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1.
PLoS One ; 15(8): e0237022, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32764775

RESUMO

BACKGROUND: Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. METHODS AND FINDINGS: A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013-2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. CONCLUSION: The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. TRIAL REGISTRATION: NCT02886533.


Assuntos
Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Estudos de Coortes , Bases de Dados Factuais , Quimioterapia Combinada , Feminino , França/epidemiologia , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Hemorragia/epidemiologia , Humanos , Incidência , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidade , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Prospectivos , Fatores de Risco , Adulto Jovem
2.
Stroke ; 51(6): 1772-1780, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32390554

RESUMO

Background and Purpose- Guideline adherent oral anticoagulant (OAC) management of patients with nonvalvular atrial fibrillation has been associated with improved outcomes, but limited data are available from Asia. We aimed to investigate outcomes in patients who received guideline compliant management compared with those who were OAC undertreated or overtreated, in a large nationwide multicenter cohort of patients with nonvalvular atrial fibrillation in Thailand. Methods- Patients with nonvalvular atrial fibrillation were prospectively enrolled from 27 hospitals-all of which are data contributors to the COOL-AF Registry (Cohort of Antithrombotic Use and Optimal INR Level in Patients With Non-Valvular Atrial Fibrillation in Thailand). Patients were categorized as follows: (1) guideline adherence group when OAC was given in high-risk or intermediate-risk, but not in low-risk patients; (2) undertreatment group when OAC was not given in the high-risk or intermediate-risk groups; and (3) overtreatment group when OAC was given in the low-risk group or when OAC was given in combination with antiplatelets without indication. Results- A total of 3327 patients who had follow-up clinical outcome data were included. The mean age of patients was 67.4 years and 58.1% were male. The numbers of patients in the guideline adherence group, undertreatment group, and overtreatment group were 2267 (68.1%), 624 (18.8%), and 436 (13.1%) patients, respectively. The overall rate of ischemic stroke, major bleeding, all bleeding, and death was 3.0%, 4.4%, 15.1%, and 7.8%, respectively. Undertreated patients had a higher risk of ischemic stroke and death compared with guideline adherent patients, and overtreated patients had a higher risk of bleeding and death compared with OAC guideline-managed patients. Conclusions- Adherence to OAC management guidelines is associated with improved clinical outcomes in Asian nonvalvular atrial fibrillation patients. Undertreatment or overtreatment was found to be associated with increased risk of adverse outcomes compared with guideline-adherent management.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial , Fidelidade a Diretrizes , Sistema de Registros , Acidente Vascular Cerebral , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Grupo com Ancestrais do Continente Asiático , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/mortalidade , Intervalo Livre de Doença , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Taxa de Sobrevida , Tailândia/epidemiologia
3.
Transfusion ; 60(5): 922-931, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32358836

RESUMO

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.


Assuntos
Transfusão de Sangue/economia , Transfusão de Sangue/métodos , Adolescente , Adulto , Contagem de Células Sanguíneas/economia , Plaquetas/citologia , Transfusão de Sangue/mortalidade , Transfusão de Sangue/estatística & dados numéricos , Análise Custo-Benefício , Contagem de Eritrócitos , Transfusão de Eritrócitos/economia , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Eritrócitos/citologia , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Plasma/citologia , Transfusão de Plaquetas/economia , Transfusão de Plaquetas/métodos , Transfusão de Plaquetas/mortalidade , Transfusão de Plaquetas/estatística & dados numéricos , Ressuscitação/mortalidade , Ressuscitação/estatística & dados numéricos , Adulto Jovem
4.
Angiology ; 71(8): 704-712, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32295386

