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1.
Am Surg ; 85(10): 1146-1149, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657312

RESUMO

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic (P < 0.001), had a higher incidence of preadmission antithrombotic therapy use (P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups (P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Tratamento de Emergência/efeitos adversos , Cálculos Biliares/cirurgia , Complicações Intraoperatórias/epidemiologia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Fatores Etários , Ductos Biliares/lesões , Conversão para Cirurgia Aberta/estatística & dados numéricos , Tratamento de Emergência/métodos , Feminino , Fibrinolíticos/uso terapêutico , Cálculos Biliares/etiologia , Hemorragia/epidemiologia , Humanos , Incidência , Intestinos/lesões , Complicações Intraoperatórias/etiologia , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados (Cuidados de Saúde) , Estudos Retrospectivos , Fatores de Risco , Segurança , Fatores Sexuais , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos
2.
BMJ ; 367: l5476, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601578

RESUMO

OBJECTIVE: To assess the effects of different oral antithrombotic drugs that prevent saphenous vein graft failure in patients undergoing coronary artery bypass graft surgery. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Medline, Embase, Web of Science, CINAHL, and the Cochrane Library from inception to 25 January 2019. ELIGIBILITY CRITERIA: for selecting studies Randomised controlled trials of participants (aged ≥18) who received oral antithrombotic drugs (antiplatelets or anticoagulants) to prevent saphenous vein graft failure after coronary artery bypass graft surgery. MAIN OUTCOME MEASURES: The primary efficacy endpoint was saphenous vein graft failure and the primary safety endpoint was major bleeding. Secondary endpoints were myocardial infarction and death. RESULTS: This review identified 3266 citations, and 21 articles that related to 20 randomised controlled trials were included in the network meta-analysis. These 20 trials comprised 4803 participants and investigated nine different interventions (eight active and one placebo). Moderate certainty evidence supports the use of dual antiplatelet therapy with either aspirin plus ticagrelor (odds ratio 0.50, 95% confidence interval 0.31 to 0.79, number needed to treat 10) or aspirin plus clopidogrel (0.60, 0.42 to 0.86, 19) to reduce saphenous vein graft failure when compared with aspirin monotherapy. The study found no strong evidence of differences in major bleeding, myocardial infarction, and death among different antithrombotic therapies. The possibility of intransitivity could not be ruled out; however, between-trial heterogeneity and incoherence were low in all included analyses. Sensitivity analysis using per graft data did not change the effect estimates. CONCLUSIONS: The results of this network meta-analysis suggest an important absolute benefit of adding ticagrelor or clopidogrel to aspirin to prevent saphenous vein graft failure after coronary artery bypass graft surgery. Dual antiplatelet therapy after surgery should be tailored to the patient by balancing the safety and efficacy profile of the drug intervention against important patient outcomes. STUDY REGISTRATION: PROSPERO registration number CRD42017065678.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Fibrinolíticos/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/prevenção & controle , Humanos , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto
3.
Lancet ; 394(10206): 1335-1343, 2019 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-31492505

RESUMO

BACKGROUND: We aimed to assess the safety of edoxaban in combination with P2Y12 inhibition in patients with atrial fibrillation who had percutaneous coronary intervention (PCI). METHODS: ENTRUST-AF PCI was a randomised, multicentre, open-label, non-inferiority phase 3b trial with masked outcome evaluation, done at 186 sites in 18 countries. Patients had atrial fibrillation requiring oral anticoagulation, were aged at least 18 years, and had a successful PCI for stable coronary artery disease or acute coronary syndrome. Participants were randomly assigned (1:1) from 4 h to 5 days after PCI using concealed, stratified, and blocked web-based central randomisation to either edoxaban (60 mg once daily) plus a P2Y12 inhibitor for 12 months or a vitamin K antagonist (VKA) in combination with a P2Y12 inhibitor and aspirin (100 mg once daily, for 1-12 months). The edoxaban dose was reduced to 30 mg per day if one or more factors (creatinine clearance 15-50 mL/min, bodyweight ≤60 kg, or concomitant use of specified potent P-glycoprotein inhibitors) were present. The primary endpoint was a composite of major or clinically relevant non-major (CRNM) bleeding within 12 months. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of their assigned study drug. This trial is registered with ClinicalTrials.gov, NCT02866175, is closed to new participants, and follow-up is completed. FINDINGS: From Feb 24, 2017, through May 7, 2018, 1506 patients were enrolled and randomly assigned to the edoxaban regimen (n=751) or VKA regimen (n=755). Median time from PCI to randomisation was 45·1 h (IQR 22·2-76·2). Major or CRNM bleeding events occurred in 128 (17%) of 751 patients (annualised event rate 20·7%) with the edoxaban regimen and 152 (20%) of 755 patients (annualised event rate 25·6%) patients with the VKA regimen; hazard ratio 0·83 (95% CI 0·65-1·05; p=0·0010 for non-inferiority, margin hazard ratio 1·20; p=0·1154 for superiority). INTERPRETATION: In patients with atrial fibrillation who had PCI, the edoxaban-based regimen was non-inferior for bleeding compared with the VKA-based regimen, without significant differences in ischaemic events. FUNDING: Daiichi Sankyo.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Fibrinolíticos/uso terapêutico , Intervenção Coronária Percutânea , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Vitamina K/antagonistas & inibidores , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/cirurgia , Idoso , Fibrilação Atrial/complicações , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Stents , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
6.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 48(3): 241-246, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31496154

