Recently published data still support the hierarchical ranking of SGAs already proposed in previous reviews ranking clozapine and olanzapine as having the highest risk, followed by amisulpride, asenapine, iloperidone, paliperidone, quetiapine, risperidone and sertindole in the middle, and aripiprazole, lurasidone and ziprasidone with the lowest risk. Number needed to harm varied considerably in our meta-analysis. Younger patients and patients with a lower baseline body mass index are most vulnerable. The greatest amount of weight gain occurs within the first weeks of treatment. AIWG occurs in all diagnostic groups and is also common in treatment with first-generation antipsychotics; therefore, awareness of this adverse event is essential for anyone prescribing antipsychotics.
Cannabis use does not seem to affect epilepsy; however, frequent use of other drugs increases seizure risk.
Purpose: This study aimed to assess alcohol consumption and the occurrence of alcohol-related seizures in patients with epilepsy within the last 12 months.Methods: In an epilepsy outpatient clinic, a standardized questionnaire was used to collect data retrospectively from consecutive adult epilepsy patients who had been suffering from the disease for at least 1 year. Logistic regression analyses were performed to identify independent predictors.Results: A total of 310 patients with epilepsy were included. Of these, 204 subjects (65.8%) consumed alcohol within the last 12 months. Independent predictors for alcohol use were antiepileptic drug monotherapy (OR 1.901) and physicians' advice that a light alcohol intake is harmless (OR 4.102). Seizure worsening related to alcohol consumption was reported by 37 of the 204 patients (18.1%) who had used alcohol. All 37 subjects had consumed large quantities of alcohol prior to the occurrence of alcohol-related seizures regardless of their usual alcohol-drinking behavior. The amount of alcohol intake prior to alcohol-related seizures was at least 7 standard drinks, which is equivalent to 1.4 L of beer or 0.7 L of wine. In 95% of cases, alcohol-related seizures occurred within 12 h after cessation of alcohol intake. Independent predictors for alcohol-related seizures were generalized genetic epilepsy (OR 5.792) and chronic heavier alcohol use (OR 8.955).Conclusions: Two-thirds of interviewed subjects had consumed alcohol within the last 12 months. This finding may be an underestimate due to patients' self-reporting and recall error. In all cases, the occurrence of alcohol related-seizures was associated with timely consumption of considerably large amounts of alcohol. Thus, a responsible alcohol intake seems to be safe for most patients with epilepsy. However, subjects with epilepsy and especially those with generalized genetic epilepsy should be made aware of an increased risk for seizures related to heavy alcohol consumption. Factors accompanying acute heavy alcohol intake such as altered sleep architecture, impaired adherence to antiepileptic medication, and metabolic disturbances may further facilitate the occurrence of seizures.
Background and objectivesMitraClip implantation is an established therapy for secondary mitral regurgitation (MR) in high-risk patients and has shown to improve several important outcome parameters such as functional capacity. Patient selection is both challenging and crucial for achieving therapeutic success. This study investigated baseline predictors of functional improvement as it was quantified by the six-minute walk distance (6MWD) after transcatheter mitral valve repair. Methods and resultsWe retrospectively analyzed 79 patients with secondary MR treated with MitraClip implantation at an academic tertiary care center. Before and four weeks after the procedure, all patients underwent comprehensive clinical assessment, six-minute walk tests and echocardiography. 6MWD significantly improved after MitraClip therapy (295 m vs. 265 m, p < 0.001). A linear regression model including seven clinical baseline variables significantly predicted the change in 6MWD (p = 0.002, R 2 = 0.387). Female gender, diabetes mellitus and arterial hypertension were found to be significant negative predictors of 6MWD improvement. At baseline, female patients had significant higher left ventricular ejection fraction (49% vs. 42%, p = 0.019) and lower 6MWD (240 m vs. 288 m, p = 0.034) than male patients. ConclusionMitraClip implantation in secondary MR significantly improves functional capacity in highrisk patients even in the short term of four weeks after the procedure. Female gender, diabetes mellitus and arterial hypertension are baseline predictors of a less favourable functional outcome. While further validation in a larger cohort is recommended, these parameters may improve patient selection for MitraClip therapy.
Background and Hypothesis The acquired von Willebrand syndrome (AvWS), which predisposes to bleeding events, is often related to valvular heart diseases. We investigated possible implications of AvWS and factor VIII levels in patients with moderate to severe mitral regurgitation (MR) undergoing transcatheter mitral valve repair (TMVR). Methods and Results 123 patients with moderate to severe MR were prospectively enrolled. Complete measurements of von Willebrand Factor activity (vWFAct), von Willebrand Factor antigen (vWFAg), and factor VIII expression before and 4 weeks after TMVR were available in 85 patients. At baseline, seven patients had a history of gastrointestinal bleeding, two patients suffered bleeding events during their hospital stay, and one patient had a bleeding 4 weeks after TMVR. Even though vWFAct, vWFAct/vWFAg ratio and vWFAg values did not change after TMVR, we observed a significantly lower vWFAct/vWFAg ratio in patients with primary MR as compared to patients with secondary MR both at baseline (p = 0.022) and 4 weeks following the TMVR procedure (p = 0.003). Additionally, patients with a mean mitral valve gradient ≥4 mmHg after TMVR had significantly lower vWFAct/vWFAg ratios as compared to patients with a mean mitral valve gradient <4 mmHg (p = 0.001). Conclusions MR of primary etiology was associated with lower vWFAct/vWFAg ratio, hinting toward HMWM loss due to shear stress caused by eccentric regurgitation jets. In addition, morphological changes leading to postprocedural transmitral gradients ≥4 mmHg were related to lower vWFAct/vWFAg ratio 4 weeks after the procedure. Alterations of the vWFAct/vWFAg ratio in turn did not translate into a greater risk for bleeding events.
