Routine transthoracic echocardiography in a general Intensive Care Unit: An 18 month survey in 704 patients

The authors analyzed 704 transthoracic echocardiographic (TTE) examinations, performed routinely to all admitted patients to a general 16-bed Intensive Care Unit (ICU) during an 18-month period. Data acquisition and prevalence of abnormalities of cardiac structures and function were assessed, as well as the new, previously unknown severe diagnoses.A TTE was performed within the first 24 h of admission on 704 consecutive patients, with a mean age of 61.5 ± 17.5 years, ICU stay of 10.6 ± 17.1 days, APACHE II 22.6 ± 8.9, and SAPS II 52.7 ± 20.4. In four patients, TTE could not be performed. Left ventricular (LV) dimensions were quantified in 689 (97.8%) patients, and LV function in 670 (95.2%) patients. Cardiac output (CO) was determined in 610 (86.7%), and mitral E/A in 399 (85.9% of patients in sinus rhythm). Echocardiographic abnormalities were detected in 234 (33%) patients, the most common being left atrial (LA) enlargement (n = 163), and LV dysfunction (n = 132). Patients with these alterations were older (66 ± 16.5 vs 58.1 ± 17.4, p < 0.001), presented a higher APACHE II score (24.4 ± 8.7 vs 21.1 ± 8.9, p < 0.001), and had a higher mortality rate (40.1% vs 25.4%, p < 0.001). Severe, previously unknown echocardiographic diagnoses were detected in 53 (7.5%) patients; the most frequent condition was severe LV dysfunction. Through a multivariate logistic regression analysis, it was determined that mortality was affected by tricuspid regurgitation (p = 0.016, CI 1.007–1.016) and ICU stay (p < 0.001, CI 1–1.019). We conclude that TTE can detect most cardiac structures in a general ICU. One-third of the patients studied presented cardiac structural or functional alterations and 7.5% severe previously unknown diagnoses.     

Single patch technique versus double patch technique in repair of complete atrioventricular septal defect

MethodsThis retrospective study included 145 consecutive patients who underwent complete atrioventricular (CAVSD) repair between January 2002 and January 2012. Peri-operative data were analyzed. Ninety-two patients had a two-patch technique (group A); 53 patients had a single-patch technique (group B).ResultsMean age was 13.17 ± 4.94 months (group A) versus 5.15 ± 1.52 months (group B), (p < 0.001). Mean weight was 9.87 ± 5.53 versus 5.23 ± 2.12 kg (p < 0.001). Down syndrome was present in 82 (90.2%) in group A and 48 (90.5%) in group B (p = 0.315). Aortic cross-clamp times in group A was 135.3 ± 19.6 min and group B 107.7 ± 21.4 min (p < 0.0001). Cardiopulmonary bypass times were shorter in group B (132.2 ± 24.3 min) than group A (159.42 ± 31.4 min) with p value <0.001. Chylothorax, post operative bleeding, ICU stay and hospital length were not significant. Reoperation for left atrioventricular valve insufficiency occurred in 5 patients (5.4%) in group A, one of them needed valve replacement and 3 patients (5.7%) in group B. Permanent pacemaker was required for postoperative heart block in 3 patients (3.3%) in group A and 2 patients (3.8%) in group B (p = 0.623). Hospital mortality was seen in 6 patients (6.5%) in group A and 3 patients (5.7%) in group B (p = 0.606).ConclusionsSingle-patch technique can be performed with the same results like the two patch technique with a significantly shorter aortic cross clamp and bypass time.     

Non-Invasive Mechanical Ventilation Versus Continuous Positive Airway Pressure Relating to Cardiogenic Pulmonary Edema in an Intensive Care Unit

