Improving drug adherence using fixed combinations caused beneficial treatment outcomes and decreased health-care costs in patients with hypertension.

We enrolled 196 patients with hypertension who were already being treated with free-drug combinations of angiotensin-II receptor blocker (ARB) and amlodipine. The free-drug combinations of ARB and amlodipine were replaced with the same dose of the fixed-dose combinations. The average home blood pressure (BP) in all patients receiving fixed-dose combinations was significantly lower than those receiving free-drug combinations (131 ± 10/75 ± 8 vs. 136 ± 11/77 ± 9 mm Hg, P < .01) accompanied with increasing drug adherence. After lowering BP by fixed-dose combinations, the costs for medications decreased by 31% over the 3 months.

Medtronic Hall valve malfunction due to pannus formation in the aortic position with peculiar movement of the leaflet: a case report.

A 63-year-old woman who had undergone aortic valve replacement (AVR) with a 22-mm Medtronic Hall valve in May 1994 was admitted to the authors' hospital in June 2006 with epigastric pain and nausea. She presented with sudden precipitous deterioration of hemodynamics under high-dose catecholamines, but this improved in ca. 10 min. Valve motion was observed with fluoroscopy for a brief period as prosthetic valve dysfunction was suspected. After 10 min, transient insufficiency in closure of the prosthetic valve was revealed. The patient was diagnosed with prosthetic valve malfunction and referred for an urgent operation. At surgery, pannus was identified at the left ventricular aspect of the prosthetic valve in the aortic position, and this directly restricted leaflet movement during the closing phase. The leaflet movement showed no consistent pattern, but normal movement and half-closure occurred regularly to generate a phenomenon in which alternating normal hemodynamics and low-output syndrome was observed. The patient underwent AVR with a 17-mm St. Jude Medical Regent valve, and was discharged without any complications.

Pulmonary embolism is an important cause of death in young adults.

BACKGROUND: Population-based analysis shows that deaths from pulmonary embolism (PE) are increasing in the older age groups, but it is unclear to what degree PE contributes to death in different ages and gender. METHODS AND RESULTS: Potential contribution factors for all PE and for critical PE (in which PE was the primary cause of death or the main diagnosis) were examined in 396,982 autopsy cases. For all PE, odds ratio (OR) in males was 0.61 (95% confidence interval (CI) 0.59-0.64, p<0.0001), compared with that in females. ORs were 1.10 (95% CI 1.05-1.14, p<0.0001) in 1991-1994 and 1.19 (95% CI 1.14-1.25, p<0.0001) in 1995-1998, compared with those in 1987-1990. ORs for ages 0-9 and 40+ were significantly low compared with that for ages 20-39. For critical PE, similar results were obtained. Pregnancy and/or delivery were found in 38.5% in cases of critical PE in females aged 20-39. CONCLUSION: Compared with other age groups, PE contributed more to deaths in those aged 20-39 years. In recent years, deaths from PE have been slightly but significantly increasing. The incidence of clinically diagnosed critical PE also has been increasing.

Unusual pulmonary embolism: septic pulmonary embolism and amniotic fluid embolism.

BACKGROUND: Septic and amniotic fluid emboli are rare sources of pulmonary embolism (PE), so the present study sought to elucidate the background of these cases. METHODS AND RESULTS: A total of 11,367 PE cases were identified from 396,982 postmortem examinations. The incidence of septic PE was 247 (2.2%) of the total. The origin of infection was found in 85.6% of the cases. Fungal embolus was detected more often than bacterial embolus. The most frequently detected fungus was aspergillus (20.8%). The primary disease associated with fungal embolus was leukemia (43.2%). The incidence of PE cases associated with pregnancy and/or delivery was 89 (0.8%) of the total PE cases. Among them, amniotic fluid embolism was found in 33 (73.3%) of 45 PE cases with vaginal delivery, and in 7 (21.2%) of 33 PE cases with cesarean delivery (p<0.0001). CONCLUSION: Fungal embolus was more frequent than bacterial embolus, and leukemia was most frequent as the primary disease in cases of fungal embolus. The main cause of PE in cesarean section cases was thrombotic embolism, and the main cause in vaginal delivery cases was amniotic fluid embolism.

Cancer and pulmonary embolism: thrombotic embolism, tumor embolism, and tumor invasion into a large vein.

BACKGROUND: The specific incidence of thrombotic pulmonary embolism (PE), tumor PE and tumor invasion into large veins according to tumor type and tumor site remains unclear. METHODS AND RESULTS: A total of 65,181 cancer patients were identified from 98,736 postmortem examinations. Thrombotic PE occurred in 2.32% of all cancer patients and comprised 88.6% of the total number of all PE events. The incidence of thrombotic PE was high in those with adenocarcinoma, leukemia and large cell carcinoma, and was low in those with hepatic cell carcinoma. The incidence of PE was high when tumor was present in hematogenous tissue, lungs, ovaries, pancreas and the biliary system, and was low when tumor was present in the liver. The incidence of tumor PE was high with large cell carcinoma, hepatic cell carcinoma and adenocarcinoma, and was also high when tumor was present in the lungs, ovaries, kidneys and liver. There was a significant correlation between the incidence of tumor PE and the incidence of tumor invasion into large veins. CONCLUSION: The incidence of thrombotic PE, tumor PE and tumor invasion into large veins varies significantly according to tumor histopathology and tumor site.

