best medical treatment
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2021 ◽  
Author(s):  
Yvonne Rosenberg ◽  
Hartmut Görtz ◽  
Ulrich Rother ◽  
Christian Uhl ◽  
Konstantinos Stavroulakis ◽  
...  

ZusammenfassungDie periphere arterielle Verschlusskrankheit (PAVK) gilt als Volkskrankheit mit weltweit mehr als 230 Mio. Betroffenen und schlechter Prognose. Durch den systemischen und progressiven Charakter der Atherosklerose sowie den Befall vieler Gefäßbereiche ist neben dem Risiko für gefäßbedingte Amputationen auch die generelle Lebenserwartung deutlich eingeschränkt. Die strikte Ausschöpfung der konservativen Therapie gilt als wichtiges Fundament der komplementären Behandlung, wird aber nicht immer erfolgreich umgesetzt. Neben dem strukturierten Gehtraining, Raucherentwöhnung, Optimierung von Ernährung und Körpergewicht, Blutdrucktherapie sowie Normalisierung von Blutzucker- und Blutfettwerten gilt die optimale Arzneimitteltherapie als zentrales Behandlungsziel. Dieser Artikel soll laienverständliche evidenzbasierte Empfehlungen zur Optimierung des sogenannten Best Medical Treatment in der Behandlung der PAVK geben.


Stroke ◽  
2021 ◽  
Author(s):  
Alastair J.S. Webb ◽  
Amy Lawson ◽  
Karolina Wartolowska ◽  
Sara Mazzucco ◽  
Peter M. Rothwell ◽  
...  

Background and Purpose: Increased cerebral arterial pulsatility is associated with cerebral small vessel disease, recurrent stroke, and dementia despite the best medical treatment. However, no study has identified the rates and determinants of progression of arterial stiffness and pulsatility. Methods: In consecutive patients within 6 weeks of transient ischemic attack or nondisabling stroke (OXVASC [Oxford Vascular Study]), arterial stiffness (pulse wave velocity [PWV]) and aortic systolic, aortic diastolic, and aortic pulse pressures (aoPP) were measured by applanation tonometry (Sphygmocor), while middle cerebral artery (MCA) peak (MCA-PSV) and trough (MCA-EDV) flow velocity and Gosling pulsatility index (PI; MCA-PI) were measured by transcranial ultrasound (transcranial Doppler, DWL Doppler Box). Repeat assessments were performed at the 5-year follow-up visit after intensive medical treatment and agreement determined by intraclass correlation coefficients. Rates of progression and their determinants, stratified by age and sex, were determined by mixed-effects linear models, adjusted for age, sex, and cardiovascular risk factors. Results: In 188 surviving, eligible patients with repeat assessments after a median of 5.8 years. PWV, aoPP, and MCA-PI were highly reproducible (intraclass correlation coefficients, 0.71, 0.59, and 0.65, respectively), with progression of PWV (2.4%; P <0.0001) and aoPP (3.5%; P <0.0001) but not significantly for MCA-PI overall (0.93; P =0.22). However, PWV increased at a faster rate with increasing age (0.009 m/s per y/y; P <0.0001), while aoPP and MCA-PI increased significantly above the age of 55 years (aoPP, P <0.0001; MCA-PI, P =0.009). Higher aortic systolic blood pressure and diastolic blood pressure predicted a greater rate of progression of PWV and aoPP, but not MCA-PI, although current MCA-PI was particularly strongly associated with concurrent aoPP ( P <0.001). Conclusions: Arterial pulsatility and aortic stiffness progressed significantly after 55 years of age despite the best medical treatment. Progression of stiffness and aoPP was determined by high blood pressure, but MCA-PI predominantly reflected current aoPP. Treatments targetting cerebral pulsatility may need to principally target aortic stiffness and pulse pressure to have the potential to prevent cerebral small vessel disease.


Author(s):  
Ossama Y Mansour ◽  
Mahmoud Elhorany ◽  
Nader A Sourour ◽  
Frédéric Clarençon

