Endoscopic Findings of Post-wedge Bronchoplastic Lobectomy

It is speculated that the advantage of wedge bronchoplastic lobectomy lies in the reduction in the incidence of major anastomotic complications. On the other hand, wedge bronchoscopic lobectomy can result in kinking at the anastomosis site. This study was performed to evaluate the operative outcomes and the postoperative endoscopic findings for wedge resection of the bronchus. From 2004 to 2012, nine patients underwent wedge bronchoplastic lobectomy for lung carcinoma. We evaluated the angles of the wedge and the distance of the preserved parts to the cut line of the bronchus (the so-called bronchial bridge). There were six right upper lobectomies, two middle and lower lobectomies, and one left lower lobectomy. Regarding bronchoscopic findings, five patients who underwent right upper lobectomy showed bulging into the bronchial lumen. There were no anastomotic strictures. Intraoperatively it was noted in these five patients that the bronchial bridge tended to be relatively long and/or the angle of the wedge resection tended to be relatively wide. To prevent bulging into the bronchial lumen after right upper wedge bronchoplastic lobectomy, bronchial wedge excisions should be shaped in order to reduce the length of the bronchial bridge

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation.

OBJECTIVES: To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. DESIGN: The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA2DS2-VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). PARTICIPANTS: Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. RESULTS: The discriminatory value of the GARFIELD-AF risk model was superior to CHA2DS2-VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to 0.78), 0.69 (0.67 to 0.71) and 0.66 (0.62 to 0.69), respectively, for the GARFIELD-AF risk models, and 0.66 (0.64-0.67), 0.64 (0.61-0.66) and 0.64 (0.61-0.68), respectively, for CHA2DS2-VASc (or HAS-BLED for bleeding). In very low to low risk patients (CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)), the CHA2DS2-VASc and HAS-BLED (for bleeding) scores offered weak discriminatory value for mortality, stroke/systemic embolism and major bleeding. C-statistics for the GARFIELD-AF risk tool were 0.69 (0.64 to 0.75), 0.65 (0.56 to 0.73) and 0.60 (0.47 to 0.73) for each end point, respectively, versus 0.50 (0.45 to 0.55), 0.59 (0.50 to 0.67) and 0.55 (0.53 to 0.56) for CHA2DS2-VASc (or HAS-BLED for bleeding). Upon validation in the ORBIT-AF population, C-statistics showed that the GARFIELD-AF risk tool was effective for predicting 1-year all-cause mortality using the full and simplified model for all-cause mortality: C-statistics 0.75 (0.73 to 0.77) and 0.75 (0.73 to 0.77), respectively, and for predicting for any stroke or systemic embolism over 1 year, C-statistics 0.68 (0.62 to 0.74). CONCLUSIONS: Performance of the GARFIELD-AF risk tool was superior to CHA2DS2-VASc in predicting stroke and mortality and superior to HAS-BLED for bleeding, overall and in lower risk patients. The GARFIELD-AF tool has the potential for incorporation in routine electronic systems, and for the first time, permits simultaneous evaluation of ischaemic stroke, mortality and bleeding risks. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF (NCT01090362) and for ORBIT-AF (NCT01165710)

Two-year outcomes of patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF.

AIMS: The relationship between outcomes and time after diagnosis for patients with non-valvular atrial fibrillation (NVAF) is poorly defined, especially beyond the first year. METHODS AND RESULTS: GARFIELD-AF is an ongoing, global observational study of adults with newly diagnosed NVAF. Two-year outcomes of 17 162 patients prospectively enrolled in GARFIELD-AF were analysed in light of baseline characteristics, risk profiles for stroke/systemic embolism (SE), and antithrombotic therapy. The mean (standard deviation) age was 69.8 (11.4) years, 43.8% were women, and the mean CHA2DS2-VASc score was 3.3 (1.6); 60.8% of patients were prescribed anticoagulant therapy with/without antiplatelet (AP) therapy, 27.4% AP monotherapy, and 11.8% no antithrombotic therapy. At 2-year follow-up, all-cause mortality, stroke/SE, and major bleeding had occurred at a rate (95% confidence interval) of 3.83 (3.62; 4.05), 1.25 (1.13; 1.38), and 0.70 (0.62; 0.81) per 100 person-years, respectively. Rates for all three major events were highest during the first 4 months. Congestive heart failure, acute coronary syndromes, sudden/unwitnessed death, malignancy, respiratory failure, and infection/sepsis accounted for 65% of all known causes of death and strokes for <10%. Anticoagulant treatment was associated with a 35% lower risk of death. CONCLUSION: The most frequent of the three major outcome measures was death, whose most common causes are not known to be significantly influenced by anticoagulation. This suggests that a more comprehensive approach to the management of NVAF may be needed to improve outcome. This could include, in addition to anticoagulation, interventions targeting modifiable, cause-specific risk factors for death. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

