Mucoepidermoid carcinoma: Evaluating the prognostic impact of primary tumor site.

Mucoepidermoid carcinoma (MEC) is one of the most common salivary gland malignancies. Our aim was to evaluate the prognostic impact of primary tumor site in patients with MEC. MATERIAL AND METHODS: This cohort identified 308 patients with MEC who underwent primary surgery between 1985 and 2015. Survival outcomes were determined using the Kaplan-Meier method. Hazard ratios for primary site were determined using the Cox proportional-hazards model. RESULTS: One hundred eighty (58%) patients were diagnosed with minor and 128 (42%) with major salivary gland cancer. Primary site in the minor salivary gland group included 137 (44%) oral cavity, 38 (12%) pharynx, 3 (0.9%) nasal cavity, and 2 (0.6%) trachea and larynx. The major salivary gland group included 118 (38%) parotid, 8 (3%) submandibular, and 2 (0.6%) sublingual. With a median follow-up of 73 months, 5-year overall survival and disease-specific survival were 84% and 91%, respectively. Patients with tumors located in the hard palate and retromolar trigone had the best survival, while patients with tumors located in the paranasal sinuses and submandibular gland had the poorest survival. After controlling for tumor grade and stage, MEC primary site was not predictive of survival or recurrence. On multivariate analysis, worse DSS was associated with stage III-IV tumors (HR: 7,11; 95% CI: 1.19-26.43; p = 0.0034) and high-grade tumors (HR: 19.12; 95% CI: 2.26-162.77; p = 0.0068). CONCLUSIONS: While high grade and advanced overall stage were found to be independent predictors of worse survival, primary tumor site was not predictive of poor outcome.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Thrombosis: Phlegmasia Cerulea Dolens Presenting with Venous Gangrene in a Child.

A 12-year-old girl with severe acute respiratory syndrome coronavirus 2 infection presented as phlegmasia cerulea dolens with venous gangrene. Emergent mechanical thrombectomy was complicated by a massive pulmonary embolism and cardiac arrest, for which extracorporeal cardiopulmonary resuscitation and therapeutic hypothermia were used. Staged ultrasound-assisted catheter-directed thrombolysis was used for treatment of bilateral pulmonary emboli and the extensive lower extremity deep vein thrombosis while the patient received extracorporeal membrane oxygenation support. We highlight the need for heightened suspicion for occult severe acute respiratory syndrome coronavirus 2 infection among children presenting with unusual thrombotic complications.

Differences among low-molecular-weight heparins: evidence in patients with acute coronary syndromes.

Low-molecular-weight heparins (LMWHs) have shown equivalent or superior efficacy and safety to unfractionated heparin as antithrombotic agents for the treatment of patients with acute coronary syndromes (ACS). In patients with unstable angina and non-ST segment elevation myocardial infarction (MI), many data support the use of the LMWH enoxaparin to reduce cardiovascular events and death. LMWHs also appear more effective than unfractionated heparin in reducing the composite end point of acute MI, recurrent ischemia, or death in patients with ST segment elevation MI, and can also be used effectively in patients undergoing thrombolysis reperfusion and percutaneous coronary intervention. However, the various LMWH preparations should not be used interchangeably. Each LMWH is a pleiotropic biological agent with a unique chemical, biochemical, biophysical, and biological profile, and it displays a unique pharmacodynamic and pharmacokinetic profile. As a result, LMWHs are not equipotent in preclinical assays or equivalent in terms of their clinical efficacy and safety. Therefore, it is essential that new, emerging, generic versions of LMWHs demonstrate clinical equivalence, in specific indications, with the existing approved LMWHs. This article highlights the chemical, biological, and pharmacological differences between the LMWH preparations that may result in different clinical outcomes during the treatment of patients with acute coronary syndromes.

Early ambulation and variability in anticoagulation during elective coronary stenting with a single intravenous bolus of low-dose, low-molecular weight heparin enoxaparin.

BACKGROUND: The best anticoagulation strategy for patients undergoing percutaneous coronary intervention (PCI) remains controversial. The primary objective of this study was to assess the feasibility of immediate sheath removal post-PCI in patients given a single low-dose intravenous (IV) bolus of enoxaparin as the sole anticoagulant. METHODS: In 53 patients with stable coronary disease undergoing elective PCI, a single IV bolus of 0.5 mg per kg enoxaparin was administered 10 minutes before PCI. Patients were pretreated with aspirin 100 mg and clopidogrel 300 mg. The femoral access sheaths were removed immediately after PCI by manual compression. Major and minor bleeding and coronary thrombosis were recorded. Anti-Xa levels were measured before, during and after PCI. RESULTS: One patient had an intracoronary thrombus 60 minutes after enoxaparin administration, and there was 1 ischemic stroke. Fifty-one of the 53 patients had their sheaths successfully pulled immediately post-PCI. One patient had a pseudoaneurysm requiring surgical repair, and 1 patient had a minor bleed. Postprocedural elevation of CK-MB > 3 times the upper limit of normal occurred in 7 patients (13.2%). Anti-Xa activity was 0.56 +/- 0.16 at 10 minutes post-IV injection, and then progressively decreased to 0.14 +/- 0.09 IU/ml at 6 hours after injection. Ten minutes after IV enoxaparin, 12 patients (23.5%) had anti-Xa levels < 0.5 IU/ml. CONCLUSIONS: Immediate removal of femoral sheaths, after a single low-dose of IV enoxaparin for elective stenting appears feasible. However, a sizeable proportion of patients achieved anti-Xa levels below the widely agreed upon "therapeutic" level after injection.

Health-related quality of life in overweight and nonoverweight black and white adolescents.

