Risultati per: Short Acting Opioid

Stroke, Ahead of Print. BACKGROUND:The tissue-based definition of transient ischemic attack, which requires the use of diffusion-weighted imaging (DWI), has limitations in its applicability to clinical practice. This contributes to the limited evidence regarding the risk of subsequent stroke and the associated predictors in the group of patients who are tissue-negative on DWI. Our aim was to assess the early and long-term prognoses of consecutive patients with tissue-negative transient ischemic attacks attended at an emergency department.METHODS:We performed a prospective cohort study of consecutive patients with neurologist-confirmed transient ischemic attack who were DWI-negative from January 2006 to June 2010. All patients underwent DWI on magnetic resonance imaging (4.0 [SD, 1.8] days) after the index event. The risk and predictors of stroke recurrence (SR) were determined at 1 year and after a median follow-up time of 6.6 (interquartile range, 5.0–9.6) years.RESULTS:A total of 370 patients were included. Previously, 244 patients with positive DWI results and 109 patients without magnetic resonance imaging performed were excluded. ABCD2 score >5 was determined in 95 (26.2%) patients; 15 (4.1%) patients experienced SR at 1 year and 18 (4.9%) beyond 1 year. Predictive models for short- and long-term prognoses were different. Large artery atherosclerosis cause (hazard ratio, 3.7 [95% CI, 1.2–11.0]) was the only predictor of 1-year SR. In contrast, male sex (hazard ratio, 4.17 [95% CI, 1.14–15.23];P=0.031), speech impairment (hazard ratio, 4.90 [95% CI, 1.05–22.93];P=0.044), and the presence of chronic microangiopathy expressed as Fazekas score of 3 (hazard ratio, 1.84 [95% CI, 1.15–2.97];P=0.012) were predictors of long-term SR follow-up.CONCLUSIONS:Patients with DWI-negative have a clinically important risk of recurrent vascular events and SR during medium- and long-term follow-ups. These patients warrant optimized secondary prevention to reduce their risk of recurrent vascular events over time. Predictors of SR varied over the follow-up.

Objectives
Opioid agonist, partial agonist and antagonist medications are used to treat opioid use disorder (OUD). This was the first omnibus narrative systematic review of the contemporary qualitative literature on patient experiences of receiving these medications.

Design
Narrative systematic review using the sample, phenomenon of interest, design, evaluation and research framework.

Data sources
PubMed, Embase and APA PsycINFO were searched between 1 January 2000 and 14 June 2023, with the addition of hand searches.

Eligibility criteria for selecting studies
Qualitative and mixed methods studies among adults with experience of receiving OUD treatment medication in community and criminal justice settings.

Data extraction and synthesis
One reviewer conducted searches using the pre-registered strategy. Two independent reviewers screened studies and assessed quality using the Consolidation Criteria for Reporting Qualitative tool. Identified reports were first categorised using domains from the addiction dimensions for assessment and personalised treatment (an instrument developed to guide OUD treatment planning), then by narrative synthesis.

Results
From 1129 studies, 47 reports (published between 2005 and 2023) were included. Five major themes (and nine subthemes) were identified: (1) expectations about initiating treatment (barriers to access; motivations to receive medication); (2) responses to medication induction and stabilisation; (3) experience of the dispensing pharmacy (attending; medication dispensing); (4) experiences of maintenance treatment (services; dose adjustment; personal and social functioning); and (5) social factors (integration and stigma) and experiences of discontinuing treatment. Together these themes reflected and endorsed the importance of patient-centred care and clinically integrated services. Further qualitative research in real-world settings is needed on extended-release buprenorphine given the relative novelty of this medication option.

Conclusions
A narrative systematic review of the qualitative studies of medications for OUD endorsed the importance of patient-centred care and clinically integrated services.

PROSPERO registration number
CRD42019139365.

This population-based retrospective cohort study uses linked health administrative databases to assess the risk of treatment discontinuation and mortality among adults in British Columbia, Canada, receiving buprenorphine/naloxone vs methadone for the treatment of opioid use disorder.

