Patient reported exposure to smoking and alcohol abuse are associated with pain and other complications in patients with chronic pancreatitis

Background/objectivesSmoking and alcohol abuse are established risk factors for chronic pancreatitis (CP). Few studies have examined how exposure to smoking and alcohol abuse act as risk factors for complications in CP. Our aim was to examine associations between patient reported exposure to smoking and alcohol abuse and complications in CP in a large cohort of patients from the Scandinavian and Baltic countries.MethodsWe retrieved data on demographics, CP related complications and patients’ histories of exposure to smoking and alcohol abuse from the Scandinavian Baltic Pancreatic Club database. Associations were investigated by univariate and multivariate logistic regression analyses. Results are presented as odds ratios (OR) with 95% confidence intervals.ResultsA complete history of smoking and alcohol exposure was available for 932 patients. In multivariate regression analyses, the presence of pain and exocrine pancreatic insufficiency were both significantly associated with history of smoking (OR 1.94 (1.40–2.68), p < 0.001 and OR 1.89 (1.36–2.62), p < 0.001, respectively) and alcohol abuse (OR 1.66 (1.21–2.26), p = 0.001 and 1.55 (1.14–2.11), p = 0.005, respectively). Smoking was associated with calcifications (OR 2.89 (2.09–3.96), p < 0.001), moderate to severe ductal changes (OR 1.42 (1.05–1.92), p = 0.02), and underweight (OR 4.73 (2.23–10.02), p < 0.001). History of alcohol abuse was associated with pseudocysts (OR 1.38 (1.00–1.90) p = 0.05) and diabetes mellitus (OR 1.44 (1.03–2.01), p = 0.03). There were significantly increased odds-ratios for several complications with increasing exposure to smoking and alcohol abuse.ConclusionSmoking and alcohol abuse are both independently associated with development of complications in patients with CP. There seems to be a dose-dependent relationship between smoking and alcohol abuse and complications in CP.     

Pain and aetiological risk factors determine quality of life in patients with chronic pancreatitis,but a brick in the puzzle is missing

Background and objectivesChronic pancreatitis (CP) is a debilitating fibro-inflammatory disease with a profound impact on patients’ quality of life (QOL). We investigated determinants of QOL in a large cohort of CP patients.MethodsThis was a multicentre study including 517 patients with CP. All patients fulfilled the EORTC QLQ-C30 questionnaire. Questionnaire responses were compared to results obtained from a general reference population (n = 11,343). Demographic characteristics, risk factors (smoking and alcohol consumption), pain symptoms, disease phenotype (complications) and treatments were recorded. A multivariable regression model was used to identify factors independently associated with QOL scores.ResultsIncluded patients had a mean age of 56.3 ± 12.8 years, 355 (69%) were men and 309 (60%) had alcohol aetiology. Compared to the reference population, patients with CP had lower global health status (50.5 vs. 66.1; p < 0.001) as well as reduced scores for all functional scales (all p < 0.001). Additionally, CP patients reported a higher burden for all symptom items, with pain being the most prominent complaint (all p < 0.001). Constant pain (coefficient −11.3; p = 0.02), opioid based pain treatment (coefficient −19.7; p < 0.001) and alcoholic aetiology (coefficient −5.1; p = 0.03) were independently associated with lowered global health status. The final multivariable model explained 18% of the variance in global health status.ConclusionsPatients with CP have significantly lower QOL compared to a population-based reference population. Factors independently associated with a lowered QOL are constant pain, opioid based pain treatment and alcohol aetiology. However, these factors only explain a fraction of QOL and additional factors need identification.     

