Showing papers by "New York Methodist Hospital published in 2012"

International evidence-based recommendations on ultrasound-guided vascular access

Abstract: To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial.

Abstract: Aims We sought to investigate the impact of multivessel disease (MVD) with and without a chronic total occlusion (CTO) in a non-infarct-related artery (IRA) on mortality in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods and results In the HORIZONS-AMI trial, of 3283 patients undergoing primary PCI, 1524 patients (46.4%) had single-vessel disease (SVD), 1477 (45.0%) had MVD without a CTO, and 283 (8.6%) had MVD with a CTO in a non-IRA. Compared with SVD patients and MVD patients without a CTO, patients with a non-IRA CTO were significantly less likely to achieve post-procedural TIMI 3 flow ( P = 0.0003), more often had absent myocardial blush ( P = 0.0002), and less frequently achieved complete ST-segment resolution ( P = 0.0001). By multivariable analysis, MVD with CTO in a non-IRA was an independent predictor of both 0- to 30-day mortality [hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.41–5.88, P = 0.004] and 30-day to 3-year mortality (HR 1.98, 95% CI 1.19–3.29, P = 0.009), while MVD without a CTO was a significant predictor for 0- to 30-day mortality (HR 2.20, 95% CI 1.00–3.06, P = 0.049) but not late mortality. Conclusion In patients with STEMI undergoing primary PCI in the HORIZONS-AMI trial, MVD with or without a CTO in a non-IRA was an independent predictor of early mortality. The presence of a CTO in a non-IRA was also an independent predictor of increased late mortality to 3 years.

Diabetes mellitus, myocardial reperfusion, and outcome in patients with acute ST-elevation myocardial infarction treated with primary angioplasty (from HORIZONS AMI).

Abstract: Diabetes mellitus (DM) increases mortality in acute ST-segment elevation myocardial infarction (STEMI) but the responsible mechanism is not fully elucidated. We compared the rate of successful myocardial reperfusion measured by tissue myocardial perfusion grade (TMPG) and outcomes in patients with and without DM undergoing primary percutaneous coronary intervention (PCI) for STEMI. Patients enrolled in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS AMI) trial were analyzed according to presence of DM with respect to TMPG after PCI and outcomes at 30 days and 3 years. Multivariable logistic regression was performed to identify the independent contribution to mortality of DM and TMPG and the interaction between the 2 was assessed. Complete data were available for 3,265 patients, of whom 533 (16.3%) had DM. Diabetic patients were significantly older and heavier and had more risk factors for coronary disease and more previous MI, revascularization, and heart failure. There were no differences in rates of Thrombolysis In Myocardial Infarction grade 3 flow after PCI in the infarct artery or TMPG 2/3 between patients with and without DM. Compared to nondiabetics, mortality was significantly higher at 30 days and at 3 years in the DM group (1.8% vs 4.5%, p = 0.0002 and 5.4% vs 11.0%, p <0.0001, respectively). DM and TMPG were significantly associated with 3-year mortality, but there was no statistical interaction between DM and TMPG (p = 0.70). In conclusion, DM is associated with a significantly higher risk of death but this association is not mediated by impaired epicardial or myocardial reperfusion.

Refining the value of secretory phospholipase A2 as a predictor of acute chest syndrome in sickle cell disease: results of a feasibility study (PROACTIVE)

Abstract: Acute chest syndrome (ACS) is defined as fever, respiratory symptoms and a new pulmonary infiltrate in an individual with sickle cell disease (SCD). Nearly half of ACS episodes occur in SCD patients already hospitalized, potentially permitting pre-emptive therapy in high-risk patients. Simple transfusion of red blood cells may abort ACS if given to patients hospitalized for pain who develop fever and elevated levels of secretory phospholipase A2 (sPLA2). In a feasibility study (PROACTIVE; ClinicalTrials.gov NCT00951808), patients hospitalized for pain who developed fever and elevated sPLA2 were eligible for randomization to transfusion or observation; all others were enrolled in an observational arm. Of 237 enrolled, only 10 were randomized; one of the four to receive transfusion had delayed treatment. Of 233 subjects receiving standard care, 22 developed ACS. A threshold level of sPLA2 ≥ 48 ng/ml gave optimal sensitivity (73%), specificity (71%) and accuracy (71%), but a positive predictive value of only 24%. The predictive value of sPLA2 was improved in adults and patients with chest or back pain, lower haemoglobin concentration and higher white blood cell counts; and those receiving less than two-thirds maintenance fluids. The hurdles identified in PROACTIVE should facilitate design of a larger, definitive, phase 3 randomized controlled trial.

