High doses of β‐blockers and alcohol abstinence improve long‐term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding

Background & aim: We analysed prognostic indicators of long‐term outcome in cirrhotic patients surviving the critical 6‐week period after an episode of acute variceal bleeding. Methods: All patients with oesophageal variceal bleeding from 2001–2007 were prospectively registered. Follow‐up extended from day 42 after index bleeding to last visit, death or liver transplantation (LT). Multivariate Cox regression analysis was performed. Results: Two hundred and fifty variceal bleeding episodes were registered. Fifty‐four patients (26%) died before day 42, and 123 patients were finally included. Median follow‐up was 23.5 months. Nadolol±nitrates alone or combined with variceal ligation were used as prophylaxis in 93% of patients. During follow‐up, 43 patients (35%) experienced rebleeding, 34 (27.5%) died and 10 (8%) were transplanted. Follow‐up β‐blocker dose (HR 0.993, 95% CI 0.987–0.998, P=0.027) and alcohol abstinence (HR 0.324, 95% CI 0.152–0.691, P=0.004) were independent rebleeding predictors. The Cox analysis disclosed the Child–Pugh score (HR 1.24, 95% CI 1.08–1.43, P=0.002), creatinine (HR 1.82, 95% CI 1.17–2.82, P=0.008), β‐blocker dose (HR 0.992, 95% CI 0.987–0.997, P=0.003), viral cirrhosis (HR 2.72, 95% CI 1.31–5.67, P=0.008), hepatocellular carcinoma (HR 9.44, 95% CI 3.54–25.20, P<0.001) and alcohol abstinence (HR 0.29, 95% CI 0.13–0.62, P=0.002) to be independent prognostic markers for mortality/LT. Conclusion: High doses of β‐blockers and alcohol abstinence decrease rebleeding and mortality in cirrhotic patients surviving the 6‐week period after acute variceal bleeding.     

Adjuvant chemotherapy indications for stage I gastric cancer patients with negative lymph node

PurposeWhether adjuvant chemotherapy (AC) has a survival benefit for pathological stage Ⅰ (T1N0 and T2N0) gastric cancer (GC) patients with negative lymph node (N0) remains controversial.MethodsPatients with surgically resected, histologically confirmed pT1N0 and pT2N0 GC between January 2011 and December 2017 at the National Cancer Center, China, were retrospectively reviewed.ResultsA total of 1601 patients who met the inclusion criteria were identified. Independent risk factors for reduced overall survival (OS) identified in the Cox regression analysis were male sex (hazard ratio [HR] 1.454, 95% confidence interval [CI] 1.127–1.876), age ≥ 65 years (HR 1.367; 95% CI 1.071–1.744 ), T2 stage (HR 1.283; 95% CI 1.005?1.638), tumor size > 3 cm (HR 1.704; 95% CI 1.346?2.158), examined lymph nodes (EN) ≤ 15 (HR 1.327; 95% CI 1.058–1.664), and non-signet ring cell carcinoma (Non-SRCC) (HR 1.639; 95% CI 1.123–2.392). While only T2 stage (HR 1.410; 95% CI 1.026?1.936), tumor size > 3 cm (HR 1.755; 95% CI 1.285?2.397), examined lymph nodes (EN) ≤ 15 (HR 1.489; 95% CI 1.101–2.015) were independent risk factors for cause-specific survival (CSS). We divided patients with pT2N0 into four sub-categories according to two significant prognostic factors (size and EN) and found that only patient in group 3 (EN ≤ 15, size >3 cm) with improved CSS benefit from AC (p = 0.049). More significant CSS benefit from AC was identified in Non-SRCC patients within group 3 (p = 0.034).ConclusionAn additional survival benefit related to AC is expected for selected pT2N0 patients. Non-SRCC patients with EN ≤ 15 and tumor size >3 cm may be particularly appropriate candidates for AC.     

