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1.
Intern Emerg Med ; 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31776841

RESUMO

In the original publication, part of the conflict of statement was incorrectly published as "Dr. Bikdeli reports that he was approached by lawyers on behalf of plaintiffs in litigation related to IVC filters". The correct statement should read as "Dr. Bikdeli reports that he is a consulting expert (on behalf of the plaintiff) for litigation related to a specific type of IVC filters".

3.
Intern Emerg Med ; 14(7): 1101-1112, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31054013

RESUMO

The association between inferior vena cava filter (IVC) use and outcome in patients presenting with major bleeding during anticoagulation for venous thromboembolism (VTE) has not been thoroughly investigated. We used the RIETE registry to compare the 30-day outcomes (death, major re-bleeding or VTE recurrences) in VTE patients who bled during the first 3 months of therapy, regarding the insertion of an IVC filter. A propensity score matched (PSM) analysis was performed to adjust for potential confounders. From January 2001 to September 2016, 1065 VTE patients had major bleeding during the first 3 months of anticoagulation (gastrointestinal 370; intracranial 124). Of these, 122 patients (11%) received an IVC filter. Patients receiving a filter restarted anticoagulation later (median, 4 vs. 2 days) and at lower doses (95 ± 52 IU/kg/day vs. 104 ± 55 of low-molecular-weight heparin) than those not receiving a filter. During the first 30 days after bleeding (after excluding 246 patients who died within the first 24 h), 283 patients (27%) died, 63 (5.9%) had non-fatal re-bleeding and 19 (1.8%) had recurrent pulmonary embolism (PE). In PSM analysis, patients receiving an IVC filter (n = 122) had a lower risk for all-cause death (HR 0.49; 95% CI 0.31-0.77) or fatal bleeding (HR 0.16; 95% CI 0.07-0.49) and a similar risk for re-bleeding (HR 0.55; 95% CI 0.23-1.40) or PE recurrences (HR 1.57; 95% CI 0.38-6.36) than those not receiving a filter (n = 429). In VTE patients experiencing major bleeding during the first 3 months, use of an IVC filter was associated with reduced mortality rates.Clinical Trial Registration NCT02832245.

4.
Prev Med ; 124: 17-22, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31054906

RESUMO

Early smoking onset age (SOA) is a public health concern with scant empirical evidence of its role in health outcomes. The study had two aims: i) to assess whether an early SOA was associated with the risk of fatal and non-fatal CVD and all-cause and CVD mortality and ii) to explore the linear and non-linear association between SOA and the outcomes of interest. Data from 4499 current or former smokers, recruited from 1995 to 2005, aged 25 to 79 years, and with a median 7.02 years of follow-up, were obtained from the REGICOR population-based cohort. In the present analysis, performed in 2018, the independent variable was SOA and the dependent variables were CVD events, CVD mortality, and all-cause mortality. Penalized smoothing spline methods were used to assess the linear and non-linear association. During follow-up, 361 deaths and 210 CVD events were recorded. A significant non-linear component was identified in the association between SOA and CVD outcomes with a cut-off point at 12 years: In the group aged ≤12 years, each year of delay in SOA was inversely associated with CVD risk (HR = 0.71; 95%CI = 0.53-0.96) and CVD mortality (HR = 0.58; 95%CI = 0.37-0.90). No association was observed in the older SOA group. A linear association was observed between SOA and all-cause mortality, and each year of delay was associated with 4% lower risk of mortality (HR = 0.96; 95%CI = 0.93-0.98). The associations were adjusted for lifelong exposure to tobacco and cardiovascular risk factors. These results reinforce the value of preventing tobacco use among teenagers and adolescents.

