Permanent Risk Factors Research Articles

Evaluation of Human Exposure to Aedes Bites in Rubber and Palm Cultivations Using an Immunoepidemiological Biomarker.

Arbovirus infections, mainly transmitted by Aedes mosquito, are emerging in Africa. Efficient vector control requires an understanding of ecological factors which could impact on the risk of transmission, such as environmental changes linked to agricultural practices. The present study aims to assess the level of human exposure to Aedes mosquito bites in different agroecosystem area, using an immunological tool which quantifies human IgG antibody response to one Ae. aegypti salivary peptide. Specific IgG responses were assessed during dry and rainy seasons, in children living in different villages in Côte d'Ivoire: N'Zikro (rubber and oil palm exploitations), Ehania-V5 (oil palm), and Ayébo (without intensive agricultural activities). In the dry season, specific IgG levels were significantly lower in Ayébo compared to Ehania-V5 and N'Zikro and, interestingly, were similarly high in both villages with cultivations. In the rainy season, no difference of specific IgG was observed between villages. Specific IgG responses remained therefore high during both seasons in villages associated with intensive agricultural. The rubber and oil palm cultivations could maintain a high level of human exposure to Aedes mosquito bites during both dry and rainy seasons. These agricultural activities could represent a permanent risk factor of the transmission of arboviruses.

The new bedside ROCky score to predict the complications in patients with intermediate-risk pulmonary embolism

ObjectivePulmonary embolism (PE) remains one of the leading causes of mortality among cardiovascular diseases. We aimed at investigating risk factors of PE complications in patients with intermediate risk and integrate them into a simple model for its' bedside prediction. MethodsAmong 173 patients with PE, 136 were classified as high or intermediate risk. Patients were retrospectively divided into groups of complicated (n = 44) or uncomplicated (n = 92) course. Study endpoints: obstructive shock, recurrent PE, needs for resuscitation/thrombolysis/hemodynamic support and death during 30 days. ResultsPredictors of PE complications were: chronic heart failure, diabetes mellitus (DM), atrial fibrillation, permanent risk factor of venous thromboembolism, syncope, positive heart-type fatty acid binding protein (hFABP), positive troponin I, heart rate (HR) ≥ 110 bpm, systolic blood pressure (SBP) ≤ 100 mmHg, creatinine clearance ≤ 70 ml/min. Multivariate logistic regression analysis was used to model a simple predictive score named ROCky (Risk of Complications): HR ≥ 110 bpm (1.5 points), SBP ≤ 100 mmHg (2.5 points), positive hFABP (2 points) and presence of DM (2.5 points). The AUROC of this model was 0.89 to predict any complication, 0.83 for obstructive shock and 0.92 for death from any cause; the optimal cut-off scores for any complication was ≥2.5 points, ≥3.5 for obstructive shock and ≥4.5 points for death within 30 days. ConclusionhFABP, tachycardia, hypotension and DM were identified as the major independent determinants of complications development in patients with pulmonary embolism and may be used in combination as the bedside simple predictive ROCky score for early risk stratification in intermediate-risk group.

Journal of Vascular Surgery: Venous and Lymphatic Disorders – July 2017 Audiovisual Summary

