SummaryWe assessed the efficacy of a comprehensive programme for stopping smoking in 210 smokers scheduled for surgery, before admission and 3 months after attending a pre-operative clinic. Participants were randomly allocated to receive an intervention incorporating nicotine replacement therapy for patients smoking more than 10 cigarettes per day ('dependent smokers'), or to a control group to receive usual care. Dependent smokers allocated to the intervention group were more likely to report abstinence before surgery than those allocated to receive usual-care (63 (73%) vs. 29 (56%), respectively; OR 2.2 (95% CI 1.0-4.8)), and 3 months after attendance (16 (18%) vs. 3 (5%), respectively; OR = 3.9 (95% CI 1.0-21.7).
The data suggest strong support for the direct marketing of smoking cessation strategies; they also highlight the need for further study of the cost-effectiveness of telephone-based direct marketing of smoking cessation strategies as a population-based strategy for reducing the prevalence of smoking in the community.
The period following heart failure hospitalization (HFH) is a vulnerable time with high rates of death or recurrent HFH.OBJECTIVE To evaluate clinical characteristics, outcomes, and treatment response to vericiguat according to prespecified index event subgroups and time from index HFH in the Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) trial. DESIGN, SETTING, AND PARTICIPANTSAnalysis of an international, randomized, placebo-controlled trial. All VICTORIA patients had recent (<6 months) worsening HF (ejection fraction <45%). Index event subgroups were less than 3 months after HFH (n = 3378), 3 to 6 months after HFH (n = 871), and those requiring outpatient intravenous diuretic therapy only for worsening HF (without HFH) in the previous 3 months (n = 801). Data were analyzed between May 2, 2020, and May 9, 2020.INTERVENTION Vericiguat titrated to 10 mg daily vs placebo. MAIN OUTCOMES AND MEASURESThe primary outcome was time to a composite of HFH or cardiovascular death; secondary outcomes were time to HFH, cardiovascular death, a composite of all-cause mortality or HFH, all-cause death, and total HFH. RESULTS Among 5050 patients in the VICTORIA trial, mean age was 67 years, 24% were women, 64% were White, 22% were Asian, and 5% were Black. Baseline characteristics were balanced between treatment arms within each subgroup. Over a median follow-up of 10.8 months, the primary event rates were 40.9, 29.6, and 23.4 events per 100 patient-years in the HFH at less than 3 months, HFH 3 to 6 months, and outpatient worsening subgroups, respectively. Compared with the outpatient worsening subgroup, the multivariable-adjusted relative risk of the primary outcome was higher in HFH less than 3 months (adjusted hazard ratio, 1.48; 95% CI, 1.27-1.73), with a time-dependent gradient of risk demonstrating that patients closest to their index HFH had the highest risk. Vericiguat was associated with reduced risk of the primary outcome overall and in all subgroups, without evidence of treatment heterogeneity. Similar results were evident for all-cause death and HFH. Addtionally, a continuous association between time from HFH and vericiguat treatment showed a trend toward greater benefit with longer duration since HFH. Safety events (symptomatic hypotension and syncope) were infrequent in all subgroups, with no difference between treatment arms.CONCLUSIONS AND RELEVANCE Among patients with worsening chronic HF, those in closest proximity to their index HFH had the highest risk of cardiovascular death or HFH, irrespective of age or clinical risk factors. The benefit of vericiguat did not differ significantly across the spectrum of risk in worsening HF.
A 75-year-old man with a 5-year history of myelodysplastic syndrome (MDS) subsequently developed worsening fatigue, dizziness, and dyspnea on exertion. There was no family history of hematologic diseases. On examination he was cachectic with no hepatosplenomegaly and petechiae, but purpuric lesions were present on his hands. The complete blood count showed pancytopenia (hemoglobin 10.2 g/dL, white blood cell count 2.8 k/uL, absolute neutrophil count 1.6 k/uL, platelets 23 k/uL) with a mean corpuscular volume of 101.3 fL. Reticulocyte count was not performed. The peripheral smear showed striking elliptocytosis (see figure). Bone marrow biopsy revealed hypercellularity with prominent megakaryocytic and granulocytic dysplastic. Conventional cytogenetic analysis detected a del(20)(q11.2) with a sideline showing a marker chromosome. The earlier hematologic assessment 5 years prior showed an isolated del(20q)(q11.2) with no evidence of elliptocytosis.Acquired elliptocytosis may be seen in a variety of bone marrow disorders, including architectural disturbances such as fibrosis and myelophthisis. It can also be a manifestation of dysplastic erythropoiesis in the setting of MDS. Acquired elliptocytosis is generally characterized by fewer elliptocytes (Ͻ 15% of total red blood cells) than the marked numbers seen in hereditary elliptocytosis (HE). Reports suggest an association between marked elliptocytosis in MDS and del(20q) that was seen in this patient. Diminished production of protein 4.1 (EBP41), a structural RBC protein implicated in some cases of HE, has also been demonstrated in MDS with elliptocytosis. An interesting feature of this case was the acquisition of elliptocytosis as the disease progressed.For additional images, visit the ASH IMAGE BANK, a reference and teaching tool that is continually updated with new atlas and case study images. For more information visit
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