Six Minute Walk Test Predicts Long-Term All-Cause Mortality and Heart Failure Rehospitalization in African-American Patients Hospitalized With Acute Decompensated Heart Failure

BackgroundThe prognostic value of the 6-minute walk test (6MWT) has been described in patients with heart failure (HF); however, limited data are available in an African-American (AA) population. We prospectively evaluated the usefulness of the 6MWT in predicting mortality and HF rehospitalization in AA patients with acute decompensated HF.Methods and ResultsTwo hundred AA patients (63.1% men, mean age 55.7 ± 12.9 years) with acute decompensated HF were prospectively studied. Patients were followed to assess 40-month all-cause mortality and 18-month HF rehospitalization. The median distance walked on the 6MWT was 213 m. Of the 198 patients with available mortality data, 59 patients (29.8%) died. Of the 191 patients with available rehospitalization data, 114 (59.7%) were rehospitalized for worsening HF. For patients who walked ≤200 m during the 6MWT, mortality was 41% compared with 19% in patients who walked >200 m (P = .001). For patients who walked ≤200 m during the 6MWT, HF rehospitalization was 68% compared with 52% in those who walked >200 m (P = .027). Multivariate Cox regression analysis showed that 6MWT distance ≤200 m was the strongest predictor of mortality (adjusted hazard ratio [HR], 2.14; confidence interval [CI], 1.20 to 3.81; P = .01) and HF rehospitalization (adjusted HR, 1.62; CI, 1.10 to 2.39; P = .015).ConclusionsIn AA patients hospitalized with acute decompensated HF, 6MWT strongly and independently predicts long-term all-cause mortality and HF rehospitalization.     

Neurocognitive impairment is associated with erectile dysfunction in cirrhotic patients

IntroductionErectile dysfunction (ED) is common in patients with chronic diseases. It is evaluated using the International Index of Erectile Function (IIEF5) questionnaire. The relationship between ED and cirrhosis is complex. The aims of our study were (1) to assess the prevalence of ED in cirrhosis and (2) to evaluate factors associated with ED, with a special focus on minimal hepatic encephalopathy (MHE).MethodsWe performed a prospective, observational study. Patients with cirrhosis were invited to complete the IIEF5 questionnaire. The exclusion criteria were clinical hepatic encephalopathy (HE) and dementia. MHE was evaluated by the psychometric hepatic encephalopathy test score (PHES) and the critical flicker frequency (CFF).ResultsBetween April 2016 and April 2017, 87 patients were included (age: 55 [51–57] years, Child–Pugh score: 8 [7–9], MELD score: 13 [11–16]. Minimal HE was diagnosed in 33% of the patients according to the PHES and in 44% of the patients according to the CFF. ED was diagnosed in 74/87 patients (85%) when compared to 12.5% in healthy controls (p < 0.001). In a multivariate analysis, the independent factors associated with ED were age, Child–Pugh and MELD scores. Significant correlations were identified between the IIEF5 and each component of the PHES.ConclusionED should be systematically screened in cirrhotics, especially in patients with MHE.     

Abnormal ankle-brachial index (ABI) predicts primary and secondary cardiovascular risk and cancer mortality

BackgroundAn abnormal ankle-brachial pressure index (ABI) is a marker of the risk for increased total and cardiovascular (CV) mortality. However, it is not clear whether it is associated with an even worse prognosis in patients with previous CV events or with cancer mortality.Materials and MethodsConsecutive subjects undergoing ABI assessment for suspected peripheral artery disease or for stratification of CV risk in ten centers in the Veneto Region (northeast Italy), between 2011 and 2014 were enrolled. The ABI was expressed as normal ≥0.9 to ≤1.3, and abnormal <0.9 or >1.3. All-cause mortality and CV or cancer mortality and hospitalizations for CV disease were collected from administrative databases up to December 2018.ResultsThe study enrolled 1,177 patients. ABI was abnormal in 57.2%. Median follow-up was 61.6 months (53.4–70.1). All-cause, CV and cancer mortality were higher in patients with abnormal than normal ABI, with hazard ratios (HR) respectively 2.0 (95% CI 1.48–2.69), 1.98 (95% CI 1.24–3.17) and 1.85 (95% CI 1.09–3.15). Among subjects with abnormal ABI, the risk of overall mortality, HR 1.57 (95% CI 1.17–2.12), and CV mortality, HR 2.39 (95% CI 1.43–3.99), was higher in those with previous CV events. These latter also had a higher risk of hospitalization for myocardial infarction and stroke: HR 1.85 (95% CI 1.023.37) and 2.17 (95% CI 1.10–4.28).ConclusionsThe co-existence of abnormal ABI and a history of CV events identifies subjects at higher risk, who call for a more aggressive approach. Abnormal ABI is also a predictor of cancer mortality.     

