Acute kidney injury after allogeneic hematopoietic stem cell transplantation – Predictors and survival impact: A single center retrospective study

Introduction and objectivesAcute kidney injury (AKI) is a frequent complication of hematopoietic stem cell transplantation (HSCT) and appears to be linked to increased morbidity and mortality. The aim of this study was to evaluate the incidence, etiology, predictors and survival impact of early AKI in the post-allogeneic HSCT setting.Patients and methodsWe performed a retrospective single center study that included 155 allogeneic transplant procedures from June 2017 through September 2019.ResultsAKI was observed in 50 patients (32%). In multivariate analysis, age (OR 31.55, 95% CI [3.42; 290.80], p = 0.002), evidence of disease at the time of transplant (OR 2.54, 95% CI [1.12; 5.75], p = 0.025), cytomegalovirus reactivation (OR 5.77, 95% CI [2.43; 13.72], p < 0.001) and hospital stay >35 days (OR 2.66, 95% CI [1.08; 6.52], p = 0.033) were independent predictors for AKI. Increasing age (HR 1.02, 95% CI [1.00; 1.04], p = 0.029), increasing length of hospital stay (HR 1.02, 95% CI [1.01; 1.03], p = 0.002), matched unrelated reduced intensity conditioning HSCT (HR 1.91, 95% CI [1.10; 3.33], p = 0.022), occurrence of grade III/IV acute graft-versus-host disease (HR 2.41, 95% CI [1.15; 5.03], p = 0.019) and need for mechanical ventilation (HR 3.49, 95% CI [1.54; 7.92], p = 0.003) predicted an inferior survival in multivariate analysis. Early AKI from any etiology was not related to worse survival.ConclusionPatients submitted to HSCT are at an increased risk for AKI, which etiology is often multifactorial. Due to AKI incidence, specialized nephrologist consultation as part of the multidisciplinary team might be of benefit.     

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

IntroductionThe incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.MethodsWe conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.ResultsIn this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p < 0.001, unadjusted OR 6.03 (2.22–16.37), p < 0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02–1.11), p = 0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60–0.98), p = 0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37–22.72), p = 0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32–5.33), p = 0.006) were independent predictors of mortality.ConclusionAKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.     

Characteristics of patients with allergic rhinitis in an outpatient clinic: A retrospective study

BackgroundAllergic rhinitis affects a significant proportion of the European population. Few surveys have investigated this disorder in Greek adults. Our objective was to describe the characteristics of patients with allergic rhinitis in an adult outpatient clinic in Thessaloniki, Greece.MethodsWe studied the medical records of adult patients referred to a Clinical Immunology outpatient clinic from 2001 to 2007. The diagnostic procedure was not changed during the whole study period, including the same questionnaire used at the time of diagnosis, skin prick tests, and serum specific IgE.ResultsA total of 1851 patient files with diagnosed allergies were analysed and allergic rhinitis was confirmed in 711 subjects (38.4%). According to ARIA classification, persistent allergic rhinitis was more prevalent than intermittent (54.9% vs. 45.1%), while 60.8% of subjects suffered from moderate/severe disease. In multivariable analysis, factors associated with allergic rhinitis were age (for every 10 years increase, OR: 0.84, 95% CI: 0.77–0.91; p < 0.001); working in school environment (teachers or students) (OR: 1.46, 95% CI: 1.05–2.02; p = 0.023); parental history of respiratory allergy (OR: 2.41, 95% CI: 1.69–3.43; p < 0.001); smoking (OR: 0.71, 95% CI: 0.55–0.91; p = 0.007); presence of allergic conjunctivitis (OR: 6.16, 95% CI: 4.71–8.06; p < 0.001); and asthma (OR: 2.17, 95% CI: 1.57–3.01; p < 0.001). Analysis after multiple imputation corroborated the complete case analysis results.ConclusionsAllergic rhinitis was documented in 38.4% of studied patients and was frequently characterised by significant morbidity. Factors associated with allergic rhinitis provide insight into the epidemiology of this disorder in our region. Further studies on the general population would contribute to evaluating allergic rhinitis more comprehensively.     

What are the sociodemographic and health determinants for older adults continue to participate in work?

