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1.
Curr Atheroscler Rep ; 25(12): 965-978, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37975955

RESUMO

PURPOSE OF REVIEW: To summarize selected late-breaking science on cardiovascular (CV) disease prevention presented at the 2023 European Society of Cardiology (ESC) congress. RECENT FINDINGS: The NATURE-PARADOX was a naturally randomized trial that used genetic data from the UK Biobank registry to create "cumulative exposure to low-density lipoprotein-cholesterol (LDL-C)" biomarker and evaluate its association with major CV events regardless of plasma LDL-C levels or age. Safety and efficacy data of inclisiran, a PCSK9-interfering mRNA (PCSK9i) administered subcutaneously twice annually, were presented. Data on two new PCSK9is were presented, recaticimab, an oral drug, and lerodalcibep, a subcutaneous drug with a slightly different architecture than currently available PSCK9is. A phase 1 trial on muvalaplin, an oral lipoprotein (a) inhibitor, was presented. An atherosclerotic CV disease (ASCVD) risk prediction algorithm for the Asian population using SCORE2 data was presented. Long-term follow-up of patients enrolled in the CLEAR outcomes trial showed sustained and more significant ASCVD risk reduction with bempedoic acid in high-risk patients. The late-breaking clinical science at the 2023 congress of the ESC extends the known safety and efficacy data of a PCSK9i with the introduction of new drugs in this class. Using cumulative exposure to LDL-C rather than a single value will help clinicians tailor the LDL-C reduction strategy to individual risk and is an important step towards personalized medicine.


Assuntos
Anticolesterolemiantes , Cardiologia , Doenças Cardiovasculares , Inibidores de Hidroximetilglutaril-CoA Redutases , Humanos , Pró-Proteína Convertase 9/genética , LDL-Colesterol , Doenças Cardiovasculares/epidemiologia , Anticolesterolemiantes/uso terapêutico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico
3.
Biomed Hub ; 7(3): 115-124, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36465803

RESUMO

Introduction: Parenteral prostanoids are the most potent therapies for pulmonary arterial hypertension (PAH) but are associated with complications and lifestyle limitations. Carefully selected stable patients may be considered for a transition from parenteral prostanoids to a more convenient oral regimen. We present our experience transitioning patients on parenteral prostanoids to selexipag on an outpatient basis. Methods: This was a retrospective cohort study of all group 1 PAH patients on parenteral prostanoids who transitioned to selexipag using a standardized outpatient-based protocol. Hospitalization and routine prognostic data were recorded. Results: Fourteen patients were followed for a median of 1,240 (1,052-1,528) days; all were functional class (FC) II (n = 9) or III (n = 5). Thirteen patients completed the transition, including 11 who underwent catheterization 376 (321-735) days after discontinuing parenteral therapy. Three patients had unfavorable transitions requiring reinitiation of parenteral treatment. Overall, pulmonary vascular resistance increased (3.3-4.5 WU, p = 0.01), cardiac index fell (4.0-2.8 L/min/m2, p = 0.01), N-terminal pro-hormone of brain natriuretic peptide worsened (111-205 pg/dL, p = 0.03), but PAH-related hospitalizations improved (27-8, p = 0.02). Cardiac imaging, FC, and 6-min walk distance (6MWD) were unchanged. Patients who failed were older (64 vs. 56 years old) with shorter 6MWD (274 vs. 392 m) and higher REVEAL 2.0 scores (11 vs. 3). Conclusions: Transition from parenteral prostanoids to oral selexipag in carefully selected low-risk patients was well-tolerated in many patients, with up to 5 years of follow-up. Overall, the hemodynamic response to transition is unpredictable and close monitoring, particularly in the first year of follow-up, is recommended. Additional evaluation of potential predictors of success is necessary.

4.
PLoS One ; 17(9): e0269488, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36083893

RESUMO

INTRODUCTION: Lack of awareness for chronic kidney disease (CKD), including end stage kidney disease (ESKD) and their management options is a major impediment to patients being able to select and use home dialysis therapies. While some instruments have been developed to measure CKD awareness, we lack validated instruments to evaluate patients' awareness of ESKD and dialysis modalities. This study is part of multipart project for developing and validating an ESKD-centric disease awareness questionnaire. METHODS: A team of specialty renal care experts developed a 45-items questionnaire encompassing the subdomains of General Kidney Knowledge, CKD Knowledge, and ESKD Knowledge. Item reduction analysis-specifically, calculation of item difficulty and item discrimination index scores-was used to items for further review and potential removal. RESULTS: Index scores were reviewed in conjunction with consideration of theoretical and substantive item content to reduce the number of items in the questionnaire, resulting in a 32-item questionnaire, retaining 5/10 items in the general kidney knowledge subdomain, 14/21 items in the CKD knowledge subdomain, and 13/14 items in the ESKD knowledge subdomain. Retained items ranged from 0.19 to 0.79 on the difficulty index, and from 0.31 to 0.81 on the discrimination index. Scores for percent correct on the reduced questionnaire spanned 0% to 87.5% correct on the full scale, 0% to 100% correct on the General Knowledge subdomain, 0% to 100% on the CKD Knowledge subdomain, and 0% to 92.3% on ESKD Knowledge subdomain. CONCLUSIONS: The questionnaire developed and refined in this study constitutes a patient disease awareness instrument that spans a range of difficulty, and yet shows strong ability to distinguish between patients with varying levels of disease awareness. This study is the first in part of a multistep project to addresses a gap in measuring ESKD specific knowledge. Accurate assessment of patients' disease awareness through a validated instrument can allow identification of knowledge domains leading to positive impacts on their healthcare decisions and improve targeted patient education efforts.