Muscle psoas indices measured by ultrasound in cirrhosis — Preliminary evaluation of sarcopenia assessment and prediction of liver decompensation and mortality

BackgroundNo data on the European population exists regarding the use of an ultrasoundbased measurement of psoas diameter for sarcopenia assessment in cirrhosis.AimsTo determine the applicability of an ultrasound measurement of the psoas muscle diameter in patients with decompensated liver cirrhosis and to assess whether this surrogate is associated with hospitalization due to decompensation and mortality.MethodsIn 75 consecutive patients with decompensated liver cirrhosis and in 20 control subjects (January 2016 to November 2017), psoas muscle diameter was prospectively measured. The reliable measurements were used for the further analysis. Relevant clinical and laboratory data was collected.ResultsUltrasound measurement was applicable in 100% of control and in 72% of study subjects. Psoas to height ratio was significantly related to hospitalization and mortality (p < 0.0001, HR 0.717, 95% CI: 0.622–0.828 and p = 0.022; HR = 0.825, 95% CI: 0.701–0.973) as was psoas muscle index (p < 0.0001, HR = 0.881, 95% CI: 0.836–0.929 and p = 0.017; HR = 0.930, 95% CI: 0.876–0.987).ConclusionsUltrasound measurement of psoas muscle diameter and its derived indices is applicable and associated with hospitalization and mortality in patients with decompensated liver cirrhosis.     

Ischemic and Bleeding Outcomes of Potent P2Y12 Inhibitor Antiplatelet Agents Versus Clopidogrel in Elderly Patients With Acute Coronary Syndrome: A Meta-Analysis of Randomized Trials

BackgroundThe role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population.Methods and resultsPubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82–1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75–1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78–1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82–1.86]; p=0.31). However, potent oral P2Y₁₂ inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68–0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09–1.59]; p<0.01).ConclusionIn comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.     

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

IntroductionPatients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.ObjectivesTo assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.MethodsWe performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.ResultsMedian DIDO time was 82 min (interquartile range, 61–132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062–1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).ConclusionA DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.     

Feasibility of pegylated interferon and ribavirin in hepatitis C-related cirrhosis with neutropenia or thrombocytopenia

AimTo investigate the feasibility of pegylated interferon plus ribavirin treatment in cirrhotic patients who presented with, or developed while on-treatment, platelet counts ≤80,000/μL and/or neutrophil counts ≤1500/μL.MethodsA retrospective analysis of prospectively gathered data on 123 cirrhotic patients treated with pegylated interferon and ribavirin. Adverse effects and haematological changes were monitored: bleeding and infectious events were registered and related to platelet and absolute neutrophil counts.ResultsAmong the 58 patients (47.2%) with nadir platelets ≤50,000/μL during therapy, 6 (10.3%) experienced a bleeding episode; of the remaining 65 patients with platelets constantly >50,000/μL, 3 (4.6%) bled. Of the 11 bleedings, 3 manifested during an infection, while patients had platelets >50,000/μL. Nadir neutrophils ≤750/μL occurred in 45 patients (38.2%) during treatment, and 14 of them (29.8%) had an infectious event. Infections were also documented in 18 of the 76 patients (23.7%) with neutrophils constantly >750/μL.ConclusionsThe study reveals the feasibility of treating cirrhotic patients with cytopenia with pegylated interferon and ribavirin, as bleeding or infectious events under therapy were unrelated to platelet and neutrophil counts. Withdrawal of therapy or variations in the pre-assigned dosages of either pegylated interferon or ribavirin owing to abnormally low haematological parameters seems to no longer be tenable.     

Treatment of chronic hepatitis C in HIV‐infected patients with compensated liver cirrhosis