ObjectiveThis study aimed to determine the sociodemographic and health factors that influence older adults who continue to participate in the workforce.MethodsData were collected and evaluated for 1762 older adults aged 65 years and older who were living in the community and were enrolled in a population-based study (FIBRA Network Study). Older adults who participated in the workforce were compared with those who did not in terms of sociodemographic characteristics, physical and mental health, and physical functioning and performance in advanced and instrumental activities characteristic of daily living. A multivariate hierarchical logistic regression analysis was performed.ResultsFactors associated with not participating in the workforce were aged (OR: 1.71, [95% CI: 1.26–2.30], p < 0.001), female gender (OR: 1.70, [95% CI: 1.22–2.37], p = 0.002), poor visual perception (OR: 1.31, [95% CI: 1.00–1.72], p = 0.046), using 4 or more medications regularly (OR: 1.41, [95% CI: 1.489–2.247], p = 0.034), having 3 or more comorbidities (OR: 1.44, [95% CI: 1.01–2.04], p = 0.040), and a handgrip strength below 24.6 kg/f (18.1–24.6 kg/f (2nd tertile): OR: 1.52, [95% CI: 1.06–2.18], p = 0.022; 0–18 kg/f (1st tertile): OR: 1.60, [95% CI: 1.08–2.38], p = 0.019). The probability estimates of the final model explained 67.9% of the events related to not participating in the workforce, as observed by the area under the ROC curve.ConclusionOur results highlight that work in later life is influenced by sociodemographic characteristics, intrinsic capacity, and multimorbidity. We suggest that strategies for optimizing healthy and active aging may help older people to continue participating in the workforce and contributing toward their communities.     

Clinical risk factors for Clostridium difficile-associated diseases

Many factors appear to influence the chance of acquiring Clostridium difficile (C. difficile) infection, and an accurate identification of risk factors could be beneficial in many ways. Thus, in the present study, clinical risk factors for C. difficile-associated disease (CDAD) in Korea were identified. A total of 93 patients who met the inclusion criteria and 186 age/gender/ward/admission period-matched control patients were included in this study. Statistically significant associations were found with presence of chronic lung diseases (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.25–9.32; p = 0.017), presence of ileus (OR, 10.05; 95% CI, 2.42–41.80; p = 0.001), presence of intensive care unit (ICU) stay (OR, 9.79; 95% CI, 3.03–31.68; p < 0.001), use of cephalosphorins (OR, 3.30; 95% CI, 1.13–9.62; p = 0.029), history of surgery (OR, 10.89; 95% CI, 3.96–29.92; p < 0.001), and history of longterm care facility stay (OR, 14.90; 95% CI, 4.02–55.26; p < 0.001). Awareness of CDAD is critical to provide appropriate clinical care. Surveillance of the national incidence rate and multicenter studies are needed, and the potential value of a C. difficile vaccine should be studied.     

Peri-aortic fat,cardiovascular disease risk factors,and aortic calcification: The Framingham Heart Study

ObjectivePerivascular fat through the secretion of paracrine and pro-inflammatory mediators may play a role in obesity-mediated vascular disease. We sought to examine associations between adipose tissue depots immediately surrounding the thoracic aorta, metabolic risk factors, and vascular calcification.MethodsIn participants free of cardiovascular disease (CVD) from the Framingham Heart Study Offspring cohort who underwent computed tomography (n = 1067, mean age 59 years, 56.1% women), thoracic peri-aortic fat depots were quantified. Visceral abdominal tissue (VAT) and calcification of the thoracic and abdominal aorta were also measured.ResultsPeri-aortic fat depots were correlated with body mass index, waist circumference (WC), VAT (all p < 0.0001), hypertension (p = 0.007), low HDL (p < 0.0001), serum triglycerides (p < 0.0001), impaired fasting glucose (p = 0.005), and diabetes (p = 0.02). These associations generally remained significant after adjustment for BMI and WC (all p-values < 0.05), but not after VAT adjustment. Thoracic aortic fat was associated with thoracic calcification in models containing VAT (OR 1.31, 95% CI 1.01–1.71, p = 0.04), but was not significant after adjustment for CVD risk factors (OR 1.16, 95% CI 0.88–1.51, p = 0.30). Thoracic aortic fat, however, was associated with abdominal aortic calcification (OR 1.48, 95% CI 1.11–1.98, p = 0.008) and coronary artery calcification (OR 1.47, 95% CI 1.09–1.98, p = 0.001) even in models including CVD risk factors and VAT.ConclusionsThoracic peri-aortic fat is associated with measures of adiposity, metabolic risk factors, and coronary and abdominal aortic calcification.     

