Proteinuria predicts 10-year cancer-related mortality in patients with type 2 diabetes

BackgroundWe conducted a cohort study to determine if proteinuria predicts cancer-related mortality in type 2 diabetic subjects.MethodsBetween July 1996 and June 2003, we enrolled 646 type 2 diabetic subjects. Participants were followed-up until December 31, 2008. The vital status was ascertained by linking records with computerized death certificates in Taiwan.ResultsDuring a median follow-up of 10.4 years, 158 subjects had died, including 59 from cancers. Subjects with proteinuria had a hazard ratio (HR) of 2.77 (95% CI 1.82–4.21) for all-cause mortality and 1.99 (95% CI 1.00–3.94) for cancer-related mortality after adjustment for demographic factors and medical conditions. Specifically, proteinuria showed a trend of increased colon cancer death. The presence of proteinuria significantly improved the predictive ability of cancer-related mortality (increase in concordance statistics or area under the ROC curve = 0.03). Patients with both proteinuria and estimated glomerular filtration rate < 60 ml/min per 1.73 m² showed higher HR for all-cause mortality than patients with proteinuria only (adjusted HRs (95% CI), 4.01 (2.42–6.67) vs. 2.69 (1.51–4.79), both p < 0.01).ConclusionsProteinuria can predict 10-year all-cause and cancer-related mortalities independently in type 2 diabetic subjects, over and above the established risk factors associated with type 2 diabetes.     

Optimal strategy of coronary revascularization in chronic kidney disease patients: A meta-analysis

BackgroundPatients with chronic kidney disease (CKD) have high risks of coronary artery disease (CAD). Coronary revascularization is beneficial for long-term survival, but the optimal strategy remains still controversial.MethodsWe searched studies that have compared percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for revascularization of the coronary arteries in CKD patients. Short-term (30 days or in-hospital) mortality, long-term (at least 12 months) all-cause mortality, cardiac mortality and the incidence of late myocardial infarction and recurrence of revascularization were estimated.Results28 studies with 38,740 patients were included. All were retrospective studies from 1977 to 2012. Meta-analysis showed that PCI group had lower short-term mortality (OR 0.55, 95% CI 0.41 to 0.73, P < 0.01), but had higher long-term all-cause mortality (OR 1.29, 95% CI 1.23 to 1.35, P < 0.01). Higher cardiac mortality (OR 1.08, 95% CI 1.01 to 1.15, P < 0.05), higher incidence of late myocardial infarction (OR 1.78, 95% CI 1.65 to 1.91, P < 0.01) and recurring revascularization rate (OR 2.94, 95%CI 2.15 to 4.01, P < 0.01) is found amongst PCI treated patients compared to CABG group.ConclusionsCKD patients with CAD received CABG had higher risk of short-term mortality but lower risks of long-term all-cause mortality, cardiac mortality and late myocardial infarction compared to PCI. This could be due to less probable repeated revascularization.     

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.     

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.     

Cardiovascular mortality in Hispanics compared to non-Hispanic whites: A systematic review and meta-analysis of the Hispanic paradox

BackgroundHispanics, the largest minority in the U.S., have a higher prevalence of several cardiovascular (CV) risk factors than non-Hispanic whites (NHW). However, some studies have shown a paradoxical lower rate of CV events among Hispanics than NHW.ObjectiveTo perform a systematic review and a meta-analysis of cohort studies comparing CV mortality and all-cause mortality between Hispanic and NHW populations in the U.S.MethodsWe searched EMBASE, MEDLINE, Web of Science, and Scopus databases from 1950 through May 2013, using terms related to Hispanic ethnicity, CV diseases and cohort studies. We pooled risk estimates using the least and most adjusted models of each publication.ResultsWe found 341 publications of which 17 fulfilled the inclusion criteria; data represent 22,340,554 Hispanics and 88,824,618 NHW, collected from 1950 to 2009. Twelve of the studies stratified the analysis by gender, and one study stratified people by place of birth (e.g. U.S.-born, Mexican-born, and Central/South American-born). There was a statistically significant association between Hispanic ethnicity and lower CV mortality (OR 0.67; 95% CI, 0.57–0.78; p < 0.001), and lower all-cause mortality (0.72; 95% CI, 0.63–0.82; p < 0.001). A subanalysis including only studies that reported prevalence of CV risk factors found similar results. OR for CV mortality among Hispanics was 0.49; 95% CI 0.30–0.80; p-value < 0.01; and OR for all-cause mortality was 0.66; 95% CI 0.43–1.02; p-value 0.06.ConclusionThese results confirm the existence of a Hispanic paradox regarding CV mortality. Further studies are needed to identify the mechanisms mediating this protective CV effect in Hispanics.     

