Outcomes and Excess Costs among Patients with Cardiovascular Disease

ObjectiveTo report on two-year cardiovascular (CV) event rates and quantify the cost of cardiovascular disease using the Australian Reduction of Atherothrombosis for Continued Health (REACH) registry.MethodsProspective registry of 2873 patients with multiple risk factors (MRF), coronary artery disease (CAD), cerebrovascular disease (CerVD) and peripheral artery disease (PAD), recruited through 273 Australian general practitioners. Government reimbursement data from 2011 was used to calculate direct health care costs (pharmaceuticals, outpatient and hospitalisation costs). The main outcome of interest was two-year rates and associated excess costs of cardiovascular death, myocardial infarction, stroke, and hospitalisation for cardiovascular procedures.ResultsThe two year follow-up data were available for 2856 (99.4%) patients. Incidence of any hospitalisation and cardiovascular death was highest among those with previous history of PAD at baseline 49% (n = 126), and 5.1% (n = 13). Non-fatal cardiovascular events were highest among the PAD and CAD groups (21.8% (n = 56) and 14.1% (n = 297) respectively). Those with previous history of PAD and CerVD at baseline had the highest likelihood of CV death (OR = 2.53 (95% CI: 1.58–4.08) and OR = 1.61 (1.05–2.46) respectively) in comparison to other groups. Patients with PAD had the highest likelihood of vascular interventions OR = 3.11 (95% CI: 2.09–4.63) at two years. Overall, the mean (SD) direct expenditure over two years of follow-up per person was A$7544 (A$10,758). In the adjusted model, patients with CAD and PAD incurred A$1093 (95% CI A$24 – A$2072) and A$4890 (95% CI A$3105 – A$6869) more in mean total costs compared to patients with MRF.ConclusionsPatients with PAD had the highest likelihood of vascular interventions and CV death, and incurred high excess costs in comparison to other groups.     

Enfermedad arterial periférica en pacientes en hemodiálisis 10 años después

Background and objectivePatients with chronic kidney disease on hemodialysis present high cardiovascular comorbidity. Peripheral arterial disease (PAD) is associated with higher mortality and the interest in its early detection and treatment is increasing. The objective of this study is to determine the frequency and severity of symptomatic PAD, and to establish its relationship with mortality in hemodialysis patients that have received treated early and compare them with a cohort of our center already reported.Material and methodsRetrospective study on a cohort of incident patients since 2014 and followed up until December 2019. Demographic data, cardiovascular risk, the presence of symptomatic PAD at baseline and during follow-up were collected. Trophic lesions were graded using the Rutherford scale.ResultsInitially, there were 91 patients and 7 cases that were not included in the study were lost to follow-up. Age 64 ± 16 years, men 51.6% (47/91). The percentage of baseline PAD was 10.7% (9/84). During a median follow-up of 35 months (20–57), the diagnosis of PAD increased to 25% (21/84). Half of the patients with PAD (52.38% [11/21]) obtained a score greater than 3 in the Rutherford Clinical Classification, which corresponds to severe disease. 13/21 patients required reoperation due to recurrence of symptoms (61.9% of cases with PAD).The development of PAD was significantly associated with the presence of an elevated index of Charlson (3.9 ± 2.1 vs 7.7 ± 3.5; P = .001) with being male (19 vs 2; P = .001), diabetic (no: 7; yes: 15; P = .001) and with a history of chronic ischemic heart disease (no: 13; yes: 8; P = .001), so that 38.1% (8/21) had ischemic heart disease in patients who developed PAD, while in the absence of PAD the presence of ischemic heart disease was 9.5% (6/63). Furthermore, more than half (66.7% [14/21]) of those who developed PAD were diabetic.Univariate analysis showed that age, C reactive protein, albumin, and number of surgical interventions, but not PAD, were associated with mortality. In the multivariate analysis adjusted for other factors, only C reactive protein was related to overall survival Exp β: 2.17; P = .011; CI (1.19–3.97). Regarding cardiovascular mortality, in the multivariate Cox analysis, only PAD was related to mortality of cardiovascular origin Exp β: 1.73; P = .006; CI (1.17–2.56).ConclusionsA significant number of patients on hemodialysis develop PAD requiring peripheral vascular surgery. PAD was not associated with overall mortality in our cohort, but it did show an association with cardiovascular mortality. Prospective studies with a larger sample size are necessary. New surgical treatments and follow-up by vascular surgeons could improve the severity of PAD and the long-term prognosis.     

