Socioeconomic deprivation, readmissions, mortality and acute exacerbations of bronchiectasis

Background: Bronchiectasis is known to cause significant morbidity in children in New Zealand. Little is known of the disease in adults. Aim: Our objective was to characterise a cohort of adults who presented to hospital with acute exacerbations of the disease. Methods: We retrospectively collected information on all exacerbations treated as inpatients from a single hospital in South Auckland, New Zealand during 2002. Results: We collected information on 307 exacerbations in 152 patients. Twenty‐seven per cent were of Maaori ethnic origin, and 44% Pacific. Seventy per cent lived in areas categorised as the 20% most deprived in New Zealand. Comorbid conditions were present in 80% of patients – most commonly chronic obstructive pulmonary disease, asthma, diabetes and cardiac disease. Seventy (46%) patients had at least one readmission and 32 patients (21%) died within 12 months of admission to hospital. Greater deprivation was associated with increased mortality at 12 months after admission after adjusting for other factors (OR 11, 95% CI 2.0–61, P= 0.006). In the subgroup who underwent high‐resolution computed tomographic scanning (93), increasing severity of bronchiectasis (modified Bhalla score) was associated with readmission within 12 months (P= 0.004), but not mortality (P= 0.419). Conclusions: We have shown that exacerbations of bronchiectasis in South Auckland are more common in patients who are predominantly of Maaori or Pacific descent and are socioeconomically deprived. Admission to hospital for an exacerbation is associated with high readmission and mortality rates.     

Outcomes and predicting response in anaemic chemotherapy patients treated with epoetin alfa. A multicentre, 4‐month,open‐label study in Australia and New Zealand

Background: The aim of the study was to evaluate the effectiveness, safety, and clinical outcomes of erythropoietin therapy in the treatment of anaemic cancer subjects receiving chemotherapy and to examine hypochromic red blood cell measurement as an indicator of functional iron sufficiency and as a predictor of responsiveness or non‐responsiveness to erythropoietin therapy. Methods: Patients who had a non‐myeloid malignancy, had Hb ≤ 11.0 g/dL, had a life expectancy of more than 6 months, were 18 years or older, were receiving chemotherapy and would continue to be treated for at least 2 months were given s.c. epoetin alfa three times a week. Results: Haemoglobin levels increased significantly at all time periods compared with baseline and the number of transfusions received decreased significantly at all time periods compared with baseline. Quality of life as measured by Functional Assessment of Cancer Therapy‐Anaemia showed significant increases at months 2 and 4 and there were significant improvements in the fatigue subscale at both time points (P < 0.05). Significant improvements at end‐point were observed for the physical, emotional and functional well‐being, and additional concern subscales (all P < 0.05). Haematocrit and reticulocytes increased significantly at end‐point compared with at baseline (haematocrit 33.4 vs 28.3%, P < 0.001; reticulocytes 105.8 vs 78.6 × 10⁹/dL, P = 0.005). The percentage of hypochromic red blood cells did not show predictive value for response to treatment status. Conclusion: Epoetin alfa improved haemoglobin levels and quality of life in anaemic cancer patients receiving chemotherapy.     

Haemoglobin and albumin as markers of HIV disease progression in the highly active antiretroviral therapy era: relationships with gender

OBJECTIVES: The aims of the study were to describe gender differences in haemoglobin and albumin and to investigate the prognostic value of these measurements in relation to highly active antiretroviral therapy (HAART). METHODS: Anaemia was defined as haemoglobin <13.5 g/dL for men and <11.5 g/dL for women. Albumin <35 g/L was defined as hypoalbuminaemia. Proportional hazards models were used to describe relationships between these markers and HIV progression and death. RESULTS: A total of 291 patients had pre-HAART and 1-year measurements. Mean haemoglobin and albumin levels pre-HAART were lower in women than in men (haemoglobin: 11.2 vs 13.2 g/dL, respectively, P<0.0001; albumin: 37.4 vs 40.2 g/L, respectively, P<0.0001), and a higher proportion of women were anaemic and hypoalbuminaemic compared with men. Despite a rise in both markers in the first year on HAART, mean haemoglobin levels remained lower by 2.08 g/dL (P<0.0001) and albumin by 2.88 g/L (P<0.0001) in women. In the 495 patients included in this analysis, haemoglobin and albumin levels were both significantly related to short-term risk of AIDS and death independently of CD4 count [hazards ratio (HR)=0.73/g/dL higher haemoglobin, 95% confidence interval (CI) 0.55-0.82, P<0.0001 and HR=0.87/g/L higher albumin, 95% CI 0.83-0.91, P<0.0001]. The prognostic value did not differ by gender. CONCLUSIONS: Women were more likely to be anaemic and/or hypoalbuminaemic pre-HAART, but post-HAART increases were similar to those in men. Both haemoglobin and albumin were strong independent prognostic factors for risk of AIDS and death, regardless of gender.     

