Early Aggressive Approach Research Articles

SAT574 Thyroglossal Duct Papillary Thyroid Cancer With Normal Eutopic Thyroid Gland: A Management Dilemma

Abstract Disclosure: H. Belal: None. J.T. Batch: None. G.Y. Gandhi: None. Background: The incidence of thyroglossal duct cyst carcinomas is less than 1%, the majority being papillary thyroid cancer. One-third arise de novo from the thyroglossal duct. The rest are direct metastasis of eutopic papillary thyroid cancer. Management in the setting of a normal eutopic thyroid gland is challenging. Clinical Case: A 35-year-old female presented with transient right facial paresthesia. CT angiogram revealed an incidental 2.3 cm thyroglossal duct cyst with internal ectopic thyroidal tissue and micro-calcifications. She denied any compressive symptoms, radiation exposure, or family history of thyroid cancer and was euthyroid. Ultrasound noted a normal thyroid gland and complex solid-cystic mass measuring 2.3 x 2.0 x 1.5 cm superior to the isthmus. Satisfactory fine needle aspiration of the mass revealed benign-appearing epithelial cells, macrophage, and colloid-like material. Due to new anterior neck pain, a Sistrunk Procedure (SP) was performed. Pathology revealed a 1.2 cm papillary thyroid carcinoma, conventional type (confirmed by TTF-1 and thyroglobulin stains), arising within the thyroglossal duct cyst. Surgical margins were free of cancer, and there was no lymphovascular invasion. A thyroid ultrasound seven months after the procedure revealed heterogenous thyroid tissue, no thyroid nodules, and several small benign-appearing reniform-shaped cervical lymph nodes in zones 1 and 2. The patient was offered yearly thyroid ultrasound surveillance versus prophylactic thyroidectomy. She elected to proceed with thyroidectomy due to concerns about disease recurrence. Final pathology results revealed right lobe 2 mm papillary microcarcinoma limited to the thyroid. Conclusion: Fine needle aspiration of thyroglossal duct cysts can have a high false negative rate, as in our patient. There is currently no consensus on treatment of thyroid carcinomas arising from thyroglossal duct cysts. There are four possible surgical strategies: 1) SP alone 2) SP with concurrent thyroid lobectomy or pyramidal lobe resection 3) SP with total or near total thyroidectomy in all patients and 4) SP and selective addition of total or near total thyroidectomy in high-risk patients. The role of radio-iodine ablation and levothyroxine suppression after SP is also unclear. Management recommendations are Grade C, relying on case reports, case series, and expert opinion. Whether or not to proceed with total thyroidectomy, especially in the setting of a normal thyroid gland, remains highly controversial. Some experts even argue for an early aggressive surgical approach with SP, total thyroidectomy, and level I lymph node sampling in all patients to provide accurate staging and allow for the use of thyroglobulin and whole-body scintigraphy in surveillance. Multisite comparative data on the long-term outcomes of patients who receive early aggressive versus conservative management is needed. Presentation: Saturday, June 17, 2023

ODP192 Empagliflozin associated Euglycemic Diabetic Ketoacidosis and the Terrible Triad