RESUMO

OBJECTIVE: To investigate the effect of emergency medical service (EMS) on the prognosis of ischemic stroke patients treated with intravenous thrombolysis. METHODS: Clinical data of 2123 ischemic stroke patients treated with intravenous thrombolysis in 70 hospitals in Zhejiang province were retrospectively analyzed. There were 808 patients sent to the hospital by ambulance (EMS group) and 1315 patients by other transportations (non-EMS group). Good outcome was defined as modified Rankin Scale (mRS) ≤ 2 at 3-month. The onset to needle time (ONT), onset to door time (ODT), door to needle time (DNT) and outcome were compared between EMS group and non-EMS group. Binary logistic regression was used to explore the influencing factors for the outcome at 3-month. RESULTS: Compared with the non-EMS group, patients in the EMS group were older, with higher baseline National Institute of Health Sroke Scale (NIHSS) score, and had a higher proportion of atrial fibrillation (all P<0.05), but there were no significant differences in ONT, ODT and DNT between two groups (all P>0.05). Binary logistic regression showed that EMS was not independently associated with good outcome (OR=0.856, 95%CI:0.664-1.103, P>0.05). CONCLUSIONS: EMS had not improve the outcome of patients receiving intravenous thrombolysis in Zhejiang province.


Assuntos
Isquemia Encefálica , Serviços Médicos de Emergência , Acidente Vascular Cerebral , Terapia Trombolítica , Administração Intravenosa , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Humanos , Prognóstico , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/estatística & dados numéricos , Resultado do Tratamento
7.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 48(3): 247-253, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31496155

RESUMO

OBJECTIVE: To investigate the effect of treatment time on the outcome of patients with ischemic stroke undergoing reperfusion therapy. METHODS: The clinical data of 3229 ischemic stroke patients who received intravenous thrombolysis with or without arterial thrombolysis from 71 hospitals in Zhejiang province from June 2017 to September 2018 were retrospectively reviewed. The good outcome was defined as modified Rankin Scale (mRS) ≤ 2. Binary logistic regression analysis was used to investigate the association of door to needle time (DNT), or door to reperfusion time (DRT) with the outcomes in patients treated by intravenous thrombolysis or bridging arterial thrombolysis, respectively. RESULTS: Binary logistic regression showed that DNT (OR=0.994, 95%CI:0.991-0.997, P<0.01) or DRT (OR=0.989, 95%CI:0.983-0.995, P<0.01) were independently associated with good outcomes, respectively. Every hour decreases in DNT resulted in a 4.7%increased probability of functional independence (mRS 0-2) in patients treated by intravenous thrombolysis; Every hour decreases in DRT was associated with a 11.4%increased probability of functional independence in patients treated by intravenous thrombolysis with arterial thrombolysis. CONCLUSIONS: Good outcomes are associated with lower DNT in ischemic stroke patients treated by intravenous thrombolysis or lower DRT in patients treated by intravenous thrombolysis bridging arterial thrombolysis.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Terapia Trombolítica , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Humanos , Reperfusão , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de Tempo , Resultado do Tratamento
8.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 48(3): 260-266, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31496157