5.
Med. clín (Ed. impr.) ; 152(1): 6-12, ene. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-181666

RESUMO

Antecedentes y objetivos: En los pacientes con enfermedad arterial periférica que requieren intervenciones quirúrgicas la anemia se ha comprobado que puede ser un factor independiente de mal pronóstico tanto a corto como a medio plazo. Pacientes y métodos: Revisión retrospectiva de los pacientes intervenidos en cirugía vascular de forma consecutiva durante 2 meses en 12 unidades de cirugía vascular. Se analizan los factores de riesgo habituales y se valora la hemoglobina (Hb) preoperatoria. Con un seguimiento de 12 meses, se registran eventos cardiovasculares, muerte y cifras de Hb. El análisis de supervivencia con tablas de Kaplan-Meier y, posteriormente, análisis de regresión logística para evaluar los factores que pueden influir en la mortalidad. Resultados: En 518 pacientes, la mortalidad al año es del 21% y los eventos cardiovasculares del 34%. La anemia preoperatoria fue del 63% en isquémicos y el 23% en aneurismas, siendo superior al año de la cirugía, el 68 y el 50%, respectivamente. Si la Hb preoperatoria es mayor de 10mg/dl, la supervivencia al año es mayor (96% vs. 90%), se producen menos eventos cardiovasculares y menos amputaciones (24% vs. 68%). Conclusiones: En el análisis multivariante, las variables que influyeron en la mortalidad fueron la edad, la insuficiencia renal, la enfermedad pulmonar obstructiva crónica, la cardiopatía isquémica, haber presentado complicaciones hospitalarias, tener un evento cardiovascular. La Hb preoperatoria influye proporcionalmente, de manera que cada unidad de Hb que aumenta, disminuye la probabilidad de muerte 0,81 veces. Una anemia con Hb preoperatoria inferior a 10 se asocia a una mayor probabilidad de amputación de la extremidad y de fallecimiento


Background and objective: In patients with peripheral artery disease requiring surgery, anaemia has been found to independently predict short and medium term higher morbidity and mortality. Patients and methods: We retrospectively studied all patients undergoing surgery, consecutively during 2months in 12 vascular surgery units. We analysed cardiovascular risk factors and preoperative haemoglobin. Statistical analysis was done with Kaplan-Meier for survival and logistic regression modelling to identify predictors of mortality. Results: 518 patients were consecutively operated on in our vascular units, the mortality rate was 21% the first year and 34% for cardiovascular events. Preoperative anaemia was present in 63% of the ischemic patients and in 23% of the patients requiring aneurysm repair, one year after surgery it increased to 68% and 50% respectively. When preoperative anaemia was superior to 10mg/dl, one year survival increased (96% vs. 90%), fewer cardiovascular events occurred and there were fewer amputations (24% vs. 68%). Conclusions: On multivariable analysis: age, renal failure, chronic lung disease, coronary artery disease, postoperative complications and previous cardiovascular events were associated with an increased risk mortality rate. Preoperative haemoglobin influenced proportionally such that for every 1mg /dl increase, the probability of mortality decreases by 0.81. Preoperative anaemia, especially when haemoglobin is inferior to 10mg/dl, is associated with an increased risk of death and amputation


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Anemia/complicações , Doença Arterial Periférica/cirurgia , Fatores de Risco , Doença Arterial Periférica/complicações , Estudos Retrospectivos , Estimativa de Kaplan-Meier , Análise de Regressão
6.
Med Clin (Barc) ; 152(1): 6-12, 2019 01 04.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29650265

RESUMO

BACKGROUND AND OBJECTIVE: In patients with peripheral artery disease requiring surgery, anaemia has been found to independently predict short and medium term higher morbidity and mortality. PATIENTS AND METHODS: We retrospectively studied all patients undergoing surgery, consecutively during 2months in 12 vascular surgery units. We analysed cardiovascular risk factors and preoperative haemoglobin. Statistical analysis was done with Kaplan-Meier for survival and logistic regression modelling to identify predictors of mortality. RESULTS: 518 patients were consecutively operated on in our vascular units, the mortality rate was 21% the first year and 34% for cardiovascular events. Preoperative anaemia was present in 63% of the ischemic patients and in 23% of the patients requiring aneurysm repair, one year after surgery it increased to 68% and 50% respectively. When preoperative anaemia was superior to 10mg/dl, one year survival increased (96% vs. 90%), fewer cardiovascular events occurred and there were fewer amputations (24% vs. 68%). CONCLUSIONS: On multivariable analysis: age, renal failure, chronic lung disease, coronary artery disease, postoperative complications and previous cardiovascular events were associated with an increased risk mortality rate. Preoperative haemoglobin influenced proportionally such that for every 1mg /dl increase, the probability of mortality decreases by 0.81. Preoperative anaemia, especially when haemoglobin is inferior to 10mg/dl, is associated with an increased risk of death and amputation.

