Cumulative Probability Of Recurrence Research Articles

Recurrence following successful eradication of neoplasia with endoscopic mucosal resection compared with endoscopic submucosal dissection in Barrett's esophagus: a retrospective comparison.

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective treatments for Barrett's neoplasia. However, little is known about recurrence rates following these techniques. We compared long-term neoplasia recurrence rates following EMR and ESD. This study included patients with Barrett's neoplasia (high grade dysplasia/adenocarcinoma) treated between July 2019 and December 2023 at a tertiary referral center in Canada. Outcomes were residual neoplasia at first follow-up, complete remission of neoplasia (CRN), and neoplasia recurrence following CRN. 157 patients were included (87 EMR, 70 ESD). Compared with EMR, the ESD group had larger lesions (median 2 vs. 3 cm, P<0.05), more adenocarcinoma (85.1% vs. 94.3%, P = 0.07), and deeper submucosal invasion (T1a: 71.6% vs. 75.8%; T1b-SM1: 25.7% vs. 6.1%; T1b≥SM2: 2.7% vs. 18.2%; P<0.05). Among 124 patients with follow-up (71 EMR, 53 ESD), 84.9% of ESD-treated patients had curative resections (i.e. R0 resection with low risk for lymph node metastasis), whereas 94.4% of EMR-treated patients had deep margin R0 resection of low risk lesions. At first follow-up, residual neoplasia (14.1% vs. 11.3%) and CRN (97.2% vs. 100%) were similar in the EMR and ESD groups, but neoplasia recurrence following CRN was significantly higher with EMR (13% vs. 1.9%, P<0.05), with cumulative probability of recurrence at 3 years of 18.3% vs. 4.2%, respectively. Neoplasia recurrence following CRN was significantly higher following EMR compared with ESD, suggesting that ESD may be superior to EMR in preventing neoplasia recurrence in Barrett's esophagus.

MOHS MICROGRAPHIC SURGERY FOR BASAL CELL CARCINOMA: A REVIEW OF TREATMENT RESULTS

Objectives: To evaluate the results of Mohs Micrography Surgery (MMS) in the treatment of basal cell carcinoma (BCC). Materials and methods: We used the database of PUBMED and EMBASE to evaluate the results of MMS in treatment of BCC. Results: Nine studies with the total number of 5845 BCC cases were included in this review, the follow-up time varied from 12 to 42 months. The overall cumulative probabilities of recurrence after MMS were 2.4%. The cumulative probability of recurrence for the primary BCC group and the recurrent BCC group was 2.9% and 7.2%, respectively. In the recurrent BCC group, the cumulative probability of recurrence after MMS was lower than after standard surgical excision (SSE) (3.9% vs 13.5%, p &lt; 0.05). In MMS group, 52% of patients required one round of excision to achieve complete removal of BCC, 34% needed two rounds and 14% needed three rounds. The size of final skin defect after MMS was 1.34 times larger than that of the primary tumor (p &lt; 0.05). Conclusion: MMS is superior to SSE in BCC treatment, with lower recurrence rate and better normal skin-sparing. Therefore, MMS is strongly recommended for surgical treatment of BCC, especially in high-risk BCC. Received 28 June 2023Revised 26 September 2023Accepted 29 November 2023

Prognosis and Risk Factors of Recurrence in HBV-Related Small Hepatocellular Carcinoma After Stereotactic Body Radiation Therapy.

ObjectiveThe role of stereotactic body radiation therapy (SBRT) for treating small hepatocellular carcinoma (sHCC) has gained increasing recognition. However, the prognosis and risk factors for recurrence in patients with sHCC remain unclear. This study investigated the risk factors for the recurrence of hepatitis B virus (HBV)-related sHCC after SBRT.MethodsA total of 240 HBV-related sHCC patients treated with SBRT between March 2011 and March 2020 were retrospectively analyzed. The cumulative probability of recurrence was calculated according to the Kaplan–Meier method. Univariate and multivariate analyses were performed with Cox proportional hazard models.ResultsRecurrent hepatocellular carcinoma developed in 134 (55.8%) patients at a median time of 27 months after SBRT. The one- and two-year rates of recurrence were 20.9 and 45.0%, respectively. The median follow-up time was 30 months. The Cox multivariate analysis indicated that age (P = 0.029, HR [1.019, 1.002–1.037]), tumor size (P = 0.012, HR [1.227, 1.045–1.440]), and aspartate aminotransferase-to-platelet ratio index (APRI) (P = 0.005, HR [1.911, 1.221–2.989]) were independent risk factors for recurrence.ConclusionPatients receiving SBRT for HBV-related sHCC may be at greater risk of recurrence if they have a high APRI score combined with advanced age and large tumor size.