White blood cell count and mortality in patients with acute pulmonary embolism

Although associated with adverse outcomes in other cardiovascular diseases, the prognostic value of an elevated white blood cell (WBC) count, a marker of inflammation and hypercoagulability, is uncertain in patients with pulmonary embolism (PE). We therefore sought to assess the prognostic impact of the WBC in a large, state‐wide retrospective cohort of patients with PE. We evaluated 14,228 patient discharges with a primary diagnosis of PE from 186 hospitals in Pennsylvania. We used random‐intercept logistic regression to assess the independent association between WBC count levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient and hospital characteristics. Patients with an admission WBC count <5.0, 5.0–7.8, 7.9–9.8, 9.9–12.6, and >12.6 × 10⁹/L had a cumulative 30‐day mortality of 10.9%, 6.2%, 5.4%, 8.3%, and 16.3% (P < 0.001), and a readmission rate of 17.6%, 11.9%, 10.9%, 11.5%, and 15.0%, respectively (P < 0.001). Compared with patients with a WBC count 7.9–9.8 × 10⁹/L, adjusted odds of 30‐day mortality were significantly greater for patients with a WBC count <5.0 × 10⁹/L (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14–2.03), 9.9–12.6 × 10⁹/L (OR 1.55, 95% CI 1.26–1.91), or >12.6 × 10⁹/L (OR 2.22, 95% CI 1.83–2.69), respectively. The adjusted odds of readmission were also significantly increased for patients with a WBC count <5.0 × 10⁹/L (OR 1.34, 95% CI 1.07–1.68) or >12.6 × 10⁹/L (OR 1.29, 95% CI 1.10–1.51). In patients presenting with PE, WBC count is an independent predictor of short‐term mortality and hospital readmission. Am. J. Hematol. 88:677–681, 2013. © 2013 Wiley Periodicals, Inc.     

Prognostic value of the Geneva prediction rule in patients in whom pulmonary embolism is ruled out

Abstract. Bertoletti L, Le Gal G, Aujesky D, Roy P‐M, Sanchez O, Verschuren F, Bounameaux H, Perrier A, Righini M. (University of Geneva, Geneva, Switzerland; Université De Saint‐Etienne, Jean Monnet, Saint‐Etienne; Brest University Hospital, Brest, France; Bern University Hospital, Bern, Switzerland; Angers University Hospital, Angers; Paris Descartes University, Paris, France; Saint‐Luc University Hospital, Bruxelles, Belgium; and University of Geneva, Geneva, Switzerland). Prognostic value of the Geneva prediction rule in patients in whom pulmonary embolism is ruled out. J Intern Med 2011; 269 : 433–440. Objectives. The prognosis of patients in whom pulmonary embolism (PE) is suspected but ruled out is poorly understood. We evaluated whether the initial assessment of clinical probability of PE could help to predict the prognosis for these patients. Design. Retrospective analysis of data obtained during a prospective multicentre management study. Setting. Six general and teaching hospitals in Belgium, France and Switzerland. Subjects. In 1334 patients in whom PE was ruled out, 3‐month mortality data were available (hospital readmission status was unknown for three patients) and clinical probability was evaluated with the revised Geneva score (RGS). Main outcome measures. Three‐month mortality and readmission rates. Results. Three‐month mortality and readmissions rates were 3% and 19%, respectively and differed significantly depending on the RGS‐determined PE probability group (P < 0.001). When compared with patients presenting with a low probability, the risk of death after 3 months was higher in cases of intermediate or high RGS‐based probability {odds ratio: 8.7 [95% confidence interval (CI): 2.7–28.5] and 22.6 (95%CI: 2.1–241.2), respectively}. The readmission risk increased with PE probability group (P < 0.001). The main causes of death were cancer, respiratory failure and cardiovascular failure. In total, 86% of patients with low RGS‐based probability were alive and had not been readmitted to hospital, whereas other patients had a twofold increased risk of death or readmission during the 3‐month follow‐up. The simplified Geneva score, calculated a posteriori, gave similar results. Conclusions. Initial assessment of clinical probability may help to stratify prognosis of patients in whom PE has been ruled out. Patients with a low probability of PE have a good prognosis. Whether patients with higher probability might benefit from more vigilant care should be evaluated.     

