion and extracted the data for this update. We evaluated risk of bias using the Cochrane 'Risk of bias' assessment tool. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI) using fixed-effect models when heterogeneity was low (I2 < 50%) and random-effects models when heterogeneity was high (I2 ≥ 50%). We used the GRADE approach to evaluate the quality of evidence. MAIN RESULTS: In the initial review, we identified nine randomised controlled trials with a total of 7047 participants and four additional trials (n = 2012 participants; mean age range 62 to 63 years; 30% to 37% women) were included in this update. Eight of the 13 trials evaluated the effects of fixed-dose combination (FDC) therapy in populations without prevalent ASCVD, and the median follow-up ranged from six weeks to 23 months. More recent trials were generally larger with longer follow-up and lower risk of bias. The main risk of bias was related to lack of blinding of participants and personnel, which was inherent to the intervention. Compared with the comparator groups (placebo, usual care, or active drug comparator), the effects of the fixed-dose combination treatment on mortality (FDC = 1.0% versus control = 1.0%, RR 1.10, 95% CI 0.64 to 1.89,  I2 = 0%, 5 studies, N = 5300) and fatal and non-fatal ASCVD events (FDC = 4.7% versus control = 3.7%, RR 1.26, 95% CI 0.95 to 1.66, I2 = 0%, 6 studies, N = 4517) were uncertain (low-quality evidence). The low event rates for these outcomes and indirectness of evidence for comparing fixed-dose combination to usual care versus individual drugs suggest that these results should be viewed with caution. Adverse events were common in both the intervention (32%) and comparator (27%) groups, with participants randomised to fixed-dose combination therapy being 16% (RR 1.16, 95% CI 1.09 to 1.25, 11 studies, 6906 participants, moderate-quality evidence) more likely to report an adverse event . The mean differences in systolic blood pressure between the intervention and control arms was -6.34 mmHg (95% CI -9.03 to -3.64, 13 trials, 7638 participants, moderate-quality evidence). The mean differences (95% CI) in total and LDL cholesterol between the intervention and control arms were -0.61 mmol/L (95% CI -0.88 to -0.35, 11 trials, 6565 participants, low-quality evidence) and -0.70 mmol/L (95% CI -0.98 to -0.41, 12 trials, 7153 participants, moderate-quality evidence), respectively. There was a high degree of statistical heterogeneity in comparisons of blood pressure and lipids (I2 ≥ 80% for all) that could not be explained, so these results should be viewed with caution. Fixed-dose combination therapy improved adherence to a multidrug strategy by 44% (26% to 65%) compared with usual care (4 trials, 3835 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS: The effects of fixed-dose combination therapy on all-cause mortality or ASCVD events are uncertain. A limited number of trials reported these outcomes, and the included trials were primarily designed to observe changes in ASCVD risk factor levels rather than clinical events, which may partially explain the observed differences in risk factors that were not translated into differences in clinical outcomes among the included trials. Fixed-dose combination therapy is associated with modest increases in adverse events compared with placebo, active comparator, or usual care but may be associated with improved adherence to a multidrug regimen. Ongoing, longer-term trials of fixed-dose combination therapy will help demonstrate whether short-term changes in risk factors might be maintained and lead to expected differences in clinical events based on these changes.

Longitudinal systolic strain profiles and outcomes in peripartum cardiomyopathy.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure that develops in the last month of pregnancy or within 5 months of delivery. Longitudinal systolic strain has been shown to be impaired in HF patients with both preserved and depressed EF, but has not previously characterized in patients with PPCM. METHODS: The purpose of our study was to investigate the prognosis and recovery in patients with PPCM and use 2D strain imaging to characterize regional and global LV strain in patients with PPCM. Between 2009 and 2014, we identified 47 newly diagnosed patients with PPCM and reduced EF (rPPCM), and 14 patients within the first 4 weeks postpartum who presented with signs and symptoms of HF, and elevated BNP/pro-NT-BNP, but preserved LVEF (pPPCM). We compared the echocardiographic characteristics of the patients with rPPCM and pPPCM with 14 healthy controls. RESULTS: All-cause mortality was 10.6% (5/47) and rehospitalization for HF rate was 31.9% (15/47) at a median follow-up of 12.5 months (range: 1-60 months) in the rPPCM group. In 25.5% (12/47) of patients with rPPCM, there was no recovery or worsening of LVEF, while complete and partial (more than 10% increase but less than 55%) recovery was seen in 57.4% (27/47) and 17% (8/47) of patients, respectively. Global and longitudinal strain (GLS) values were not independent predictors of all-cause mortality or the composite endpoint of all-cause mortality, rehospitalization, or no LVEF recovery in these patients. GLS and segmental strain were significantly lower in the preserved EF group compared with controls but higher compared with PPCM with reduced EF. CONCLUSION: Global and segmental longitudinal strain parameters were significantly reduced in PPCM patients.