Role of vitamin K2 in preventing the recurrence of hepatocellular carcinoma after curative treatment: A meta-analysis of randomized controlled trials

Abstract: Background Hepatocellular cancer is notorious for recurrence even after curative therapy. High recurrence determines the long term prognosis of the patients. Vitamin K2 has been tested in trials for its effect on prevention of recurrence and improving survival. The results are inconclusive from individual trials and in our knowledge no systematic review which entirely focuses on Vitamin K2 as a chemo preventive agent is available to date. This review is an attempt to pool all the existing trials together and update the existing knowledge on the topic.

Characteristics and Clinical Significance of Angiographically Mild Lesions in Acute Coronary Syndromes

Abstract: Objectives The aim of this study was to assess whether residual nonculprit (NC) lesions, defined as visual diameter stenosis ≥30% after successful percutaneous coronary intervention, affect the rate of future events in patients with acute coronary syndromes. Background In patients with acute coronary syndromes, approximately one-half of recurrent events after percutaneous coronary intervention arise from untreated lesions. Methods Patients enrolled in PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) were divided into 3 groups: those with no NC lesions, 1 NC lesion, or ≥2 NC lesions. Time to events for major adverse cardiac events was estimated up to 3 years. Results Among 697 patients, 13.3% had no NC lesions, 19.7% had 1 NC lesion, and 67.0% had ≥2 NC lesions. The median diameter stenoses of the NC lesions in the latter 2 groups were 36.7% (interquartile range: 31.0% to 43.4%) and 37.4% (interquartile range: 32.0% to 46.5%), respectively (p = 0.22). At least 1 thin-cap fibroatheroma was present in one-half the patients in each group. At 3 years, the incidence of major adverse cardiac events was 8.5%, 15.2%, and 24.3%, respectively (p = 0.0009). NC lesion–related events occurred in 0%, 5.0%, and 15.9% of patients, respectively (p 50%), while the other 32 arose from normal or near normal segments. Conclusions Residual NC lesions are common after percutaneous coronary intervention for acute coronary syndromes and portend a higher rate of recurrent ischemic events within 3 years, especially when angiographically more severe. Conversely, the absence of NC lesions by angiography is highly predictive of freedom from events not related to the originally treated culprit lesion(s).

Robotic thoracoscopic plication for symptomatic diaphragm paralysis

Abstract: Diaphragmatic paralysis is an uncommon condition characterized by significant elevation of a hemidiaphragm, and can cause dyspnea. The goal of diaphragm plication is to improve dyspnea by correcting the dysfunctional movement of a diaphragm during inspiration. Minimally invasive thoracoscopic diaphragm plication has been widely used and has been reported to lead to significant improvements in dyspnea and postoperative pulmonary function. Advantages of thoracoscopic plication compared to open thoracotomy are less postoperative pain and shorter hospitalization, yet technical difficulties due to limited workspace afforded by the ribcage and the elevated hemidiaphragm have been a major drawback in using the thoracoscopic approach for this disorder. We describe our experience with robotic thoracoscopic plication for the treatment of diaphragmatic paralysis. This is, to our knowledge, the first report of this kind.

Burn disaster response planning in New York City: updated recommendations for best practices.

Abstract: Since its inception in 2006, the New York City (NYC) Task Force for Patients with Burns has continued to develop a city-wide and regional response plan that addressed the triage, treatment, transportation of 50/million (400) adult and pediatric victims for 3 to 5 days after a large-scale burn disaster within NYC until such time that a burn center bed and transportation could be secured. The following presents updated recommendations on these planning efforts. Previously published literature, project deliverables, and meeting documents for the period of 2009-2010 were reviewed. A numerical simulation was designed to evaluate the triage algorithm developed for this plan. A new, secondary triage scoring algorithm, based on co-morbidities and predicted outcomes, was created to prioritize multiple patients within a given acuity and predicted survivability cohort. Recommendations for a centralized patient and resource tracking database, plan operations, activation thresholds, mass triage, communications, data flow, staffing, resource utilization, provider indemnification, and stakeholder roles and responsibilities were specified. Educational modules for prehospital providers and nonburn center nurses and physicians who would provide interim care to burn injured disaster victims were created and pilot tested. These updated best practice recommendations provide a strong foundation for further planning efforts, and as of February 2011, serve as the frame work for the NYC Burn Surge Response Plan that has been incorporated into the New York State Burn Plan. Language: en

ACR Appropriateness Criteria® Acute Respiratory Illness in Immunocompromised Patients.