BackgroundTo compare the application of non-invasive ventilation (NIV) versus continuous positive airway pressure (CPAP) in the treatment of patients with cardiogenic pulmonary edema (CPE) admitted to an intensive care unit (ICU).MethodsIn a prospective, randomized, controlled study performed in an ICU, patients with CPE were assigned to NIV (n=56) or CPAP (n=54). Primary outcome was intubation rate. Secondary outcomes included duration of ventilation, length of ICU and hospital stay, improvement of gas exchange, complications, ICU and hospital mortality, and 28-day mortality. The outcomes were analyzed in hypercapnic patients (PaCO₂ > 45 mmHg) with no underlying chronic lung disease.ResultsBoth devices led to similar clinical and gas exchange improvement; however, in the first 60 min of treatment a higher PaO₂/FiO₂ ratio was observed in the NIV group (205±112 in NIV vs. 150±84 in CPAP, P=.02). The rate of intubation was similar in both groups (9% in NIV vs. 9% in CPAP, P=1.0). There were no differences in duration of ventilation, ICU and length of hospital stay. There were no significant differences in ICU, hospital and 28-d mortality between groups. In the hypercapnic group, there were no differences between NIV and CPAP.ConclusionsEither NIV or CPAP are recommended in patients with CPE in the ICU. Outcomes in the hypercapnic group with no chronic lung disease were similar using NIV or CPAP.     

Neutrophil,lymphocyte and platelet ratio as a predictor of mortality in septic-acute kidney injury patients

BackgroundAKI is frequent in critically ill patients, in whom the leading cause of AKI is sepsis. The role of intrarenal and systemic inflammation appears to be significant in the pathophysiology of septic-AKI. The neutrophils to lymphocytes and platelets (N/LP) ratio is an indirect marker of inflammation. The aim of this study was to evaluate the prognostic ability of N/LP ratio at admission in septic-AKI patients admitted to an intensive care unit (ICU).MethodsThis is a retrospective analysis of 399 septic-AKI patients admitted to the Division of Intensive Medicine of the Centro Hospitalar Universitário Lisboa Norte between January 2008 and December 2014. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. N/LP ratio was calculated as: (Neutrophil count × 100)/(Lymphocyte count × Platelet count).ResultsFifty-two percent of patients were KDIGO stage 3, 25.8% KDIGO stage 2 and 22.3% KDIGO stage 1. A higher N/LP ratio was an independent predictor of increased risk of in-hospital mortality in septic-AKI patients regardless of KDIGO stage (31.59 ± 126.8 vs 13.66 ± 22.64, p = 0.028; unadjusted OR 1.01 (95% CI 1.00–1.02), p = 0.027; adjusted OR 1.01 (95% CI 1.00–1.02), p = 0.015). The AUC for mortality prediction in septic-AKI was of 0.565 (95% CI (0.515–0.615), p = 0.034).ConclusionsThe N/LP ratio at ICU admission was independently associated with in-hospital mortality in septic-AKI patients.     

Recurrent hospitalizations with moderate to severe hyponatremia in older adults and its associated mortality

BackgroundRecurrent hospitalizations with hyponatremia are commonly encountered in older adults admitted to Internal Medicine wards. However, the incidence and the prognostic implication of this phenomenon have never been studied.MethodsMedical charts of all older adults (≥ 75 years) admitted to Internal Medicine wards at a tertiary medical center during 2009–2010 with symptomatic moderate to severe hyponatremia (blood sodium ≤ 130 meq/l) upon admission were reviewed. The study group included patients with one or more hospitalizations with hyponatremia in the year following the first hospitalization with hyponatremia. The control group included patients with a single hospitalization with hyponatremia. Mortality rates were studied one year following the second hospitalization with hyponatremia in the study group and one year following the single hospitalization with hyponatremia in the control group. Regression analysis was used to study the association between recurrent hospitalizations with hyponatremia and 1-year mortality while controlling for demographics, chronic co-morbidities, albumin serum levels, and the number of hospitalizations.ResultsThe cohort included 431 older adults: 301 (69.8%) women; mean age of 84.6 ± 5.6 years. Overall, 120 (27.8%) patients had recurrent hospitalizations with hyponatremia and 125 (29.0%) patients died within a year. 1-Year mortality rates were higher in patients with recurrent hospitalizations with hyponatremia than in patients with a single hospitalization with hyponatremia (42.5% vs. 23.8%; p < 0.0001). Regression analysis showed that recurrent hospitalizations with hyponatremia were independently associated with 1-year mortality (odds ratio 1.9; 95% confidence interval 1.1–3.2; p = 0.018).ConclusionsRecurrent hospitalizations with hyponatremia in older adults are common and associated with 1-year mortality.     