Walking Speed Drives the Prognosis of Older Adults with Cardiovascular and Neuropsychiatric Multimorbidity

BackgroundWe investigated the impact of multiple cardiovascular and neuropsychiatric diseases on all-cause and cause-specific mortality in older adults, considering their functional status.MethodsThis cohort study included 3241 participants (aged ≥ 60 years) in the Swedish National study of Aging and Care in Kungsholmen (SNAC-K). Number of cardiovascular and neuropsychiatric diseases was categorized as 0, 1, or ≥ 2. Functional impairment was defined as walking speed of < 0.8m/s. Death certificates provided information on 3- and 5-year mortality. Hazard ratios (HR) were derived from Cox models (all-cause mortality) and Fine-Gray competing risk models (cardiovascular and non-cardiovascular mortality).ResultsAfter 3 years, compared with participants with preserved walking speed and without either cardiovascular or neuropsychiatric diseases, the multivariable-adjusted HR (95% confidence interval) of all-cause mortality for people with functional impairment in combination with 0, 1, and ≥ 2 cardiovascular diseases were 1.88 (1.29-2.74), 3.85 (2.60-5.70), and 5.18 (3.45-7.78), respectively. The corresponding figures for people with 0, 1, and ≥ 2 neuropsychiatric diseases were, respectively, 2.88 (2.03-4.08), 3.36 (2.31-4.89), and 3.68 (2.43-5.59). Among people with ≥ 2 cardiovascular or ≥ 2 neuropsychiatric diseases, those with functional impairment had an excess risk for 3-year all-cause mortality of 18/100 person-years and 17/100 person-years, respectively, than those without functional impairment. At 5 years, the association between the number of cardiovascular diseases and mortality resulted independent of functional impairment.ConclusionsFunctional impairment magnifies the effect of cardiovascular and neuropsychiatric multimorbidity on mortality among older adults. Walking speed appears to be a simple clinical marker for the prognosis of these two patterns of multimorbidity.     

Characteristics of acute heart failure in very elderly patients — EVE study (EAHFE very elderly)

ObjectivesTo determine the characteristics and prognostic factors of early death in the very elderly with acute heart failure (AHF).Patients and methodsWe performed a prospective, observational study of AHF patients attended in Emergency Departments (ED), analyzing 45 variables collected in ED and studying troponin, natriuretic peptides and echocardiographies, not always available in the ED. The patients were divided into 2 groups: nonagenarian (age ≥ 90 years) and controls (age < 90 years). The study variables were mortality and death or reconsultation to the ED for AHF within 30 days after inclusion.ResultsWe included 4700 patients (nonagenarians: 520, 11.1%). The 30-day mortality was 21.5% and 8.7% (p < 0.01), respectively with a combined event of 33.3% and 26.7% (p = 0.001). Age ≥ 90 years was maintained in all the models associated with death (OR: 1.94, CI 95%: 1.40–2.70). In nonagenarians, chronic kidney insufficiency (OR: 2.07, CI95%: 1.16–3.69), severe functional dependence (OR: 2.18, CI95%; 1.30–3.64) and basal oxygen saturation < 90% (OR: 1.97, CI95%: 1.17–3.32) and hyponatremia < 135 mEq/L (OR: 1.89, CI95%: 1.05–3.42) were predictive variables of mortality. We observed an association between elevated troponin levels and natriuretic peptide values > 5180 pg/mL and mortality (OR: 4.26, CI95%: 1.83–9.89; and OR: 3.51, CI95%: 1.45–8.48; respectively).ConclusionsThe profile of nonagenarians with AHF differs from that of younger patients. Although very advanced age is an independent prognostic factor of mortality, these patients have fewer predictive factors of mortality, being only functional deterioration, basal kidney disease, hyponatremia and respiratory insufficiency on arrival at the ED and probably troponin values and elevated natriuretic peptides.     

Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality

BackgroundPrognostic factors of mortality in elderly patients with dementia with aspiration pneumonia (AP) are scarcely known. We determined the mortality rate and prognostic factors in old patients with dementia hospitalized due to AP.MethodsWe prospectively studied 120 consecutive patients aged ≥ 75 years with dementia admitted with AP to two tertiary university hospitals. We collected data on demographic and clinical variables and comorbidities. Oropharyngeal swallowing was assessed by the water swallow test.ResultsSixty-one (50.8%) patients were female, and mean age was 86 ± 9 years. The swallow test was performed in 68 patients, revealing aspiration in 92.6%. Patients with repeat AP (28.3%) were more-frequently taking thickeners (61.8% vs.11.6%, p < 0.0001) and were less-frequently prescribed angiotensin-converting-enzyme (ACE) inhibitors (8.8% vs. 27.9%, p < 0.001) than patients with a first episode. Hospital mortality was 33.3%; these patients had lower lymphocyte counts and higher percentage of multilobar involvement. In the multivariate model, involvement of ≥ 2 pulmonary lobes was associated with hospital mortality (OR 3.051, 95% CI 1.248 to 7.458, p < 0.01). Six-month mortality was 50.8%; these patients were older and had worse functional capacity and laboratory data indicative of malnutrition. In the multivariate model, lower albumin levels were associated with six-month mortality (OR 1.129, 95% CI 1.008 to 1.265, p < 0.03).ConclusionIn-hospital and 6-month mortality were high (one-third and one-half patients, respectively). Multilobar involvement and lower lymphocyte counts were associated with hospital mortality, and older age, greater dependence and malnutrition with six-month mortality.     

The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults

AimsIt is unknown whether sex differences in the association of diabetes with cardiovascular outcomes vary by race. We examined sex differences in the associations of diabetes with incident congestive heart failure (CHF) and coronary heart disease (CHD) between older black and white adults.MethodsWe analyzed data from the Cardiovascular Health Study (CHS), a prospective cohort study of community-dwelling individuals aged ≥ 65 from four US counties. We included 4817 participants (476 black women, 279 black men, 2447 white women and 1625 white men). We estimated event rates and multivariate-adjusted hazard ratios for incident CHF, CHD, and all-cause mortality by Cox regression and competing risk analyses.ResultsOver a median follow-up of 12.5 years, diabetes was more strongly associated with CHF among black women (HR, 2.42 [95% CI, 1.70–3.40]) than black men (1.39 [0.83–2.34]); this finding did not reach statistical significance (P for interaction = 0.08). Female sex conferred a higher risk for a composite outcome of CHF and CHD among black participants (2.44 [1.82–3.26]) vs. (1.44 [0.97–2.12]), P for interaction = 0.03). There were no significant sex differences in the HRs associated with diabetes for CHF among whites, or for CHD or all-cause mortality among blacks or whites. The three-way interaction between sex, race, and diabetes on risk of cardiovascular outcomes was not significant (P = 0.07).ConclusionsOverall, sex did not modify the cardiovascular risk associated with diabetes among older black or white adults. However, our results suggest that a possible sex interaction among older blacks merits further study.     

Diabetes-related foot ulcers and associated factors: Results from the Nord-Trøndelag Health Survey (HUNT3) (2006–2008)

AimTo determine the proportion of people with diabetes reporting a history of foot ulcer and investigate associated factors and healing time in the Nord-Trøndelag Health Survey (HUNT3), Norway.MethodsIn 2006–2008, all inhabitants in Nord-Trøndelag County aged ≥ 20 years were invited to take part in this population-based study; 54% (n = 50,807) attended. In participants reporting to have diabetes we examined the relationships between foot ulcers requiring more than 3 weeks to heal (DFU) and sociodemographic, lifestyle and clinical variables using logistic regression analysis.ResultsAmong participants with diabetes, 7.4% (95% confidence interval (CI) 6.2%–8.6%) reported a DFU. The median healing time was 6.0 weeks. In the final model, factors associated with a DFU were age ≥ 75 years (odds ratio (OR) 2.3, 95% CI 1.4–3.7), male sex (OR 2.0, 95% CI 1.3–3.1), waist circumference ≥ 102 cm (men) or 88 cm (women) (OR 1.95, 95% CI 1.2–3.2), insulin use (OR 2.1, 95% CI 1.3–3.4) and any macrovascular complication (OR 1.8, 95% CI 1.1–2.8).ConclusionsThe proportion of people with diabetes reporting a DFU was 7.4%, associated factors were age ≥ 75 years, male sex, waist circumference ≥ 102 cm (men) or 88 cm (women), insulin use and any macrovascular complication. The median healing time was 6 weeks.     