OBJECTIVES: To assess the impact of obesity on quality of life (QOL) in black and white adolescents. STUDY DESIGN: One hundred ten overweight (body mass index [BMI], 41.7 +/- 8.9 kg/m2) and 34 nonoverweight adolescents (BMI, 20.6 +/- 2.9 kg/m2) and their parents completed measures of QOL. RESULTS: Overweight was associated with poorer adolescent-reported QOL and parent reports of their children's QOL. Examining groups by weight status and race, overweight whites reported the greatest impairment on Social/Interpersonal, Self-Esteem, and Physical Appearance QOL (all P < .01), whereas parents of overweight blacks reported the poorest General Health Perceptions scores regarding their children. Interactions between BMI z-score and race were detected for Social/Interpersonal, Self-esteem, Daily Living, Self-Efficacy, Self-regard, and Physical Appearance QOL (all P < .05): Higher BMI in whites was associated with greater impairments in QOL than in blacks. Parents reported similar relations for their children. CONCLUSIONS: According to adolescent and parent reports, overweight is associated with poorer QOL in adolescence, regardless of race; however, compared with overweight white adolescents, blacks report less impairment in QOL. Future research is required to determine whether differences in QOL are predictive of treatment success.

Intra-aortic balloon counterpulsation in US and non-US centres: results of the Benchmark Registry.

AIMS: To examine differences in patient characteristics and outcomes in 19636 patients enrolled in the USA and 3027 patients enrolled in other countries undergoing intra-aortic balloon pump (IABP) counterpulsation. METHODS AND RESULTS: Indications for IABP use; a larger percentage of US patients were identified as 'early support and stabilization for angiography or angioplasty' (21.1% US vs 11.8% non-US), and 'pre-operative support for high-risk CABG' (15.9% vs 6.6%). A smaller percentage of US patients vs non-US patients were identified as 'weaning from cardiopulmonary bypass' (14.3% vs 28.2%), and 'refractory ventricular failure' (6.2% vs 9.8%). One out of five patients in both groups was listed as 'cardiogenic shock' (18.9% US vs 20.2% non-US). All cause, risk-adjusted, in-hospital mortality (20.1% vs 28.7%; P<0.001), and mortality with IABP in place (10.8% vs 18.0%; P<0.001) were lower at US vs non-US sites. In both US and non-US institutions, IABP associated complication rates, such as IABP-related mortality (0.05% vs 0.07%), major limb ischaemia (0.9% vs 0.8%), and severe bleeding (0.9% vs 0.8%), were low. CONCLUSIONS: IABP counterpulsation is deployed at an earlier clinical stage in US patients. Mortality rates are higher for non-US patients, particularly for patients with non-surgery cardiac interventions, even after adjusting for risk factors. Complication rates were low. Physicians should therefore not be reluctant to use IABP in high-risk patients undergoing cardiac procedures.

Prospective evaluation of clinical outcomes after acute ST-elevation myocardial infarction in patients who are ineligible for reperfusion therapy: Preliminary results from the TETAMI registry nd randomized trial

BACKGROUND: Treatment with lytics or primary percutaneous coronary interventions (PCI) reduces the mortality rate of patients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours. Patients presenting >12 hours are generally considered to be ineligible for reperfusion therapy, and there are currently no specific treatment recommendations for this subgroup.Methods- All patients with STEMI 12 hours. Apart from 34 of these patients who had a stuttering infarction and were referred for reperfusion, the remaining patients did not receive reperfusion therapy.Registry patients who received reperfusion therapy, compared with TETAMI randomized patients (all of whom received antithrombotic therapy) and registry patients who did not receive reperfusion, were younger (61 years versus 63 years and 67 years), were more likely to be male (78% versus 73% and 63%), and had persistent ST-segment elevation as opposed to LBBB or Q waves...

The safety and efficacy of subcutaneous enoxaparin versus intravenous unfractionated heparin and tirofiban versus placebo in the treatment of acute ST-segment elevation myocardial infarction Patients ineligible for reperfusion (TETAMI): a randomized trial

The aims of the Safety and Efficacy of Subcutaneous Enoxaparin Versus Intravenous Unfractionated Heparin and Tirofiban Versus Placebo in the Treatment of Acute ST-Segment Elevation Myocardial Infarction Patients Ineligible for Reperfusion (TETAMI) study were to demonstrate that enoxaparin was superior to unfractionated heparin (UFH) and that tirofiban was better than placebo in patients with acute ST-segment elevation myocardial infarction (STEMI) who do not receive timely reperfusion. BACKGROUND: An optimal treatment strategy has not been identified for the many STEMI patients ineligible for acute reperfusion. METHODS: A total of 1224 patients were enrolled in 91 centers in 14 countries between July 1999 and July 2002. Patients with STEMI ineligible for reperfusion were randomized to enoxaparin, enoxaparin plus tirofiban, UFH, or UFH plus tirofiban. All patients received oral aspirin. The primary efficacy end point was the 30-day combined incidence of death, reinfarction, or recurrent angina; the primary analysis was the comparison of the pooled enoxaparin and UFH groups. REULTS: The incidence of the primary efficacy end point was 15.7% enoxaparin versus 17.3% for UFH (odds ratio 0.89 [95% confidence interval CI = 0.66 to 1.21]) and 16.6% for tirofiban versus 16.4% for placebo (odds ratio 1.02 [95% CI 0.75 to 1.38]). The Thrombolysis In Myocardial Infarction (TIMI) major hemorrhage rate was 1.5% for enoxaparin versus 1.3% for UFH (odds ratio 1.16 [95% CI 0.44 to 3.02]) and 1.8% versus 1% for tirofiban versus Placebo (odds ratio 1.82 ([95% CI 0.67 to 4.95])...