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3.
Lancet ; 395(10241): 1927-1936, 2020 06 20.
Artigo em Inglês | MEDLINE | ID: mdl-32563378

RESUMO

BACKGROUND: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. METHODS: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. FINDINGS: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82-1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). INTERPRETATION: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.


Assuntos
Antifibrinolíticos/efeitos adversos , Hemorragia Gastrointestinal/tratamento farmacológico , Tromboembolia/induzido quimicamente , Ácido Tranexâmico/efeitos adversos , Doença Aguda , Adulto , Idoso , Antifibrinolíticos/administração & dosagem , Antifibrinolíticos/uso terapêutico , Estudos de Casos e Controles , Método Duplo-Cego , Feminino , Hemorragia Gastrointestinal/mortalidade , Hemorragia Gastrointestinal/prevenção & controle , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Placebos/administração & dosagem , Valor Preditivo dos Testes , Embolia Pulmonar/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Tromboembolia/epidemiologia , Ácido Tranexâmico/administração & dosagem , Ácido Tranexâmico/uso terapêutico , Trombose Venosa/epidemiologia
4.
J Cancer Res Ther ; 16(1): 167-169, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32362630

RESUMO

Lymphoproliferative malignancies can involve both nodal- and extra-nodal tissues. The most common extranodal site involved is the gastrointestinal (GI) tract, and it is secondary to the widespread primary nodal disease. However, about 33% of non-Hodgkin's lymphoma primarily arise from tissues other than lymph nodes, spleen, or bone marrow, for example, GI tract, skin, or the central nervous system and are called primary extranodal lymphomas. The most common site of GI localization is stomach (50%-60%) followed by small bowel. Primary colonic lymphoma is seen only in 6% of GI lymphomas and up to 0.5%-1% of all colon malignancies. Hence, primary GI lymphoma is extremely rare, and primary colonic lymphoma is an even rarer occurrence. There is clearly a paucity of cases reported in literature resulting in unclear treatment protocol. Here, we report a case of a 51-year-old man who presented with abdominal pain, weight loss, and bright red blood per rectum. A colonoscopy revealed diffuse bleeding ulcers involving the entire colon. Pathology was consistent with primary diffuse large B-cell lymphoma arising from the colon. The patient was started on treatment with rituximab, cyclophosphamide, adriamycin, vincristine, and prednisone.


Assuntos
Neoplasias do Colo/virologia , Infecções por Vírus Epstein-Barr/complicações , Hemorragia Gastrointestinal/virologia , Herpesvirus Humano 4/isolamento & purificação , Linfoma Difuso de Grandes Células B/virologia , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias do Colo/tratamento farmacológico , Neoplasias do Colo/patologia , Infecções por Vírus Epstein-Barr/virologia , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/patologia , Humanos , Linfoma Difuso de Grandes Células B/tratamento farmacológico , Linfoma Difuso de Grandes Células B/patologia , Masculino , Prognóstico
5.
Aliment Pharmacol Ther ; 51(11): 1004-1013, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32363690

RESUMO

BACKGROUND: Upper gastrointestinal bleeding is a common medical emergency associated with substantial mortality. Tranexamic acid may be effective for reducing mortality in upper gastrointestinal bleeding. AIM: To examine the effects of tranexamic acid in upper gastrointestinal bleeding by systematic review and meta-analysis. METHODS: We searched PubMed, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL) and other relevant websites for randomised controlled trials investigating the effect of tranexamic acid published from inception to December 10, 2019. The primary outcome of interest was mortality. Estimates of effect were pooled with a random effects model. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: The search identified 1572 citations. Eleven trials comprising 2076 patients were eligible for inclusion. Of these, 10 trials (2013 patients) compared tranexamic acid with placebo. Risk of death was significantly reduced in patients who received tranexamic acid compared with those who received placebo (RR 0.59, 95% CI 0.43-0.82, P = 0.001) with no significant heterogeneity noted among studies (I2  = 0%, P = 0.81). The GRADE assessment rated the quality of the evidence for mortality as moderate due to risk of bias. There were no statistically significant differences between tranexamic acid and placebo for the prevention of re-bleeding, need for surgical interventions, need for blood transfusions or frequency of thromboembolic events. CONCLUSIONS: Moderate-quality evidence shows that tranexamic acid is superior to placebo for the reduction in mortality in patients with upper gastrointestinal bleeding. While our findings lend further support to the use of tranexamic acid for treating patients with upper gastrointestinal bleeding, additional higher-quality trials are needed.