けいれん発作群発に対するリドカイン持続静注の有効性について(<特集>小児科学教室大澤真木子教授開講5周年記念)

けいれん発作を反復する群発状態は,日常生活を障害し,発作重積状態に移行したり,神経学的後遺症を残す可能性があり,早急に対処すべき症候である.けいれん発作群発を呈し,ジアゼパムの直腸内または静脈内投与が無効であった22症例に対して,リドカイン持続静注療法を試みた.「群発」は繰り返すけいれん発作の間欠期に意識が回復する状態とし,発作頻度は(1)初回けいれん発作の場合には24時間以内に3回以上,(2)てんかん症例では,日常的な発作頻度を超え通常の生活に支障を来す状態,と規定した.リドカインは1～4mg/kgを静注後,1～4mg/kg/hrで持続静注を行った.初回発作で基礎疾患のない,神経学的に正常な9症例は平均年齢1歳4カ月で,熱性けいれんの家族歴が高かった.7例ではリドカイン開始後に発作の再燃はなく,中止による再発を認めなかった.1例では発作消失したが中止後に再発し,リドカイン再導入して消失した.1例ではリドカイン無効であった.てんかんの1歳8カ月から22歳までの13例では,17エピソードの発作群発に対して,発作消失3例4エピソード,発作減少5例6エピソード,無効7例7エピソードであった.有効例と無効例とを比較して,年齢,発達障害,神経学的合併症の有無,リドカイン使用量について比較したが,差を認めなかった.両群とも呼吸,循環動態,意識水準,睡眠覚醒リズム,食事摂取などに明らかな影響を認めなかった.ジアゼパム抵抗性の発作群発状態に対して,リドカイン持続静注は基礎疾患のない,発達正常な乳幼児に対してきわめて有用であった.基礎疾患を有し,てんかんとして治療中の発作群発状態には有効率が低いが,副作用なく著効例もあるため,エピソードの早期に試みる方法である.Clusters of seizures, which has been defined as acute repetitive seizures in between which the patient regains consciousness, is a not uncommon event in clinical practice, and may present considerable health risks to patients. In this setting, continuous intravenous (iv) lidocaine treatment was performed in 22 patients whose cluster of seizures did not respond to rectal or intravenous diazepam (DZP). With cardiac and respiratory monitoring, the patients were administered an iv lidocaine dose of 1 to 4 mg/kg followed by continuous iv lidocaine (1 to 4 mg/kg/hr). In 9 patients in whom episodes of convulsions recurred more than 3 times within 24 hours and who had no underlying disorder with normal development at onset, 7 patients experienced no relapse of seizures after the start of the treatment. Relapse occurred only once in one other patient after termination of lidocaine but disappeared after reinfusion, and one patient had no response. In 17 episodes of 13 patients, who had been diagnosed with epilepsy and in whom the frequency of seizures disturbed their daily routine, seizures were terminated in 3 patients with 4 episodes. The incidence of seizures was decreased in 5 patients with 6 episodes, and there was an absence of response in 7 patients with 7 episodes. Continuous iv lidocaine was particularly useful for clusters of seizures seen in infants with normal development and no underlying disorder. Lidocaine was less effective in patients with refractory epilepsy, although some cases were controlled completely. These results suggest that lidocaine treatment should be tried at an early stage in clusters of seizures

Long-term Survival of a Patient with Typical Lung Carcinoid Tumor and Supraclavicular Lymph Node Metastasis Treated by Surgical Resection

Herein we report on the long-term survival of a surgical case of typical carcinoid tumor and supraclavicular lymph node metastasis at initial diagnosis. The present study is a follow-up to a previously published case report. Initially, a 73-year-old man was admitted to hospital for evaluation of an enlarged lymph node in his right supraclavicular fossa. Serum progastrin-releasing peptide (ProGRP) concentrations were markedly elevated, and carcinoid was diagnosed by histopathological examination of the excised supraclavicular lymph node. The patient underwent right upper lobectomy and mediastinal lymph node dissection via median sternotomy. The final diagnosis was Stage IIIB (pT1aN3M0) typical carcinoid. Serum ProGRP concentrations decreased to within the normal range, and follow-up computed tomography, performed approximately 10 years after surgery, showed no recurrence. For this patient, radical resection of metastatic lymph nodes was an effective treatment for his typical lung carcinoid