Early occurrence of pseudocysts in acute pancreatitis – A multicenter international cohort analysis of 2275 cases

BackgroundPseudocysts being the most frequent local complications of acute pancreatitis (AP) have substantial effect on the disease course, hospitalization and quality of life of the patient. Our study aimed to understand the effects of pre-existing (OLD-P) and newly developed (NEW-P) pseudocysts on AP.MethodsData were extracted from the Acute Pancreatitis Registry organized by the Hungarian Pancreatic Study Group (HPSG). 2275 of 2461 patients had uploaded information concerning pancreatic morphology assessed by imaging technique. Patients were divided into “no pseudocyst” (NO-P) group, “old pseudocyst” (OLD-P) group, or “newly developed pseudocyst” (NEW-P) groups.ResultsThe median time of new pseudocyst development was nine days from hospital admission and eleven days from the beginning of the abdominal pain. More NEW-P cases were severe (15.9% vs 4.7% in the NO-P group p < 0.001), with longer length of hospitalization (LoH) (median: 14 days versus 8 days, p < 0.001), and were associated with several changed laboratory parameters. OLD-P was associated with male gender (72.2% vs. 56.1%, p = 0.0014), alcoholic etiology (35.2% vs. 19.8% in the NO-P group), longer hospitalization (median: 10 days, p < 0.001), a previous episode of AP (p < 0.001), pre-existing diagnosis of chronic pancreatitis (CP) (p < 0.001), current smoking (p < 0.001), and increased alcohol consumption (unit/week) (p = 0.014).ConclusionMost of the new pseudocysts develop within two weeks. Newly developing pseudocysts are associated with a more severe disease course and increased length of hospitalization. Pre-existing pseudocysts are associated with higher alcohol consumption and smoking. Because CP is more frequently associated with a pre-existing pseudocyst, these patients need closer attention after AP.     

Exocrine pancreas insufficiency in chronic pancreatitis – Risk factors and associations with complications. A multicentre study of 1869 patients

Background/objectivesThere is scarce information about risk factors for exocrine pancreas insufficiency (EPI) in chronic pancreatitis (CP), and how it associates with other complications. The aim of the present study was to examine risk factors for EPI and associations to procedures and other CP related complications in a large, Northern European cohort.Patients and methodsWe retrieved cross-sectional data on demographics, status on EPI, aetiological risk factors for CP, CP related complications as well as surgical and endoscopic treatment from the Scandinavian Baltic Pancreatic Club Database. Associations were assessed by univariate and multivariate logistic regression analyses. Results are presented as odds ratios (OR) with 95% confidence intervals.ResultsWe included 1869 patients with probable or definitive CP in the study. Exocrine pancreas insufficiency was present in 849 (45.4%) of patients. In multivariate analyses, EPI associated with smoking aetiology (OR 1.47 (1.20–1.79), p < 0.001), and nutritional/metabolic aetiology (OR 0.52 (0.31–0.87), p = 0.01) to CP. Pancreatic or common bile duct stenting procedure and pancreatic resection were both associated with EPI (ORs 1.44 (1.15–1.80), p = 0.002 and 1.54 (1.02–2.33), p = 0.04, respectively). The presence of diabetes mellitus (OR 2.45 (1.92–3.15), p < 0.001), bile duct stenosis (OR 1.48 (1.09–2.00), p = 0.02) and underweight (2.05 (OR 1.40–3.02), p < 0.001) were all associated with presence of EPI.ConclusionsSmoking, bile duct stenosis, previous stenting and resection procedures are all associated with EPI in patients with CP. Presence of EPI were also associated with malnutrition and diabetes mellitus. Hence, intensive nutritional surveillance is needed in these patients.     