Differences in cardiovascular mortality in smokers, past-smokers and non-smokers: Findings from the FRENA registry

BackgroundThe influence of smoking on outcome in patients with coronary artery disease (CAD) is controversial. Even less is known about its influence in patients with cerebrovascular (CVD), or peripheral artery (PAD) disease.Patients and methodsFRENA is an ongoing, observational registry of consecutive outpatients with symptomatic CAD, CVD, or PAD. We reviewed their cardiovascular mortality according to smoking status.ResultsAs of May 2008, 2501 patients had been enrolled in FRENA. Of these, 439 (18%) were current smokers, 1086 (43%) past-smokers, 976 (39%) had never smoked. Current- and past-smokers were 10 years younger, more often males, and more likely to have chronic lung disease, but had diabetes, hypertension, heart failure, or renal insufficiency less often than non-smokers. Over a mean follow-up of 14 months, 123 patients died (cardiovascular death, 68). On univariate analysis, current smokers had a significantly lower rate of cardiovascular death: 1.1 (95% CI: 0.4–2.4) per 100 patient-years in current smokers; 1.9 (95% CI: 1.2–2.8) in past-smokers; 3.5 (95% CI: 2.5–4.7) in non-smokers, with no differences between patients with CAD, CVD or PAD. Mean age at cardiovascular death was 82 ± 6.4; 70 ± 9.9 and 67 ± 15 years, respectively. On multivariate analysis, smoking status was not independently associated with a lower risk for cardiovascular death.ConclusionsCurrent and past-smokers with CAD, CVD or PAD had a less than half cardiovascular mortality than those who never smoked, but this may be explained by the confounding effect of additional variables. They died over 10 years younger than non-smokers.     

Red blood cell distribution width and diabetes-associated complications

AimRed blood cell distribution width (RDW) is a marker of cardiovascular morbidity and mortality. However, there is little data on the relationship between RDW and diabetes-associated complications. The aim was to investigate whether there is any association between RDW, nephropathy, neuropathy and peripheral arterial disease (PAD) in a type 2 diabetic population.MethodsThis study included 196 diabetic patients with proliferative diabetic retinopathy. All subjects were investigated for diabetic nephropathy, diabetic neuropathy and PAD. Participants underwent 24-h blood pressure monitoring and were analysed for markers of the metabolic syndrome, inflammation, and insulin resistance.Results57% of the participants had diabetic nephropathy, 46% had diabetic neuropathy while 26% had PAD. No significant association was found between RDW, diabetic neuropathy and PAD (p = NS). However, RDW was strongly associated with diabetic nephropathy (p = 0.006), even following adjustment for potential confounding variables. Multivariate logistic regression analysis showed RDW (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.15–2.35, p = 0.006), estimated glomerular filtration rate (OR 0.98, 95% CI 0.96–0.99, p < 0.001), night-time diastolic blood pressure (OR 1.07, 95% CI 1.03–1.11, p = 0.001) and erythrocyte sedimentation rate (OR 1.03, 95% CI 1.004–1.05, p = 0.019) to be independently associated with diabetic nephropathy.ConclusionsThis is the first study to report lack of association between RDW, neuropathy and PAD in subjects with type 2 diabetes mellitus. More importantly, RDW was shown to be significantly associated with diabetic nephropathy in a type 2 diabetic population with advanced proliferative retinopathy independent of traditional risk factors, including diabetes duration and glycaemic control.     