Clinical Outcomes of Manual Aspiration Thrombectomy in Patients with Acute Myocardial Infarction: An Updated Meta-Analysis.

BACKGROUND: Recent trials on manual aspiration thrombectomy (AT) in patients with ST-elevation myocardial infarction did not show any significant benefits of AT. AIMS: The present meta-analysis was designed to systematically evaluate prospective randomized trials and assess the effects of AT on all-cause mortality, major cardiovascular events (MACE), target vessel revascularization, myocardial reinfarction, stroke and surrogate myocardial perfusion markers. METHODS AND RESULTS: We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with AT plus primary percutaneous coronary intervention (PCI) versus PCI. We identified 16 prospective randomized trials which enrolled 10,437 controls that underwent conventional PCI and 10,385 patients who underwent PCI with AT with an average follow-up duration of 5.8 months. A significant reduction in MACE with AT was noted (OR 0.91; 95% CI 0.82-0.99; p = 0.04). In spite of improved TIMI 3 and myocardial blush grade 3 rates, AT did not significantly reduce all-cause mortality, target-vessel revascularization and myocardial infarction. Stroke rates were increased with AT. CONCLUSION: The results of this large meta-analysis of 20,822 patients suggest that adjunctive AT to PCI may be associated with improved myocardial reperfusion but limited benefits related to the clinical end-points. © 2015 S. Karger AG, Basel.

Epidemiology of vancomycin-resistant Enterococcus faecalis: a case-case-control study.

Although much is known about vancomycin-resistant (VR) Enterococcus faecium, little is known about the epidemiology of VR Enterococcus faecalis. The predilection of VR E. faecalis to transfer the vancomycin resistance determinant to Staphylococcus aureus is much greater than that of VR E. faecium. The epidemiology of VR E. faecalis has important implications regarding the emergence of vancomycin-resistant S. aureus (VRSA); 8 of 13 reported VRSA cases have been from Michigan. A retrospective case-case-control study was conducted at the Detroit Medical Center, located in southeastern Michigan. Unique patients with VR E. faecalis infection were matched to patients with strains of vancomycin-susceptible (VS) E. faecalis and to uninfected controls at a 1:1:1 ratio. Five hundred thirty-two VR E. faecalis cases were identified and were matched to 532 VS E. faecalis cases and 532 uninfected controls. The overall mean age of the study cohort (n = 1,596) was 63.0 ± 17.4 years, and 747 (46.8%) individuals were male. Independent predictors for the isolation of VR E. faecalis (but not VS E. faecalis) compared to uninfected controls were an age of ≥65 years, nonhome residence, diabetes mellitus, peripheral vascular disease, exposure to cephalosporins and fluoroquinolones in the prior 3 months, and immunosuppressive status. Invasive procedures and/or surgery, chronic skin ulcers, and indwelling devices were risk factors for both VR E. faecalis and VS E. faecalis isolation. Cephalosporin and fluoroquinolone exposures were unique, independent predictors for isolation of VR E. faecalis. A majority of case patients had VR E. faecalis present at the time of admission. Control of VR E. faecalis, and ultimately VRSA, will likely require regional efforts focusing on infection prevention and antimicrobial stewardship.

Epidemiology and risk factors for isolation of Escherichia coli producing CTX-M-type extended-spectrum ß-lactamase in a large U.S. Medical Center.

