Clinical Impact of the Volumetric Quantification of Ventricular Secondary Mitral Regurgitation by Three-Dimensional Echocardiography.

BACKGROUND: The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients. METHODS: We included 229 patients (70 ± 13 years, 74% men) with v-SMR. We compared EROA and RegVol calculated by the 3DEVM, 2DEVM, and PISA methods. The end point was a composite of heart failure hospitalization and death for any cause. RESULTS: After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm2 (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001). CONCLUSIONS: Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.

Alpha-lipoic acid for diabetic peripheral neuropathy.

BACKGROUND: Diabetic peripheral neuropathy (DPN) is a frequent complication in people living with type 1 or type 2 diabetes. There is currently no effective treatment for DPN. Although alpha-lipoic acid (ALA, also known as thioctic acid) is widely used, there is no consensus about its benefits and harms. OBJECTIVES: To assess the effects of alpha-lipoic acid as a disease-modifying agent in people with diabetic peripheral neuropathy. SEARCH METHODS: On 11 September 2022, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and two clinical trials registers. We also searched the reference lists of the included studies and relevant review articles for additional references not identified by the electronic searches. SELECTION CRITERIA: We included randomised clinical trials (RCTs) that compared ALA with placebo in adults (aged 18 years or older) and that applied the study interventions for at least six months. There were no language restrictions. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. The primary outcome was change in neuropathy symptoms expressed as changes in the Total Symptom Score (TSS) at six months after randomisation. Secondary outcomes were change in neuropathy symptoms at six to 12 months and at 12 to 24 months, change in impairment, change in any validated quality of life total score, complications of DPN, and adverse events. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: Our analysis incorporated three trials involving 816 participants. Two studies included people with type 1 or type 2 diabetes, while one study included only people with type 2 diabetes. The duration of treatment was between six months and 48 months. We judged all studies at high risk of overall bias due to attrition. ALA compared with placebo probably has little or no effect on neuropathy symptoms measured by TSS (lower score is better) after six months (mean difference (MD) -0.16 points, 95% confidence interval (CI) -0.83 to 0.51; 1 study, 330 participants; moderate-certainty evidence). The CI of this effect estimate did not contain the minimal clinically important difference (MCID) of 0.97 points. ALA compared with placebo may have little or no effect on impairment measured by the Neuropathy Impairment Score-Lower Limbs (NIS-LL; lower score is better) after six months (MD -1.02 points, 95% CI -2.93 to 0.89; 1 study, 245 participants; low-certainty evidence). However, we cannot rule out a significant benefit, because the lower limit of the CI surpassed the MCID of 2 points. There is probably little or no difference between ALA and placebo in terms of adverse events leading to cessation of treatment within six months (risk ratio (RR) 1.48, 95% CI 0.50 to 4.35; 3 studies, 1090 participants; moderate-certainty evidence). No studies reported quality of life or complications associated with DPN. AUTHORS' CONCLUSIONS: Our analysis suggests that ALA probably has little or no effect on neuropathy symptoms or adverse events at six months, and may have little or no effect on impairment at six months. All the studies were at high risk of attrition bias. Therefore, future RCTs should ensure complete follow-up and transparent reporting of any participants missing from the analyses.

Coronary artery tortuosity and mid-term all-cause mortality of patients with ischemia and non-obstructive coronary arteries.

Background: Coronary artery tortuosity (CAT) is a frequently encountered angiographic feature of patients with ischemia and non-obstructive coronary arteries (INOCA). However, there is limited data regarding the possible correlation between CAT and all-cause mortality in these patients. Aim: To assess the survival prognostic implications of CAT in INOCA patients and the predictors of all-cause mid-term mortality of these patients. Methods: All consecutive INOCA patients, with preserved ejection fraction evaluated for clinical ischemia by coronary angiography in our department between January 2014 and December 2020 were considered for inclusion. Patients with epicardial coronary artery stenosis ≥ 50%, severe pulmonary hypertension, or decompensated extra cardiac disease were excluded. Eleid classification was used for CAT severity characterization. We assessed all-cause mortality in January 2023. Results: Our sample included 328 INOCA patients. 15.54% died during the mean follow-up of 3.75 ± 1.32 years. 79.88% had CAT. CAT patients were older (65.10±9.09 versus 61.24±10.02 years, p=0.002), and more often female (67.18% versus 31.82%, p<0.001). CAT was inversely correlated with all-cause mid-term mortality (OR 0.35, 95%CI 0.16 - 0.77, p=0.01). CAT severity had no impact on survival. In CAT patients the initial multivariable analysis identified NT-proBNP levels (HR 3.96, p=0.01), diabetes mellitus (DM) (HR 4.76, p=0.003), and atrial fibrillation (HR 2.68, p=0.06) as independent predictors of all-cause mortality. In the final analysis, NT-proBNP and DM were the main independent predictors of survival. Conclusions : In our INOCA cohort, CAT patients were older and more likely female. CAT was inversely correlated with mid-term all-cause mortality. NT-proBNP and DM were the main independent predictors of mortality of CAT patients.