7.
Int Angiol ; 37(5): 370-376, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29792018

RESUMO

BACKGROUND: Advancements in open and endovascular techniques have brought a widespread indication of revascularization in the majority of patients with critical limb ischemia (CLI). However, some cases still have a dismal short-term outcome. Identifying preoperative variables that characterize these patients could be important to prevent futile decisions. The aim of this study was to define predictive risk factors of mortality and/or major amputation after revascularization for CLI. METHODS: Retrospective study of 515 consecutive patients (mean age=73 years; 73% males) undergoing open (N.=228; 44.3%) or endovascular (N.=287; 55.7%) surgery for CLI between 2005 and 2015. Neither redo-procedures (ipsilateral or contralateral) nor acute limb ischemia patients were included as new cases. RESULTS: Thirty-day amputation, mortality or combined event rates were 1.4% (N.=7), 4.5% (N.=23) and 5.6% (N.=29), while at 90 days were 4.1 (N.=21), 9.1% (N.=47) and 12.8% (N.=66), respectively. We found no significant differences between open or endovascular surgery. Risk factors associated with a 90-day combined event were age (OR=1.04, P=0.014), preoperative hemoglobin (OR=0.80; P=0.003), history of acute myocardial infarction (OR=2.68; P=0.007), ischemic ulcers (OR=2.57; P=0.014) and below-the-knee revascularization (OR=2.20; P=0.007). The discrimination of the model was good (area under ROC curve=0.75). Model predicted probabilities of the combined death and/or lower limb major amputation end-point ranged (95% interval) from 1.1% to 38.1%. CONCLUSIONS: Certain preoperative variables can predict satisfactorily the short-term outcome after revascularization for CLI, although they are not sufficiently useful to identify the patient in whom revascularization can be clearly futile. Further research is needed to refine a predictive model suitable for decision-making.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Amputação , Tomada de Decisão Clínica , Estado Terminal , Técnicas de Apoio para a Decisão , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidade
8.
Ann Vasc Surg ; 50: 225-230, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29481938

RESUMO

BACKGROUND: Disease progression in the contralateral carotid artery (CA) after a carotid endarterectomy (CEA) was common in the past. Current medication regimens for these patients are better and have probably modified this progression. We evaluated the rate of disease progression in the contralateral CA over the last decade. METHODS: A retrospective analysis of 291 consecutive patients undergoing a CEA between 2005 and 2014 was performed. Disease progression in the contralateral CA after CEA was determined by a duplex ultrasound. Statistics were calculated by Kaplan-Meier life-tables and Cox regression. RESULTS: Of the 291 patients, 246 (84.5%) received at baseline antiplatelet and/or anticoagulant agents, and 223 (77%) received statins. These proportions increased over the second half of the study. Disease progression in the contralateral CA was evaluated in 200 patients during a mean follow-up of 3.5 years. Progression-free survival rates from any disease progression at 1 and 5 years were of 89.3% and 68.6%, respectively. Free survival rates from <50% to >50% progression or from 50% to 69% to a higher category at 1 and 5 years were of 89.3% and 75.5%, respectively. Finally progression-free survival rates to a >70% stenosis or occlusion at 1 and 5 years were of 96.8% and 90.1%, respectively. Age (hazard ratio = 1.034, P = 0.048) and dyslipidemia (hazard ratio = 1.93, P = 0.045) were also associated with any disease progression. CONCLUSIONS: Current rates of disease progression in the contralateral CA after CEA are similar to those reported more than 1 decade ago. Further research will be needed to evaluate the impact of current medical regimens at these stages of disease.


Assuntos
Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas , Idoso , Anticoagulantes/uso terapêutico , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/mortalidade , Progressão da Doença , Intervalo Livre de Doença , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Espanha , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla
9.
World J Surg ; 42(8): 2674-2681, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29404750

