Complete revascularization with multivessel PCI for myocardial infarction

BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) of the culprit lesion reduces the risk of cardiovascular death or myocardial infarction. Whether PCI of nonculprit lesions further reduces the risk of such events is unclear. METHODS We randomly assigned patients with STEMI and multivessel coronary artery disease who had undergone successful culprit-lesion PCI to a strategy of either complete revascularization with PCI of angiographically significant nonculprit lesions or no further revascularization. Randomization was stratified according to the intended timing of nonculprit-lesion PCI (either during or after the index hospitalization). The first coprimary outcome was the composite of cardiovascular death or myocardial infarction; the second coprimary outcome was the composite of cardiovascular death, myocardial infarction, or ischemia-driven revascularization. RESULTS At a median follow-up of 3 years, the first coprimary outcome had occurred in 158 of the 2016 patients (7.8%) in the complete-revascularization group as compared with 213 of the 2025 patients (10.5%) in the culprit-lesion-only PCI group (hazard ratio, 0.74; 95% confidence interval [CI], 0.60 to 0.91; P=0.004). The second coprimary outcome had occurred in 179 patients (8.9%) in the complete-revascularization group as compared with 339 patients (16.7%) in the culprit-lesion-only PCI group (hazard ratio, 0.51; 95% CI, 0.43 to 0.61; P<0.001). For both coprimary outcomes, the benefit of complete revascularization was consistently observed regardless of the intended timing of nonculprit-lesion PCI (P=0.62 and P=0.27 for interaction for the first and second coprimary outcomes, respectively). CONCLUSIONS Among patients with STEMI and multivessel coronary artery disease, complete revascularization was superior to culprit-lesion-only PCI in reducing the risk of cardiovascular death or myocardial infarction, as well as the risk of cardiovascular death, myocardial infarction, or ischemia-driven revascularization. (Funded by the Canadian Institutes of Health Research and others; COMPLETE ClinicalTrials.gov number, NCT01740479. opens in new tab.

Geoepidemiologic variation in outcomes of primary sclerosing cholangitis.

Primary sclerosing cholangitis (PSC) is a chronic, progressive, hepatobiliary disease characterized by inflammation and fibrosis of the intra- and extra-hepatic bile ducts. Its natural history is one that generally progresses towards cirrhosis, liver failure, cholangiocarcinoma, and ultimately disease-related death, with a median liver transplantation-free survival time of approximately 15-20 years. However, despite its lethal nature, PSC remains a heterogenous disease with significant variability in outcomes amongst different regions of the world. There are also many regions where the outcomes of PSC have not been studied, limiting the overall understanding of this disease worldwide. In this review, we present the geoepidemiologic variations in outcomes of PSC, with a focus on survival pre- and post-liver transplantation as well as the concurrence of inflammatory bowel disease and hepatobiliary neoplasia

“Homomorphic” Tumor Metastases as an Endodiagnostic Clue: A Case Series of Renal-Cell Carcinoma Metastatic to the Stomach

Distinguishing between a primary malignancy and a metastasis can be challenging in some cases. Herein, we describe 2 cases of gastric lesions that were endoscopically sampled and ultimately found to be metastatic from a renal-cell carcinoma. In both cases, the gastric metastases were endoscopically homomorphic to the primary organ (the kidney); i.e., grossly resembling and thus providing an endoscopic clue as to the primary tumor source. We report on the evaluation of obscure metastatic gastric involvement of malignancy and present the concept of homomorphism as a potential diagnostic clue in determining the source of unknown and often unsuspected primary malignancy

Ever-increasing diversity of drug-induced pancreatitis.