Metabolic syndrome and cardiovascular risk prediction in peripheral arterial disease

Background and aimsMetabolic syndrome (MetS) was reported to be associated with increased cardiovascular risk in various settings, however its prognostic impact in peripheral arterial disease (PAD) is scanty.Methods and resultsWe prospectively studied 173 patients with intermittent claudication and ankle/brachial index (ABI) <0.90, in whom MetS was defined using the criteria of both the revised version of the Adults Treatment Panel III (rATP III) and the International Diabetes Federation (IDF). Of these patients, 52.6% met the rATP III and 54.9% the IDF criteria for MetS. During a median follow-up of 31 months, 54 cardiovascular events occurred. Kaplan–Meier curves showed a greater incidence of ischemic events in patients with MetS than in those without. However, adjusted Cox analyses revealed that only IDF-MetS was independently associated with increased cardiovascular risk (HR = 1.91, 95% CI 1.03–3.51, p = 0.038). Kaplan–Meier curves for the four groups of patients delineated according to the bootstrapped ABI cut-off value (0.73) and the presence or absence of IDF-MetS revealed that the syndrome improved the predictive power of ABI alone. Actually, among patients with an ABI ≤ 0.73, those with IDF-MetS had a higher cardiovascular risk than those without the syndrome (HR = 2.55, 95% CI 1.22–5.12, p = 0.012). This was confirmed by c-statistic, which was 0.56 for ABI alone and increased to 0.65 (p = 0.046) when IDF-Mets was added to the pressure index.ConclusionIn PAD, IDF-MetS, but not rATP III-MetS, is associated with an increased risk of cardiovascular events. Furthermore, IDF-MetS adds to the prognostic value of ABI, currently the most powerful prognostic indicator in PAD.     

Aspirin for primary prevention of cardiovascular events in patients with diabetes: A meta-analysis

BackgroundTo systematically review trials concerning the benefit and risk of aspirin therapy for primary prevention of cardiovascular events in patients with diabetes mellitus.MethodsWe searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Eligible studies were prospective, randomized controlled trials of aspirin therapy for primary cardiovascular prevention in patients with diabetes with follow-up duration at least 12 months.Results7 trials included 11,618 individuals with diabetes. Aspirin therapy was not associated with a statistically significant reduction in major cardiovascular events (relative risk [RR] 0.92, 95% confidence interval [CI] 0.83–1.02, p = 0.11). Aspirin use also did not significantly reduce all-cause mortality (0.95, 95% CI 0.85–1.06; p = 0.33), cardiovascular mortality (0.95, 95% CI 0.71–1.27; p = 0.71), stroke (0.83, 95% CI 0.63–1.10; p = 0.20), or myocardial infarction (MI) (0.85, 95% CI 0.65–1.11; p = 0.24). There was no significant increased risk of major bleeding in aspirin group (2.46, 95% CI 0.70–8.61; p = 0.16). Meta-regression suggested that aspirin agent could reduce the risk of stroke in women and MI in men.ConclusionsIn patients with diabetes, aspirin therapy did not significantly reduce the risk of cardiovascular events without an increased risk of major bleeding, and showed sex-specific effects on MI and stroke.     

In-hospital mortality and length of stay in patients with diabetes having foot disease

ObjectiveWe aimed to determine whether in-patient mortality and length of stay were greater in diabetes patients with foot disease compared to those without foot disease.MethodsRetrospective data analysis of admissions over four years (2007–2010) to University Hospital Birmingham. Based on discharge diagnostic codes we grouped admissions into those 1) with amputation, 2) with foot disease and 3) without foot disease. Inpatient mortality and length of stay were compared between the three groups, adjusting for confounders.ResultsWe identified 25,118 admissions with diabetes of which 1149 admissions (4.6%) had foot disease and another 195 (0.8%) had a code for lower limb amputation. When compared to those without foot disease the adjusted odds ratio for inpatient mortality was 1.31 (95% CI 1.04–1.65 P = 0.02) in the foot disease group, and 1.02 (95% CI 0.56–1.85 P = 0.95) in the amputation group; and the adjusted relative ratio for length of stay was 2.01 (95 CI 1.86–2.16 P < 0.001) in the foot disease group and 3.08 (95% CI 2.60–3.65 P < 0.001) in the amputation group.ConclusionFoot disease in hospitalised patients with diabetes is associated with increased length of stay and inpatient mortality. Our study adds to evidence on excess mortality associated with diabetic foot disease and to evidence on excess mortality observed in people with diabetes admitted to hospitals.     