Abstract Background Among diabetic patients, newer drug classes such as SGLT2i have been reported to present with Euglycemic Diabetic Ketoacidosis (eDKA), wherein these patients are without signs of elevated glucose levels. However, this condition can coexist with acute pancreatitis (AP) and hypertriglyceridemia (HTG), which is also known as the terrible triad. Clinical Case We were presented with a 31-year old diabetic male maintained on empagliflozin 25mg OD and metformin 500mg OD, discontinued his medication four months ago, and recently started retaking empagliflozin one week ago. He presented with drowsiness, severe abdominal pain rated as 9/10, and vomiting. An NGT was inserted and on further workup, acidosis was present on ABG with an anion gap of 28 mEq/L. AP was noted on abdominal ultrasound with an amylase of 768 U/L. CBG was 167mg/dL, Hba1c of 7.4%, Creatinine of 1. 05mg/dL, with ketonuria on urinalysis. Hydration was started with referral to endocrinology service. Insulin drip was started, and CBGs ranged from 145-229mg/dL while on drip. Hydration was increased accordingly, considering the patient's intake and output. Further workup was done, and lipid profile revealed severe hypertriglyceridemia at 1724.78mg/dL and elevated VLDL at 342mg/dL. Statin was prescribed, and eventually, insulin drip was titrated down with resolution of acidosis. Insulin was then shifted to subcutaneous regimen. Diet was also transitioned to clear liquids and eventually into diabetic diet. The patient was sent home and was uneventful after. eDKA develops due to increased glucagon secretion and decreased insulin production, promoting glucose to fat metabolism and ultimately stimulating ketogenesis. These agents decrease the blood glucose level by increasing urinary glucose excretion leading to a reduction in insulin secretion from the pancreatic β-cells. The terrible or enigmatic triad consisting of AP, HTG, and DKA/eDKA has been well reported but has a complex process. HTG results as a product of the reduced lipoprotein lipase activity in peripheral tissues, which decreases the removal of VLDL from the plasma. In AP cases, HTG only accounts for a minority (2-7%) of cases, but the risk was increased with levels above 1000mg/dL, such as in our patient. In the study by Simons-Linares et al., having the said triad had higher odds of having SIRS, shock, sepsis, and parenteral nutrition when compared to AP patients alone. eDKA patients can present with non-specific signs and symptoms such as nausea, vomiting, and abdominal pain, which can delay the diagnosis in patients. Fortunately, it was recognized early on, and there was a quick response in managing the case. Conclusion To date, there is scarcity among reports of the terrible triad, especially with empagliflozin use. Therefore, we can stress the importance of keen assessments and history taking in detecting the triad for an early aggressive approach to prevent adverse outcomes. Presentation: No date and time listed

High-grade mucoepidermoid carcinoma in thyroglossal cyst: Post-surgical histological surprise and dilemmas

Occurrence of malignancy in the TG cyst has been rarely reported, though rare, and papillary carcinoma predominates the common type but squamous cell carcinomas, anaplastic carcinoma, and medullary have been reported rarely. Mucoepidermoid carcinomas are most commonly seen in salivary glands, and as per the available literature, there was only two cases reported in thyroglossal cyst. We are presenting a 67-year-old lady presented with a 6×8 cm hard swelling below symphysis menti with no thyromegaly and moving on protrusion of tongue, and on MRI, it was found to be thyroglossal cyst with infiltration of strap muscles. Cytological investigation revealed it to be a TG cyst malignancy. The patient underwent total thyroidectomy and radical Sistrunk’s operation. Histopathological and immunohistochemistry revealed it to be a histological examination revealed a low-grade mucoepidermoid carcinoma consistent with origin in a thyroglossal duct remnant it invaded the hyoid bone and adjacent strap muscles. Various diagnostic and treatment dilemmas in the treatment of TG cyst malignancy are discussed with reference to mucoepidermoid carcinoma. We are reporting an usual histological surprise in a thyroglossal cyst malignancy being the only second reported case of TG cyst mucoepidermoid carcinoma this case highlights the importance of removal of thyroglossal duct cysts at an early stage and aggressive surgical approach in high-grade tumors.

Early Aggressive Treatment Approaches for Multiple Sclerosis.

Purpose of reviewThis review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches.Recent findingsNatalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation.SummaryTraditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.

Combination of histological and molecular data for improving outcome prediction in non-muscle invasive bladder cancer-narrative review.

The majority of patients with bladder cancer are diagnosed in non-muscle invasive stage. Most of them will experience recurrence or progression to more aggressive disease during follow-up. That raises the need for improvements with regard to risk assessment. Current risk stratification, based only on clinicopathologic features, does not fully reflect biological heterogeneity of the cancer and its role in prognosis. Many studies addressed the topic of variant histology and its influence on treatment and outcomes. It has been shown that accurate identification of variant histology implicates patient prognosis and inform right treatment decisions. Most studies on histological variants of bladder cancer suggest a more aggressive clinical course, with higher risk of recurrence and progression than in conventional urothelial cancer, even when diagnosed in non-muscle invasive stage. That prompts early aggressive treatment approach whenever variant histology is detected. Emerging genomic information are expected to complement clinical and pathological data and change the paradigms in the management of bladder cancer. Several reports highlighted the clinical significance of molecular stratification of bladder cancer, but the available evidence is based on retrospective data. Molecular subtyping gives promise not only for improving risk assessment, but also in predicting response to Bacillus Calmette-Guerin (BCG) or chemotherapy. Finally, molecular alterations might become targets for novel drugs to improve the overall response of these patients. However, its implementation into clinical practice requires further validation in prospective trials, especially in the context of non-muscle invasive bladder cancer.