Sarcopenia assessed by total psoas index - is it correlated with post-operative complications in all digestive cancers?

Background and aims: In cancer patients sarcopenia may be a predictor for postoperative complications of curative or palliative surgery. Several indices including the total psoas area index (TPAI) are proposed for the diagnosis of this condition, but there is no validated cut-off point.Our study aimed to assess the role of TPAI as a marker for sarcopenia and to compare the utility of previously proposed cut-off values for predicting post-operative complications in patients with digestive cancers undergoing surgery. Methods: We retrospectively included all adult patients with digestive cancers admitted to a tertiary center for elective surgery between January and December 2019. Sarcopenia was considered based on TPAI evaluated on abdominal computed tomography (CT) and for analysis we used different cut-off points published by various authors. The primary endpoint was the occurrence of any complications as defined by the Clavien-Dindo classification. The secondary endpoints were fistula development, low- versus high-grade Clavien-Dindo post-operative complications, moderate or severe anemia at discharge, major bleeding, hypoalbuminemia at discharge, and decrease in albumin levels by at least 1g/dL. Results: We included 155 patients with a mean age of 64.78 ± 11.40 years, of which 59.35% were males; 58.06% developed postoperative complications. TPAI evaluated as a continuous variable was not a predictor for the development of post-operative complications neither in the general study sample, nor in the gender subgroups of patients. Sarcopenia defined by previously proposed cut-off values was not a predictor of the secondary end-points either. Conclusion: TPAI as a sole parameter for defining sarcopenia was not a predictor for postoperative complications in patients undergoing surgery for digestive neoplasia.

The complex interplay between right ventricular dysfunction and atrial fibrillation - a narrative review.

Atrial fibrillation (AF) is one of the most common sustained arrhythmias in clinical practice, associated with multiple comorbidities and complication. The potential predictors of AF onset and perpetuation or specific drivers of complications need future investigation. Right ventricular (RV) dysfunction plays an important role in the development of new-onset AF warranting in-depth analysis in relation to AF. RV may play a significant role in a better characterization of the cardiac substrate of AF patients. The relation between RV dysfunction and AF is bidirectional as AF may be one of the causes of RV dysfunction and their coexistence worsens the overall patient prognosis. Our aim is to present in a narrative review the most relevant data regarding the complex relationship between AF and RV dysfunction.

The platelet to lymphocyte ratio in heart failure: a comprehensive review.

Introduction: At the crossroads of heart failure (HF) and systemic inflammation, platelets and lymphocytes are both influenced as well as actively participating in the bidirectional relationship. The platelet to lymphocyte ratio (PLR) could therefore be a marker of severity. This review aimed to assess the role of PLR in HF. Methods: We searched the PubMed (MEDLINE) database using the keywords "platelet", "thrombocyte", "lymphocyte", "heart failure", "cardiomyopathy", "implantable cardioverter defibrillator", "cardiac resynchronization therapy" and "heart transplant". Results: We identified 320 records. 21 studies were included in this review, with a total of 17,060 patients. PLR was associated with age, HF severity, and comorbidity burden. Most studies reported the predictive power for all-cause mortality. Higher PLR was associated with in-hospital and short-term mortality in univariable analysis, however, it was not consistently an independent predictor for this outcome. PLR > 272.9 associated an adjusted HR of 3.22 (95%CI 1.56 - 5.68, p<0.001) for 30-day fatality. During long-term follow-up from 6 months to 5 years, PLR was an independent predictor of mortality in most studies, with cut-off values ranging from > 150 to > 194.97 and adjusted HR from 1.47 (95%CI 1.06 - 2.03, p=0.019) to 5.65 (95%CI 2.47-12.96, p<0.001). PLR > 173.09 had an adjusted OR 2.89 (95%CI 1.17-7.09, p=0.021) for predicting response to cardiac resynchronization therapy. PLR was not associated with outcomes after cardiac transplant or implantable cardioverter-defibrillator. Conclusion: Increased PLR could be an auxiliary biomarker of severity and survival prognosis in HF patients.