RESUMO

BACKGROUND: The treatment of acute limb ischemia (ALI) has barely changed over the last years. However, the progressive implementation of anticoagulants, antiplatelet agents or statins within the population might have modified the profile and prognosis of patients suffering an ALI. The aim of this study was to evaluate the current results of the management of ALI secondary to a native artery occlusion. METHODS: Retrospective study of 220 consecutive patients (mean age 78 years; 49% male) was conducted between 2007 and 2015. ALI secondary to trauma or grafts/stents occlusions were excluded. Statistical analysis was performed with logistic regression. RESULTS: A total of 141 cases (64.1%) were attributed to embolism and 79 (35.9%) to acute arterial thrombosis. Peripheral neuro-ischemic impairment occurred in 135 patients (61.4%), being severe in 42 (19.1%). ALI treatment included anticoagulation (n = 27; 12.3%), regional fibrinolysis (n = 2; 1%), embolectomy/thrombectomy (n = 129; 58.6%), angioplasty/stenting (n = 8; 3.6%), bypass (n = 47; 21.3%) or direct major limb amputation (n = 7; 3.2%). Limb salvage and survival rates at 30/90 days were 95%/95% and 82.3%/74.1%, respectively. Independent risk factors for major amputation were diabetes, severe neuro-ischemic impairment, acute arterial thrombosis and treatment delay >1 day after vascular consultation. In addition, age, chronic peripheral arterial disease, any neuro-ischemic impairment and a hospitalization for any other reason simultaneous to the ALI were independently associated with mortality. CONCLUSIONS: Regardless of excellent limb salvage rates, patients currently suffering from an ALI are, when compared to previous studies, older than before and with an increased rate of mortality. Risk factors do not appear to be modifiable once the ALI appears so prevention strategies should be aimed to avoid the episode.


Assuntos
Arteriopatias Oclusivas/complicações , Extremidades/irrigação sanguínea , Isquemia/terapia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Feminino , Humanos , Isquemia/etiologia , Isquemia/mortalidade , Salvamento de Membro , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
10.
J Clin Hypertens (Greenwich) ; 20(1): 69-75, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29316186

RESUMO

Renal denervation and spironolactone have both been proposed for the treatment of resistant hypertension, but their effects on preclinical target organ damage have not been compared. Twenty-four patients with 24-hour systolic blood pressure ≥140 mm Hg despite receiving three or more full-dose antihypertensive drugs, one a diuretic, were randomized to receive spironolactone or renal denervation. Changes in 24-hour blood pressure, urine albumin excretion, arterial stiffness, carotid intima-media thickness, and left ventricular mass index were evaluated at 6 months. Mean baseline-adjusted difference between the two groups (spironolactone vs renal denervation) at 6 months in 24-hour systolic blood pressure was -17.9 mm Hg (95% confidence interval [CI], -30.9 to -4.9; P = .01). Mean baseline-adjusted change in urine albumin excretion was -87.2 (95% CI, -164.5 to -9.9) and -23.8 (95% CI, -104.5 to 56.9), respectively (P = .028). Mean baseline-adjusted variation of 24-hour pulse pressure was -13.5 (95% CI, -18.8 to -8.2) and -2.1 (95% CI, -7.9 to 3.7), respectively (P = .006). The correlation of change in 24-hour systolic blood pressure with change in log-transformed urine albumin excretion was r = .713 (P < .001). At 6 months there was a reduction in albuminuria in patients with resistant hypertension treated with spironolactone as compared with renal denervation.


Assuntos
Anti-Hipertensivos/uso terapêutico , Espessura Intima-Media Carotídea , Hipertensão , Rim/inervação , Eliminação Renal , Espironolactona/administração & dosagem , Simpatectomia/métodos , Rigidez Vascular , Idoso , Pressão Sanguínea , Monitorização Ambulatorial da Pressão Arterial/métodos , Diuréticos/administração & dosagem , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipertensão/cirurgia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
11.
JACC Cardiovasc Interv ; 9(23): 2440-2448, 2016 12 12.
Artigo em Inglês | MEDLINE | ID: mdl-27838262