Timing matters: real-world effectiveness of early combination of biologic and conventional synthetic disease-modifying antirheumatic drugs for treating newly diagnosed polyarticular course juvenile idiopathic arthritis

ObjectivesTo compare real-world effectiveness of two adaptive treatment strategies of disease-modifying antirheumatic drugs (DMARDs) in treating children with newly diagnosed polyarticular course juvenile idiopathic arthritis (pcJIA): early aggressive use of...

Predictive factors of lethality and complications of deep fascial space infections of the neck.

to identify predictive factors for lethality and complications of deep fascial space infections of the neck (DFSIN), establishing an early and aggressive treatment in the neck before the progression to descending mediastinitis. we retrospectively analyzed 133 cases of DFSIN treated at Discipline of Head and Neck Surgery of the Medicine School of Santa Casa de Misericórdia de São Paulo. We accessed demographic characteristics, associated diseases, clinical presentation, laboratorial tests, length of hospital stay, number of involved anatomic neck spaces, intra-operative and microbiology findings. We analyzed these data using logistic regression to predict DFSIN lethality and life threatening complications (mediastinitis, septic shock, pneumonia, pleural empyema, skin necrosis). lethality and complication ratios were 9% and 50.3%, respectively. The logistic regression model showed that patients with septic shock were more likely to have progression to death (p < 0.001) and, the presence of more than two involved neck spaces (p < 0.001) and older individuals (p = 0.017) were more likely to have complicated deep neck infections. Descending necrotizing mediatinitis increased the lethality ratio by 50%, and was associated to necrotizing fasciitis (p=0.012) and pleural empyema (p<0.001). septic shock is a lethal predictive factor and age as well as more than two involved neck spaces are the predictive factors for complications. Necrotizing fasciitis is an important factor for complications and death. Therefore, its surgical treatment must be more aggressive. Descending mediastinitis has a high lethal rate and the successful treatment is based on early diagnosis and aggressive surgical approach.

Acute Type A Aortic Dissection: Managing More Than Just the Entry-Tear

As emergency repair for acute type A aortic dissection is improving, the reintervention rate increases. Over 10% of cases require an aortic reintervention, which should ideally be performed in an early stage to allow for positive aortic remodeling and to prevent limitations by the stiffened aortic flap. These reinterventions remain a surgical challenge and may come with complications. We provide a comprehensive overview of different management strategies and their success in treating aortic adverse remodelling, based on current evidence of the literature. Two meta-analyses and an additional literature search yielded comparable mortality rates between limited repair and extensive repair. Cardiopulmonary bypass time, cross clamping time and cardiac arrest time were significantly shorter in limited repairs. Reintervention rate was generally lower in extensive repair, although not always significant. In conclusion, the early aggressive approach may be useful to lower reintervention rates. However, it has not yet been proven to be more beneficial. It will be imperative to develop a patient-specific early stage prediction model for residual aortic reintervention.

Management of the ruptured sinus of valsalva aneurysmsa

Background: RSOV is associated with a dramatic onset of symptoms to a state of biventricular failure due to sudden volume overload. Controversies exist about RSOV repairs among various centers are the surgical approach (chamber involved, transaortic or both) and the closure technique (primary/ patch closure). There have been no clinical trials to show that one technique is superior to other. In the present study, we reviewed our 16 years’ experience with repair of RSOV through exclusive transaortic approach.Methods: 40 patients underwent RSOV repair through transaortic approach from January 2000 to December 2016. The mean age was 30.2 years. The origin of RSOV was right coronary sinus in 75% of cases and non-coronary sinus in 22.5% of cases. There was one giant calcified unruptured aneurysm arising from right coronary sinus. Right ventricle was most common chamber of rupture comprising 96.67% cases. All patients underwent transaortic repair of RSOV using dacron patch. VSD repair was done in 25% cases. Aortic valve replacement was done in 62.5% cases for moderate to severe AR.Results: There were 7.5% in hospital deaths with no late deaths. Inotropic and ventilatory support required for 3±1.6 days and 1.8±1.2 days respectively. The mean ICU stay and hospital stay was 3.5±1.6 days and 7.5±2.5 days respectively. None of the patient required permanent pacemaker implantation. The 37 survivors were followed up for 6.4±3.6 years; all had an improvement in functional NYHA class with superior results in those with no aortic regurgitation. 7.5% patients developed mild AR during follow up which medical management was done.Conclusions: Surgical treatment of ruptured sinus of Valsalva aneurysm using the transaortic patch technique has an acceptably low operative risk, lesser distortion of aortic valve and good long-term symptom-freedom survival. An early aggressive approach is recommended to prevent worsening of symptoms and more extensive disease.