Impact of systemic inflammation on the relationship between insulin resistance and all-cause and cancer-related mortality

BackgroundInsulin resistance and inflammation play an important role in a variety of chronic diseases.ObjectiveWe investigated the influence of systemic inflammation on the relationship between insulin resistance and mortality risk in apparently healthy adults.MethodsThis study examined the mortality outcomes for 165,849 Koreans enrolled in a health-screening program. The subjects were divided into four groups according to their homeostatic model assessment of insulin resistance (HOMA-IR) and high-sensitivity C-reactive protein (hs-CRP) levels: group 0, HOMA-IR < 75% and hs-CRP < 2.0 mg/L; group 1, HOMA-IR ≥ 75% and hs-CRP < 2.0 mg/L; group 2, HOMA-IR < 75% and hs-CRP ≥ 2.0 mg/L; and group 3, HOMA-IR ≥ 75% and hs-CRP ≥ 2.0 mg/L. The Cox proportional hazard models were used to assess hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause, cardiovascular disease, and cancer-related mortality.ResultsDuring the follow-up period of 1,417,325.6 person-years, a total of 1316 deaths (182 from cardiovascular disease) occurred. The multivariate-adjusted HRs for all-cause mortality were significantly higher in groups 2 (HR 1.40; 95% CI: 1.19–1.64) and group 3 (HR 1.68; 95% CI: 1.34–2.10) than that in group 0. For cardiovascular mortality, the sex-adjusted hazards were also significantly higher in groups 2 and 3 than that in group 0; however, this increased risk disappeared during multivariate analysis. Groups 2 and 3 had significantly higher risk for cancer-related mortality than group 0, with multivariate-adjusted hazard ratios of 1.48 (95% CI: 1.18–1.86) and 1.84 (95% CI: 1.35–2.51), respectively.ConclusionsSystemic inflammation can be used to stratify the subjects according to the all-cause and cancer-related mortality risks, irrespective of the insulin-resistance status. And this tendency is most pronounced in cancer-related mortality.     

Body mass index and all-cause mortality among type 2 diabetes mellitus patients: Findings from the 5-year follow-up of the MADIABETES cohort

PurposeTo analyse the association between body mass index (BMI) and all-cause mortality in a 5-year follow-up study with Spanish type 2 diabetes mellitus (T2DM) patients, seeking gender differences.Methods3443 T2DM outpatients were studied. At baseline and annually, patients were subjected to anamnesis, a physical examination, and biochemical tests. Data about demographic and clinical characteristics was also recorded, as was the treatment each patient had been prescribed. Mortality records were obtained from the Spanish National Institute of Statistics. Survival curves for BMI categories (Gehan-Wilcoxon test) and a multivariate Cox proportional hazard analysis were performed to identify adjusted Hazard Ratios (HRs) of mortality.ResultsMortality rate was 26.38 cases per 1000 patient-years (95% CI, 23.92–29.01), with higher rates in men (28.43 per 1000 patient-years; 95% CI, 24.87–32.36) than in women (24.31 per 1000 patient-years; 95% CI, 21.02–27.98) (p = 0.079). Mortality rates according to BMI categories were: 56.7 (95% CI, 40.8–76.6), 28.4 (95% CI, 22.9–34.9), 24.8 (95% CI, 21.5–28.5), 21 (95% CI, 16.3–26.6) and 23.7 (95% CI, 14.3–37) per 1000 person-years for participants with a BMI of < 23, 23–26.8, 26.9–33.1, 33.2–39.4, and > 39.4 kg/m², respectively. The BMI values associated with the highest all-cause mortality were < 23 kg/m², but only in males [HR: 2.78 (95% CI, 1.72–4.49; p < 0.001)], since in females this association was not significant [HR: 1.14 (95% CI, 0.64–2.04; p = 0.666)] (reference category for BMI: 23.0–26.8 kg/m²). Higher BMIs were not associated with higher mortality rates.ConclusionsIn an outpatient T2DM Mediterranean population sample, low BMI predicted all-cause mortality only in males.     