Prevalence of anaemia in inflammatory bowel disease in Switzerland: A cross-sectional study in patients from private practices and university hospitals

BackgroundAnaemia represents a common complication of inflammatory bowel disease (IBD). Most studies on anaemia in IBD patients have been performed in tertiary referral centres (RC) and data from gastroenterologic practices (GP) are lacking. We investigated the frequency and severity of anaemia in IBD patients from tertiary referral centres and gastroenterologic practices compared to the general population.MethodsData were acquired from patients included in the Swiss IBD Cohort Study. IBD activity was evaluated by CDAI and modified Truelove and Witts severity index (MTWSI). Anaemia was defined as haemoglobin ≤ 120 g/L in women and ≤ 130 g/L in men.Results125 patients from RC (66 with Crohn's disease (CD) and 59 with ulcerative colitis (UC)) and 116 patients from GP (71 CD and 45 UC) were included and compared to 6074 blood donors. Anaemia was found in 21.2% (51/241) of the IBD patients and more frequently in patients from RC as compared to GP and healthy controls (28.8% vs. 12.9% vs. 3.4%; P < 0.01). IBD patients from RC suffered more frequently from active disease compared to IBD patients in GP (36% vs. 23%, P = 0.032). Supplementation therapy (iron, vitamine B12, folic acid) was performed in 40% of anaemic IBD patients in GP as compared to 43% in RC.ConclusionsAnaemia is a common complication in patients with IBD and significantly more prevalent in patients from referral centres as compared to patients from gastroenterologic practices. Physicians treating IBD patients should pay attention to the presence of anaemia and ensure sufficient supplementation therapy.     

Clinical outcome following Transcatheter Aortic Valve Implantation in patients with impaired left ventricular systolic function

Objectives: To determine the prevalence of impaired left ventricular (LV) systolic function and its impact on the in‐hospital and long‐term outcome in patients who underwent Transcatheter Aortic Valve Implantation (TAVI). Background: Although impaired LV function may be considered a contra‐indication for aortic valve replacement, the hemodynamic characteristics of transcatheter valves may offer procedural and long‐term clinical benefit in such patients. Methods: 230 consecutive patients underwent TAVI with the Medtronic‐CoreValve System. Impaired LV function was defined by a Left Ventricular Ejection Fraction (LVEF) ≤ 35% (European Multicenter Study on Operative Risk Stratification and Long‐term Outcome in patients with Low‐Flow/Low‐Gradient Aortic Stenosis). Study endpoints were selected and defined according to the Valve Academic Research Consortium recommendations. Results: Compared with patients with a LVEF > 35% (n = 197), those with LVEF ≤ 35% (n = 33) were more often male (78.8 % vs. 46.7%, P < 0.001), more symptomatic (NYHA class III or IV, 97.0% vs. 77.2%, P = 0.008) and had a higher prevalence of prior coronary artery disease (63.6% vs. 43.1%, P = 0.029). The Logistic EuroSCORE was 14.8% and 22.8, respectively (P = 0.012). No difference was observed between the two groups in in‐hospital or 30‐day mortality (3.0% vs. 9.6%, P = 0.21), the Combined Safety Endpoint at 30 days (24.2% and 24.4%, P = 0.99) and survival free from readmission at one year (69.2% and 69.7%, P = 0.85). After adjustment, LVEF ≤ 35% was not associated with an increased risk of 30‐day mortality, in‐hospital complications and survival free from readmission at follow‐up. Conclusion: The immediate and long‐term outcome after TAVI did not differ between patients with an impaired and preserved LVEF. LVEF ≤ 35% did not predict adverse immediate and long‐term outcome. These findings suggest that TAVI should not be withheld in selected patients with impaired LV function. © 2011 Wiley Periodicals, Inc.     