A Case of Mycotic Aneurysm of the Ascending Aorta at the Suture Line Early Post Orthotopic Heart Transplantation

We report a 44 year old man who presented with a rapidly expanding mycotic aneurysm of the ascending aorta post orthotopic heart transplant for end stage dilated cardiomyopathy (Figure-1). Prior to transplant, he was bridged with HeartWare left ventricular assist device, and temporary extracorporeal right ventricular assist device (tempRVAD). The site of tempRVAD outflow graft was infected by multi resistant pseudomonas aeruginosa, treated with prolonged course of aminoglycosides with complete wound healing. At 6 weeks after transplantation, the patient presented with increasing malaise and pyrexia. Serial blood cultures revealed gram negative bacteraemia with multi resistant pseudomonas aeruginosa. A transoesophageal echocardiography showed no evidence of intra-cardiac endocarditis. CT chest and abdomen with contrast revealed 2 small ascending aortic aneurysms, presumably mycotic, at the level of aortic anastomosis suture line. PET scan showed increased FDG uptake in the ascending aorta consistent with an infective process. The size of aneurysm grew rapidly in serial weekly CT, despite of optimal antibiotic and blood pressure management. The patient subsequently underwent surgery 3 weeks after presentation, during which the aneurysm was successfully resected with replacement of ascending aorta with allograft. This case highlights the rare but significant occurrence of suture line aortitis with myocotic aneurysm presenting as bacteraemia during post-transplant period. A high index of clinical suspicions guiding appropriate imaging modalities is crucial in confirming the diagnosis. Once diagnosed, an early aggressive surgical approach is often indicated. Figure-1

Prospective study to correlate the level of glycosylated haemoglobin with wound healing, vasculopathy and neuropathy in diabetic foot patients

Background: Diabetes mellitus is a prevalent global health problem and diabetic foot represents one of its dreadful complications. Early aggressive approach and multidisciplinary intervention prevent limb loss and disease fatality. Glycosylated haemoglobin (HbA1c) reflects long term glycaemic control and helps in prediction of complications as well as response to treatment. Methods: A total of 50 patients with diabetic foot ulcer (Wegner grade 1, 2) made nucleus of this study. Every patient underwent proper clinical, hematological and sonological assessment. Optimum treatment was provided and the effect of improvement in HbA1c value was correlated with duration of wound healing, vasculopathy and neuropathy over a 12 week follow uu. Results: Mean age of presentation was 53.4 years and patients developed diabetic ulcers (Wegner grade 1, 2) at a mean HbA1c value of 6.6. Foot trauma was inciting event in 70% cases. 70% patients had neuropathy and 30% had vasculopathy at presentation. Mean duration of healing was 42.6 days. Healing was faster in the group with lower HbA1c; however there was no improvement in neuropathy or, vasculopathy in 12 weeks duration. Conclusions: Based on the observations of present study it may be submitted that lower HbA1c value contributes to faster wound healing, however it doesn’t improve neuropathy and/or vasculopathy over duration of 12 weeks.

An aggressive multidisciplinary approach reduces mortality in rhinocerebral mucormycosis.

