The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Steal syndrome of the hand with a strong palpable radial pulse at the wrist after creation of a basilic-vein-transposition fistula in the arm above the elbow

Steal syndrome is a major complication after creation of an arteriovenous fistula (AVF) and may lead to ischemic symptoms in the hand. A strong palpable radial pulse at the wrist typically excludes the diagnosis of steal syndrome in patients with brachial-artery-based AVF. We present a patient with steal syndrome and a palpable radial pulse after creation of an above-the-elbow AVF using the basilic vein transposition approach. The patient had a brachial artery with high bifurcation and the vein was mistakenly anastomosed to the dominant aberrant ulnar artery. The steal syndrome was treated by proximalization of arterial flow to the proximal brachial artery

An atypical case of hemodialysis access stent migration

Endovascular stent fractures are commonly seen in arteries but are rare events in the venous system. Stents deployed in hemodialysis vascular accesses can fracture and migrate to proximal locations. Complications associated with stent fracture include in-stent stenosis and central vein stenosis. In this report, we present a unique case of a hemodialysis access stent fracture that migrated to the left ventricle and manifested with chest pain

The outcomes of a novel two-stage proximal brachial artery to proximal basilic/brachial vein arteriovenous graft extension for dialysis access

Background: We describe a technique to mature a basilic/brachial vein in the mid-arm in preparation for a second stage loop proximal brachial artery to basilic/brachial vein arteriovenous graft (BBAVG). This can occur after a failed basilic/brachial vein transposition or a lack of adequate veins in the distal arm. This allows a mature vein to be used in an end-to-end configuration as an outflow to a BBAVG while preserving proximal vessels for the future. Methods: This single-center retrospective study was performed from 2015 to 2021, including 104 AVG patients divided into three groups: (1) Patients who failed a basilic vein transposition and had an enlarged vein suitable for an AVG outflow; (2) Patients who had a small caliber basilic/brachial vein after the transposition, requiring a mid-arm brachial artery to brachial/basilic arteriovenous fistula (AVF) creation with a subsequent AVG extension; (3) and lastly, patients who had no distal arm veins available and required a primary brachial artery to basilic/brachial AVF with AVG extension. A survival analysis was performed looking at time to loss of primary and secondary patency, calculated with Kaplan-Meier estimates and Cox regression models adjusted for covariates. Results: The median follow-up time was 11 months (IQ = 11-30 months). The survival analysis showed 28% lost primary patency at a median time of 9 months, and 14% lost secondary patency at a median time of 61 months. Overall secondary patency of the vascular access measured at 12 months was 85.6%. Loss of primary (p = 0.008) and secondary patency (p = 0.017), as well as patency during the first 12 months (p = 0.036), were all significantly associated with increased age when adjusting for covariates. Conclusions: Our results suggest that the graft extension technique using a mature vein from a previous fistula can result in reliable and durable access. This is important for patients with limited access for hemodialysis, as the axillary vein is preserved for future use if needed

Echocardiographic changes after arteriovenous fistula creation in hemodialysis patients

Background: Pulmonary hypertension (PH) is common in end-stage renal disease (ESRD) patients and is associated with increased all-cause and cardiovascular mortality in this group. There is scarce data on the long-term effect of arteriovenous fistula (AVF) creation on pulmonary hypertension (PH) and the reflected changes in echocardiographic measurements. Materials and methods: This is a retrospective study of 54 patients who underwent AVF creation between 2009 and 2014 and with echocardiographic evaluations before and after surgery. We analyzed pairwise changes in right ventricular systolic pressure (RVSP), right atrial pressure (RAP) during systole, left ventricular mass (LVM), tricuspid regurgitation (TR), mitral E/E’ ratio, and ejection fraction (EF), as well as the factors that predicted change in RVSP after surgery. Results: The median time for the preoperative echocardiogram was 0.3 years (interquartile range (IQR) 0.2 – 0.7 years) prior to AVF creation, while the follow-up echo was done 1.3 (0.6 – 2.1) years after surgery. 67% of the patients had RVSP > 37 mmHg at baseline. There was a significant reduction in RVSP after AVF creation compared to baseline (median 33 (IQR 26 – 43) vs. 46 mmHg, p = 0.0015), with 59% of the patients experiencing a decrease and 19% remaining stable. There were also significant decreases in LVM (201 (143 – 256) vs. 215 (163 – 276), p = 0.045) and RAP systole (10 (10 – 15) vs. 3 (3 – 8); p < 0.001) after surgery. Higher preoperative weight (p = 0.038) and RVSP (p = 0.006), and use of loop diuretics (p = 0.015) were significantly associated with improvement in RVSP after AVF creation. Conclusion: Our results suggest that AVF creation is associated with a significant reduction or stable measurements of RVSP in the ESRD population, likely due to an improvement in volume status

Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy

Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated.This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG.University hospital, United States.As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG.Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection.Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG

Efectos de la intoxicación por glifosato en la población agrícola: revisión de tema

Introduction: Glyphosate is an herbicide that has been used by farmersto eradicate unwanted plants and illicit crops in rural areas. The workersexposed to this compound has shown various clinical results includingmultiple organ toxicity, nephrotoxicity, hepatotoxicity, gastrointestinal, cardiovascularand respiratory effects. Objective: To evaluate the toxicity ofglyphosate (Roundup®) in farmers with chronical exposure of it as an herbicide.Materials and methods: It was performed by a systematic review of the literature published during the period 2000 to 2016, about glyphosate poisoning,acute and chronic effects, considerations for treatment, social impact by herbicidespraying. In addition, some data from the Ministry of health and social protection wasused. The databases used included the National Library of Medicine USA (Pubmed /Medline), SciELO, google scholar for searching clinical studies, case reports, reviewarticles, opinion articles and laws. In English, Spanish and Polish languages. Thefollowing MeSH terms were used alone or in combination: “glyphosate intoxication”,“glyphosate poisoning”, “glyphosate herbicide”, “glyphosate human toxicity”. Results:Information was obtained pertaining human health impact caused by glyphosate,finding clinical presentations of intoxication by said substance and which treatmentwould be optimal to treat them. Conclusions: Studies have shown that glyphosate ishighly toxic because of the multiple organ compromise in the human body, involvingthe rural population health with chronical exposure of it.Introducción: El glifosato es un herbicida que se ha utilizado por los agricultorespara erradicar plantas no deseadas y cultivos ilícitos en el área rural.La exposición a este compuesto, por parte de los trabajadores ha demostradoresultados clínicos que varían incluyendo toxicidad de múltiples órganos,nefrotoxicidad, hepatotoxicidad, efectos gastrointestinales, cardiovasculares yrespiratorios. Objetivo: Evaluar la toxicidad del glifosato (Roundup®) en agricultoresexpuestos crónicamente al uso de este compuesto como herbicida.Materiales y métodos: Se realizó una revisión sistematica de la literatura publicadadurante el periodo comprendido entre 2000 y 2016, sobre intoxicaciónpor glifosato, efectos agudos y crónicos, consideraciones para el tratamiento,repercusiones sociales por la aspersión de herbicidas. Además se utilizarondatos del ministerio de salud y protección social. Las bases de datos utilizadasincluyeron la Librería Nacional de Medicina de Estados Unidos (Pubmed/Medline),SciELO, google académico en búsqueda de estudios clínicos, reportes decaso, artículos derevisión, artículos de opinión y leyes en idioma inglés ,españoly polaco. Se emplearon los siguientes términos MeSH solos o en combinación:“glyphosate intoxication”, “glyphosate poisoning”, “glyphosate herbicide”,“glyphosate human toxicity”. Resultados: Se obtuvo información con relaciónal impacto del glifosato en la salud humana, encontrando como son las manifestacionespor intoxicación por dicha sustancia y cómo será su tratamientoóptimo. Conclusiones: En los estudios que se han realizado queda comprobadoque el glifosato es altamente toxico por el compromiso que genera en losmúltiples sistemas del cuerpo, lo que compromete la salud de la poblaciónagrícola que tiene historia de exposición

Utility of Closed Suction Drains in Groin Incisions after Femoral Artery Exposure

Surgical groin wounds are at risk of delayed healing and infection, leading to costly and prolonged postoperative recoveries. This study assesses the use of closed suction drains (CSDs) as a wound care adjunct in groin incisions to prevent surgical site infections (SSI). A single-center retrospective review was performed on 210 consecutive patients after vascular surgery with common femoral artery exposure from 2016 to 2021. The cohort was divided into 2 groups, groins with and without CSD, looking for surgical site complications. A subgroup analysis comparing postoperative outcomes between complicated and uncomplicated groin incisions within both groups was also performed. Of 293 surgical groins, 20% (n = 59) had drains. Overall, the CSD group had higher SSI rates (14% vs. 5.6%), but also had higher proportion of smokers (92% vs. 83%; P = 0.019), diabetes (56% vs. 36%; P = 0.005), coronary artery disease (69% vs. 46%; P = 0.001), hyperlipidemia (69% vs. 51%; P = 0.01), and previous groin surgery (54% vs. 17%; P < 0.001). The higher risk of SSI was not significant after adjustment of these confounders. A separate analysis within each group showed SSI groins with CSD had lower reintervention rates (37.5%) than those without CSD (69%), as well as shorter length of hospital stay (7 [5-11] vs. 22 [7-25] days). Our study suggests that CSDs can be a beneficial adjunct for groin wounds after common femoral artery exposure in patients with comorbidities cited above. CSDs decrease the risk of reintervention and length of hospital stay