Renal Denervation for Resistant Hypertension in the contemporary era: A Systematic Review and Meta-analysis

Renal denervation (RDN) is a catheter-based ablation procedure designed to treat resistant hypertension (RH). The objective of our study is to determine the effect of RDN on blood pressure and renal function in patients with RH in comparison to medical therapy alone. We performed an extensive literature search for randomized control trials (RCT) reporting office and 24 hr. blood pressure changes and estimated glomerular filtration rate (eGFR) at baseline and 6 months. We calculated a weighted standardized mean difference of blood pressure and renal outcomes between RDN and control groups using random effects models. Our search yielded 608 studies of which we included 15 studies for the final analysis. A total of 857 patients were treated with RDN and 616 patients treated with medical therapy +/- sham procedure. Only 5 studies were double-blinded RCT with sham control. The adjusted standardized mean difference in the change in office based systolic and diastolic pressures (p = 0.18; p = 0.14); 24 hr. systolic and diastolic pressures (p = 0.20; p = 0.18); and eGFR (p = 0.20) from baseline to 6 months is statistically insignificant with significant heterogeneity. Subgroup analysis showed that among sham controlled trials, 24 hr. systolic blood pressure showed a modest but statistically significant benefit favoring renal denervation in patients with RH. Our meta-analysis of 15 RCTs showed no significant benefit of RDN on blood pressure control in patients with resistant hypertension. Subgroup analysis of sham control studies showed a modest benefit in 24 hr. systolic blood pressure at 6 months with RDN.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Serologic Rebound after Stopping Azoles for Primary Pulmonary Coccidioidomycosis: A Case-Controlled Observational Study

Background: We sought to characterize the outcomes of patients with primary pulmonary coccidioidomycosis whose post-treatment complement fixation (CF) titer increased by more than 2 dilutions (serologic rebound) after discontinuation of antifungal treatment. Methods. We conducted a retrospective chart review of patients with primary pulmonary coccidioidomycosis and identified immunocompetent, non-pregnant adults who received antifungal treatment and then experienced a serologic rebound after treatment discontinuation. We compared these to matched controls similarly treated who did not have serologic rebound. Results. Fifty-eight patients experienced serologic rebound. Thirty (52%) of these were associated with symptoms. Nine were associated with radiographic progression. The median time to serologic rebound was 3.5 months. Antifungal treatment was reinitiated in 37 (63.7%) patients. Four of the 58 (6.9%) with rebounded serology subsequently developed extra-thoracic dissemination. Compared with matched controls, patients with rebounded serology were more likely to have post-treatment symptoms, reinitiation of antifungal therapy, and a longer duration of clinical follow-up. However, they were not more likely to experience extra-thoracic dissemination. Conclusion: Serological rebound, manifested in at least 2-dilution rise of CF titer following antifungal treatment of primary pulmonary coccidioidomycosis, was uncommon, but resulted in longer clinical follow-up. Continued monitoring of such patients is important to identify the patients who develop subsequent symptoms, as well as extra-thoracic dissemination

Evaluating urgent care center referrals to the emergency department

Abstract Background and objectives Urgent care centers (UCCs) are increasingly popular with an estimated number of 9600 stand‐alone centers in the United States compared to emergency departments (EDs). These facilities offer a potentially more convenient and affordable option for patients seeking care for a variety of low‐acuity conditions. Because of the limitations of UCCs, patients occasionally are referred to EDs for further care. Prior studies have attempted to evaluate the appropriateness of these UCC referrals. Our study is the first to consider if these referrals require ED‐specific care and the diagnostic concordance of these referrals. Methods We performed a retrospective chart review to identify patients who were referred from UCCs to our ED between October 2020 and June 2021. We used a Boolean search strategy to screen charts for the terms urgent care, emergency department, referral, or transfer. Cases were manually screened until 300 met the inclusion criteria. Cases had to feature the patient being seen by a UCC provider and directly referred to the ED on the same day. Patients who presented to the ED of their own volition were excluded. Three independent abstractors reviewed the charts. All abstractors and a senior investigator piloted the use of a data collection sheet and discussed the management of any ambiguous data. A senior physician reviewed all discrepancies among abstractors. Data collected included ED final diagnosis and whether the final diagnosis was similar to the UCC diagnosis. A referral was deemed to require ED‐specific care and resources if (1) the patient was admitted, (2) imaging (other than an x‐ray) was performed, (3) specialist consultation was required, or (4) care was provided in the ED that is not conventionally available at UCCs. Results From the 300 patient charts, 55% of patients referred from UCCs to the ED did not require ED‐specific care or resources and 64% had discordant diagnoses between UCC diagnosis and ED diagnosis. A total of 41% of patients underwent advanced imaging studies, 26% received specialty consultations, and 15% were admitted. Subgroup analysis for lacerations, extremity/fracture care, and abnormal electrocardiograms (ECGs) showed disproportionally high levels of discordant diagnoses and referrals that did not require ED‐specific care or resources. Conclusion Our data found that 55% of patients referred to EDs from UCCs did not require ED‐specific care or resources and 64% carried a discordant diagnosis between UC and ED diagnosis. We suggest quality remedies, such as educational sessions and engagement with telemedicine sub‐specialists as well as a coordinated formalized system for UCC to ED referrals

Social Determinants of Health and Mortality After Premature and Non-premature Acute Coronary Syndrome

Objective: To describe and compare the determinants of 1-year mortality after premature vs non-premature acute coronary syndrome (ACS). Patients and Methods: Participants presenting with ACS were enrolled in a prospective registry of 29 hospitals in 4 countries, from January 22, 2012 to January 22, 2013, with 1-year of follow-up data. The primary outcome was all-cause 1-year mortality after premature ACS (men aged <55 years and women aged <65 years) and non-premature ACS (men aged ≥55 years and women aged ≥65 years). The associations between the baseline patient characteristics and 1-year mortality were analyzed in models adjusting for the Global Registry of Acute Coronary Events (GRACE) score and reported as adjusted odds ratio (aOR) (95% CI). Results: Of the 3868 patients, 43.3% presented with premature ACS that was associated with lower 1-year mortality (5.7%) than those with non-premature ACS. In adjusted models, women experienced higher mortality than men after premature (aOR, 2.14 [1.37-3.41]) vs non-premature ACS (aOR, 1.28 [0.99-1.65]) (Pinteraction=.047). Patients lacking formal education vs any education had higher mortality after both premature (aOR, 2.92 [1.87-4.61]) and non-premature ACS (aOR, 1.78 [1.36-2.34]) (Pinteraction=.06). Lack of employment vs any employment was associated with approximately 3-fold higher mortality after premature and non-premature ACS (Pinteraction=.72). Using stepwise logistic regression to predict 1-year mortality, a model with GRACE risk score and 4 characteristics (education, employment, body mass index [kg/m2], and statin use within 24 hours after admission) had higher discrimination than the GRACE risk score alone (area under the curve, 0.800 vs 0.773; Pcomparison=.003). Conclusion: In this study, women, compared with men, had higher 1-year mortality after premature ACS. The social determinants of health (no formal education or employment) were strongly associated with higher 1-year mortality after premature and non-premature ACS, improved mortality prediction, and should be routinely considered in risk assessment after ACS