Blood glucose level on postoperative day 1 is predictive of adverse outcomes after cardiovascular surgery

AimHyperglycaemia is now a recognized predictive factor of morbidity and mortality after coronary artery bypass grafting (CABG). For this reason, we aimed to evaluate the postoperative management of glucose control in patients undergoing cardiovascular surgery, and to assess the impact of glucose levels on in-hospital mortality and morbidity.MethodsThis was a retrospective study investigating the association between postoperative blood glucose and outcomes, including death, post-surgical complications, and length of stay in the intensive care unit (ICU) and in hospital.ResultsA total of 642 consecutive patients were enrolled into the study after cardiovascular surgery (CABG, carotid endarterectomy and bypass in the lower limbs). Patients’ mean age was 68 ± 10 years, and 74% were male. In-hospital mortality was 5% in diabetic patients vs 2% in non-diabetic patients (OR: 1.66, P = 0.076). Having blood glucose levels in the upper quartile range (≥ 8.8 mmol/L) on postoperative day 1 was independently associated with death (OR: 10.16, P = 0.0002), infectious complications (OR: 1.76, P = 0.04) and prolonged ICU stay (OR: 3.10, P < 0.0001). Patients presenting with three or more hypoglycaemic episodes (< 4.1 mmol/L) had increased rates of mortality (OR: 9.08, P < 0.0001) and complications (OR: 8.57, P < 0.0001).ConclusionGlucose levels greater than 8.8 mmol/L on postoperative day 1 and having three or more hypoglycaemic episodes in the postoperative period were predictive of mortality and morbidity among patients undergoing cardiovascular surgery. This suggests that a multidisciplinary approach may be able to achieve better postoperative blood glucose control.     

Comparison effectiveness of acute coronary syndrome treatments on geriatric function

ObjectivesThe study objectives were to compare short time complications, mortality, and effectiveness of primary Percutaneous Coronary Intervention (PCI) with optimal medical therapy in older adults with acute coronary syndromes (ACS).MethodsA prospective cohort study, which patients 60 years old and over with ACS were collecting by face to face interview and assessment of the electronic document, in two educational hospitals of Tehran medical university from May 2018 to Jan. 2019. Patients were evaluated in two groups (primary PCI and medical) in terms of complications, mortality and effectiveness, 24 hours and 30 days after treatment. Initially, 312 patients were enrolled in the study that 192 were excluded for different reasons. In the final, 120 patients have met all inclusion criteria.ResultsOne hundred and twenty patients were collected with mean age 71.2 ± 8.2 years old. In both groups every 1 point increase in Instrumental Activity Daily Living (IADL), the Major Adverse Cardiac Effect (MACE) was significantly reduced up to 88% (P = 0.007). Short-term mortality was significantly higher in the optimal medical therapy group (P = 0.006). In comparison complications 24 hours between two groups, atrial fibrillation was significantly higher in the medical group which risk increased 11 times (OR = 10.93, CI 95% = 1.38–87.04, P = 0.02).ConclusionsNotwithstanding, primary PCI reduced poor outcomes, and improve quality of life, but a lesser option for older adult patients. Primary PCI in older adult patients could maintain independence in functional daily living that results in reduced mortality and MACE considerably.     

Upper gastrointestinal bleeding in elderly patients in a Tunisian hospital: A retrospective study

Background and study aimsThe older age group presents a major problem in the management of acute gastrointestinal bleeding with a relatively high mortality. The study aims to describe the background characteristics, causes and outcome of acute upper gastrointestinal bleeding in the elderly in Tunisia.Patients and methodsWe retrospectively reviewed data of 401 patients aged ? 60 years presenting with upper gastrointestinal bleeding. Information collected included history, physical examination findings, laboratory data, endoscopic findings and length of hospital stay. Patients were divided into two groups: group A (65–79 years) and group B (>79 years).ResultsGroup A included 315 patients and group B 86 patients. There was a male preponderance in both groups. Co-morbidity (p < 0.01) and use of non-steroidal anti-inflammatory drugs (NSAIDs) or anti-platelet drugs (p < 0.01) were more common in group B. Oesophagitis was the cause of bleeding in 38.37% in group B, as compared with 19% in group A. The main cause of bleeding in group A was peptic ulcer. Rebleeding (6/86) and emergency surgery (1/86) were rare in group B and not different from those in group A. However, the bleeding-related mortality in the very elderly group was higher (13.9% vs. 4.76%; p = 0.02).In multivariate analysis, only shock on admission was independently related to mortality (p = 0.02).ConclusionOesophagitis is the major cause of upper gastrointestinal haemorrhage in the very elderly patients. While rebleeding and emergency surgery rates are relatively low, the bleeding-related mortality was higher in the very elderly group.     