[11C]Methionine emerges as a new biomarker for tracking active myeloma lesions

Erythropoiesis‐stimulating agents (ESAs) were combined with ruxolitinib in 59 anaemic myelofibrosis patients (93% with Dynamic International Prognostic Scoring System [DIPSS] intermediate‐2/high risk; 52·5% transfusion‐dependent). Anaemia response (AR) rate was 54% and 76% of patients responded at 5 years. A further 15% displayed minor improvement in anaemia and 78% of patients reduced spleen size. Endogenous erythropoietin levels <125 u/l correlated with a higher AR rate (63% vs. 20%, P = 0·008). No thrombotic events or other toxicities occurred. Overall survival was 62% at 4 years, influenced by DIPSS and transfusion dependency. ESAs seem effective in improving anaemia in ruxruxolitinib‐treated myelofibrosis patients.     

Highly sensitive AFP-L3% assay is useful for predicting recurrence of hepatocellular carcinoma after curative treatment pre- and postoperatively

Aim: The micro‐total analysis system (µTAS), a fully automated immunoassay system using microchip capillary electrophoresis, is highly sensitive and able to quickly assay the AFP‐L3%. The clinical usefulness of this system was studied. Methods: We retrospectively enrolled 250 patients who underwent curative treatment for primary hepatocellular carcinoma (HCC) (93 patients underwent hepatic resection and 157, radiofrequency ablation [RFA]). Results: The sensitivity for µTAS AFP‐L3% was 40.3% at the cutoff value of 5% in a range of AFP less than 20 ng/mL where the conventional method was unable to determine AFP‐L3%. The sensitivity for AFP‐L3% remained high even at stage I and at tumor size less than 2 cm (42.5% and 46.0%, respectively). Recurrence rate of patients with AFP‐L3% greater than 5% was significantly higher than that of patients with less than 5% (P = 0.001). Furthermore, in resected patients, the postoperative AFP‐L3% remained elevated with value greater than 5% was related to HCC recurrence (P = 0.001). Multivariate analysis revealed that multiple tumors (P = 0.004), preoperative AFP‐L3% greater than 5% (P = 0.003), albumin less than 3.5 g/dL (P = 0.008), and RFA (P = 0.003) were significant prognostic factors of recurrence. Conclusions: The µTAS was found to be a highly sensitive assay for AFP‐L3% in patients with curative treatment of HCC. A cutoff value of 5% was useful for predicting recurrence after the curative treatment and detecting small tumors and early stage HCC. Additionally, postoperative AFP‐L3% was found to be a prognostic factor of HCC recurrence.     

Acute kidney injury is under‐recognised and under‐reported in hospitalised patients in Australia

Acute kidney injury (AKI) in hospitalised patients is associated with adverse outcomes; however, it remains unrecognised and under‐reported. A total of 48 045 serum creatinine results from 8129 tertiary hospital inpatients were reviewed. The prevalence of AKI was 4.33%. Mortality was significantly higher in patients with AKI (16.76%) compared to those without AKI (1.88%, P < 0.001). Documentation of AKI in discharge summaries was poor.     

Quality of life, physical function and MRI T2* in elderly low-risk MDS patients treated to a haemoglobin level of ≥120 g/L with darbepoetin alfa ± filgrastim or erythrocyte transfusions

Objective: Anaemia in low‐risk myelodysplastic syndromes (MDS) is associated with reduced quality of life (QoL). Response to treatment with erythropoietin ± granulocyte colony‐stimulating factor (G‐CSF) is associated with improved QoL, but whether transfusion therapy with higher haemoglobin (Hb) target levels has similar effects is unknown. The objective for this prospective phase II Nordic multicentre trial was to assess QoL, response rate and physical function in elderly anaemic MDS patients treated to a target Hb level of >120 g/L. Methods: Thirty‐six elderly patients with low‐ and intermediate‐1 risk MDS received darbepoetin (DA) 300 μg/wk, with the addition of G‐CSF if no response. If the Hb target was reached at 16 wk, treatment was maintained until week 26. Remaining patients were transfused to reach the target level for at least 8 wk. Results: Twenty‐seven patients completed the study. Response rate to DA ± G‐CSF was 67% in evaluable patients and 56% according to intention to treat. Eighteen patients reached the target Hb level according to protocol. QoL scores for fatigue, dyspnoea, constipation, and physical, role and social functioning improved significantly during study, with similar results for transfused and untransfused patients. Maintaining Hb >120 g/L did not confer a higher transfusion rate, once the target was reached. In two of fourteen patients, magnetic resonance imaging T2* indicated cardiac iron overload, however, without association with ferritin levels. Conclusions: In elderly anaemic MDS patients, an increment in haemoglobin is associated with improved QoL, whether induced by growth factor treatment or transfusion therapy.     

Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program

OBJECTIVES: To evaluate the effect of an exercise‐based model of hospital and in‐home follow‐up care for older people at risk of hospital readmission on emergency health service utilization and quality of life. DESIGN: Randomized controlled trial. SETTING: Tertiary metropolitan hospital in Australia. PARTICIPANTS: One hundred twenty‐eight patients (64 intervention, 64 control) with an acute medical admission, aged 65 and older and with at least one risk factor for readmission (multiple comorbidities, impaired functionality, aged ≥75, recent multiple admissions, poor social support, history of depression). INTERVENTION: Comprehensive nursing and physiotherapy assessment and individualized program of exercise strategies and nurse‐conducted home visit and telephone follow‐up commencing in the hospital and continuing for 24 weeks after discharge. MEASUREMENTS: Emergency health service utilization (emergency hospital readmissions and visits to emergency department, general practitioner (GP), or allied health professional) and health‐related quality of life (Medical Outcomes Study 12‐item Short Form Survey (SF‐12v2^?) collected at baseline and 4, 12, and 24 weeks after discharge. RESULTS: The intervention group required significantly fewer emergency hospital readmissions (22% of intervention group, 47% of control group, P=.007) and emergency GP visits (25% of intervention group, 67% of control group, P<.001). The intervention group also reported significantly greater improvements in quality of life than the control group as measured using SF‐12v2^? Physical Component Summary scores (F (3, 279)=30.43, P<.001) and Mental Component Summary scores (F (3, 279)=7.20, P<.001). CONCLUSION: Early introduction of an individualized exercise program and long‐term telephone follow‐up may reduce emergency health service utilization and improve quality of life of older adults at risk of hospital readmission.     

Glucosylsphingosine is a key biomarker of Gaucher disease

Gaucher disease (GD) involves the accumulation of glucosylceramide (GL1) and its deacylated lysolipid, glucosylsphingosine (lyso‐GL1) which is implicated in mediating immune dysregulation and skeletal disease. The aim of our study was to assess plasma Lyso‐GL1 as a biomarker of GD and its response to therapy. Plasma lyso‐GL1 in 169 patients with GD type 1 (GD1) was measured by LC‐MS/MS. Significant predictors of plasma LGL1 were assessed by Pearson's correlation coefficient, Wilcoxon Mann Whitney test and multiple linear regression. Propensity scores were used to match patients on treatment mode: Enzyme Replacement Therapy (ERT) vs. Eliglustat Tartrate SRT (ELI‐SRT). Plasma Lyso‐GL1 levels in healthy controls averaged 1.5 ng/ml (1.3–1.7; 95% CI). In untreated GD patients, the levels were massively elevated (180.9 ng/ml: 95% CI, 145.4–216.5) and imiglucerase ERT resulted in marked reduction (89 ng/ml: 95% CI, 69.2–129.4) (P < 0.001). Lyso‐GL1 correlated with chitotriosidase (r = 0.59 P < 0.001), CCL18 (r = 0.62 P <0.001), hepatomegaly (r = 0.28 P < 0.001), splenomegaly (r = 0.27 P = 0.003), splenectomy (P = 0.01) and treatment mode (P < 0.001). By multiple linear regression, the strongest predictors of lyso‐GL1 were age (P < 0.001), splenectomy (P = 0.02), Chitotriosidase (P < 0.001) and CCL18 levels (P = 0.001). After propensity score matching to obtain comparable groups of patients on ERT vs ELI‐SRT, lyso‐GL1 levels were lower among patients receiving ELI‐SRT by 113 ng/ml (95% CI: 136–90.3 ng/ml P < 0.001). Plasma lyso‐GL1 is a key biomarker of GD. ERT reduced lyso‐GL1 levels. By propensity scoring, ELI‐SRT resulted in greater reduction of lyso‐GL1 than ERT. Am. J. Hematol. 91:1082–1089, 2016. © 2016 Wiley Periodicals, Inc.     

