Susceptibility to exacerbation in chronic obstructive pulmonary disease

Background Although we know that exacerbations are key events in chronic obstructive pulmonary disease (COPD), our understanding of their frequency, determinants, and effects is incomplete. In a large observational cohort, we tested the hypothesis that there is a frequent-exacerbation phenotype of COPD that is independent of disease severity. Methods We analyzed the frequency and associations of exacerbation in 2138 patients enrolled in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End points (ECLIPSE) study. Exacerbations were defined as events that led a care provider to prescribe antibiotics or corticosteroids (or both)or that led to hospitalization (severe exacerbations). Exacerbation frequency was observed over a period of 3 years. Results Exacerbations became more frequent (and more severe) as the severity of COPD increased; exacerbation rates in the first year of follow-up were 0.85 per person for patients with stage 2 COPD (with stage defined in accordance with Global Initiative for Chronic Obstructive Lung Disease [GOLD] stages), 1.34 for patients with stage 3, and 2.00 for patients with stage 4. Overall, 22% of patients with stage 2 disease, 33% with stage 3, and 47% with stage 4 had frequent exacerbations (two or more in the first year of follow-up). The single best predictor of exacerbations, across all GOLD stages, was a history of exacerbations. The frequent-exacerbation phenotype appeared to be relatively stable over a period of 3 years and could be predicted on the basis of the patient"s recall of previous treated events. In addition to its association with more severe disease and prior exacerbations, the phenotype was independently associated with a history of gastroesophageal reflux or heartburn, poorer quality of life, and elevated white-cell count. Conclusions Although exacerbations become more frequent and more severe as COPD progresses, the rate at which they occur appears to reflect an independent susceptibility phenotype. This has implications for the targeting of exacerbation-prevention strategies across the spectrum of disease severity. (Funded by GlaxoSmithKline; ClinicalTrials .gov number, NCT00292552.)

Foreign-Medical-School Graduates object to the VISA Qualifiying Examination

To the editor; The Visa Qualifying Examination is a two-day test composed of approximately 950 multiple-choice questions conerneing the basic and clinical sciences....

Early use of TIPS in patients with cirrhosis and variceal bleeding.

Background Patients with cirrhosis in ChildPugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have undergone rescue treatment with a transjugular intrahepatic porto - systemic shunt (TIPS). This study evaluated the earlier use of TIPS in such patients. Methods We randomly assigned, within 24 hours after admission, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered stent within 72 hours after randomization (early-TIPS group, 32 patients) or continuation of vasoactive-drug therapy, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (pharmacotherapyEBL group, 31 patients). Results During a median follow-up of 16 months, rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapyEBL group as compared with 1 patient in the early-TIPS group (P=0.001). The 1-year actuarial probability of remaining free of this composite end point was 50% in the pharmacotherapyEBL group versus 97% in the early-TIPS group (P<0.001). Sixteen patients died (12 in the pharmacotherapyEBL group and 4 in the early-TIPS group, P=0.01). The 1-year actuarial survival was 61% in the pharmacotherapyEBL group versus 86% in the early-TIPS group (P<0.001). Seven patients in the pharmacotherapyEBL group received TIPS as rescue therapy, but four died. The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapyEBL group than in the early-TIPS group. No significant diferences were observed between the two treatment groups with respect to serious adverse events. Conclusions In these patients with cirrhosis who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with signif icant reductions in treatment failure and in mortality. (Current Controlled Trials number, ISRCTN58150114.)

Antecedentes históricos de la medicina legal en España

L'obra està plantejada com una posada en antecedents per a l'actual disciplina de Medicina legal en l'àmbit de l'estat espanyol. Sense la voluntat de fer un estudi exhaustiu, que hauria estat massa extens, l'autor proposa l'estudi d'aquesta disciplina des de l'època visigoda i fins la meitat del segle XIX, moment en que la Medicina legal ja té les bases que seran les arrels de la disciplina actual.

Anàlisi dels aspectes mèdics de la mort violenta a Lleida a la Baixa Edat Mitjana: vol. 1

Aquest treball és el primer volum de la tesi presentada pel doctor Camps i Clemente, publicada pel Seminari Pere Mata per tal de donar-li major difusió. En aquesta tesi, l'autor estudia d'una forma extensa i profunda els episodis de mort violenta reportats a Lleida entre els anys 1308 i 1516. Els 342 procediments estudiats es guarden a la Paeria de Lleida i aporten dades sobre la realitat mèdico-sanitària i social de l'època baix-medieval.