Risk factors for development of endocrine insufficiency in chronic pancreatitis

Endocrine insufficiency is a common and frequent complication of chronic pancreatitis. Identifying the role of pancreatic damage in the development of diabetes is important for early identification and appropriate management.MethodsAll consecutive CP patients between January 2019 and May 2020 were retrospectively studied. Relevant statistical tests were performed. A two sided p value < 0.05 was considered statistically significant.ResultsTotal 587 chronic pancreatitis patients were included of which 118 (20.1%) patients developed diabetes with duration of 12 (IQR 4–48) months. Older age (OR 1.079; 95% CI 1.045–1.113; p < 0.001), presence of pancreatic parenchymal (OR 2.284; 95% CI 1.036–5.038; p = 0.041) and ductal (OR 2.351; 95% CI 1.062–5.207; p = 0.035) calcifications, exocrine insufficiency (OR 6.287; 95% CI 2.258–17.504; p < 0.001), and pancreatic duct stricture (OR 3.358; 95% CI 1.138–9.912; p = 0.028) were independently associated with development of diabetes mellitus in chronic pancreatitis patients. On cox-regression analysis, smoking (HR 2.370; 95% CI 1.290–4.354; p = 0.005) and pancreatic ductal calcification (HR 2.033; 95% CI 1.286–3.212; p = 0.002) were independently associated with earlier onset of diabetes mellitus in patients with chronic pancreatitis.ConclusionPancreatic calcification, pancreatic duct stricture and pancreatic exocrine insufficiency are associated with development of diabetes mellitus in chronic pancreatitis indicating disease progression. Smoking is the modifiable risk factors associated with early onset of diabetes mellitus in CP patients.     

Natural course of pain in chronic pancreatitis is independent of disease duration

ObjectivesPain burn-out during the course of chronic pancreatitis (CP), proposed in the 1980s, remains controversial, and has clinical implications. We aimed to describe the natural course of pain in a well-characterized cohort.MethodsWe constructed the clinical course of 279 C P patients enrolled from 2000 to 2014 in the North American Pancreatitis Studies from UPMC by retrospectively reviewing their medical records (median observation period, 12.4 years). We assessed abdominal pain at different time points, characterized pain pattern (Type A [short-lived pain episodes] or B [persistent pain and/or clusters of recurrent severe pain]) and recorded information on relevant covariates.ResultsPain at any time, at the end of follow-up, Type A pain pattern or B pain pattern was reported by 89.6%, 46.6%, 34% and 66% patients, respectively. In multivariable analyses, disease duration (time from first diagnosis of pancreatitis to end of observation) did not associate with pain - at last clinical contact (OR, 1.0, 95% CI 0.96–1.03), at NAPS2 enrollment (OR 1.02, 95% CI 0.96–1.07) or Type B pain pattern (OR 1.01, 95% CI 0.97–1.04). Patients needing endoscopic or surgical therapy (97.8 vs. 75.2%, p < 0.001) and those with alcohol etiology (94.7 vs. 84.9%, p = 0.007) had a higher prevalence of pain. In multivariable analyses, invasive therapy associated with Type B pain and pain at last clinical contact.ConclusionsOnly a subset of CP patients achieve durable pain relief. There is urgent need to develop new strategies to evaluate and manage pain, and to identify predictors of response to pain therapies for CP.     

Clinical,laboratory and evolutionary features of abdominal tuberculosis in comparison with other forms of extrapulmonary tuberculosis

Background/objectivesTuberculosis is a multisystem disease that might affect any organ. Abdominal tuberculosis (ABT) represents 5–17% from all extrapulmonary tuberculosis (EPT) sites. We aimed to study the clinical, laboratory and evolutionary features of ABT cases and to identify predictive factors associated with ABT.MethodsWe conducted a retrospective study including all patients hospitalized in the infectious diseases department for EPT between 1991 and 2019. We studied the characteristics of ABT cases, and we compared them with other EPT cases.ResultsWe identified 519 patients with EPT, among whom 86 (16.6%) patients had ABT. There were 58 females (67.4%). Peritoneal tuberculosis was the most common clinical form of ABT (68.6%), followed by intestinal tuberculosis (18.6%). Patients aged 60 years and above were significantly less affected with ABT (odds ratio (OR) = 0.2; p = 0.001). The revealing systemic symptoms including fever (OR = 2.04; p = 0.006), weight loss (OR = 2.5; p < 0.001) and anorexia (OR = 1.7; p = 0.021) were significantly more frequent among ABT patients. Inflammatory markers including C-reactive protein levels (37 [10–89] mg/l vs 10 [4–57] mg/l; p < 0.001) and erythrocyte sedimentation rates (43 [15–95] mm/h vs 27 [15–60] mm/h; p = 0.044) were significantly higher among ABT cases. Multivariate logistic regression analysis showed that anorexia (adjusted OR (AOR) = 1.9; p = 0.015) and pulmonary involvement (AOR = 3.3; p = 0.002) were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal (AOR = 0.18; p = 0.001) and osteo-articular (AOR = 0.2; p = 0.01) sites, 40–59 (AOR = 0.2; p < 0.001) and ≥60 (AOR = 0.2; p < 0.001) age groups as well as hemoglobin rate (AOR = 0.7; p < 0.001) were independently associated with lower rate of ABT.ConclusionsAnorexia and pulmonary involvement were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal and osteo-articular sites, 40–59 and ≥60 age groups and hemoglobin rate were independently associated with lower rate of ABT.     