Fitness Fatness Index and Alzheimer-specific mortality

ObjectiveWe evaluated the specific association between a Fitness Fat Index (FFI) and Alzheimer's-specific mortality among a national sample of the broader U.S. adult population.MethodsFFI was calculated as cardiorespiratory fitness (CRF) divided by waist-to-height ratio (WHR). Data from the 1999–2006 National Health and Nutrition Examination Survey (NHANES) were used to identify 16,146 participants, ages 20–85. Data from participants in these cycles were linked to death certificate data from the National Death Index. Person-months of follow-up were calculated from the date of the interview until date of death or censoring on December 31, 2011, whichever came first.ResultsIn a Cox proportional hazard model, for every 1 FFI unit increase, participants had a 14% reduced hazard of Alzheimer-specific death (HR = 0.86; 95% CI: 0.83–0.90; P < 0.001). When including diabetes and hypertension (via physician-diagnosis) as covariates, results were unchanged (HR = 0.87; 95% CI: 0.82–0.91; P < 0.001). Results were also unchanged when restricting the sample to those 50 + years (HR = 0.92; 95% CI: 0.88–0.97; P = 0.005) or stratifying by men (HR = 0.85; 95% CI: 0.81–0.91; P < 0.001) or women (HR = 0.86; 95% CI: 0.79–0.94; P = 0.002).ConclusionIn this national sample of individuals at risk for Alzheimer's disease, increased FFI was associated with reduced risk of Alzheimer's-specific death. Thus, a more favorable fitness-to-fatness ratio is associated with reduced risk of Alzheimer's-specific mortality, underscoring the importance of fitness promoting and fatness reducing strategies.     

All-cause mortality in patients with diabetes under glucagon-like peptide-1 agonists: A population-based,open cohort study

AimThe glucagon-like peptide-1 receptor agonist (GLP1a) liraglutide has been described to benefit patients with type 2 diabetes mellitus (T2DM) at high cardiovascular risk. However, there are still uncertainties relating to these cardiovascular benefits: whether they also apply to an unselected diabetic population that includes low-risk patients, represent a class-effect, and could be observed in a real-world setting.MethodsWe conducted a population-based, retrospective open cohort study using data derived from The Health Improvement Network database between Jan 2008 to Sept 2015. Patients with T2DM exposed to GLP1a (n = 8345) were compared to age, gender, body mass index, duration of T2DM and smoking status-matched patients with T2DM unexposed to GLP1a (n = 16,541).ResultsPatients with diabetes receiving GLP1a were significantly less likely to die from any cause compared to matched control patients with diabetes (adjusted incidence rate ratio [aIRR]: 0.64, 95% CI: 0.56–0.74, P-value < 0.0001). Similar findings were observed in low-risk patients (aIRR: 0.64, 95% CI: 0.53–0.76, P -value = 0.0001). No significant difference in the risk of incident CVD was detected in the low-risk patients (aIRR: 0.93, 95% CI: 0.83–1.12). Subgroup analyses suggested that effect is persistent in the elderly or across glycated haemoglobin categories.ConclusionsGLP1a treatment in a real-world setting may confer additional mortality benefit in patients with T2DM irrespective of their baseline CVD risk, age or baseline glycated haemoglobin and was sustained over the observation period.     