RESUMO

This retrospective study assessed the risk factors for adverse events following off-pump coronary artery bypass graft (CABG) surgery with dual antiplatelet therapy (DAPT). Records (between 2013 and 2017) were reviewed for patients who discontinued DAPT (clopidogrel 75 mg and aspirin 100 mg) ≤5 days before off-pump CABG. The primary outcome was the incidence of a Bleeding Academic Research Consortium (BARC) type 4 major event. Factors associated with bleeding events and perioperative myocardial ischemia were evaluated using multivariable logistic regression. The incidence of major bleeding events was 17.6% in 2012 patients. Adjusted multiple logistic regression analysis showed that the risk of postoperative bleeding increased when DAPT was discontinued <3 days before surgery (day 2: adjusted odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.09-2.64; day 1: adjusted OR: 2.37, 95% CI: 1.49-3.77; day 0: adjusted OR: 2.45, 95% CI: 1.53-3.92). The adjusted risk of mortality (OR: 13.14, 95% CI: 4.55-37.94) was increased with bleeding complications. In subgroup analysis, perioperative myocardial ischemia was related to increased blood loss (adjusted OR: 1.10, 95% CI: 1.02-1.18). Aspirin and clopidogrel should optimally be discontinued >3 days before CABG to reduce the risk of bleeding complications, myocardial ischemia, and death.


Assuntos
Aspirina/administração & dosagem , Clopidogrel/administração & dosagem , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Hemorragia/epidemiologia , Isquemia Miocárdica/epidemiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Pequim/epidemiologia , Clopidogrel/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Esquema de Medicação , Quimioterapia Combinada , Feminino , Hemorragia/mortalidade , Hemorragia/prevenção & controle , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/prevenção & controle , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
5.
Nutr Metab Cardiovasc Dis ; 30(5): 730-737, 2020 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-32127336

RESUMO

BACKGROUND AND AIM: Elderly patients are at increased risk of hemorrhagic and thrombotic complications after an acute coronary syndrome (ACS). Frailty, comorbidities and low body weight have emerged as conditioning the prognostic impact of dual antiplatelet therapy (DAPT). The aim of the present study was to investigate the prognostic impact of body mass index (BMI) on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study comparing low-dose (5 mg) prasugrel vs clopidogrel among elderly patients with ACS. METHODS AND RESULTS: Our population is represented by 1408 patients enrolled in the Elderly-ACS 2 trial. BMI was calculated at admission. The primary endpoint of this analysis was cardiovascular (CV) mortality. Secondary endpoints were all-cause death, recurrent MI, Bleeding Academic Research Consortium (BARC) type 2 or 3 bleeding, and re-hospitalization for cardiovascular reasons or stent thrombosis within 12 months after index admission. Patients were grouped according to median values of BMI (

Assuntos
Síndrome Coronariana Aguda/terapia , Índice de Massa Corporal , Clopidogrel/administração & dosagem , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Cloridrato de Prasugrel/administração & dosagem , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Clopidogrel/efeitos adversos , Comorbidade , Feminino , Idoso Fragilizado , Avaliação Geriátrica , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Itália , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos , Recidiva , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento
6.
Medicine (Baltimore) ; 99(12): e19575, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32195968

RESUMO

Liver cirrhotic predisposes patients to coagulopathy and bleeding. Little is known about outcomes of acute myocardial infarction (AMI) in cirrhotic patients.Data from Taiwan National Health Insurance Research Database during 2001 to 2013 were retrieved for patients admitted with cirrhosis and AMI. We excluded patients with missing information, <20 years old, previous AMI, previous coronary intervention, and liver transplant. Patients were separated into cirrhotic and non-cirrhotic. Primary outcomes included all-cause mortality, recurrent myocardial infarction (MI), major cardiac and cerebrovascular events (MACCE: recurrent MI, revascularization, ischemic stroke, and heart failure), and liver outcomes (hepatic encephalopathy, ascites tapping, spontaneous peritonitis, and esophageal varices bleeding).A total of 3217 cirrhotic patients and 6434 non-cirrhotic patients were analyzed, with a mean follow up of 2.8 ±â€Š3.3 years. In cirrhotic patients with AMI, subsequent coronary and cerebrovascular events were lower in comparison to non-cirrhotic patients, with higher all-cause mortality observed from adverse liver related outcomes and bleeding. There were significantly lower cumulative incidence of both recurrent MI and MACCE in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (hazard ratio [HR] 0.82, confidence interval [CI] 0.71-0.94, P = .006 and HR 0.86, 95% CI 0.79-0.92, P < .001, respectively). There was significantly higher cumulative incidence of liver related outcome in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 2.27, 95% CI 2.06-2.51, P < .001). And there was significantly higher all-cause mortality in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 1.30, 95% CI 1.23-1.38, P < .001).In cirrhotic cohort with AMI, a decreased in coronary and cerebrovascular events were observed. However, these patients also had higher all-cause mortality due to adverse liver outcomes and bleeding.