RESUMO

OBJECTIVE: To compare the time delay between in-hospital stroke and out-of-hospital stroke patients, and to explore the influence factors for the prognosis of in-hospital stroke patients treated by intravenous thrombolysis. METHODS: Clinical data of 3050 patients with ischemic stroke who received intravenous thrombolysis in 71 hospitals in Zhejiang province from June 2017 to September 2018 were analyzed. Differences of time delay including door to imaging time (DIT), imaging to needle time (INT) and door to needle time (DNT) between in-hospital stroke (n=101) and out-of-hospital stroke (n=2949) were observed. The influencing factors for the outcome at 3 month after intravenous thrombolysis in patients with in-hospital stroke were analyzed using binary logistic regression analysis. RESULTS: Patients with in-hospital stroke had longer DIT[53.5 (32.0-79.8) min vs. 20.0 (14.0-28.0) min, P<0.01], longer IDT[47.5(27.3-64.0)min vs. 36.0(24.0-53.0)min, P<0.01], and longer DNT[99.0 (70.5-140.5) min vs. 55.0 (41.0-74.0) min, P<0.01], compared with patients with out-of-hospital stroke; patients in comprehensive stroke center had longer DIT[59.5(44.5-83.3) min vs. 37.5(16.5-63.5) min, P<0.01], longer DNT[110.0(77.0-145.0) min vs. 88.0 (53.8-124.3) min, P<0.05], but shorter INT[36.5(23.8-60.3)min vs. 53.5 (34.3-64.8) min, P<0.05], compared with patients in primary stroke center. Age (OR=0.934, 95%CI: 0.882-0.989, P<0.05) and baseline National Institute of Health Stroke Scale score (OR=0.912, 95%CI: 0.855-0.973, P<0.01) were independent risk factors for prognosis of in-hospital stroke patients. CONCLUSIONS: In-hospital stroke had longer DIT and DNT than out-of-hospital stroke, which suggests that a more smooth thrombolysis process of in-hospital stroke should be established.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Administração Intravenosa , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Hospitais/estatística & dados numéricos , Humanos , Prognóstico , Terapia Trombolítica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
9.
Angiol Sosud Khir ; 25(3): 23-28, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31503244

RESUMO

The authors carried out a retrospective analysis of clinical efficacy of streptokinase and alteplase (actilyse®) in patients presenting with high- and intermediate-to-high risk pulmonary artery thromboembolism (PATE) who were discharged from hospital after appropriate treatment performed. Of the total number of the treated patients, we formed 2 groups comprising 20 patients each, receiving alteplase (group 1) and streptokinase (group 2). The patients were comparable by the main clinical characteristics, predisposing factors, severity of pulmonary artery thromboembolism (PATE) and duration of treatment. Efficacy of thrombolytic therapy assessed clinically and instrumentally did not differ. However, by the stratified risk and frequency of PATE relapses, the condition of patients receiving alteplase turned out to be more severe. Based on the obtained results, a conclusion was made that actilyse is a drug of choice for treatment of patients with PATE.


Assuntos
Fibrinolíticos , Embolia Pulmonar , Fibrinolíticos/uso terapêutico , Humanos , Embolia Pulmonar/tratamento farmacológico , Estudos Retrospectivos , Terapia Trombolítica , Ativador de Plasminogênio Tecidual
10.
Stud Health Technol Inform ; 264: 768-772, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438028

RESUMO

A systematic review and meta-analysis was conducted to investigate the effects of computerized guideline-oriented clinical decision support system (CDSS) on antithrombotic therapy in patients with atrial fibrillation. PubMed, the Cochrane Library, and Web of Science were queried. Four studies were included in this meta-analysis. The proportion of appropriate antithrombotic therapy in accordance with clinical guidelines was significantly higher in the CDSS group than in the control group (risk ratio (RR): 1.03, 95% confidence interval (CI): 1.01 to 1.04, P = 0.004). Although the incidence of thromboembolic events was similar between the two groups (RR: 1.12, 95% CI: 0.88 to 1.42, P = 0.357), the incidence of major bleeding tended to be lower in the CDSS group compared with the control group (RR: 0.79, 95% CI: 0.61 to 1.01, P = 0.063). Computerized guideline-oriented CDSS may be effective for appropriate antithrombotic therapy as compared with control in patients with atrial fibrillation.