Decreased IGF-1 levels potentiate association of inflammation with all-cause and cardiovascular mortality in prevalent hemodialysis patients

ObjectiveInsulin-like growth factor-1 (IGF-1) and inflammation have both been linked to high cardiovascular risk and mortality in the general population, as well as in hemodialysis (HD) patients. We hypothesized that the association of low IGF-1 with chronic inflammation may increase the mortality risk in HD patients.DesignWe investigated the interactions between inflammatory biomarkers (IL-6 and TNF-α) and IGF-1 as predictors of death over a 4 years of follow-up (median — 47 months, interquartile range — 17.5–75 months) in 96 prevalent HD patients (35% women, mean age of 64.9 ± 11.6 years).ResultsA significant interaction effect of low IGF-1 (defined as a level less than median) and high IL-6 (defined as a level higher than median) on all-cause and cardiovascular mortality was found: crude Cox hazard ratios (HR) for the product termed IGF-1 × IL-6 were 4.27, with a 95% confidence interval (CI): 2.10 to 8.68 (P < 0.001) and 7.49, with a 95% CI: 2.40–24.1 (P = 0.001), respectively. Across the four IGF-1–IL-6 categories, the group with low IGF-1 and high IL-6 exhibited the worse outcome in both all-cause and cardiovascular mortality (multivariable adjusted hazard ratios were 4.92, 95% CI 1.86 to 13.03, and 14.34, 95% CI 1.49 to 137.8, respectively). The main clinical characteristics of patients in the low-IGF-1-high IL-6 group didn't differ from other IGF-1–IL-6 categorized groups besides gender that consequently was inserted in all multivariable models together with the other potential confounders.ConclusionsAn increase in mortality risk was observed in HD patients with low IGF-1 and high IL-6 levels, especially cardiovascular causes.     

Prolongation of the heart rate-corrected QT interval is associated with cardiovascular diseases: Systematic review and meta-analysis

BackgroundConflicting findings have described the association between prolonged heart rate-corrected QT interval (QTc) and cardiovascular disease.AimsTo identify articles investigating the association between QTc and cardiovascular disease morbidity and mortality, and to summarize the available evidence for the general and type 2 diabetes populations.MethodsA systematic search was performed in PubMed and Embase in May 2022 to identify studies that investigated the association between QTc prolongation and cardiovascular disease in both the general and type 2 diabetes populations. Screening, full-text assessment, data extraction and risk of bias assessment were performed independently by two reviewers. Effect estimates were pooled across studies using random-effect models.ResultsOf the 59 studies included, 36 qualified for meta-analysis. Meta-analysis of the general population studies showed a significant association for: overall cardiovascular disease (fatal and non-fatal) (hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.33–2.12; I² = 69%); coronary heart disease (fatal and non-fatal) in women (HR 1.27, 95% CI 1.08–1.50; I² = 38%; coronary heart disease (fatal and non-fatal) in men (HR 2.07, 95% CI 1.26–3.39; I² = 78%); stroke (HR 1.59, 95% CI 1.29–1.96; I² = 45%); sudden cardiac death (HR 1.60, 95% CI 1.14–2.25; I² = 68%); and atrial fibrillation (HR 1.55, 95% CI 1.31–1.83; I² = 0.0%). No significant association was found for cardiovascular disease in the type 2 diabetes population.ConclusionQTc prolongation was associated with risk of cardiovascular disease in the general population, but not in the type 2 diabetes population.     