Assuntos
Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Insuficiência Cardíaca/etiologia , Hemorragia/etiologia , Hemorragia/mortalidade , Hospitalização/tendências , Humanos , Incidência , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Infarto do Miocárdio/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Taiwan/epidemiologia
7.
Medicine (Baltimore) ; 99(13): e18982, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32221060

RESUMO

RATIONALE: Carbapenem-resistant Klebsiella pneumonia (CRKP) infections have been a concerning threat, especially in organ transplant patients with very high mortality. Allograft hemorrhage associated with CRKP infection has never been described. PATIENT CONCERNS: A total of 6 recipients tested positive for CRKP were identified in 297 adult kidney transplant recipients who received kidney from donors according to Chinese type donation after cardiac death (DCD) at our center between January 2006 and December 2017. DIAGNOSES: CRKP identification was performed via Vitek 2 system, and the susceptibility was tested by broth microdilution and disk diffusion. Based on the signs of infection and the positive culture, the diagnosis of CRKP infection was established. INTERVENTIONS: Therapy with antibiotic such as including ceftazidime-avibactam or tigecycline and surgical control of primary infection source including allograft nephrectomy and/or thorough debridement was administrated. OUTCOMES: The most striking aspect was that spontaneous recurrent hemorrhage occurred in all the 6 patients. The mortality of CRKP infection in our study was 50%. LESSONS: CRKP infection possibly due to donor-to-recipient transmission in DCD kidney transplants was essentially a necrotic hemorrhagic inflammation and characterized by recurrent hemorrhage and high mortality. The pre-donation screening for CRKP colonization should be mandatory and, if positive, donation should be contraindicated. And, the effective infection source control such as allograft nephrectomy and/or thorough debridement was important to improve outcomes. Further investigation will be required to further characterize the clinical efficacy of new pharmacotherapeutic schemes including ceftazidime-avibactam.


Assuntos
Carbapenêmicos/farmacologia , Hemorragia/etiologia , Transplante de Rim/efeitos adversos , Infecções por Klebsiella/complicações , Klebsiella pneumoniae/efeitos dos fármacos , Adulto , Aloenxertos , China , Feminino , Hemorragia/mortalidade , Humanos , Infecções por Klebsiella/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
8.
Cardiovasc Ther ; 2020: 8647837, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32190122

RESUMO

Background: Anemia following acute myocardial infarction (AMI) is associated with poor outcomes. While previous studies in patients with AMI have focused on anemia at admission, we hypothesized that hemoglobin (Hb) decline during hospitalization and lower discharge Hb would be associated with greater long-term mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Methods: We analyzed records of 983 STEMI patients who were treated with primary PCI. The primary end point was all-cause mortality at 1 year and 2 years. The relationship between discharge Hb levels, decline in Hb levels, bleeding event classification, and all-cause mortality was determined. Results: Overall, 16.4% of patients had bleeding events, which were classified by the Thrombolysis in Myocardial Infarction (TIMI) score as 7% minimal, 8.6% minor, and 0.9% major. No significant gastrointestinal bleed and cerebral hemorrhage occurred in hospitals among these patients. The incidence rate of the 2-year all-cause mortality increased with severity of the bleeding event score (8.78% for no bleeding vs. 11.59% for minimal bleeding vs. 20.24% for minor bleeding vs. 55.56% for major bleeding, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006-1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006-1.034, P < 0.001). Discharge Hb was significantly associated with 2-year mortality in an unadjusted model (hazard ratio (HR) per 1 g/L decrease in discharge Hb = 1.020, 95% confidence interval (CI): 1.006-1.034. Conclusions: In this population of patients hospitalized for STEMI, all-cause mortality increased with lower discharge Hb, and discharge Hb was a significant predictor of mortality risk.


Assuntos
Anemia/sangue , Hemoglobinas/metabolismo , Hemorragia/sangue , Alta do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Anemia/diagnóstico , Anemia/mortalidade , Biomarcadores/sangue , Causas de Morte , Feminino , Hemorragia/diagnóstico , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento
9.
Am J Cardiol ; 125(8): 1142-1147, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32087994

RESUMO

Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.