Importance of high IgG anti-Toxoplasma gondii titers and PCR detection of T. gondii DNA in peripheral blood samples for the diagnosis of AIDS-related cerebral toxoplasmosis: a case-control study

BackgroundCerebral toxoplasmosis (CT) continues to cause significant morbidity and mortality in human immunodeficiency virus (HIV)-infected patients in Brazil. In clinical practice, the initial diagnosis is usually presumptive and alternative diagnosis tools are necessary. Our objective was to evaluate whether the detection of high titers of IgG anti-Toxoplasma gondii and T. gondii DNA in blood samples are associated with the diagnosis of CT.MethodsIn this case-control study we included 192 patients with HIV-1 infection: 64 patients with presumptive CT (cases) and 128 patients with other diseases (controls). Blood samples to perform indirect immunofluorescense reaction (IFI) to detect anti-T. gondii IgG antibodies and polymerase chain reaction (PCR) were collected before or within the first three days of anti-Toxoplasma therapy. Two multivariate logistic regression models were performed: one including the variable qualitative serology and another including quantitative serology.ResultsIn the first model, positive IgG anti-T. gondii (OR 4.7, 95% CI 1.2-18.3; p = 0.027) and a positive T. gondii PCR result (OR 132, 95% CI 35-505; p < 0.001) were associated with the diagnosis. In the second model, IgG anti-T. gondii titres ≥ 1:1024 (OR 7.6, 95% CI 2.3-25.1; p = 0.001) and a positive T. gondii PCR result (OR 147, 95% CI 35-613; p < 0.001) were associated with the diagnosis.ConclusionsQuantitative serology and molecular diagnosis in peripheral blood samples were independently associated with the diagnosis of CT in HIV-infected patients. These diagnostic tools can contribute to a timely diagnosis of CT in settings where Toxoplasma infection is common in the general population.     

An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital

ObjectivesTo investigate the association of different chronic comorbidities, considered singularly and together in Cumulative Illness Rating Scale (CIRS) indexes, with pneumonia diagnosis in a group of elderly frail hospitalized patients.Design and methodsWith a retrospective cohort design, all clinical records of frail (Rockwood ≥ 5) nonterminal patients ≥ 65 years old acutely admitted over a 8-month span in an internal medicine ward were evaluated. Pneumonia status and its categorization (community-acquired, CAP, vs healthcare-associated, HCAP) were defined according to chest radiology findings and validated criteria. Chronic comorbidities, CIRS Comorbidity Score and CIRS Severity Index were collected for each participant through a standardized methodology. Multivariate logistic regression models were applied to assess the association of each comorbid condition or scores with pneumonia.Results1199 patients (546 M, median age 81.9, IQR 72.8–87.9 years), of whom 239 with pneumonia (180 CAP, 59 HCAP) were evaluated. CIRS Comorbidity Score was significantly associated with pneumonia, both at an age- and sex-adjusted model and at a multivariate model (OR for each unitary increase 1.03, 95% CI 1.001–1.062, p = 0.04), together with provenience from nursing home (OR 1.96, 95% CI 1.41–2.73, p < 0.001). Among single comorbidities, only COPD (OR 2.7, 95% CI 1.9–3.6, p < 0.001) and dementia (OR 2.3, 95% CI 1.7–3.3, p < 0.001) were associated with pneumonia, while stroke, cancer, cardiovascular, chronic liver and kidney disease were not.ConclusionsIn a small cohort of elderly frail hospitalized patients, measures of multimorbidity, like CIRS, are significantly associated with the risk of pneumonia. COPD and dementia are the main conditions concurring to define this risk.     

Females,Hispanics and older individuals are at greatest risk of developing metabolic syndrome in the U.S.