Incidence rate and predictors of recurrent aneurysms after clipping: long-term follow-up study of survivors of subarachnoid hemorrhage.

Recurrent aneurysms are a major cause of re-aneurysmal subarachnoid hemorrhage (aSAH), but information on long-term clip durability and predictors is insufficient. This study aimed to present the incidence rate of > 10years and investigate predictors of a recurrent aneurysm in aSAH survivors. We included 1601 patients admitted with aSAH and treated by microsurgical clipping between January 1993 and May 2010. Of these patients, 435 aSAH survivors were included in this study (27.2%). The total follow-up time was 5680.9 patient-years, and the overall incidence rate was 0.77% per patient-year. The cumulative probability of recurrence without residua and regrowth of the neck remnant was 0.7% and 13.9% at 10years, respectively. Neck remnant (hazard ratio [HR], 10.311; 95% confidence interval [CI], 5.233-20.313) and alcohol consumption over the moderate amount (HR, 3.166; 95% CI, 1.313-7.637) were independent risk factors of recurrent aneurysm. Current smoking and multiplicity at initial aSAH presentation were significant factors in a univariate analysis. Furthermore, de novo intracranial aneurysms (DNIAs) were more common in the recurrent group than in the non-recurrent group (40.9% vs. 11.5%, P < 0.001). In the present study, we noted the long-term clip durability and predictor of recurrence after microsurgical clipping. These findings can assist clinicians in identifying patients at a high risk of recurrent aneurysm and recommending selective long-term surveillance after microsurgical clipping.

Recurrence and Visual Outcomes of Phototherapeutic Keratectomy in Lattice Corneal Dystrophy: A Cohort Study.

To evaluate recurrence and visual outcomes of phototherapeutic keratectomy (PTK) in lattice corneal dystrophy. Kaplan-Meier survival analyses were retrospectively performed. Recurrence was defined as central biomicroscopic findings of recurrence with decreased visual acuity: loss of at least two lines or visual acuity ≤ 20/40) at any time during the follow-up. Twenty-two virgin eyes and 10 with previous keratoplasty (20 patients; 13 women and 7 men) were studied during a mean of 4.7 ± 3.5 years (range: 11 months to 18 years). One and 5 years after the first PTK (PTK1), 1 of 32 and 12 of 32 eyes, respectively, recurred. The cumulative probabilities of recurrence were 3%, 48%, and 89% in the whole sample at 1, 5, and 10 years, respectively. All cases in the virgin group and 8 eyes in the previous keratoplasty group improved their visual acuity. There were no significant differences in recurrence probability between groups (log-rank test; P = .86). A second PTK (PTK2) was performed in 15 of 32 eyes, with 6 postoperative recurrences recorded. The cumulative probabilities of recurrence in the whole sample were 18%, 30%, and 44% at 1, 3, and 5 years, respectively. Visual acuity improved in 11 of 13 eyes in the virgin group and 2 of 2 eyes in the previous keratoplasty group. Recurrence probability after PTK1 and PTK2 was similar in the whole sample (log-rank test; P = .637). Persistent graft edema after PTK1 in one eye was the only complication found. PTK can be an effective, safe, and repeatable treatment to delay keratoplasty in symptomatic lattice corneal dystrophy. [J Refract Surg. 2022;38(1):43-49.].

Sarcomas of the hand: A retrospective series of 26 cases

BackgroundHand sarcomas frequently suffer from a delayed diagnosis, and the current guidelines for their management are often not followed. MethodsThe objectives of our study were to determine: (1) the rate of inadequate initial treatments; (2) the rates of mortality, recurrence, and complementary excision in a cohort of patients with a sarcoma of the hand who were treated at our reference center between 2000 and 2015. ResultsThe series comprised 26 patients (mean age 40 years). Of the 20 patients not initially treated at a reference center, 17 had inadequate initial treatment. Of the six patients treated at our center, one had inadequate initial care. Significantly more patients had inadequate initial care outside a reference center (p=0.0045). The cumulative probabilities of recurrence or metastases at 5 years were 15% and 30%, respectively. Survival by cumulative incidence was 71% at 5 years and 56% at 10 years. ConclusionsSarcomas of the hand are a deadly pathology. All diagnostic uncertainty warrants referral of the patient to a reference center. Level of proofIV.