RESUMO

OBJECTIVES: The aim of this study was to assess the effectiveness of inferior vena cava (IVC) filter use among patients who develop recurrent symptomatic venous thromboembolism (VTE) on anticoagulant therapy. BACKGROUND: There is a lack of efficacy evidence of IVC filter therapy in patients with VTE recurrence on anticoagulant therapy. METHODS: In this cohort study of patients with acute VTE identified from the RIETE (Registro Informatizado de la Enfermedad Tromboembólica) registry, the associations between IVC filter placement for VTE recurrence in the first 3 months of anticoagulant therapy and the outcomes of all-cause mortality, pulmonary embolism (PE)-related mortality, second recurrent VTE, and major bleeding rates through 30 days after diagnosis of recurrence were assessed. RESULTS: Among 17 patients treated with filters and 49 matched patients treated without filters for VTE recurrence that presented as deep vein thrombosis, propensity score-matched groups showed no significant differences in death for filter insertion compared with no insertion (17.7% vs. 12.2%; p = 0.56). Among 48 patients treated with filters and 91 matched patients treated without filters for VTE recurrence that presented as PE, propensity score-matched groups showed a significant decrease in all-cause death for filter insertion compared with no insertion (2.1% vs. 25.3%; p = 0.02). The PE-related mortality rate was not significantly lower for filter insertion than no insertion (2.1% vs. 17.6%; p = 0.08), though the point estimates markedly differed. CONCLUSIONS: Among patients with VTE recurrence during the first 3 months of anticoagulant therapy, IVC filter insertion was not associated with a survival benefit in patients who recurred with deep vein thrombosis, although it was associated with a lower risk for all-cause death in patients who recurred with PE.


Assuntos
Anticoagulantes/uso terapêutico , Embolia Pulmonar/terapia , Filtros de Veia Cava , Veia Cava Inferior , Tromboembolia Venosa/terapia , Trombose Venosa/terapia , Idoso , Idoso de 80 Anos ou mais , Canadá , Distribuição de Qui-Quadrado , Equador , Europa (Continente) , Feminino , Hemorragia/etiologia , Humanos , Israel , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pontuação de Propensão , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/mortalidade , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/mortalidade
12.
Ann Vasc Surg ; 36: 153-158, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27321978

RESUMO

BACKGROUND: According to the current guidelines, long-term survival is an important factor influencing decision making in patients with severe asymptomatic carotid stenosis. Nevertheless, data are lacking for populations with a low incidence of coronary heart disease, the main cause of death among these patients. We aimed to assess the long-term survival after carotid endarterectomy (CEA) in a Mediterranean hospital. METHODS: Retrospective analysis was conducted of 291 consecutive patients (main age 69 years, 78.7% men) who underwent a CEA for symptomatic (n = 147, 50.5%) or asymptomatic (n = 144, 49.5%) carotid stenosis in 2005-2014 at the Hospital del Mar (Barcelona, Spain). A Kaplan-Meier life table was done and a multivariable Cox regression model was built for the analysis of the long-term survival-associated risk factors. RESULTS: The immediate combined mortality and/or neurological morbidity rate was 2.7%. The mean follow-up was 55 months (complete in 99.7%). During follow-up 62 patients (21.3%) died, being cancer the most frequent cause (35.5%). Cumulative 3- and 5-year survival rates were 89% and 81%, respectively. Independent risk factors (Cox regression) related to survival included age (hazards ratio [HR] 1.09, P < 0.001), an American Society of Anesthesiologists class IV score (HR 4.04, P = 0.015), and the preoperative hemoglobin value (HR 0.73, P < 0.001). The discrimination of the resulting model was 0.719 (95% confidence interval 0.644-0.794). Previous symptomatic carotid stenosis was not related to long-term survival. CONCLUSIONS: The long-term survival of patients submitted to CEA in our series lies in the lower limit of the estimated range by other groups and is markedly related to cancer. Our study suggests that predictive models for survival are influenced by regional characteristics.


Assuntos
Estenose das Carótidas/cirurgia , Doença das Coronárias/mortalidade , Técnicas de Apoio para a Decisão , Endarterectomia das Carótidas , Sobreviventes , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Doença das Coronárias/diagnóstico , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Espanha/epidemiologia , Fatores de Tempo , Resultado do Tratamento
13.
J Hypertens ; 34(9): 1863-71, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27327441