Circulation, Volume 150, Issue 22, Page 1815-1817, November 26, 2024.

The American Academy of Pediatrics (AAP) released its first clinical guidance on prescribing opioids for outpatient acute pain management to youth. Although it cautions against the dangers of rising opioid use disorder among children and teens, it also notes that a decrease in opioid prescription rates may leave some youth with pain that is not adequately treated.

With great interest, we read the paper by Ammer-Hermenau et al, which features a multicentre microbiome study that included buccal and rectal samples taken at admission from 450 patients with acute pancreatitis.1 Severe acute pancreatitis was post hoc defined as persistent organ failure and/or collections that required drainage. These patients were propensity score matched with patients with mild acute pancreatitis. Remarkedly, over-representation of 10 known short-chain fatty acid (SCFA)-producing bacteria was found in the severe group. The authors conclude that SCFAs might be associated with worse outcomes and speculate that the increased mortality that was observed in the intervention group of the Probiotics in Pancreatitis Trial (PROPATRIA) could be explained by SCFA producers in the probiotics formula.2 There are, however, some limitations to this study, and we believe the author’s statements are in need of nuance. First, the authors did not include a control group…

Objective
In patients with Crohn’s disease (CD) on combination therapy (infliximab and immunosuppressant) and stopping infliximab (cohort from the study of infliximab diSconTinuation in CrOhn’s disease patients in stable Remission on combined therapy with Immunosuppressors (STORI)), the risk of short-term (≤6 months) and mid/long-term relapse ( >6 months) was associated with distinct blood protein profiles. Our aim was to test the external validity of this finding in the SPARE cohort (A proSpective Randomized Controlled Trial comParing infliximAb-antimetabolites Combination Therapy to Anti-metabolites monotheRapy and Infliximab monothErapy in Crohn’s Disease Patients in Sustained Steroid-free Remission on Combination Therapy).

Design
In SPARE, patients with CD in sustained steroid-free clinical remission and on combination therapy were randomly allocated to three arms: continuing combination therapy, stopping infliximab or stopping immunosuppressant. In the baseline serum of the STORI and SPARE (arm stopping infliximab) cohorts, we studied 202 immune-related proteins. The proteins associated with time to relapse (univariable Cox model) were compared between STORI and SPARE. The discriminative ability of biomarkers (individually and combined in pairs) was evaluated by the c-statistic (concordance analysis) which was compared with C-reactive protein (CRP), faecal calprotectin and a previously validated model (CEASE).

Results
In STORI and SPARE, distinct blood protein profiles were associated with the risk of short-term (eg, high level: CRP, haptoglobin, interleukin-6, C-type lectin domain family 4 member C) and mid/long-term relapse (eg, low level: Fms-related tyrosine kinase 3 ligand, kallistatin, fibroblast growth factor 2). At external validation, the top 10 biomarker pairs showed a higher c-statistic than the CEASE model, CRP and faecal calprotectin in predicting short-term (0.76–0.80 vs 0.74 vs 0.71 vs 0.69, respectively) and mid/long-term relapse (0.66–0.68 vs 0.61 vs 0.52 vs 0.59, respectively).

Conclusion
In patients with CD stopping infliximab, we confirm that the risk of short-term and mid/long-term relapse is associated with distinct blood protein profiles showing the potential to guide infliximab withdrawal.

Trial registration number
NCT00571337 and NCT02177071.