The efficacies of entecavir and tenofovir in terms of enhancing prognosis after curative treatment of hepatitis B virus–related hepatocellular carcinoma

Background/aimsWhether entecavir (ETV) or tenofovir disoproxil fumarate (TDF) affords the better prognosis after curative treatment of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) remains unclear. We compared recurrence and death rates between patients taking ETV and those taking TDF. MethodsBetween 2013 and 2017, patients with HBV-related HCC who had undergone hepatic resection (n=421) or radiofrequency ablation (n=305) as first-line anti-HCC treatment in three institutes were consecutively enrolled. All patients received ETV or TDF as a first-line antiviral. The cumulative probabilities of recurrence and death were assessed. We adjusted for viral factors, including the HBV-DNA load, and tumor and demographic factors. ResultsDuring the study period (median 46.6 [interquartile range 25.3–58.9] months), 227 patients experienced recurrence and 53 died. In the ETV (n=405) and TDF (n=321) groups, the annual incidences of recurrence (10.61 and 11.21 per 100 person-years, respectively; P=727) and death (2.28 and 1.79 per 100 person-years, respectively; P=277) were similar, with adjusted hazard ratios (aHRs) of 0.932 (P=0.622) and 0.667 (P=0.193), respectively. When stratified by treatment modality and the timing of antiviral therapy commencement, the values were similar (all P>0.05). Inverse probability of treatment weighting (IPTW) analyses yielded results that were similar in the two groups in terms of recurrence (aHR=1.038, P=0.963) and death (aHR=0.799, P=0.431). Furthermore, the early (<2 years) and late (≥2 years) recurrence risks were not statistically different in the two groups (both P=0.400), as confirmed by IPTW analysis (P=0.502 and P=0.377, respectively). ConclusionsThe prognoses in terms of recurrence and death after curative treatment of HBV-related HCC were not statistically different between the ETV and TDF groups. Further validation studies are needed.

Incidence of HCC recurrence after DAA treatment for HCV in a multicentre Italian cohort study

AbstractBackground and aimThe present real‐life multicentre, prospective study aims to investigate the effects of direct‐acting antivirals (DAAs) in HCV patients with a previous successfully treated hepatocellular carcinoma (HCC), in terms of neoplastic recurrence and sustained virological response (SVR) rates.MethodsFrom March 2015 to March 2017, all consecutive HCV patients with a previous successfully treated HCC who underwent DAA therapy were enrolled. Neoplastic recurrence was used as the primary outcome, whereas the secondary outcomes were patient characteristics predicting HCC recurrence. Cumulative probabilities of recurrence were extracted from time‐to‐event curves based on the Kaplan‐Meier method. Hazard ratios with 95% confidence intervals were estimated using univariate and multivariate Cox regressions.ResultsA total of 101 patients were enrolled: 83% of them were in Child‐Pugh class A, 88% had a history of HCC BCLC stage 0/A and 91.1% achieved SVR. The median time from the last successful HCC treatment to DAA start was 10.1 months [IQR: 5.6‐16.7]. Thirty‐one HCC recurrences were observed from DAA start (median follow‐up: 31.7 months). The incidence rate of recurrence was 20.5/100 person‐years. The 6‐, 12‐ and 24‐months HCC recurrence rates from the last HCC treatment were 1%, 8.9% and 25.6% respectively. DAA treatment failure, higher level of total bilirubin, higher BMI and higher level of AFP were significantly associated with higher risk of HCC recurrence in both univariate and Cox multivariate analysis.ConclusionsOur data suggest that the achievement of SVR and the absence of well‐known HCC risk factors reduce recurrence in patients who have taken DAAs.

Long-term Results of Trimethoprim-Sulfamethoxazole Versus Placebo to Reduce the Risk of Recurrent Toxoplasma gondii Retinochoroiditis

To compare the effects of 1 year of treatment with trimethoprim-sulfamethoxazole (TMP-SMZ) vs placebo in reducing the risk of recurrence of toxoplasmic retinochoroiditis during a 6-year follow-up period. Randomized, double-masked clinical trial. This cohort included 141 subjects recruited in Campinas, Brazil. The inclusion criterion was unilateral active recurrent toxoplasmic retinochoroiditis. All subjects were treated with 1 dose of TMP-SMZ (160mg/800mg) twice daily for 45days, and all lesions healed after this treatment. After this initial treatment, subjects were randomly assigned to group 1 (1 TMP-SMZ dose every other day for 311days) or group 2 (1 identical placebo tablet containing starch with no active ingredients every other day for 311days). Between the second and sixth years of follow-up appointments, none of the subjects received treatment unless a new recurrence episode had occurred. The primary outcomes were recurrent toxoplasmic retinochoroiditis within the first year of follow-up and recurrent toxoplasmic retinochoroiditis in the 6 years of follow-up. The cumulative probability of recurrence 1, 2, 3, 4, 5, and 6 years after the initial infection was, respectively, 13.0% (9/69), 17.4% (12/69), 20.3% (14/69), 23.2% (16/69), 26.1% (18/69), and 27.5% (19/69) in the placebo group and 0%, 0%, 0%, 0%, 0%, and 1.4% (1/72) in the TMP-SMZ group (P < .001; log-rank test). There were 3 cases (3/69; 4.3%) of multiple recurrences in the same individual in the placebo group. No treatment-limiting toxicity or side effects were observed in either group. New recurrences were more frequent among female subjects. TMP-SMZ may be used safely for prophylaxis of recurrent toxoplasmic retinochoroiditis and may provide long-term benefits.