Assuntos
Síndrome Coronariana Aguda/cirurgia , Anemia/epidemiologia , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Hemorragia Pós-Operatória/epidemiologia , Síndrome Coronariana Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/epidemiologia , Angina Instável/cirurgia , Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Aspirina/uso terapêutico , Causas de Morte , Clopidogrel/uso terapêutico , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Stents Farmacológicos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Heparina/uso terapêutico , Hirudinas , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidade , Estimativa de Kaplan-Meier , Masculino , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/cirurgia , Fragmentos de Peptídeos/uso terapêutico , Cuidados Pós-Operatórios , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/mortalidade , Cloridrato de Prasugrel/uso terapêutico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Proteínas Recombinantes/uso terapêutico , Medição de Risco , Stents , Ticagrelor/uso terapêutico , Doenças Urológicas/induzido quimicamente , Doenças Urológicas/epidemiologia , Doenças Urológicas/mortalidade
11.
J Trauma Acute Care Surg ; 88(5): 636-643, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31977997

RESUMO

BACKGROUND: Severe liver injuries pose a challenge to trauma surgeons. While the use of hepatic angioembolization (HAE) has been evaluated as a component of the nonoperative management of liver injury, little is known about the efficacy of postoperative HAE in patients who require hemorrhage control laparotomy (HCL) for liver injury. The purpose of this study is to evaluate the impact of HAE following HCL on patient survival. METHODS: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2014. In propensity score matched (2:1) patients who underwent HCL-only or HCL + HAE, the impact of adjunctive use of HAE on patient survival was examined with the Cox proportional hazards regression analysis adjusting for transfusion requirement within 4 hours. We also performed a subgroup analysis in patients without severe traumatic brain injury (Abbreviated Injury Scale head ≤3). RESULTS: A total of 1,675 patients met our inclusion criteria. Of those, 75 (4.5%) patients underwent HAE after HCL (median hours to HAE, 5 hours after admission). In 225 propensity score-matched patients, the use of HAE following HCL was significantly associated with improved 24-hour mortality, but not in-hospital mortality. In the subgroup of patients without severe traumatic brain injury (n = 189), we observed significant survival benefits (24-hour and in-hospital mortality) associated with the adjunctive use of HAE. CONCLUSION: The results of our study suggest that the adjunctive use of HAE might improve survival of patients who require HCL for liver injury. Further prospective study to determine the indication for postoperative HAE is still warranted. LEVEL OF EVIDENCE: Therapeutic study, level III.


Assuntos
Embolização Terapêutica/métodos , Hemorragia/terapia , Hemostasia Cirúrgica/métodos , Fígado/lesões , Cuidados Pós-Operatórios/métodos , Adulto , Idoso , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Fígado/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Adulto Jovem
12.
Am J Cardiol ; 125(6): 924-930, 2020 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-31954508

RESUMO

The prevalence of coexisting coronary artery disease (CAD) is high in patients who underwent transcatheter aortic valve implantation (TAVI). Our objective was to first determine if the severity of CAD before TAVI had an important impact on post-TAVI outcomes and second, if revascularization with percutaneous coronary intervention (PCI) before TAVI modified this relation. In this retrospective population-based study in Ontario, Canada, we identified all patients with obstructive CAD who underwent TAVI from April 1, 2012 to March 31, 2017. Our primary outcomes of interest were all-cause mortality within 30-day and 1-year post-TAVI procedure. Secondary outcomes included 30-day and 1-year all-cause readmissions. We developed multivariable Cox proportional hazard models, with a robust sandwich-type variance estimator to account for clustering within TAVI centers. These models included an interaction term between severity of CAD and PCI before TAVI. The study cohort included 888 of whom 444 (50%) patients underwent PCI before TAVI procedure. In the Cox models, we found that severity of CAD before TAVI was not significantly associated with post-TAVI outcomes. The only exception was 1 to 2 vessel/s disease which was a significant predictor of 1-year readmission. Pre-TAVI PCI was not significantly associated with outcomes, nor did it modify the relation between severity of CAD pre-TAVI and outcomes. In conclusion, we did not find a consistent relation between severity of CAD and revascularization with post-TAVI outcomes.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Hemorragia/etiologia , Revascularização Miocárdica , Substituição da Valva Aórtica Transcateter , Disfunção Ventricular Esquerda/diagnóstico , Idoso , Causas de Morte , Estudos de Coortes , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Correlação de Dados , Feminino , Hemorragia/mortalidade , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/mortalidade , Ontário , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Substituição da Valva Aórtica Transcateter/mortalidade , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
13.
J Trauma Acute Care Surg ; 88(2): 314-319, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804417