RESUMO

OBJECTIVE: Both renal denervation (RDN) and spironolactone have been proposed for the treatment of resistant hypertension. However, they have not been compared in a randomized clinical trial. We aimed to compare the efficacy of spironolactone versus RDN in patients with resistant hypertension. METHODS: A total of 24 patients with office SBP at least 150 mmHg and 24-h SBP at least 140 mmHg despite receiving at least three full-dose antihypertensive drugs, one a diuretic, but without aldosterone antagonists, were randomized to receive RDN or spironolactone (50 mg) as add-on therapy. Primary endpoint was change in 24-h SBP at 6 months. Comparisons between treatment groups were performed using generalized linear models adjusted by age, sex, and baseline values. RESULTS: Spironolactone was more effective than RDN in reducing 24-h SBP and 24-h DBP: mean baseline-adjusted differences between the two groups were -17.9 mmHg (95%CI -30.9 to -4.9); P = 0.010 and -6.6 mmHg (95%CI -12.9 to -0.3); P = 0.041, for 24-h SBP and 24-h DBP, respectively. As regards changes in office blood pressure, mean baseline-adjusted differences between the two groups were -12.1 mmHg (95%CI -29.1 to 5.1); P = 0.158 and of -5.3 mmHg (95%CI -16.3 to 5.8); P = 0.332, for office SBP and office DBP, respectively. Otherwise, the decrease of estimated glomerular filtration rate was greater in the spironolactone group; mean baseline-adjusted difference between the two groups was -10.7 ml/min per 1.73 m (95%CI -20.1 to -1.4); P = 0.027. CONCLUSION: We conclude that spironolactone is more effective than RDN to reduce 24-h SBP and 24-h DBP in patients with resistant hypertension. Therefore, spironolactone should be the fourth antihypertensive drug to prescribe if deemed well tolerated' in all patients with resistant hypertension before considering RDN.


Assuntos
Pressão Sanguínea , Vasoespasmo Coronário/tratamento farmacológico , Vasoespasmo Coronário/cirurgia , Diuréticos/uso terapêutico , Hipertensão/tratamento farmacológico , Hipertensão/cirurgia , Rim/inervação , Espironolactona/uso terapêutico , Simpatectomia , Idoso , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Monitorização Ambulatorial da Pressão Arterial , Quimioterapia Combinada , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
14.
Rev. esp. quimioter ; 29(3): 119-121, jun. 2016. tab
Artigo em Espanhol | IBECS | ID: ibc-153085

RESUMO

We report a quasi-experimental study of the implementation of an antimicrobial stewardship program in two surgical wards, with a pre-intervention period with just assessment of prescription and an intervention period with a prospective audit on antibiotic prescription model. There was a significant reduction of length of stay and the total days of antimicrobial administration. There were no differences in mortality between groups. The antimicrobial stewardship program led to the early detection of inappropriate empirical antibiotic treatment and was associated with a significant reduction in length of stay and the total duration of antimicrobial therapy (AU)


Presentamos un estudio cuasi-experimental de la aplicación de un programa de uso de terapia antimicrobiana en dos salas quirúrgicas, con un período de pre-intervención en que se realizó evaluación de la prescripción y un período de intervención con una auditoría prospectiva sobre la prescripción antibiótica siguiendo un modelo de recomendación. Hubo una reducción significativa de la estancia media y del total de días de tratamiento antibiótico. No hubo diferencias en la mortalidad entre los grupos. El programa de uso de terapia antimicrobiana condujo a la detección precoz de tratamiento antibiótico empírico inadecuado y se asoció con una reducción significativa de la estancia media y la duración total de la terapia antimicrobiana (AU)


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Anti-Infecciosos/administração & dosagem , Anti-Infecciosos/uso terapêutico , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Salas Cirúrgicas , Antibacterianos/uso terapêutico , Estudos Prospectivos , Diagnóstico Precoce , Tempo de Internação/economia , Tempo de Internação/legislação & jurisprudência , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Cefotaxima/uso terapêutico , Ciprofloxacino/uso terapêutico , Piperacilina/uso terapêutico
15.
World J Surg ; 40(5): 1272-8, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26711643