Introduction : Distal vessel occlusions represent about 25–40% of acute ischemic stroke (AIS), either as primary occlusion or secondary occlusion complicating mechanical thrombectomy (MT) for large vessel occlusion. Our aim was to evaluate safety and effectiveness of MT associated with the best medical treatment (BMT) in the management of AIS patients with distal vessel occlusion in comparison with the BMT alone. Methods : Retrospective analysis was conducted on AIS patients treated by MT+BMT for primary distal vessel occlusion between 2015 and 2020, and were compared with a historic cohort managed by BMT alone between 2006 and 2015 selected based on the same inclusion criteria. A secondary analysis was conducted using propensity score matching (PSM) including the following: NIHSS, age and treatment with intravenous thrombolysis (IVT) as covariates. Results : Of 650 patients screened, 44 patients with distal vessel occlusions treated by MT+BMT were selected and compared with 36 patients who received BMT alone. After PSM, 28 patients in each group were matched without significant difference. Good clinical outcome defined as mRS≤2 was achieved by 53.6% of the MT+BMT group and 57% of the BMT group (OR, 0.87; 95%CI, 0.3–2.4; P = 1.00). The mortality rate was comparable in both groups (7% vs 10.7% in MT+BMT and BMT patients, respectively; OR = 0.64; 95%CI, 0.1‐4; P = 1.00). Symptomatic intracranial haemorrhage (ICH) was seen in only one patient treated by MT+BMT (3.6%). Conclusions : Mechanical thrombectomy seems to be comparable with the best medical treatment regarding the effectiveness and safety in the management of patients with distal vessel occlusions.


2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Tilman Reiff ◽  
Hans-Henning Eckstein ◽  
Ulrich Mansmann ◽  
Olav Jansen ◽  
Gustav Fraedrich ◽  
...  

Abstract Background Asymptomatic carotid artery stenosis (ACS) can be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or best medical treatment (BMT) only. For all treatment options, optimization of vascular risk factors such as arterial hypertension, hyperlipidemia, smoking, obesity, and insufficient physical activity is essential. Data on adherence to BMT and lifestyle modification in patients with ACS are sparse. The subject of this investigation is the implementation and quality of risk factor adjustment in the context of a randomized controlled trial. Methods A total of 513 patients in the prematurely terminated, randomized, controlled, multicenter SPACE-2 trial (ISRCTN 78592017) were analyzed within one year after randomization into 3 groups (CEA, CAS, and BMT only) for implementation of prespecified BMT recommendations and lifestyle modifications. Measurement time points were the screening visit and visits after one month (D30), 6 months (M6), and one year (A1). Differences between groups and follow-up visits (FUVs) relative to the screening visit were investigated. Findings For all FUVs, a significant increase in statin medication (91% at A1; p < 0.0001) was demonstrated to be associated with a significant decrease (p < 0.01) in cholesterol levels (median 167 mg/dl at A1) and LDL cholesterol levels (median 93 mg/dl at A1). The lowest cholesterol levels were achieved by patients in the BMT group. Seventy-eight percent of all patients reached predefined target cholesterol levels (< 200 mg/dl), with significantly better rates in the BMT group (p = 0.036 at D30). Furthermore, a significant decrease in arterial blood pressure at all FUVs (p < 0.05) was associated with a significant increase in antihypertensive medication (96% at A1, p < 0.0001). However, only 28% of patients achieved the predefined treatment goal of a systolic blood pressure of ≤ 130 mmHg. Forty-two of a total of 100 smokers at the screening visit quit smoking within one year, resulting in a significant increase in nonsmokers at all FUVs (p < 0.0001). Recommended HbA1c levels (< 7%) were achieved in 82% without significant changes after one year. Only 7% of obese (BMI > 25) patients achieved sufficient weight reduction after one year without significant changes at all FUVs (median BMI 27 at A1; p = 0.1201). The BMT group showed significantly (p = 0.024) higher rates of adequate physical activity than the intervention groups. Furthermore, after one year, the BMT group showed a comparatively significantly better implementation of risk factor modification (77%; p = 0.027) according to the treating physician. Interpretation SPACE-2 demonstrated sustained improvement in the noninterventional management of vascular risk factors in patients treated in a clinical trial by general practitioners, internists and neurologists. The best implemented treatment targets were a reduction in cholesterol and HbA1c levels. In this context, a significant increase in statin use was demonstrated. Blood pressure control missed its target but was significantly reduced by intensification of antihypertensive medication. Patients on BMT only had better adjusted lipid parameters and were more physically active. However, all groups failed to achieve sufficient weight reduction. Due to insufficient patient recruitment, the results must be interpreted cautiously. Trial registration: ISRCTN Registry, ISRCTN78592017, Registered 16 June 2007, https://www.isrctn.com/search?q=78592017.


QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Ahmed A Mohammed ◽  
Tarek A Hamdy ◽  
Anas M Askoura ◽  
Ahmed M Abdulhakim

Abstract Background Otitis media with effusion (OME) is a worldwide major health problem for both children and adult, who have a history of chronic eustachian tube dysfunction. Aim of the Work to review the effect of intratympanic injection of steroids in treatment of chronic otitis media with effusion (persistent more than 3 months after failure to medical treatment [e.g. local & systemic steroids or decongestants] or surgical ventilation tubes). Material and Methods This systematic review was done as a collective analysis of 5 retrospective and prospective cohort studies done on patients with OME. Studies on Patients who were diagnosed with chronic otitis media with effusion not responding to conventional methods of treatment. Results The data analysed and results showed an improvement of 41.2% of the cases treated with intratympanic injection of steroids compared to 11% improvement in cases treated by conventional medical methods with a relative improvement around 6.4 folds to intratympanic injection of steroids over medical treatment. All of these studies have shown that there are more advantages of directed ototopical steroid therapy over systemic therapy. Topical medications often have limited systemic effects due to their limited systemic uptake. It may be less expensive as compared to systemic medications. Conclusion Intratympanic injection of long acting steroids has good effect in management of OME resistant to medical and surgical treatment and has superior effect and high rate of recovery on local nasal steroid spray. In children combination of ventilation tubes and intratymapnic injection of steroids is the best known modality of treatment. Further studies are needed to evaluate the best medical treatment of chronic OME.


2021 ◽  
Vol 12 ◽  
Author(s):  
Peter B. Sporns ◽  
André Kemmling ◽  
Sarah Lee ◽  
Heather Fullerton ◽  
Wolfgang G. Kunz ◽  
...  

Rationale: Early evidence for the benefit of mechanical thrombectomy (MT) in pediatric patients with intracranial large vessel occlusion has been shown in previous retrospective cohorts. Higher-level evidence is needed to overcome the limitations of these studies such as the lack of a control group and the retrospective design. Randomized trials will very likely not be feasible, and several open questions remain, for example, the impact of arteriopathic etiologies or a possible lower age limit for MT. Save ChildS Pro therefore aims to demonstrate the safety and effectiveness of MT in pediatric patients compared to the best medical management and intravenous thrombolysis.Design: Save ChildS Pro is designed as a worldwide multicenter prospective registry comparing the safety and effectiveness of MT to the best medical care alone in the treatment of pediatric arterial ischemic stroke (AIS). It will include pediatric patients (&lt;18 years) with symptomatic acute intracranial arterial occlusion who underwent either MT or best medical treatment including intravenous thrombolysis.Outcomes: The primary endpoint of Save ChildS Pro is the modified Rankin Scale score at 90 days post-stroke. Secondary endpoints will comprise the decrease of the Pediatric National Institutes of Health Stroke Scale score from admission to discharge and rate of complications.Discussion: Save ChildS Pro aims to provide high-level evidence for MT for pediatric patients with AIS, thereby improving functional outcome and quality of life and reducing the individual, societal, and economic burden of death and disability resulting from pediatric stroke.Clinical Trial Registration: Save ChildS Pro is registered at the German Clinical Trials Registry (DRKS; identifier: DRKS00018960).


Stroke ◽  
2021 ◽  
Author(s):  
Lukas Meyer ◽  
Matthias Bechstein ◽  
Maxim Bester ◽  
Uta Hanning ◽  
Caspar Brekenfeld ◽  
...  

Background and Purpose: This study evaluates the benefit of endovascular treatment (EVT) for patients with extensive baseline stroke compared with best medical treatment. Methods: This retrospective, multicenter study compares EVT and best medical treatment for computed tomography (CT)–based selection of patients with extensive baseline infarcts (Alberta Stroke Program Early CT Score ≤5) attributed to anterior circulation stroke. Patients were selected from the German Stroke Registry and 3 tertiary stroke centers. Primary functional end points were rates of good (modified Rankin Scale score of ≤3) and very poor outcome (modified Rankin Scale score of ≥5) at 90 days. Secondary safety end point was the occurrence of symptomatic intracerebral hemorrhage. Angiographic outcome was evaluated with the modified Thrombolysis in Cerebral Infarction Scale. Results: After 1:1 pair matching, a total of 248 patients were compared by treatment arm. Good functional outcome was observed in 27.4% in the EVT group, and in 25% in the best medical treatment group ( P =0.665). Advanced age (adjusted odds ratio, 1.08 [95% CI, 1.05–1.10], P <0.001) and symptomatic intracerebral hemorrhage (adjusted odds ratio, 6.35 [95% CI, 2.08–19.35], P <0.001) were independently associated with very poor outcome. Mortality (43.5% versus 28.9%, P =0.025) and symptomatic intracerebral hemorrhage (16.1% versus 5.6%, P =0.008) were significantly higher in the EVT group. The lowest rates of good functional outcome (≈15%) were observed in groups of failed and partial recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 0/1–2a), whereas patients with complete recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 3) with recanalization attempts ≤2 benefitted the most (modified Rankin Scale score of ≤3:42.3%, P =0.074) compared with best medical treatment. Conclusions: In daily clinical practice, EVT for CT–based selected patients with low Alberta Stroke Program Early CT Score anterior circulation stroke may not be beneficial and is associated with increased risk for hemorrhage and mortality, especially in the elderly. However, first- or second-pass complete recanalization seems to reveal a clinical benefit of EVT highlighting the vulnerability of the low Alberta Stroke Program Early CT Score subgroup. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03356392.