BackgroundThe increasing prevalence of metabolic syndrome (MetS) and MetS related complications in the U.S. poses a serious public health burden. We aim to identify high risk groups at greatest risk of developing MetS in the U.S.MethodsUsing data from the 2001–2012 National Health and Nutrition Examination Survey (NHANES), MetS prevalence among adults (age ≥ 18) was stratified by sex, race/ethnicity and age to identify groups at greatest risk of MetS. Mutlivariate logistic regression models evaluated for predictors of MetS.ResultsOverall, the prevalence of MetS in the U.S. was 78 million during the study period. There was a greater prevalence of MetS in females compared to males (34.4% vs. 29.6%, p < 0.001). Females had a 25% higher risk of MetS compared to males (OR, 1.25; 95% CI, 1.18–1.32, p < 0.001). Hispanics had a higher risk of MetS when compared to non-Hispanic whites (OR, 1.13; 95% CI, 1.04–1.23, p < 0.01). The prevalence of MetS increased with increasing age (age <40: 17.5% vs. age 40–49: 29.7% vs. age 50–59: 37.5% vs. age 60–69: 44.4% vs. age ≥70: 47.0%, p < 0.001), and individuals age 70 and over were more than 5 times more likely to have MetS than those less than age 40 (OR, 5.12, 4.71–5.57, p < 0.001)ConclusionsThe high prevalence of MetS in the U.S. affects females, Hispanics, and older individuals the greatest. The aging population and increasing Hispanic population further highlight the huge burden of disease MetS will place on the healthcare system in the U.S.     

Benefits of adding fluticasone propionate/salmeterol to tiotropium in COPD: A meta-analysis

ObjectiveThis meta-analysis was performed to evaluate the efficacy and safety of adding fluticasone propionate/salmeterol (FSC) to tiotropium (Tio) in COPD patients.MethodsA systematic search was made of MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases, and a hand search of leading respiratory journals. Randomized clinical trials on treatment of stable COPD with the addition of FSC, compared with tiotropium alone, were reviewed. Studies were pooled to odds ratio (OR) and weighted mean differences (WMD), with 95% confidence interval (CI).ResultsSix trials met the inclusion criteria. Compared with tiotropium, addition of FSC presented significant effects on trough forced expiratory volume in 1 s (FEV₁) (WMD 54.64 mL; 95% CI 51.76 to 57.52 mL; P < 0.001), COPD exacerbations (OR 0.73; 95% CI 0.55 to 0.96; p = 0.03), and health-related quality of life (WMD 4.63; 95% CI 4.26 to 5.01; P < 0.001). No significant increase was noticed in adverse events in the Tio + FSC group (OR 1.24; 95% CI 0.98 to 1.57; p = 0.07).ConclusionsThe addition of FSC to subjects with COPD treated with tiotropium significantly improves lung function, quality of life and COPD exacerbations without increasing the risk of adverse events.     

Case-finding for coeliac disease in secondary care: A prospective multicentre UK study

BackgroundCoeliac disease affects 1% of the population. Despite this high prevalence, the majority of individuals are undetected. Many patients present with subtle symptoms which may also contribute to under diagnosis. Our aim was to determine the relative importance of different presenting characteristics.MethodsUnselected gastroenterology patients referred to 4 hospitals in South Yorkshire were investigated for coeliac disease. Diagnosis was based on positive serology and the presence of villous atrophy. Odds ratios were calculated for presenting characteristics and multivariate analysis performed to identify independent risk factors.Results4089 patients were assessed (41.5% male, mean age 55.8 ± 18.2 years); 129 had coeliac disease (3.2%, 95% CI 2.6–3.7%). Multivariate analysis of patients referred to secondary care showed family history of coeliac disease (OR 1.26, p < 0.0001), anaemia (OR 1.03, p < 0.0001) and osteoporosis (OR 1.1, p = 0.006) were independent risk factors for diagnosis of coeliac disease. When compared to population controls, diarrhoea (OR 4.1, p < 0.0001), weight loss (OR 2.7, p = 0.02), irritable bowel syndrome symptoms (OR 3.2, p = 0.005) thyroid disease (OR 4.4, p = 0.01) and diabetes (OR 3.0, p = 0.05) were also associated with increased coeliac disease risk.ConclusionsCoeliac disease accounts for 1 in 31 referrals in secondary care to unselected gastroenterology clinics. A low threshold for coeliac disease testing should be adopted.     