RESUMO

BACKGROUND: Timely angioembolization (AE) is known to improve outcomes of patients with hemorrhage resulting from pelvic fracture. The hybrid emergency room system (HERS) is a novel trauma resuscitation room equipped with a computed tomography scanner, fluoroscopy equipment, and an operating room setup. We hypothesized that the HERS would improve the timeliness of AE for pelvic fracture. METHODS: A retrospective medical record review of patients who underwent AE for pelvic fracture at our institution from April 2015 to December 2018 was conducted. Patients' demographics, location of AE, Injury Severity Score, Revised Trauma Score, probability of survival by the trauma and injury severity score (TRISS Ps) method, presence of interventional radiologists (IRs) upon patient arrival, time from arrival to AE, and in-hospital mortality were analyzed. These data were compared between patients who underwent AE in the HERS (HERS group) and in the regular angio suite (non-HERS group). RESULTS: Ninety-six patients met the inclusion criteria. The HERS group comprised 24 patients, and the non-HERS group, 72 patients. Interventional radiologists were more frequently present upon patient arrival in the HERS than non-HERS group (IRs, 79% vs. 22%, p < 0.01). The time from arrival to AE was shorter in the HERS than non-HERS group (median [range], 46 [5-75] minutes vs. 103 [2-690] minutes, p < 0.01). There were no differences in the rate of in-hospital mortality (13% vs. 15%, p = 0.52) between the two groups. Survivors in the HERS group had a lower probability of survival by the trauma and injury severity score (median [range], 61% [1%-98%] vs. 93% [1%-99%], p < 0.01) than survivors in the non-HERS group. CONCLUSION: The HERS improved the timeliness of AE for pelvic fracture. More severely injured patients were able to survive in the HERS. The new team building involving the addition of IRs to the traditional trauma resuscitation team will enhance the benefit of the HERS. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Embolização Terapêutica/métodos , Serviço Hospitalar de Emergência/organização & administração , Fraturas Ósseas/complicações , Hemorragia/terapia , Ossos Pélvicos/lesões , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Procedimentos Clínicos/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/terapia , Hemorragia/etiologia , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/organização & administração , Estudos Retrospectivos , Análise de Sobrevida , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Adulto Jovem
14.
Eur J Haematol ; 104(1): 26-35, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31541609

RESUMO

BACKGROUND AND OBJECTIVES: In patients with multiple myeloma (MM), unexpected bleeding complications remain a major issue. Since routine coagulation parameters are often inconspicuous, diagnosis and treatment of the underlying coagulation disorders are challenging. PATIENTS AND METHODS: In our single-center observational study, we analyzed 164 patients with MM for coagulation disorders and bleeding complications. RESULTS: Prolonged closure times (CTs), measured by PFA-100, were the most common, abnormal coagulation test, found in 66% of bleeding patients vs 5% in non-bleeding, followed by qualitative defects of von Willebrand factor (VWF:CB/VWF:Ag ratios), found in 34% vs 1% in the non-bleeding group. Increased serum free light chains (SFLC) and SFLC ratios were significantly associated with prolonged CTs and acquired von Willebrand syndrome (AVWS). Prolonged CTs and AVWS were associated with disease progression, determined by dynamics of SFLC ratios (P < .001), serum creatinine level (P = .013), Beta-2 microglobulin (P = .03), LDH (P = .016), and bone marrow infiltration (P < .001). Of note, response to myeloma therapy was frequently correlated with normalization of coagulation parameters. CONCLUSIONS: Bleeding complications in MM are predominantly caused by defects in primary hemostasis and associated with disease progression. In a peri-interventional workup, determination of CTs and VWF:CB/VWF:Ag ratios are of significant importance to assess bleeding risk.