Hello and welcome to the July issue of the JVS-VL. We have four interesting papers to tell you about, which are featured in this month's JVS-VL. First is a paper by Brownson and colleagues from Yale, “Characteristics of provoked deep vein thrombosis in a tertiary care center”. The authors retrospectively studied 425 patients over an 18-month period at their institution with provoked deep vein thrombosis (DVT) and divided them into those with transient risk factors, such as surgery that resolved in 2 weeks and those with permanent risk factors such as cancer, long-term immobilization, or a hypercoagulable state. They found that those with transient risk factors were younger and had more calf DVT as well as a significantly lower risk of recurrent DVT and death at 7 months. The authors question whether those with transient risk factors who develop DVT should be treated differently and have a shorter period of anticoagulation. The next paper “Clinical characteristics and prognostic features of intravenous leiomyomatosis with inferior vena cava or intracardiac extension” by Zhang and colleagues from Beijing, China is a retrospective analysis of 38 patients with intravenous leiomyomatosis, whose mean age was 44 years. Fifty-eight percent of patients had a history of uterine leiomyoma and 24% had a history of uterine leiomyoma without extension into the deep veins. The most common symptoms were chest tightness, lower limb swelling, palpitation, dizziness, and abdominal distention. Sixty percent underwent one-stage surgery and 40% underwent two-stage surgery and 72% received postoperative antiestrogen hormone therapy. Unfortunately, at a median follow-up of 12 months, 50% showed evidence of recurrence. Postoperative antiestrogen hormone therapy, duration of postoperative hormonal therapy, and heart involvement were not associated with recurrence. The authors conclude that this rare disease requires surgery as the primary treatment, and although the recurrence rate is high, postoperative antiestrogen hormone therapy is not correlated with recurrence. The next paper is the Editors' Choice and is titled “Clinical presentation of women with pelvic source varicose veins in the perineum as first steps in the development of a disease-specific patient assessment tool” by Gibson and coauthors from Bellevue and Seattle, Washington and Boston, Massachusetts. They prospectively studied 72 women with symptomatic pelvic source varicose veins and compared them to 1160 women with saphenous vein incompetence alone. The severity of disease was objectively evaluated using the revised Venous Clinical Severity Score (rVCSS). The study revealed that those with pelvic source varicose veins were younger and thinner than those with saphenous incompetence and also had large infants. The most common symptoms were aching in 68%, throbbing in 47%, and heaviness 35%, and premenopausal women noted that symptoms were worse during menses. Since the VCSS is poorly associated with patient-reported discomfort, it is not good for evaluating pelvic source varicose veins. A disease-specific tool for the evaluation of pelvic source varicose veins is critically needed. The final highlighted paper is by Marston and coauthors from North Carolina and is titled “Incidence of venous leg ulcer healing and recurrence after treatment with endovenous laser ablation”. They retrospectively reviewed all open and healed venous ulcer patients treated with laser ablation. Laser ablation of the great saphenous vein, small saphenous vein, or both was performed on 173 limbs. Deep venous insufficiency was present in 31% and concomitant phlebectomy was performed in 34%. At a median follow-up of 25 months, venous ulcers healed after laser ablation in 57% at 3 months, 74% at 6 months, and 78% at 12 months, but ulcers recurred in 9% at 1 year, 20% at 2 years, and 29% at 3 years. Ulcers recurred more often in patients with deep venous insufficiency and in those patients who did not undergo phlebectomy of associated varicose veins at the time of laser ablation. The authors suggest phlebectomy at the time of laser ablation for patients with open or healed venous ulcers and particularly in those with isolated superficial venous insufficiency. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5YmFjY2E4ZWRkYzM5YzMwMGM0YzcxNzAwZWE3MTdjMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3OTM3OTE2fQ.gSrZb5TQHy5bf-ns-ZZTj19DBn0yNrQw0UuGnDH0RYwFFbVbW7Ke2UL5BFHo4LftO-mQtyCBkLh-w9tmqqKz7UUKR85RBSrnHQ0wPjR4FFUClwLo_LdHtK_No6JZoUAvrF4P9g75SryQ0c1kUYo16aX_kjYgWgS1hpu9rLL_WnHgSBj3w4qNgwArBgKhw4hnkLzsa_LtmHYU8iHTb9kLOWWjyQBUS0rdmC-yV5gzH7cxtMcuLPV5hgFqnV_-jaM9gu3V75SN0QtdroudvJQ4DNlUJESOMfiZRTKDuHhLVHtfgR0MeJ2xiPAqOxmH1by8E7Pd-6s55HwQ0Jc42shRYw Download .mp4 (332.17 MB) Help with .mp4 files Video

Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation-The EWA study.

