Assessing culprit lesions and active complex lesions in patients with early acute myocardial infarction by multidetector computed tomography

BACKGROUND: Accurate, non-invasive characterization of culprit lesions in patients after acute myocardial infarction (AMI) remains challenging. In this prospective study, multidetector row computed tomography (MDCT) is used to assess culprit and active complex lesions in patients early after AMI. METHODS AND RESULTS: We enrolled 103 patients with first non ST-elevation AMI who underwent 64-slices MDCT and conventional coronary angiography (CCAG). The definition of culprit lesion, stable non-culprit lesions and non-culprit active complex lesions was based on the findings of CCAG. The lesions were analyzed with MDCT data. In culprit lesions (n=103), luminal artery stenosis, remodeling index, plaque area and burden were significantly higher than non-culprit lesions (n=129). Multivariate discriminant analysis showed that MDCT density could discriminate culprit from non-culprit lesions. Receiver-operator characteristic curve analysis identified the optimal cutoff value of lesion density for discrimination between culprit and non-culprit lesion as 49.6 Hounsfield units (HU); this value was associated with a sensitivity, specificity and accuracy of 88.4%, 87.4%, and 87.9%, respectively. The MDCT in the stable non-culprit lesions (81.8+/-15.5 HU) was significantly higher than that in culprit lesions or non-culprit active complex lesions (33.2+/-13.8 and 48.3+/-15.7 HU, p<0.001). CONCLUSIONS: MDCT can predict culprit lesions in patients early after AMI, and identify multiple complex lesions.     

Do physicians with diabetes have differences in dialysis use and survival than other patients with diabetes

Aims

To assess whether the increased knowledge and resources available to physicians led to differences in dialysis and survival rates between physicians and non-physician patients with diabetes.

Methods

All newly diagnosed (1997–2009) type 2 diabetes patients aged ≥35 years from the National Health Insurance Program of Taiwan database were included. After propensity score matching (1:10), we estimated the relative risk of dialysis and death using Cox proportional hazards model adjusted for demographic characteristics and comorbidities.

Results

Physicians with diabetes were more likely to start dialysis than general patients, with a 48% increased hazard risk (HR) (P = 0.006). Physicians with diabetes had significantly lower risk of death (HR: 0.88; P = 0.025). However, those requiring dialysis had a non-significant increased risk of death (HR: 1.19). There was an increased HR for death in older physicians (HR: 1.81; P < 0.001) and those with cancer or catastrophic illness. The HR of dialysis (7.89; P < 0.0001) increased dramatically with increasing Charlson Comorbidity Index scores.

Conclusions

Physicians with DM survived longer than other patients with diabetes, likely benefiting from their professional resources in disease control and prevention. Nonetheless, they displayed no advantage from their medical backgrounds compared with the general patients if they developed end stage renal disease.     

No overall increased risk of cancer in patients with rheumatoid arthritis: a nationwide dynamic cohort study in Taiwan

The association between rheumatoid arthritis (RA) and cancer is still controversial. This study aimed to estimate cancer incidence (both overall and site-specific) among patients with RA and to determine whether their cancer risk was higher than in the general population. We used the nationwide dynamic cohort from the National Health Insurance Research Database of Taiwan and obtained a total of 30,504 patients with no history of cancer who were newly diagnosed with RA between 1996 and 2008; they were followed up until 2010. Standardized incidence ratios (SIR) by age for various types of cancer were calculated in 5-year calendar periods by 5-year age intervals (quinquinquennium) to compare elevated risk of increasing age and increased cancer rate in later calendar years in Taiwan. During 225,432 person-years of follow-up, 1,595 cancers occurred, corresponding to 7.08 per 1,000 person-years. The SIR for all cancers was 0.93 (95 % CI 0.88–0.97). Most cancers were found in the first 2 years after diagnosis of RA, but the incidence decreased afterward. A significant excess of Hodgkin’s lymphoma (SIR 3.31, 95 % CI 1.24–8.81) and non-Hodgkin’s lymphoma (SIR 3.18, 95 % CI 2.64–3.83) was seen among patients with RA, whereas the risk of colorectal cancer was 29 % lower than the general population. In conclusion, this study showed that patients with RA do not have increased overall risk of cancers but have higher risk of hematologic malignancies and lower risk of colorectal cancer, than the general population.     