Red blood cell distribution width and diabetes-associated complications

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

Severity of acute intracerebral haemorrhage,elderly age and atrial fibrillation: Independent predictors of poor outcome at three months

Background and purposePrognostic risk factors of haemorrhagic stroke are not yet fully identified. This study investigated clinical factors leading to poor outcome at three months in patients with intracerebral haemorrhage (ICH) in order to better understand the role of clinical features in prognostic evaluation.Subjects and methodsThis was a prospective cohort study on patients having ICH admitted to two Italian hospitals (the Stroke Units at “Ospedale Santa Maria della Misericordia“, Perugia and “Ospedale C. Poma“, Mantua) between January 1, 2006 and June 30, 2010.ResultsA total of 470 consecutive ICH patients (mean age 73.89 ± 13.02 years) were included and of these, 241 (51.1%) were males. At three months, 293 (62.3%) patients had poor outcome including 133 (27.6%) deaths. The resulting significant predictors of poor outcome from univariate analysis included: age, NIH Stroke Scale Score (NIHSSS) at admission, hyperglycaemia and the presence of atrial fibrillation (AF). These variables were confirmed in logistic regression analyses as being independent predictors of disability: age (OR 1.04 95% CI, 1.02–1.07, p = 0.0001), AF (OR 3.18 95% CI, 1.12–9.05 p = 0.03) and NIHSSS (OR 1.38 95% CI, 1.28–1.48, p = 0.0001), while elderly age (OR 1.10 95% CI, 1.06–1.14, p ≤ 0.0001) and high NIHSSS (OR 1.25 95% CI, 1.19–1.31, p ≤ 0.0001) resulted being independent predictors of mortality.ConclusionsThis study found that severity of ICH, elderly age and AF were independent predictors of poor outcome in ICH patients at three months. Thereby, this highlights the importance of understanding the roles of clinical features in ICH prognostic evaluation.     

Prevalence and risk factors of Clostridium difficile infection in patients hospitalized for flare of inflammatory bowel disease: A retrospective assessment

BackgroundRecent studies have identified a high frequency of Clostridium difficile infections in patients with active inflammatory bowel disease.AimsTo retrospectively assess the determinants and results of Clostridium difficile testing upon the admission of patients hospitalized with active inflammatory bowel disease in a tertiary care centre and to determine the predicting factors of Clostridium difficile infections.MethodsWe reviewed all admissions from January 2008 and December 2010 for inflammatory bowel disease flare-ups. A toxigenic culture and a stool cytotoxicity assay were performed for all patients tested for Clostridium difficile.ResultsOut of 813 consecutive stays, Clostridium difficile diagnostic assays have been performed in 59% of inpatients. The independent predictive factors for the testing were IBD (ulcerative colitis: OR 2.0, 95% CI 1.5–2.9; p < 0.0001) and colonic involvement at admission (OR 2.2, 95% CI 1.5–3.1, p < 0.0001). Clostridium difficile infection was present in 7.0% of the inpatients who underwent testing. In a multivariate analysis, the only independent predictor was the intake of nonsteroidal anti-inflammatory drugs within the two months before admission (OR 3.8, 95% CI 1.2–12.3; p = 0.02).ConclusionsClostridium difficile infection is frequently associated with active inflammatory bowel disease. Our study suggests that a recent intake of nonsteroidal anti-inflammatory drugs is a risk factor for inflammatory bowel disease -associated Clostridium difficile infection.     

COVID-19 associated infections in the ICU setting: A retrospective analysis in a tertiary-care hospital