Assuntos
Fibrilação Atrial , Sistemas de Apoio a Decisões Clínicas , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral , Anticoagulantes , Fibrilação Atrial/tratamento farmacológico , Humanos
11.
Nervenarzt ; 90(10): 987-994, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31407044

RESUMO

Significant advances in the acute treatment of patients with intracerebral hemorrhage (ICH) have been achieved in recent years. While many randomized trials have provided neutral results, important findings have been generated for the design of follow-up studies. Furthermore, a number of observational studies have been published, which in turn provide the basis for further methodologically stronger investigations. The focus is on avoidance of early bleeding progression, which can be influenced by blood pressure management and hemostasis. Furthermore, ICH surgery may experience a renaissance through minimally invasive techniques. In addition, perihemorrhagic edema and its pharmacological modulation are becoming increasingly more important. Optimal treatment of ventricular involvement is continuing to develop dynamically. Finally, long-term antithrombotic treatment has been intensely studied in observational analyses and is currently being investigated in randomized trials. This article addresses these most relevant topics in acute and long-term treatment of ICH patients and provides an overview of current debates in these areas of treatment.


Assuntos
Hemorragia Cerebral , Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/cirurgia , Fibrinolíticos/uso terapêutico , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/tendências
12.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(7): 842-846, 2019 Jul.
Artigo em Chinês | MEDLINE | ID: mdl-31441407

RESUMO

OBJECTIVE: To observe the damage of high mobility group box 1 (HMGB1) on human umbilical vein endothelial cell (HUVEC) barrier permeability and the protective effect of unfractionated heparin (UFH), and to explore the down-regulated protection effect mechanism of UFH on HMGB1-mediated vascular endothelial cadherin (VE-cadherin) expression. METHODS: The trypsin-digested HUVEC were subcultured in culture flasks. When the cells were grown to 80%, they were randomly divided into four groups: phosphate buffer (PBS) control group (200 µL PBS), recombinant human high mobility group box 1 (rhHMGB1) treatment group (100 µg/L rhHMGB1), UFH control group (10 kU/L UFH), and UFH pretreatment group (10 kU/L UFH+100 µg/L rhHMGB1). The cells in each group were challenged with different reagent for 24 hours, and the activity of endothelial cells was determined by methyl thiazolyl tetrazolium (MTT) colorimetric assay. The permeability of endothelial cells was measured by Transwell method, and the expression and distribution of VE-cadherin was observed by immunofluorescence. The protein expressions of VE-cadherin and phosphorylated p38 mitogen-activated protein kinase (p-p38MAPK) were determined by Western Blot. RESULTS: After treatment with 100 µg/L rhHMGB1 for 24 hours, the activity of endothelial cells was not significantly different from that of the PBS control group (A value: 0.230±0.004 vs. 0.255±0.006, P > 0.05), but the permeability was significantly increased (glucan FD40 fluorescence intensity: 11.05±0.12 vs. 6.34±0.39, P < 0.05). Compared with PBS control group, the fluorescence microscopy showed that the VE-cadherin membrane localization was reduced, the distribution was loose, and there were obvious fissures between cells in rhHMGB1 treatment group, and quantitative analysis showed the protein expression of VE-cadherin was decreased significantly (VE-cadherin/ß-actin: 0.16±0.04 vs. 0.31±0.03, P < 0.05), and the expression of p-p38MAPK protein was significantly increased (p-p38MAPK/ß-actin: 0.79±0.03 vs. 0.26±0.05, P < 0.05). UFH pretreatment could protect HMGB1-mediated endothelial cell injury, cell permeability was significantly reduced (glucan FD40 fluorescence intensity: 9.11±0.23 vs. 11.05±0.12), fluorescence expression of VE-cadherin was enhanced, membrane localization was significantly increased, quantitative analysis showed that VE-cadherin protein expression was significantly up-regulated (VE-cadherin/ß-actin: 0.24±0.02 vs. 0.16±0.04), and p38MAPK phosphorylation level was significantly decreased (p-p38MAPK/ß-actin: 0.54±0.05 vs. 0.79±0.03), the difference was statistically significant as compared with rhHMGB1 treatment group (all P < 0.05). There was no significant difference in all parameters between PBS control group and UFH control group. CONCLUSIONS: UFH can protect the endothelial cell barrier from the HMGB1 by regulating the expression and distribution of VE-cadherin. The mechanism may be related to the inhibition of p38MAPK phosphorylation by UFH.