Prognostic Impact of Severe Atrial Functional Tricuspid Regurgitation in Atrial Fibrillation Patients.

Background and Aim: Atrial fibrillation (AF) is an epidemic disease with a significant global health impact. Atrial functional tricuspid regurgitation (AF-TR) is a more recently acknowledged complication of AF. The main purpose of this study was to determine the prognostic value of severe AF-TR in patients with AF, and its determinants. Methods: In this retrospective, observational study, we included AF patients admitted consecutively to a tertiary clinical hospital between January 2018 and February 2020, irrespective of cause of hospitalization. Patients with organic TR, significant pulmonary hypertension, left ventricular ejection fraction < 50%, those with implanted cardiac devices and those with in-hospital mortality were excluded. Severe TR was defined according to current guidelines. Median follow-up time was 34 (28−39) months. Primary endpoint was all-cause mortality. Results: We included 246 AF patients, with a mean age of 71.5 ± 9.4 years. 86.2% had AF-TR, while 8.1% had severe AF-TR. Mortality rate was 8.5%. Right atrial diameter (p = 0.005), systolic pulmonary artery pressure (sPAP) (p = 0.015) and NT-proBNP (p = 0.026) were independent predictors for the presence of severe valvular dysfunction. In multivariable survival analysis, severe AF-TR, was an independent predictor of all-cause mortality (HR 5.4, 95% CI 1.1−26.2, p = 0.035). Conclusion: Severe AF-TR was an independent predictor of mortality in AF patients, while mild/moderate AF-TR apparently had no impact on prognosis.

Stroke risk scores for prediction of mortality and hemorrhages in atrial fibrillation patients.

Background: Atrial fibrillation (AF) is an emerging epidemic worldwide, responsible for a twofold increase in mortality, independent of other risk factors. Stroke prevention is the cornerstone of AF management. However, oral anticoagulation imposes an increased risk of bleeding. Several risk scores have been developed for estimating both the thromboembolic and the bleeding risks. The aim of the study was to determine the usefulness of different stroke risk scores as predictors of mortality and hemorrhagic events in AF patients. Methods: We retrospectively enrolled 211 AF patients hospitalized in the Cardiology Ward of our tertiary hospital. The primary endpoints were mortality and non-minor bleeding events. The mean follow-up period was 378 days for bleeding events and 5 years and 1 month for mortality. For each patient, we evaluated the following stroke risk scores: CHADS2, CHA2DS2-VASc, R2CHADS2, ABC, ATRIA, GARFIELD. Results: The mean age in our cohort is 66, with a slight predominance of women (52.2%). For a CHA2DS2-VASc ≥ 4 as well as for a score of 2-3, 5-year survival was worse than for patients with a score of 0-1(chi-squared=8.13; p=0.01). Similarly, all subgroups of patients with an ABC <2%, had a worse 5-year survival when compared with an ABC score of ≥2% (chi-squared=12.85; p=0.005). C-statistics show a modest predictive value for mortality, for all stroke scores except Garfield, with similar AUCs, the highest being for CHA2DS2-VASc (AUC 0.656; p=0.0001). CHA2DS2-VASc also correlates with bleeding events, having a good predictive ability (AUC 0.723; 95%CI 0.658-0.782, p=0.001), mildly superior to HAS-BLED (AUC 0.674; 95% CI 0.523-0.825; p = 0.04) and very close to Garfield-bleeding (0.765; 95%CI 0.702-0.80; p=0.0001). Conclusions: CHA2DS2-VASc is comparable to HAS-BLED and Garfield-bleeding in predicting bleeding events in AF patients. CHA2DS2-VASc and ABC correlate directly and consistently with mortality rate. For CHA2DS2-VASc, the AUCs for our endpoints are similar to the ones for stroke prediction, highlighting the potential of extending its applicability to various outcomes.

Systemic lupus erythematosus on social networking sites: Friends or foes?

Systemic lupus erythematosus (SLE) is one of the most studied autoimmune diseases. The interest shown for this pathology is translated into international scientific journals, congresses, meetings and, recently, in large data available online. Social networking sites (SNS) have gradually advanced from ways to facilitate interpersonal relations to important sources of information, including medical data regarding SLE, with sites largely accessed by both doctors and patients. Albeit the use of SNS can be valuable in providing education and promoting development of public health, it can be misleading if unprofessional sources of information are used; therefore, both "friends and foes" of the data accessed on large scale should always be considered. This viewpoint is a discussion of the potential benefits and harms related to the SNS use for SLE patients as well as for their physicians.