Anàlisi dels aspectes mèdics de la mort violenta a Lleida a la Baixa Edat Mitjana: vol. 2

Aquí tenim el segon volum de la tesi del doctor Camps i Clemente sobre la mort violenta en el territori lleidatà durant els segles XIV i XV

Las Topografías médicas burgalesas : 1884-1917. Un intento de contribución a la historia natural, social y sanitaria de la província de Burgos en los siglos XIX y XX

Aquest és un dels treballs de López Gómez que s'insereix en la línia d'estudi de les topografies mèdiques com a material molt útil per al¿estudi de la història de la medicina a nivell local. En aquest cas estudia les topografies mèdiques de la província de Burgos a partir de documents conservats a l¿Arxiu de la Reial Acadèmia de Medicina de Barcelona. També inclou un petit estudi sobre la biografia i obra del doctor Ildefonso Díez Santaolalla (1851-1929).

El Ácido cianhídrico a través de la historia

El llibre tracta des d'una perspectiva històrica els usos de l'àcid cianhí­dric, de la famí­lia dels cianurs, i les seves potencialitats letals. No es limita al seu ús com un dels verins més comuns i famosos al llarg de la història sinó que també recalca la seva presència a la vida quotidiana, a la indústria per exemple, fet que el converteix en un agent molt perillós.

Censura e Inquisición en las crónicas de Indias. De sus adversidades e infortunios

Desde su aparición hasta nuestros días, las crónicas de Indias han sufrido uncamino de infortunios. Entre los hechos que han contribuido a su escasa difusión,la falta de lectores o el poco reconocimiento, podemos destacar, en losprimeros siglos, la existencia del Tribunal Inquisitorial, las interferencias estatales en materia de Indias, la propia complejidad de las obras, las modas literarias, la rigidez de algún cura bien avenido con el poder, el temor a las copias y apropiaciones ilegales o las envidias y recelos entre los cronistas, ya fueran éstos laicos o religiosos (inquinas entre las órdenes). Asimismo, también las órdenes religiosas censuraban los documentos o textos de sus propios religiosos, cuando no encarcelaban a aquellos que sin su consentimiento habíanhecho públicas determinadas opiniones. Tal es el caso de «Motolinía», encarceladopor su propia orden, por haber escrito una Carta dirigida al emperador Carlos V contra Bartolomé de las Casas, sin previa autorización de sussuperiores...

Fray Toribio de Motolinía y la política colonial española: los Tributos y las leyes nuevas

La empresa providencial de la conquista y el recuerdo al buen caballeroy venturoso capitán, Hernando Cortés, conforman temáticamente la epístola proemial de la Historia de los indios de la Nueva España, de fray Toribio de Paredes, así como la historia de los pueblos precolombinos mexicas. Motolinía seguidamente pasará a arremeter contra los tributos que pesan sobre los indios. De esta manera, ya en el tratado primero, hará mención de las plagas que asolaron a las poblaciones amerindias tras la llegada de los españoles. A las tres primeras, la peste y el sarampión, las muertes ocasionadas por las guerras, y el hambre, llega la cuarta, esto es, la de los estancieros y negros que los conquistadores pusieron para cobrar los tributos. Así explica nuestro cronista el poder abusivo de tales hombres: «En los años primeros eran tan absolutos estos calpixques que en maltratar a los indios y en cargarlos y enviarlos lejos de su tierra y darles otros muchos trabajos, que muchos indios murieron por su causa y a sus manos, que es lo peor»...