Assuntos
Caderinas/metabolismo , Fibrinolíticos/uso terapêutico , Proteína HMGB1/metabolismo , Heparina/uso terapêutico , Antígenos CD/metabolismo , Permeabilidade Capilar , Células Cultivadas , Células Endoteliais , Humanos
13.
Am Surg ; 85(7): 721-724, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31405415

RESUMO

Despite the incorporation of anticoagulant and antiplatelet (ACAP) drugs in our trauma triage criteria, it is unclear whether trauma team activation (TTA) impacts outcomes in geriatric patients on ACAP drugs sustaining falls. We hypothesized that TTA in this cohort was associated with improved outcomes. The hospital electronic database was queried to identify normotensive, awake patients aged ≥65 years on ACAP agent from 2014 to 2018 presenting to the emergency department after falls. The outcome was in-hospital mortality. The association between TTA and mortality was examined using logistic regression analysis and 1:1 propensity score matching analysis. In this study, 4540 patients on ACAP drugs were analyzed, with TTA occurring in 500 (11%). TTA occurred in younger but more severely injured patients with lower Glasgow Coma Score. Logistic regression revealed that TTA was not associated with mortality (odds ratio [95% confidence intervals], 2.04 [0.89-4.25]). The 1:1 propensity score analysis revealed similar mortality for the matched groups (non-TTA, 1.6% vs TTA, 2.2%, P = 0.64). In the elderly patients on ACAP agents, the current triage criteria resulted in the appropriate use of TTA for more severely injured patients. The lack of outcome benefit suggests that ACAP drug use as a criterion for TTA should be re-evaluated.


Assuntos
Acidentes por Quedas/mortalidade , Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Mortalidade Hospitalar , Centros de Traumatologia/estatística & dados numéricos , Triagem/normas , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Avaliação de Resultados (Cuidados de Saúde) , Melhoria de Qualidade , Estudos Retrospectivos , Triagem/métodos
14.
BMC Neurol ; 19(1): 152, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31277605

RESUMO

BACKGROUND: Simultaneous cerebral and myocardial infarction is called cardiocerebral infarction (CCI), and is rarely encountered. Because of the narrow time window and complex pathophysiology, CCI is challenging to immediately diagnose and treat. CASE PRESENTATION: A 73-year-old woman suddenly developed right hemiplegia and severe aphasia. Twelve-lead electrocardiography showed tachycardic atrial fibrillation without any significant ST-T change. Magnetic resonance imaging revealed a proximal middle cerebral artery occlusion. She was immediately treated with alteplase at the dosage approved for ischemic stroke followed by mechanical thrombectomy as bridging therapy, and complete recanalization was achieved. Aphasia improved and she began to complain of chest pain, and reported that she had experienced chest discomfort just prior to right limb weakness. Coronary angiography showed a partial filling defect in the right coronary artery with rapid and adequate distal flow, for which percutaneous coronary intervention was not required. Alteplase was suggested to have effectively resolved the coronary emboli. The occlusions of the cerebral and coronary arteries were assumed to have occurred nearly simultaneously and cardiogenic embolism due to atrial fibrillation was considered as the most likely etiology. CONCLUSIONS: As seen in the present case, CCI may benefit from immediate treatment with intravenous tissue plasminogen activator (IV-tPA). Although which of percutaneous coronary intervention or cerebral thrombectomy should be performed first remains unclear, we must decide whether to rescue the brain or heart first in each patient within a limited window of time. This dilemma has recently become evident in this era with mechanical thrombectomy strongly established as an effective intervention for acute ischemic stroke. Close cooperation between stroke physicians and cardiologists is becoming more important.