Influence of age on perioperative major adverse cardiovascular events and mortality risks in elective non-cardiac surgery

Background and aimsAdvanced age increases the risk of perioperative cardiovascular complications and may pose reluctance to subject elderly patients to surgery. We examined the impact of high age on perioperative major adverse cardiovascular events (MACE) and mortality in a nationwide cohort of patients undergoing elective surgery.MethodsAll Danish patients aged ≥ 20 years undergoing non-cardiac, elective surgery in 2005–2011 were identified from nationwide administrative registers. Risks of 30-day MACE (non-fatal ischemic stroke, non-fatal myocardial infarction, or cardiovascular death) and all-cause mortality were analyzed by multivariable logistic regression models (adjusted for comorbidities, revised cardiac risk index, cardiovascular pharmacotherapy, body mass index, and surgery type).ResultsA total of 386,818 procedures on 302,459 patients were included; mean age was 54.8 years (min–max 20–104), and 44% were men. A total of 1297 (0.34%) had perioperative MACE and 1449 (0.37%) died. Advanced age was associated with increased risks of MACE (odds ratio [OR], 1.87; 95% CI, 1.78–1.98 per 10-year high) and mortality (OR, 1.87; 95% CI, 1.78–1.96 per 10-year high). A total of 21,511 procedures were performed on patients > 80–90 years old, and 1662 on patients > 90 years. The numbers of MACE and crude mortality rates were 331 (1.7%) and 388 (2.0%) among > 80–90 years old, and 50 (3.0%) and 67 (4.0%) for those aged > 90 years.ConclusionThe risk of mortality and major adverse cardiovascular events within 30 days after surgery increased with advanced age. However, despite advanced age, the absolute event rates appeared to be relatively modest and around 4% for people aged above 90 years.     

Vascular access type and mortality in elderly incident hemodialysis patients

IntroductionThe ideal vascular access type for elderly hemodialysis (HD) patients remains debatable. The aim of this study was to analyze the association between patterns of vascular access use within the first year of HD and mortality in elderly patients.MethodsSingle-center retrospective study of 99 incident HD patients aged ≥ 80 years from January 2010 to May 2021. Patients were categorized according to their patterns of vascular access use within the first year of HD: central venous catheter (CVC) only, CVC to arteriovenous fistula (AVF), AVF to CVC, and AVF only. Baseline clinical data were compared among groups. Survival outcomes were analyzed using Kaplan–Meier survival curves and Cox's proportional hazards model.ResultsWhen compared with CVC to AVF, mortality risk was significantly higher among CVC only patients and similar to AVF only group [HR 0.93 (95% CI 0.32–2.51)]. Ischemic heart disease [HR 1.74 (95% CI 1.02–2.96)], lower levels of albumin [HR 2.16 (95% CI 1.28–3.64)] and hemoglobin [HR 4.10(95% CI 1.69–9.92)], and higher levels of c-reactive protein [HR 1.87(95% CI 1.11–3.14)] were also associated with increased mortality risk in our cohort, p < 0.05.ConclusionOur findings suggested that placement of an AVF during the early stages of dialysis was associated with lower mortality compared to persistent CVC use among elderly patients. AVF placement appears to have a positive impact on survival outcomes, even in those who started dialysis with a CVC.     

Prevalence of diabetes and depressive symptomatology and their effect on mortality risk in elderly Italians: The Italian Longitudinal Study on Aging

AimThis study assessed the prevalence of depressive symptomatology (DS) in older individuals with diabetes to determine whether diabetes and DS are independent predictors of mortality, and if their coexistence is associated with an increased mortality risk.MethodsAnalyses were based on data from the Italian Longitudinal Study on Aging (ILSA), a prospective community-based cohort study in which 5632 individuals aged 65–84 years were enrolled. The role of diabetes and DS in all-cause mortality was evaluated using the Cox model, adjusted for possible confounders, for four groups: 1) those with neither diabetes nor DS (reference group); 2) those with DS but without diabetes; 3) those with diabetes but no DS; and 4) those with both diabetes and DS.ResultsType 2 diabetes mellitus (T2DM) was present in 13.8% of the participants; they presented with higher baseline rates of DS compared with the non-diabetic controls. During the first follow-up period, participants with DS but not diabetes had a 42% higher risk of all-cause mortality compared with the reference control group (HR = 1.42; 95% CI: 1.02–1.96), while participants with diabetes but not DS had an 83% higher risk of death than the reference group (HR = 1.83; 95% CI: 1.19–2.80). The risk of death for those with both disorders was more than twice that for the reference group (HR = 2.58; 95% CI: 1.55–4.29). Analyses of deaths from baseline to the second follow-up substantially confirmed these results.ConclusionThe prevalence rate of DS is higher in elderly people with diabetes and their coexistence is associated with an increased mortality risk.     