Late-career unemployment and all-cause mortality,functional disability and depression among the older adults in Taiwan: A 12-year population-based cohort study

ObjectiveTo evaluate whether late-career unemployment is associated with increased all-cause mortality, functional disability, and depression among older adults in Taiwan.MethodIn this long-term prospective cohort study, data were retrieved from the Taiwan Longitudinal Study on Aging. This study was conducted from 1996 to 2007. The complete data from 716 men and 327 women aged 50–64 years were retrieved. Participants were categorized as normally employed or unemployed depending on their employment status in 1996. The cumulative number of unemployment after age 50 was also calculated. Logistic regression analysis was used to examine the effect of the association between late-career unemployment and cumulative number of late-career unemployment on all-cause mortality, functional disability, and depression in 2007.ResultsThe average age of the participants in 1996 was 56.3 years [interquartile range (IQR) = 7.0]. A total of 871 participants were in the normally employed group, and 172 participants were in the unemployed group. After adjustment of gender, age, level of education, income, self-rated health and major comorbidities, late-career unemployment was associated with increased all-cause mortality [Odds ratio (OR) = 2.79; 95% confidence interval (CI) = 1.74–4.47] and functional disability [OR = 2.33; 95% CI = 1.54–3.55]. The cumulative number of late-career unemployment was also associated with increased all-cause mortality [OR = 1.91; 95% CI = 1.35–2.70] and functional disability [OR = 2.35; 95% CI = 1.55–3.55].ConclusionLate-career unemployment and cumulative number of late-career unemployment are associated with increased all-cause mortality and functional disability. Older adults should be encouraged to maintain normal employment during the later stage of their career before retirement. Employers should routinely examine the fitness for work of older employees to prevent future unemployment.     

Outcomes of dementia: Systematic review and meta-analysis of hospital administrative database studies

IntroductionAim of the study was to compare various outcomes of dementia patients with elderly patients without dementia by conducting a systematic review of previous population-based studies.MethodsThe relevant studies were retrieved from search of electronic databases.ResultsThe pooled data from included 11 studies consisted of outcomes of 1,044,131 dementia patients compared to 9,639,027 elderly patients without dementia. Meta-analysis showed that the mortality in dementia patients was 15.3% as compared to 8.7% in non-dementia cases (RR 1.70, CI 95%, 1.27-2.28, p 0.0004). However, there was significant heterogeneity between the studies (p < 0.00001). Dementia patients had significantly increased overall readmission rate (OR 1.18; 95% CI, 1.08-1.29, p < 0.001). They had higher complication rates for urinary tract infections (RR 2.88; 95% CI, 2.45-3.40, p < 0.0001), pressure ulcers (RR 184; 95% CI, 1.31-1.46, p < 0.0001), pneumonia (RR 1.66; 95% CI, 1.36-2.02, p < 0.0001), delirium (RR 3.10; 95% CI, 2.31-4.15, p < 0.0001), and, dehydration and electrolyte imbalance (RR 1.87; 95% CI, 1.55-2.25, p < 0.0001). Dementia patients had more acute cardiac events (HR 1.16; 95% CI, 1.06-1.28, p 0.002), while fewer revascularization procedures (HR 0.12; 95% CI, 0.08-0.20, p < 0.001). Patients with dementia had lesser use of ITU (reduction by 7.5%; 95% CI, 6.9-8.1), ventilation (reduction by 5.4%; 95% CI, 5.0-5.9), and dialysis (reduction by 0.5%; 95% CI, 0.4-0.8).DiscussionCompared to older adult population, patients with dementia had poorer outcome. Despite higher mortality rate and readmission rate, they underwent fewer interventions and procedures.     

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.     

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.     