Thrombin-receptor antagonist vorapaxar in acute coronary syndromes

Background: Vorapaxar is a new oral protease-activatedreceptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation. Methods: In this multinational, double-blind, randomized trial, we compared vorapaxar with placebo in 12,944 patients who had acute coronary syndromes without ST-segment elevation. The primary end point was a composite of death from cardiovascular causes, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization. RESULTS: Follow-up in the trial was terminated early after a safety review. After a median follow-up of 502 days (interquartile range, 349 to 667), the primary end point occurred in 1031 of 6473 patients receiving vorapaxar versus 1102 of 6471 patients receiving placebo (KaplanMeier 2-year rate, 18.5% vs. 19.9%; hazard ratio, 0.92; 95% confidence interval [CI], 0.85 to 1.01; P = 0.07). A composite of death from cardiovascular causes, myocardial infarction, or stroke occurred in 822 patients in the vorapaxar group versus 910 in the placebo group (14.7% and 16.4%, respectively; hazard ratio, 0.89; 95% CI, 0.81 to 0.98; P = 0.02). Rates of moderate and severe bleeding were 7.2% in the vorapaxar group and 5.2% in the placebo group (hazard ratio, 1.35; 95% CI, 1.16 to 1.58; P<0.001). Intracranial hemorrhage rates were 1.1% and 0.2%, respectively (hazard ratio, 3.39; 95% CI, 1.78 to 6.45; P<0.001). Rates of nonhemorrhagic adverse events were similar in the two groups. Conclusions: In patients with acute coronary syndromes, the addition of vorapaxar to standard therapy did not significantly reduce the primary composite end point but significantly increased the risk of major bleeding, including intracranial hemorrhage. (Funded by Merck; TRACER ClinicalTrials.gov number, NCT00527943.)

Acute coronary syndromes

Mehta et al. do not show any significant difference between early and delayed intervention in patients with acute coronary syndrome. In their study, 9.9% of patients in the...

Acute coronary syndromes

Mehta et al. do not show any significant difference between early and delayed intervention in patients with acute coronary syndrome. In their study, 9.9% of patients in the...

Acerca de la denominada Crónica de Zaragoza.

La denominada Cronica Caesaraugustana o Crónica de Zaragoza, atribuida generalmente a Máximo, obispo de esta ciudad, es una fuente muy valiosa para el conocimiento de la España visigoda. Nos proporciona noticias acerca de acontecimientos cuya memoria habría caído en el olvido de no ser por ella. Otras veces constituye nuestra referencia para poder datar hechos que otros textos reproducen sin ningún tipo de ubicación cronológica. Esta importancia, realmente indiscutible, ha propiciado que los investigadores la consulten y la citen en múltiples ocasiones.

Bivalirudin for patients with acute coronary syndromes

Background: Current guidelines for patients with moderate- or high-risk acute coronary syndromes recommend an early invasive approach with concomitant antithrombotic therapy, including aspirin, clopidogrel, unfractionated or low-molecular-weight heparin, and glycoprotein IIb/IIIa inhibitors. We evaluated the role of thrombin-specific anticoagulation with bivalirudin in such patients. Methods: We assigned 13,819 patients with acute coronary syndromes to one of three antithrombotic regimens: unfractionated heparin or enoxaparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin alone. The primary end points were a composite ischemia end point (death, myocardial infarction, or unplanned revascularization for ischemia), major bleeding, and the net clinical outcome, defined as the combination of composite ischemia or major bleeding. Results: Bivalirudin plus a glycoprotein IIb/IIIa inhibitor, as compared with heparin plus a glycoprotein IIb/IIIa inhibitor, was associated with noninferior 30-day rates of the composite ischemia end point (7.7% and 7.3%, respectively), major bleeding (5.3% and 5.7%), and the net clinical outcome end point (11.8% and 11.7%). Bivalirudin alone, as compared with heparin plus a glycoprotein IIb/IIIa inhibitor, was associated with a noninferior rate of the composite ischemia end point (7.8% and 7.3%, respectively; P = 0.32; relative risk, 1.08; 95% confidence interval [CI], 0.93 to 1.24) and significantly reduced rates of major bleeding (3.0% vs. 5.7%; P<0.001; relative risk, 0.53; 95% CI, 0.43 to 0.65) and the net clinical outcome end point (10.1% vs. 11.7%; P = 0.02; relative risk, 0.86; 95% CI, 0.77 to 0.97). Conclusions: In patients with moderate- or high-risk acute coronary syndromes who were undergoing invasive treatment with glycoprotein IIb/IIIa inhibitors, bivalirudin was associated with rates of ischemia and bleeding that were similar to those with heparin. Bivalirudin alone was associated with similar rates of ischemia and significantly lower rates of bleeding. (ClinicalTrials.gov number, NCT00093158.)