Background Chronic subclinical intravascular hemolysis is a common complication after valve replacement associated with worse prognosis, occurring in up to 80% of patients after mitral valve surgery. While serious intravascular hemolysis after MitraClip implantation has been reported anecdotally, data on the impact of transcatheter mitral valve repair on the prevalence of subclinical hemolysis are lacking. Methods and results From August 2017 to November 2019, 77 patients with high perioperative risk and moderate-to-severe or severe mitral regurgitation were prospectively enrolled in a single-center trial. All participants were treated with transcatheter edge-to-edge mitral valve repair using the MitraClip NT, NTR or XTR system. Before and three months after the procedure, all patients underwent comprehensive clinical assessment including laboratory measurement of hemoglobin, haptoglobin and lactic acid dehydrogenase in venous blood samples. Presence of subclinical intravascular hemolysis was defined as hemoglobin <13.8 g/dl for males or <12.4 g/dl for females, haptoglobin <65 mg/dl and lactic acid dehydrogenase >250 U/l. Levels of the hemolysis marker haptoglobin significantly decreased three months after the intervention (127±71 mg/dl at three months vs. 158±73 mg/dl at baseline, p<0.001), accompanied by an increase in lactic acid dehydrogenase (251±88 U/l vs. 222±55 U/l, p<0.01), implying the induction of intravascular hemolysis by transcatheter mitral valve repair. Higher residual mitral regurgitation was associated with lower haptoglobin levels three months after mitral valve repair (p<0.05), hinting that shear stress caused by regurgitation flow is the primary mechanism for hemolysis after MitraClip implantation. Concurrently, we observed a trend towards an increase in the presence of subclinical intravascular hemolysis (9.1% at three months vs. 3.9% at baseline, p=0.289). Hemoglobin levels remained unchanged (12.1±1.5 g/dl at three months vs 12.3±1.8 g/dl at baseline, p=0.107). No patient needed treatment for intravascular hemolysis. Conclusion Transcatheter edge-to-edge mitral valve repair in a high-risk collective is associated with the induction of hemolysis. Yet, prevalence of subclinical intravascular hemolysis is low when compared to mitral valve surgery, emphasizing the good safety profile of minimal-invasive mitral valve therapy. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): ReForM-B research grant, University of Regensburg
Background MitraClip implantation induces hemodynamic unloading and reverse remodeling of the left atrium (LA) and the left ventricle (LV). However little data exist concerning the effects of MitraClip implantation on LA and LV strain reflecting LA and LV function. Methods and results From August 2017 to September 2018 62 patients with moderate to severe mitral regurgitation were prospectively enrolled in our single-center RETORT-MR trial (Regensburg Trial on TMVR Techniques in Mitral Regurgitation). All included patients were treated using the MitraClip procedure. Two dimensional speckle tracking echocardiography (2DSTE) of the LA as well as of the LV could be performed in 35 patients with follow-up 2DSTE at four weeks and/or three months after MitraClip implantation. In 25.7% of patients primary mitral regurgitation was present (n=9) and in 74.3% of subjects a secondary entity of mitral regurgitation had been diagnosed (n=26). 57.1% of patients (n=20) suffered from heart failure with preserved ejection fraction (HFpEF) and 42.9% of patients (n=15) had heart failure with reduced ejection fraction (HFrEF). Global longitudinal strain (GLS) was reduced at baseline (−15.3%), at four-week (−14.5%, n=27) and at three-month follow-up (−13.9%, n=28) with no statistically significant differences indicating a sustained mechanical impairment of LV. In contrast significant deterioration was observed in the peak atrial longitudinal strain (PALS) representing LA reservoir function (15.3% at baseline vs. 11.8% at four-week follow-up, n=25, p=0.015 and 16.0% at baseline vs. 13.2% at three-month follow-up, n=25, p=0.03). Similarly to LA reservoir function LA booster function indicating left atrial active contraction was significantly reduced after MitraClip implantation (12.5% at baseline vs. 8.0% at four-week follow-up, n=10, p=0.028). Contrary to LA functional parameters LA size did not change significantly after MitraClip implantation (LA volume index at baseline 74.5 ml/m2 vs. 70.1 ml/m2 at four-week follow-up, n=27, p=0.489). Conclusion The present study revealed a deterioration of LA functional parameters (LA reservoir and LA booster function) after MitraClip insertion. It is known that severe mitral regurgitation can cause structural changes of the LA such as fibrosis. MitraClip insertion leads to a significant reduction of regurgitant volumes but structural changes of the LA may not be reversible. In addition MitraClip implantation increases afterload in the LA potentially explaining the observed deterioration of LA functional parameters. Acknowledgement/Funding None
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