Abstract: The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies such as stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep high the population of immunosuppressed patients in our health care system today. This ACR Appropriateness Criteria ® topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever; in those with negative, equivocal, or nonspecific findings on chest radiography; in those with diffuse or confluent opacities on chest radiography; and in those in whom noninfectious disease is suspected. The use of chest radiography, chest CT, transthoracic needle biopsy, and nuclear medicine imaging are all discussed in the contexts of these clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Clinical application of cine-MRI in the visual assessment of mitral regurgitation compared to echocardiography and cardiac catheterization.

Abstract: Background Detecting and quantifying the severity of mitral regurgitation is essential for risk stratification and clinical decision-making regarding timing of surgery. Our objective was to assess specific visual parameters by cine-magnetic resonance imaging (MRI) in the determination of the severity of mitral regurgitation and to compare it to previously validated imaging modalities: echocardiography and cardiac ventriculography.

Derivation of a pediatric growth curve for inferior vena caval diameter in healthy pediatric patients: brief report of initial curve development.

Abstract: Background A validated tool has long been sought to provide clinicians with a uniform and accurate method to assess hydration status in the pediatric emergency medicine population. Outpatient clinicians use CDC height- and weight-based curves for the assessment of physical development. In hospital, daily weights provide objective data; however, these are usually not available at presentation. One of the most promising techniques for the rapid assessment of volume is ultrasound (US) to obtain an indexed inferior vena cava diameter (IVCDi); as previously described. Prior studies have focused on IVCDi in dehydrated patients and have shown that it provides accurate estimates of right atrial pressure and volume status. The objective of this study is to derive an IVC growth curve in healthy pediatric patients.

Comparison of 1.5 and 3.0 T for contrast-enhanced pulmonary magnetic resonance angiography

Abstract: Objective: In a recent multi-center trial of gadolinium contrast-enhanced magnetic resonance angiography (Gd-MRA) for diagnosis of acute pulmonary embolism (PE), two centers utilized a common MRI platform though at different field strengths (1.5T and 3T) and realized a signal-to-noise gain with the 3T platform. This retrospective analysis investigates this gain in signal-to-noise of pulmonary vascular targets. Methods: Thirty consecutive pulmonary MRA examinations acquired on a 1.5T system at one institution were compared to 30 consecutive pulmonary MRA examinations acquired on a 3T system at a different institution. Both systems were from the same MRI manufacturer and both used the same Gd-MRA pulse sequence, although there were some protocol adjustments made due to field strength differences. Region-of-interests were manually defined on the main pulmonary artery, 4 pulmonary veins, thoracic aorta, and background lung for objective measurement of signal-to-noise, contrast-to-noise, and bolus timing bias ...

ACR Appropriateness Criteria® Radiologic Management of Thoracic Nodules and Masses

Abstract: Pulmonary and mediastinal masses represent a wide range of pathologic processes with very different treatment options. Although advances in imaging (such as PET and high-resolution CT) help in many cases with the differential diagnosis of thoracic pathology, tissue samples are frequently needed to determine the best management for patients presenting with thoracic masses. There are many options for obtaining tissue samples, each of which has its own set of benefits and drawbacks. The purposes of this report are to present the most current evidence regarding biopsies of thoracic nodules and masses and to present the most appropriate options for select common clinical scenarios. The ACR Appropriateness Criteria ® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Point of care ultrasound for sepsis management in resource-limited settings: time for a new paradigm for global health care.