A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum ß-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially bla(CTX-M-15) type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.

COVID-19 Symptoms Can Prolong Seasonal Flu Infection Symptoms and Recovery Times Among Obese African American Female Population.

According to several studies, obesity increases rates of metabolic syndrome plus other comorbidities like diabetes and cardiovascular diseases. However, little evidence exists as to whether obesity assists in the prolongation of COVID-19 and seasonal flu-like symptoms especially among African American 55-74-year age groups. The purpose of this study is to show that COVID-19 symptoms can prolong recovery times and symptoms of seasonal flu-infected obese African Americans. The aim of the study is to investigate risk factors which include modifiable (i.e., obesity) and non-modifiable (i.e., age, race) effect on prolongation and recovery times for some inpatient COVID-19 and seasonal flu-infected African American from a single hospital in Detroit, MI.

Giant Calcified Left Circumflex Coronary Artery Aneurysm With Complex Coronary-to-Left Ventricular Communication.

A 64-year-old asymptomatic man had an incidental finding of a giant left circumflex artery (LCX) aneurysm, with the distal LCX draining into a confluence receiving terminal portions of all coronary arteries and communicating with the left ventricle through a transmural fistulous tract. We believe that this is the first case reported with such a complex LCX abnormality. (Level of Difficulty: Beginner.).

Higher Obesity Trends Among African Americans Are Associated with Increased Mortality in Infected COVID-19 Patients Within the City of Detroit.

As the city of Detroit raids itself of deaths by shifting from homicides, COVID-19 infection continues to harrow the city with more deaths. From March 19 to May 15, more Detroiters died in 2 months than were killed in 2 years of city homicides. African Americans or Blacks (highest-risk phenotypes) developing COVID-19 infection are more likely to die disproportionately. The confluence of diabetes, hypertension, cardiovascular disease, and the higher prevalence of obesity among Blacks have provided the needed environment for viruses like COVID-19 to thrive and cause serious infections. The purpose of this study is to connect mortality rates from COVID-19 infection to increasing obesity trends among African Americans within the city of Detroit. Statistical analyses were conducted using SPSS ver. 23. Results showed that the highest mortality rates among African Americans occurred more in the obese individuals infected with COVID-19 in the city of Detroit. Out of 1930 deaths from COVID-19 infections, 733 deaths were due to obesity alone in patients without reported comorbid conditions like diabetes, hypertension, and cardiovascular disease. Mortality rate for both male and female African Americans amounted to a total of 11.9%. Thirty-eight percent of reported COVID-19-infected African Americans were obese.

Utilization and safety of extracranial-intracranial bypass surgery in symptomatic steno-occlusive disorders.

OBJECTIVE: The objective of this study was to investigate patterns of utilization and safety of extracranial-intracranial (EC-IC) bypass in patients with symptomatic cerebrovascular steno-occlusive disorders. METHODS: Patients with one of the steno-occlusive conditions (defined as symptomatic intracranial stenosis, extracranial stenosis, and moyamoya disease) were identified using all nonfederal hospitalizations in New York (2005-2014) and Florida (2005-2015). EC-IC bypass surgery was defined using the corresponding procedure codes. Patients were included if there was a prior history of ischemic stroke or transient ischemic attack. Patients were excluded for any preceding diagnosis of cerebral hemorrhage, aneurysm, or trauma. The primary outcome was perioperative ischemic stroke, cerebral hemorrhage, or mortality occurring within 30 days of surgery. We also determined yearly trends for the volume of EC-IC bypass procedures in the study period. RESULTS: Among 346 patients with steno-occlusive disease treated with EC-IC bypass, median age was 52.5 years and 52.5% were female. Rates of EC-IC bypass surgery procedure increased until 2011 and then decreased coinciding with the publication of the Carotid Occlusion Surgery Study trial. Thirty-day event rates of stroke, hemorrhage, or death decreased in patients treated with EC-IC bypass (odds ratio: 0.2, confidence interval: 0.0.4-0.99; P = 0.03) over the 10-year study period. CONCLUSIONS: Overall utilization of EC-IC bypass procedure is relatively low, whereas the 30-day complication rates for patients with steno-occlusive conditions appear to be relatively low and improving. Further research is needed to confirm these findings and to determine the subset of patients who would most likely benefit from this intervention.