RESUMO

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) is a prophylactic procedure, so the decision to operate should consider, as recent guidelines suggest, the life expectancy of the patient. Several models for predicting life span have been already designed, but little is known about how intervened patients evolve in Southern European Countries, where the incidence of coronary artery disease, the main cause of death among these subjects, is low. METHODS: We conducted a retrospective analysis of 176 consecutive patients who underwent elective EVAR at the Vascular Surgery Department of the Hospital del Mar (Barcelona, Spain) during 2000-2014. Cox regressions were performed to identify preoperative factors associated with long-term survival after EVAR, and a risk model was developed. RESULTS: Three- and five-year survival rates were 73.9 and 53.9 %, respectively. During the follow-up, 72 deaths (40.9 %) were registered, cancer being the most frequent cause (41.7 %). Preoperative variables negatively associated with long-term survival were serum creatinine ≥ 150 µmol/L (HR 2.5; 95 % CI 1.4-4.2), chronic obstructive pulmonary disease (HR 1.9; 95 % CI 1.2-3.1), atrial fibrillation (HR 2.0; 95 % CI 1.2-3.4), and prior cancer history (HR 1.9; 95 % CI 1.2-3.1). Distal pulses present in both lower limbs were marginally associated with survival (HR 0.65; 95 % CI 0.4-1.07). The survival predictive model showed a good discrimination capacity (C statistic = 0.703; 95 % CI 0.641-0.765). CONCLUSIONS: Long-term survival of patients submitted to EVAR in our setting was worse than expected and markedly related to cancer. Our study suggests that predictive models for long-term survival after EVAR may be influenced by regional characteristics of the intervened population. This effect should be taken in consideration in the decision-making process of these patients.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Doença da Artéria Coronariana/epidemiologia , Procedimentos Endovasculares/mortalidade , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Doença da Artéria Coronariana/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento
16.
Nefrología (Madr.) ; 33(4): 564-570, jul.-ago. 2013. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-117274

RESUMO

Introducción/objetivo: La guía de la National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/KDOQI) recomienda que la repermeabilización de prótesis arteriovenosas (AV) para hemodiálisis trombosadas debe alcanzar resultados favorables en el 40 % a 3 meses si es por técnica endovascular, o en el 50 % a 6 meses y el 40 % al año si es por un procedimiento quirúrgico. Este estudio evalúa los resultados de un tratamiento híbrido (endovascular y quirúrgico mínimamente invasivo) de las trombosis de prótesis AV asociadas a estenosis anastomóticas venosas. Pacientes y métodos: Entre 2008 y 2012 se intervinieron 27 pacientes consecutivos (edad media: 69,7 años; 52 % varones) con trombosis de prótesis AV (74,1 % extremidad superior) asociadas a estenosis anastomótica venosa mediante trombectomía abierta (miniincisión en trayecto), stent cubierto autoexpandible (Fluency®, Bard) y angioplastia a alta presión (> 20 atm). Resultados: La permeabilidad inmediata con hemodiálisis eficaz fue del 89 %, con una estancia media de 1,9 días y ausencia de complicaciones posoperatorias. La permeabilidad primaria a 3, 6 y 12 meses fue, respectivamente, del 51,9 %, 44,4 % y 16,2 % (seguimiento medio: 15 meses). La permeabilidad secundaria tras un nuevo episodio trombótico y procedimiento de similares características (62,9 % de los casos) fue del 70,4 %, 51,9 % y 37 %, respectivamente. Conclusiones: A pesar de ser seguro y poco invasivo, este tratamiento híbrido de las trombosis de prótesis AV asociadas a estenosis anastomóticas venosas solo (..) (AU)


Introduction/objective: The NKF-K/DOQI guidelines recommend that the repermeabilisation of thrombosed arteriovenous (AV) grafts for haemodialysis must achieve positive results in 40% at 3 months, if it is performed by endovascular technique, or 50% at 6 months and 40% at one year if it is performed by surgical procedure. This study assesses the results of a hybrid treatment (minimally invasive surgical and endovascular treatment) of AV graft thrombosis associated to venous anastomotic stenosis. Patients and Method: Between 2008 and 2012, 27 consecutive patients underwent surgery (average age: 69.7, 52% male) due to AV graft thrombosis associated to venous anastomotic stenosis (74.1% upper extremity) by open thrombectomy (mini-incision in the graft), covered self-expanding stent (Fluency®, Bard), and high pressure angioplasty (>20atm). Results: Immediate patency with effective haemodialysis was 89%, with an average stay of 1.9 days and no postoperative complications. Primary patency at 3, 6, and 12 months was 51.9%, 44.4%, and 16.2% respectively (mean follow-up: 15 months). Secondary patency after a new thrombotic episode and similar procedure (62.9% of cases) was 70.4%, 51.9%, and 37% respectively. Conclusions: Despite being safe and minimally (..) (AU)