Non-invasive markers of bone turnover and plasma cytokines differ in osteoporotic patients with multiple myeloma and monoclonal gammopathies of undetermined significance

Abstract Aims: To determine whether various markers of bone turnover and/or plasma cytokines differ in patients with multiple myeloma (MM) compared with patients with monoclonal gammopathies of undetermined significance (MGUS). Methods: We studied 22 MM patients and 18 MGUS patients presenting over an 18‐month period and compared their data with those from 20 age‐ and sex‐matched patients presenting with primary osteoporosis. According to the Salmon and Durie classification, there were eight patients with stage I, nine with stage II and five with stage III disease. All patients had densitometric evidence of osteoporosis and were classified according to bone marrow evidence of plasma cell dyscrasia. Measured variables included markers of bone formation and bone resorption, and plasma cytokines. Results: Patients with MM and MGUS did not differ with respect to their mean age, male : female sex ratio, height, weight, serum calcium, 25‐hydroxyvitamin D and parathyroid hormone concentrations. Patients with MM had significantly lower concentrations of haemoglobin (109 vs 135 g/L) and serum transforming growth factor (TGF)‐β (261 vs 348 pg/mL) than patients with MGUS, and higher concentrations of serum paraproteins (31.1 vs 7.4 g/L), β2‐microglobulin (3.5 vs 2.2 g/L), % plasma cell numbers (35.3 vs 2.1%) and urinary deoxypyridinoline excretion rates (u‐DPYD; 7.7 vs 5.9 nmol/mmol creatinine; P < 0.05 for all comparisons). In multivariate analysis, the serum paraprotein (β coefficient = –0.067; 95% confidence intervals (CI), –0.019 to –0.005; P = 0.0012), u‐DPYD excretion rates (β coefficient = –0.012; 95% CI, –0.113 to –0.02; P = 0.0058) and serum TGF‐β concentrations (β coefficient = –0.002; 95% CI, –0.0002 to –0.02; P = 0.02) were the most important variables differentiating between MM and MGUS, after excluding lytic bone lesions, % plasma cell numbers and haemoglobin concentrations. Conclusions: The well‐established criteria for diagnosing MM include the presence of lytic bone lesions, plasmacytosis, haemoglobin and paraprotein concentrations. The u‐DPYD excretion rate, a sensitive non‐invasive marker of bone resorption, may help in differentiating between MM and MGUS, as well as serving as a marker of underlying bone disease activity in these patients. (Intern Med J 2001; 31: 272–278)     

Treatment of anaemia in inflammatory bowel disease with iron sucrose

Background: Inflammatory bowel disease (IBD)‐associated anaemia usually responds to intravenous iron. If not, additive treatment with erythropoietin has been proposed. The objective of the present retrospective study was to evaluate the effectiveness of treatment with iron sucrose alone. Methods: Sixty‐one patients with IBD and anaemia (average haemoglobin 97?g/L) were treated with iron sucrose (iron dose 1.4?±?0.5?g). The indications for iron sucrose were poor response and/or intolerance to oral iron. Treatment response was defined as an increase in haemoglobin of ≥20?g/L or to normal haemoglobin levels (≥120?g/L). Two independent investigators retrospectively assessed laboratory variables, clinical findings, and concomitant medication. Results: Two patients were transferred to other hospitals after treatment and therefore could not be evaluated. Fifty‐four of the remaining 59 patients (91%) responded within 12 weeks. Sixty percent of the patients had responded within 8 weeks. Five patients had no or only a partial response to iron sucrose of which three had prolonged gastrointestinal blood losses. Eight patients with normal or elevated levels of ferritin could be considered to have anaemia of chronic disease, and all of them responded to iron sucrose. During a follow‐up period of 117?±?85 (4–291) (mean?±?s (standard deviation) (range)) weeks 19 patients (32%) needed at least one second course of iron sucrose because of recurrent disease. Conclusions: Anaemia associated with IBD can be successfully treated with intravenously administered iron sucrose, provided that bowel inflammation is treated adequately and enough iron is given. Treatment with iron sucrose is safe. Follow‐up of haemoglobin and iron parameters to avoid further iron deficiency anaemia is recommended.     