Long-term outcomes of augmented unilateral recess-resect procedure in children with intermittent exotropia.

BackgroundInitial overcorrection after exotropia surgery has been considered as a desirable result. Recently, there had been several studies that reported better surgical results of augmented bilateral lateral rectus muscle recession procedure over the conventional procedure.ObjectivesTo compare the long-term results of augmented unilateral lateral rectus recession-medial rectus resection procedure (RR) with the original surgery in exotropic children.Data extractionA retrospective cohort study was performed on a total of 121 children with exotropia who underwent RR from February 2005 to December 2012 and were followed-up for at least 24 months. In 64 patients, RR was performed based on the original surgical table (original RR group). In 57 patients, the amount of medial rectus muscle resection was increased by 1 mm (augmented RR group).ResultsIn the original RR group, 47 of 64 patients (73.4%) had a successful outcome, 13 patients (20.3%) had recurrence, and 4 patients (6.3%) had overcorrection at 2 years after surgery. In the augmented RR group, 45 of 57 patients (79.0%) were successful, 4 patients (7.0%) had recurrence and 8 patients (14.0%) had overcorrection at 2 years after surgery. The recurrence rate was significantly lower in the augmented RR group than the original RR group, whereas the overcorrection rate was not significantly different between two groups at 2 years after surgery (P = 0.036 and P = 0.153, respectively). The cumulative probability of recurrence was lower in the augmented group at 36 months after surgery (P = 0.046, log rank test).ConclusionsThe long-term success rate of augmented RR in exotropic children was 79.0% and the recurrence rate was significantly lower than original RR with comparable overcorrection rates. Augmented RR can be considered as an alternative procedure in children with basic and convergence insufficiency type exotropia.

Trimethoprim-Sulfamethoxazole Versus Placebo in Reducing the Risk of Toxoplasmic Retinochoroiditis Recurrences: A Three-Year Follow-up

To compare the effects of 1 year of treatment with trimethoprim/sulfamethoxazole (TMP-SMZ) vs a placebo in reducing the risk of toxoplasmic retinochoroiditis recurrences during a 3-year follow-up period. Randomized, double-masked clinical trial. This cohort included 141 volunteers recruited in Campinas, Brazil. Inclusion criterion was unilateral active recurrent toxoplasmic retinochoroiditis. All volunteers were treated with 1 tablet of TMP-SMZ (160 mg/800 mg) twice daily for 45days, and all lesions healed after this treatment. After this initial treatment, the volunteers were randomly assigned to Group 1(1TMP-SMZ tablet every 2days for 311days) or Group 2 (1 identical placebo tablet containing starch with no active ingredients every 2days for 311days). At the second- and third-year follow-up appointments, none of the volunteers received treatment unless a new recurrence episode had occurred. The primary outcomes were recurrent toxoplasmic retinochoroiditis within the first year of follow-up and recurrent toxoplasmic retinochoroiditis within the third year of follow-up. The cumulative probability of recurrence at 1, 2, and 3 years of follow-up were, respectively, 13.0% (9/69), 17.4% (12/69), and 20.3% (14/69) in the placebo group and 0% (0/72) in the TMP-SMZ group (P < .001, log-rank test). There was no case of multiple recurrences in the same individual. No treatment-limiting toxicity or side effects were observed in either group. New recurrences were more frequent among female volunteers. TMP-SMZ may be used safely for prophylaxis of recurrent toxoplasmic retinochoroiditis, with long-term benefits.

Treatment outcomes and recurrence following standard cold forceps polypectomy for diminutive polyps.