IntroductionOur work describes the frequency of superinfections in COVID-19 ICU patients and identifies risk factors for its appearance. Second, we evaluated ICU length of stay, in-hospital mortality and analyzed a subgroup of multidrug-resistant microorganisms (MDROs) infections.MethodsRetrospective study conducted between March and June 2020. Superinfections were defined as appeared ≥48 h. Bacterial and fungal infections were included, and sources were ventilator-associated lower respiratory tract infection (VA-LRTI), primary bloodstream infection (BSI), secondary BSI, and urinary tract infection (UTI). We performed a univariate analysis and a multivariate analysis of the risk factors.ResultsTwo-hundred thirteen patients were included. We documented 174 episodes in 95 (44.6%) patients: 78 VA-LRTI, 66 primary BSI, 9 secondary BSI and 21 UTI. MDROs caused 29.3% of the episodes. The median time from admission to the first episode was 18 days and was longer in MDROs than in non-MDROs (28 vs. 16 days, p < 0.01). In multivariate analysis use of corticosteroids (OR 4.9, 95% CI 1.4–16.9, p 0.01), tocilizumab (OR 2.4, 95% CI 1.1–5.9, p 0.03) and broad-spectrum antibiotics within first 7 days of admission (OR 2.5, 95% CI 1.2–5.1, p < 0.01) were associated with superinfections. Patients with superinfections presented respect to controls prolonged ICU stay (35 vs. 12 days, p < 0.01) but not higher in-hospital mortality (45.3% vs. 39.7%, p 0.13).ConclusionsSuperinfections in ICU patients are frequent in late course of admission. Corticosteroids, tocilizumab, and previous broad-spectrum antibiotics are identified as risk factors for its development.     

Endoscopic resection for superficial colorectal neoplasia in Italy: A prospective multicentre study

BackgroundSince there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.MethodsProspective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥ 10 mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.ResultsOverall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. Enbloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16–4.26]; p = 0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56–4.87]; p = 0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions < 20 mm, follow-up limited to 1 year.ConclusionIn this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.     

Transcatheter arterial chemoembolisation for hepatocellular carcinoma in cirrhosis: Survival rate and prognostic factors

BackgroundThe role of prognostic variables in the treatment of hepatocellular carcinoma (HCC) by transarterial chemoembolisation (TACE) is controversial.AimsTo evaluate the survival of patients with HCC on cirrhosis treated with TACE and to analyse the prognostic factors affecting survival.MethodsFrom 1996 to 2006, 580 consecutive patients with HCC in cirrhosis were observed. Of these 194 patients underwent TACE. The primary end-point was survival. Independent predictors of survival were identified using the Cox model.ResultsThe cumulative 1-year, 3-year, and 5-year survival rates were 96%, 60%, and 41%, respectively. The multivariate analysis showed significant reduction of survival among patients with serum bilirubin values >2 mg/dl compared to patients with values <2 mg/dl (Hazard ratio 3.84; CI 95% 1.70–8.66; p-value = 0.001). Multivariate analysis performed in the group of patients treated with TACE alone showed that elevated serum bilirubin (Hazard ratio 2.96; CI 95% 1.20–7.3; p-value 0.02) and incomplete tumour response (Hazard ratio 2.88; CI 95% 1.18–7.05; p-value 0.02) are correlated with a worse outcome.ConclusionsTACE was well tolerated and overall survival rate was 41% after 5 years. Complete tumour response and serum bilirubin <2 mg/dl were identified as predictors of survival.     

Comparison of the model for end-stage liver disease (MELD), MELD-Na and MELDNa for outcome prediction in patients with acute decompensated hepatitis

Background and aimThe model for end-stage liver disease (MELD) is used to predict the outcome of patients with cirrhosis. Incorporation of serum sodium (Na) into MELD may further increase its prognostic ability. Two Na-containing MELD models, MELD-Na and MELDNa, were proposed to enhance the prognostic ability. This study compared the predictive accuracy of these models for acute decompensated hepatitis.MethodsWe investigated the outcome of 182 patients with acute decompensated hepatitis.ResultsTwenty (11%) patients died at 3 months. The MELD-Na and MELDNa both had significantly higher area under the receiver operating characteristic curve (AUC) in comparison to MELD (MELD-Na: 0.908, MELDNa: 0.895, MELD: 0.823, p = 0.004 and 0.001, respectively). Among 96 patients without specific antiviral treatment, the MELD-Na and MELDNa consistently had significantly higher AUC than the MELD (MELD-Na: 0.901, MELDNa: 0.882, MELD: 0.810, p = 0.008 and 0.004, respectively). Three independent indicators, pre-existing cirrhosis (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 1.72–18.7), serum albumin <3.7 g/dL (OR: 5.68, 95% CI: 1.18–27.03) and serum sodium (Na) < 138 mequiv./L (OR: 10.0, 95% CI: 2.08–47.62), were associated with 3-month mortality.ConclusionMELD-Na and MELDNa provide better prognostic accuracy than the MELD for patients with acute decompensated hepatitis. The adequacy of liver reserve determines the outcome of these patients.     

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.