Glucose dysregulation and its association with COVID-19 mortality and hospital length of stay

Background and aimsWe investigate the impact of blood glucose on mortality and hospital length of stay (HLOS) among COVID-19 patients.MethodsRetrospective study of 456 patients with confirmed COVID-19 and glycemic dysregulation in the New York City area.ResultsWe found that impaired glucose adjusted for other organs systems involved (OR:1.87; 95% CI:1.36–2.57, p < 0.001), increased glucose nadir (OR:34.28; 95% CI:3.97–296.05, p < 0.01) and abnormal blood glucose levels at discharge (OR:5.07; 95% CI:2.31–11.14, p < 0.001) were each significantly associated with increased odds for mortality. New or higher from baseline insulin requirement during hospitalization (OR:0.34; 95% CI:0.15–0.78; p < 0.05) was significantly associated with decreased odds for mortality. Increased glucose peak (B = 0.001, SE=<0.001, p < 0.001), new or higher from baseline insulin requirement during hospitalization (B = 0.11, SE = 0.03, p < 0.001), and increased days to dysglycemia (B = 0.15, SE = 0.04, p < 0.001) were each significantly associated with increased HLOS. Increased glucose nadir (B = ?0.67, SE = 0.07, p < 0.001), insulin intravenous drip (B = ?0.10, SE = 0.05, p < 0.05), and increased proportion days endocrine system involved (B = ?0.25, SE = 0.06, p < 0.001) were each significantly associated with decreased HLOS.ConclusionGlucose dysregulation adversely affects mortality and HLOS in COVID-19. These data can help clinicians to guide patient treatment and management in COVID-19 patients.     

Clinical outcomes of acute pancreatitis in patients with cirrhosis

BackgroundAP outcomes in cirrhotic patients have not yet been studied. We aim to investigate the outcomes of cirrhotics patients with acute pancreatitis.MethodsThe National Inpatient Sample (NIS) database (2003–2013) was queried for patients with a discharge diagnosis of AP and liver cirrhosis. Cirrhosis was further classified as compensated and decompensated using the validated Baveno IV criteria. Primary outcome was inpatient mortality. The analysis was adjusted for age, gender, race, Charlson comorbidity index (CCI), median income quartile, and hospital characteristics.ResultsOver 2.8 million patients with acute pancreatitis were analyzed. Cirrhosis prevalence was 2.8% (80,093). Both compensated and decompensated cirrhosis subjects had significantly higher mortality. Highest odds ratios (OR) were: inpatient mortality (OR 3.4, P < 0.001), Shock (OR 1.5, P = 0.02), Ileus (OR: 1.3, p = 0.02, ARDS (OR 1.2, p = 0.03), upper endoscopy performed (OR 2.0, p < 0.001), blood transfusions (OR 3.1, p < 0.001), gastrointestinal bleed (OR 5.5, p < 0.001), sepsis (OR 1.3, p = 0.005), portal vein thrombosis (PVT) (OR 7.2, p < 0.001), acute cholecystitis (OR 1.3, p < 0.001). Interestingly, cirrhosis patients had lower hospital length of stay, (OR 0.16, p < 0.001), AKI (OR 0.93, p = 0.06), myocardial infarction (OR 0.31, p < 0.001), SIRS (OR 0.62, p < 0.001), parenteral nutrition requirement (OR 0.84, p = 0.002). Decompensated cirrhosis had higher inflation-adjusted hospital charges (+$3896.60; p < 0.001).ConclusionAP patients with cirrhosis have higher inpatient mortality, but it is unlikely to be due to AP severity as patients had lower incidence of SIRS and AKI. Higher mortality is possibly related to complications of cirrhosis and portal hypertension itself such as GI bleed, shock, PVT, AC and sepsis.     

