Internal and emergency medicine
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Smoking is associated with increased morbidity and mortality in cardiac patients. However, data on the prognostic impact of smoking in heart failure (HF) patients on cardiac resynchronization therapy with defibrillator (CRT-D) are absent. We investigated the effects of smoking on all-cause mortality and on a composite endpoint (all-cause death/appropriate device therapy), appropriate and inappropriate device therapy, in 649 patients with HF who underwent CRT-D between January 2003 and October 2011 in 6 Centers (4 in Italy and 2 in USA). 68 patients were current smokers, 396 previous-smokers (patients who had smoked in the past but who had quit before the CRT-D implant), and 185 had never smoked. ⋯ After adjusting for age, left ventricular ejection fraction, QRS width and ischemic etiology, both current and previous smoking were independent predictors of all-cause death [HR = 5.07 (95 % CI 2.68-9.58), p < 0.001 and HR = 2.43 (95 % CI 1.38-4.29), p = 0.002, respectively) and of composite endpoint [HR = 1.63 (1.04-2.56); p = 0.033 and HR = 1.46 (1.04-2.04) p = 0.027]. In addition, current smokers had a significantly higher rate of inappropriate device therapy compared to never smokers [HR = 21.74 (4.53-104.25), p = 0.005]. Our study indicates that in patients with HF who received a CRT-D device, current and previous smoking increase the event rate per person-time of death and of appropriate and inappropriate ICD therapy more than other known negative prognostic factors such as age, left ventricular dysfunction, prolonged QRS duration and ischemic etiology.
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To systematically investigate putative causes of non-coronary high-sensitive troponin elevations in patients presenting to a tertiary care emergency department. In this cross-sectional analysis, patients who received serial measurements of high-sensitive troponin T between 1 August 2010 and 31 October 2012 at the Department of Emergency Medicine were included. The following putative causes were considered to be associated with non-acute coronary syndrome-related increases in high-sensitive troponin T: acute pulmonary embolism, renal insufficiency, aortic dissection, heart failure, peri-/myocarditis, strenuous exercise, rhabdomyolysis, cardiotoxic chemotherapy, high-frequency ablation therapy, defibrillator shocks, cardiac infiltrative disorders (e.g., amyloidosis), chest trauma, sepsis, shock, exacerbation of chronic obstructive pulmonary disease, and diabetic ketoacidosis. ⋯ The most commonly encountered mechanism underlying the troponin T elevation was renal insufficiency that was present in 286 patients (57 %), followed by cerebral ischemia in 95 patients (19 %), trauma in 75 patients (15 %) and heart failure in 41 patients (8 %). Non-acute coronary syndrome-associated elevation of high-sensitive troponin T levels is commonly observed in the emergency department. Renal insufficiency and acute cerebral events are the most common conditions associated with high-sensitive troponin T elevation.
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The purpose of this study is to assess the incidence and describe the clinical and pathological features of macrovascular thrombosis during the course of thrombotic micro-angiopathy (TMA) in a 6 year retrospective study of all adults with TMA, admitted to a teaching-hospital ICU. Of the 55 patients identified, all had anaemia and thrombocytopenia and 45 (82 %) had renal or neurological impairment. All patients received plasmapheresis, steroids, and strict blood pressure control. ⋯ By multivariate analysis, factors independently associated with macrovascular thrombosis were undetectable ADAMTS13 activity (odds ratio 7.33, 95 % confidence interval 1.3-41.3), cardiac involvement with TMA (odds ratio, 3.46; 95 % confidence interval, 1.1-13.9) and TMA flare (odds ratio 9.03; 95 % confidence interval 1.03-79.4). In conclusion, half of the patients with TMA experience macrovascular thrombosis. Patients with TTP-related ADAMTS13 deficiency and those with cardiac manifestations of TMA are at higher risk for arterial or deep venous thrombosis.
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Long-term oxygen therapy (LTOT) improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. Adherence to LTOT guidelines is problematic, both because efficacy has been demonstrated only in specific groups of COPD patients, and because it implies high costs. Introduces treatment high costs. ⋯ Adherence was higher for LTOT prescribed by pulmonologists compared to internists. This survey showed that the adherence to LTOT guidelines in a sample of medical records of patients prescribed LTOT is poor. Considering the high costs and the impact on the patients' quality of life of LTOT, these results suggest that the adherence should be carefully monitored.