Summary. The greatest benefit of hepatitis C virus (HCV) therapy is seen in cirrhotics attaining sustained virological response (SVR). However, concerns about toxicity and poorer responses often discourage treatment of cirrhotics. This may be particularly relevant in HIV–HCV‐coinfected patients, in whom progression of liver fibrosis is faster and treatment responses lower. This is a retrospective analysis of HIV–HCV‐coinfected patients who had received peginterferon–ribavirin therapy at our institution. Individuals naïve for interferon in whom liver fibrosis had been assessed using elastometry within the year before being treated were chosen. Response rates and toxicities were compared in cirrhotics (>14.5 KPa) and noncirrhotics. Patients with previous liver decompensation were excluded. Overall, 41 cirrhotics and 190 noncirrhotics entered the study. Groups were similar in age, gender, HCV genotypes and baseline serum HCV‐RNA. SVR occurred at similar rates in cirrhotic and noncirrhotics, either considered by intention‐to‐treat (39%vs 45%; P = 0.4) or as treated (50%vs 52%, P = 0.8). In multivariate analysis (odds ratio, 95% CI, P), SVR was associated with HCV genotypes 2–3 (5, 2.9–11, <0.01) and lower serum HCV‐RNA (2, 1.4–3.03 for every log decrease, <0.01) but not with cirrhosis (1.2, 0.4–3.6, 0.6). Treatment discontinuations because of adverse events tended to be more common in cirrhotics than in noncirrhotics (17%vs 12%; P = 0.2), but only severe thrombocytopenia was more frequent in cirrhotics than in non‐cirrhotics (20%vs 3% at week 24; P < 0.01). Response to peginterferon–ribavirin therapy is similar in HIV–HCV coinfected patients with and without liver cirrhosis. Therefore, treatment must be encouraged in all compensated cirrhotic patients, although closer monitoring and management of side effects, mainly thrombocytopenia, may be warranted.     

Low-density lipoprotein cholesterol levels are associated with poor clinical outcomes in COVID-19

Background and aimsSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the sole causative agent of coronavirus infectious disease-19 (COVID-19).Methods and resultsWe performed a retrospective single-center study of consecutively admitted patients between March 1st and May 15th^, 2020, with a definitive diagnosis of SARS-CoV-2 infection. The primary end-point was to evaluate the association of lipid markers with 30-days all-cause mortality in COVID-19.A total of 654 patients were enrolled, with an estimated 30-day mortality of 22.8% (149 patients). Non-survivors had lower total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-c) levels during the entire course of the disease. Both showed a significant inverse correlation with inflammatory markers and a positive correlation with lymphocyte count. In a multivariate analysis, LDL-c ≤ 69 mg/dl (hazard ratio [HR] 1.94; 95% confidence interval [CI] 1.14–3.31), C-reactive protein >88 mg/dl (HR 2.44; 95% CI, 1.41–4.23) and lymphopenia <1000 (HR 2.68; 95% CI, 1.91–3.78) at admission were independently associated with 30-day mortality. This association was maintained 7 days after admission. Survivors presented with complete normalization of their lipid profiles on short-term follow-up.ConclusionHypolipidemia in SARS-CoV-2 infection may be secondary to an immune-inflammatory response, with complete recovery in survivors. Low LDL-c serum levels are independently associated with higher 30-day mortality in COVID-19 patients.     

Influence of potassium levels on one-year outcomes in elderly patients with acute heart failure

BackgroundAbnormal serum potassium levels (K⁺) in patients with heart failure (HF) relate to worse prognosis. We evaluated whether admission K⁺ levels predict 1-year outcomes in elderly patients admitted for acute HF.MethodsWe evaluated 2865 patients aged >74 years from the RICA Spanish Heart Failure Registry, classified according to admission serum K⁺ levels: hyperkalemia (>5.5 mmol/L), normokalemia (3.5–5.5 mmol/L) and hypokalemia (<3.5 mmol/L). We explored whether K⁺ levels were significantly associated with one-year all-cause mortality or hospital readmission and their combination.ResultsMean admission K⁺ value was 4.3 ± 0.6 mmol/L; 97 patients (3.38%) presented with hyperkalemia and 174 (6.06%) with hypokalemia. Overall, 43% of the patients died or were readmitted for HF during the follow-up period; the risk was higher for those with hyperkalemia (59% vs 41% in hypokalemic patients). The HR for one-year mortality was 1.43 (p = .073) and 1.67 for readmissions (p = .007) when K⁺ was >5.5 mmol/L and 1.08 (p = .618) and 0.90 (p = .533) respectively for K⁺ < 3.5 mmol/L. The HR for the combined outcome was 1.59 (1.19–2.13); p = .002 in hyperkalemic patients and 0.96 (0.75–1.23); p = .751in hypokalemic patients. Multivariate analysis showed a significant association of admission K⁺ values >5.5 mmol/L with the combined outcome of mortality and readmission (HR 1.15 [95% CI 1.04–1.27], p = .008).ConclusionIn patients hospitalized for decompensated HF, admission hyperkalemia predicts a higher mid-term risk for HF readmission and mortality, probably related to the significant higher risk of readmission.     