We appreciate the constructive dialogue from Cheng on our study’s findings.1 We agree that any clinical database study has limitations that necessitate careful interpretation of results. Manual medical records review is a logical next step to mitigate these shortcomings and allow a more thorough examination of each patient’s course. Nevertheless, we re-analysed our data in response to points raised. The analyses in our original paper suggest an elevated risk of undergoing an esophagogastroduodenoscopy (EGD) in patients treated with glucagon-like peptide-1 receptor agonists (GLP-1 RA) compared with control. As mentioned in our prior reply,2 we recognise that there is a potential diagnostic bias from this observation. We re-ran our cohorts and found that the rate of undergoing an EGD in the propensity-score matched cohort receiving short-acting GLP-1 RA was 6.13% compared with 5.22% in the matched control cohort (OR 1.185; 95% CI 1.131 to 1.241), reflecting the…

We write in response to the Letter to the Editor by van den Berg et al1 commenting on our recent article ‘Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis’.2 We greatly appreciate the interest in our work and are grateful to clarify some aspects of the study. The primary endpoint of our study investigated whether microbial compositions can be employed as early predictors for severity of acute pancreatitis (AP). Patients with revised Atlanta classification III (RAC III) showed highly significant microbial differences compared with RAC I and RAC II. Further analysis revealed a higher abundance of species that are known producers of short-chain fatty acids (SCFA) in severe AP. Van den Berg et al mention the lack of a healthy control cohort, however, it is already known from previous studies that the microbial composition in stool samples of patients with AP…

Circulation, Volume 150, Issue Suppl_1, Page A4145819-A4145819, November 12, 2024. Introduction:Despite early mitigation efforts, the opioid pandemic in the United States has persisted and affected many Americans. A public health emergency was declared urging all prescribers to use caution in prescribing opioids. Alternative approaches to postoperative pain management during transvenous cardiac device implants (TCDI) in adults have not been described.Methods:We report a single-center retrospective analysis of 612 consecutive patients that underwent TCDI between January 2021 and January 2024 with ultrasound guided pectoral nerve block (PNB) using liposomal bupivacaine prior to implant for postoperative pain management. Pain scores (0-10) were recorded systematically in the postoperative period, at discharge, and at wound check follow-up. Any need for opioid use in the postoperative period was recorded as well.Results:A total of 612 patients were evaluated, 50% female with a mean age of 71.2 years. All patients received PNB successfully with no device site infection or hematomas. The mean Visualized Analog Scale (VAS) pain scores at 1, 3, and 5 hours after the procedure, at discharge, and at the follow-up visit were 1.93, 1.22, 1.10, 1.05, and 0.13 respectively. During follow-up, no patients required opioids for pain control throughout the entire postoperative period of 14 days.Conclusion:Pectoral nerve block with liposomal bupivacaine can be performed safely preoperatively during TCDI and provides adequate pain control without need for opioid use postoperatively. Further research is needed to assess broad scale implications of this approach to larger patient populations.

Circulation, Volume 150, Issue Suppl_1, Page A4136932-A4136932, November 12, 2024. Introduction:Annually, over 500,000 Americans are hospitalized due to heart failure (HF), marking it as a major contributor to morbidity and mortality. It also poses a significant financial burden and leads to considerable losses in productivity.Objective:This study investigates the predictive accuracy of different socioeconomic metrics on the risk and outcomes of HF in Maryland.Methodology:A retrospective analysis of the Maryland State Inpatient Database (2016-2020) was conducted to assess the predictive accuracy of race/ethnicity, insurance status, household median income, and neighborhood poverty level (measured by the Distressed Communities Index) on the risk of heart failure-related hospital admissions and outcomes. Multivariate logistic regression models were also used to adjust for confounders.Result:During the study period, a total of 389,220 cases of HF were reported in the Maryland SID. The majority of these patients were white (56.8%) and female (51.1%), with a median age of 73 years (interquartile range [IQR] 62-82 years). The in-hospital mortality rate was 5.1%, while rates of atrial fibrillation, cardiac arrest and prolonged hospital stay were 34.4%, 0.3%, and 48.4%, respectively. Multivariate analysis revealed a substantial area under the ROC curve (AUC) indicating good model performance: 0.88 for predicting HF, 0.64 for atrial fibrillation, 0.64 for cardiac arrest 0.57 for prolonged hospital stays, 0.63 for mortality. Subgroup analyses showed variable predictiveness by race (AUC = 0.4378), payment method (AUC = 0.5754), income quartile (AUC = 0.5202), and deprivation composite score (AUC = 0.4751). Patients with private insurance had the highest risk of stress cardiomyopathy (odds ratio [OR] = 1.98; 95% confidence interval [CI] 1.70-2.29). Socioeconomic metrics, including neighborhood distress, showed varying predictive accuracy for the HF-related admissions and selected short-term outcomes, with the highest predictive accuracy for neighborhood distress on the risk of HF (AUC = 0.50, std: 0.006), atrial fibrillation (AUC = 0.48, std: 0.0007), cardiac arrest (AUC = 0.51, std: 0.007), and prolonged hospital stays (AUC = 0.53, std: 0.0005) and mortality (AUC = 0.50, std: 0.0015).Conclusion:Neighborhood poverty level demonstrates significant predictive power for assessing the risk of HF-related hospital admissions and the short-term outcomes among Maryland residents, exceeding factors like insurance and race/ethnicity.

