Risultati per: Terapia antibiotica: breve durata vs. lunga durata

To the Editor We read with interest the recent study that compared the fecal immunochemical test (FIT) positivity threshold vs multitarget stool RNA (mt-sRNA) testing for colorectal cancer screening. However, we have concerns regarding the study methodology and the capability of FIT to fully replace the mt-sRNA panel.

In Reply Our study adjusted the FIT cutoff to yield the same overall positivity rate as reported for the mt-sRNA test (17%) to enhance comparability of diagnostic performance of both tests. Below we address each of the 3 points made by Drs Yang and Ma.

This randomized clinical trial assesses the effect of a liberal vs a restrictive hemoglobin threshold for red blood cell transfusion on unfavorable neurological outcome in patients with acute brain injury.

This randomized clinical trial examines whether 3 cycles of carboplatin, etoposide, and vincristine chemotherapy is noninferior to 6 cycles for enucleated unilateral retinoblastoma with high-risk pathological features.

This randomized trial showed no difference in local or systemic side effects in patients receiving their vaccines on either schedule.

A strategy of early AVR was superior to clinical surveillance due to a reduction in hospitalizations.

Circulation, Volume 150, Issue Suppl_1, Page A4145834-A4145834, November 12, 2024. Introduction:Managing severe aortic stenosis in patients with a history of coronary artery bypass grafting (CABG) is challenging. Traditionally, surgical aortic valve replacement (SAVR) was the standard treatment, but transcatheter aortic valve replacement (TAVR) offers a less invasive alternative. This meta-analysis compares the 30-day outcomes of TAVR versus SAVR in patients with prior CABG.Methods:A systematic review and meta-analysis were conducted according to PRISMA guidelines. Studies comparing TAVR and SAVR in patients with prior CABG were included. The primary outcomes were 30-day (cardiovascular) CV mortality, all-cause mortality, stroke, and myocardial infarction. Heterogeneity was assessed using the Chi-squared test and I-squared statistic. P value

Circulation, Volume 150, Issue Suppl_1, Page A4145840-A4145840, November 12, 2024. Introduction:High levels of blood pressure (BP) are responsible for 7.6 million deaths each year worldwide, more than any other risk factor. The diagnosis of hypertension is associated with a significant increase in the risk of kidney or cardiovascular events, with no prior history of these events. Our study aims to analyze trends in hypertensive heart disease and hypertensive heart and kidney disease-related mortality in the United States, focusing on different races.Method:We retrieved death certificate data from the CDC-WONDER database for adults aged ≥25 years. Crude mortality rates (CMRs) and age-adjusted mortality rates (AAMRs) per 100,000 persons were calculated. Temporal trends were examined using the average annual percent change (AAPC) determined by joinpoint regression.Result:From 1999 to 2020, a total of 100,705 people died from hypertensive heart and renal disease in the USA. The overall AAMR of 1.4 per 100,000 displayed a trend during this period (AAPC: 4.8, 95% CI [3.3–6.2]). Total deaths from hypertensive heart disease and renal disease associated with heart failure were 5,274, showing an increasing trend from 1999 to 2020. The AAMR for hypertensive heart and renal disease with heart failure was 0.1 (AAPC: 5.2, 95% CI [3.8–6.7]). Black or African Americans have the highest AAMR (0.1, 95% CI [0.1–0.1]). Total deaths from hypertensive heart disease and renal disease associated with renal failure were 34,519, showing an increasing trend from 1999 to 2020. The AAMR for hypertensive heart and renal disease with renal failure was 0.4 (AAPC: 3.9, 95% CI [2.6–5.1]). Black or African American has the highest AAMR (1.6, 95% CI [1.5–1.6]), followed by American Indian or Alaska Native (0.5, 95% CI [0.4–0.5]), Asians and Pacific Islanders (0.4, 95% CI [0.4–0.4]), and White (0.4, 95% CI [0.3–0.4]).Conclusion:African Americans and other identified high-risk races should get targeted therapies to reduce the burden of hypertensive-related morbidity and mortality; those with renal impairment should receive special attention. The goals of these interventions ought to be to increase access to healthcare, raise public knowledge of hypertension, and support lifestyle changes.

