Mohan Palla

White-coat hypertension and cardiovascular events: a meta-analysis.

Background: White-coat hypertension (WCH) is a frequent condition particularly in children and elderly individuals. The prognostic significance of WCH is still a matter of debate. Methods: The present study was designed to systematically review cohort studies and assess the effects of WCH compared with normotension and sustained HTN on cardiovascular events and death, stroke, and all-cause mortality. We systematically searched the electronic databases, MEDLINE, PUBMED, EMBASE, and Cochrane for prospective cohort studies, which evaluated participants with office, and ambulatory, and/or home blood pressure. Results: We included 14 studies with a total number of 29 100 participants (13 538 normotensive patients, 4806 with WCH and 10 756 with sustained HTN) with mean age of 59 years and follow-up of 8 years. Individuals with WCH had higher rates of cardiovascular disease morbidity and mortality but not significantly different all-cause mortality and stroke risk compared with normotensive patients. Cardiovascular disease morbidity and mortality, all-cause mortality, and stroke rates were significantly increased in patients with sustained HTN compared with WCH. Conclusion: The cardiovascular morbidity and mortality associated with WCH may be slightly higher compared with normotension but well below the risks associated with sustained HTN.

Myocardial fibrosis on cardiac magnetic resonance and cardiac outcomes in hypertrophic cardiomyopathy: a meta-analysis

Objective Late gadolinium enhancement (LGE) on cardiac MRI that indicates the extent of myocardial fibrosis in hypertrophic cardiomyopathy (HCM) is a potential risk factor of sudden cardiac death (SCD) in non-high-risk patients according to conventional clinical markers. Methods The present study was designed to systematically review prospective trials and assess the association between LGE and SCD in HCM. We systematically searched the electronic databases, MEDLINE, PubMed, Embase and Cochrane for prospective cohort studies of the effects of LGE on clinical outcomes (SCD/aborted SCD, all-cause mortality, cardiac and heart failure death) in HCM. Results We identified six clinical studies, examining 1414 patients without LGE and 1653 with LGE and an average follow-up of 3.05 years. The incidence of SCD/aborted SCD in patients with HCM and LGE was significantly increased as compared with patients without LGE (OR 2.52, 95% CI 1.44 to 4.4, p=0.001). The all-cause mortality and cardiac death rates were also significantly increased in patients with LGE. The extent of LGE was not significantly related to the risk of SCD. Conclusions LGE is significantly associated with SCD risk, cardiac mortality and all-cause mortality in patients with non-high-risk HCM according to conventional risk factors.

Epidemiology and Risk Factors for Isolation of Escherichia coli Producing CTX-M-Type Extended-Spectrum β-Lactamase in a Large U.S. Medical Center

ABSTRACT A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum β-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially blaCTX-M-15 type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.

Meta-Analysis of Transcatheter Aortic Valve Replacement Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Valve Stenosis

Transcatheter aortic valve replacement (TAVR) is a viable option in the treatment of severe aortic stenosis in patients at high risk for surgery. We sought to further investigate outcomes in patients at low to intermediate risk with aortic stenosis who underwent surgical aortic valve replacement (SAVR) versus TAVR. We systematically searched the electronic databases, MEDLINE, PubMed, EMBASE, and Cochrane for prospective cohort studies of the effects of TAVR versus SAVR on clinical outcomes (30-day mortality, all-cause mortality, stroke and myocardial infarction, major vascular complications, paravalvular regurgitation, permanent pacemaker implantation, major bleeding, and acute kidney injury). We identified 5 clinical studies, examining 1,618 patients in the TAVR group and 1,581 patients in the SAVR group with an average follow-up of 1.05 years. No difference in all-cause mortality, stroke, and myocardial infarction between the 2 approaches was found. TAVR was associated with higher rates of vascular complications, permanent pacemaker implantation, and moderate or severe paravalvular regurgitation (p <0.001 for all), whereas more major bleeding events were seen in the SAVR group (p <0.001). In conclusion, TAVR was found to have similar survival and stroke rates and lower major bleeding rates as compared with SAVR in patients at low or intermediate surgical risk. However, SAVR was associated with less pacemaker placements and paravalvular regurgitation rates.