Association between the visiting time and the clinical findings on admission in patients with acute heart failure

BackgroundThere have been few reports about the clinical significance of the time of admission for acute heart failure (AHF).MethodsFive hundred thirty-one patients with AHF admitted to the intensive care unit (ICU) were analyzed. The patients were assigned to either the daytime HF group (n = 195, visited from 08:00 to 20:00, Group D) or nighttime HF group (n = 336, visited from 20:00 to 08:00, Group N). The clinical findings and outcomes were compared between these groups.ResultsThe systolic blood pressure (SBP), the number of patients with clinical scenario (CS) 1, and the heart rate (HR) were significantly higher in group N (SBP, 171.0 ± 38.9 mmHg; CS 1, 80.9%; HR, 116.9 ± 28.0 beats/min) than in group D (SBP, 154.2 ± 37.1 mmHg; CS 1, 66.2%; HR, 108.6 ± 31.4 beats/min). The patients in group N were more likely to have orthopnea (91.1%) than those in group D (70.3%). A multivariate logistic regression model identified a SBP ≥164 mmHg [odds ratio (OR): 2.043; 95% confidence interval (CI): 1.383–3.109], HR ≥114 beats/min (OR: 1.490; 95%CI: 1.001–2.218), and orthopnea (OR: 2.257; 95%CI: 1.377–3.701) to be independently associated with Group N. The length of ICU stay was shorter in group N (5.8 ± 10.5 days) than in group D (7.8 ± 11.5 days).ConclusionThe nighttime HF was characterized by high SBP, high HR, and orthopnea, and the length of ICU stay was shorter in the nighttime HF group.     

Facteurs de risque de mortalité hospitalière au cours de l’embolie pulmonaire en milieu de pneumologie

ObjectivesThe objective of our work is to identify the risk factors for hospital mortality during pulmonary embolism in a pneumology department.Material and methodAll patients admitted to the pneumology department of Habib-Bourguiba hospital between 2014 and 2019, with a final diagnosis of PE are analyzed.ResultsOne hundred patients were included, 62% of whom were female, with an average age of 63 ± 16 years. Pulmonary fibrosis was noted in eight patients. On admission, the mean Simplified Pulmonary Embolism Severity Index score was 1.46 ± 1.05. The mean duration of hospitalization was 10.6 ± 7 days. The hospital mortality rate was 12%. The independent risk factors for intra-hospital mortality were arterial hypotension (OR: 6.13; 95% CI: 2.88–14.35; p = 0.001), cancer (OR: 2.66; 95% CI: 1.22–9.54; p = 0.026), a VD/LV ratio at echocardiography > 0.9 (OR: 1.84; 95% CI: 1.06–7.69; p = 0.039) and severe hypoxemia (OR: 4.86; 95% CI: 2.19–11,34; p = 0.006).ConclusionPulmonary embolism mortality remains high despite improvements in diagnostic and therapeutic management. It is important for our country to take these results into consideration for a better management of patients admitted for pulmonary embolism, and to improve survival.     

Outcome of tracheostomy after pediatric cardiac surgery

ObjectiveTo investigate the incidence, timing indications and outcome of tracheotomy in children who underwent cardiac surgeries.MethodsAll pediatric cardiac patients (under 14 years of age) who underwent cardiac surgeries and required tracheotomy from November 2000 to November 2010 were reviewed. The data were collected and reviewed retrospectively.ResultsSixteen children underwent tracheotomy after cardiac surgery. Fifteen of these cases had surgery for congenital heart disease, and one had surgery for an acquired rheumatic mitral valve disease. The mean ± SEMs of the durations of ventilation before and after tracheotomy were 60.4 ± 9.8 and 14.5 ± 4.79 days respectively (P value 0.0002). The means ± SEM of the lengths of ICU stay before and after tracheotomy were 63.31 ± 10.15 and 22 ± 5.4 days respectively (P value 0.0012). After the tracheotomy 12/16 patients (75%) were weaned from their ventilators and 10/16 were discharged from the PCICU. Six patients were discharged from the hospital and 3 were successfully decannulated. The overall survival rate was 9/16 (56%).ConclusionTracheostomy shortens the duration of mechanical ventilation and facilitates discharge from the ICU. The mortality of tracheotomy patients is still significant but is mainly related to the primary cardiac disease.     

