Pulmonary vein isolation is often attempted as an interventional approach for drug-refractory paroxysmal atrial fibrillation to prevent conduction from aberrant foci of ectopy near the pulmonary veins. Both radiofrequency ablation by catheter as well as cryoballoon ablation approaches are in use. In this multicenter, randomized trial of 762 patients with drug-resistant paroxysmal atrial fibrillation, study participants were randomized to either radiofrequency ablation or cryoballoon ablation and followed for a mean duration of 1.5 years for subsequent recurrence, use of antiarrhythmic drugs, or repeat ablation. In this study, the 1 year Kaplan-Meier clinical failure rate was 34.6% in the cryoballoon group vs. 35.9% in the radiofrequency group (p < 0.001 for inferiority). By one year, there was also similar rates of a composite of death, cerebrovascular events, or severe procedure-related complications (10.2% vs. 12.8%, p = 0.24). In this study, there was no difference in safety or efficacy between cryoballoon and radiofrequency ablation for paroxysmal atrial fibrillation.
Over the last 30 years, there has been an increased prevalence of obesity in the United States documented as early as 1980. The National Health and Nutrition Examination Survey (NHANES) continues to be administered annually to identify trends in national disease prevalence. In this report of NHANES survey results from 2013-2015, 2638 men and 2817 women were surveyed on health and demographics including race, smoking status, and education. In this nationally representative survey, the age-adjusted prevalence of obesity was 37.7% (95% CI: 35.8 to 39.7%) for men and 35.0% (95% CI; 32.8% to 37.3%) for women. Compared to surveys prior to 2005, there are significant increasing linear trends among women (p = 0.004) but not among men ( p = 0.30) for overall obesity. The prevalence of obesity remains high in the United States and appears to be rising for women.
The complications of chronic hypertension are well established, as are the risks brief episodes of severe hypertension. However, the short-term outcomes of hypertensive urgency (asymptomatic systolic blood pressures greater than 180mmHg or diastolic blood pressures greater than 110mmHg) are unknown and there is significant practice variation between hospital admission or outpatient management. In this retrospective cohort study of patients seen in outpatient clinic in the Cleveland Clinic Healthcare system, 58,535 patients met blood pressure criteria for hypertensive urgency. In propensity-matched analysis, the outcomes of 852 patients sent home were compared with 426 patients admitted to the hospital for hypertensive urgency. There was no significant difference in major adverse cardiovascular events up to 6 months (0.9% vs. 0.9%, p > 0.99), however patients sent home were more likely to have uncontrolled hypertension at 1 month (86.3% vs. 81.9%, p = 0.04). Patients who were initially admitted were more likely to be readmitted up to 30 days after initial office visit (11.3% vs. 6.9%, p = 0.009). Despite significant practice variation, there was not much difference in major adverse cardiovascular events up to 6 months afterwards, however most patients still had uncontrolled hypertension in subsequent follow-up.
Histologic transformation of low grade follicular lymphoma often results in aggressive, treatment resistant diffuse large B-cell lymphoma. There are few studies of patients who have transformed follicular lymphoma who previously responded to immunotherapy. In the PRIMA trial, 1,018 patients with follicular lymphoma were followed for a median of 6 years and disease progression was observed in 463 (45.5%) patients. Of these patients, 37% of biopsies during the first year of follow-up showed histologic transformation. Response to immunotherapy or rituximab had no impact on the risk of histologic transformation, however of patients who previously responded to immunotherapy but had histological transformation, there was statistically significantly more disease progression after salvage chemotherapy (28.2 vs. 9.6%, p < 0.001). Overall survival was worse (3.8 vs. 6.4 years, HR 3.9) for patients with histological transformation. The authors suggest that histological transformation in patients with follicular lymphoma that previously responded to immunotherapy is associated with poor outcomes that might be best served with aggressive salvage chemotherapy and/or autologous stem cell transplantation.
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