Epidemiology of vancomycin-resistant Enterococcus faecalis: a case-case-control study

ABSTRACT Although much is known about vancomycin-resistant (VR) Enterococcus faecium, little is known about the epidemiology of VR Enterococcus faecalis. The predilection of VR E. faecalis to transfer the vancomycin resistance determinant to Staphylococcus aureus is much greater than that of VR E. faecium. The epidemiology of VR E. faecalis has important implications regarding the emergence of vancomycin-resistant S. aureus (VRSA); 8 of 13 reported VRSA cases have been from Michigan. A retrospective case-case-control study was conducted at the Detroit Medical Center, located in southeastern Michigan. Unique patients with VR E. faecalis infection were matched to patients with strains of vancomycin-susceptible (VS) E. faecalis and to uninfected controls at a 1:1:1 ratio. Five hundred thirty-two VR E. faecalis cases were identified and were matched to 532 VS E. faecalis cases and 532 uninfected controls. The overall mean age of the study cohort (n = 1,596) was 63.0 ± 17.4 years, and 747 (46.8%) individuals were male. Independent predictors for the isolation of VR E. faecalis (but not VS E. faecalis) compared to uninfected controls were an age of ≥65 years, nonhome residence, diabetes mellitus, peripheral vascular disease, exposure to cephalosporins and fluoroquinolones in the prior 3 months, and immunosuppressive status. Invasive procedures and/or surgery, chronic skin ulcers, and indwelling devices were risk factors for both VR E. faecalis and VS E. faecalis isolation. Cephalosporin and fluoroquinolone exposures were unique, independent predictors for isolation of VR E. faecalis. A majority of case patients had VR E. faecalis present at the time of admission. Control of VR E. faecalis, and ultimately VRSA, will likely require regional efforts focusing on infection prevention and antimicrobial stewardship.

Invasive pulmonary aspergillosis in patients with influenza infection: Report of two cases and systematic review of the literature

Superinfection or coinfections are major causes of morbidity and mortality in patients with influenza. There are limited data on invasive pulmonary aspergillosis (IPA) in this setting. We conducted a systematic review of the literature for patients with IPA following influenza infection. A total of 68 patients (two reported from our institution and 66 identified by literature review) were analyzed. The majority of patients had underlying comorbid illnesses. Overall, the mortality rate in this cohort was 47%. On multivariate analysis, H1N1 infection was associated with better outcome (odds ratio [OR]: 0.19; 95% CI: 0.05–0.67; p = 0.010), whereas corticosteroid therapy during hospitalization was associated with worse outcome (OR: 13.5; 95% CI: 3.65–49.67; p < 0.0001). In conclusion, IPA is an emerging serious infection in patients with influenza. A high index of suspicion is necessary for the timely identification and treatment of these patients.

Clinical Outcomes of Manual Aspiration Thrombectomy in Patients with Acute Myocardial Infarction: An Updated Meta-Analysis

Background: Recent trials on manual aspiration thrombectomy (AT) in patients with ST-elevation myocardial infarction did not show any significant benefits of AT. Aims: The present meta-analysis was designed to systematically evaluate prospective randomized trials and assess the effects of AT on all-cause mortality, major cardiovascular events (MACE), target vessel revascularization, myocardial reinfarction, stroke and surrogate myocardial perfusion markers. Methods and Results: We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with AT plus primary percutaneous coronary intervention (PCI) versus PCI. We identified 16 prospective randomized trials which enrolled 10,437 controls that underwent conventional PCI and 10,385 patients who underwent PCI with AT with an average follow-up duration of 5.8 months. A significant reduction in MACE with AT was noted (OR 0.91; 95% CI 0.82-0.99; p = 0.04). In spite of improved TIMI 3 and myocardial blush grade 3 rates, AT did not significantly reduce all-cause mortality, target-vessel revascularization and myocardial infarction. Stroke rates were increased with AT. Conclusion: The results of this large meta-analysis of 20,822 patients suggest that adjunctive AT to PCI may be associated with improved myocardial reperfusion but limited benefits related to the clinical end-points.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis

Background Endovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA). Methods We conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3. Results A total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0–2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0–2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42). Conclusions This meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.