Circulation, Volume 150, Issue Suppl_1, Page A4145933-A4145933, November 12, 2024. Introduction:Cardiogenic shock (CS) remains a clinical challenge with a high mortality rate. An escalation strategy from intra-aortic balloon pump (IABP) to Impella has been proposed for patients with CS refractory to IABP therapy, but clinical data on this approach are lacking. This study aimed to elucidate the short-term clinical outcomes after IABP-Impella escalation in patients with CS.Methods and Results:From the Japanese nationwide registry of Impella (J-PVAD) database between 2020 and 2022, a total of 2,578 patients with CS who received Impella support were classified into the IABP-Impella group (n=189) or the Primary Impella group (n=2,389). We applied a 1:3 propensity score matching, selecting 180 patients in the IABP-Impella group and 540 patients in the Primary Impella group. Before matching, the IABP-Impella group presented significantly longer shock-to-Impella time, worse laboratory data indicating multiorgan damage, and more frequent inotrope use compared to the Primary Impella group. After matching, the baseline characteristics were well-balanced between the two groups. The clinical outcomes within 30 days after the initiation of Impella were compared between the matched groups. The IABP-Impella group showed a significantly higher rate of additional mechanical circulatory support (MCS) use than the Primary Impella group (33.9% vs. 25.6%, p=0.034). Although the incidence of mortality was similar between the two groups (30.6% vs. 30.9%, p >0.99), the incidence of major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) tended to be higher in the IABP-Impella group (43.0% vs. 36.3%, p=0.053). Notably, the incidence of infection was significantly higher in the IABP-Impella group than in the Primary Impella group (10.0% vs. 4.8%, p=0.018). Kaplan-Meier estimates revealed that infection occurred more frequently in the IABP-Impella group during the 30-day follow-up period (log-rank p=0.016).Conclusions:Patients undergoing the IABP-Impella escalation strategy showed poorer baseline clinical conditions in baseline and were associated with a higher likelihood of further MCS upgrade and an increased risk of infection.

Circulation, Volume 150, Issue Suppl_1, Page A4145961-A4145961, November 12, 2024. Introduction:Approximately 20% of ischemic strokes are linked to a cardioembolic source, with 80% of cardioembolic strokes being attributed to atrial fibrillation. This study aimed to investigate the impact of non-valvular atrial fibrillation (NVAF) on mortality and recurrent stroke following a minor stroke event, considering AF as the most prevalent sustained cardiac rhythm disorder associated with stroke.Methods and Materials:Consecutive patients experiencing minor acute ischemic stroke (NIHSS