Assuntos
Transtornos da Coagulação Sanguínea , Hemorragia , Hemostasia , Mieloma Múltiplo , Adulto , Idoso , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/mortalidade , Feminino , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Cadeias Leves de Imunoglobulina/sangue , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/sangue , Mieloma Múltiplo/mortalidade , Proteínas de Neoplasias/sangue , Fator de von Willebrand/metabolismo
15.
Leuk Lymphoma ; 60(13): 3107-3115, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31842650

RESUMO

The application of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) has revolutionized the treatment of acute promyelocytic leukemia (APL). More than 80-90% of patients are expected to be cured with a combination of ATRA, ATO and/or chemotherapy. In this review, we focus on the remaining obstacles to a cure for all patients with APL. We review the issue of early death and coagulopathy and discuss the particular challenges in the care of patients with high-risk APL and patients with relapsed APL. We also give recommendations and highlight ongoing efforts to improve the persistently high early death rate and the outcomes of high risk and relapsed APL patients.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Hemorragia/mortalidade , Leucemia Promielocítica Aguda/tratamento farmacológico , Recidiva Local de Neoplasia/tratamento farmacológico , Indução de Remissão/métodos , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Trióxido de Arsênio/administração & dosagem , Trióxido de Arsênio/efeitos adversos , Intervalo Livre de Doença , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Incidência , Leucemia Promielocítica Aguda/mortalidade , Leucemia Promielocítica Aguda/patologia , Mortalidade , Recidiva Local de Neoplasia/epidemiologia , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Padrão de Cuidado , Fatores de Tempo , Tretinoína/administração & dosagem , Tretinoína/efeitos adversos
16.
J Korean Med Sci ; 34(50): e318, 2019 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-31880415

RESUMO

BACKGROUND: The aim of this study was to assess the prognostic value of massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI) for the mortality of trauma patients with severe hemorrhage. METHODS: Seventeen relevant articles were obtained by searching the PubMed databases through February 15, 2019. The estimated mortality rates and injury severity scores were obtained through a meta-analysis. In addition, diagnostic test accuracy (DTA) reviews were conducted to obtain the sensitivity, specificity, diagnostic odds ratio, and the summary receiver operating characteristic curve. RESULTS: At 24 hours, the estimated mortality rates were 0.194, 0.126, and 0.168 in assessments using MT, CAT, and RI, respectively. In addition, the pooled sensitivity of CAT (0.89; 95% confidence interval [CI], 0.82-0.94) was significantly higher than that of MT (0.63; 95% CI, 0.57-0.68) and RI (0.69; 95% CI, 0.63-0.75). Overall, the pooled specificity of MT and CAT was 0.82 (95% CI, 0.80-0.83) and 0.85 (95% CI, 0.83-0.88), respectively, while the pooled sensitivity was 0.49 (95% CI, 0.44-0.54) and 0.50 (95% CI, 0.38-0.62), respectively. CONCLUSION: CAT may be a more sensitive predictor for 24-hour mortality than other predictors. Furthermore, RI also appears to be a useful predictor for 24-hour mortality. Both MT and CAT showed high specificity for overall mortality.


Assuntos
Transfusão de Sangue , Hemorragia/diagnóstico , Hemorragia/mortalidade , Ressuscitação , Área Sob a Curva , Bases de Dados Factuais , Hemorragia/patologia , Humanos , Prognóstico , Curva ROC , Fatores de Risco , Índice de Gravidade de Doença
17.
PLoS One ; 14(12): e0226075, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31856173