Role of IL‐28B and inosine triphosphatase polymorphisms in efficacy and safety of Peg‐Interferon and ribavirin in chronic hepatitis C compensated cirrhosis with and without oesophageal varices

Summary. Genetic factors can influence the outcome of antiviral therapy in chronic hepatitis C (HCV). We evaluated the role of interleukin‐28B single nucleotide polymorphisms (SNPs) and inosine triphosphatase (ITPA) gene variants in HCV cirrhosis treated with Peg‐Interferon and ribavirin. A prospective cohort of 233 patients with compensated cirrhosis received 1–1.5 μg/kg/week of Peg‐Interferon alpha‐2b plus 1000–1200 mg/day of RBV for 48 weeks. A sustained virologic response (SVR) was achieved in 27% of patients. On multivariate logistic analysis, the absence of oesophageal varices (OR 3.64 CI 95% 1.27–10.44 P = 0.016), infection with genotype 2 or 3 (OR 4.06, CI 95% 1.08–15.26, P = 0.038), C/C alleles of rs12979860 SNP (OR 7.04, CI 95% 2.40–20.72, P < 0.001) and rapid virologic response (RVR) (OR 78.29, CI 95% 16.07–381.29, P < 0.001) were independently associated with SVR. Patients who experienced post‐treatment relapse received lower total doses of Peg‐Interferon (52.0 ± 15.8 μg/kg vs 65.7 ± 13.3 μg/kg, P < 0.001) and lower total dose of RBV (3829 ± 1210 mg vs 4709 ± 954 mg, P < 0.001) than patients who achieved an SVR. ITPA variants predictive of high ITPase activity were associated with reduction of haemoglobin ≥3 g/dL in the first 4 weeks (P < 0.001), and with reduction of haemoglobin <10 g/dL (P = 0.03) on treatment. In conclusion, combination therapy with Peg‐Interferon and RBV in patients with HCV cirrhosis must be guided by virus genotype, severity of portal hypertension, favourable IL‐28B polymorphisms and ITPA variants, and RVR on treatment.     

A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome

Abstract. Herlitz J, Bång A, Ekström L, Aune S, Lundström G, Holmberg S, Holmberg M, Lindqvist J (Sahlgrenska University Hospital, Göteborg, Sweden). A comparison between patients suffering in‐hospital and out‐of‐hospital cardiac arrest in terms of treatment and outcome. J Intern Med 2000; 248: 53–60. Aim. To compare treatment and outcome amongst patients suffering in‐hospital and out‐of‐hospital cardiac arrest in the same community. Patients. All patients suffering in‐hospital cardiac arrest in Sahlgrenska University Hospital covering half the catchment area of the community of Göteborg (500 000 inhabitants) and all patients suffering out‐of‐hospital cardiac arrest in the community of Göteborg. Criteria for inclusion were that resuscitation efforts should have been attempted. Time of survey. From 1 November 1994 to 1 November 1997. Methods. Data were recorded both prospectively and retrospectively. Results. In total, 422 patients suffered in‐hospital cardiac arrest and 778 patients suffered out‐of‐hospital cardiac arrest. Patients with in‐hospital cardiac arrest included more women and were more frequently found in ventricular fibrillation. The median interval between collapse and defibrillation was 2 min in in‐hospital cardiac arrest compared with 7 min in out‐of‐hospital cardiac arrest (< 0.001). The proportion of patients being discharged from hospital was 37.5% after in‐hospital cardiac arrest, compared with 8.7% after out‐of‐hospital cardiac arrest (P < 0.001). Corresponding figures for patients found in ventricular fibrillation were 56.9 vs. 19.7% (P < 0.001) and for patients found in asystole 25.2 vs. 1.8% (P < 0.001). Conclusion. In a survey evaluating patients with in‐hospital and out‐of‐hospital cardiac arrest in whom resuscitation efforts were attempted, we found that the former group had a survival rate more than four times higher than the latter. Possible strong contributing factors to this observation are: (i) shorter time interval to start of treatment, and (ii) a prepared selection for resuscitation efforts.     

Growth differentiation factor 15 is associated with left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

Background

There is evidence suggesting that growth differentiation factor 15 (GDF‐15) appears to be associated with stroke in patients with atrial fibrillation (AF). AF‐related thromboembolic stroke is predominantly attributed to the thrombus from the left atrium (LA) or left atrial appendage (LAA).

Hypothesis

GDF‐15 is related to LA/LAA thrombus in nonvalvular AF (NVAF) patients.

Methods

A total of 894 patients with NVAF without anticoagulation therapy were included in this study. All patients routinely underwent transesophageal echocardiography for detection of LA/LAA thrombus. GDF‐15 was measured by enzyme‐linked immunosorbent assay. Logistic regression models were used to test for association.