Background:Rhinocerebral mucormycosis occurs in immunocompromised hosts with uncontrolled diabetes, solid organ transplants, and hematologic malignancies. Primary disease is in the paranasal sinuses but often progresses intracranially, via direct extension or angioinvasion. Rhinocerebral mucormycosis is rapidly fatal with a mortality rate of 85%, even when maximally treated with surgical debridement, antifungal therapy, and correction of underlying processes.Methods:We performed a retrospective chart review of patients with rhinocerebral mucormycosis from 2011 to 2014. These patients were analyzed for symptoms, surgical and medical management, and outcome. We found four patients who were diagnosed with rhinocerebral mucormycosis. All patients underwent rapid aggressive surgical debridement and were started on antifungal therapy on the day of diagnosis. Overall, we observed a mortality rate of 50%.Results:An early aggressive multidisciplinary approach with surgical debridement, antifungal therapy, and correction of underlying disease have been shown to improve survivability in rhinocerebral mucormycosis.Conclusion:A multidisciplinary approach to rhinocerebral mucormycosis with otolaryngology, neurosurgery, and ophthalmology, infectious disease and medical intensivists can help reduce mortality in an otherwise largely fatal disease. Even despite these measures, outcomes remain poor, and a high index of suspicion must be maintained in at-risk populations, in order to rapidly execute a multifaceted approach.

Management of bacterial severe sepsis and septic shock

Bacterial sepsis is a leading cause of pediatric morbidity and mortality worldwide. Early diagnosis, a coordinated and aggressive approach to initial resuscitation, and timely and appropriate antibiotic therapy are paramount to improving outcomes of these dangerous infections. The basic tenants of initial and ongoing resuscitation include rapid isotonic intravenous fluid boluses with reassessment for physiologic response, empiric broad-spectrum antibiotics directed to cover suspected sources of infection, source control, vasoactive infusions, supportive critical care and monitoring of response to therapy. In addition to resuscitation of bacterial sepsis, this article will review approaches to empiric antibiotic choice in septic shock, and detail definitive management of infections caused by several specific organisms, including Staphylococcus aureus , group A Streptococcus, Pseudomonas aeruginosa, Mycobacterium tuberculosis , and Clostridium difficile . Lastly, management of several common pediatric infections, including community acquired bacterial pneumonia and bacterial meningitis, will be reviewed.

Characteristics of Korean Patients with Antithyroid Drug-Induced Agranulocytosis: A Multicenter Study in Korea.

BackgroundAntithyroid drugs (ATDs) can lead to the development of agranulocytosis, which is the most serious adverse effect. Characteristics of ATD-induced agranulocytosis (AIA) have seldom been reported due to the rarity. In this study, we characterized the clinical features for AIA in Korean patients.MethodsWe retrospectively reviewed data from patients with AIA diagnosed between 1997 and 2014 at four tertiary hospitals. Agranulocytosis was defined as an absolute neutrophil count (ANC) below 500/mm3.ResultsThe mean age of the patients (11 males, 43 females) was 38.2±14.9 years. Forty-eight patients (88.9%) with AIA had fever and sore throat on initial presentation, 20.4% of patients developed AIA during the second course of treatment, and 75.9% of patients suffered AIA within 3 months after initiation of ATD. The patients taking methimazole (n=39) showed lower levels of ANC and more frequent use of granulocyte-macrophage colony-stimulating factor than propylthiouracil (n=15) users. The median duration of agranulocytosis was 5.5 days (range, 1 to 20). No differences were observed between the long (≥6 days) and short recovery time (≤5 days) groups in terms of age, gender, ATDs, duration of ATDs, or initial ANC levels. Four patients (7.4%) who were taking ATDs for less than 2 months died of sepsis on the first or second day of hospitalization.ConclusionThe majority of AIA incidents occur in the early treatment period. Considering the high fatality rate of AIA, an early aggressive therapeutic approach is critical and patients should be well informed regarding the warning symptoms of the disease.

A proven case of cutaneous rhizopus infection presenting with severe limb pain very soon after induction treatment in a patient with acute lymphoblastic leukemia.

Objective and Importance. Invasive mucormycosis may complicate the course of patients with hematologic malignancies and has a very high mortality rate. Early diagnosis and aggressive approach combined with surgical and medical treatment have paramount importance for cure. Clinical Presentation. We report here a case of a patient with acute lymphoblastic leukemia presenting with a subcutaneous mass lesion which was sampled by an ultrasound guided needle biopsy. The pathology showed microorganisms with aseptate hyphae with wide, irregular walls and more or less branching with highly vertical angles which suggested a mold infection. The specimen was also cultured where Rhizopus spp. grew. Conclusion. Posaconazole 200 mg QID was commenced. She recovered from neutropenia and pain on day 20 of treatment. After 4 courses of hyper-CVAD chemotherapy, the remaining soft tissue mass was removed surgically and she underwent allogeneic HSCT from a full matched sibling donor under secondary prophylaxis.