Natural course of chronic pancreatitis and predictors of its progression

BackgroundThe natural course of chronic pancreatitis(CP) and its complications has been inadequately explored. We aimed to describe the natural history and factors affecting the progression of alcoholic(ACP), idiopathic juvenile(IJCP) and idiopathic senile(ISCP) variants of CP.MethodsThis study was a retrospective analysis from a prospectively maintained database of patients with CP following up at a tertiary care centre from 1998 to 2019. Cumulative rates of pain resolution, diabetes, steatorrhea, pseudocysts and pancreatic cancer were computed using Kaplan-Meier analysis, and the factors affecting their incidence were identified on multivariable-adjusted Cox-proportional-hazards model.ResultsA total of 1415 patients were included, with 540(38.1%) ACP, 668(47.2%) IJCP and 207(14.6%) ISCP with a median follow-up of 3.5 years(Inter-quartile range: 1.5–7.5 years). Diabetes occurred at 11.5, 28 and 5.8 years(p < 0.001) while steatorrhea occurred at 16, 24 and 18 years(p = 0.004) after onset for ACP, IJCP and ISCP respectively. Local complications including pseudocysts occurred predominantly in ACP(p < 0.001). Ten-year risk of pancreatic cancer was 0.9%, 0.2% and 5.2% in ACP, IJCP and ISCP, respectively(p < 0.001). Pain resolution occurred more frequently in patients with older age of onset[Multivariate Hazard Ratio(HR):1.7(95%CI:1.4–2.0; p < 0.001)], non-smokers[HR:0.51(95%CI:0.34–0.78); p = 0.002] and in non-calcific CP[HR:0.81(0.66–1.0); p = 0.047]. Occurrence of steatorrhea[HR:1.3(1.03–1.7); p = 0.028] and diabetes[HR:2.7(2.2–3.4); p < 0.001] depended primarily on age at onset. Occurrence of pancreatic cancer depended on age at onset[HR:12.1(4.7–31.2); p < 0.001], smoking-history[HR:6.5(2.2–19.0); p < 0.001] and non-alcoholic etiology[HR:0.14(0.05–0.4); p < 0.001].ConclusionACP, IJCP and ISCP represent distinct entities with different natural course. Age at onset of CP plays a major prognostic role in all manifestations, with alcohol predominantly causing local inflammatory complications.     

Vascular complications of chronic pancreatitis: A tertiary center experience

IntroductionVascular complications such as venous thrombosis (VT) and pseudoaneurysm are not uncommon in patients with chronic pancreatitis (CP). The aim of this study to was to evaluate the prevalence and risk factors for vascular complications in patients with CP.MethodsA retrospective analysis of a prospectively maintained database of patients with CP presenting from January 2002 to August 2019 was performed. Venous thrombosis and pseudoaneurysm were identified using radiological imaging, and their risk factors were identified using multivariate Cox-proportional hazards.ResultsOf 1363 patients with CP, 166 (12.2%) had vascular complications. Isolated VT was present in 132, pseudoaneurysm in 17, and both in 17 patients. They were more commonly seen in males and alcoholic CP (ACP), and less commonly in patients with pancreatic atrophy and calcification. It involved the vessels in the closest proximity to the pancreas, VT most commonly involving the splenic vein whereas pseudoaneurysm most commonly involved the splenic artery. Alcoholic CP [odds ratio (OR) 2.1, p = 0.002], pseudocyst (OR 4.6, p < 0.001) and inflammatory head mass (OR 3.1, p = 0.006) were independent risk factors for VT, whereas ACP (OR 3.49, p = 0.006) and pseudocyst (OR 3.2, p = 0.002) were independent risk factors for pseudoaneurysm. Gastrointestinal bleed occurred in 3.5% patients, and more commonly in patients with pseudoaneurysm than VT (64.7% vs 15.9%), and in patients with ACP in comparison to other etiologies (p < 0.001).ConclusionVascular complications are a common complication of CP, VT being more frequent than pseudoaneurysm. Pseudocyst and ACP are independent risk factors for the development of vascular complications.     

