6-month group. Overall, fatal and nonfatal VTE during and after treatment occurred in 8% of those receiving 3 months of anticoagulation (n ϭ 31) and in 8% of those receiving 6 months anticoagulation (n ϭ 29; P ϭ .80; 95% confidence interval [CI] difference, -3.1% to 4.7%). No patients in either group had a fatal hemorrhage during treatment, but there were eight major hemorrhages in those treated for 6 months and none in those treated for 3 months (P ϭ .008; 95% CI, -3.5% to -0.7%). Adverse events occurred in 8% of the patients receiving 3 months of anticoagulation (n ϭ 31) and in 9% of the patients receiving 6 months of anticoagulation (n ϭ 35; P ϭ .79, 95% CI -4.9% to 3.2%).Comment: The data with regard to the hard end points in this study-death from VTE or major hemorrhage-are likely reliable. The data with respect to recurrence, extension, or failure to resolve VTE are likely highly unreliable because they were derived from review forms completed by clinicians at each individual site, without specific requirements for imaging during follow-up. Indeed, the idea that the DVT resolved in Ͼ95% of the patients treated with oral anticoagulation is completely disparate with regard to the findings of serial imaging studies in patients with DVT. The authors also provide no information about possible postphlebitic syndrome in their patients. Follow-up is too short for such an analysis. Overall, the study indicates no difference in death from VTE with 3 or 6 months of anticoagulation in a patient with VTE and unidentified risk factors. The data are not sufficient to conclude that there is no difference in recurrence of VTE with the two treatment paradigms. Heritability of Platelet Responsiveness to Aspirin in ActivationPathways Directly and Indirectly Related to Cyclooxygenase-1 Faraday N, Yanek LR, Mathias R, et al. Circulation 2007;115:2490-6.Conclusion: There is a genetic basis to variability in residual platelet function after aspirin exposure.Summary: It is known that the inability of aspirin to suppress platelet function can be associated with future risk of myocardial infarction, stroke, and cardiovascular death. The authors sought to determine if there was genetic variation that could be linked to insufficient aspirin responsiveness.Aspirin responsiveness was assessed in 1880 asymptomatic patients. The mean age was 44 Ϯ 13 years, and 58% were women. Patients were recruited from 309 white and 208 black families with premature coronary heart disease. Platelet function was determined ex vivo before and after ingestion of aspirin (81 mg/d for 2 weeks). Platelet function was determined with a panel of tests assessing platelet activation in pathways indirectly and directly related to cyclooxygenase-1 (COX-1). Multivariable regression analysis was also used to determine the proportion of phenotypic variance related to coronary heart disease risk factor covariates.Arachidonic acid-induced thromboxane B 2 production was inhibited by Ͼ99% with aspirin (P Ͻ .0001). Platelet activation by pathways indirectly related to COX-1...
BackgroundThe individual components of the metabolic syndrome are risk factors for coronary artery disease. The underlying pathophysiology of a low-grade inflammatory process postulates that the metabolic syndrome could compromise a procedure such as coronary artery bypass graft surgery (CABG) done on cardiopulmonary bypass (CPB).MethodsFrom a single institution, 370 patients with the metabolic syndrome (IDF and ATP III criteria) and 503 patients without the metabolic syndrome were identified. The influence of the metabolic syndrome on the pre-operative core risk factors for CABG mortality as well as its effect on the mortality and major morbidity post surgery were investigated.ResultsPatients with the metabolic syndrome were operated on less urgently than those without the metabolic syndrome. The EuroSCORE was also lower in those with the metabolic syndrome. Patients with the metabolic syndrome required fewer units of homologous red blood cells, but stayed statistically longer in hospital.ConclusionsIn this surgical population the metabolic syndrome had no detrimental clinical effect on either the pre-operative risk factors or the outcome after CABG.
This case report describes the history of a patient with an aggressive course of a metastatic extra-adrenal pheochromocytoma (paraganglioma) who received different combination chemotherapy regimens with no or short-lasting clinical benefit. However, during treatment with single-agent paclitaxel, there was a significant clinical improvement, a partial biochemical response and a minor roentgenologic response, which was sustained for 1 year. In this report we present this case and also review the literature on the chemotherapy used for this rare disease over the past 15 years. To enable the activity of paclitaxel against this neoplasm to be determined, more patients need to be treated.
Fifty patients undergoing primary coronary artery bypass surgery and 50 patients undergoing valve surgery received either high-dose aprotinin (2 million units loading dose, 2 million units added to the CPB prime, and 500,000 unitslhr maintenance infusion) or placebo. Mean postoperative blood loss in the first six hours was reduced from 321 ml in the placebo group to 172 ml in the aprotinin group (95 % confidence interval (Cl) for difference = 95 to 189 ml). Seven patients in the placebo group and 16 patients in the aprotinin group did not require transfusion with homologous blood. This study adds to the growing body of evidence that the administration of high-dose aprotinin reduces blood loss and blood transfusion requirements associated with primary cardiac surgery.
SummaryAim:The purpose of this article is to present the results of a private cardiac surgical practice. This information could also serve as a hermeneutical text for new wisdom.Methods:A personal database of 1 750 consecutive patients who had had coronary artery bypass graft (CABG) surgery was statistically analysed. Mortality and major morbidity figures were compared with large registries. Risk factors for postoperative death were determined.Results:Over a period of 12 years, 1 344 (76.8%) males and 406 (23.2%) females were operated on. The observed mortality rate was 3.03% and the expected mortality rate (EuroSCORE) was 3.87%. After stepwise logistic regression, independent risk factors for death were urgency (intra-aortic balloon pump), renal impairment (chronic kidney disease, stage III), re-operation and an additional procedure. Apart from the 53 deaths, another 91 patients had major complications.Conclusion:Mortality and morbidity rates compared favourably with other international registries. Mortality was related to co-morbidities. This outcome contributes to a hermeneutical understanding focusing on new spiritual wisdom and meaning for the surgeon.
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