RESUMO

BACKGROUND: Despite the adoption of Maternal and Perinatal Death Surveillance and Response (MPDSR) by Nigeria's Federal Ministry of Health to track and rectify the causes of maternal mortality, very limited documentation exists on experiences with the method and its outcomes at institutional and policy levels. OBJECTIVE: The objective of this study was to identify through the MPDSR process, the medical causes and contributory factors of maternal mortality, and to elucidate the policy response that took place after the dissemination of the results. METHODS: The study was conducted at the Central Hospital, Benin between October 1, 2017, and May 31, 2019. We first developed a strategic plan with the objective to reduce maternal mortality by 50% in the hospital in two years. An MPDSR committee was established and the members and all staff of the Maternity Department of the hospital were trained to use the nationally approved protocol. All consecutive cases of maternal deaths in the hospital were then reviewed using the MPDSR protocol. The results were submitted to the hospital Management and its supporting agencies for administrative action to correct the identified deficiencies. RESULTS: There were 18 maternal deaths in the hospital during the period, and 4,557 deliveries giving a maternal mortality ratio (MMR) of 395/100,000 deliveries. This amounted to a seven-fold reduction in MMR in the hospital at the onset of the project. The main medical causes identified were obstetric hemorrhage (n = 10), pulmonary embolism (n = 2), ruptured uterus (n = 2), eclampsia (n = 1), anemic heart failure (n = 1) and post-partum sepsis (n = 2). Several facility-based and patient contributory factors were identified such as lack of blood in the hospital and late reporting with severe obstetric complication among others. Response to the recommendations from the committee include increased commitment of hospital managers to immediately rectify the attributable causes of deaths, the establishment of a couples health education program, mobilization and sensitization of staff to handle pregnant women with great sensitivity, promptness and care, the refurbishing of an intensive care unit, and the increased availability of blood for transfusion through the intensification of blood donation drive in the hospital. CONCLUSION: We conclude that the results of MPDSR, when acted upon by hospital managers and policymakers can lead to an improvement in quality of care and a consequent decline in maternal mortality ratio in referral hospitals.


Assuntos
Causas de Morte , Mortalidade Materna , Bases de Dados Factuais , Assistência à Saúde , Parto Obstétrico/efeitos adversos , Feminino , Política de Saúde , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Hemorragia/etiologia , Hemorragia/mortalidade , Hospitais , Humanos , Nigéria , Gravidez , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Sepse/etiologia , Sepse/mortalidade , Adulto Jovem
18.
Blood ; 134(26): 2354-2360, 2019 12 26.
Artigo em Inglês | MEDLINE | ID: mdl-31697817

RESUMO

The Platelets for Neonatal Thrombocytopenia (PlaNeT-2) trial reported an unexpected overall benefit of a prophylactic platelet transfusion threshold of 25 × 109/L compared with 50 × 109/L for major bleeding and/or mortality in preterm neonates (7% absolute-risk reduction). However, some neonates in the trial may have experienced little benefit or even harm from the 25 × 109/L threshold. We wanted to assess this heterogeneity of treatment effect in the PlaNet-2 trial, to investigate whether all preterm neonates benefit from the low threshold. We developed a multivariate logistic regression model in the PlaNet-2 data to predict baseline risk of major bleeding and/or mortality for all 653 neonates. We then ranked the neonates based on their predicted baseline risk and categorized them into 4 risk quartiles. Within these quartiles, we assessed absolute-risk difference between the 50 × 109/L- and 25 × 109/L-threshold groups. A total of 146 neonates died or developed major bleeding. The internally validated C-statistic of the model was 0.63 (95% confidence interval, 0.58-0.68). The 25 × 109/L threshold was associated with absolute-risk reduction in all risk groups, varying from 4.9% in the lowest risk group to 12.3% in the highest risk group. These results suggest that a 25 × 109/L prophylactic platelet count threshold can be adopted in all preterm neonates, irrespective of predicted baseline outcome risk. Future studies are needed to improve the predictive accuracy of the baseline risk model. This trial was registered at www.isrctn.com as #ISRCTN87736839.


Assuntos
Hemorragia/prevenção & controle , Recém-Nascido Prematuro , Transfusão de Plaquetas/mortalidade , Trombocitopenia Neonatal Aloimune/terapia , Feminino , Hemorragia/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Contagem de Plaquetas , Prognóstico , Fatores de Risco , Taxa de Sobrevida , Trombocitopenia Neonatal Aloimune/sangue , Trombocitopenia Neonatal Aloimune/mortalidade
19.
Aerosp Med Hum Perform ; 90(12): 1016-1025, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31747998

