Ankylosing spondylitis: A state of the art factual backbone.

Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects 1% of the general population. As one of the most severe types of spondyloarthropathy, AS affects the spinal vertebrae and sacroiliac joints, causing debilitating pain and loss of mobility. The goal of this review is to provide an overview of AS, from the pathophysiological changes that occur as the disease progresses, to genetic factors that are involved with its onset. Considering the high prevalence in the population, and the debilitating life changes that occur as a result of the disease, a strong emphasis is placed on the diagnostic imaging methods that are used to detect this condition, as well as several treatment methods that could improve the health of individuals diagnosed with AS.

Outcomes and total costs of outpatient vs. inpatient peri-procedural anticoagulation management of mechanical prosthetic heart valve patients.

BACKGROUND/OBJECTIVES: The most cost-effective periprocedural management of patients with mechanical heart valves (MHV) is uncertain. The objective was to compare the effectiveness, safety and costs for inpatient intravenous unfractionated heparin (IVUH) vs. outpatient low molecular weight heparin (LMWH) "bridging" as periprocedural anticoagulation management for MHV patients. METHODS: In a case-cohort study, Olmsted County, MN residents with MHV who received outpatient periprocedural LMWH management (cases) over the 11-year period, 1997-2007, were matched to residents with MHV who received inpatient IVUH periprocedural management on valve location and type, and on procedure type. Patients were followed for 3 months following hospitalization to identify thromboembolism (TE) and major bleeding. Total costs from 30 days before to 90 days after the procedure were determined from the Olmsted County Healthcare Expenditure and Utilization Database. Outcomes were compared using survival analysis and costs were compared using the Wilcoxon rank sum. RESULTS: 149 cases (100 aortic, 29 mitral, 20 both; 64% bileaflet) were compared to 149 cohort members (100 aortic, 29 mitral, 20 both; 75% bileaflet). While the 3-month cumulative incidence of TE did not differ significantly among cases (2.7%) and cohort members (4.7%; p = 0.36), major bleeding was significantly lower in cases (5.4% vs. 15.4%; p < 0.005). Total costs were significantly higher for cohort members ($50,984 vs. $39,347; p = 0.002) due to higher inpatient costs ($47,729 vs. $34,860; p = 0.0002). CONCLUSIONS: Outpatient bridging LMWH therapy is equally effective, but safer and less costly than inpatient IVUH as periprocedural anticoagulation management for MHV patients.

Three-month cumulative incidence of thromboembolism and bleeding after periprocedural anticoagulation management of arterial vascular bypass patients.

The objective of this study was to determine 3-month cumulative incidence of peri-procedural thromboembolism (TE) including graft occlusion, and peri-procedural bleeding for chronically anticoagulated vascular bypass graft (BG) patients requiring temporary warfarin interruption for an invasive procedure. Appropriate peri-procedural management of patients receiving chronic warfarin therapy to preserve lower extremity arterial BG patency is unknown. In a protocol driven, cohort study design, all BG patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation (1997-2007) were followed forward in time to estimate the 3-month cumulative incidence of TE and bleeding. Decisions to provide "bridging" low molecular weight heparin (LMWH) were individualized based on estimated risk of TE and bleeding. There were 78 BG patients (69 ± 10 years; 38% women), of whom 73% had a distal autogenous and 53% had prosthetic BG; 45% received antiplatelet therapy. Peri-procedural LMWH was prescribed for 77% of patients and did not vary by BG distal anastomosis location or type. The 3-month cumulative incidence of TE was 5.1% (95% CI 1.4-12.6), including two BG occlusions, one DVT, and one myocardial infarction. Major bleeding occurred in 1 patient (1.28%, 95% CI 0.0-6.94). One patient died due to heart failure. TE and bleeding did not differ by bridging status. The 3-month cumulative incidence of TE among BG patients in whom warfarin is temporarily interrupted for an invasive procedure may be higher than in other "bridging" populations (atrial fibrillation, prosthetic heart valve, venous thromboembolism). This finding underscores the often tenuous nature of distal bypass grafts necessitating an aggressive approach to peri-procedural anticoagulation management.

Aortic stenosis and angiodysplastic gastrointestinal bleeding: Heyde's disease.

Obscure gastrointestinal (GI) bleeding can be a perplexing and difficult problem in elderly patients, especially if they are hemodynamically unstable. If aortic stenosis is also present, the cause of the GI bleeding may be explained. We present a 66-year-old man with a medical history of coronary artery disease who presented with acute GI bleeding. During his hospital course, the patient had a colonoscopy showing diffuse angiodysplasia and an echocardiogram showing severe aortic stenosis. This combination of angiodysplasia and aortic stenosis is known as Heyde's syndrome. It has been hypothesized that the aortic stenosis causes an acquired von Willebrand factor deficiency that leads to GI bleeding. Aortic valve replacement, when possible, can prevent recurrent GI bleeding in these cases, but medical decisions in these cases are complex and difficult.

Heyde's syndrome: A critical review of the literature.

Heyde's syndrome is an uncommon association between aortic stenosis and gastrointestinal bleeding. Although initially described during the late 1950s, with subsequent reports of a possible link between these disorders, controversy persists regarding the incidence, pathogenesis, and treatment of this syndrome. The main disagreements center on the actual association of aortic stenosis and angiodysplasia, though other controversies include the pathogenesis of Heyde's syndrome, ranging from von Willebrand factor deficiency and age-related degeneration to mucosal ischemia and cholesterol embolization. A variety of treatment modalities of the syndrome has been applied, including medical management, endoscopic therapy, embolization, and aortic valve replacement. Here, the controversies surrounding Heyde's syndrome, which focus on pathogenesis and treatment, are reviewed with the aim of providing a clearer understanding of the syndrome and the implications for patient care.