Safety of direct oral anticoagulants in patients with mild to moderate cirrhosis: a systematic review and meta-analysis.

To evaluate major bleeding in cirrhosis with use of traditional anticoagulation or direct oral anticoagulants (DOACs), using a standardized definition. Anticoagulation in patients with cirrhosis is often a clinical conundrum for providers as the necessary balance between thrombotic and bleeding risk is complicated by end organ damage. Recent meta-analyses have sought to evaluate the safety and efficacy of direct oral anticoagulants in patients with liver disease. These recent analyses are limited by various bleeding definitions, broad inclusion criteria, and few indications for anticoagulation. We sought to conduct a meta-analysis using a validated definition for major bleeding and compare rates between traditional anticoagulation and DOACs in patients with cirrhosis. Articles were eligible for inclusion if the international society on thrombosis and hemostasis (ISTH) definition of a major bleed was the primary safety outcome. Additionally, only articles including patients with cirrhosis and receiving treatment with anticoagulation for an indication for stroke prevention or venous thromboembolism were eligible. Eligible articles needed a DOAC comparator group against traditional anticoagulant medication. Seven studies met inclusion criteria and compiled data for 683 patients in the meta-analysis. Pooled trial analysis demonstrated no statistically significant difference in the primary outcome of ISTH major bleeding (OR 0.55, 95%CI 0.28-1.07, I2 0%). Individual secondary outcomes of all bleeding, intracerebral hemorrhage, or gastrointestinal bleeding also demonstrated no significant difference between DOACs and traditional anticoagulation. Use of DOACs in patients with mild to moderate cirrhosis carries similar risk to use of traditional anticoagulation.

Pharmacologic Treatment of Hypertensive Urgency in the Outpatient Setting: A Systematic Review.

BACKGROUND: Hypertensive urgency (HU), defined as acute severe uncontrolled hypertension without end-organ damage, is a common condition. Despite its association with long-term morbidity and mortality, guidance regarding immediate management is sparse. Our objective was to summarize the evidence examining the effects of antihypertensive medications to treat. METHODS: We searched the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Web of Science, Google Scholar, and Embase through May 2016. STUDY SELECTION: We evaluated prospective controlled clinical trials, case-control studies, and cohort studies of HU in emergency room (ER) or clinic settings. We initially identified 11,223 published articles. We reviewed 10,748 titles and abstracts and identified 538 eligible articles. We assessed the full text for eligibility and included 31 articles written in English that were clinical trials or cohort studies and provided blood pressure data within 48 h of treatment. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration. The main outcome measured was blood pressure change with antihypertensive medications. Since studies were too diverse both clinically and methodologically to combine in a meta-analysis, tabular data and a narrative synthesis of studies are presented. RESULTS: We identified only 20 double-blind randomized controlled trials and 12 cohort studies, with 262 participants in prospective controlled trials. However, we could not pool the results of studies. In addition, comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies. CONCLUSIONS: Longitudinal studies are still needed to determine how best to lower blood pressure in patients with HU. Longer-term management of individuals who have experienced HU continues to be an area requiring further study, especially as applicable to care from the generalist.

Increased physician-reported sleep apnea: the National Ambulatory Medical Care Survey.

BACKGROUND: Despite increased recognition of sleep apnea as a major health problem, little is known about physician practice patterns regarding this condition. METHODS: We used the National Ambulatory Medical Care Survey (NAMCS) data between the years of 1990 to 1998, a weighted estimate of the frequency of physicians' diagnoses nationwide in their outpatient practices, to address the following questions: (1) has there been an increase in physician reporting of sleep apnea, (2) which physicians reported diagnoses of sleep apnea, and (3) what are the demographic characteristics of patients with diagnoses of sleep apnea? RESULTS: During this 9-year period, there was a 12-fold increase in the diagnosis of sleep apnea in outpatients, from 108,121 to 1,305,624 diagnoses (p < 0.001). Among other primary sleep disorders, only insomnia had an increase in reporting (fourfold, p < 0.001). Report of sleep apnea was greatest among primary care providers (37%), pulmonologists (24%), and otolaryngologists (18%). Sleep apnea was reported more often in men than in women (3:1, respectively), and 80% of diagnoses occurred in the following age groups: 30 to 39 years (12%), 40 to 49 years (33%), 50 to 59 years (27%), and 60 to 69 years (12%). Conditions associated with sleep apnea included hypertension (10%), obesity (6%), and COPD (7%). Increased reporting of sleep apnea by NAMCS physicians was associated with increases in the number of accredited sleep laboratories and the number of sleep publications in the medical literature during the period of review (p < 0.001). CONCLUSION: Sleep apnea is recognized increasingly by physicians. Further investigation is necessary to define those factors that influence physician recognition and reporting of sleep apnea, and approaches associated with optimum patient outcomes.