The recurrence rate after standard cold forceps polypectomy (CFP) of diminutive polyps of≤5mm has not been fully determined. The aim of this study was to analyze the long-term follow-up results and recurrence rate after CFP of diminutive polyps. We retrospectively reviewed the medical records of 884 (738 men; age 53years) asymptomatic subjects who underwent surveillance colonoscopy after CFP of 1-2 diminutive adenomatous polyps. Cumulative recurrence at the CFP site and risk factors for recurrence were analyzed. Overall recurrence over 59.7months was 17% after CFP of 1111 diminutive polyps. The rate of definite recurrence was 4%, and probable recurrence was 13%. Recurrence as advanced adenoma was 0.5% (5/1111). The cumulative probabilities of recurrence at 3, 5, and 7years after CFP were 10.0, 16.0, and 21.1%, respectively. Multivariate analysis revealed that polyp 4-5mm in size and right colonic polyp were risk factors for recurrence (hazard ratio [HR] 1.37; 95% confidence interval [CI] 1.01-1.86 and HR 1.49; 95% CI 1.08-2.04, respectively). The recurrence rate for 10 endoscopists who performed at least 50 CFPs ranged from 11.0 to 25.2%; the probability of recurrence in those in the top half in terms of recurrence rate was 1.6-fold higher than that of those in the bottom half (95% CI 1.17-2.19). Although recurrence may develop after standard CFP of diminutive polyps, recurrence as advanced adenoma is rare. Large polyp size, right colon polyp, and endoscopist are risk factors for recurrence after standard CFP.

Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence.

Girls and women with type 1 diabetes are at increased risk for developing eating disorders (EDs), and these disorders are associated with serious diabetes-related medical complications. This study describes the longitudinal course of disturbed eating behavior (DEB) and EDs in a cohort with type 1 diabetes. A total of 126 girls with type 1 diabetes receiving care for diabetes at The Hospital for Sick Children in Toronto participated in a series of seven interview-based assessments of ED behavior and psychopathology over a 14-year period, beginning in late childhood. Survival analysis was used. Mean age was 11.8 ± 1.5 years at time 1 and 23.7 ± 2.1 years at time 7. At time 7, 32.4% (23/71) met the criteria for a current ED, and an additional 8.5% (6/71) had a subthreshold ED. Mean age at ED onset (full syndrome or below the threshold) was 22.6 years (95% CI 21.6-23.5), and the cumulative probability of onset was 60% by age 25 years. The average time between onset of ED and subsequent ED remission was 4.3 years (95% CI 3.1-5.5), and the cumulative probability of remission was 79% by 6 years after onset. The average time between remission of ED and subsequent recurrence was 6.5 years (95% CI 4.4-8.6), and the cumulative probability of recurrence was 53% by 6 years after remission. In this longitudinal study, EDs were common and persistent, and new onset of ED was documented well into adulthood. Further research regarding prevention and treatment for this vulnerable group is urgently needed.

Naturally Occurring Autoantibodies to Oxidation-Specific Epitopes in Patients with Venous Thromboembolism

