Differences and similarities between spontaneous dissections of the internal carotid artery and the vertebral artery

Background and Purpose—To compare potential risk factors, clinical symptoms, diagnostic delay, and 3-month outcome between spontaneous internal carotid artery dissection (sICAD) and spontaneous vertebral artery dissection (sVAD). Methods—We compared patients with sICAD (n=668) and sVAD (n=302) treated in 3 university hospitals. Results—Patients with sICAD were older (46.3±9.6 versus 42.0±10.2 years; P<0.001), more often men (62.7% versus 53.0%; P=0.004), and presented more frequently with tinnitus (10.9% versus 3.4%; P<0.001) and more severe ischemic strokes (median National Institutes of Health Stroke Scale, 10±7.1 versus 5±5.9; P<0.001). Patients with sVAD had more often bilateral dissections (15.2% versus 7.6%; P<0.001) and were more often smokers (36.0% versus 28.7%; P=0.007). Thunderclap headache (9.2% versus 3.6%; P=0.001) and neck pain were more common (65.8% versus 33.5%; P<0.001) in sVAD. Subarachnoid hemorrhage (6.0% versus 0.6%; P<0.001) and ischemic stroke (69.5% versus 52.2%; P<0.001) were more frequent in sVAD. After multivariate analysis, sex difference lost its significance (P=0.21), and all other variables remained significant. Time to diagnosis was similar in sICAD and sVAD and improved between 2001 and 2012 compared with the previous 10-year period (8.0±10.5 days versus 10.7±13.2 days; P=0.004). In sVAD, favorable outcome 3 months after ischemic stroke (modified Rankin Scale, 0–2: 88.8% versus 58.4%; P<0.001), recurrent transient ischemic attack (4.8% versus 1.1%; P=0.001), and recurrent ischemic stroke (2.8% versus 0.7%; P=0.02) within 3 months were more frequent. Conclusions—sICAD and sVAD patients differ in many aspects. Future studies should perform separate analyses of these 2 entities

Statins and the risk of cancer after heart transplantation

BACKGROUND: Although newer immunosuppressive agents, such as mTOR (mammalian target of rapamycin) inhibitors, have lowered the occurrence of malignancies after transplantation, cancer is still a leading cause of death late after heart transplantation. Statins may have an impact on clinical outcomes beyond their lipid-lowering effects. The aim of the present study was to delineate whether statin therapy has an impact on cancer risk and total mortality after heart transplantation. METHODS AND RESULTS: A total of 255 patients who underwent heart transplantation at the University Hospital Zurich between 1985 and 2007 and survived the first year were included in the present study. The primary outcome measure was the occurrence of any malignancy; the secondary end point was overall survival. During follow-up, a malignancy was diagnosed in 108 patients (42%). The cumulative incidence of tumors 8 years after transplantation was reduced in patients receiving a statin (34% versus 13%; 95% confidence interval, 0.25-0.43 versus 0.07-0.18; P<0.003). Statin use was associated with improved cancer-free and overall survival (both P<0.0001). A Cox regression model that analyzed the time to tumor formation with or without statin therapy, adjusted for age, male sex, type of cardiomyopathy, and immunosuppressive therapy (including switch to mTOR inhibitors or tacrolimus), demonstrated a superior survival in the statin group. Statins reduced the hazard of occurrence of any malignancy by 67% (hazard ratio, 0.33; 95% confidence interval, 0.21-0.51; P<0.0001). CONCLUSIONS: Although it is not possible to adjust for all potential confounders because of the very long follow-up period, this registry suggests that statin use is associated with improved cancer-free and overall survival after cardiac transplantation. These data will need to be confirmed in a prospective trial

Transfusion practice in anemic, non-bleeding patients: Cross-sectional survey of physicians working in general internal medicine teaching hospitals in Switzerland

<div><p>Background</p><p>Transfusion practice might significantly influence patient morbidity and mortality. Between European countries, transfusion practice of red blood cells (RBC) greatly differs. Only sparse data are available on transfusion practice of general internal medicine physicians in Switzerland.</p><p>Methods</p><p>In this cross-sectional survey, physicians working in general medicine teaching hospitals in Switzerland were investigated regarding their self-reported transfusion practice in anemic patients without acute bleeding. The definition of anemia, transfusion triggers, knowledge on RBC transfusion, and implementation of guidelines were assessed.</p><p>Results</p><p>560 physicians of 71 hospitals (64%) responded to the survey. Anemia was defined at very diverging hemoglobin values (by 38% at a hemoglobin <130 g/L for men and by 57% at <120 g/L in non-pregnant women). 62% and 43% respectively, did not define anemia in men and in women according to the World Health Organization. Fifty percent reported not to transfuse RBC according to international guidelines. Following factors were indicated to influence the decision to transfuse: educational background of the physicians, geographical region of employment, severity of anemia, and presence of known coronary artery disease. 60% indicated that their knowledge on Transfusion-related Acute Lung Injury (TRALI) did not influence transfusion practice. 50% of physicians stated that no local transfusion guidelines exist and 84% supported the development of national recommendations on transfusion in non-acutely bleeding, anemic patients.</p><p>Conclusion</p><p>This study highlights the lack of adherence to current transfusion guidelines in Switzerland. Identifying and subsequently correcting this deficit in knowledge translation may have a significant impact on patient care.</p></div

Availability of guidelines for transfusion of packed red blood cells in the physicians’ work place.

<p>Regional differences are illustrated using coloured dots which represent teaching hospitals participating in the questionnaire.</p

Knowledge on transfusion related acute lung injury (TRALI).

<p>Physicians knowledge of TRALI and if their knowledge on TRALI influences their transfusion practice.</p

Self-perception of red blood cell (RBC) transfusion practice in anemia.

<p>Self-perception of red blood cell (RBC) transfusion practice in anemia (<b>A</b>). Association between the physician’s self-perception and the place of study (<b>B</b>).</p

Transfusion threshold in anemia without acute bleeding and with stable oxygen delivery.

<p>Case vignette #1. In a 72-year-old male patient with stable vital parameters hospitalized due to pneumonia anemia was detected. There were no signs of active bleeding or coronary artery diseases <b>(A, B)</b>. Case vignette #2. Anemia was detected in an 84-year-old female patient with stable vital parameters suffering from osteoporotic fracture of TH12 vertebra. She had known diabetes mellitus type 2, arterial hypertension, and stable coronary artery disease <b>(C, D)</b>. The red bar indicates the recommendation of the AABB guidelines. Regional differences are illustrated on the maps using colored dots which represent teaching hospitals participating in the questionnaire.</p

Number of physicians responding to the online questionnaire.

<p>560 physicians from 71 Swiss hospitals working in the field of internal medicine participated in this study. The illustration indicates the number of participating physicians of the respective hospital.</p

Definition of anemia.

<p>Threshold of hemoglobin level for men (<b>A</b>) and non-pregnant women (<b>B</b>), below which the presence of an anemia was diagnosed. The red bar indicates the threshold according to the definition of the World Health Organization. Estimated prevalence of anemia in the physician’s own patient population (<b>C</b>).</p