Aspirin to Prevent Recurrent Venous Thromboembolism

Taken together, two trials suggest that aspirin is moderately effective.

In the recent Italian WARFASA trial, aspirin lowered the incidence of recurrent venous thromboembolism (VTE) after first unprovoked VTE events (JW Gen Med May 24 2012). Now, in an international study (ASPIRE), investigators have addressed the same issue in 822 adults who completed 3 to 12 months of standard anticoagulation therapy for unprovoked VTE (42% with pulmonary embolism, 57% with proximal deep venous thrombosis only). Patients then were randomized to receive either 100 mg of aspirin or placebo daily. During average follow-up of 3 years, the following outcomes were noted:

• In the intent-to-treat analysis, the annual rate of recurrent VTE (the primary outcome) was 6.5% in the placebo group and 4.8% in the aspirin group (P=0.09).
• The annual rate of a secondary outcome — a composite of VTE events, myocardial infarction, stroke, or cardiovascular death — was 8.0% in the placebo group and 5.2% in the aspirin group (P=0.01).
• Major bleeding occurred in six placebo recipients and eight aspirin recipients.
• All-cause mortality was 4% in both groups.

Comment: After completing initial courses of anticoagulation, patients with unprovoked VTE are at high risk for recurrence. Indefinite continuation of warfarin lowers that risk substantially but confers considerable ongoing bleeding risk. Aspirin offers a reasonable compromise for such patients. In ASPIRE, a reduction in the VTE endpoint with aspirin didn't quite reach statistical significance, but a combined venous–arterial endpoint did. Because the ASPIRE and WARFASA trials were nearly identical, the two research teams planned prospectively to pool their results. The pooled results appear in this report: Aspirin lowered risk for recurrent VTE by 32% (P=0.007) and lowered risk for combined vascular events (venous and arterial) by 34% (P=0.002) without significantly raising risk for major bleeding.
— Allan S. Brett, MD
Published in Journal Watch General Medicine November 4, 2012
CITATION:
Brighton TA et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 2012 Nov 4; [e-pub ahead of print]. [Link to free full-text NEJM article PDF | Medline® abstract]

República Bananera de Guatemala

Written by Martín Rodríguezon November 26, 2012—Leave a Comment

Cuando ya parecía que los diputados y los empresarios no podían desprestigiar más la política y al Congreso, llegó la ley Tigo. Es un momento cúspide de la democracia. Nos enseñará si el Presidente está tan vendido como la gran mayoría de nuestros diputados y si el MP y las Cortes pueden juzgar a los políticos y empresarios más importantes de nuestro país.
Hay países en donde la dignidad de los políticos vale menos que verse al espejo y entonces “se concede en usufructo bienes públicos para traer el desarrollo”. Guatemala ha sido parte de esos países entreguistas, llamados repúblicas bananeras. Concesionamos las tierras para la UFCO, la línea aérea, las bandas de celular, todos los canales de televisión abierta, los puertos y aeropuertos, el subsuelo, la energía eléctrica, todo. El 90 por ciento de nuestra historia de casi 200 años como República.
Como ahora estamos en el año 2012 y los asuntos públicos se administran con un poquito más de transparencia; como ahora tenemos una clase media pujante que puede tener dignidad; como ahora tenemos fiscales y jueces que meten presos a militares matones (si la CC no lo revierte), a narcos, a políticos y empresarios; como ahora todo el dinero se puede rastrear, uno pensaría que los políticos no se animarían a conceder como república bananera la banda ancha para teléfonos, la televisión, la radio y el internet para siempre. Miles de millones de quetzales que les pudimos cobrar a las empresas y se perdieron para escuelas, hospitales, seguridad social o el organismo judicial.
Pero casi todo el PP, liderado por Pérez, Baldetti, Sinibaldi y Rivera; la bancada Todos y las otras bancadas de los Alejos; casi todo el bloque de Lider, de Baldizón; y el partido Unionista de Arzú; aprobaron sin discusión la entrega de estos bienes públicos. Ley promovida por la empresa Tigo, propiedad del ex ministro de Comunicaciones del gobierno de Cerezo, Mario López.
Tanto descaro no puede sino recibir dos respuestas de parte de la institucionalidad pública. El presidente Pérez, el que se ofreció en campaña como un institucionalista, un defensor de los intereses nacionales, tiene que vetarla. E independientemente de que la vete, el MP y los jueces (los bancos, que son tan dignos, seguro ayudarán) tienen que llevarlos presos por querernos ver la cara de estúpidos. Si no, ya dejemos de llamarnos democracia y añadamos una palabra al nombre del país: República Bananera de Guatemala.

http://martinrodriguezpellecer.com/2012/11/26/88-republica-bananera-de-guatemala/

Requested DocAlert: Do Omega-3 Fatty Acid Supplements Prevent Heart Disease? Meta-analysis and Systematic Review Results