Assuntos
Antifibrinolíticos/uso terapêutico , Hemorragia Gastrointestinal/tratamento farmacológico , Ácido Tranexâmico/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Ensaios Clínicos Controlados como Assunto/normas , Ensaios Clínicos Controlados como Assunto/estatística & dados numéricos , Feminino , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Masculino , Mortalidade , Resultado do Tratamento
6.
Medicine (Baltimore) ; 99(20): e20188, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32443339

RESUMO

INTRODUCTION: The Chinese herb da huang (DH) (Rhubarb) is commonly used for GIF intensive care unit (ICU)/pediatric intensive care unit (PICU) gastrointestinal failure (GIF) patients in China. However, the potential preventive and therapeutic effect of DH in these patients has not yet been studied systematically. OBJECTIVES: The aim of this study was to evaluate the preventive and therapeutic effects of DH in treating ICU/PICU GIF patients with the most recent evidence. METHODS: We systematically searched 7 databases from inception to March 30, 2018. RevMan 5.3 software was used to perform a meta-analysis. GRADE methodology was applied to evaluate the quality of evidence for each outcome. The review protocol was registered on PROSPERO (CRD42018092710) in advance. RESULTS: Seven studies comprising 788 pediatric or adult participants were included in this analysis. Three indicators, including GIF occurrence rates (gastrointestinal mucosal hemorrhage, enteroplegia), multiple organ dysfunction syndrome (MODS)-related items (occurrence rates of MODS, mortality rates of MODS) and duration in the ICU was analyzed. The GIF occurrence rate meta-analysis result was (RR 0.47, CI 95% 0.37-0.60; P = .95); MODS related items indicator result was (RR 0.44, CI 95% 0.33-0.59; P = .41); ICU duration ICU result was (RR -2.87, CI 95% -3.53--2.21; P = .40). The safety of Chinese herb DH (Rhubarb) remains unclear. CONCLUSION: Current evidence suggests that the Chinese herb rhubarb (DH) powder combined with Western medicine was inferior to Western medicine alone in terms of preventive and therapeutic effects in ICU/PICU patients in terms of decreasing GIF occurrence rates (gastrointestinal mucosal hemorrhage and enteroplegia), occurrence rates of MODS, mortality from MODS, and shortened duration time in the ICU/PICU. However, larger sample sizes and rigorously-designed studies are necessary to conclusively determine the association between DH powder and outcomes in ICU/PICU GIF patients.


Assuntos
Gastroenteropatias/tratamento farmacológico , Unidades de Terapia Intensiva Pediátrica/normas , Unidades de Terapia Intensiva/normas , Rheum/efeitos adversos , Adulto , Criança , China/epidemiologia , Medicamentos de Ervas Chinesas/efeitos adversos , Medicamentos de Ervas Chinesas/uso terapêutico , Feminino , Gastroenteropatias/patologia , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/prevenção & controle , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Masculino , Insuficiência de Múltiplos Órgãos/epidemiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Resultado do Tratamento
7.
BMC Infect Dis ; 20(1): 281, 2020 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-32295538