Clinical features and course of ulcerative colitis diagnosed in asymptomatic subjects

Background and AimsAlthough some ulcerative colitis (UC) patients are diagnosed when they do not have any UC-related symptoms, clinical features and prognosis of UC diagnosed in asymptomatic patients remain unclear.MethodsData for UC patients who were asymptomatic at diagnosis were retrospectively reviewed from the IBD database of the Asan Medical Center. The clinical characteristics and prognosis of those patients were analyzed and compared with matched (1:4) symptomatic UC patients.ResultsOnly nineteen asymptomatic UC patients (1.1%) were identified from 1665 UC patients. The proportion of males was 78.9% (n = 15), and their median age at diagnosis was 48 years (range, 34–71 years). At diagnosis, proctitis was noted in 11 patients (57.9%), left-sided colitis in 4 (21.1%), extensive colitis in 0 (0%), and atypical distribution in 4 (21.1%). The 5-year cumulative probability of symptom development was 68.5% (95% confidence interval [CI], 62.8%–74.2%). After UC diagnosis, oral 5-aminisalicylic acid (ASA) and topical 5-ASA were used in 14 (73.7%) and 16 (84.2%) patients, respectively. During follow-up (3.7-year median for asymptomatic patients versus 3.7-year median for symptomatic patients; P = 0.961), the 5-year cumulative probability of corticosteroids (23.7% versus 57.1%; P = 0.022) and azathioprine (0% versus 24.7%; P = 0.003) use was higher in symptomatic patients than in asymptomatic patients.ConclusionsThe frequency of asymptomatic UC patients was 1.1% in our UC patient cohort. A majority of these patients became symptomatic during follow-up. Asymptomatic UC patients at diagnosis appear to have a better prognosis than symptomatic UC patients.     

Low ankle-brachial index predicts early risk of recurrent stroke in patients with acute cerebral ischemia

ObjectiveLow Ankle-Brachial Blood Pressure Index (ABI) identifies patients with symptomatic and asymptomatic peripheral arterial disease (PAD). We sought to investigate the association of low ABI with early risk of stroke recurrence in patients with acute cerebral ischemia (ACI) and without history of symptomatic PAD.MethodsConsecutive patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) and no previous history of PAD were prospectively evaluated with ABI measurements. Demographic characteristics, vascular risk factors and secondary prevention therapies were documented. An ABI ≤0.90 in either leg was considered as evidence of asymptomatic PAD, and an ABI >0.90 was considered as normal. Patients with elevated ABI (>1.30) were excluded. The outcome of interest was recurrent stroke during 30-day follow-up.ResultsA total of 176 patients with acute cerebral ischemia (mean age 64 ± 14 years, 59.1% men, 76.7% AIS) were evaluated. Asymptomatic PAD was detected in 14.8% (95%CI: 10.2–20.8%) of the studied population. The following factors were independently associated with low ABI on multivariate logistic regression models, after adjustment for potential confounders: coronary artery disease (p = 0.008), diabetes mellitus (p = 0.017) and increasing age (p = 0.042). The cumulative 30-day recurrence rate was higher in patients with low ABI (19.2%; 95%CI: 4.1–34.3) compared to the rest (3.3%; 95%CI: 0.4–6.2%; p = 0.001). Atherothrombotic stroke (ASCO grade I; p < 0.001), increasing age (p = 0.002) and low ABI (p = 0.004) were independent predictors of stroke recurrence on multivariate Cox regression models adjusting for confounders.ConclusionsLow ABI appears to be associated with a higher risk of early recurrent stroke in patients with ACI and no history of symptomatic PAD.