Triggers of acute pulmonary thromboembolism developed in hospital, with focusing on toilet activities as triggering acts.

BACKGROUND: The recognition of the trigger which is the action leading to the occurrence of acute pulmonary thromboembolism (APTE) is important to perform early diagnosis and early management of APTE. METHODS AND RESULTS: The trigger of APTE in 138 patients who developed APTE in hospital was investigated. The triggers of APTE were specified in 57 patients. Approximately half of these patients developed APTE during toilet activities (defecation and micturition). Mortality of the patients with APTE associated with toilet activities was 33%. APTE associated with toilet activities was independently related to a recent major surgery, heart diseases and a recent angiography. CONCLUSIONS: Defecation and micturition would be common triggers of APTE after operation and angiography, especially in patients with cardiac dysfunction.

Association between antithrombotic treatments and prognosis of patients with acute pulmonary thromboembolism in Japan.

The utility of thrombolysis in patients with acute pulmonary thromboembolism (APTE) remains controversial, although anticoagulation therapy for APTE is well-established in Western countries. Nonetheless, large clinical trials of antithrombotic treatments for APTE have yet to be performed in Japan. In the present study, the association between antithrombotic treatments (thrombolysis and anticoagulation) and the clinical outcomes was retrospectively investigated in 225 APTE patients. In-hospital mortality was significantly lower in hemodynamically stable patients who received anticoagulation therapy than in those who received no adequate therapy (0% vs 33%). Thrombolysis in patients with or without cardiogenic shock failed to improve the in-hospital outcomes compared with those who received anticoagulation treatment (8% vs 3%). There was no significant difference in the bleeding rate between patients receiving thrombolysis and anticoagulation (3% vs 3%). These results indicate that anticoagulation could reduce the mortality of hemodynamically stable APTE patients and that the outcome after thrombolysis or anticoagulation treatment was similar. However, this study was limited because it was executed retrospectively. Further prospective randomized trials to investigate the efficacy of thrombolysis in Japan should be performed to completely address this issue.

Prognostic significance of early diagnosis in acute pulmonary thromboembolism with circulatory failure.

Despite the advances in our understanding of venous thromboembolic disease, the prevalence of pulmonary thromboembolism (PTE) at autopsy has not changed over 3 decades. When patients survive long enough to have a diagnosis of massive PTE and start receiving treatment, the outlook is considered to be moderately good. However, the diagnosis is often difficult to obtain and is frequently missed. We hypothesize that mortality of acute PTE is reduced by early diagnosis. Eighty-five patients with acute PTE with circulatory failure who survived 1 h after the onset were divided into two groups: the early Dx group consisted of the patients whose disease was diagnosed as acute PTE within 24 h of the onset, and the Late Dx group included patients whose disease was not diagnosed within 24 h of onset, or died without clinical diagnosis between 1 and 24 h after the onset. Overall mortality was significantly low in the Early Dx group compared with that of the Late Dx group (21.6% vs 67.6%, P < 0.0001). Multiple logistic regression analysis demonstrated that a reduction in in-hospital mortality was associated with early diagnosis (odds ratio for in-hospital death, 0.094; 95% confidence interval, 0.03-0.33). The results of our study suggested that early diagnosis might favorably affect the in-hospital clinical outcome of hemodynamically unstable patients with acute PTE.

[Clinical experience with retrievable vena cava filters for prevention of pulmonary thromboembolism].

OBJECTIVES: To evaluate the feasibility, effectiveness and complications of the retrievable vena cava filter [Güther tulip vena cava filter(GTF)] for the prevention of pulmonary thromboembolism in patients with deep vein thrombosis. METHODS: Seventeen patients, 3 males and 14 females, aged 21 to 82 years (mean age 59 +/- 19 years), underwent implantation of GTFs between December 2000 and February 2002 at Mie University Hospital. All patients were treated under diagnoses of deep vein thrombosis with or without pulmonary thromboembolism based on venous ultrasonography, venography or computed tomography. Eleven patients were treated with thrombolysis. RESULTS: Significant thromboembolus was trapped within the filter in 3 of 12 patients. No acute pulmonary thromboembolism occurred during implantation or at retrieval of the GTF. Retrieval of the GTF was attempted in 9 patients, and 8 GTFs were retrieved successfully. Mean interval of the filter implantation was 13.4 +/- 6.3 days and the mean retrieval time was 4.8 +/- 3.2 min. No complications occurred except for one case of minor hemorrhage at the puncture site. CONCLUSIONS: The placement and retrieval of the retrievable vena cava filter was feasible and safe. This filter was also effective for the prevention of pulmonary thromboembolism. This retrievable vena cava filter may be a good first-choice filter for both permanent and temporary use.