RESUMO

BACKGROUND: Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that commonly has a lethal course caused by the tick-borne Huaiyangshan banyang virus [former SFTS virus (SFTSV)]. The viral load in various body fluids in SFTS patients and the best infection control measure for SFTS patients have not been fully established. CASE PRESENTATION: A 79-year-old man was bitten by a tick while working in the bamboo grove in Nagasaki Prefecture in the southwest part of Japan. Due to the occurrence of impaired consciousness, he was referred to Nagasaki University Hospital for treatment. The serum sample tested positive for SFTSV-RNA in the genome amplification assay, and he was diagnosed with SFTS. Furthermore, SFTSV-RNA was detected from the tick that had bitten the patient. He was treated with multimodal therapy, including platelet transfusion, antimicrobials, antifungals, steroids, and continuous hemodiafiltration. His respiration was assisted with mechanical ventilation. On day 5, taking the day on which he was hospitalized as day 0, serum SFTSV-RNA levels reached a peak and then decreased. However, the cerebrospinal fluid collected on day 13 was positive for SFTSV-RNA. In addition, although serum SFTSV-RNA levels decreased below the detectable level on day 16, he was diagnosed with pneumonia with computed tomography. SFTSV-RNA was detected in the bronchoalveolar lavage fluid on day 21. By day 31, he recovered consciousness completely. The pneumonia improved by day 51, but SFTSV-RNA in the sputum remained positive for approximately 4 months after disease onset. Strict countermeasures against droplet/contact infection were continuously conducted. CONCLUSIONS: Even when SFTSV genome levels become undetectable in the serum of SFTS patients in the convalescent phase, the virus genome remains in body fluids and tissues. It may be possible that body fluids such as respiratory excretions become a source of infection to others; thus, careful infection control management is needed.


Assuntos
Líquidos Corporais/virologia , Encefalopatias/virologia , Infecções por Bunyaviridae/epidemiologia , Hemorragia Gastrointestinal/virologia , Phlebovirus/genética , Pneumonia/virologia , RNA Viral/sangue , Idoso , Animais , Encefalopatias/tratamento farmacológico , Líquido da Lavagem Broncoalveolar/virologia , Infecções por Bunyaviridae/tratamento farmacológico , Infecções por Bunyaviridae/virologia , Terapia Combinada , Hemorragia Gastrointestinal/tratamento farmacológico , Hospitais Universitários , Humanos , Japão/epidemiologia , Masculino , Técnicas de Amplificação de Ácido Nucleico , Phlebovirus/isolamento & purificação , Pneumonia/tratamento farmacológico , Escarro/virologia , Carrapatos/virologia , Resultado do Tratamento , Carga Viral
9.
PLoS One ; 15(2): e0229101, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32084186

RESUMO

Current guidelines recommend antibiotic prophylaxis for all patients with various degrees of cirrhosis and upper gastrointestinal (UGI) bleeding. This study assessed the need for antibiotic prophylaxis in patients with low Child-Pugh scores. We retrospectively screened all patients with cirrhosis who underwent upper endoscopies for UGI bleeding in a referral hospital in Taiwan between 2003 and 2014, from which 913 patients were enrolled after excluding patients with active bacterial infections, recent antibiotic use, early death, and Child-Pugh class C cirrhosis. Among them, 73 (8%) received prophylactic antibiotics, and 45 (4.9%) exhibited 14-day bacterial infection. Neither Child-Pugh score nor model for end stage liver disease score were optimal for predicting bacterial infection because their areas under the curves were 0.610 (95% confidence interval [CI]: 0.529-0.691) and 0.666 (95% CI: 0.591-0.742), respectively. Antibiotic prophylaxis did not reduce the risks of 14-day bacterial infection (relative risk [RR]: 0.932, 95% CI: 0.300-2.891, P = 0.902), 14-day rebleeding (RR: 0.791, 95% CI: 0.287-2.181, P = 0.650), or 42-day mortality (RR: 2.710, 95% CI: 0.769-9.524, P = 0.121). The results remained similar after propensity score adjustment. On-demand antibiotic treatment might suffice for patients with Child-Pugh class A/B cirrhosis and UGI bleeding.


Assuntos
Antibioticoprofilaxia/métodos , Hemorragia Gastrointestinal/tratamento farmacológico , Cirrose Hepática/tratamento farmacológico , Idoso , Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/microbiologia , Feminino , Hemorragia Gastrointestinal/microbiologia , Mortalidade Hospitalar , Humanos , Cirrose Hepática/microbiologia , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
10.
Medicine (Baltimore) ; 99(1): e18602, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31895810

RESUMO

RATIONALE: Henoch-Schönlein purpura (HSP) is a small-vessel vasculitis that has been extensively studied in children, but little is known about its natural history in adults. There is no consensus regarding the treatment of glucocorticosteroids use for HSP. The efficacy of glucocorticoid for preventing from severe complications or relapse is also controversial in HSP. PATIENT CONCERNS: A 21-year-old male was admitted to the hospital due to abdominal pain for more than 20 days, hematochezia for more than 10 days, and rash for 2 days. DIAGNOSES: The diagnosis of HSP is based on the European League against Rheumatism and the Paediatric Rheumatology European Society in 2006. INTERVENTIONS: The patient received glucocorticosteroids treatment for 17 days at the time of first hospitalization. OUTCOMES: The abdominal pain and hematochezia completely disappeared on the 6th day after the use of glucocorticosteroids, and purpura completely disappeared on the 8th day. LESSONS: Our patient has a good response to glucocorticoid. Glucocorticosteroids may be effective for the treatment of HSP.