Circulation, Volume 150, Issue Suppl_1, Page A4147011-A4147011, November 12, 2024. Introduction:Guidelines recommend dual antiplatelet therapy (DAPT) for 12 months following percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). However, prolonged DAPT may increase bleeding risk. Monotherapy with the potent P2Y12 inhibitor ticagrelor after short DAPT offers a promising strategy to balance thrombotic and bleeding risks.Objective:To compare outcomes of short DAPT (≤3 months) followed by ticagrelor monotherapy until 12 months vs. 12-month DAPT in patients undergoing PCI for ACS.Methods:We systematically searched PubMed, Scopus, and Cochrane Central databases for studies comparing short DAPT followed by ticagrelor monotherapy vs. 12-month DAPT following PCI. Outcomes of interest included net adverse clinical events (NACE), major adverse cardiovascular/cerebrovascular events (MACCE), and any bleeding at 12 months post-PCI. Statistical analysis was done using R software. Random effects models were used to generate risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity was assessed using I2statistics. Analysis followed the PRISMA guideline.Results:The systematic review identified 4 randomized controlled trials including 5,293 patients. Ticagrelor monotherapy was used in 2,667 (50.38%) patients. At 12 months, NACE (RR 0.81; 95%CI 0.57-1.14; p=0.227; I2=45%), MACCE (RR 1.11; 95%CI 0.86-1.42; p=0.415; I2=3%), and any bleeding (RR 0.68; 95%CI 0.46-1.01; p=0.055; I2=34%) were comparable between the two groups.Conclusion:After PCI for STEMI, short DAPT for ≤3 months followed by ticagrelor monotherapy was non-inferior to 12-month DAPT in terms of NACE, MACCE, and bleeding. Ticagrelor monotherapy following short DAPT may be considered for STEMI patients after PCI.

Circulation, Volume 150, Issue Suppl_1, Page A4114970-A4114970, November 12, 2024. Background:Pulsed field ablation (PFA) and high-power short-duration radiofrequency ablation (HPSD) are emerging techniques for treating atrial fibrillation (AF), offering promising results compared to cryoballoon ablation (CBA). This network meta-analysis aims to evaluates the efficacy and safety of PFA, HPSD, and CBA.Method:PubMed, Embase, Cochrane Central Register of Controlled Trials, and EBSCO Information Services were systematically searched for relevant studies until April 2024. The primary outcome is freedom from atrial arrhythmia. A random-effects model was used for data synthesis, and P-scores were employed for outcome ranking. Point estimation (odd ratios) was calculated for comparisons.Results:Fifteen studies were included in our network meta-analysis, involving 5,093 atrial fibrillation patients: 812 (16%), 2,659 (52%), and 1,622 (32%) patients underwent PFA, CBA, and HPSD, respectively. PFA demonstrated the highest efficacy (P-scores 99.3%). Point estimation between PFA and HPSD, and PFA and CBA, were 1.394 (95% CI: 1.047-1.858) and 1.479 (95% CI: 1.134–1.929), respectively. PFA had higher complications compared to HPSD (OR=4.44, 95% CI: 1.405-14.031) and CBA (OR=2.581, 95% CI: 0.992–6.720). HPSD had the shortest fluoroscopic time (P-scores 100%), while CBA had the longest (P-scores 0%). PFA had the shortest procedural time compared to CBA and HPSD with P-scores of 100% 50% and 0%, respectively.Conclusion:PFA showed higher efficacy but higher complication risk than HPSD and CBA. HPSD and CBA demonstrated similar efficacy and safety.

Circulation, Volume 150, Issue Suppl_1, Page A4136013-A4136013, November 12, 2024. Introduction:The use of Transcatheter Aortic Valve Replacement(TAVR) has provided a safer alternative to open surgical approaches. The introduction of frailty scoring systems has proven effective in improving healthcare approaches and outcomes in various aspects of medicine. As there is a paucity of data on the impact of frailty among TAVR patients, we aim to conduct a retrospective study to investigate further.Methods:Our study analyzed adult cases with a primary procedural code for TAVR among hospitalizations between 2016 and 2021 through the National Inpatient Sample(NIS). Frailty status was explored through the criteria of Gilbert’s frailty index. Multivariable regression models helped evaluate differences in short-term outcomes and complications between them.Results:Our study involved 374200 cases of TAVR that were divided into LFR(285425 cases, 76.3%), IFR(86005 cases, 23.0%), and HFR(2770 cases, 0.7%). Compared to patients with LFR, patients with MFR and HFR showed higher odds of several complications, including cardiogenic shock(MFR: aOR 6.933, p