Results

LA/LAA thrombus was detected by transesophageal echocardiography in 69 (7.72%) patients with AF. The GDF‐15 levels in the patients with LA/LAA thrombus were significantly higher than those without LA/LAA thrombus (log₁₀ GDF‐15: 2.989 ± 0.023 ng/L vs 2.831 ± 0.007 ng/L; P < 0.001). Logistic regression analysis showed that GDF‐15 was an independent risk factor for LA/LAA thrombus (odds ratio [per quarter]: 1.799, 95% confidence interval: 1.381‐2.344, P < 0.001) after adjusting for potential clinical risk factors. The optimal cutoff point for GDF‐15 predicting LA/LAA thrombus was 809.9 ng/L (sensitivity, 75.3%; specificity, 61.5%), determined by ROC curve. The area under the curve was 0.709 (95% confidence interval: 0.644‐0.770, P < 0.001).

Conclusions

Elevated GDF‐15 indicated a significantly increased risk for LA/LAA thrombus in NVAF patients. Thus, GDF‐15 might be a potentially useful adjunct in discriminating LA/LAA thrombus in NVAF patients.     

Low glomerular filtration rate is a risk factor for ribavirin‐associated anaemia in old patients with chronic hepatitis C

Elderly patients with chronic hepatitis C have a reduced responsiveness to antiviral therapy with Peg‐interferon and ribavirin. The dose reduction or the discontinuation of ribavirin due to the occurrence of anaemia is one of the most important causes for the low sustained viral response observed in older patients. We aimed to evaluate the relationship between baseline renal function and the early onset of ribavirin‐associated anaemia in older (≥60 years) patients. Using data from 348 patients with chronic hepatitis C consecutively treated with peg‐interferon plus ribavirin, we investigated which factors were associated with the occurrence of anaemia in elderly patients (≥60 years). Ribavirin‐induced anaemia occurred in 40.5% of patients. Older patients showed a rate of anaemia significantly higher than younger patients (51.5% vs 36.3%; P = 0.009). Consequently, the rate of ribavirin dose reduction or discontinuation due to anaemia was 35.1% in older patients and 23.5% in younger patients (P = 0.029). A significantly higher proportion of older patients had a low baseline glomerular filtration rate (GFR) compared with younger patients (56.7% vs 27.1%; P < 0.001). At the multivariate regression analysis, low baseline GFR (<70 mL/min) was associated with an increased risk of ribavirin‐associated anaemia only in the older patients (OR: 3.526; 95% CI: 1.385–8.979; P = 0.008). In this subset, baseline GFR was significantly correlated with both absolute (r = ?0.320; P < 0.001) and relative (r = ?0.324; P < 0.001) haemoglobin decrease within the first 8 weeks of treatment. In patients aged >60 years, a low pre‐treatment GFR was strongly associated with the risk to develop ribavirin‐related anaemia with consequent reduction in ribavirin doses.     

Do clinical characteristics and outcome in nonagenarians with a hip fracture differ from younger patients?

Aim: To compare clinical characteristics and outcome of nonagenarian hip fracture patients with younger patients aged 65–89 years. Methods: This was a cohort follow‐up study of admissions for a hip fracture between 2005–2010 (mean follow up of 3.5 years) in two teaching hospitals in the Netherlands; 230 nonagenarians and 1014 patients aged 65–89 years were included. Clinical characteristics, adverse events, mobility and mortality were compared. Results: Nonagenarians were more likely to be female and anemic (both P < 0.001), and had more trochanteric fractures (P = 0.005). The number of American Society of Anesthesiologists III/VI classified patients did not differ between the two groups. During the hospital stay, adverse events were more frequently observed in nonagenarians compared with younger patients (P < 0.001). The length of stay was significantly longer in nonagenarians (P < 0.001), and the 90‐day readmission rate was similar. Absolute mortality was higher in nonagenarians (P < 0.001), excess mortality, however, was comparable. Before admission, 40.0% of the nonagenarians lived in their own home, and 40.9% had returned 3 months postfracture. The rate of returning to their own home was lower compared with younger patients (P < 0.001). Prefracture mobility was worse in nonagenarians compared with the younger group, but 3 months after discharge, the number of patients that regained prefracture mobility was comparable in both age groups. Conclusions: Nonagenarian hip fracture patients differ significantly from younger patients aged 65–89 years with respect to clinical characteristics and long‐term outcome. However, almost half of the nonagenarians returned to their own home and more than half regained their prefracture level of mobility. Given these findings, prevention strategies for hip fracture and adverse events during hospital stay that focus particularly on frail nonagenarians are highly recommended. Geriatr Gerontol Int 2013; 13: 190–197.