Resultados de la ablación con catéter con mínimo o nulo empleo de fluoroscopia en pacientes pediátricos con taquiarritmias supraventriculares

Introduction and objectivesIonizing radiation exposure in catheter ablation procedures carries health risks, especially in pediatric patients. Our aim was to compare the safety and efficacy of catheter ablation guided by a nonfluoroscopic intracardiac navigation system (NFINS) with those of an exclusively fluoroscopy-guided approach in pediatric patients.MethodsWe analyzed catheter ablation results in pediatric patients with high-risk accessory pathways or supraventricular tachycardia referred to our center during a 6-year period. We compared fluoroscopy-guided procedures (group A) with NFINS guided procedures (group B).ResultsWe analyzed 120 catheter ablation procedures in 110 pediatric patients (11 ± 3.2 years, 70% male); there were 62 procedures in group A and 58 in group B. We found no significant differences between the 2 groups in procedure success (95% group A vs 93.5% group B; P = .53), complications (1.7% vs 1.6%; P = .23), or recurrences (7.3% vs 6.9%; P = .61). However, fluoroscopy time (median 1.1 minutes vs 12 minutes; P < .0005) and ablation time (median 96.5 seconds vs 133.5 seconds; P = .03) were lower in group B. The presence of structural heart disease was independently associated with recurrence (P = .03).ConclusionsThe use of NFINS to guide catheter ablation procedures in pediatric patients reduces radiation exposure time. Its widespread use in pediatric ablations could decrease the risk of ionizing radiation.     

Implications of left ventricular mass index on early postoperative outcome in patients undergoing aortic valve replacement

Aim of the workTo study the prognostic influence of the preoperative left ventricular mass index (LVMI) on early postoperative outcome in patients undergoing aortic valve replacement (AVR).Patients and methodsWe studied 61 patients (41 males and 20 females) who underwent elective AVR for isolated or mixed aortic valve lesions. LVMI was calculated by trans-thoracic echocardiography in all patients. We classified our patients into two groups: group 1 patients had increased LVMI (>134 g/m² in males and >110 g/m² in females) and group 2 patients who had normal LVMI. Aortic valve replacement was done in all patients.ResultsWe found 48 (age 28.4 ± 12 years) patients with increased LVMI (group 1) and 13 (age 27.2 ± 12 years) with normal LVMI (group 2). There was significantly increase in the need of prolonged use of inotropic support (62.5% versus 31%, P value = 0.041), intensive care unit (ICU) stay and post-operative hospital stay (4.02 ± 2.1 versus 2.3 ± 1.8 days, P value = 0.011 and 8.4 ± 2.4 versus 6.6 ± 2.8 days, 0.025 respectively) in group 1 compared with group 2. The occurrence of post operative ventricular arrhythmia and atrial fibrillation (AF) was higher in group 1 but still statistically insignificant. During post operative period two patients died in group 1 and one patient in group 2.ConclusionThe increase of LVMI values is associated with increased in-hospital morbidity in patients undergoing aortic valve replacement.     

Ethnicity and sepsis characteristics and outcomes. Population based study

BackgroundTwo distinct ethnic groups live in Southern Israel: urban Jews and rural Bedouin Arabs. These groups differ in their socioeconomic status, culture and living environment, and are treated in a single regional tertiary care hospital. We hypothesized that these two ethnic groups have different patterns of sepsis-related intensive care admissions.MethodsThe study included all adult patients admitted to the Soroka University Medical Center Intensive Care Units between January 2002 and December 2008, with a diagnosis of sepsis. Demographic data, medical history, and hospitalization and outcomes data were obtained. Primary outcome was all-cause mortality.ResultsJewish patients admitted to the ICU (1343, 87%) were on average 17 years older than Bedouin Arabs (199, 13%). For the population < 65 years, Bedouin Arabs had slightly higher age-adjusted prevalence of ICU sepsis admissions than Jewish patients (39.5 vs. 43.0, p = 0.25), while for the population > 65 years there was a reverse trend (21.8 vs. 19.8 p = 0.49). There were no differences in the type of organ failure, sepsis severity or length of hospitalization between the two groups. Twenty eight days/in-hospital mortality was 33.9% in Bedouin Arabs vs. 45.5% in Jews, p = 0.004. Following adjustment for comorbidities, age and severity of the disease, survival was unrelated to ethnicity, both at 28 days (odds ratio for Bedouin Arabs 0.86, 95% CI 0.66–1.24) and following hospital discharge (hazard ratio 0.86, 95% 0.67–1.09).ConclusionsSepsis-related ICU admissions are more prevalent among Bedouin Arabs at younger age compared with the Jewish population. Adjusted for confounders, ethnicity does not influence prognosis.     