Background: Naturally occurring IgM autoantibodies (NAb) recognize oxidation-specific epitopes which are altered self structures on apoptotic cells, oxidized LDL, or vessel wall proteins. Oxidation-specific epitopes are proinflammatory antigens and potential markers for chronic inflammatory conditions. The risk of venous thromboembolism (VTE) is associated with (pro)inflammatory states such as dyslipoproteinemia, obesity or cancer. We hypothesize that natural antibodies may target epitopes which are also involved in the pathogenesis of VTE. In pursuing a “proof of concept”, we studied Nab in patients with a high venous thrombotic risk and evaluated their association with the risk of recurrent VTE.Methods: We determined Nab levels in 663 patients with a first unprovoked deep vein thrombosis and/or pulmonary embolism who were prospectively followed after discontinuation of anticoagulation in the Austrian Study on Recurrent Venous Thromboembolism, a multicentre cohort study. We excluded those with coagulation inhibitor deficiencies, lupus anticoagulant, cancer, pregnancy, long-term antithrombotic therapy, or homozygosity/double heterozygosity for factor V Leiden and/or the prothrombin mutation. Study end point was recurrent VTE.Nab target different oxidation-specific epitopes including phosphorylcholine-containing oxidized phospholipids which were generated by oxidation of low density lipoproteins (LDL) with CuSO4. Levels of IgM against oxidized (Ox) LDL were determined in venous blood drawn three weeks after discontinuation of anticoagulants by chemiluminescent enzyme linked immunoabsorbent assay and expressed as relative light units (RLU)/100ms.To determine the effect of anti-OxLDL IgM on the recurrence risk, models for time-to-event-data were used. Their direct effect on the recurrence risk was estimated by a cause-specific Cox proportional-hazards model, followed by a Fine-Gray model to account for competing events (death, restart of antithrombotics) and expressed by subdistribution hazard ratios (SHR). Anti-OxLDL IgM levels are given as median (25th, 75th percentiles).Results: Levels of anti-OxLDL IgM in patients with a first unprovoked VTE were 20.17 RLU/100ms (12.26, 34.72). Levels did not correlate with either age (rs=-0.16) or BMI (rs=-0.16). Levels correlated with sex [higher in women; 24.24 (14.6, 40.0) vs. 16.76 (10.46, 27.9) RLU/100ms, p<0.001]. 151 (22.8%) of 663 patients (mean age 48 years, 54% women) had recurrence during a median of 67 months. Anti-OxLDL IgM levels were higher in patients without recurrence [20.84 (12.32, 36.85) vs. 17.60 (11.97, 26.93) RLU/100ms, p=0.02]. For each doubling of anti-OxLDL IgM levels, the SHR of recurrence was 0.85 (95% CI 0.74-0.98; p = 0.02) and was 0.95 (0.82-1.1; p=0.5) after adjustment for sex.Patients with anti-OxLDL IgM levels within the second tercile (14.6 - <28.64 RLU/100ms) had a similar recurrence risk as patients with levels within the first tercile (<14.60 RLU/100ms) (SHR 0.93, 95% CI 0.65–1.33, p=0.7). The recurrence risk was significantly lower in patients with anti-OxLDL IgM levels within the third tercile (>28.64 RLU/100ms) (SHR 0.58, 95% CI 0.38–0.87, p<0.01). After adjustment for sex, the recurrence risk was still lower among patients with high anti-OxLDL IgM (SHR 0.75, 95% CI 0.49–1.14, p=0.2) but without statistical significance.We stratified patients according to an anti-OxLDL IgM level corresponding to the 60th percentile (14.6 RLU/100ms). The cumulative probability of recurrence after 5 years in patients with anti-OxLDL IGM > 60th percentile was 12.3% (8.5-16.9%) and was 20.3% (16.4-24.6%) among those with lower levels (p<0.001) (Figure). The corresponding SHR was 0.55 (0.38-0.78; p <0.001) for higher anti-OxLDL IgM and was 0.67 (95% CI 0.47-0.96; p=0.03) after adjustment for sex.Conclusions: An association exists between anti-OxLDL IgM and VTE recurrence which is consistent with a protective function of NAb via their ability to bind proinflammatory oxidation-specific epitopes. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Endoscopic ultrasonography assessment of para-esophageal varices predicts efficacy of propranolol in preventing recurrence of esophageal varices

Volume of para-esophageal varices (PEV) correlates with esophageal varices recurrence. The effect of propranolol on volumetric change of PEV has not been studied. The relation between EV recurrence and volumetric change of PEV in patients undergoing endoscopic variceal ligation (EVL) with and without propranolol are studied. Sixty-six patients who achieved EV eradication by primary EVL were randomly allocated to a propranolol group (n = 33) or control group (n = 33). The endpoints of the study were EV recurrence and volumetric change of PEV assessed by using endoscopic ultrasonography (EUS) at 3-month intervals for 2 years. The cumulative probability of recurrence at two years was 28% in the propranolol group (n = 9) and 68% in the control group (n = 20) (p = 0.005, log-rank test). Difference of the volumetric change of PEV became significant as early as at the third month [-0.12 (-0.38-0.34) vs. 0.14 (-0.06-0.57), p < 0.001] between the two groups. Regression of PEV was achieved in 20 patients of the propranolol group at a median time of three months (range 3-12 months), and no EV recurrence was found at the end of follow-up for two years. On multivariate analysis, the volumetric change of PEV at the third month and use of propranolol were determinants of EV recurrence. Propranolol may reduce both EV recurrence rate and volume of PEV in patients achieving endoscopic eradication. Regression of PEV is a predictor of durable eradication of EV without recurrence in patients using propranolol. EUS is an objective and useful tool to measure PEV and predict recurrence of EV.