Assuntos
Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico por imagem , Administração Intravenosa , Idoso , Fibrilação Atrial/complicações , Doença da Artéria Coronariana/complicações , Imagem de Difusão por Ressonância Magnética , Eletrocardiografia , Procedimentos Endovasculares , Feminino , Fibrinolíticos/uso terapêutico , Coração , Humanos , Infarto da Artéria Cerebral Média/terapia , Trombectomia , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
15.
Emerg Med Clin North Am ; 37(3): 365-379, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262409

RESUMO

Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Algoritmos , Glicemia/análise , Encéfalo/diagnóstico por imagem , Tomada de Decisão Clínica , Ensaios Clínicos como Assunto , Medicina de Emergência , Procedimentos Endovasculares , Febre/prevenção & controle , Fibrinolíticos/uso terapêutico , Humanos , Hipertensão/terapia , Oxigenoterapia , Transferência de Pacientes , Telemedicina , Tenecteplase/uso terapêutico , Trombectomia , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/uso terapêutico
16.
MMW Fortschr Med ; 161(Suppl 5): 21-24, 2019 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-31313267

RESUMO

BACKGROUND: For patients undergoing acute coronary syndrome, participation in cardiac rehabilitation includes, in addition to lifestyle modification, optimal adjustment to secondary preventive medication. As a result, follow-up events can be prevented very effectively. METHOD: The PATIENT-CARE registry study examined the treatment of patients during rehabilitation. Of particular interest was whether LDL cholesterol (LDL-C) targets were met. RESULTS: The rate of treated patients increased in almost all classes of medication. At discharge, 96.7% of patients received statins, 98.5% antithrombotics and 22.3% antidiabetics. LDL-C was significantly reduced during rehabilitation - on average by 21.3 mg/dl (0.55 mmol/l). 41.9% of the patients achieved the LDL-C target value. CONCLUSION: The results show that the optimization of secondary drug prevention in the outpatient sector must be continued unconditionally and consistently.


Assuntos
Síndrome Coronariana Aguda/terapia , Reabilitação Cardíaca , LDL-Colesterol/sangue , Fibrinolíticos/uso terapêutico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipoglicemiantes/uso terapêutico , Humanos , Sistema de Registros , Resultado do Tratamento
17.
JAMA ; 322(4): 326-335, 2019 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-31334795

RESUMO

Importance: Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown. Objectives: To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke. Design, Setting, and Participants: The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg/dL if had diabetes or ≥150 mg/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria. Interventions: Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg/dL [4.4-7.2 mmol/L]; intensive treatment group: n = 581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg/dL [4.4-9.9 mmol/L]; standard treatment group: n = 570) for up to 72 hours. Main Outcomes and Measures: The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity. Results: Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 529 [46%] women, 920 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futility based on prespecified interim analysis criteria. During treatment, the mean blood glucose level was 118 mg/dL (6.6 mmol/L) in the intensive treatment group and 179 mg/dL (9.9 mmol/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P = .55; unadjusted risk difference, -0.83% [95% CI, -5.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]). Conclusions and Relevance: Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting. Trial Registration: ClinicalTrials.gov Identifier: NCT01369069.


Assuntos
Hiperglicemia/tratamento farmacológico , Hipoglicemiantes/administração & dosagem , Insulina/administração & dosagem , Acidente Vascular Cerebral/complicações , Idoso , Isquemia Encefálica/complicações , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Hiperglicemia/complicações , Hipoglicemia/induzido quimicamente , Hipoglicemiantes/efeitos adversos , Infusões Intravenosas , Injeções Subcutâneas , Insulina/efeitos adversos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
18.
Expert Rev Cardiovasc Ther ; 17(7): 479-496, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31198065

RESUMO

Introduction: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for a large proportion of patients with severe aortic stenosis. Despite numerous technological and clinical advances, TAVI remains associated with thrombotic complications requiring antithrombotic pharmacotherapy, which exposes to the risk of bleeding, especially in elderly individuals. The optimal antithrombotic regimen following TAVI is uncertain and several investigations are ongoing. Areas covered: Clinical guidelines are mostly driven by observational trials and experts' opinions, thus resulting into low-grade level of evidence. The aim of the current review is to critically explore the epidemiology, pathophysiology and prognostic value of thrombotic and bleeding events after TAVI, and to review the current literature on antithrombotic strategies following the procedure. Expert opinion: Thrombotic and bleeding events remain major complications occurring in the frail population that is currently offered TAVI. Waiting for upcoming evidence from ongoing randomized clinical trials, tailoring antithrombotic therapies based on patients' characteristics, values and circumstances is a preferable approach.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Fibrinolíticos/uso terapêutico , Trombose/tratamento farmacológico , Substituição da Valva Aórtica Transcateter/efeitos adversos , Feminino , Humanos , Masculino , Trombose/etiologia , Resultado do Tratamento
19.
Zhonghua Liu Xing Bing Xue Za Zhi ; 40(6): 610-615, 2019 Jun 10.
Artigo em Chinês | MEDLINE | ID: mdl-31238606