Circulation, Volume 150, Issue Suppl_1, Page A4144508-A4144508, November 12, 2024. Background:Hypertension in pregnancy affects around 15% of all pregnant women and is one of the leading causes of maternal and fetal, mortality and morbidity. Hydralazine and labetalol are administered intravenously to control hypertension in pregnant women. However, data regarding their comparative efficacy and safety is limited. Considering the paucity of data, we conducted a systematic review and meta-analysis to pool all the studies published on this subject and provide robust evidence.Methods:We followed PRISMA guidelines for conducting this systematic review and meta-analysis. Two investigators searched PubMed/MEDLINE, Scopus, the Cochrane Library, and Google Scholar from inception until May 2024. The randomized controlled trials (RCTs) which compared the effects of intravenous labetalol versus hydralazine in pregnant women with hypertensive disorder of pregnancy were included in our pooled analysis. A random-effects model was used to calculate the weighted mean differences (MD) for continuous outcomes and odds ratio (OR) for the discrete outcomes along with the corresponding 95% confidence intervals (CIs). We considered a p-value of less than 0.05 statistically significant in all cases.Results:A total of 8 RCTs with total population of 1138 patients were pooled. The pooled analysis showed that the final systolic blood pressure (MD = -4.74, 95% CI: -12.09 to 2.62, p = 0.21) and diastolic pressure (MD = -0.86, 95% CI: -9.22 to 7.49, p = 0.84) remained comparable. The incidence of maternal hypotension (OR = 0.13, 95% CI: 0.06 to 0.29, p

Circulation, Volume 150, Issue Suppl_1, Page A4142798-A4142798, November 12, 2024. Background:Spontaneous coronary artery dissection (SCAD) refers to the nontraumatic, non-iatrogenic, and nonatherosclerotic separation of the coronary artery wall leading to acute coronary syndrome. This condition predominantly affects women with minimal or no traditional cardiac risk factors. We aimed to determine the differences in clinical presentation between SCAD and Type 1 myocardial infarction (MI) in the Aurora Health Care community.Methods:A retrospective, matched cohort, multicenter community study was carried out on adult patients aged >18 years admitted to all Aurora Hospitals from January 2012 to December 2022. A total of 57 patients were diagnosed with SCAD during that period. SCAD group and Type 1 MI group were matched by age and gender at a 1:5 ratio using a propensity score-based matching. Outcomes between the SCAD and the Type 1 MI groups were compared using chi-squared tests or Fisher’s exact tests, and t-tests or nonparametric equivalents (Wilcoxon).Results:A higher percentage of Type 1 MI patients presented as NSTEMI compared to SCAD patients (70% vs. 59.6%, p=0.028). Although not statistically significant, SCAD patients had a higher occurrence of STEMI than Type 1 MI patients (42.1% vs. 32.6%, p=0.169).On admission, SCAD patients had a higher maximum troponin (12,000 vs. 3,550, p=0.012). Type 1 MI patients had higher HgbA1C (6 vs. 5.4, p=0.0008). Both patients had similar LDL levels, but Type 1 MI had lower HDL levels (44 vs. 48, p=0.024). ESR, CRP, and D-dimer levels showed no significant difference. LV ejection fraction was 53% in both groups, and the LV global longitudinal strain was similar. The Type 1 MI group exhibited higher grades of diastolic dysfunction (Grade 2 and Grade 3) and mitral valve disease. E/e was higher in Type 1 MI compared to SCAD (11.5 vs 8.8, p

Circulation, Volume 150, Issue Suppl_1, Page A4147673-A4147673, November 12, 2024. Background:Cardiogenic shock (CS) affects up to 10% of hospitalized patients with acute myocardial infarction (AMI), leading to over 30% mortality despite treatment. In patients with AMI-CS refractory to vasopressors and inotropes, temporary mechanical circulatory support (MCS) devices have been used to provide hemodynamic support. Recently, Impella demonstrated significant mortality benefit in AMI-CS in the DanGer shock trial. However, it has not demonstrated such benefit over other devices, such as IABP and ECMO in other trials (ISAR-Shock, IMPRESS in Severe Shock, IMPELLA-STIC). Here we performed this network meta-analysis of all available studies including the DanGer shock trial comparing Impella with other MCS devices in AMI-CS patients.Method:We performed a Bayesian network meta-analysis to synthesize direct and indirect evidence from relevant studies published until April 2024 using PubMed, Embase, and Scopus databases comparing Impella with other strategies for treating AMI-CS patients. The primary outcome was a short-term mortality defined as in-hospital or 30-day mortality. This study is registered with PROSPERO, and data analysis was performed using the “BUGSnet” package in R.Result:Out of 7,211 studies, 17 were deemed eligible. These included five RCTs and 12 observational studies, encompassing 16,654 patients with AMI-CS assigned to 3 different MSC interventions: Impella, IABP, and ECMO in 9 different combinations or alone. Based on SUCRA value, IABP was the most effective strategy in regard to short-term mortality (73.46), long-term mortality (75.59), major bleeding (66.4), renal replacement therapy (73.02); Impella along with IABP for stroke (95.24), ischemic stroke (99.68), device-related bleeding (90.22), MI (94.38); ECMO for hemolysis (91.66); standard of care for peripheral ischemic complications (88.66), sepsis (78.71). In sub-analysis using the RCTs only, Impella was ranked best for short-term mortality (74.53).Conclusion:Based on the findings of this network meta-analysis, IABP could potentially provide both short-term and long-term mortality benefits, as well as reduce the risk of bleeding. Meanwhile, combining it with Impella could potentially reduce the risk of cerebral ischemia.