Assuntos
Falência Renal Crônica , Insuficiência Renal Crônica , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/terapia , Diálise Renal , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Inquéritos e Questionários
5.
J Thorac Dis ; 13(3): 1466-1475, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33841939

RESUMO

BACKGROUND: Group 3 pulmonary hypertension (PH) is a common complication in patients with lung diseases but there are currently no FDA-approved therapies. The data is conflicting, but a few small studies suggest potential benefits in using Group 1 PH therapies in these patients, particularly in severe PH with right ventricular (RV) dysfunction. METHODS: A retrospective cohort study of patients with severe Group 3 PH with RV dysfunction who received parenteral prostanoids from 2007-2018 at our institution was undertaken. Severe PH was defined as mean pulmonary arterial pressure (mPAP) ≥35 mmHg or mPAP 25-34 with cardiac index (CI) <2.4 L/min/m2. Routine prognostic studies including N-terminal prohormone of brain natriuretic peptide (NT-proBNP), 6-minute walk distance (6MWD), WHO Functional Class assessment, oxygen requirement, arterial oxygen saturation, right ventricular systolic pressure (RVSP) and right heart catheterization (RHC) pressures, were obtained before initiation of parenteral therapy and at first clinical follow-up. RESULTS: Nine patients were included. Five were female (55.6%) with a median [interquartile range (IQR)] of 69 [54-71] years. Median CI was 1.8 (1.6-2.4) L/min/m2 and median pulmonary vascular resistance (PVR) was 14.7 (10.7-17.1) Wood units (WU). We found no statistically significant improvement in NT-proBNP levels, exercise capacity, or functional class. Resting oxygen requirement worsened from 4 to 6 L/min (P=0.04) and exertional oxygen saturation nadir worsened from 90% to 83% (P=0.01) despite the increase in FiO2 with exertion. Overall results were heterogenous: several patients demonstrated clinical stabilization, with two undergoing lung transplantation and one showing long-term stability with medical therapy. Symptoms remained severe for most: three patients discontinued prostanoid therapy, choosing to pursue hospice care. CONCLUSIONS: We found no statistically significant improvement in NT-proBNP levels, exercise capacity, or functional class, while oxygen requirement at rest and oxygen saturation during exertion significantly worsened. Our results suggest that parenteral prostanoids should not generally be considered in the treatment of Group 3 PH patients.

6.
BMJ Case Rep ; 13(6)2020 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-32532906

RESUMO

A 50-year-old woman with a history of kidney transplant presented with 2 days of abdominal pain after 6 months of recurrent streptococcal pharyngitis, fevers, weight loss and a new rash on her chest and back. Her examination was notable for a unilateral tonsillar exudate and 2-3 mm pink papules with a fine scale over her chest and back. CT of the abdomen and chest demonstrated several large lymph nodes, and laboratory investigation revealed new cytopenias and elevated transaminases. Urine antigen testing for Histoplasma capsulatum was negative, but a fungal complement fixation panel was reactive for Histoplasma antibodies. Skin biopsy revealed intracellular organisms consistent with H. capsulatum She underwent treatment with liposomal amphotericin B but due to nephrotoxicity, drug interactions and worsening transaminitis, therapy was changed to itraconazole. The diagnosis and management of disseminated histoplasmosis presents multiple challenges, which are of particular importance in patients with a history of renal transplantation.