Depression in Behçet’s disease patients: Relationship with disease pattern,activity and quality of life

Aim of the workTo determine the frequency of depression in Behçet’s disease (BD) patients and to clarify its burden on patients’ clinical manifestations, disease activity status and quality of life (QoL).Patients and methods35 BD patients with 35 matched control were included in this study. Disease activity was assessed by Behçet Syndrome Activity Score (BSAS). All participants were requested to complete the Hamilton depression rating scale (HDRS), Multidimensional assessment of fatigue (MAF) questionnaire and the short form-36 (SF-36) QoL Scale.ResultsThe mean age of the patients was 40.3 ± 13.5 years (17–72 years) and they were 27 males and 8 females. The frequency of depression in BD patients was 74.3% with increased male frequency (p = 0.007) and major organ involvement (p = 0.04) among depressed patients. Significant differences (p < 0.001, p = 0.04, p = 0.001 respectively) between depressed and non depressed BD patients with respect to BSAS, MAF and SF-36. Highly significant positive correlations between HDRS and number of major organ, BSAS, MAF, (p < 0.001) and significant correlation with number of non major organs (r = 0.3, p = 0.04). Significant negative associations were observed between HDRS and SF-36 (r = ?0.6, p < 0.001). On regression number of major organ involvement (p < 0.001), BSAS (p = 0.01), MAF (p = 0.002), and SF-36 QoL (p < 0.001) significantly correlated with HDRS.ConclusionDepression is a significant comorbidity in patients with BD and is closely related to fatigue, number of major organ involvement and overall disease activity with a negative impact on QoL. Therefore, early interference and depression management in routine clinical practice is important to reduce patients’ symptoms, and improve QoL.     

A systematic review and meta-analysis on the quality of life after hepatic resection

BackgroundQuality of life (QoL) after hepatic resection is a pertinent issue that has been poorly studied. The aim of this study was to compare changes in QoL before and after hepatic resection.MethodsA systematic review was performed using Medline, EMBASE, and the Cochrane library. Whenever possible, pooled mean differences of survey scores pre- and post-operatively were calculated.Results22 studies were included comprising a total of 1785 participants. Using the EORTC-QLQ 30C survey, patients with benign disease tend to have better QoL post-surgery than those with malignant disease. There were post-operative improvements in the following FACT-HEP domains: physical at 9 months (MD 3.14, 95%CI 2.70 to 3.58, P < 0.001), social and family at 3 (MD 1.45, 95%CI 0.12 to 2.77, p = 0.030), 6 (MD 1.12, 95%CI 0.21 to 2.04, p = 0.020), 9 (MD 0.66, 95%CI 0.03 to 1.28, p = 0.040), and 12 (MD 0.58, 95%CI 0.12 to 1.03, p = 0.010) months, emotional at 9 (P < 0.001) and 24 months (P < 0.001), hepatobiliary at 24 months (p < 0.001), and global health status at 9 months (p = 0.002).ConclusionQoL scores tend to deteriorate post-surgery, but recover to baseline in the long-term at 9-months. Patients with malignant disease, and those who underwent major hepatectomy, have poorer QoL scores.     