Vitamin K antagonist warfarin is widely used in clinical practice and excessive anticoagulation is a well-known complication of this therapy. Little is known about permanent and temporary predictors for severe overanticoagulation. The aim of this study was to investigate the occurrence and predicting factors for episodes with very high (≥9) international normalized ratio (INR) values in warfarin treated patients with atrial fibrillation (AF). Excessive Warfarin Anticoagulation (EWA) study screened all patients (n = 13618) in the Turku University Hospital region with an INR ≥2 between years 2003–2015. Patients using warfarin anticoagulation for AF with very high (≥9) INR values (EWA Group) were identified (n = 412 patients) and their characteristics were compared to a control group (n = 405) of AF patients with stable INR during long-term follow-up. Over 20% (n = 92) of the EWA patients had more than one event of very high INR and in 105 (25.5%) patients EWA led to a bleeding event. Of the several temporary and permanent EWA risk factors observed, strongest were excessive alcohol consumption in 9.6% of patients (OR 24.4, 95% CI 9.9–50.4, p<0.0001) and reduced renal function (OR 15.2, 95% CI 5.67–40.7, p<0.0001). Recent antibiotic or antifungal medication, recent hospitalization or outpatient clinic visit and the first 6 months of warfarin use were the most significant temporary risk factors for EWA. Excessive warfarin anticoagulation can be predicted with several permanent and temporary clinical risk factors, many of which are modifiable.

PREDICTORS OF SHORT TERM OUTCOMES IN HIGH AND MODERATE RISK PULMONARY THROMBOEMBOLISM

Aim. To investigate on the clinical, anamnestic and laboratory-instrumental predictors of short term outcomes development in pulmonary thromboembolism (PTE). Material and methods. To the study, 136 patients included with the high and intermediate risk PTE confirmed by multispiral computed tomography. The endpoints were obstructive shock, fatal relapse, fatal outcome, necessity of resuscitation, urgent thrombolysis and hemodynamic support. Follow-up lasted for 30 days. Patients were selected to groups of complicated (n=44) and noncomplicated (n=92) course. Results. The predictors of adverse course of PTE were chronic heart failure of II stage (p=0,02), diabetes type 2 (p=000001), atrial fibrillation (p=0,001), permanent risk factor for PTE (p=0,002), syncope (p=0,02), positive test for the fatty acid binding cardiac protein (cFABP) (p=0,00001), troponin I positive test (p=0,02), heart rate ≥110 bpm (p=0,002), systolic BP ≤100 mmHg (p=0,00001), creatinine clearance ≤70 mL/min (p=0,0008). By the method of logistic regression a combination selected showing most predictive power, that includes heart rate ≥110 bpm, BP ≤100 mmHg, positive cFABP and diabetes. Upon the logistic regression coefficients the prediction score was formulated, named ROCky (Risk of Complications) that includes heart rate ≥110 bpm (1,5 points), BP ≤100 mmHg (2,5 pts), positive cFABP test (2 pts), diabetes type 2 (2,5 pts). The threshold estimated for prediction of combination endpoint ≥2,5 (Se 84%, Sp 75%), obstructive shock ≥3,5 (Se 83%, Sp 83%) and fatal outcome within 30 days ≥4,5 (Se 79%, Sp 82%). Combination of ≥2,5 points by ROCky and presence of echocardiographical signs of the right ventricle dysfunction showed more efficacy than the algorithm of European Society of Cardiology (2014) in the studied population of hemodynamically stable patients, for the obstructive shock, fatal relapse of PTE, fatal outcome and combination endpoint. Conclusion. The ROCky scale has demonstrated high efficacy in prediction of complications among hemodynamically stable patients and can be recommended for further investigation and implementation into clinical practice.

Modified Risk Factors for Coronary Heart Disease (CHD) in Minahasa Ethnic Group From Manado City Indonesia

Coronary heart disease (CHD) is a non-transmitted disease which is particular concern at the global, national, and local level. CHD has become a concern because it has caused a lot of deaths. Risk factors linked with CHD consist of permanent risk factors and variable risk factors. The purpose of the research is to analyze the correlation between variable risk factors and CHD in the Minahasa ethnic society in Manado City. This research was an observational case-control study conducted by Prof. dr. R. D. Kandou Hospital, Manado, from August to October 2016. In total, there were 220 patients included. The sampling used a simple random sampling method and the data obtained were analyzed by chi-squared test. According to the results, hypertension, smoking, and behavioral type were connected to cases of CHD. The correlation degree showed that the respondents suffering hypertension were 5.70 times more likely to suffer CHD, the smoking respondents were 2.25 times more likely to experience, and behavior type A respondents were 2.96 times more likely to suffer CHD. Hypertension, smoking, and behavioral type are linked with CHD, so there should be some promotion and preventive actions from the health governmental institution to society, especially aimed at adults, about the quality of life enhancement by healthy behavior and avoiding CHD risk factors. Keywords: behavioral type, Case-control study, hypertension, smoking behavior.

