BACKGROUND & AIMS:Gastrointestinal bleeding (GIB) is common in patients with cardiovascular (CV) disease, but a complete understanding of subsequent outcomes is unknown. We assessed outcomes after GIB in patients with CV disease. METHODS:INTERBLEED is an international multicenter prospective study comparing adults with CV disease (coronary or peripheral arterial disease, heart failure, atrial fibrillation, cerebrovascular disease, or venous thromboembolic disease) with GIB to those without. Outcomes included major adverse cardiovascular events (MACE; myocardial infarction, stroke, or CV-related death), all-cause death, and recurrent GIB at 12 months. Multivariable regression modelling yielded odds ratios (ORs) with 95% confidence intervals (CIs), and reverse Kaplan-Meier curves were created. RESULTS:A total of 3814 patients were enrolled: 1612 patients with GIB and 2202 without. On multivariable analyses, patients with CV disease experiencing GIB were more likely to die within 12 months (OR, 2.29; 95% CI, 1.24-4.19). GIB was associated with recurrent GIB (OR, 4.28; 95% CI, 2.80-6.53) but not MACE. However, resumption of antithrombotic therapy between 4 and 7 days (OR, 0.37; 95% CI, 0.17-0.83) or 8 and 30 days (OR, 0.37; 95% CI, 0.17-0.81) after GIB were associated with lower odds of MACE within 12 months compared with discontinuation or lack of resumption within 60 days. Any antithrombotic use after enrollment was associated with lower all-cause death (OR, 0.45; 95% CI, 0.28-0.71). Neither antithrombotic use nor early resumption was associated with higher odds of recurrent GIB. CONCLUSIONS:GIB in patients with CV disease is independently associated with subsequent morbidity and mortality. Patterns in antithrombotic resumption were associated with outcomes. Further research into optimal antithrombotic management after GIB is essential.
ABSTRACT Background Clinical trials have demonstrated the long‐term efficacy of ustekinumab in the treatment of ulcerative colitis (UC). However, real‐world data on its long‐term effectiveness beyond 1 year of follow‐up remain limited. Methods This multicenter cohort study evaluated the effectiveness of ustekinumab in adults with UC treated in routine clinical practice for up to 4 years. Data were obtained from two prospective Dutch registries: IBDREAM and the ICC registry. The primary outcome was corticosteroid‐free remission at year 3, with remission defined as a hierarchical, composite endpoint based on endoscopic, biochemical, and clinical parameters. Subgroup analysis was performed in patients with difficult‐to‐treat IBD, defined as prior failure of ≥ 2 advanced therapies with different mechanisms of action. Secondary outcomes included dose escalation and safety. Results A total of 198 patients were included; median age was 49 years, 48% were women, median disease duration was 8 years, and 42.4% had difficult‐to‐treat IBD. At years 2, 3, and 4, 35.8% (49/137), 34.3% (34/99), and 26.6% (17/64) of patients were in corticosteroid‐free remission. Among patients in corticosteroid‐free remission at week 12 ( n = 83), 50.0% remained in remission at year 3. Corticosteroid‐free remission rates at year 3 in patients with difficult‐to‐treat IBD and other patients were 19.2% and 51.1%, respectively. One‐hundred‐seven adverse events were recorded in 64 patients, including six serious adverse events. Conclusion These real‐world data confirm the effectiveness of ustekinumab in inducing and maintaining remission for up to 4 years in UC. The medication was particularly effective in patients with limited prior exposure to advanced therapies. Results support the established safety profile of ustekinumab.
OBJECTIVE:To determine whether vaginal oestrogen therapy improves outcomes after prolapse surgery in postmenopausal women. DESIGN:Double-blind, randomised, placebo-controlled trial with 12 month follow-up. SETTING:Multicentre, 22 hospitals in the Netherlands. POPULATION:Postmenopausal women with POP-Q stage ≥ 2 scheduled for primary native-tissue prolapse repair. METHODS:Women were randomised (1:1) to vaginal oestriol cream (1 mg/g) or identical placebo, started 4-6 weeks preoperatively and continued to 12 months postoperatively (twice-weekly maintenance). MAIN OUTCOME MEASURE:Subjective improvement in prolapse symptoms at 12 months postoperatively, defined as "much" or "very much" improved on the Patient Global Impression of Improvement (PGI-I) scale. RESULTS:In total 293 women participated, 57 women dropped out. At 12 months, 92% of women in the oestrogen group versus 80% in the placebo group reported improvement on the PGI-I scale (p = 0.02). Pelvic floor-related quality of life was better in the oestrogen group (median score PFDI-20: 17 vs. 25, p = 0.03), and fewer women reported discomfort/pain (EQ-5D-5L: 61% vs. 77%, p = 0.04). Anatomical outcomes, composite surgical success, sexual function and reintervention rates did not differ between groups. The cream was easy to use; 80% would use it for 1 year if it provided meaningful health benefits. CONCLUSIONS:Perioperative vaginal oestrogen improved patient-reported outcomes and pelvic floor-related quality of life at 12 months, without affecting anatomical outcomes. These findings support discussing vaginal oestrogen as an adjunctive treatment option in shared decision-making with postmenopausal women undergoing primary prolapse surgery. TRIAL REGISTRATION:NL-OMON55535, https://www.onderzoekmetmensen.nl/en/trial/55535.
Elbow fractures in children represent a frequent but diagnostically challenging presentation in both primary and secondary care. Due to multiple ossification centers and often subtle clinical signs, these injuries are at risk of being overlooked. Missed fractures may result in malunion, growth disturbances, chronic pain, or long-term functional impairment. This review highlights three commonly underdiagnosed fracture types: medial epicondyle fractures, lateral condyle fractures, and supracondylar humeral fractures. Using illustrative case material, we discuss key aspects of clinical evaluation, pitfalls in radiographic interpretation, and the importance of systematic assessment of neurovascular status. In cases of persisting pain with initially normal radiographs, additional imaging such as oblique X-rays, ultrasound, or CT should be considered. Structured follow-up and timely referral to pediatricorthopedic expertise are essential to prevent complications. With a pragmatic, knowledge-based approach, clinicians can significantly reduce the risk of missed diagnoses and optimize functional outcomes for pediatric patients.
This article explores what highquality oncological care requires when cure is no longer possible. As the focus shifts toward quality of life, with or without active antitumor therapy, patients typically receive structured information when treatment is initiated, but far less explicit information when treatment is withheld. The absence of systematic discussion about symptom burden, likely disease trajectories, and prognostic uncertainty can negatively affect physical, psychosocial, and existential wellbeing. Clear, scenariobased information is essential not only for patients and their families but also for general practitioners, who often assume primary responsibility in later disease stages. Given the increasing complexity of treatment options and disease courses, oncologists should take the lead in outlining realistic prognostic scenarios. Providing equal attention to the expected course of illness and to treatmentrelated information helps ensure shared decisionmaking and equips general practitioners to deliver informed, careful, and continuous care.