Determinants of Prolonged Length of Hospital Stay of Patients with Atrial Fibrillation.

BACKGROUND AND AIM: The increasing prevalence and high hospitalization rates make atrial fibrillation (AF) a significant healthcare strain. However, there are limited data regarding the length of hospital stay (LOS) of AF patients. Our purpose was to determine the main drivers of extended LOS of AF patients. METHODS: All AF patients, hospitalized consecutively in a tertiary cardiology center, from January 2018 to February 2020 were included in this retrospective cohort study. Readmissions were excluded. Prolonged LOS was defined as more than seven days (the upper limit of the third quartile). RESULTS: Our study included 949 AF patients, 52.9% females. The mean age was 72.5 ± 10.3 years. The median LOS was 4 days. A total of 28.7% had an extended LOS. Further, 82.9% patients had heart failure (HF). In multivariable analysis, the independent predictors of extended LOS were: acute coronary syndromes (ACS) (HR 4.60, 95% CI 1.66-12.69), infections (HR 2.61, 95% CI 1.44-3.23), NT-proBNP > 1986 ng/mL (HR 1.96, 95% CI 1.37-2.82), acute decompensated HF (ADHF) (HR 1.76, 95% CI 1.23-2.51), HF with reduced ejection fraction (HFrEF) (HR 1.69, 95% CI 1.15-2.47) and the HAS-BLED score (HR 1.42, 95% CI 1.14-1.78). CONCLUSION: ACS, ADHF, HFrEF, increased NT-proBNP levels, infections and elevated HAS-BLED were independent predictors of extended LOS, while specific clinical or therapeutical AF characteristics were not.

Stroke Risk Scores as Predictors of Severe Outcomes in Atrial Fibrillation: A Comprehensive Review.

BACKGROUND: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. It increases the risk of stroke, heart failure, death, hospitalizations, and costs. AREA OF UNCERTAINTY: Several scores were introduced to stratify the stroke risk and need for anticoagulation in patients (pts) with AF . CHA2DS2-VASc, the most frequently used score, as well as other stroke risk scores have been additionally applied to estimate outcomes for different other conditions, with inhomogeneous results. To date, there has been no consensus regarding the usefulness of these scores to estimate outcomes outside of thromboembolic risk assessment, and their value in estimating different end-point outcomes is still a subject of debate. We conducted this review to investigate whether the stroke risk scores' utility can be extended for the prediction of other severe outcomes in pts with AF. DATA SOURCES: We searched PubMed database and included studies that stratified the outcome of pts with AF by different stroke risk scores. We also included studies with a separate analysis of the pts with AF subpopulation. RESULTS: Mortality rates increased with higher CHADS2 [from 2.28% (2.00%-2.58%) to 13.2% (8.24%-20.8%) per year] and CHA2DS2-VASc scores [risk ratio 1.26 (1.21-1.32), P < 0.0001 for score ≥3]. CHADS2 and CHA2DS2-VASc predicted poor outcome in stroke [odds ratio (OR) ranging 1.42-6 for CHADS2 and 1.3-7.3 for CHA2DS2-VASc]. Acute myocardial infarction rates increased with higher CHADS2 [OR 2.120 (1.942-2.315) P < 0.001] and CHA2DS2-VASc [OR 1.63 (1.53-1.75), P < 0.001]. Limited data were reported for ABC( Age, Biomarkers, Clinical histoty) and R2CHADS2. No statistically significant correlation was found for major bleeding. CONCLUSIONS: CHADS2 and CHA2DS2-VASc are useful tools in identifying pts with AF at higher risk for all-cause death, regardless of other pathologies. Both scores correlated with the development of acute myocardial infarction, cardiovascular hospitalization, outcome in stroke, major adverse cardiovascular events, and major adverse cardiovascular and cerebral events, but not with serious bleeding.

Comparative role of hematological indices for the assessment of in-hospital outcome of heart failure patients.