The risk of recurrence in women with venous thromboembolism while using estrogens: a prospective cohort study

The optimal duration of anticoagulation for women who had venous thromboembolism (VTE) associated with estrogen use is unknown. To test the hypothesis that women who had a first VTE while using estrogens have a low risk of recurrence. A Prospective cohort study of 630 women (333 estrogen users, 297 non-users) with a first VTE, who were followed for an average of 69 months after anticoagulation withdrawal. Women with a previous or secondary VTE, coagulation inhibitor deficiency, lupus anticoagulant, cancer, pregnancy, requirement of long-term antithrombotic therapy or homozygosity or double heterozygosity for factor V Leiden and/or the G20210A prothrombin mutation were excluded. The endpoint was objectively documented symptomatic recurrent VTE. VTE recurred in 22 (7%) estrogen users and in 49 (17%) non-users. After 1, 2 and 5 years, the cumulative probability of recurrence was 1% (95% confidence interval [CI], 0-2), 1% (95% CI, 0-2) and 6% (95% CI, 3-9) among estrogen users and 5% (95% CI, 2-7), 9% (95% CI, 6-13) and 17% (95% CI, 12-22) among non-users. Compared with non-users, estrogen users had an adjusted relative risk (RR) of recurrent VTE of 0.4 (95% CI, 0.2-0.8). Compared with non-users in the respective age groups, the RR of recurrence was 0.4 (95% CI, 0.2-0.8) among estrogen-containing-contraceptive users and 0.7 (95% CI, 0.3-1.5) among women using estrogen-containing menopausal hormone therapy. Women who had their first VTE while using estrogens have a low risk of recurrent VTE. These women might not benefit from extended anticoagulant therapy.

The Risk Of Recurrence In Women With Venous Thromboembolism While Using Estrogens: A Prospective Observational Cohort Study

▪ ObjectiveBecause of the high recurrence risk, guidelines recommend indefinite anticoagulation in women with a first unprovoked proximal deep-vein thrombosis (DVT) and/or pulmonary embolism (PE). The optimal duration of anticoagulation in women who had venous thromboembolism (VTE) while using estrogens is unknown. We therefore compared the risk of recurrent VTE between women who used estrogens at the time of first VTE and women who did not. MethodsThis analysis was performed within the frame of the Austrian Study on Recurrent Venous Thromboembolism (AUREC), an on-going prospective observational study. Patients with a first objectively confirmed DVT of the leg and/or PE who had received anticoagulants for 3 to 18 months were included. Exclusion criteria were: age < 18 years; VTE associated with surgery, trauma, cancer or pregnancy; long-term anticoagulation; natural inhibitor deficiency; lupus anticoagulant; homozygosity or double heterozygosity for factor V Leiden and/or the prothrombin mutation. Women were advised to refrain from further estrogen use and were excluded in case of non-adherence. The study end point was recurrent symptomatic DVT and/or PE verified by imaging. The local ethics committee approved the study and all patients gave written informed consent. ResultsWe followed 630 women (mean age 46 +/- 17 years) who had been treated with oral anticoagulants for 7 (+/- 3) months for an average of 69 (+/- 52) months. Recurrent VTE was recorded in 71 patients (11%). Recurrent VTE occurred in 22 (7%) of 333 estrogen users and in 49 (17%) of 297 non-users. After 1, 2 and 5 years, the cumulative probability of recurrence was 1% (95% CI 0-2), 1% (95% CI 0-2) and 6% (95% CI 3-9) among estrogen users and 5% (95% CI 2-7), 9% (95% CI 6-13) and 17% (95% CI 12-22) among non-users, respectively (p < 0.001, Figure). Compared to non-users, estrogen users had a relative risk (RR) of recurrent VTE of 0.4 (95% CI 0.2-0.8) after adjustment for age, site of first VTE and factor V Leiden carrier status. Compared to non-users in the respective age groups, the RR of recurrent VTE was 0.4 (95% CI 0.2-0.8) among estrogen containing contraceptive users and was 0.7 (95% CI 0.3-1.5) among women using estrogen containing hormone replacement therapy. [Display omitted] ConclusionWomen who had their first VTE while using estrogens have a low risk of recurrent VTE. The recurrence risk is particularly low in estrogen containing contraceptive users. We therefore propose that these women should receive anticoagulant therapy for no longer than 3 months. Disclosures:No relevant conflicts of interest to declare.

Amphetamine‐associated seizures: Clinical features and prognosis

Forty-four patients presenting with first-ever seizure within 24 h of illicit use of amphetamine or related analogs (amphetamine-associated seizures, AAS) were identified over 8 years. Patients with AAS were compared to control groups of other first-ever seizure patients (provoked n = 126 and unprovoked n = 401). Cumulative probability of recurrence was calculated using Kaplan-Meier analysis. Seizure recurrence and development of epilepsy were less likely in patients with AAS compared to provoked or unprovoked controls. Forty percent of patients with AAS had clinical risk factors for epilepsy, epileptiform abnormalities on electroencephalography (EEG), or an epileptogenic lesion on neuroimaging. Sleep deprivation was more frequently present in those with AAS. AAS likely relate to an intrinsic proconvulsant effect of these drugs combined with patient susceptibility and environmental factors.