Recurrent Thrombotic Events after Discontinuation of Vitamin K Antagonist Treatment for Splanchnic Vein Thrombosis: A Multicenter Retrospective Cohort Study

It is generally recommended that patients with splanchnic vein thrombosis (SVT) should receive a minimum of 3 months of anticoagulant treatment. However, little information is available on the long-term risk of recurrent thrombotic events. The aim of this study was to evaluate the risk of venous and arterial thrombosis after discontinuation of vitamin K antagonist (VKA) in SVT patients. Retrospective information from a cohort of SVT patients treated with VKA and followed by 37 Italian Anticoagulation Clinics, up to June 2013, was collected. Only patients who discontinued VKA and did not receive any other anticoagulant drug were enrolled in this study. Thrombotic events during follow-up were centrally adjudicated. Ninety patients were included: 33 unprovoked SVT, 27 SVT secondary to transient risk factors, and 30 with permanent risk factors. During a median follow-up of 1.6 years, 6 venous and 1 arterial thrombosis were documented, for an incidence of 3.3/100 patient-years (pt-y). The recurrence rate was highest in the first year after VKA discontinuation (8.2/100'pt-y) and in patients with permanent risk factors (10.2/100'pt-y). Liver cirrhosis significantly increased the risk of recurrence. In conclusion, the rate of recurrent vascular complications after SVT is not negligible, at least in some patient subgroups.

Use of MKSAP 16 for American Board of Internal Medicine Examination.

In reviewing MKSAP 16 in preparation for an American Board of Internal Medicine recertification examination, Dr. Melissa Gennarelli, an internist at Westchester Medical Center/New York Medical College, asked Dr. Wilbert S. Aronow, a Professor of Cardiology at Westchester Medical Center/New York Medical College, 2 questions. The first question was why he currently recommends that diabetics with hypertension should have their systolic blood pressure reduced to < 140 mm Hg when MKSAP 16 (page 29 of Cardiovascular Medicine) recommends a systolic blood pressure goal of < 130 mm Hg. The second question was why he does not use dronedarone to treat high-risk patients with permanent atrial fibrillation when MKSAP 16 (page 52 of Cardiovascular Medicine) recommends the use of dronedarone in patients with atrial fibrillation to reduce hospitalization for cardiovascular events or mortality. In reply to the first question, Dr. Aronow stated that on the basis of clinical trial data, the 2009 European Society of Hypertension guidelines [1], the American College of Cardiology Foundation/American Heart Association 2011 expert consensus document on hypertension in the elderly [2], and an excellent review article on this topic [3] recommend a systolic blood pressure goal of <140 mm Hg in diabetics with hypertension. The 2013 American Diabetes Association guidelines recommend a systolic blood pressure goal of < 140 mm Hg in most diabetics with hypertension [4]. In reply to the second question, Dr. Aronow stated that the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy (PALLAS) randomized 3,236 patients with permanent atrial fibrillation and risk factors for major vascular events to treatment with dronedarone or double-blind placebo [5]. This study was stopped for safety reasons with a median follow-up of 3.5 months because dronedarone increased the rates of heart failure, stroke, and cardiovascular mortality in patients with permanent atrial fibrillation at risk for major vascular events [5].

Enzymatic intracrine regulation of white adipose tissue.

Abdominal fat formation has become a permanent risk factor for metabolic syndrome and various cancers in one-third of the world's population of obese and even lean patients. Formation of abdominal fat involves additional mechanisms beyond an imbalance in energy intake and expenditure, which explains systemic obesity. In this review, we briefly summarized autonomous regulatory circuits that locally produce hormones from inactive precursors or nutrients for intra-/auto-/paracrine signaling in white adipose depots. Enzymatic pathways activating steroid and thyroid hormones in adipose depots were compared with enzymatic production of retinoic acid from vitamin A. We discussed the role of intracrine circuits in fat-depot functions and strategies to reduce abdominal adiposity through thermogenic adipocytes with interrupted generation of retinoic acid.