RESUMO

BACKGROUND: Hemorrhage and traumatic brain injury can be lethal if left unattended. The transportation of severely wounded combat casualties from the battlefield to higher level of care via aeromedical evacuation (AE) may result in unintended complications. This could become a serious concern at the time of evacuation of mass casualties or for prolonged field care scenarios with limited resources.METHODS: Following instrumentation (t1), anesthetized Sprague-Dawley rats were injured or not [75-kPa blast and 30% estimated blood-volume controlled hemorrhage] (t2). After 15 min, all rats were resuscitated with saline. During the simulated 3-h evacuation, 8000 ft (2440 m) vs. sea-level heart rate, temperature, and oxygenation (Spo2) were continuously recorded. One group of rats was euthanized immediately after evacuation (t3) and another after a 72-h recovery period (t4). Hematology and metabolic levels were measured at t1, t2, t3, and t4.RESULTS: Survival was 100% in control-uninjured animals, 83% in injured animals under normobaria, and significantly reduced to 50% under hypobaria. This AE setting resulted in significantly lower hemodynamics, thermoregulation, and oxygenation parameters in the animals under hypobaria than those under normobaria. The initial lower mean arterial pressure (MAP) with the reduced oxygen level before AE were critical factors for the survival of injured animals. We observed a general increase of white blood cells and platelet ability to aggregate at t4 in all experimental groups.CONCLUSION: Physiological parameters were affected during aeromedical evacuation in all groups. This was worsened for injured animals with MAP less than 60 mmHg associated with low Spo2 in a simulated aeromedical evacuation. This represented a high risk of mortality for severely polytraumatized animals.Arnaud F, Pappas G, Maudlin-Jeronimo E, Goforth C. Simulated aeromedical evacuation in a polytrauma rat model. Aerosp Med Hum Perform. 2019; 90(12):1016-1025.


Assuntos
Resgate Aéreo , Altitude , Pressão Sanguínea/fisiologia , Traumatismo Múltiplo/mortalidade , Animais , Traumatismos por Explosões/mortalidade , Modelos Animais de Doenças , Hemorragia/mortalidade , Hipóxia/mortalidade , Hipóxia/fisiopatologia , Masculino , Ratos , Ratos Sprague-Dawley
20.
Am J Surg ; 218(6): 1110-1113, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31627838

RESUMO

BACKGROUND: The use of Tranexamic Acid (TXA) in trauma patients remains controversial. The CRASH II trial, while randomized and prospective, did not include patients suffering from major bleeding. We wanted to examine our population of patients who underwent a massive transfusion protocol (MTP) (greater than 10 Units of packed red blood cells in the first 24 h of admission) to see if those who were undergoing massive transfusion and received TXA had any benefit in mortality. Our hypothesis was that massively transfused patients who received TXA and those that did not had no difference in mortality. METHODS: We performed a single institution retrospective review of our Trauma Registry for all patients who received a massive transfusion between 2010 and 2017. Patients were separated into two cohorts, those who received TXA within the first 24 h of admission and those who did not. The primary outcome of the study was mortality. Secondary outcomes included total blood products transfused, Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), Myocardial Infarction (MI), and cardiac arrest. RESULTS: 283 patients received MTP between 2010 and 2017. 179 (63%) did not receive TXA and 104 (37%) were treated with TXA. The groups were then propensity matched and yielded 62 patients in each group (124 total) (ISS 36 ±â€¯12 no TXA vs. 37 ±â€¯13 TXA; p = 0.59). There was no significant difference observed in mortality (50% no TXA vs. 39% TXA; p = 0.21), total PRBC's transfused (20 ±â€¯11 no TXA vs. 23 ±â€¯18 TXA; p = 0.45), DVT (8% no TXA vs. 6% TXA; p = 0.99), PE (2% no TXA vs. 3% TXA; p = 0.99), MI (3% no TXA vs. 0% TXA; p = 0.50), or cardiac arrest (26% no TXA vs. 18% TXA; p = 0.28). CONCLUSION: There does not appear to be any benefit to TXA administration in Trauma Patients in our institution. This is a single-center retrospective review. More data from other similar centers in the region or the United States is warranted.


Assuntos
Antifibrinolíticos/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Hemorragia/mortalidade , Hemorragia/prevenção & controle , Ácido Tranexâmico/uso terapêutico , Centros de Traumatologia , Adulto , Feminino , Hospitais Urbanos , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Pontuação de Propensão , Estudos Retrospectivos , Estados Unidos
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