Assuntos
Dor Abdominal/tratamento farmacológico , Hemorragia Gastrointestinal/tratamento farmacológico , Glucocorticoides/uso terapêutico , Púrpura de Schoenlein-Henoch/tratamento farmacológico , Dor Abdominal/etiologia , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Púrpura de Schoenlein-Henoch/complicações , Resultado do Tratamento , Adulto Jovem
11.
J Gastroenterol Hepatol ; 35(8): 1397-1403, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31900982

RESUMO

BACKGROUND AND AIM: This aims to study incidence of re-bleeding on anticoagulation and survival of Budd-Chiari syndrome (BCS) patients presenting with variceal bleeding. METHODS: Budd-Chiari syndrome patients presenting with variceal bleed between 01/01/2007 and 01/05/2019 were retrospectively studied. Patients underwent endoscopic treatment ± endovascular therapy, followed by anticoagulation. Variceal re-bleed (on anticoagulation) and survival were studied. RESULTS: Of 376 BCS patients diagnosed during the study period, 40 (10.7%) patients, presenting with variceal bleed (age 33 [25-40] years; male patients 70%; Rotterdam score 1.13 [0.63-1.22]), Group 1 were compared with 40 randomly selected age-matched BCS patients presenting with ascites, no bleeds (40 [23-42] years; male patients 42.5%; Rotterdam score 1.11 [1.09-1.16]), Group 2. The commonest site of obstruction was hepatic vein (65%) in Group 1 and combined hepatic veins and inferior vena cava (57.5%) in Group 2 (P < 0.01). Thirty-six Group 1 patients underwent endoscopic intervention (variceal ligation, 33; sclerotherapy, 2; glue injection, 1). Endovascular intervention was performed in 30 Group 1 patients (angioplasty ± stent, 22; endovascular shunt, 8) and in 34 Group 2 patients (angioplasty ± stent, 26; endovascular shunt, 8). All 80 patients were started on anticoagulation. Variceal bleed on anticoagulation occurred in five patients in Group 1 and three patients in Group 2. One-year and 5-year survival were 94.2% and 87.5%, respectively, in Group 1 and 100% and 80%, respectively, in Group 2. CONCLUSIONS: About one-tenth of BCS patients present with variceal bleed. On management with endoscopic ± endovascular therapy, followed by anticoagulation, variceal re-bleed in these patients were comparable with those in BCS patients presenting with ascites and survival was excellent at 1 and 5 years.


Assuntos
Anticoagulantes/uso terapêutico , Síndrome de Budd-Chiari/complicações , Varizes Esofágicas e Gástricas/tratamento farmacológico , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/cirurgia , Adulto , Endoscopia Gastrointestinal , Procedimentos Endovasculares , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
12.
Curr Opin Endocrinol Diabetes Obes ; 27(1): 22-27, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31815783

RESUMO

PURPOSE OF REVIEW: To summarize the use of gastrointestinal peptides in the management of portal hypertension. RECENT FINDINGS: Vasoactive peptides are commonly used in the management of acute variceal hemorrhage and hepatorenal syndrome, which are portal hypertensive complications of cirrhosis. The main vasoactive peptides that are used are somatostatin and its long-acting analogue octreotide, and vasopressin and its analogue terlipressin. Early initiation of vasoactive peptides in the management of acute variceal hemorrhage and hepatorenal syndrome is associated with improved outcomes. Octreotide is the available vasoactive peptide in the Unites States. Recent developments and ongoing clinical trials may improve our understanding of hepatorenal syndrome and influence the use of vasoactive peptides, particularly terlipressin. SUMMARY: Here, we review the literature on the use of vasoactive peptides in the management of acute variceal hemorrhage and hepatorenal syndrome.