Impact of cumulative operative time on postoperative complication risk in simultaneous resections of colorectal liver metastases and primary tumors

BackgroundSimultaneous resection of colorectal liver metastases (CLM) and primary colorectal cancers (CRC) is nuanced without firm rules for selection. This study aimed to identify factors associated with morbidity after simultaneous resection.MethodsUsing a prospective database, patients undergoing simultaneous CLM-CRC resection from 1/1/2017-7/1/2020 were analyzed. Regression modeling estimated impact of colorectal resection type, Kawaguchi–Gayet (KG) hepatectomy complexity, and perioperative factors on 90-day complications.ResultsOverall, 120 patients underwent simultaneous CLM-CRC resection. Grade≥2 complications occurred in 38.3% (n = 46); these patients experienced longer length of stay (median LOS 7.5 vs. 4, p < 0.001) and increased readmission (39% vs. 1.4%, p < 0.001) compared to patients with zero or Grade 1 complications. Median OR time was 298 min. Patients within highest operative time quartile (>506 min) had higher grade≥2 complications (57%vs. 23%, p = 0.04) and greater than 4-fold increased odds of grade≥2 morbidity (OR 4.3, 95% CI (Confidence Interval) 1.41–13.1, p = 0.01). After adjusting for Pringle time, KG complexity and colorectal resection type, increasing operative time was associated with grade≥2 complications, especially for resections in highest quartile of operative time (OR 7.28, 95% CI 1.73–30.6, p = 0.007).ConclusionIn patients undergoing simultaneous CLM-CRC resection, prolonged operative time is independently associated with grade≥2 complications. Awareness of cumulative operative time may inform intraoperative decision-making by surgical teams.     

The importance of characteristics of angina symptoms for the prediction of coronary artery disease in a cohort of stable patients in the modern era

ObjectiveAngina is an important clinical symptom indicating underlying coronary artery disease (CAD). Its characteristics are important for the diagnosis and risk stratification of patients with CAD. Currently, we aimed to investigate the association of chest pain characteristics with the presence of obstructive CAD in a contemporary cohort of patients undergoing coronary angiography for suspected stable CAD.MethodsConsecutive patients undergoing coronary angiography for suspected stable CAD (n = 686) in a single university hospital cardiology department were enrolled. Chest pain was classified as typical angina, atypical angina, nonangina chest pain, and lack of symptoms. The presence of significant angiographic CAD was diagnosed by standard coronary angiography.ResultsTypical angina symptoms were associated with a higher prevalence of CAD (odds ratio [OR], 3.47, p < 0.001), whereas atypical angina symptoms were associated with a lower prevalence of CAD (OR, 0.49, p = 0.003) than the nonangina symptoms/or asymptomatic status. In multivariate analysis, typical angina symptoms remained an independent predictor of CAD (OR, 2.54, p < 0.001), with a greater predictive accuracy than other clinical risk factors (area under the curve [AUC], 0.715, p < 0.001) and similar to the accuracy of the high-sensitivity C-reactive protein (AUC, 0.712, p < 0.001). In a multivariate model, the combination of all studied factors further improved the predictive accuracy (AUC, 0.81, p < 0.001).ConclusionIn a contemporary cohort of patients referred for coronary angiography for stable CAD, the presence of typical angina symptoms was the most important independent predictor of obstructive CAD. The association of atypical angina symptoms with low CAD prevalence compared to nonangina chest pain or absence of significant symptoms probably reflects different management and referral strategies in these groups of patients.     

Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies

Background/objectivesThis study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center.MethodsThis retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage.ResultsOf 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups.ConclusionsStandardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.     