HEPACONTROL. A program that reduces early readmissions,mortality at 60 days,and healthcare costs in decompensated cirrhosis

Background & aimsDecompensated cirrhosis patients have an elevated incidence of early readmission, mortality and economic burden. The aims of HEPACONTROL were to reduce early readmission and to evaluate its impact on mortality and emergency department visits.Patients and methodsQuasi-experimental study with control group which compared two cohorts of patients discharged after being admitted for cirrhosis-related complications. A prospective cohort (n = 80), who followed the HEPACONTROL program, which began with a follow-up examination seven days after discharge at the Hepatology Unit Day Hospital and a retrospective cohort of patients (n = 112), who had been given a standard follow-up. Outcome variables that were compared between both groups were early readmission rates, the number of emergency department visits post-discharge, financial costs and mortality.ResultsThe rate of early readmission was lower in the group with HEPACONTROL (11.3% vs 29.5%; P = .003). Also, the mean number of visits to the emergency department post-discharge (1.10 ± 1.64 vs 1.71 ± 2.36; P = .035), mortality at 60 days (3.8% vs 14.3%; P = .016), and the cost of early readmission were all lower compared with the group with standard follow-up (P = .029).ConclusionsHEPACONTROL decreases the incidence of early readmission the rate of emergency department visits and mortality at 60 days in patients with decompensated cirrhosis, and it is cost-effective.     

Impact of elective hospital admissions on glycaemic control in adolescents with poorly controlled type 1 diabetes

AimDifferent treatment strategies have been used to manage adolescents with poorly controlled type 1 diabetes. We investigated whether a brief elective hospital admission improves haemoglobin A_1c (HbA_1c) over 12 months.MethodsWe studied a retrospective cohort of adolescents with poorly controlled type 1 diabetes attending a tertiary care pediatric diabetes clinic in Montreal, Canada, between January 2005 and December 2010. Hospitalized adolescents (admitted group) were matched with controls (non-admitted group) for age and baseline HbA_1c. HbA_1c values at baseline, 6 and 12 months were obtained from the clinic database.ResultsThirty patients aged 11 to 17 years with a first elective admission for poor metabolic control were paired with 30 non-admitted patients. At baseline, HbA_1c was 12.2 ± 1.6% in admitted and 12.0 ± 1.2% in non-admitted patients. There were no clinically important differences in potential confounders between groups. There was no improvement in the primary outcome as assessed by the change in HbA_1c at 12 months in the admitted group (–1.3 ± 2.3%) compared with the non-admitted group (–2.1 ± 1.7%) (P = 0.078). No improvement in intermediary measures of glycaemic control was observed (HbA_1c at 6 months or change at 6 months). After 12 months, HbA_1c values were higher in the admitted group (10.9 ± 1.9%) versus the non-admitted group (9.9 ± 1.4%) (P = 0.016).ConclusionElective hospital admission for adolescents with poorly controlled type 1 diabetes does not seem to be an effective strategy to improve HbA_1c over 12 months.     