Circulation, Volume 150, Issue Suppl_1, Page A4120469-A4120469, November 12, 2024. Introduction:Transcatheter cardiac interventions have emerged as a viable alternative to open heart surgery for specific congenital heart disease lesions. There is literature to support racial and ethnic disparities in medicine, indicating that patients from racially and ethnically marginalized populations are less likely to receive advanced less invasive procedures. This study seeks to delve into the existence of such inequities between transcatheter and surgical interventions, shedding light on potential inequalities in access and outcomes.Methods:We analyzed California and Florida’s State Inpatient and Ambulatory Surgery Databases from 2005 to 2017 to study patients under 18 admitted with diagnosis of atrial septal defect, pulmonary stenosis, aortic stenosis, and ventricular septal defects. Multivariable logistic regression, adjusted for patient characteristics, assessed race and ethnicity’s influence on procedure type and in-hospital mortality. We also used log-transformed linear regression to examine associations with length of stay, hospitalization cost, and cost per day.Results:We identified 13,771 records who had open surgeries, and 2,045 records who had CBI. Compared to non-Hispanic White patients, Black patients were significantly more likely to undergo open surgical procedures (adjusted Odds Ratio [aOR] 1.49, p < .001). Additionally, Black, Hispanic, and other race patients had higher risks of in-hospital death (aOR 1.92, p = 0.016 for Black; aOR 1.93, p < 0.01 for Hispanic; aOR 2.37, p < 0.01 for other races). Black and Hispanic patients also experienced longer lengths of stay (Adjusted Means Ratio [aMR] 1.34, p < 0.01 for Black; aMR 1.16, p < 0.01 for Hispanic), and higher costs (aMR 1.12, p = .01 for Black; aMR 1.11, p = .01 for Hispanic), but Black patients had a lower cost per day (aMR 0.96, p = .02).Conclusion:Racial and ethnic gaps persist in pediatric cardiac care, with Black patients facing reduced access to less invasive procedures, higher mortality rates, longer hospital stays, and increased costs compared to non-Hispanic whites. However, the higher costs are likely attributed to longer hospital stays rather than expensive interventions. It is imperative to tackle these disparities to prioritize patient-centered care and streamline resource allocation in healthcare.

Circulation, Volume 150, Issue Suppl_1, Page A4142090-A4142090, November 12, 2024. Background:The persistently patent arterial duct accounts for ~12% of congenital heart lesions. Untreated, it may result in heart failure due to volume loading of the left heart, pulmonary hypertension, and infective endarteritis. Percutaneous device closure is the preferred occlusion technique, with the standard approach consisting of femoral artery access for angiography and venous access for device delivery (AA). A venous-only strategy (VA) for angiography and device delivery can also be employed.Hypothesis:We hypothesized that VA would eliminate arterial complications, and reduce procedure times and radiation exposure compared to standard AA.Methods:This retrospective cohort study reviewed isolated arterial duct device closures at the Hospital for Sick Children from January 1, 2011 through December 31, 2022. Exclusions included premature neonates, children requiring arterial access for monitoring and those who underwent other procedures. Children were categorized based upon initial access determined by operator preference, into VA or AA groups.Results:The cohort consisted of 405 children, 252 (62.2%) females, with a median age of 3.1 years (IQR1.30–5.84), median weight 13.2kg (IQR 9.0–19.5), and duct diameter of 2.9mm (IQR 2.0–3.5) with no significant differences between the groups. Type A ducts were more frequent in the AA group (90% vs. 72%). The VA group included 106 children, of which 14 (13.2%) required AA conversion for angiography due to complex anatomy, to assess device positon prior to release, but remained in the VA group for analysis.Children in the VA group had lower dose area product (DAP) (p

