Distal Versus Conventional Transradial Artery Access for Coronary Angiography and Intervention: A Meta-Analysis

BackgroundDistal transradial artery access (dTRA) through the anatomical snuffbox is a novel approach for performing coronary angiography and interventions. However, the safety and efficacy of dTRA as compared to conventional TRA (cTRA) remains unknown. We aim to evaluate the outcomes of dTRA versus cTRA for coronary angiography and intervention.MethodsElectronic search of the National Library of Medicine PubMed and Cochrane Library databases was performed until April 2019 for studies comparing the clinical outcomes of dTRA approach versus conventional TRA (cTRA) approach in coronary angiography and interventions. Random-effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was failure of access site utilization. Other outcomes included access site hematoma, radial artery spasm, dissection, and occlusion.ResultsFive studies (4 observational and 1 randomized controlled) with a total of 6746 patients (dTRA n = 3209 and cTRA n = 3537) were available for analysis. The failure rate was similar in dTRA and cTRA groups (5.26% versus 3.75%; RR = 1.36; 95%CI 0.41–4.48; p = 0.62). Similarly, no difference was observed between dTRA and cTRA in regards to access site hematoma (1.20% versus 1.24%, RR = 1.01; 95%CI 0.49–2.07; p = 0.99), radial artery spasm (1.42 versus 3.84%, RR = 0.91; 95%CI 0.32–2.62; p = 0.86), or radial artery dissection (0.11 versus 0.20%, RR = 0.63; 95%CI 0.18–2.16; p = 0.46). The rate of radial artery occlusion was lower with dTRA (2.30 versus 4.86%, RR = 0.51; 95%CI 0.32–0.81; p = 0.004) as compared to cTRA.ConclusionDistal TRA appears to be a safe and effective alternative to conventional TRA. The outcomes of this novel technique warrant further randomized studies.     

Prevalence of non-alcoholic fatty liver disease and liver fibrosis in a general population cohort from Argentina

Introduction and ObjectivesSouth America is one of the regions with the highest rates of non-alcoholic fatty liver disease (NAFLD). This study aimed to assess the prevalence and severity of NAFLD in suburban Argentina.Patients and MethodsThe study involved a general community cohort of 993 subjects evaluated sequentially with a comprehensive lifestyle questionnaire, laboratory testing, abdominal ultrasound (US) and transient elastography with XL probe. NAFLD was diagnosed according to standard criteria.ResultsThe prevalence of NAFLD by the US was 37.2% (326/875) overall, 50.3% in subjects with overweight/obesity, 58.6% with hypertriglyceridemia, 62.3% with diabetes/hyperglycemia and 72.1% with all three risk factors. Male gender (OR 1.42, 95% CI 1.03–1.47, p = 0.029), age (50–59 years: OR 1.98, 95 CI 1.16–3.39, p = 0.013 and ≥60 years: OR 1.86, 95% CI 1.13–3.09, p = 0.015), BMI (25–29: OR 2.87, 95% CI 1.86–4.51, p<0.001 and ≥30: OR 9.57, 95% CI 6.14–15.20, p<0.001), diabetes/hyperglycemia (OR 1.65, 95% CI 1.05–2.61, p = 0.029) and hypertriglyceridemia (OR 1.73, 95% CI 1.20–2.48, p = 0.002) were independent predictors of NAFLD. Among patients with steatosis, 22.2% (69/311) had ≥F2 fibrosis (overweight 25%, hypertriglyceridemia 32%, diabetes/hyperglycemia 34%). BMI (OR 5.22, 95% CI 2.64–11.74, p<0.001), diabetes/hyperglycemia (OR 2.12, 95% CI 1.05–4.29, p = 0.04) and hypertriglyceridemia (OR 1.94, 95% CI 1.03–3.68, p = 0.040) were independent predictors of liver fibrosis.ConclusionsThis general population study from Argentina showed a high prevalence of NAFLD. Significant liver fibrosis was present in 22% of subjects with NAFLD. This information adds to the existing knowledge of NAFLD epidemiology in Latin America.     