Clonal populations of hematopoietic cells with paroxysmal nocturnal hemoglobinuria phenotype in patients with splanchnic vein thrombosis

IntroductionSplanchnic vein thrombosis (SVT) is a serious complication in patients with paroxysmal nocturnal hemoglobinuria (PNH). Mutant PNH clones can be associated with an increased risk of SVT even in the absence of overt disease, but their prevalence in non-selected SVT patients remains unknown. Materials and MethodsPatients with objective diagnosis of SVT and without known PNH were tested for the presence of PNH clone using high-sensitivity flow cytometric analysis. ResultsA total of 202 SVT patients were eligible, 58.4% were males, mean age was 54.6years (range 17–94), site of thrombosis was portal in 103 patients, mesenteric in 67, splenic in 37, and supra-hepatic in 10. SVT was associated with JAK2 V6167F in 28 of 126 (22.2%) screened patients, liver cirrhosis in 15.3% patients, recent surgery in 10.9%, and myeloproliferative neoplasm in 10.6%, whereas in 34.6% of patients neither permanent nor transient risk factors were detected. None of the patients had a clearly demonstrable PNH clone, but in two patients (0.99%, 95% CI 0.17-3.91) we observed very small PNH clones (size 0.014% and 0.16%) confirmed in two independent samples. One patient had portal vein thrombosis and no associated risk factors, the second had superior mesenteric vein thrombosis and inflammatory bowel disease. ConclusionsVery small PNH clones can be detected in patients with SVT and no clinical manifestations of disease. Future studies are needed to explore the potential role of this finding in the pathogenesis of SVT.

Low-Molecular-Weight Heparin for Prevention of Venous Thromboembolism After Varicose Vein Surgery in Moderate-Risk Patients: A Randomized, Controlled Trial

Deep vein thrombosis (DVT) after varicose vein surgery (VVS) is not well recognized. Observational studies have yielded variable estimates of the risk, but evidence from randomized trials is lacking. Our aim was to compare the use of thromboprophylaxis with and without low-molecular-weight heparin (LMWH). We prospectively randomized moderate-risk patients scheduled for VVS in two arms. The first group of patients received bemiparin for 10 days at a prophylactic dose, early ambulation, and compression therapy for 3 months; the second group received early ambulation and compression therapy alone. The primary efficacy outcome was the composite of DVT (symptomatic or asymptomatic detected by mandatory, bilateral duplex scan). Secondary efficacy and primary safety end points were superficial venous thrombosis, postoperative bleeding, and clinical pulmonary embolism (PE). We assessed transient and permanent risk factors for venous thromboembolism. Two-hundred sixty-two patients were eligible for evaluation. There were no cases of DVT. There were also no cases of clinical PE, death, or major bleeding. No significant differences were seen between groups in the rates of bleeding episodes. The data show no superiority of a short-term regimen of LMWH and early ambulation and compression therapy, as compared with early ambulation and compression therapy alone, in patients undergoing VVS in a moderate-risk population.

Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations)

This document is a compilation of the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guideline recommendations for atrial fibrillation (AF) from the “ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation),”* the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)”† and the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran).”‡ Updated and new recommendations from 2011 are noted and outdated recommendations have been removed. No new evidence was reviewed, and no recommendations included herein are original to this document. The ACCF/AHA Task Force on Practice Guidelines chooses to republish the recommendations in this format to provide the complete set of practice guideline recommendations in a single resource. ### 1.1. Pharmacological and Nonpharmacological Therapeutic Options #### 1.1.1. Rate Control During AF Class I 1. Measurement of the heart rate at rest and control of the rate using …