Background. The mutual relation between heart failure (HF) and inflammation is reflected in blood cell homeostasis. Neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR) and platelet-lymphocyte ratio (PLR) were linked to HF severity and prognosis. Aims. Our objective was to compare the three ratios for predicting in-hospital outcome of HF patients, in order to establish which is best suited for clinical practice. Methods. Consecutive HF patients admitted to a Cardiology Department from a tertiary hospital were retrospectively evaluated for inclusion. Readmissions and pathologies modifying the hematological indices were excluded. Extended length of hospital stay (LOS) was considered over 7 d. In-hospital all-cause mortality was evaluated. Results: The hematological indices in heart failure (HI-HF) cohort included 1299 patients with a mean age of 72.35 ± 10.45 years, 51.96% women. 2.85% died during hospitalization. 22.17% had extended LOS. In Cox regression for in-hospital mortality alongside parameters from the OPTIMIZE-HF proposed model, all three ratios were independent predictors of mortality. In Cox regression including NT-proBNP, dyspnea at rest, chronic obstructive pulmonary disease (COPD), age and systolic blood pressure, only MLR was an independent predictor of in-hospital mortality (HR 1.68, 95% CI 1.22 - 2.32, p = .002). In multivariable logistic regression, all three ratios independently predicted extended LOS. MLR > 0.48 associated the highest probability (OR 1.76, 95% CI 1.25 - 2.46, p = .001). Conclusions. Hematological indices could be cost-effective and easily available auxiliary biomarkers for in-hospital prognosis of HF patients. We propose MLR > 0.48 as the strongest predictor of in-hospital mortality and prolonged hospitalization.

The neutrophil to lymphocyte ratio in heart failure: a comprehensive review.

INTRODUCTION: Heart failure (HF) and systemic inflammation are interdependent processes that continuously potentiate each other. Distinct pathophysiological pathways are activated, resulting in increased neutrophil count and reduced lymphocyte numbers, making the neutrophil to lymphocyte ratio (NLR) a potential indirect marker of severity. We conducted this comprehensive review to characterize the role of NLR in HF. METHODS: We searched the PubMed (MEDLINE) database using the key words "neutrophil", "lymphocyte", "heart failure", "cardiomyopathy", "implantable cardioverter defibrillator", "cardiac resynchronization therapy" and "heart transplant". RESULTS: We identified 241 publications. 31 were selected for this review, including 12,107 patients. NLR was correlated to HF severity expressed by clinical, biological, and imaging parameters, as well as to short and long-term prognosis. Most studies reported its survival predictive value. Elevated NLR (>2.1-7.6) was an independent predictor of in-hospital mortality [adjusted HR 1.13 (95% CI 1.01-1.27) - 2.8 (95% CI 1.43-5.53)] as well as long-term all-cause mortality [adjusted HR 1.43 (95% CI 1.1-1.85) - 2.403 (95% CI 1.076-5.704)]. Higher NLR levels also predicted poor functional capacity [NLR > 2.26/2.74, HR 3.93 (95% CI 1.02-15.12) / 3.085 (95% CI 1.52-6.26)], hospital readmissions [NLR > 2.9/7.6, HR 1.46 (95% CI 1.10-1.93) / 3.46 (95% CI 2.11-5.68)] cardiac resynchronization therapy efficacy [NLR > 3.45/unit increase, HR 12.22 (95% CI 2.16-69.05) / 1.51 (95% CI 1.01-2.24)] and appropriate implantable cardioverter defibrillator shocks (NLR > 2.93), as well as mortality after left ventricular assist device implantation [NLR > 4.4 / quartiles, HR 1.67 (95% CI 1.03-2.70) / 1.22 (95% CI 1.01-1.47)] or heart transplant (NLR > 2.41, HR 3.403 (95% CI 1.04-11.14)]. CONCLUSION: Increased NLR in HF patients can be a valuable auxiliary biomarker of severity, and most of all, of poor prognosis.

Is syncope a predictor of mortality in acute pulmonary embolism?

Whether syncope as a presenting symptom independently classifies acute pulmonary embolism (APE) into a high mortality risk group remains a matter of controversy. We retrospectively included all consecutive patients admitted to our clinic with APE from January 2014 to December 2016. Our sample consisted of 76 patients with a mean age of 69 ±13.6 years, 64.5% female. 14.3% presented with syncope at admission. In-hospital mortality was 20.8%. Patients with syncope were more likely to require inotropic support (OR = 5.2, 95 % 1.17-23.70, p=0.03) due to the association of cardiogenic shock (OR= 15.95% CI 3.02-74.32, p < 0.001) and systolic blood pressure below 90 mmHg (OR=5.52, 95% CI 1.24-24.47, p=0.03). Patients with syncope had a higher PESI score (150.9 ± 51.1 vs 99.9 ± 30.1, p < 0.001) and a greater in-hospital mortality (OR= 4.5, 95% CI 1.14-17.62, p=0.03). However, multivariate logistic regression equations did not identify syncope as an independent predictor of mortality. In our sample, syncope did not independently reclassify the patient in a higher mortality group, but due to the association with hemodynamic instability, which remains the primary tool in therapeutic decision-making.