Association of indirect measurement of cell function by bioimpedance analysis with complications in oncologic hepatic surgery

BackgroundBioelectric impedance vector analysis (BIVA) is a reliable tool to assess body composition. The aim was to study the association of BIVA-derived phase angle (PA) and standardized PA (SPA) values and the occurrence of surgery-related morbidity.MethodsPatients undergoing hepatectomy for cancer in two Italian centers were prospectively enrolled. BIVA was performed the morning of surgery. Patients were then stratified for the occurrence or not of postoperative morbidity.ResultsOut of 190 enrolled patients, 76 (40%) experienced postoperative complications. Patients with morbidity had a significant lower PA, SPA, body cell mass, and skeletal muscle mass, and higher extracellular water and fat mass. At the multivariate analysis, presence of cirrhosis (OR 7.145, 95% CI:2.712–18.822, p < 0.001), the Charlson comorbidity index (OR 1.236, 95% CI: 1.009–1.515, p = 0.041), the duration of surgery (OR 1.004, 95% CI:1.001–1.008, p = 0.018), blood loss (OR 1.002. 95% CI: 1.001–1.004, p = 0.004), dehydration (OR 10.182, 95% CI: 1.244–83.314, p = 0.030) and SPA < ?1.65 (OR 3.954, 95% CI: 1.699–9.202, p = 0.001) were significantly and independently associated with the risk of complications.ConclusionIntroducing BIVA before hepatic resections may add valuable and independent information on the risk of morbidity.     

Histopathological growth patterns and positive margins after resection of colorectal liver metastases

BackgroundHistopathological growth patterns (HGPs) of colorectal liver metastases (CRLM) may be an expression of biological tumour behaviour impacting the risk of positive resection margins. The current study aimed to investigate whether the non-desmoplastic growth pattern (non-dHGP) is associated with a higher risk of positive resection margins after resection of CRLM.MethodsAll patients treated surgically for CRLM between January 2000 and March 2015 at the Erasmus MC Cancer Institute and between January 2000 and December 2012 at the Memorial Sloan Kettering Cancer Center were considered for inclusion.ResultsOf all patients (n = 1302) included for analysis, 13% (n = 170) had positive resection margins. Factors independently associated with positive resection margins were the non-dHGP (odds ratio (OR): 1.79, 95% confidence interval (CI): 1.11–2.87, p = 0.016) and a greater number of CRLM (OR: 1.15, 95% CI: 1.08–1.23 p < 0.001). Both positive resection margins (HR: 1.41, 95% CI: 1.13–1.76, p = 0.002) and non-dHGP (HR: 1.57, 95% CI: 1.26–1.95, p < 0.001) were independently associated with worse overall survival.ConclusionPatients with non-dHGP are at higher risk of positive resection margins. Despite this association, both positive resection margins and non-dHGP are independent prognostic indicators of worse overall survival.     

Waist-to-height ratio and dynapenic abdominal obesity in users of hemodialysis services

Background and aimsAbdominal obesity and decreased muscle strength are risk factors for individuals on hemodialysis. Thus, the combination of these two factors known as dynapenic abdominal obesity acts as an important marker of the nutritional status of this population. Therefore, the objective of the work was to investigate the association between abdominal obesity, dynapenia, and sociodemographic, clinical, and nutritional factors in individuals with chronic kidney disease undergoing hemodialysis.Methods and ResultsCross-sectional study with 940 individuals undergoing hemodialysis in southeastern Brazil. Dynapenic abdominal obesity was defined by the combination of the presence of abdominal obesity, indicated by the waist-to-height ratio, and the reduction in muscle strength, measured by handgrip strength. Binary logistic regression was performed to calculate the odds ratio (OR) and the respective confidence intervals (95% CI). Dynapenic abdominal obesity was present in 45.42% of the study population. We found that being 18–59 years (OR: 3.17; 95% CI 2.35–4.28; p < 0.001) and being overweight (OR: 2.58; 95% CI 1.92–3.47; p < 0.001) increased the chances for the presence of dynapenic abdominal obesity; however, the habit of consuming meals away from home (OR: 0.63; 95% CI 0.47–0.85; p = 0.003) and having preserved behavioral adductor muscle thickness (OR: 0.52; 95% CI 0.38–0.71; p < 0.001) are considered protective factors.ConclusionDynapenic abdominal obesity, present in individuals on hemodialysis, may represent a valid nutritional tool for assessing cardiovascular risk and mortality in this population, in order to implement the most effective preventive and/or therapeutic intervention possible.