Abstract: Dear Editor, We applaud the ESICM Global Intensive Care Working Group for its pivotal contribution to the improvement of sepsis management in developing countries [1]. Dunser et al. acknowledge that health-care practices of industrialized nations are not available to the majority of humanity. On the basis of this current reality the authors offer guidelines regarding approaches to the management of sepsis in limited-resource settings. Surprisingly, we found no mention of the use of point-of-care ultrasound (POC-US) [2] beyond a generic recommendation to ‘‘use imaging techniques when available’’ [1]. Since 1985 ultrasonography has been recommended for developing countries by the World Health Organization (WHO) [3], as an inexpensive, rapidly deployable, and portable tool with minimal side effects. This is true today more than ever. Notwithstanding the lack of randomized, controlled trials on POC-US use in the specific setting of sepsis, increasing scientific evidence suggests tremendous potential for this tool in managing critical patients with infectious diseases. POC-US can be of great aid in the diagnosis of infectious diseases in rural areas [4], and generically in the detection of septic foci in febrile states [5]. It has a significant impact on mitigating diagnostic uncertainty in undifferentiated shock, narrowing differential diagnosis [6], and improving the specificity of early recognition of hypovolemia [7] and septic shock cardiovascular patterns [8]. Lung ultrasound has indeed a broad spectrum of established applications in the diagnosis and management of respiratory infectious diseases [9]—the leading cause of childhood mortality in developing countries [10]. The potential of POCUS in sepsis management is wide [11], and includes procedure-guidance applications that are increasingly acknowledged as best practice [12, 13]. With regards to education, innovative ultrasound curricula have been shaped for non-imaging specialists [14]. Short-term POC-US training programs are proven to deliver adequate knowledge and skills to novices [15]. And proof-of-concept studies have been conducted in the screening for infection sources in resource-limited settings of tropical countries [16]. Furthermore, low-cost technology can now provide minimally POC-UStrained operators (paramedics, midwives) with tele-mentoring and second-opinion facilities [17], mitigating the impracticable availability of ‘‘experienced practitioners’’ in all settings. This is of paramount importance for sustainable healthcare delivery where the patient-tophysician ratio is dramatically high. The use of POC-US represents a paradigm shift for improving health-

The dosimetric effects of photon energy on the quality of prostate volumetric modulated arc therapy

Abstract: Purpose Studies comparing the dosimetric effects of high- and low-energy photons to treat prostate cancer using 3-dimensional conformal and intensity modulated radiation therapy have yielded mixed results. With the advent of newer radiation delivery systems like volumetric modulated arc therapy (VMAT), the impact of changing photon energy is readdressed. Methods and Materials Sixty-five patients treated for prostate cancer at our institution from 2011 to 2012 underwent CT simulation. A target volume encompassing the prostate and entire seminal vesicles was treated to 50.4 Gy, followed by a boost to the prostate and proximal seminal vesicles to a total dose of 81 Gy. The VMAT plans were generated for 6-MV and 10-MV photons under identical optimization conditions using the Eclipse system version 8.6 (Varian Medical Systems, Palo Alto, CA). The analytical anisotropic algorithm was used for all dose calculations. Plans were normalized such that 98% of the planning target volume (PTV) received 100% of the prescribed dose. Dose-volumetric data from the treatment planning system was recorded for both 6-MV and 10-MV plans, which were compared for both the entire cohort and subsets of patients stratified according to the anterior–posterior separation. Results Plans using 10-MV photons had statistically significantly lower relative integral dose (4.1%), gradient measure (4.1%), skin D max (16.9%), monitor units (13.0%), and bladder V 30 (3.1%) than plans using 6-MV photons ( P 21 cm) for most parameters, with statistically significant differences in bladder V 30 , bladder V 65 , integral dose, conformity index, and monitor units. Conclusions The main dosimetric benefits of 10-MV as compared with 6-MV photons are seen in thicker patients, though for the entire cohort 10-MV plans resulted in a lower integral dose, gradient measure, skin D max , monitor units, and bladder V 30 , possibly at the expense of higher rectum V 81 .

Initial Strategy of Revascularization Versus Optimal Medical Therapy for Improving Outcomes in Ischemic Heart Disease: A Review of the Literature

Abstract: Defining optimal management of patients with stable coronary artery disease continues to be a central area of debate. While it has been established that all patients with coronary artery disease should at least be managed with optimal medical therapy, many patients with stable coronary artery disease continue to be treated with revascularization, whether by percutaneous coronary intervention or coronary artery bypass grafting. What remains unclear is whether revascularization further improves outcomes when added to medical therapy. We start by reviewing trials that define optimal medical therapy. We then review results of randomized trials comparing both revascularization strategies with optimal medical therapy and assess the strengths and limitations of each. Next, we briefly describe the ongoing ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, which will seek to determine optimal management for patients with stable ischemic heart disease in a population of patients at a uniformly higher risk prior to diagnostic cardiac catheterization. We conclude that revascularization and medical therapy should be used as complementary strategies. Available data have shown some benefits of revascularization in addition to medical therapy, but further trials are needed to better define the optimal population and magnitude and cost effectiveness of adding revascularization to optimal medical therapy.