P2Y12 Receptor Antagonists: Which One to Choose? A Systematic Review and Meta-Analysis

BACKGROUND Pharmacological properties of the currently available P2Y12 receptor antagonists differ significantly and lead to different degrees of platelets inhibition and cardiovascular outcomes. METHODS We performed a systematic review and meta-analysis of the comparative effects of newer antiplatelet agents versus clopidogrel on major adverse cardiovascular events (MACE), all-cause mortality, myocardial infarction (MI), stroke, major bleeding and stent thrombosis, in patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary intervention (PCI). RESULTS We identified 11 prospective randomized studies comparing newer antiplatelets to clopidogrel. The total number of participants included in meta-analysis was 70239. The total number of participants treated with clopidogrel was 34792 while 35447 patients were assigned to newer P2Y12 inhibitors, of which 29.4% received ticagrelor, 35.2% prasugrel and 35.4% were loaded with intravenous cangrelor. Ticagrelor use was associated with significantly reduced MACE, all-cause mortality, myocardial infarction and stent thrombosis and similar rates of stroke and major bleeding compared to clopidogrel in patients with ACS and/or PCI. Prasugrel use was associated with significantly lower rates of MACE, MI and stent thrombosis but significantly high rates of major bleeding and thus no all-cause mortality benefit compared to clopidogrel. CONCLUSION Newer P2Y12 receptor antagonists are associated with better cardiovascular outcomes in patients with ACS and/or undergoing PCI. Prasugrel use resulted in higher major bleeding rates and no overall mortality benefit compared with clopidogrel.

Surgical site infections in genital reconstruction surgery for gender reassignment, Detroit: 1984-2008.

BACKGROUND Gender reassignment surgery (i.e., male-to-female or female-to-male) entails a series of complex surgical procedures. We conducted a study to explore epidemiologic characteristics of patients who underwent genital reconstruction operations as components of gender reassignment and to analyze risk factors for surgical-site infections (SSIs) following these operations. METHODS The study was a retrospective cohort study conducted from 1984-2008 at Harper University Hospital, a tertiary hospital with 625 beds in Detroit, Michigan. Surgical site infection was defined according to established criteria. RESULTS Records were available for 82 patients who underwent a total of 1,383 operations as part of genital-reconstruction processes. Thirty-nine (47.6%) of the patients underwent female-to-male reassignment (FTM) and 43 (52.4%) underwent male-to-female reassignment (MTF). The average age of the study cohort was 39.5±9.8 y. Of the patients in the cohort, 56 (68.3%) were Caucasian and 67 (81.7%) were single. The average number of operative encounters per patient was 11.8±4.6 for FTM and 4.9±2.4 for MTF. Forty-three (52.4%) patients developed an SSI at least once during their genital reconstruction process, of whom 34 (87%) were in the FTM group and nine (21%) in the MTF group (p<0.001). Staphylococci were the most common pathogens (61%) isolated in these infections, followed by Enterobacteriaceae (50%), Enterococcus (39%), and Pseudomonas aeruginosa (33.3%). Surgical site infection was associated independently with an increased frequency of operative procedures and operating room encounters. CONCLUSIONS More than 50% of patients who underwent genital reconstruction operations developed an SSI at some point during the genital reconstruction process. Surgical site infections are more common in FTM than in MTF reconstruction operations, and for both FTM and MTF, SSIs are associated independently with an increased frequency of total operative procedures and encounters.