Title: Association Between Omega-3 Fatty Acid Supplementation and Risk of Major Cardiovascular Disease Events: A Systematic Review and Meta-Analysis
Date Posted: September 11, 2012
Authors: Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS.
Citation: JAMA 2012;308:1024-1033. [JAMA abstract]
Study Question:
What is the effect of omega-3 fatty acid supplementation on major cardiovascular outcomes?
Methods:
A systematic review and meta-analysis was conducted using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through August 2012. Criteria for inclusion included randomized controlled clinical trials evaluating the effect of omega-3 on all-cause mortality, cardiac death, sudden death, myocardial infarction, and stroke. Subgroup analyses were performed for the presence of blinding, and whether primary or secondary prevention. Meta-regression analyses were performed for the omega-3 dose. A statistical significance threshold of 0.0063 was assumed after adjustment for multiple comparisons.
Results:
Of the 3,635 citations retrieved, 20 studies of 68,680 patients were included, reporting 7,044 deaths, 3,993 cardiac deaths, 1,150 sudden deaths, 1,837 myocardial infarctions, and 1,490 strokes. No statistically significant association was observed with all-cause mortality, cardiac death, sudden death, myocardial infarction, and stroke when all supplement studies were considered.
Conclusions:
Overall, omega-3 polyunsaturated fatty acid supplementation was not associated with a lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke based on relative and absolute measures of association.
Perspective:
Among the known and putative benefits of dietary and supplemental omega-3 PUFAs include their ability to lower triglyceride levels (at the expense of raising low-density lipoprotein cholesterol), prevent atrial fibrillation and sudden death, decrease platelet aggregation, lower blood pressure, reduce depression, and improve cognitive function. The inability to demonstrate a clear benefit despite the large clinical trials is similar to the anti-oxidant vitamin supplements. Despite the attempts to neutralize differences in study designs, a neutral meta-analysis does not establish lack of benefit, albeit it blunts the enthusiasm. Among the concerns drawing conclusions from this report are that of the 20 studies included, only eight had 3 or more years of follow-up and four included primary and secondary prevention. Would anyone accept this design in a statin or antiplatelet trial?
Author(s):
Melvyn Rubenfire, M.D., F.A.C.C. (Disclosure)
Topic(s):
Prevention/Vascular, General Cardiology
© 2012 American College of Cardiology Foundation

Jazzanova, verdaderamente buenos !!!

http://www.youtube.com/watch?v=Z9sQEOfIy8g&feature=em-share_video_user

Should You Warn Patients About Substandar​d Colleagues​?

Introduction

Have you ever been caught between loyalty to another physician whose skills you don't respect, and wanting to warn a patient if you knew they were scheduled to have a procedure performed by that physician?
More than 24,000 physicians answered this question in Medscape's 2012 Top Ethical Dilemmas Survey Report. Some felt that it just wasn't their business to tell a patient. "I wouldn't destroy a patient-doctor relationship by interjecting myself," said one reader.
Others said it was their duty to make sure that patients are protected from potential harm at the hands of substandard colleagues. "The phrase 'do no harm' includes protecting patients from harm," one respondent said. In addition, substandard physicians harm not only patients but also the entire medical profession, as one reader pointed out. "We must stop protecting our less proficient colleagues, since they're the ones driving up our malpractice costs."
Close to one half of the respondents (47%) said that they would inform the patient, but 16% said "no," and 37% said "it depends."
"I think it very much depends on the situation," confirms Kenneth Prager, MD, Professor of Clinical Medicine and Director of Clinical Ethics, Columbia University Medical Center, New York, New York. "The question is nuanced and complicated, with a spectrum of scenarios that are highly individual."
Even respondents who felt strongly about informing the patients commented that the particular circumstances would influence their action. In the words of one respondent, "This is very touchy!"

How Close Are You to the Patient?

Many respondents said that they would inform only if it were their own patient, family member, or friend. "If you have no relationship with the patient, then keep your opinions to yourself," one reader advised.
Others felt that the nature of the relationship was less important than the personality of the patient. "It depends on how receptive the patient would be to my input," a respondent wrote. Another quipped, "It depends on the patients' reputation for bringing lawsuits." And some thought the nature of the patient's relationship with the other physician played a role in the decision. "How invested are they in the other doctor?" one respondent queried. "Are they a regular patient, or is this a one-time procedure?"
A large number of respondents felt that the only important issue is whether the patient has asked for an opinion about the other physician. "I'd inform the patient only if the patient initiated the question," one reader said. Another added, "I wouldn't hunt down every patient on the other physician's schedule to issue a warning."
Several respondents felt that the seriousness and the complexity of the procedure make a difference. "I'd be less worried about a cholecystectomy than I would about major cancer surgery," one wrote.

Fuente: http://www.medscape.com/viewarticle/775585?src=wnl_edit_medp_imed&spon=18