Recurrent Ischemic Stroke and Bleeding in Patients With Atrial Fibrillation Who Suffered an Acute Stroke While on Treatment With Nonvitamin K Antagonist Oral Anticoagulants: The RENO-EXTEND Study

Background: In patients with atrial fibrillation who suffered an ischemic stroke while on treatment with nonvitamin K antagonist oral anticoagulants, rates and determinants of recurrent ischemic events and major bleedings remain uncertain. Methods: This prospective multicenter observational study aimed to estimate the rates of ischemic and bleeding events and their determinants in the follow-up of consecutive patients with atrial fibrillation who suffered an acute cerebrovascular ischemic event while on nonvitamin K antagonist oral anticoagulant treatment. Afterwards, we compared the estimated risks of ischemic and bleeding events between the patients in whom anticoagulant therapy was changed to those who continued the original treatment. Results: After a mean follow-up time of 15.0±10.9 months, 192 out of 1240 patients (15.5%) had 207 ischemic or bleeding events corresponding to an annual rate of 13.4%. Among the events, 111 were ischemic strokes, 15 systemic embolisms, 24 intracranial bleedings, and 57 major extracranial bleedings. Predictive factors of recurrent ischemic events (strokes and systemic embolisms) included CHA2DS2-VASc score after the index event (odds ratio [OR], 1.2 [95% CI, 1.0–1.3] for each point increase; P=0.05) and hypertension (OR, 2.3 [95% CI, 1.0–5.1]; P=0.04). Predictive factors of bleeding events (intracranial and major extracranial bleedings) included age (OR, 1.1 [95% CI, 1.0–1.2] for each year increase; P=0.002), history of major bleeding (OR, 6.9 [95% CI, 3.4–14.2]; P=0.0001) and the concomitant administration of an antiplatelet agent (OR, 2.8 [95% CI, 1.4–5.5]; P=0.003). Rates of ischemic and bleeding events were no different in patients who changed or not changed the original nonvitamin K antagonist oral anticoagulants treatment (OR, 1.2 [95% CI, 0.8–1.7]). Conclusions: Patients suffering a stroke despite being on nonvitamin K antagonist oral anticoagulant therapy are at high risk of recurrent ischemic stroke and bleeding. In these patients, further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischemic stroke and bleeding

Class V resin-composite restorations using two different adhesives: prospective RCT

Aim. To prospectively evaluate, and in vitro analyse, an etch & rinse/two-steps (E&R) adhesive and a self-etch/one-step (SE) adhesive in class V composite restorations. Methods. 52 teeth with cervical lesions were selected from 14 patients and randomly divided in two groups: A assigned to a beginner operator, B to a dentist with 15 years experience. Groups were then randomly divided in two subgroups: E&R adhesive was used in subgroups A1 and B1 (Gluma Comfort Bond, Heraeus Kulzer), while SE in A2 and B2 (iBond, Heraeus Kulzer). Cavity margins were placed on both enamel and cement. All restorations were performed using the same composite and evaluated at baseline and 24-month (Hickel’s criteria). Micro-tensile laboratory tests were performed to test the bond strength of the two adhesives, comparing in vitro Vs in vivo. Results. No statistical difference between the clinical performance of the adhesives and the two operators. There was a statistically significant difference between baseline and 24-month follow-up, in both groups, for polishing procedure, post-op sensitivity and marginal adaptation. Under laboratory conditions, the E&R adhesive gave better results than the SE adhesive, even if statistically significant differences could only be found in terms of adhesion on enamel. Conclusions. This study suggests that both E&R and SE adhesives can be recommended for clinical use in class V composite restorations, either for a beginner operator than for an expert one

Prospective observational cohort study of early recurrent TIA: Features, frequency, and outcome

OBJECTIVES: To evaluate the frequency, clinical and etiologic features, and short- and long-term outcomes of early recurrent TIA. METHODS: This prospective observational cohort study enrolled all consecutive patients with TIA referred to our emergency department and diagnosed by a vascular neurologist. Expedited assessment and best secondary prevention were performed within 24 hours. Primary endpoints were stroke and a composite outcome including stroke, acute coronary syndrome, and vascular death at 3, 12, and, for a subset of patients, 60 months; secondary outcomes were TIA relapse, cerebral hemorrhage, new-onset atrial fibrillation, and death resulting from other causes. Concordance between index TIA and subsequent stroke etiologies was also evaluated. RESULTS: A total of 1,035 patients (822 with a single TIA, 213 with recurrent TIA = 21%) were enrolled from August 2010 to December 2017. Capsular warning syndrome and large artery atherosclerosis showed the strongest relationship with early recurrent TIA. The risk of stroke was significantly higher in the early recurrent TIA subgroup at each follow-up, and most stroke episodes occurred within 48 hours of index TIA. TIAs with lesion, dysarthria, and leukoaraiosis were the 3- and 12-month independent predictors of stroke incidence after early recurrent TIA subgroup. Index TIA and subsequent stroke etiologies showed substantial concordance. An ABCD3 score >6 predicted a higher risk of stroke recurrence over the entire follow-up. CONCLUSIONS: Our study evaluated long-term outcome after early recurrent TIA. Our observations support the importance of promptly detecting and treating patients with early recurrent TIAs to reduce the high early and long-term risk of poor clinical outcomes