Assuntos
Anticorpos Antifúngicos/sangue , Histoplasma , Histoplasmose , Itraconazol/administração & dosagem , Transplante de Rim , Linfadenopatia , Tomografia Computadorizada por Raios X/métodos , Antifúngicos/administração & dosagem , Antígenos de Fungos , Diagnóstico Diferencial , Feminino , Histoplasma/imunologia , Histoplasma/isolamento & purificação , Histoplasmose/sangue , Histoplasmose/diagnóstico , Histoplasmose/fisiopatologia , Histoplasmose/terapia , Humanos , Hospedeiro Imunocomprometido , Transplante de Rim/efeitos adversos , Transplante de Rim/métodos , Linfadenopatia/diagnóstico por imagem , Linfadenopatia/etiologia , Transtornos Linfoproliferativos/diagnóstico , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Radiografia Abdominal/métodos , Radiografia Torácica/métodos , Resultado do Tratamento
7.
BMJ Case Rep ; 13(1)2020 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-31900296

RESUMO

Malignant mesothelioma is an uncommon form of neoplastic transformation of the mesothelial cells that line the serosal surfaces of the body. It most commonly affects the pleura and is often associated with pleural effusions and pleural-based masses. The annual incidence in the United States is only 3300 cases, representing less than 0.3% of all cancers worldwide, although this is likely underestimated. We present a case of diffuse epithelioid malignant pleural mesothelioma in a patient with remote, short-term asbestos exposure complicated by recurrent left-sided hydropneumothoraces and pleural-based invasion of the T12 vertebral body, which represent two rare coexisting complications. This case illustrates the importance of maintaining a broad differential for hydropneumothorax, particularly as the risk factors may be decades removed and the degree of asbestos exposure to induce a malignant mesothelioma may be smaller than has been traditionally thought.


Assuntos
Amianto/efeitos adversos , Hidropneumotórax/cirurgia , Neoplasias Pulmonares/terapia , Mesotelioma/terapia , Neoplasias Pleurais/terapia , Neoplasias Torácicas/terapia , Idoso , Diagnóstico Diferencial , Humanos , Masculino , Mesotelioma Maligno , Invasividade Neoplásica , Neoplasias Torácicas/secundário
8.
PLoS One ; 14(4): e0215091, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30964936

RESUMO

Improvement in Home Dialysis (HoD) utilizations as a mean to improve the patient reported and health services outcomes, has been a long-held goal of the providers and healthcare system in United States. However, measures to improve HoD rates have yielded limited success so far. Lack of patient awareness of chronic kidney disease (CKD) and its management options, is one of the important barriers against patient adoption of HoD. Despite ample evidence that Comprehensive pre-ESERD Patient Education (CPE) improves patient awareness and informed HoD choice, use of CPE among US advanced CKD patients is low. Need for significant resources, lack of validated data showing unequivocal and reproducible benefits, and the lack of validated CPE protocols proven to have consistent efficacy in improving not only patient awareness but also HoD rates in US population, are major limitations deterring adoption of CPE in routine clinical practice. We recently demonstrated that if a structured, protocol based CPE is integrated within the routine nephrology care for patients with advanced CKD, it substantially improves informed HoD choice and utilizations. However, this requires establishing CPE resources within each nephrology practice. Efficacy of a stand-alone CPE model, independent of clinical care, has not been examined till date. In this report we report the efficacy of our structured CPE protocol, delivered outside the realm of routine nephrology care-as a stand-alone patient education program, in a geographically distant region, and show that: when provided opportunity for informed dialysis choice, a majority of advanced CKD patients in US would prefer HoD. We also show that initiating CPE leads to accelerated growth in HoD utilizations and reduces disparities in HoD utilizations, goals for system improvements. Finally, the reproducibility of our structured CPE protocol with consistent efficacy data suggest that initiating such programs at institutional levels has the potential to improve informed dialysis selection and HoD rates across any similar large healthcare institute within US.


Assuntos
Comportamento de Escolha , Hemodiálise no Domicílio/educação , Falência Renal Crônica/terapia , Educação de Pacientes como Assunto , Tomada de Decisões , Atenção à Saúde , Feminino , Hemodiálise no Domicílio/métodos , Hemodiálise no Domicílio/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Estados Unidos
9.
BMJ Case Rep ; 20182018 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-29735493

RESUMO

An 86-year-old woman presented with marked blistering of her left index fingertip and ulceration of the left middle fingertip, with a 2-year history of recurrent blistering and ulceration of her fingers bilaterally. She denied any preceding finger trauma, although she reported frequent gardening. She denied systemic symptoms. Her medical history was significant for a 2-year history of atrial fibrillation on carvedilol, amiodarone and apixaban, and she was a lifetime non-smoker. On admission, she had elevated inflammatory markers but unremarkable autoantibodies. Radiograph of the hand revealed diffuse soft tissue fullness and subtle irregularities at the tuft of the index finger, but all other investigations were unremarkable. The lesion was incised and drained, revealing blood-tinged purulent fluid. Wound biopsy revealed spongiosis with neutrophils, consistent with a diagnosis of blistering distal dactylitis.


Assuntos
Vesícula/microbiologia , Dedos/microbiologia , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/isolamento & purificação , Idoso de 80 Anos ou mais , Vesícula/tratamento farmacológico , Vesícula/patologia , Vesícula/cirurgia , Diagnóstico Diferencial , Drenagem , Feminino , Dedos/patologia , Humanos , Imunocompetência , Recidiva , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/patologia , Infecções Estafilocócicas/cirurgia , Resultado do Tratamento
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