Influence of left ventricular systolic function on the long-term benefit of beta-blockers after ST-segment elevation myocardial infarction

IntroductionBeta-blockers are recommended after ST-elevation myocardial infarction (STEMI), but their benefit in patients with preserved left ventricular ejection fraction (LVEF) is unclear.MethodsConsecutive patients discharged in sinus rhythm after STEMI between January 2010 and April 2015 were followed until December 2017. Percutaneous coronary intervention (PCI) was performed in 969 (99.7%, including 112 with rescue PCI) and three (0.3%) received only thrombolytic therapy without rescue PCI.ResultsOf these 972 patients, mean age 62.6±13.5 years, 212 (21.8%) were women and 835 (85.9%) were prescribed beta-blockers at discharge. Patients who did not receive beta-blockers had more comorbidities than those who did, including chronic obstructive pulmonary disease (14.6% vs. 4.2%), anemia (8.0% vs. 3.7%), and cancer (7.3% vs. 2.8%), and more frequently had inferior STEMI (75.9% vs. 56.0%) and high-grade atrioventricular block (13.1% vs. 5.3%) (all p<0.01). After a mean follow-up of 49.6±24.9 months, beta-blocker treatment at discharge was independently associated with lower mortality (HR 0.61, 95% confidence interval [CI] 0.38-0.96, p=0.03). This effect was present in 192 patients with LVEF ≤40% (HR 0.57, 95% 95% CI 0.34-0.97, p=0.04) but was not clear in 643 patients with LVEF >40% (HR 0.67, 95% 95% CI 0.25-1.76, p=0.42).ConclusionIn the LVEF >40% group, the results raise reasonable doubts about the real benefit of systematic use of beta-blockers as treatment for these patients. These findings reinforce the need for large randomized clinical trials within this group of patients.     

Best quality indicator of vitamin K antagonist therapy to predict mortality and bleeding in haemodialysis patients with atrial fibrillation

BackgroundThere is a high prevalence of atrial fibrillation (AF) in patients undergoing haemodialysis. Oral anticoagulant therapy with vitamin K antagonists (VKAs) is the only accepted treatment for the prevention of thromboembolism in haemodialysis patients with AF. However, in this population, the risk of bleeding is greatly increased. The aim of the study was to evaluate the ability of treatment quality indicators of VKA therapy to predict mortality and bleedings in a population of haemodialysis patients with AF.Materials and methodsA total of 129 patients were included in this cohort study. Deaths and bleeding events were recorded during a follow-up of 4 years. In all patients, International Normalized Ratio (INR) values were assessed at least once a month. Time in therapeutic range (TTR) and INR variability, as measured by the standard deviation of INR, were updated at each INR measurement. A Cox model with time-dependent co-variates and sandwich variance was applied.ResultsDuring follow-up, 71 patients died and 55 bleeding episodes occurred in 31 patients. INR variability was the only indicator associated with both mortality (hazard ratio [HR]=1.67, 95% confidence interval [CI] 1.12; 2.49, p=0.012) and bleeding (HR=2.85, 95% CI: 1.71; 4.75, p=0.0001). HR of mortality was higher in patients with INR >3 (HR=2.06, 95% CI: 1.09; 3.88, p=0.0259) than in subjects in therapeutic range 2<INR≤3. TTR was inversely associated with the risk of recurrent haemorrhagic events (HR=0.88, 95% CI: 0.80; 0.95, p=0.0023), but not with a first episode of bleeding. Results were consistent after censoring patients at VKA withdrawal.DiscussionOur study suggests that, in haemodialysis patients with AF taking VKAs, INR variability is the quality indicator that best predicts clinical outcomes. In this population, if more treatment quality indicators are considered together, it may become easier to identify patients at particularly high risk of bleeding and death.     

Estimating liver function in a large cirrhotic cohort: Signal intensity of gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid-enhanced MRI