With over 100000 hospital admissions per annum, acute pancreatitis remains the leading gastrointestinal cause of hospitalization in the United States and has far-reaching impact well beyond. It has become increasingly recognized that drug-induced pancreatitis (DIP), despite accounting for less than 3% of all cases, represents an important and growing though often inconspicuous cause of acute pancreatitis. Nevertheless, knowledge of DIP is often curtailed by the limited availability of evidence needed to implicate given agents, especially for non-prescription medications. Indeed, the majority of available data is derived from case reports, case series, or case control studies. Furthermore, the mechanism of injury and causality for many of these drugs remain elusive as a definitive correlation is generally not established (&lt; 10% of cases). Several classification systems have been proposed, but no single system has been widely adopted, and periodic updates are required in light of ongoing pharmacologic expansion. Moreover, infrequently prescribed medications or those available over-the-counter (including herbal and other alternative remedies) are often overlooked as a potential culprit of acute pancreatitis. Herein, we review the ever-increasing diversity of DIP and the potential mechanisms of injury with the goal of raising awareness regarding the nature and magnitude of this entity. We believe this manuscript will aid in increasing both primary and secondary prevention of DIP, thus ultimately facilitating more expedient diagnosis and a decrease in DIP-related morbidity

Homomorphic Adenocarcinoma Metastases to the Liver: A Report of 2 Cases.

BACKGROUND Distinguishing between primary and metastatic malignancy can be challenging despite advances in diagnostic imaging, tissue sampling techniques, and immunohistochemistry. CASE REPORT Herein, we describe 2 cases of obscure liver lesions which were ultimately determined to be malignant and from metastatic disease. In both cases, the liver metastases were uniquely "homomorphic," i.e., radiographically resembling the primary tumor source (in the first case a dilated tubular appearance akin to the hepatopancreatic ampulla and in the second case a haustrated bowel appearance akin to the colon). CONCLUSIONS These cases illustrate the recently reported concept of tumor homomorphism as a potential diagnostic pearl to facilitate timely diagnosis of malignant-appearing liver lesions of obscure etiology and source and thereby guide management accordingly

Real-world prevalence of endoscopic findings in patients with gastroesophageal reflux symptoms: a cross-sectional study

Background and study aims  Data regarding endoscopic findings and symptom correlation in patients with gastroesophageal reflux disease (GERD) symptoms are largely limited to single-center experiences. We performed a nationwide study to examine the association between patient-reported GERD symptoms and clinically relevant endoscopic findings. Patients and methods  Using the National Endoscopic Database, we retrospectively identified all esophagogastroduodenoscopies (EGDs) performed for GERD symptoms from 2000 to 2014. Patients were categorized into three symptom groups: 1) typical reflux only (R); 2) airway only (A); and 3) both R and A (R + A). Outcomes were the point prevalence of endoscopic findings in relation to patient-reported GERD symptom groups. Statistical analyses were performed using R. Results  A total of 167,459 EGDs were included: 96.8 % for R symptoms, 1.4 % for A symptoms, and 1.8 % for R + A symptoms. Of the patients, 13.4 % had reflux esophagitis (RE), 9.0 % Barrett's esophagus (BE), and 45.4 % hiatal hernia (HH). The R + A group had a significantly higher point prevalence of RE (21.6 % vs. 13.3 % and 12 %; P  &lt; 0.005) and HH (56.9 % vs. 45.3 % and 38.3 %; P  &lt; 0.005) compared to the R or A groups, respectively. The R group had a significantly higher point prevalence of BE compared to the A or R + A groups, respectively (9.1 % vs. 6.1 % and 6.1 %, P  &lt; 0.005). Conclusions  On a national level, patients experiencing R + A GERD symptoms appear more likely to have RE and HH, while those with only R symptoms appear more likely to have BE. These real-world data may help guide how providers and institutions approach acid-suppression therapy, set thresholds for recommending EGD, and develop management algorithms

Atherosclerotic cardiovascular disease in inflammatory bowel disease: The role of chronic inflammation.

Inflammatory bowel disease (IBD) causes systemic vascular inflammation. The increased risk of venous as well as arterial thromboembolic phenomena in IBD is well established. More recently, a relationship between IBD and atherosclerotic cardiovascular disease (ASCVD) has been postulated. Systemic inflammatory diseases, such as rheumatoid arthritis and systemic lupus erythematosus, have well characterized cardiac pathologies and treatments that focus on prevention of disease associated ASCVD. The impact of chronic inflammation on ASCVD in IBD remains poorly characterized. This manuscript aims to review and summarize the current literature pertaining to IBD and ASCVD with respect to its pathophysiology and impact of medications in order to encourage further research that can improve understanding and help develop clinical recommendations for prevention and management of ASCVD in patients with IBD