The presence of pulmonary hypertension (PH) significantly worsens outcomes in patients with advanced sarcoidosis, but its optimal management is unknown. We aimed to characterize a large sarcoidosis-associated pulmonary hypertension (SAPH) cohort to better understand patient characteristics, clinical outcomes, and management strategies including treatment with PH therapies. Patients at Duke University Medical Center with biopsy-proven sarcoidosis and SAPH confirmed by right heart catheterization (RHC) were identified from 1990–2010. Subjects were followed for up to 11 years and assessed for differences by treatment strategy for their SAPH, including those who were not treated with PH-specific therapies. Our primary outcomes of interest were change in 6-minute walk distance (6MWD) and change in N-terminal pro-brain natriuretic peptide (NT-proBNP) by after therapy. We included 95 patients (76% women, 86% African American) with SAPH. Overall, 70% of patients had stage IV pulmonary sarcoidosis, and 77% had functional class III/IV symptoms. Median NT-proBNP value was elevated (910 pg/mL), and right ventricular dysfunction was moderate/severe in 55% of patients. Median values for mean pulmonary artery pressure (49 mmHg) and pulmonary vascular resistance (8.5 Woods units) were consistent with severe pulmonary hypertension. The mortality rate over median 3-year follow-up was 32%. Those who experienced a clinical event and those who did not had similar overall echocardiographic findings, hemodynamics, 6MWD and NT-proBNP at baseline, and unadjusted analysis showed that only follow-up NT-proBNP was associated with all-cause hospitalization or mortality. A sign test to evaluate the difference between NT-Pro-BNP before and after PH therapy produced evidence that a significant difference existed between the median pre- and post-NT-Pro-BNP (−387.0 (IQR: −1373.0-109), p = 0.0495). Use of PH-specific therapy may be helpful in selected patients with SAPH and pre-capillary pulmonary vascular disease. Prospective trials are needed to characterize responses to PH-specific therapy in this subset of patients with SAPH.
Our objective was to use community-based, national databases to evaluate diagnostic imaging and antibiotic prophylaxis practice patterns before and after the release of the 2011 American Academy of Pediatrics guidelines for acute febrile urinary tract infection. Using the National Ambulatory and Hospital Ambulatory Medical Care Surveys, urinary tract infection encounters were identified for patients aged 2 months to 18 years. Primary outcomes were utilization of antibiotics (as proxy for prophylaxis) and diagnostic imaging during encounters. Weighted multivariate logistic regression models were used to examine the association between time period (before and after 2011) and each of the primary outcomes. Among 8 588 035 weighted encounters, adjusting for covariates, there was insufficient evidence to suggest a difference between time periods for antibiotic utilization (odds ratio = 0.66, P = .12) or diagnostic imaging (odds ratio = 1.16, P = .56). Thus, we did not find evidence of changes in antibiotic utilization or diagnostic imaging practice patterns after the release of the 2011 American Academy of Pediatrics guidelines.
independently reviewed and abstracted data from each study. Results were then merged and a third-party referee resolved any discrepancies. Analysis was done through RevMan 5.3.RESULTS: A total of 62 articles matched our inclusion criteria. Of these, 5 studies directly compared open (intra-vesical in 2 and extravesical in 3) with robotic surgery with a cumulative odds ratio of 1.06 favoring open reimplant (CI: 0.4-2.94). The intra-vesical open technique possessed an average OR time range of 147-166 min, LOS 1-2.9 d, and a complication rate of 25% (23/90); whereas the extra-vesical open technique possessed an avg. OR time range of 109-120 min, LOS 1.3-1.7 d, and complication rate of 19% (16/84). The avg. OR time for robotic reimplant in these studies was 165-233 min, LOS 1-1.7 d, and complication rate of 12% (14/118). When comparing data from the 1997 VUR guidelines to robotic reimplant data, we found a cumulative odds ratio of 2.01 favoring open reimplant (CI: 1.58-2.56). In addition, in our review of both techniques, the avg. range of OR time for open surgery was 56-176 min, avg. LOS 1-12 d, with a complication rate of 6.6% (173/2617); whereas the avg. OR time for robotic reimplant was 162-227 min, avg. LOS 1-7.4 d, with a complication rate of 10% (69/663).CONCLUSIONS: The overall weighted success rate was significantly higher for open surgery compared to robotic surgery, though more recent comparisons showed similar success rates. Open surgery had a longer LOS but shorter OR time compared to robotic reimplant.
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