The role of PET/CT in decreasing inter-observer variability in treatment planning and evaluation of response for cervical cancer.

Abstract: We have previously introduced anatomic biologic contouring (ABC) with PET/CT, using a distinct "halo" to unify contouring methods in treatment planning for lung and head and neck cancers. The objective of this study is to assess the utility of PET/CT in planning and treatment response for cervical cancer. Forty-two patients with stages II-IIIB cervix cancer were planned for irradiation using PET/CT. A CT-based Gross Tumor Volume (GTV-CT) was delineated by two independent observers while the PET remained obscured. The Planning Target Volume (PTV) was obtained by adding a 1.5 cm margin around the GTV. The same volumes were recontoured using PET/CT data and termed GTV-ABC and PTV-ABC, respectively. The values of GTV-CT and GTV-ABC and the absolute differences between the two observers were analyzed. Additionally, 23 of these patients had PET/CT performed 3 months after treatment. The anatomic biologic value (ABV) was calculated using the product of maximum diameter and mean SUV of the cervical tumor. The pre- and post-treatment ABVs were compared. A "halo" was observed around areas of maximal SUV uptake. The mean halo SUV was 1.91 ± 0.56 (SD). The mean halo thickness was 2.12 ± 0.5 (SD) mm. Inter-observer GTV variability decreased from a mean volume difference of 55.36 cm(3) in CT-based planning to 12.29 cm(3) in PET/CT-based planning with a respective decrease in standard deviation (SD) from 55.78 to 10.24 (p <0.001). Comparison of mean pre-treatment and post-treatment ABV's revealed a decrease of ABV from 48.2 to 7.8 (p<0.001). PET/CT is a valuable tool in radiation therapy planning and evaluation of treatment response for cervical cancer. A clearly visualized "halo" was successfully implemented in GTV contouring in cervical cancer, resulting in decreased inter-observer variability in planning. PET/CT has the ability to quantify treatment response using anatomic biologic value.

Holotranscobalamin: Not Ready for Prime Time

Abstract: To the Editor: In their recent article in Clinical Chemistry (1), Valente and colleagues advocate that holotranscobalamin II (holoTC)1 become the primary diagnostic test of vitamin B12 status. I believe that study flaws undercut the authors' recommendation. Moreover, the validation difficulties extend to deeper, more basic issues that continue to limit translation of the holoTC concept, despite its theoretical attractiveness. Validation efforts have typically compared holoTC against serum B12 in general populations and have used imperfect tools with often-arbitrary cutpoints to define B12 status. Such approaches and their reliance on methylmalonic acid (MMA), despite its questionable diagnostic specificity, have been critiqued (2). Valente et al. reuse this model with just 1 modification, the substitution of erythrocyte vitamin B12 (RBC-B12) for MMA as the arbiter of B12 status. That innovation misfires, however, because RBC-B12 is probably an even poorer standard than MMA. No convincing data anywhere, including the references cited by Valente and colleagues, justify the report's assumption that RBC-B12 represents tissue B12 status. Very little is known about what RBC-B12 concentrations really mean. The measurement of RBC-B12 has been deemed insufficiently informative …

Case series analysis of post-brachytherapy prostate edema and its relevance to post-implant dosimetry. Post-implant prostate edema and dosimetry.