Assuntos
Hipertensão Portal/tratamento farmacológico , Fragmentos de Peptídeos/uso terapêutico , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/tratamento farmacológico , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Síndrome Hepatorrenal/tratamento farmacológico , Síndrome Hepatorrenal/etiologia , Humanos , Hipertensão Portal/complicações , Cirrose Hepática/complicações , Cirrose Hepática/tratamento farmacológico , Lipressina/uso terapêutico , Octreotida/uso terapêutico , Somatostatina/análogos & derivados , Somatostatina/uso terapêutico , Terlipressina/uso terapêutico
14.
Platelets ; 31(3): 329-336, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31037994

RESUMO

Although acid suppressants are needed to attenuate gastrointestinal bleeding (GIB) after percutaneous coronary intervention (PCI), pharmacodynamic interaction between clopidogrel and proton pump inhibitor (PPI) can increase the risk of high platelet reactivity (HPR). We sought to evaluate serial changes of platelet measures and influence of rabeprazole on platelet measures. After 600-mg clopidogrel loading for elective PCI, clopidogrel-sensitive patients were recruited and randomly assigned to add rabeprazole of daily 20 mg (n = 40) or famotidine of daily 40 mg (n = 40). Platelet measures were performed with light transmittance aggregometry and VASP-P assay. Primary endpoint was 5 µM ADP-induced platelet aggregation (PA) at 30-day follow-up. HPR was defined as 5 µM ADP-induced PA > 46%. Baseline platelet measures did not differ significantly between the groups. The 30-day level of 5 µM ADP-induced PA was similar between the famotidine vs. rabeprazole group (30.0 ± 16.4% vs. 30.2 ± 13.9%, P= .956). In addition, other platelet measures were comparable between the groups. At 30-day follow-up, the incidence of HPR was similar between the famotidine and rabeprazole groups (20.5% vs. 15.4%; P= .555). In conclusion, adjunctive use of rabeprazole showed the similar antiplatelet effect even in clopidogrel-sensitive patients compared with adjunctive famotidine, which may support the similar effect of rabeprazole and famotidine on the antiplatelet effect of dual antiplatelet therapy with clopidogrel plus aspirin.


Assuntos
Clopidogrel/farmacocinética , Famotidina/farmacologia , Inibidores da Agregação de Plaquetas/farmacocinética , Inibidores da Bomba de Prótons/farmacologia , Rabeprazol/farmacologia , Idoso , Clopidogrel/efeitos adversos , Interações Medicamentosas , Famotidina/administração & dosagem , Famotidina/efeitos adversos , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Testes de Função Plaquetária , Inibidores da Bomba de Prótons/administração & dosagem , Inibidores da Bomba de Prótons/efeitos adversos , Rabeprazol/administração & dosagem , Rabeprazol/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto
15.
Am J Cardiovasc Drugs ; 20(1): 81-103, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31254174