The Romanian Society of Internal Medicine's Choosing Wisely Campaign.

Quality of care in medicine is not necessarily proportional to quantity of care and excess is often useless or even more, potentially detrimental to our patients. Adhering to the European Federation of Internal Medicine's initiative, the Romanian Society of Internal Medicine (SRMI) launched the Choosing Wisely in Internal Medicine Campaign, aiming to cut down diagnostic procedures or therapeutics overused in our country. A Working Group was formed and from 200 published recommendations from previous international campaigns, 36 were voted as most important. These were submitted for voting to the members of the SRMI and posted on a social media platform. After the two voting rounds, the top six recommendations were established. These were: 1. Stop medicines when no further benefit is achieved or the potential harms outweigh the potential benefits for the individual patient. 2. Don't use antibiotics in patients with recent C. difficile without convincing evidence of need. 3. Don't regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result from activity. Promote early mobilization. 4. Don't initiate an antibiotic without an identified indication and a predetermined length of treatment or review date. 5. Don't prescribe opioids for treatment of chronic or acute pain for sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment. 6. Transfuse red cells for anemia only if the hemoglobin concentration is less than 7 g/dL or if the patient is hemodynamically unstable or has significant cardiovascular or respiratory comorbidity. Don't transfuse more units of blood than absolutely necessary.

Left Ventricular noncompaction in a patient with systemic lupus erythematosus.

Left ventricular noncompaction is a rare structural cardiomyopathy that can occur isolated or in relationship with other conditions, mainly with musculoskeletal diseases or congenital heart defects. The association of left ventricular noncompaction and connective tissue disorders, including systemic lupus erythematosus, was scarcely described in the literature. Reported cases are, more likely, cardiomyopathies mimicking left ventricular noncompaction or transient left ventricular noncompaction with ventricular function improving after appropriate treatment. We present the case of a 23-year-old woman admitted for cardiac evaluation because of ECG abnormalities observed during a routine check-up. Echocardiography showed severe systolic and diastolic dysfunction, diffuse hypokinesis and hypertrabeculation, suggestive of left ventricular non-compaction. Cardiac magnetic resonance imaging confirmed the diagnosis. She later presented with specific clinical and biological parameters and was diagnosed with systemic lupus erythematosus. Corticosteroid and hydroxychloroquine treatment induced general improvement of signs and symptoms, but no recovery of cardiac function.

Influence of decision aids on oral anticoagulant prescribing among physicians: a randomised trial.

BACKGROUND: Oral anticoagulants (OAC) are underused in treatment of atrial fibrillation (AF), with differences in patient and physician preferences. For risk communication, the graphic showing risks on treatment contains all the information, therefore, the graphic showing risks without treatment may not be necessary. Here, our objective was to assess whether decision aids require information of risks without treatment and specifically whether presentation of 5-year stroke risk in patients with AF increases use of OACs compared with presentation of 1-year risk and whether decisions on treatment are different when physicians decide their own treatment vs. that of the patient. DESIGN: Randomised controlled trial with 23 factorial design, performed at 12 university hospitals, one internal medicine course and one national medical conference. RESULTS: Of 968 physicians who participated, 83·3% prescribed anticoagulation therapy. Treatment decisions were not influenced by the number of graphics or by the time frame of risk estimation, with risk differences of 0·5% (95% confidence interval, -4·0% to 5·4%) and 3·4% (-1·3% to 8·1%). However, physician-to-patient prescription rates were 5·4% (0·2-10·6%) more frequent after seeing the 5-year risk graphic. Physician-to-self intentions to prescribe occurred less frequently, with risk difference of 15·4% (10·8-20%). Physicians considered the baseline risk and the absolute risk reduction only when prescribing to patients but not to themselves. CONCLUSIONS: Risks could be communicated using decision aids with only one graphic. Showing the risk of stroke at 5 years could increase the prescription of OACs to patients with AF. Faced with the same risk of stroke, physicians prescribed less to themselves than to patients.