Extensive Frontoparietal Abscess: Complication of Frontal Sinusitis (Pott's Puffy Tumor).

First described in 1768, the Pott's puffy tumor is a subperiosteal abscess associated with frontal bone osteomyelitis, resulting from trauma or frontal sinusitis. The classic clinical presentation consists of purulent rhinorrhea, fever, headache, and frontal swelling. The diagnosis is confirmed by CT scan and treatment requires intravenous antibiotics, analgesia, and surgical intervention. Early diagnosis and aggressive medical and surgical approach are essential for a good outcome. It rare and the early diagnosis is important; we describe the case of a 14-year-old adolescent with Pott's puffy tumor who was initially treated inadequately, evolving with extensive frontoparietal abscess. The patient underwent surgical treatment with endoscopic endonasal and external approaches combined. Intravenous antibiotics were prescribed for a prolonged time, with good outcome and remission of the complaints.

Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience

Sinus of Valsalva aneurysm is a rare anomaly with a higher incidence in Eastern than Western populations. Recent improvements in diagnostic techniques have resulted in more patients undergoing surgical repair. Uncorrected, the intracardiac shunts and frequently associated cardiac lesions cause a preventable deterioration in heart function. We retrospectively analyzed the data of 33 patients who underwent repair of ruptured sinus of Valsalva aneurysm from May 2000 to January 2010. The aneurysms originated from the right coronary sinus in 24 patients and from the noncoronary sinus in 9, and ruptured into the right ventricle in 21, right atrium in 10, and left ventricle in 2. Operative procedures included simple plication (1), patch repair (32), and aortic valve replacement (10). There were 3 early deaths. The 30 survivors were followed up for 5.4 ± 2.6 years; all had an improvement in functional class, with superior results in those with no aortic regurgitation. Surgical treatment of ruptured sinus of Valsalva aneurysm has an acceptably low operative risk and good long-term symptom-freedom survival. An early aggressive approach is recommended to prevent worsening symptoms and more extensive disease.

Early Aggressive Versus Initially Conservative Treatment in Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: A Randomized Controlled Trial

This study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS. A total of 313 patients ≥ 75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year. During admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03). The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185).

Primary central nervous system lymphoma: implication of high-dose chemotherapy followed by auto-SCT

Primary central nervous system lymphoma is a rare and distinct subtype of non-Hodgkin's lymphoma that is sensitive to radiation and chemotherapy. Decisions regarding the initial therapeutic approach are influenced by age and risk of therapy-related neurotoxicity. Despite several albeit small phase II studies, and the acknowledged need for larger prospective trials, there is supporting evidence to consider auto-SCT following induction chemotherapy in patients with good performance status. The international extranodal lymphoma study group is conducting a randomized phase II study comparing consolidative radiation therapy to high-dose therapy. Novel therapeutic options including early aggressive approach with upfront auto-SCT and strategies to prevent relapse following transplantation is an area of focus.

Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience

Sinus of Valsalva aneurysm is a rare anomaly with a higher incidence in Eastern than Western populations. Recent improvements in diagnostic techniques have resulted in more patients undergoing surgical repair. Uncorrected, the intracardiac shunts and frequently associated cardiac lesions cause a preventable deterioration in heart function. We retrospectively analyzed the data of 33 patients who underwent repair of ruptured sinus of Valsalva aneurysm from May 2000 to January 2010. The aneurysms originated from the right coronary sinus in 24 patients and from the noncoronary sinus in 9, and ruptured into the right ventricle in 21, right atrium in 10, and left ventricle in 2. Operative procedures included simple plication (1), patch repair (32), and aortic valve replacement (10). There were 3 early deaths. The 30 survivors were followed up for 5.4 ± 2.6 years; all had an improvement in functional class, with superior results in those with no aortic regurgitation. Surgical treatment of ruptured sinus of Valsalva aneurysm has an acceptably low operative risk and good long-term symptom-freedom survival. An early aggressive approach is recommended to prevent worsening symptoms and more extensive disease.