Absolute lymphocyte count and risk of short-term infection in patients with immune thrombocytopenia

Patients with immune thrombocytopenia (ITP) may be at increased risk of infection because of the steroids and other immunosuppressive agents used in its treatment. This study aimed to identify events that are associated with infection within 6 months of diagnosis and the impact that infection has on survival. We retrospectively evaluated 239 patients (107 men, 132 women; median age 61 years) diagnosed between January 1997 and August 2011. Every patient received steroid treatment according to the platelet count and the extent of bleeding. Logistic regression analysis was used to identify risk factors associated with the development of infection within 6 months of ITP being diagnosed. Sixty-two patients (25.9 %) developed an infection within 6 months of diagnosis. Multivariate analysis revealed that a lower absolute lymphocyte count (ALC) at diagnosis (<1?×?10⁹/l) was an independent risk factor for infection (P?=?0.039; 95 % confidence interval, 1.033–3.599; odds ratio, 1.928). The time to infection event is significant shorter in those of low ALC, compared with those of higher ALC (P?=?0.032). Furthermore, the 1-year mortality rate after ITP diagnosis was significantly higher in those patients who developed an infection (P?=?0.001). ITP patients with a low absolute lymphocyte count at diagnosis have an increased risk of infection, and those who develop infections have lower 1-year survival.     

A “Bone Marrow Score” for Predicting Hematological Disease in Immunocompetent Patients With Fevers of Unknown Origin

Delayed diagnosis of hematological malignancies in immunocompetent patients with fever of unknown origin (FUO) remains an exhausting challenge for non-hematologist physicians. This retrospective cohort study aimed to establish a scoring system, “bone marrow (BM) score”, to identify FUO patients who require early bone marrow biopsy (BMB) to diagnose hematological disease.Two cohorts, comprising 85 (training) and 20 (validation) eligible immunocompetent patients, with FUOs diagnosed between January 1, 2006 and July 31, 2013, underwent BMBs and were enrolled in the study. Demographic, laboratory, imaging, diagnostic, and outcome data were collected and retrospectively analyzed. Factors associated with hematological etiologies diagnosed using BMBs in the training cohort were identified and scored according to the relative hazards. These were further validated using the validation cohort.For the training cohort, 29 of 85 (34.1%) patients had hematological etiologies diagnosed using BMB. Seven factors significantly predicted the diagnostic yield of hematological diseases in the BM and were scored, with the 6 points for leucoerythroblastic changes in peripheral blood smears, 5.5 for elevated ferritin level (>1000 ng/mL), 4 for splenomegaly, 2 for thrombocytopenia, 1.5 for each of elevated lactate dehydrogenase levels and anemia, and 1 for neutropenia. When the cut-off value of the scoring system was set to 6, its sensitivity and specificity to diagnose hematological diseases in the BM of immunocompetent FUO patients were 93% and 58%, respectively. For the validation cohort, 7 of 20 (35%) patients had hematological disease, and all had BM scores higher than the cut-off, with the sensitivity and specificity at 100% and 77%, respectively.As immunocompetent FUO patients with hematological disease have poor prognoses, the “BM score” is valuable for non-hematologist physicians to identify immunocompetent FUO patients requiring early BMB.     

Comparison of 7-day and repeated 24-h recall of type 2 diabetes

Purpose  

Patient reporting of type 2 diabetes symptoms in a questionnaire with a 7-day recall period was expected to be different from symptom reports using a 7-day diary with repeated 24-h recall based on cognitive theory of memory processes and prior literature. This study compared these two types of recall in patients diagnosed with type 2 diabetes (T2D).     

Comparison of Iodixanol and Iohexol in Patients Undergoing Intravenous Pyelography: A Prospective Controlled Study

Background. Nephropathy associated with contrast medium exposure is a well-known complication of IVP. However, it is uncertain whether iso-osmolar non-iodinated contrast medium (iodixanol) is less nephrotoxic than low-osmolar contrast medium (iohexol). Materials and Methods. In this single-center, double-blind, prospective study, 50 patients undergoing IVP were randomized into two groups receiving different contrast medium: iodixanol and iohexol. Patients in high risk for contrast nephropathy were included, 28 with renal insufficiency and 19 with diabetes mellitus. We compared the nephrotoxic effect (contrast nephropathy), complement and cytokines profile between the iodixanol and iohexol groups. The mean volume of contrast medium in each IVP procedure was 0.8 mL/kg. Results. The incidence of contrast nephropathy was 4 percent among all patients (one iodixanol and one iohexol). We found no significant differences in contrast nephropathy and allergic reactions between the two groups. There was no significant difference in cytokine profiles in both groups (p > 0.05).The incidence of allergic reaction was 16 percent among all patients. Twelve percent (3/25) had late reaction after iohexol exposure compared to four percent (2/25) with iodixanol (p = 1.0). One patient had severe skin rash due to late adverse reaction after iodixanol. No mortality was found. Conclusions. New iodixanol and iohexol contrast medium for routine IVP examination are safe and have low nephrotoxicity profile, especially in elderly or high-risk patients. Iodixanol contrast medium has an increased risk to induce severe late adverse reaction compared to iohexol. Allergic reaction may be the main adverse effect after contrast medium infusion.