Pregnancy after catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis

To assess the safety and efficacy of low-molecular-weight heparin (LMWH) in pregnancy and puerperium in women with previous acute iliofemoral deep venous thrombosis (DVT) treated with catheter-directed thrombolysis (CDT). Consecutive patients treated for acute iliofemoral DVT using CDT between June 1999 and June 2009 were followed yearly by colour duplex ultrasound scanning. A subgroup of these patients who became pregnant during the follow-up period, three months to 10 years after CDT, was included in the present study. During pregnancy, thromboprophylaxis using LMWH was prescribed according to individual risk assessment, and the women were regularly assessed for adverse events. Women on warfarin had this treatment discontinued before the sixth week of pregnancy in order to prevent potential teratogenic adverse effects. Administration of LMWH was started at international normalized ratio ≤ 2.0, and continued during pregnancy, delivery and puerperium. Postnatal, the anticoagulation treatment was converted back to warfarin and LMWH discontinued after a bridging period. Women, who, prior to pregnancy, had discontinued anticoagulation treatment after CDT, were prescribed anticoagulation treatment using LMWH as early in pregnancy as practical. LMWH was continued during pregnancy, delivery and for six weeks postpartum. All women were prescribed graduated compression stockings. A total of 33 women completed 45 pregnancies, 44 singletons and 1 gemelli. In 24 (53%) of the cases, the mother had been treated with adjunctive stenting immediately following the CDT. In nine (21%) of the pregnancies, the mother had been on long-time anticoagulation treatment using warfarin prior to conception due to permanent severe risk factors. Thrombophilia was demonstrated in 31 (69%) of the pregnancies, and in 29 (64%) of the patients, the previous DVT was oestrogen-related. Thromboprophylaxis using tinzaparin was given in 41 (91%) and using dalteparin in four (9%) of the pregnancies. Doses of LMWH during pregnancy were adjusted according to risk assessment. One pregnancy was terminated by induced delivery at week 22 due to fetal malformations, and two of the pregnancies (4%) were complicated by intrauterine fetal death, one in week 39 due to severe fetal infection and one in week 23 due to intrauterine fetal growth restriction caused by severe antiphospholipid syndrome. All but one of the pregnancies was carried out without recurrence of DVT or maternal pulmonary embolism and the mother remained having patent deep veins postnatal. The mother with the antiphospholipid syndrome had a recurrent DVT complicated by iliac stent occlusion. This mother was prior to pregnancy on long-time treatment using warfarin. During pregnancy, she was erroneously treated with LMWH in standard prophylaxis doses instead of therapeutic doses and without adding aspirin. After CDT for acute iliofemoral DVT including adjunctive stenting, pregnancy can be carried out almost uneventful even in women at high risk of thromboembolism. Thromboprophylaxis during pregnancy, using LMWH in a dosage adjusted to individual risk assessment, is essential.

Trombofilia y trombosis

Venous thromboembolism (VTE) accounts for an important share of morbidity and mortality in our societies. Circumstances related to its pathogenesis are vessel wall changes, flow abnormalities (stasis), and hypercoagulability states (thrombophilia). Thrombophilic states may be congenital, because of loss of function such as in natural anticoagulants (antithrombin, protein C, protein S), or gain of function such as Factor V Leiden or prothrombin mutations. VTE diagnosis is achieved by clinical probability, non-invasive imaging techniques such as Doppler or angio-TC and D-dimer measurement. It is treated by the administration of low molecular weight heparin subcutaneously, followed by antivitamin K (acenocumarol, warfarin) orally for 3–6 months or indefinitely if permanent risk factors exist. New oral anticoagulants have been developed within the last few years, which are direct inhibitors of thrombin or factor Xa (dabigatran, rivaroxaban, apixaban). In the short term these may replace antivitamin K drugs.

Nuevas evidencias en la prevención secundaria de la enfermedad tromboembólica venosa

The risk of recurrent venous thromboembolism is nearly 40% of all patients after 10 years of follow up. The risk is higher in patients with permanent risk factors, who should receive indefinite anticoagulation with acenocoumarol or warfarin, except cancer patients who should receive lower doses of low molecular weight heparin The remaining patients should receive a 3-month course of treatment, after which the need to continue this treatment should be reevaluated. The decision to continue should be individually tailored and balanced against hemorrhagic risk. Determination of D-dimer values at the end of treatment and the presence of residual vein thrombosis or right ventricular dysfunction could be useful to identify patients at low risk of recurrence, who can safely discontinue anticoagulation. The emergence of new oral anticoagulants has opened up a new scenario for secondary prevention in the next few years.