Circulation, Volume 150, Issue Suppl_1, Page ASa306-ASa306, November 12, 2024. Introduction:Manual pulse palpation during cardiopulmonary resuscitation has poor reliability in both hospital and prehospital settings. Recently, point-of-care ultrasonography (POCUS) of the carotid artery has been used for pulse determination in the in-hospital setting. However, this approach has not been evaluated for out-of-hospital cardiac arrest (OHCA) events where adequate views and prolonged pauses during pulse checks could be challenges. Our objective was to evaluate the potential use of POCUS for pulse determination by paramedics using carotid artery and subxiphoid cardiac views. We hypothesized that carotid POCUS views may be obtained more quickly and successfully in the prehospital setting than the traditional subxiphoid cardiac view.Methods:This was a retrospective analysis of carotid and subxiphoid POCUS use for pulse determination at a high-volume, ground-based EMS agency. Adult patients suffering from medical OHCA with POCUS attempted were included. Those under 18 years of age, protocol deviations, missing data, or uninterpretable data were excluded. Video was recorded throughout each CPR pause in which ultrasounds were conducted. EMS clinicians alternated carotid and subxiphoid views. Pause length and view adequacy were evaluated by two expert paramedic reviewers. Disagreements were adjudicated by an EMS physician. Statistical analysis: McNemar’s test was used to evaluate for differences between adequate view and compression pauses < 10 seconds between carotid and subxiphoid approaches. Generalized estimating equations were used to evaluate the association of adequate view and compression pauses < 10 seconds to POCUS approaches.Results:A total of 196 POCUS recordings from 94 patients were analyzed. Videos were evaluated by rates for adequate views with k=0.83 with 92% agreement. Overall, 73% (n=143) had a pause length < 10 seconds, and 62% (n=121) had an adequate view. Adequate views and compression pauses < 10 seconds were achieved more frequently using carotid POCUS (Figure). Adjusting for body mass index, carotid views had increased odds (AOR 9.3, 95% CI: 4.3-20.4) of combined adequate view and compression pause < 10 seconds as compared to subxiphoid imaging.Conclusion:Paramedic-obtained carotid POCUS demonstrated improved view adequacy and fewer extended CPR pauses. Limitations include the high level of POCUS training for paramedics and the single agency data source, making generalizability difficult to determine.

Circulation, Volume 150, Issue Suppl_1, Page A4145168-A4145168, November 12, 2024. Introduction:Ebstein’s anomaly (EA) is associated with ECG signature of right bundle branch block (RBBB). Patients with EA also have high incidence of accessory pathways (AP) and it has been hypothesized that the absence of RBBB on ECG may be associated with a higher prevalence of AP. This study aims to assess the prevalence of RBBB in patients with EA and examine the correlation between its absence and the presence of AP.Methods:Adults (age >18 years) with EA, identified using the Mayo Adult Congenital Heart Disease registry, were divided into 3 groups based on the QRS morphology of their first ECG. Those with prior AP ablation were excluded. The demographic characteristics, baseline ECG data, echocardiographic parameters and EP study data were retrospectively collected and compared between the three groups using Chi-square or ANOVA test as appropriate.Results:Of 596 patients with EA, 358(60.06%) patients had a RBBB, bifascicular block or an incomplete RBBB (group1) ; 18 (3.02%) patients had either a LBBB , ventricular pre-excitation, isolated left anterior or posterior fascicular block (group 2); and 220 (36.92%) patients had normal QRS (group 3). The characteristics of these groups are compared in the table. Patients with RBBB had larger RV size, reduced RV systolic function and higher likelihood of tricuspid valve surgery. EP study was performed in 51 (14%), 3 (17%) and 51 (23%) patients in groups 1, 2,and 3 respectively. One or more APs were noted in 11/51 (22%) and 14/51 (30%) patients with RBBB and normal QRS respectively (p=0.18). Additionally, in patients who did not undergo an EP study, supraventricular tachycardia was documented in 39/307 (13%), 2/15(13%) and 13/169 patients (8%) in group 1,2 and 3 respectively during followup .Conclusion:In a large cohort of adults with EA in a tertiary referral center, greater than one-third of patients had a normal QRS complex without RBBB. However, EP study did not reveal a significant difference in the prevalence of accessory pathways between patients with and without RBBB. In EA, the absence of RBBB may not increase the risk of an underlying accessory pathway.