The relationship between physical performance and cardiac function in an elderly Russian cohort

This study aims to determine the cardiac dysfunction prevalence, to investigate the relationship between the Short Physical Performance Battery (SPPB) test and structural and functional echocardiographic parameters and to determine whether SPPB scores and cardiac dysfunction are independent mortality predictors in an elderly Russian population. A random sample of 284 community-dwelling adults aged 65 and older were selected from a population-based register and divided into two age groups (65–74 and ≥75). The SPPB test, echocardiography and all-cause mortality were measured. The prevalence of cardiac dysfunction was 12% in the 65–74 group and 23% in the ≥75 group. The multivariate models could explain 15% and 23% of the SPPB score total variance for the 65–74 and ≥75 age groups, respectively. In the younger age group, the mean follow-up time was 2.6 ± 0.46 years, and the adjusted hazard ratio (HR) for risk of mortality from cardiac dysfunction was 4.9. In the older age group, the mean follow-up time was 2.4 ± 0.61 years, and both cardiac dysfunction and poor physical performance were found to be independent predictors of mortality (adjusted HR = 3.4 and adjusted HR = 4.2, respectively). The cardiac dysfunction prevalence in this elderly Russian population was found to be comparable to, or even lower than, reported prevalences for Western countries. Furthermore, the observed correlations between echocardiographic abnormalities and SPPB scores were limited. Cardiac dysfunction was shown to be a strong mortality predictor in both age groups, and poor physical performance was identified as an independent mortality predictor in the oldest subjects.     

Association between growth hormone therapy and mortality,cancer and cardiovascular risk: Systematic review and meta-analysis

ObjectiveThe potential involvement of growth hormone therapy in tumor promotion and progression has been of concern for several decades. Our aim was to assess systematically the association between growth hormone therapy and all-cause, cancer and cardiovascular mortality, cancer morbidity and risk of second neoplasm mainly in patients treated during childhood and adolescence.DesignA systematic review of all articles published until September 2013 was carried out. The primary efficacy outcome measures were the all-cause, cancer and cardiovascular standardized mortality ratios (SMR). The secondary efficacy outcome measures were the standardized incidence ratio (SIR) for cancer and the relative risk (RR) for second neoplasms. The global effect size was calculated by pooling the data. When the effect size was significant in a fixed model we repeated the analyses using a random model.ResultsThe overall all-cause SMR was 1.19 (95% CI 1.08–1.32, p < 0.001). Malignancy and cardiovascular SMRs were not significantly increased. Both the overall cancer SIR 2.74 (95% CI 1.18–5.41), and RR for second neoplasms 1.99 (95% CI 1.28–3.08, p = 0.002), were significantly increased.ConclusionThe results of this meta-analysis may raise concern on the long-term safety of GH treatment. However, several confounders and biases may affect the analysis. Independent, long-term, well-designed studies are needed to properly address the issue of GH therapy safety.     

Impact of a Home Telehealth Program After a Hospitalized COPD Exacerbation: A Propensity Score Analysis

IntroductionCurrently there is lack of data regarding the impact of a home telehealth program on readmissions and mortality rate after a COPD exacerbation-related hospitalization.ObjectiveTo demonstrate if a tele-monitoring system after a COPD exacerbation admission could have a favorable effect in 1-year readmissions and mortality in a real-world setting.MethodsThis is an observational study where we compared an intervention group of COPD patients treated after hospitalization that conveyed a telehealth program with a followance period of 1 year with a control group of patients evaluated during one year before the intervention began. A propensity-score analyses was developed to control for confounders. The main clinical outcome was 1-year all-cause mortality or COPD-related readmission.ResultsThe analysis comprised 351 telemonitoring patients and 495 patients in the control group. The intervention resulted in less mortality or readmission after 12 months (35.2% vs. 45.2%; hazard ratio [HR] 0.71 [95% CI = 0.56–0.91]; p = 0.007). This benefit was maintained after the propensity score analysis (HR = 0.66 [95% CI = 0.51–0.84]). This benefit, which was seen from the first month of the study and during its whole duration, is maintained when mortality (HR = 0.54; 95% CI = [0.36–0.82]) or readmission (subdistribution hazard ratio [SHR] 0.66; 95% CI = [0.50–0.86]) are analyzed separately.ConclusionTelemonitoring after a severe COPD exacerbation is associated with less mortality or readmissions at 12 months in a real world clinical setting.