RESUMO

BACKGROUND: Clinical trials have indicated that the direct-acting oral anticoagulants dabigatran and rivaroxaban have better risk/benefit profiles than do vitamin K antagonists (VKAs) for stroke prevention in non-valvular atrial fibrillation (NVAF). OBJECTIVE: Our objective was to compare the 1-year real-life risk of major clinical events with dabigatran or rivaroxaban versus VKAs for NVAF. METHODS: This was a high-dimensional propensity score (hdPS)-matched cohort study of new users of dabigatran, rivaroxaban or VKAs for NVAF in the French national healthcare systems database in 2013 followed-up for 1 year [22]. Hazard ratios (HRs) with 95% confidence intervals (CIs) for clinical events and death were determined during exposure. RESULTS: In 2013, a total of 103,101 new anticoagulant users had definite NVAF: 44,653 VKA, 27,060 dabigatran, and 31,388 rivaroxaban. In matched populations, HRs were as follows for dabigatran versus VKAs (20,489 per group): stroke and systemic embolism (SSE) 0.75 (95% CI 0.63-0.88), clinically relevant bleeding (CRB) 0.58 (95% CI 0.51-0.66), hemorrhagic stroke (HS) 0.22 (95% CI 0.14-0.36), gastrointestinal bleeding (GIB) 0.98 (95% CI 0.80-1.19), acute coronary syndrome (ACS) 0.79 (95% CI 0.65-0.95), death 0.74 (95% CI 0.67-0.82), composite (any of the above) 0.71 (95% CI 0.66-0.76). For matched rivaroxaban versus VKA (23,053 per group) HRs were as follows: SSE 0.98 (95% CI 0.85-1.14), CRB 0.83 (95% CI 0.75-0.92), HS 0.65 (95% CI 0.49-0.87), GIB 1.08 (95% CI 0.90-1.30), ACS 0.84 (95% CI 0.71-1.00), death 0.77 (95% CI 0.71-0.84), composite 0.84 (95% CI 0.79-0.89). Numbers needed to treat to observe one fewer death were 49 ± 0.05 with dabigatran or rivaroxaban versus VKAs. CONCLUSION: Consistent with results from clinical trials and other observational studies, dabigatran and rivaroxaban were at least as effective and safer than VKAs for the prevention of thromboembolic events in NVAF over 1 year in the French population. STUDY REGISTRATION: European Medicines Agency EUPAS 13017 (www.encepp.eu) Clinicaltrials.gov id NCT02785354.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Dabigatrana/efeitos adversos , Dabigatrana/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Sistemas de Dados , Feminino , Fibrinolíticos/efeitos adversos , Fibrinolíticos/uso terapêutico , Hemorragia Gastrointestinal/tratamento farmacológico , Humanos , Masculino , Pontuação de Propensão , Vitamina K/antagonistas & inibidores
16.
Am J Emerg Med ; 38(4): 810-814, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31870672

RESUMO

OBJECTIVE: In 2018, the FDA approved andexanet alfa for the reversal of life-threatening hemorrhages in patients anticoagulated with apixaban or rivaroxaban. Yet, cost-effective factor Xa inhibitor reversal remains controversial. The objective of this study was to describe real world utilization of andexanet alfa. METHODS: This was a retrospective case series of patients receiving andexanet alfa between July 28, 2018 and April 29, 2019 at a large academic health system. Baseline demographics, anticoagulant type and reversal, as well as brain imaging were collected. Primary endpoints were stability of hematoma for intracranial hemorrhage (ICH), and hemostatic effectiveness for patients undergoing surgical procedures. Secondary endpoints were thromboembolism and 30 day mortality. RESULTS: Of the 25 patients evaluated, 13 received andexanet alfa for ICH. Eleven of the 13 had follow-up imaging available and stability was observed in 90.9%. Three patients received andexanet alfa for reversal prior to surgical procedures, and 100% hemostatic effectiveness was achieved. Nine patients received andexanet alfa for reversal of extracranial bleeding, including gastrointestinal bleed (n=4). There were no thrombotic events in our cohort, and 30 day mortality was 24%. Sixty-four percent of patients would have met exclusion criteria for the ANNEXA-4 trial. CONCLUSION: This is the largest series to date describing real-world utilization of andexanet alfa. Our series showed hemostatic efficacy in 90.9% of patients with ICH, and 100% in patients undergoing surgical procedures. There were no thrombotic complications. Yet, larger and comparative studies are needed to clarify the optimal agent and patient selection for reversal of factor Xa inhibitors.


Assuntos
Fator Xa/uso terapêutico , Hemorragia/tratamento farmacológico , Hemostáticos/uso terapêutico , Proteínas Recombinantes/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia/induzido quimicamente , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Pirazóis/efeitos adversos , Pirazóis/antagonistas & inibidores , Piridonas/efeitos adversos , Piridonas/antagonistas & inibidores , Estudos Retrospectivos , Rivaroxabana/efeitos adversos , Rivaroxabana/antagonistas & inibidores , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento
17.
J Clin Pharm Ther ; 45(1): 191-198, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31557362