BackgroundTo assess whether gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid-enhanced MRI study is useful to estimate liver function in comparison to the presence or absence of cirrhosis, Child Pugh (CP), Model for End-stage Liver Disease (MELD), ALBI scores and biochemical test.MethodsWe retrospectively reviewed all consecutive Gd-EOB-DTPA-enhanced-MRI studies performed between 2010 and 2016 in patients with focal liver lesions undergoing clinical evaluation. Patients were divided in study and control group according to the presence of cirrhosis, and then classified by CP, MELD and ALBI. Signal intensity was calculated through the liver-to-muscle ratio in portal- (SI-POR) and hepatobiliary-phase(SI-HEP).ResultsThree-hundred-three Gd-EOB-DTPA liver-enhanced-MRI studies were included. One-hundred-ninety-one patients (63%) were cirrhotic. SI-HEP was significantly lower in cirrhotic group (0.55 ± 0.29 vs 0.66 ± 0.40, p = 0.004).The SI-HEP progressively decreased from CP-A to CP-C (0.59 ± 0.28 to 0.25 ± 0.19, p < 0.0001) and a significant difference was found between MELD ≤ 9 and MELD > 9 groups (0.61 ± 0.31 vs 0.49 ± 0.28, p = 0.007). No differences between ALBI grades were evident. Among biochemical parameters a moderate correlation was found among SI-HEP and total bilirubin, AST and albumin.ConclusionSI-HEP after Gd-EOB-DTPA-enhanced-MRI effectively stratified patients with different Child Pugh grades and MELD scores. This technique could hence be useful as a novel radiological marker to estimate the underlying liver function.     

Complete Revascularization in Patients With STEMI and Multi-Vessel Disease: A Meta-Analysis of Randomized Controlled Trials

BackgroundPercutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). However, efficacy of complete vs culprit only revascularization in patients with STEMI and multivessel disease remains unclear.MethodsWe searched PubMed/MEDLINE, and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and contrast induced nephropathy. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI).ResultsTwelve trials with 7592 patients were included. There was a significantly lower risk of MACE [HR 0.61; 95% CI (0.43–0.60); p = 0.0009; I² = 72%], cardiovascular mortality [HR 0.74; 95% CI (0.56–0.99); p = 0.04; I² = 2%], and repeat revascularization [HR 0.43; 95% CI (0.31–0.59); p < 0.00001; I² = 67%] in patients treated with complete compared with culprit-only revascularization. There was no statistically significant difference in MI [HR 0.77; 95% CI (0.52–1.12); p = 0.17; I² = 49%], all-cause mortality [HR 0.86; 95% CI (0.65–1.13); p = 0.28; I² = 14%], heart failure [HR 0.82 95% CI (0.51–1.32); p = 0.42; I² = 26%], major bleeding [HR 1.07; 95% CI (0.66–1.75); p = 0.78; I² = 25%], stroke [HR 0.67; 95% CI (0.24–1.89); p = 0.45; I² = 54%], or contrast induced nephropathy, although higher contrast volumes were used in the complete revascularization group [HR 1.22; 95% CI (0.78–1.92); p = 0.39; I² = 0%].ConclusionComplete revascularization was associated with a significantly lower risk of MACE, cardiovascular mortality, and repeat revascularization compared with culprit-only revascularization. These results suggest complete revascularization with PCI following STEMI and multivessel disease should be considered.     

Elevated lactate/albumin ratio as a novel predictor of in-hospital mortality in hospitalized cirrhotics

Introduction and ObjectivesNovel predictors of prognosis in cirrhotic patients have been emerging in recent years and studies show that the lactate/albumin ratio can serve as an early prognostic marker in different patient groups. We aimed to uncover the clinical significance of the lactate/albumin ratio in hospitalized patients with acutely decompensated cirrhosis.Materials and MethodsA retrospective single-center cohort study was conducted in a tertiary medical center. Subjects included had an established diagnosis of liver cirrhosis and were admitted to the ICU or the Internal Medicine department with a clinical picture of acute-on-chronic liver failure between the years 2010 and 2021. The primary outcome was to assess the utility of the lactate/albumin ratio as a prognostic marker to predict mortality in hospitalized cirrhotic patients with acute-on-chronic hepatic failure.ResultsTwo hundred seventy-nine patients were included in this study. Univariate analysis revealed that mean WBC count, platelet/creatinine ratio, aspartate transaminase (AST), lactate, and MELD score were all significantly associated with the primary outcome. Multivariate analysis showed that the lactate/albumin ratio was the strongest statistically significant (p < 0.001) predictor of death during hospitalization - OR 13.196 (95% CI 3.6–48.3), followed by mean WBC count, MELD score, and serum lactate levels. A ROC curve was constructed, which resulted in an area under the curve (AUC) equal to 0.77. Crosstabs from the ROC showed a sensitivity of 66.7% and a specificity of 76.2% when the lactate/albumin ratio chosen as a cutoff was 0.9061ConclusionsElevated lactate/albumin ratio predicts in-hospital mortality in hospitalized cirrhotics with acute-on-chronic hepatic failure.     