2021 ◽  
Vol 8 ◽  
Author(s):  
Gerlinde Logghe ◽  
Bram Trachet ◽  
Patrick Segers ◽  
Julie De Backer ◽  
Joscha Mulorz ◽  
...  

Objective: Thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) aims to induce false lumen (FL) thrombosis by sealing intimal tears between the true (TL) and the FL, and blocking the inflow into the FL. Incomplete thrombosis of the FL is correlated with poor clinical outcome. We hypothesize that the number of major and minor branches arising from the FL affects FL patency and may negatively influence TEVAR induced FL thrombosis.Methods: Computed tomography (CT)-scans from 89 patients diagnosed with TBAD [best medical treatment (BMT) n = 52, TEVAR n = 37] from two high-volume vascular surgery centers were analyzed retrospectively. Analysis included evaluation of the FL patency status, the number, location and size of intimal tears, and the presence of minor and major side branches originating from the FL. Multiple regression analysis was conducted to evaluate obtained parameters as predictors for FL thrombosis status.Results: In univariate analysis, the strongest correlation for FL patency was found for the number of major (R = 0.79) and minor (R = 0.86) side branches originating from the FL. When applying a multiple linear regression model, the number of major (normalized beta 0.37; P &lt; 0.001) and minor (normalized beta 0.41; P &lt; 0.01) side branches arising from the FL were valid predictors for the axial length of the patent and non-patent FL, and additionally determined the length of the patent FL at 12-month follow-up in patients that underwent TEVAR.Conclusions: Our data suggest that the number of minor side branches that originate from the FL in TBAD is an important determinant of FL patency, to a greater degree than previously assumed.


2021 ◽  
Vol 12 ◽  
Author(s):  
Philipp Gruber ◽  
Samarth Singh ◽  
Lukas Andereggen ◽  
Jatta Berberat ◽  
Luca Remonda

Symptomatic intracranial atherosclerotic disease (sICAD) remains a challenging disorder in the neurovascular field. Despite best medical treatment, the recurrence rate for stroke remains high in patients with intracranial high-grade stenosis (&gt;70–99%). Furthermore, two large randomized trials (SAMMPRIS and VISSIT) failed to prove the efficacy of percutaneous transluminal angioplasty and stenting in patients with sICAD. Drug-coated balloon percutaneous transluminal angioplasty (DCB-PTA) represents an alternative treatment modality with therapeutic benefits for interventional cardiology. However, there are very few articles in the existing literature that relate to the use of DCB-PTA in sICAD patients. Here, we aimed to review the rationale underlying the use of DCB-PTA in sICAD patients and summarize recent developments in the neurovascular field.


2021 ◽  
Vol 14 (7) ◽  
pp. e239187
Author(s):  
Victoria Liu ◽  
Adnan Pirbhai ◽  
Syed Faraz Masood

A 67-year-old woman presented with painful, acute vision loss after 5 days of fever and muscle aches while visiting the Dominican Republic. She had no recent history of ocular surgery, dental work or recent trauma. Anterior chamber aspiration confirmed an initial diagnosis of endogenous endophthalmitis, positive for Streptococcus mitis that progressed to panophthalmitis on return to Canada. Treatment included systemic antibiotics, intravitreal antibiotics and intravitreal dexamethasone. Despite the best medical treatment, the left eye progressed to corneal perforation 5 weeks after presentation. An evisceration with fitted orbital implant was successful in alleviating pain following the surgery. S. mitis is a rare, but possible cause of endogenous endophthalmitis and panophthalmitis. It was important to work with a multidisciplinary and global team to coordinate and offer appropriate treatment measures. Although vision was lost, evisceration of the left eye provided ocular comfort and good cosmetic outcomes for the patient.


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