Serum high sensitivity C-reactive protein,nitric oxide metabolites,plasma fibrinogen,and lipid parameters in Indian type 2 diabetic males

AimsInflammation is postulated to play a role in diabetogenesis and its further vascular complications. The aim was to assess the inflammatory and lipid parameters in patients of type 2 diabetic mellitus with or without complication.Material and methodsSerum high sensitivity C-reactive protein (hs-CRP), nitric oxide metabolite (NO_X), fibrinogen, and lipid parameters were measured in eighty type 2 diabetic males (40–65 years) without (n = 40, group B) and with complication (16 retinopathy, group C; 24 hypertension, group D); and compared with 40 healthy, age and sex matched nondiabetic males (group A) from the general population.ResultThe mean age of subjects and fasting plasma glucose among groups A, B, and C + D were 51.0 ± 7.1 vs. 48.7 ± 5.7 vs. 50.2 ± 6.1 years (p > 0.05); and 96.7 ± 10.4 vs. 134.3 ± 27.8 vs. 136.4 ± 29.8 mg/dl (p < 0.001) respectively. Patients with retinopathy were older, with longer duration of diabetes, and high fasting plasma glucose (p < 0.001). The mean hs-CRP, NO_X, fibrinogen, TC, TG, and LDL_C varied significantly (p < 0.001) between control and diabetics. hs-CRP, NO_X, and fibrinogen were found to be highest in retinopathy group whereas no significant (p > 0.05) difference was noted between groups B and D in relation to hs-CRP and NO_X. TC and LDL_C were significantly (p < 0.001) high among group B patients. Significant positive correlation was observed between all three inflammatory markers in all categories of patients; between FPG, hs-CRP, and fibrinogen among patients with hypertension; between FPG, hs-CRP, and NO_X in patients with retinopathy. However, none of the lipid parameters showed any significant correlation with any of the inflammatory markers in any group of patients studied.ConclusionLow grade systemic inflammation, in association with dyslipidemia, plays a role in diabetogenesis and its complications.     

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.     

Cambios en el tratamiento y disminución de la mortalidad del síndrome aórtico agudo. Lecciones del Registro Español del Síndrome Aórtico Agudo (RESA)

Introduction and objectivesThe Spanish Registry of Acute Aortic Syndrome (RESA) was launched in 2005 to identify the characteristics of acute aortic syndrome (AAS) in Spain. The aim of this study was to analyze the differences in management and mortality in the 3 RESA iterations.MethodsWe analyzed data from patients with AAS prospectively included by 24 to 30 tertiary centers during the 3 iterations of the registry: RESA I (2005-2006), RESA-II (2012-2013), and RESA III (2018-2019).ResultsAAS was diagnosed in 1902 patients (74% men; age, 60.7 ± 12.5 years): 1329 (69.9%) type A and 573 (30.1%) type B. Comparison of the 3 periods revealed that the use of computed tomography increased as the first diagnostic technique (77.1%, 77.9%, and 84.2%, respectively; P = .001). In type A, surgical management increased (79.6%, 78.7%, and 84.5%; P = .045) and overall mortality decreased (41.2%, 34.5%, and 31.2%; P = .002), due to a reduction in surgical mortality (33.4%, 25.1%, and 23.9%; P = .003). In type B, endovascular treatment increased (22.8%, 32.8%, and 38.7%; P = .006), while medical and surgical treatment decreased. Overall type B mortality also decreased (21.6%, 16.1%, and 12.0%; P = .005) in line with a reduction in mortality with medical (16.8%, 13.8%, and 8.8%, P = .030) and endovascular (27.0%, 18.0%, and 9.2%; P = .009) treatments.ConclusionsThe iterations of RESA show a decrease in mortality from type A AAS, coinciding with an increase in surgical treatment and a reduction in surgical mortality. In type B, the use of endovascular treatment was associated with improved survival, allowing better management in patients with complications.     

The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity,severe infection and mortality in anca-associated vasculitis: A retrospective study

IntroductionAnti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients.MethodsWe conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method.ResultsWe registered 45 cases of AVV. The mean age at diagnosis was 67.5 ± 12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0 ± 10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9 ± 2.5 mg/dL, erythrocyte sedimentation rate (ESR) was 76.9 ± 33.8 mm/h, hemoglobin was 9.5 ± 1.7 g/dL, C-reactive protein was 13.2 ± 5.8 mg/dL and NLR was 8.5 ± 6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6 ± 10.5 vs. 62.6 ± 11.3, p = 0.002, adjusted OR 1.08 [95% CI 1.01–1.16], p = 0.035) and higher NLR (11.9 ± 7.4 vs. 5.9 ± 5.0, p = 0.002, adjusted OR 1.14 [95% CI 1.01–1.29], p = 0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647–0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12–34.32], p = 0.037).ConclusionsNLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.