AHA 2011 Scientific Sessions highlight key studies

AHA 2011 Scientific Sessions highlight key studies

Dronedarone in High-Risk Permanent Atrial Fibrillation

Dronedarone restores sinus rhythm and reduces hospitalization or death in intermittent atrial fibrillation. It also lowers heart rate and blood pressure and has antiadrenergic and potential ventricular antiarrhythmic effects. We hypothesized that dronedarone would reduce major vascular events in high-risk permanent atrial fibrillation. We assigned patients who were at least 65 years of age with at least a 6-month history of permanent atrial fibrillation and risk factors for major vascular events to receive dronedarone or placebo. The first coprimary outcome was stroke, myocardial infarction, systemic embolism, or death from cardiovascular causes. The second coprimary outcome was unplanned hospitalization for a cardiovascular cause or death. After the enrollment of 3236 patients, the study was stopped for safety reasons. The first coprimary outcome occurred in 43 patients receiving dronedarone and 19 receiving placebo (hazard ratio, 2.29; 95% confidence interval [CI], 1.34 to 3.94; P=0.002). There were 21 deaths from cardiovascular causes in the dronedarone group and 10 in the placebo group (hazard ratio, 2.11; 95% CI, 1.00 to 4.49; P=0.046), including death from arrhythmia in 13 patients and 4 patients, respectively (hazard ratio, 3.26; 95% CI, 1.06 to 10.00; P=0.03). Stroke occurred in 23 patients in the dronedarone group and 10 in the placebo group (hazard ratio, 2.32; 95% CI, 1.11 to 4.88; P=0.02). Hospitalization for heart failure occurred in 43 patients in the dronedarone group and 24 in the placebo group (hazard ratio, 1.81; 95% CI, 1.10 to 2.99; P=0.02). Dronedarone increased rates of heart failure, stroke, and death from cardiovascular causes in patients with permanent atrial fibrillation who were at risk for major vascular events. Our data show that this drug should not be used in such patients. (Funded by Sanofi-Aventis; PALLAS ClinicalTrials.gov number, NCT01151137.).

Risk factors for recurrent laryngeal nerve palsy after thyroidectomy

AbstractThis study investigates the incidence of temporary and permanent recurrent laryngeal nerve palsy (RLNP) and possible risk factors for patients with different types of thyroid gland diseases. 1224 consecutive patients who underwent thyroidectomy for treatment of various thyroid diseases between the years 2001–2005. The rates of RLNP were evaluated. The surgeon and type of thyroid gland disorder were recognised as possible risk factors for RLNP. The incidence of temporary/permanent RLNP for the whole group was 4.5/0.8%. The rates of temporary RLNP for groups, classified as multinodular goitre, Graves’ disease, thyroid cancer or Hashimoto’s disease were 4.3%, 4.3%, 5.2% and 5.7%, respectively. The rates of permanent RLNP for the same groups were 0.4%, 0.9%, 1.6% and 1.9%, respectively. The frequency of temporary RLNP for individual surgeons ranges from 2.8 to 7.0% and the rates of permanent RLNP is between 0–3.1%. There was no relationship between the surgeon’s experience (the number of procedures performed) and RLNP rates. Total thyroidectomy is a safe procedure associated with a low incidence of RLNP not only for benign multinodular goitre, but also for Graves’disease, thyroid cancer and Hashimoto’s disease. The rates of RLNP among individual surgeons are acceptable with small inter-individual differences.

Which patients with unprovoked VTE should receive extended anticoagulation? the minority

Venous thromboembolism (VTE) is associated with a long term risk of recurrence. This risk is at least in part related to the presence of major identifiable risk factors at the time of the index event. It is generally low in the presence of removable risk factors, and very high in the presence of permanent risk factors such as active cancer. This categorization is important because it drives the duration of secondary prevention treatment with anticoagulant drugs. Unfortunately, up to 40-50% of VTE events remain classified as unprovoked. This large group of patients is obviously heterogeneous, with an unpredictable risk of recurrence. Evidences from clinical trials suggest that extending secondary prevention with vitamin K antagonists (VKAs) for 1 or 2years after an initial course of treatment in patients with unprovoked VTE does not provide additional benefit in terms of reducing the long term risk of recurrence. Prolonging indefinitely the duration of treatment would likely be effective in reducing this risk, but at the cost of unnecessarily expose the majority of patients to several complications, there including major bleeding events, and inconveniences. A number of variables have been identified to predict the individual risk of recurrence in these patients and some clinical prediction rules have been proposed. Improved patients stratification, together with a better understanding of the mechanisms underlying unprovoked VTE, should allow physicians to individually tailor the optimal duration of secondary prevention and to identify those patients (likely the minority) for whom indefinite duration of treatment is warranted.

Analysis of the permanent renal injury risk factors in congenital neuropathic bladder

Analysis of the permanent renal injury risk factors in congenital neuropathic bladder