RESUMO

WHAT IS KNOWN AND OBJECTIVE: As terlipressin becomes more widely used in clinical practice, more papers had reported the correlation between hyponatremia and terlipressin treatment. This study was performed to evaluate the clinical characteristics and risk factors of severe hyponatremia in cirrhotic patients treated with terlipressin and the effects of concomitant drugs. METHODS: We conducted a retrospective evaluation of patients with cirrhosis treated with terlipressin at the gastroenterology department of Hospital between 1 January 2016 and 30 June 2018. Patients treated with terlipressin for gastrointestinal bleeding due to peptic ulcer and other non-hepatic factors were excluded. RESULTS AND DISCUSSION: After the patients received terlipressin, their serum sodium concentrations decreased from 138.2 ± 4.3 mmol/L to 129.3 ± 7.2 mmol/L. Statistically significant differences were observed with respect to sex, initial serum sodium concentration, lowest serum sodium concentration, hyponatremia duration and total drug dose. Among the patients with hyponatremia, statistically significant differences in albumin level, serum creatinine level, hyponatremia duration and total drug dose were found between the patients with severe hyponatremia and those with non-severe hyponatremia. Logistic regression analysis revealed that initial serum sodium concentration (odds ratio, 95% confidence interval: 18.475, 3.967-86.035; P = .000) was a risk factor for reduced serum concentration, and that albumin level (1.105, 1.012-1.207; P = .026), serum creatinine level (0.975, 0.952-0.997; P = .028) and hyponatremia duration (1.297, 1.064-1.583; P = .010) were risk factors of severe hyponatremia. WHAT IS NEW AND CONCLUSION: The incidence of severe hyponatremia among patients with cirrhosis who are treated with terlipressin is high. Moreover, higher initial serum sodium concentrations and increased duration of terlipressin administration are associated with a higher the incidence of severe hyponatremia. The initial albumin level is a risk factor for severe hyponatremia as is serum creatinine, although the latter is negatively correlated with the occurrence of the condition.


Assuntos
Hemorragia Gastrointestinal/tratamento farmacológico , Hiponatremia/etiologia , Cirrose Hepática/tratamento farmacológico , Terlipressina/administração & dosagem , Adulto , Idoso , Creatinina/sangue , Relação Dose-Resposta a Droga , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Úlcera Péptica/complicações , Úlcera Péptica/tratamento farmacológico , Estudos Retrospectivos , Fatores de Risco , Albumina Sérica Humana/metabolismo , Sódio/sangue , Vasoconstritores/administração & dosagem
18.
Rev Med Chil ; 148(11): 1674-1678, 2020 Nov.
Artigo em Espanhol | MEDLINE | ID: mdl-33844775

RESUMO

In patients with actively bleeding gastric varices, the treatment of choice is the endoscopic use of sclerosing agents such as cyanoacrylate. We report a 69-year-old man who, after being treated with cyanoacrylate, suffered from recurrent febrile episodes. After an extensive study and broad-spectrum antibiotic treatment, discarding other presumably infectious focus, the superinfection of the cyanoacrylate plug was suspected, and its surgical removal was decided. A partial gastrectomy of the gastric fundus, a splenectomy, and a distal pancreatectomy were performed. The patient evolved without fever and without new episodes of bacteremia, but with decompensation of his cirrhosis manifested by ascites, spontaneous bacterial peritonitis, pneumonia, and collections in the pancreatic bed. These complications were managed with medical treatment consisting in a long course of broad-spectrum antibiotics. Thereafter, the patient evolved satisfactorily.


Assuntos
Cianoacrilatos , Varizes Esofágicas e Gástricas , Idoso , Hemorragia Gastrointestinal/tratamento farmacológico , Humanos , Cirrose Hepática , Masculino , Soluções Esclerosantes/uso terapêutico
19.
Artigo em Inglês | MEDLINE | ID: mdl-31785730

RESUMO

Acute upper gastrointestinal bleeding (UGIB) remains a public health burden with a persistent high mortality despite advances in modern day management. Proton pump inhibitors (PPI) as medical therapy is an attractive adjuvant to endoscopic treatment in UGIB but the method and dose of PPI therapy remains controversial. This chapter aims to describe the current evidence addressing acute PPI use in the management of UGIB. It will explore the evidence behind the timing, the dosage and the mode of administration of PPI during initial UGIB management, prior to and immediately following endoscopy, as well as in the short-term following discharge.


Assuntos
Hemorragia Gastrointestinal/tratamento farmacológico , Inibidores da Bomba de Prótons/uso terapêutico , Humanos , Inibidores da Bomba de Prótons/farmacologia
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