Liver hanging maneuver versus conventional approach for open hepatectomy: a meta-analysis

BackgroundThis study aimed to compare the safety and efficacy of the liver hanging maneuver (LHM) versus conventional approach for open hepatectomy.MethodsA comprehensive medical literature search was performed. Perioperative outcomes and long-term survival outcomes were reported. Subgroup analyses were conducted according to surgical approaches, modification of LHM, geographical region and indications for liver resection.ResultsA total of 16 studies including 1109 patients were enrolled. The LHM was performed on 471 (37%) patients. The pooled outcomes showed hepatectomy with the LHM was associated with less estimated blood loss [standard mean difference (SMD): −0.77, P < 0.001], lower intraoperative transfusion rate [odds ratio (OR): 0.28, P = 0.003], less transection time (SMD: −0.68, P = 0.01), shorter duration of hospitalization (SMD:−0.19, P = 0.004), lower total complication rate (OR: 0.63, P = 0.008) and longer overall survival [hazard ration (HR): 0.70, P = 0.002] compared to conventional open hepatectomy. Subgroup analyses showed similar outcomes to overall analyses.ConclusionsThe present meta-analysis suggested that the LHM was a safe and feasible alternative to conventional open hepatectomy with better perioperative and long-term outcomes. It was unnecessary to combine the LHM with anterior approach (AA) in consideration of perioperative outcomes.     

Robotic pancreaticoduodenectomy decreases the risk of clinically relevant post-operative pancreatic fistula: a propensity score matched NSQIP analysis

BackgroundA single-institution study demonstrated robotic pancreaticoduodenectomy (RPD) was protective against clinically-relevant postoperative pancreatic fistula (CR-POPF) compared to open pancreaticoduodenectomy (OPD). We sought to compare the national rate of CR-POPF by approach.MethodsProcedure-targeted pancreatectomy Participant User Data File was queried from 2014 to 2017 for all patients undergoing pancreaticoduodenectomy. A modified fistula risk score was calculated and patients were stratified into risk categories. Multivariate logistic regression and propensity score matching was used.ResultsThe rate of CR-POPF (15.6% vs. 11.9%; p = 0.026) was higher in OPD compared to RPD. On subgroup analysis, OPD had higher CR-POPF in high risk patients (32.9% vs. 19.4%; p = 0.007). On multivariable analysis OPD was a predictor of increased CR-POPF (Odds Ratio [OR] = 1.61 [1.15–2.25]; p = 0.005). Other operative factors associated with increased CR-POPF included soft pancreatic texture (OR = 2.65 [2.27–3.09]; p < 0.001) and concomitant visceral resection (OR = 1.41 [1.03–1.93]; p = 0.031). Increased duct size (reference <3 mm) was predictive of decreased CR-POPF: 3–6 mm (OR = 0.70 [0.61–0.81]; p < 0.001) and ≥6 mm (OR = 0.47 [0.37–0.60]; p < 0.001). Following propensity score matching, RPD continued to be protective against the occurrence of CR-POPF (OR = 1.54 [1.09–2.17]; p = 0.013).ConclusionsThis is the largest multicenter study to evaluate the impact of RPD on POPF. It suggests that RPD can be protective against POPF, especially for high risk patients.     

Negative prognostic impact of sarcopenia before and after neoadjuvant chemotherapy for pancreatic cancer

ObjectivesTo elucidate the prognostic impact of sarcopenia before and after neoadjuvant chemotherapy (NAC) for pancreatic cancer (PC).MethodsWe retrospectively studied 75 consecutive PC patients who underwent neoadjuvant gemcitabine plus S-1 combination therapy followed by pancreatectomy between 2008 and 2016. According to the skeletal muscle volume index (SMI), the patients were divided into the muscle attenuation group (MAG) and normal group (NG) before or after NAC. Prognostic factors for overall survival (OS) were analyzed by Cox proportional hazards models.ResultsThe MAG showed significantly poorer OS than the NG before and after NAC. Pre-NAC, median OS was 20.0 months in the MAG versus 49.0 months in the NG (p = 0.006). Post-NAC, median OS was 21.3 months in the MAG versus 48.8 months in the NG (p = 0.014). Multivariate analysis, excluding muscle attenuation after NAC because of confounding factors and lower hazard ratio (2.08, 95% confidence interval: 1.14–3.78, p = 0.016) than that before NAC (2.14, 1.23–3.70, p = 0.007) by univariate analysis, revealed the following independent prognostic factors: muscle attenuation pre-NAC (2.25, 1.26–4.05, p = 0.007); borderline resectability (1.96, 1.04–3.69, p = 0.038); operative blood loss (2.60, 1.38–4.88, p = 0.003); and distant metastasis (3.31, 1.40–7.82, p = 0.006).ConclusionsSarcopenia before and after NAC for PC is suggested to be a poor prognostic factor, with a stronger impact before than after NAC.     