Assuntos
Humanos , Oclusão de Enxerto Vascular/cirurgia , Trombose/cirurgia , Angioplastia/métodos , Trombectomia/métodos , Anastomose Cirúrgica/efeitos adversos
17.
Nefrologia ; 33(4): 564-70, 2013.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-23897189

RESUMO

INTRODUCTION/OBJECTIVE: The NKF-K/DOQI guidelines recommend that the repermeabilisation of thrombosed arteriovenous (AV) grafts for haemodialysis must achieve positive results in 40% at 3 months, if it is performed by endovascular technique, or 50% at 6 months and 40% at one year if it is performed by surgical procedure. This study assesses the results of a hybrid treatment (minimally invasive surgical and endovascular treatment) of AV graft thrombosis associated to venous anastomotic stenosis. PATIENTS AND METHOD: Between 2008 and 2012, 27 consecutive patients underwent surgery (average age: 69.7, 52% male) due to AV graft thrombosis associated to venous anastomotic stenosis (74.1% upper extremity) by open thrombectomy (mini-incision in the graft), covered self-expanding stent (Fluency, Bard), and high pressure angioplasty (>20atm). RESULTS: Immediate patency with effective haemodialysis was 89%, with an average stay of 1.9 days and no postoperative complications. Primary patency at 3, 6, and 12 months was 51.9%, 44.4%, and 16.2% respectively (mean follow-up: 15 months). Secondary patency after a new thrombotic episode and similar procedure (62.9% of cases) was 70.4%, 51.9%, and 37% respectively. CONCLUSIONS: Despite being safe and minimally invasive, this hybrid treatment for AV graft thrombosis associated to venous anastomotic stenosis only achieves competitive results compared to open surgery after a second iterative procedure. Because of this and the associated costs, this technique should be reserved for difficult surgical approach stenoses.


Assuntos
Angioplastia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Prótese Vascular/efeitos adversos , Diálise Renal/instrumentação , Stents , Trombectomia , Trombose/etiologia , Trombose/terapia , Idoso , Constrição Patológica , Feminino , Humanos , Masculino
18.
World J Surg ; 34(8): 1975-9, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20386903

RESUMO

OBJECTIVE: This study was designed to assess the incidence of peripheral arterial occlusive disease (PAOD) in a population-based cohort of men aged 55-74 years and to establish a predictive function based on risk factors for the disease. METHODS: This was a prospective study of 699 men representative of an urban population. Cardiovascular risk factors, history of cardiovascular events, and ankle-brachial index (ABI) at baseline and at 5 years were measured. PAOD was defined as a confirmed ABI <0.9. RESULTS: A total of 468 (67%) subjects could be evaluated at 5 years. In the remaining 233 subjects, 94 had PAOD at baseline, 66 died during the study, and 73 were lost to follow-up. At the end of the 5-year study period, 56 (12%) subjects developed PAOD (21.4% ABI <0.6, 78.6% ABI between 0.61 and 0.9). Independent predictors for PAOD were age older than 70 years at baseline (odds ratio [OR] 2.5, P = 0.004), smoking history more than 40 pack-year (OR = 2.27, P = 0.007), history of cerebrovascular disease (OR = 3.49, P = 0.02), and symptomatic coronary disease (OR = 3.36, P = 0.004). The 5-year incidence of PAOD was 22.4% for subjects older than 70 years, 21.5% for heavy smokers, 29.4% for those with previous cerebrovascular events, and 25% for subjects with ischemic heart disease. The risk for PAOD in subjects without risk factors was 6%. CONCLUSIONS: Twelve percent of adult men aged between aged 55 and 74 years developed PAOD during a follow-up of 5 years. Besides subjects with history of cardiovascular disease, men older than aged 70 years and heavy smokers constituted a high-risk group for PAOD and, therefore, the object of directed efforts of primary prevention.


Assuntos
Arteriopatias Oclusivas/epidemiologia , Aterosclerose/epidemiologia , Doenças Vasculares Periféricas/epidemiologia , Fatores Etários , Idoso , Arteriopatias Oclusivas/terapia , Aterosclerose/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/terapia , Estudos Prospectivos , Fatores de Risco , Fumar/epidemiologia , Espanha/epidemiologia , População Urbana
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