Abstract: Purpose: We evaluated the post-operative pattern of prostate volume (PV) changes following prostate brachythe - rapy (PB) and analyzed variables which affect swelling. Material and methods: Twenty-nine patients treated with brachytherapy (14) or combined brachytherapy and ex- ternal beam radiotherapy modality (15) underwent pre- and post-implant computed tomography (CT). Prostate volume measurements were done on post-operative days 1, 9, 30, and 60. An observer performed 139 prostate volume (PV) meas- urements. We analyzed the influence of pre-implant PV, number of needles and insertion attempts, number and activ- ity of seeds, Gleason score, use of hormonal therapy and external beam radiation therapy on the extent of edema. We computed a volume correction factor (CF) to account for dosimetric changes between day 1 and day 30. Using the cal- culated CF, the dose received by 90% (D90) of the prostate on day 30 (D90Day30) was obtained by dividing day 1 (D90Day1) by the CF. Results: The mean PV recorded on post-operative day 1 was 67.7 cm3, 18.8 cm3 greater than average pre-op value (SD 15.6 cm3). Swelling returned to pre-implant volume by day 30. Seed activity, treatment modality, and Gleason score were significant variables. The calculated CF was 0.76. After assessment using the CF, the mean difference between es- timated and actual D90Day30 was not significant. Conclusions: We observed maximum prostate size on post-operative day 1, returning to pre-implant volume by day 30. This suggests that post-implant dosimetry should be obtained on or after post-operative day 30. If necessary, day 30 dosimetry can be estimated by dividing D90Day1 by a correction factor of 0.76. J Contemp Brachyther 2012; 4, 2: 75-80 DOI: 10.5114/jcb.2012.29363

Operator Versus Core Laboratory Assessment of Angiographic Reperfusion Markers in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction

Abstract: Background—Thrombolysis In Myocardial Infarction (TIMI) flow and Myocardial Blush Grade (MBG) are important prognostic indicators before and after primary percutaneous coronary intervention (PCI) in ST-segment–elevation myocardial infarction; however, the concordance and relative prognostic utility of operator (Op) versus angiography core laboratory (ACL) assessed TIMI flow and MBG are unknown. Methods and Results—Baseline and final Op and ACL TIMI flow and MBG assessment were compared from the Harmonizing Outcomes with RevascularIZatiON and Stents in AMI trial in 3345 patients undergoing primary PCI using Cohen’s κ coefficient. κ Was highest for pre-PCI TIMI flow (0.51, representing moderate agreement) and lowest for post-PCI MBG (0.20, representing fair agreement). Discordance between Op and ACL for final TIMI flow (0 to 2 versus 3) occurred in 12.9% of patients and for final MBG (0 to 1 versus 2 to 3) in 22.4%. Among 415 patients with final TIMI flow 0 to 2 by ACL, Op scoring was TIMI flow 3 in 267 (64...

A comprehensive comparative review of adenosine diphosphate receptor antagonists.

Abstract: Introduction: Thrombosis risk necessitates dual antiplatelet therapy with aspirin and an adenosine diphosphate (ADP) receptor antagonist, in patients who have acute coronary syndrome. Current guidelines emphasize the critical role of dual antiplatelet therapy in both medical management and invasive strategy, especially in patients undergoing percutaneous coronary intervention. With the availability of multiple ADP-receptor antagonists, it is crucial to select the most appropriate agent for each patient. Areas covered: The pertinent trials were identified through a MEDLINE search, in addition to a manual search from the articles retrieved. This review examines the differences between clopidogrel, prasugrel and ticagrelor in terms of their pharmacological/pharmacokinetic properties, clinical efficacy, drug interactions and safety parameters. Expert opinion: Prasugrel and ticagrelor exhibit greater platelet inhibition and superior efficacy compared with clopidogrel, at the expense of higher bleeding risk. Pr...

Hysteroscopic Removal of Cervical Ectopic Pregnancy Following Failed Intramuscular/Intra-Sac Methotrexate: A Case Report

Abstract: Background: Cervical pregnancy is a diagnosis associated with significant morbidity, specifically life-threatening hemorrhage that potentially requires hysterectomy to prevent maternal death. Conservative and fertility-sparing management strategies are poorly described in the literature, and there is no clear standard of care. Case: The patient was a 34-year-old gravida 1, para 0 who had conceived spontaneously after laparoscopic treatment of endometriosis, and was found to have cervical pregnancy. She received both intramuscular and intra-sac methotrexate, with no resolution of the ectopic pregnancy. The pregnancy was removed hysteroscopically. Results: Subsequently, the patient was able to achieve a normal clinical pregnancy with ovulation induction/intrauterine insemination. This pregnancy was carried to term. Conclusions: Although cervical pregnancy is particularly hazardous and potentially fatal, conservative/fertility-sparing management of these pregnancies can be successful. (J GYNECOL SUR...