Conventional vs high-sensitive troponins in acute exacerbations of chronic obstructive pulmonary disease

BackgroundCardiac troponins (cTn), either conventional or high-sensitive (hscTn) assays, are often performed during acute exacerbations of chronic obstructive pulmonary disease (AECOPD).ObjectivesTo compare factors affecting abnormal conventional cTn and hscTn.MethodsWe retrospectively studied data from AECOPD patients with conventional or hscTn performed at presentation. Binary logistic regression was used to identify predictors for abnormal conventional cTn (>0.5 ug/L) and hscTn (>40 ng/L).ResultsThere were 466 patients in the conventional cTn and 313 patients in the hscTn groups. Ischaemic electrocardiographic change was the only significant predictor for abnormal conventional cTn (OR 6.662 [CI 1.233–35.990], p = 0.028) while B-type natriuretic peptide levels (Adj OR 1.004 [CI 1.000–1.006], p = 0.010) and SpO₂/FiO₂ ratio (Adj OR 0.115 [CI 0.017–0.069], p = 0.026) were significant predictors of abnormal hscTn.ConclusionsPredictors of abnormal cTn differ between assays and should be taken into consideration when interpreting cTn during AECOPD.     

Tocilizumab in refractory giant cell arteritis. Monotherapy versus combined therapy with conventional immunosuppressive drugs. Observational multicenter study of 134 patients

ObjectiveTo compare the efficacy and safety of TCZ in monotherapy (TCZ_MONO) vs. combined with conventional immunosuppressive drugs (TCZ_COMBO) in Giant Cell Arteritis (GCA) in a clinical practice scenario.MethodsMulticenter study of 134 patients with refractory GCA. Patients on TCZ_MONO (n = 82) were compared with those on TCZ_COMBO (n = 52). Drugs were methotrexate (MTX) (n = 48), azathioprine (n = 3), and leflunomide (n = 1). The main outcomes were: prolonged remission (normalization of clinical and laboratory parameters for at least 6 months) and the number of relapses.ResultsPatients on TCZ_COMBO were younger (68.8 ± 8.0 vs 71.2 ± 9.0 years; p = 0.04), with a trend to a longer GCA duration (median [IQR],18.5 [6.25–34.0] vs. 13.0 [7.75–33.5] months; p = 0.333), higher C-reactive protein (CRP) levels (2.1[1–4.7] vs 1.2 [0.2–2.4] mg/dL; p = 0.003), and more prevalence of extra-cranial large-vessel vasculitis (LVV) (57% vs. 34.1%; p = 0.007). In both groups, rapid and sustained improvement was observed. Despite the longer GCA duration, and the higher CRP levels and prevalence of LVV in the TCZ_COMBO, the improvement was similar in both groups at 12 months. Moreover, in the TCZ_COMBO group, prolonged remission was significantly higher at 12-month. Relapses and serious adverse events were similar in both groups.ConclusionIn clinical practice, TCZ in monotherapy or combined with conventional immunosuppressive agents is effective and safe in patients with GCA. Nevertheless, the addition of immunosuppressive drugs, usually MTX, seems to allow a higher rate of prolonged remission, even in patients with a longer GCA duration, more extra-cranial LVV involvement, and higher acute-phase reactants.     

Symptomatic diabetic autonomic neuropathy in type 1 diabetes (T1D): Findings from the T1D exchange

AimsWe aimed to evaluate the contemporary prevalence of and risk factors for symptomatic diabetic autonomic neuropathy (DAN) in participants with type 1 diabetes (T1D) enrolled in the T1D Exchange Clinic Registry.MethodsDAN symptoms and severity were assessed with the Survey of Autonomic Symptoms (SAS) in adults with ≥5 years of T1D participating in the T1D Exchange from years 2010–2017. Associations of demographic, clinical, and laboratory factors with symptomatic DAN were assessed.ResultsOf the 4919 eligible T1D participants, 965 (20%) individuals completed the SAS questionnaire [mean age 40 ± 17 years, median diabetes duration 20 years (IQR: 13,34), 64% female, 90% non-Hispanic White, and 82% with private insurance]. DAN symptoms were present in 166 (17%) of responders with 72% experiencing moderate severity symptoms or worse. Symptomatic DAN participants had higher hemoglobin A1c (p = 0.03), longer duration (p = 0.004), were more likely to be female (p = 0.03), and more likely to have lower income (p = 0.03) versus no DAN symptoms. Symptomatic DAN was associated with diabetic peripheral neuropathy (p < 0.0001), smoking (p = 0.002), cardiovascular disease (p = 0.02), depression (p < 0.001), and opioid use (p = 0.004).ConclusionsDAN symptoms are common in T1D. Socioeconomic factors and psychological comorbidities may contribute to DAN symptoms and should be explored further.     