RESUMO

Objective: To explore the patient and hospital related determinants of adherence to early antithrombotic therapy among patients with acute ischemic stroke (AIS). Methods: AIS patients aged 50 years old or above who were eligible for early antithrombotic therapy, were included from the China National Stroke Registry Ⅱ (CNSR Ⅱ) project. Characteristics related to patients and hospitals were collected. Univariate analysis method was conducted to explore the correlation between hospital or patient-related determinants and early antithrombotic therapy. A 2-level logistic regression model was set up to identify patient and hospital-related variables that were associated with the adherence to early antithrombotic therapy, with patient as level 1 and hospital as level 2. Results: A total of 16 910 patients were included in the study, with 14 332 (84.75%) of them having received early antithrombotic therapy. Results from the univariate analysis showed that the patient determinants to early antithrombotic therapy would include age, type of health insurance, average income and history of dyslipidemia. Hospital determinants would include factors as: level and region of the hospital, academic status, with/without stroke unit, quality control on single disease and the percentage of neurological beds in total beds (P<0.05). Data on multilevel model showed that the patient-related determinants on early antithrombotic therapy would include age, gender, average income, history of hypertension, National Institutes of Health Stroke Scale (NIHSS) score at admission while hospital related determinants would include percentage of neurological beds in total beds, and region of the hospital (P<0.05). Conclusions: The quality of a hospital was associated with the adherence to early antithrombotic therapy. AIS patients at advanced age or with high NIHSS score at admission should be paid more attention.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Adesão à Medicação , Qualidade da Assistência à Saúde , Acidente Vascular Cerebral/tratamento farmacológico , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , China , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multinível , Sistema de Registros , Fatores Socioeconômicos
20.
J Stroke Cerebrovasc Dis ; 28(8): 2098-2108, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31160219

RESUMO

Sneddon syndrome (SS) is an episodic or chronic, slowly progressive disorder and characterized by generalized livedo racemosa (patchy, violaceous, skin discoloration) and recurrent cerebrovascular events. The histopathology of skin and brain is remarkable for a noninflammatory thrombotic vasculopathy involving medium- and small-sized dermal and cerebral arteries, respectively. Approximately 80% of the SS patients are women with a median age of diagnosis at 40 years. However, the onset of the disease during childhood have been reported. Etiopathogenesis of SS is unknown with 2 primary mechanisms proposed - autoimmune/inflammatory versus thrombophilia. SS is primarily classified as antiphospholipid positive or negative type. Neurological manifestations usually occur in 3 phases: (1) prodromal symptoms such as headaches, dizziness, and vertigo, (2) recurrent strokes, and (3) early onset dementia. Livedo racemosa precedes the onset of recurrent strokes by more than 10 years, but in many instances, the significance of the skin lesion is recognized only after the appearance of the stroke. The involvement of the heart valves, systolic labile hypertension, and retinal changes are also commonly associated with this syndrome. Treatment of SS is primarily based on anecdotal reports. Antiplatelet and antithrombotic agents are used for secondary stroke prophylaxis, and a recent study showed a relatively lower stroke recurrence rate with the universal use of antiplatelet/antithrombotic agents. Routine use of anti-inflammatory or immunosuppressive therapies is controversial. Neuropsychiatric prognosis of SS is relatively poor with predominant deficits in the concentration, attention, visual perception, and visuospatial skills.


Assuntos
Artérias Cerebrais/patologia , Livedo Reticular/etiologia , Pele/irrigação sanguínea , Síndrome de Sneddon/complicações , Acidente Vascular Cerebral/etiologia , Anti-Inflamatórios/uso terapêutico , Artérias Cerebrais/efeitos dos fármacos , Fibrinolíticos/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Livedo Reticular/patologia , Livedo Reticular/fisiopatologia , Livedo Reticular/prevenção & controle , Inibidores da Agregação de Plaquetas/uso terapêutico , Recidiva , Fatores de Risco , Síndrome de Sneddon/tratamento farmacológico , Síndrome de Sneddon/patologia , Síndrome de Sneddon/fisiopatologia , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
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