Hematocrit and the Risk of Recurrent Venous Thrombosis: a Prospective Cohort Study

AbstractAbstract 807Venous thromboembolism (VTE) is a multifactorial disease which often recurs. The risk of recurrence is higher in men than in women, but no explanation for this sex-related difference has thus far been found. Men and women differ with regard to hematocrit levels, which in turn are positively related to the risk of a first VTE. The impact of the hematocrit on the risk of recurrence has never been evaluated. We hypothesized that hematocrit levels are predictive for the recurrence risk and that the difference in recurrence risk between men and women could be explained by hematocrit.Patients with a first objectively diagnosed VTE were prospectively followed for an average of 43 months after discontinuation of anticoagulation. Patients with VTE provoked by surgery, trauma, pregnancy, or female hormone use, patients with a natural inhibitor deficiency, a lupus anticoagulant, homozygous or double heterozygous coagulation disorders, cancer, or with indefinite anticoagulation were excluded. The endpoint was symptomatic recurrent VTE.150 (23%) of 653 patients (mean age 52 years, 226 women) had recurrent VTE. The risk of recurrence was higher in men than in women [hazard ratio (HR) 1.9 (95% CI 1.3–2.9; p=0.001)]. Mean hematocrit (+standard deviation) was significantly higher in patients with recurrence than in those without: 43.0% (+3.2) vs 42.1% (+3.7); p=0.006. In a Cox proportional hazards model, the HR of recurrence was 1.07 (95% CI 1.02–1.13; p=0.004) for each 1% increase of hematocrit, and was 1.07 (95% CI 1.02–1.13; p=0.007) after adjustment for age, body mass index, smoking status and factor V Leiden. After adjustment for sex the association between hematocrit and recurrence risk disappeared (HR 1.04, 95% CI 0.98–1.10; p=0.25). Hematocrit levels were significantly higher in men than in women (43.7% vs. 39.7%, p<0.001). Male sex remained a significant determinant of the recurrence risk after adjustment for hematocrit: HR 1.7 (95% CI 1.1–2.7; p = 0.03). A high hematocrit significantly increased the risk of recurrence among women but not among men (Table 1). After 5 years the cumulative probability of recurrence was 5.7% (95% CI 0%-12.4%) among women with hematocrit <39%, 26.7% (95% CI 13.8%-39.6%) among women with hematocrit levels between 39% and 41%, and 25.8% (95% CI 11.5%-40.1%) among those with a hematocrit >41% (p=0.02). We next compared the risk of recurrence between men and women at corresponding hematocrit levels. At hematocrit levels between 37% and 42%, women had a significantly lower recurrence risk than men. At higher levels, the risk of recurrence in women even exceeded those of men.A high hematocrit is a strong risk factor of recurrent VTE in women but not in men. In particular, women with a low hematocrit (less than 39%) have a very low risk of recurrence. The sex-related difference in the risk of VTE recurrence is not explained by hematocrit levels. Disclosures:No relevant conflicts of interest to declare.

Panayiotopoulos syndrome: A clinical, EEG, and neuropsychological study of 93 consecutive patients

To explore the clinical, electroencephalography (EEG), neuropsychological features, and prognosis of Panayiotopoulos syndrome (PS). Of 1,794 children aged between 1 and 14 years referred for the first afebrile focal seizure, between January 1992 and December 2004, 93 (5.2%) had PS according to clinical criteria. Age at onset ranged from 1.1 to 8.6 years, and was earlier in children with more than one seizure. Autonomic seizures followed a stereotypical onset and progression. Emesis, pallor, or flushing was almost always among the first symptoms that usually culminated in vomiting (77.4% of patients). More than half (55%) of seizures were longer than 30 min but these did not appear to affect remission and number of seizures. Interictal EEG showed great variability, with 79.5% of patients showing spikes of variable localizations and evolution over time; 16.1% had background abnormalities only, and 5.4% had consistently normal EEG studies. Onsets in five ictal EEGs were posterior or anterior-left or right. On neuropsychological testing, IQ and subtests of Wechsler Intelligence Scale for Children-Revised (WISC-R) were within normal limits, although some minor statistically significant differences were found in arithmetic, comprehension, and picture arrangement in comparison with controls. Cumulative probability of recurrence was 57.6%, 45.6%, 35.1%, and 11.7% at 6, 12, 24, and 36 months, respectively, after the first seizure. Thirty-four (58.6%) of 59 patients treated with antiepileptic drugs continued having seizures before ultimate remission. PS is a uniform childhood susceptibility to autonomic seizures that is related to early age of development and with excellent prognosis with regard to seizure remission and neuropsychological development.