A Doppler Echocardiographic Pulmonary Flow Marker of Massive or Submassive Acute Pulmonary Embolus.

BACKGROUND: To date, echocardiography has not gained acceptance as an alternative imaging modality for the detection of massive pulmonary embolism (MPE) or submassive pulmonary embolism (SMPE). The objective of this study was to explore the clinical utility of early systolic notching (ESN) of the right ventricular outflow tract (RVOT) pulsed-wave Doppler envelope in the detection of MPE or SMPE. METHODS: Two hundred seventy-seven patients (mean age, 56 ± 16 years; 52% women), without known pulmonary hypertension, who underwent contrast computed tomographic angiography for suspected pulmonary embolism (PE) and underwent echocardiography were retrospectively studied. Extent of PE was categorized using standard criteria. ESN identified from pulsed-wave spectral Doppler interrogation of the RVOT was analyzed, as were other echocardiography parameters such as McConnell's sign, the "60/60" sign, and acceleration and deceleration times of the RVOT Doppler signal. Analysis was conducted using probability statistics and receiver operating characteristic curve analysis. RESULTS: Of the 277 patients studied, 100 (44%) had MPE or SMPE, 87 (38%) had subsegmental PE, and 90 (39%) did not have PE. ESN was observed in 92% of patients with MPE or SMPE, 2% with subsegmental PE, and in no patients without PE. Interobserver assessment of early systolic notching demonstrated 97% agreement (κ = 0.93, P < .001). Compared with more widely recognized echocardiographic parameters, the area under the receiver operating characteristic curve (AUC) of 0.96 (95% CI, 0.92-0.98) for ESN was superior to that for McConnell's sign (AUC, 0.75; 95% CI, 0.68-0.80), the 60/60 sign (AUC, 0.74; 95% CI, 0.68-0.79), and RVOT acceleration time ≤ 87 msec (AUC, 0.84; 95% CI, 0.79-0.88), as well as other study Doppler variables, in patients with computed tomography-confirmed MPE or SMPE. CONCLUSIONS: The pulmonary Doppler flow pattern of ESN appears to be a promising noninvasive sign observed frequently in patients with MPE or SMPE. Future prospective study to ascertain diagnostic utility in a broader population is warranted.

Masked hypertension and cardiovascular outcomes: an updated systematic review and meta-analysis.

BACKGROUND: As many as one-third of individuals with normal office blood pressure (BP) are diagnosed with masked hypertension (HTN) based on ambulatory BP measurements (ABPM). Masked HTN is associated with higher risk of sustained HTN (SH) and increased cardiovascular morbidity. METHODS: The present study was designed to systematically review cohort studies and assess the effects of masked HTN compared to normotension and SH on cardiovascular events and all-cause mortality. We systematically searched the electronic databases, such as MEDLINE, PubMed, Embase, and Cochrane for prospective cohort studies, which evaluated participants with office and ambulatory and/or home BP. RESULTS: We included nine studies with a total number of 14729 participants (11245 normotensives, 3484 participants with masked HTN, 1984 participants with white-coat HTN, and 5143 participants with SH) with a mean age of 58 years and follow-up of 9.5 years. Individuals with masked HTN had significantly increased rates of cardiovascular events and all-cause mortality than normotensives and white-coat HTN and had lower rates of cardiovascular events than those with SH (odds ratio 0.61, 95% confidence interval 0.42-0.89; P=0.010; I2=84%). Among patients on antihypertensive treatment, masked HTN was associated with higher rates of cardiovascular events than in those with normotension and white-coat HTN and similar rates of cardiovascular events in those with treated SH. CONCLUSION: Prompt screening of high-risk individuals with home BP measurements and ABPM, the diagnosis of masked HTN, and the initiation of treatment, may mitigate the adverse cardiovascular effects of masked HTN.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis.

BACKGROUND: Endovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA). METHODS: We conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3. RESULTS: A total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0-2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0-2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42). CONCLUSIONS: This meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.