Safety of Hypothermic Circulatory Arrest During Unilateral Antegrade Cerebral Perfusion for Aortic Arch Surgery

BackgroundHypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during aortic arch surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP.MethodsFrom January 2009 to January 2016, 1691 patients who underwent aortic arch surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients.ResultsThe multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (P _{for interaction}< 0.05). The high temperature group had a significant protective effect in the UACP ≤ 40 minutes subgroup (HR, 0.30; 95% CI, 0.12-0.74; P = 0.01) but not in the UACP > 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99).ConclusionsThis study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.     

Comorbidity assessment for mortality risk stratification in elderly patients with acute coronary syndrome

BackgroundThe Charlson's is the most used comorbidity index. It comprises 19 comorbidities, some of which are infrequent in elderly patients with acute coronary syndrome (ACS), while some others are manifestations of cardiac disease rather than comorbidities. Our goal was to simplify comorbidity assessment in elderly non-ST-segment elevation ACS patients.MethodsThe study group consisted of 1 training (n = 920, 76 ± 7 years) and 1 testing (n = 532; 84 ± 4 years) cohorts. The end-point was all-cause mortality at 1-year follow-up. Comorbidities were assessed selecting those medical disorders other than cardiac disease that were independently associated with mortality by multivariable analysis.ResultsA total of 130 (14%) patients died in the training cohort. Six comorbidities were predictive: renal failure, anemia, diabetes, peripheral artery disease, cerebrovascular disease and chronic lung disease. The increase in the number of comorbidities yielded a gradient of risk on top of well-known clinical predictors: ≥3 comorbidities (27% mortality, HR = 1.90, 95% CI 1.20–3.03, p = .006); 2 comorbidities (16% mortality, HR = 1.29, 95% CI 0.81–2.04, p = .30); and 0–1 comorbidities (7.6% mortality, reference category). The discrimination accuracy (C-statistic = 0.80) and calibration (Hosmer-Lemeshow test, p = .20) of the predictive model using the 6 comorbidities was comparable to the predictive model using the Charlson index (C-statistic = 0.80; Hosmer-Lemeshow test, p = .70). Similar results were reproduced in the testing cohort (≥3 comorbidities: 24% mortality, HR = 2.37, 95% CI 1.25–4.49, p = .008; 2 comorbidities: 14% mortality, HR = 1.59, 95% CI 0.82–3.07, p = .20; 0–1 comorbidities: 7.5% reference category).ConclusionA simplified comorbidity assessment comprising 6 comorbidities provides useful risk stratification in elderly patients with ACS.     

Diabetes mellitus as an independent prognostic predictor and its association with renal dysfunction in patients with hepatocellular carcinoma

Background: Patients with hepatocellular carcinoma (HCC) often have coexisting cirrhosis, which may predispose to the development of diabetes mellitus (DM). Diabetic HCC patients may have renal insufficiency and a subsequent worse outcome. This study investigated the interaction between DM, cirrhosis and renal dysfunction and the impact of these factors on HCC. Methods: A prospective database of 1713 HCC patients was analysed. Results: A total of 392 (22.9%) patients were diabetic. Diabetic patients had a significantly higher Child–Turcotte–Pugh (CTP) score, model for end‐stage liver disease score and serum creatinine level, but had significantly lower serum albumin, sodium, alanine aminotransferase, aspartate aminotransferase and bilirubin levels. The serum creatinine level progressively increased and correlated well with increasing CTP class in both diabetic and non‐diabetic patients. After a mean follow‐up of 18 ± 16 months, DM was shown to be an independent predictor of mortality in the Cox proportional hazard model after adjusting for other predictors [hazard ratio (HR): 1.2, 95% confidence interval (CI): 1.02–1.42]. Diabetic patients more often had renal insufficiency, defined as serum creatinine >1.5 mg/dl (17.3 vs 8.3%, P<0.0001). Renal insufficiency was an independent prognostic predictor in diabetic patients (HR: 2.26, 95% CI: 1.57–3.24) but not in non‐diabetic patients, because it was significantly associated with the severity of cirrhosis in the non‐diabetic group (P<0.001) but not in the diabetic group (P=0.143). Conclusions: DM is associated with inadequate liver reserve and independently predicts decreased survival in HCC patients. Both advanced cirrhosis and DM are associated with renal insufficiency, which is a poor prognostic predictor for HCC.