Association of periodontitis with microvascular complications of diabetes mellitus: A nationwide cohort study

BackgroundPeriodontitis is a common chronic inflammatory disease and one of oral complications in diabetes. Diabetes-related microvascular complications and periodontitis are also closely related to systemic inflammation. We hypothesized that periodontitis and oral hygiene markers might increase the risk of microvascular complications in diabetes mellitus.MethodsWe enrolled 11,353 diabetes participants without prior microvascular complications who received complete oral health checkups in the National Health Insurance Service-National Health Screening Cohort in 2003–2004. The primary outcome was the first development of diabetes-related microvascular complications, including nephropathy, neuropathy, and retinopathy.ResultsThe age of all participants was 55.27 ± 9.46 years, and 7833 (68.99%) participants were male. Periodontitis was noted in 8.37%. During the 7.03 ± 4.30 year of the mean follow-up period, 7227 patients experienced diabetes-related microvascular complications (2645 with nephropathy, 2513 with neuropathy, 2069 with retinopathy). Multivariable Cox regression analyses revealed that periodontitis was an independent risk factor for diabetes-related microvascular complications (adjusted hazard ratio (HR):1.13; 95% confidence interval (CI):1.04–1.23; p = 0.004). In the secondary analysis for individual microvascular complications, periodontitis was an independent risk factor for retinopathy (adjusted HR: 1.21; 95% CI: 1.04–1.40; p = 0.013).ConclusionsThe presence of periodontitis was associated with an increased risk of microvascular complications in diabetes patients.     

Metabolic risk factors in first acute coronary syndrome (MERIFACS) Study

ObjectivesIn acute coronary syndrome (ACS) patients the focus is on major conventional risk factors - CRF [diabetes, hypertension, elevated low-density cholesterol (LDL-C) and smoking] whereas others - specific metabolic risk factors - MRF [high-density lipoprotein cholesterol (HDL-C), body-mass index (BMI), waist-hip ratio (WHR), and triglycerides, and HbA1c get less attention.MethodsThis is a prospective case–control observational study from 15 tertiary care hospitals in India. CRF and MRF in patients presenting with first incidence of ACS (n = 2153) were compared with matched controls (n = 1210).ResultsPropensity score matching (PSM) yielded 1193 cases and matched 1210 controls. Risk factor prevalence in cases vs. controls were CRF: hypertension - 39.4% vs 16.4% (p < 0.0001), diabetes - 42.6% vs 12.7% (p < 0.0001), smoking - 28.3% vs 9.3% (p < 0.0001) and elevated LDL-C - 70.2% vs 57.9% (p < 0.0001). MRF: High BMI - 54.7% vs 55.1% (p = 0.84), increased waist: hip ratio 79.5% vs 63.6% (p < 0.0001), high HbA1c - 37.8% vs 14.9% (p < 0.0001), low HDL-C - 56.2% vs 42.8% (p < 0.0001) and elevated triglycerides - 49.7% vs 44.2% (p = 0.007). Adjusted Odds ratios by multivariate analysis were CRF: hypertension - 2.3 (p < 0.001), diabetes - 4.7 (p < 0.001), high LDL-C - 3.3 (p < 0.001) and smoking- 6.3 (p < 0.001). MRF: High waist: hip ratio - 2.4 (p < 0.001) high HbA1c - 3.2 (p < 0.001), low HDL-C 2.2 (p < 0.001) and elevated triglycerides - 0.878 p = 0.17.ConclusionIn India, the risk of ACS conferred by specific metabolic risk factors (High waist: hip ratio, Low HDL-C and High HbA1c) is comparable to that caused by CRF.     

Metabolic syndrome and long-term cardiovascular outcomes in NSTEMI with unstable angina

Background and aimMetabolic syndrome (MS) is associated with cardiovascular mortality and morbidity in patients with acute coronary syndrome. The purpose of this study was to evaluate the impact of MS on long-term clinical outcomes in patients with pure non-ST segment myocardial infarction (NSTEMI) or unstable angina pectoris (USAP).Methods and resultsWe prospectively enrolled 310 consecutive NSTEMI/USAP patients (74 females; mean age, 59.3 ± 11.9 years). The study population was divided into two groups: MS(+) and MS(−). The clinical outcomes of the patients were followed for up to 3 years.Increased 3-year cardiovascular mortality and reinfarction were observed in the MS(+) group, as compared to the MS(−) group (15 vs. 3.4%, p = 0.001, and 22.2 vs. 8.3%, p = 0.001, respectively). Hospitalization rates for heart failure and stroke were not significantly different between the two groups on follow-up. By a Cox multivariate analysis, a significant association was noted between MS and the adjusted risk of 3-year cardiovascular mortality (odds ratio 3.4, 95% confidence interval, 1.24–9.1, p = 0.02).ConclusionThese results suggest that MS is associated with an increased risk of 3-year cardiovascular mortality and reinfarction in patients with NSTEMI/USAP.