The differential diagnosis for syncope is long and involves multiple organ systems. Among the potential diagnoses include pulmonary embolism (PE), however current international guidelines do not establish a diagnostic work up for pulmonary embolism in patients hospitalized for syncope, nor are there extensive studies examining the prevalence of pulmonary embolism in this group. In this cross sectional, multicenter study, researchers utilized a systematic diagnostic workup to assess the prevalence of PE in 560 patients over the age of 18 admitted for a first episode of syncope to 11 hospitals in Italy from March 2012 to October 2014. Pulmonary embolism was ruled out in 330 patients based on a low pretest clinical probability defined by the Wells score and a negative D-dimer assay. The remaining 230 patients received CT pulmonary angiography or ventilation-perfusion lung scanning. Pulmonary embolism was diagnosed in 97 of these patients, who had either a high pretest clinical probability, positive D-dimer assay, or both. Therefore, the overall prevalence rate of pulmonary embolism in patients hospitalized for a first syncopal episode was 17.3% (95% CI: 14.2% to 20.5%), or nearly one of every six. Pulmonary embolism prevalence was highest for patients who presented with syncope of undetermined origin (25%), yet nearly 13% of patients with potential alternative explanations were also diagnosed. This study is one of the first to demonstrate such a high prevalence rate and shows that a more comprehensive pulmonary embolism evaluation for patients with syncope may be warranted.
There are two options for management of patients who have recurrent or persisting complaints after an initial episode of left-sided diverticulitis: elective sigmoidectomy or conservative management. Despite diverticulitis being such a common condition, studies comparing the two treatments have been sparse. In this multicenter, randomized control trial (DIRECT trial), 109 patients with either recurrent (three or more presentations of acute diverticulitis within two years) or persistent abdominal symptoms (ongoing left lower quadrant pain or change in bowel habits for three or more months) were randomized to sigmoidectomy (n = 53) or conservative management (n = 56) to study the effects on quality of life. At 6 months’ follow-up, scores measured using the Gastrointestinal Quality of Life Index (GIQLI) were significantly higher in patients who underwent surgery compared to conservative management (mean difference 14.2, 95% CI: 7.2 to 21.1, p < 0.0001). 34% of patients in the surgical group and 40% of patients in the conservative management group had a severe adverse event within this time frame, but there were no patient deaths. Of note, patients, physicians, and researchers were not masked to treatment assignment. This study concludes that elective sigmoid resection results in better subjective quality of life than conservative management in patients with recurrent or ongoing complaints after acute diverticulitis.
Non-Hodgkin lymphoma (NHL) is about 10 times more common in HIV-infected patients than in HIV-negative individuals and is a significant cause of morbidity and death in this population. In this large prospective cohort study, researchers sought to investigate whether chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) are associated with increased incidence of NHL in HIV-infected patients. By following 52,479 HIV-infected patients with chronic HBV and HCV from 18 of 33 cohorts from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE), researchers found that 252 antiretroviral therapy-naïve patients and 310 antiretroviral therapy patients developed NHL. The incidence rates were 219 and 168 cases per 100,000 person-years, respectively. 77% of treatment-naïve patients later began ART, which limited the study of associations in that group. Researchers conclude that HIV-positive patients who receive antiretroviral therapy and who are co-infected with chronic HBV and HCV are at a significantly higher risk for developing NHL. No such significance was found for therapy-naïve patients. This highlights the necessity for routine screening for chronic HBV and HCV in order to improve non-Hodgkin lymphoma morbidity and mortality in HIV-positive patients.
Glucagon-like peptide-1 (GLP-1) analogs are commonly used second or third-line treatments for patients with type 2 diabetes. While the US Food and Drug Administration and European Medicines Agency have had recent concerns that GLP-1 analogs might be associated with an increased risk of breast cancer, studies looking into this have been lacking. In this population based cohort study, investigators aimed to analyze this relationship by observing 44,984 women at least 40 years of age from the Clinical Practice Research Datalink, UK who were newly treated with a glucose lowering drug from January 2007 until March 2015, with follow-up until March 2016. Compared with dipeptidylpeptidase-4 (DPP-4) inhibitor use, GLP-1 use was not associated with an overall increased risk of breast cancer (incidence of 4.4 vs. 3.5 per 1000 person years, HR 1.40, 95% CI: 0.91 to 2.16). Interestingly, secondary analyses revealed that associations were observed with two to three years of use and with three to four years of use, but they returned to null with longer durations of use. A possible tumor promoter effect cannot be ruled out, but researchers believe this phenomenon is likely caused by increased cancer detection. In conclusion, this study provides reassurance to patients, clinicians, and government agencies that GLP-1 usage is not tied to increased risk of breast cancer.
Allocation of resources in hospitals is a complicated but important topic that must be reevaluated from time to time. In order to study recent 10-year trends in pediatric hospital resource use for patients with and without a psychiatric diagnosis, investigators conducted a retrospective, longitudinal cohort study utilizing hospital discharge data from 33 tertiary care U.S. children’s hospitals from 2005 through 2014. There was a significantly higher cumulative percent growth in resource use for children (ages 3 to 17 years) hospitalized with a psychiatric diagnosis compared to without (p < 0.001). Specifically, there was an increase of 137.7% for hospitalizations with a psychiatric diagnosis vs. 6.0% without; in which hospital days increased by 92.9% vs. 5.9% and costs increased 142.7% vs. 18.9%. Children admitted with both a medical condition and coexisting psychiatric disorder exhibited the largest increase in resource use (hospitalizations by 160.5%, hospital days by 112.4%; costs by 156.2%). Developmental disorders (22.3%), attention deficit/hyperactivity disorder (18.1%), and anxiety disorders (14.2%) were the most common psychiatric diagnoses in this group. This study concludes that resource allocation planning for tertiary care pediatric hospitals should focus on meeting the rising demand for psychiatric care, especially for children with a medical condition and coexisting psychiatric diagnoses.
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