Neuroendocrine markers and psychological features in patients with irritable bowel syndrome

Background and aims

The key role of the brain-gut axis in the pathophysiology of irritable bowel syndrome (IBS) has been recognized. The aim of this study was to assess the possible association between IBS, neuroendocrine markers, and psychological features.

Methods

One hundred and twenty-five consecutive IBS patients and 105 healthy subjects were enrolled. Plasma serotonin, plasma and urinary cortisol, and plasma neuropeptide Y levels were evaluated. All patients were given a questionnaire to assess IBS symptom severity. In 66 patients, a psychodiagnostic assessment was carried out.

Results

A high incidence of specific psychological features, including state anxiety (69.69 %), trait anxiety (54.54 %), obsessions and compulsions (28.78 %), was observed in IBS patients. A positive correlation between neuropeptide Y and state anxiety (r?=?0.287, p?=?0.024) and simulation/social ingenuity (r?=?0.269, p?=?0.039) was found in these patients. In diarrhea-predominant IBS, plasma cortisol was linearly related to plasma serotonin (r?=?0.5663, p?<?0.001).

Conclusions

In IBS patients, a significant correlation was found between specific psychological features and neuroendocrine markers, especially plasma cortisol and neuropeptide Y; in diarrhea-predominant IBS, a correlation between plasma cortisol and serotonin was found, although it needs to be confirmed in more extensive cohorts.     

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

Objective

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

Background

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

Methods

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

Results

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD)?=??0.68; 95 % CI?=??1.20 to ?0.16; p?=?0.0099), shorter incision length (pooled WMD?=??1.37; 95 % CI?=??2.74 to 0.000199; p?=?0.05), less estimated blood loss (pooled WMD?=??20.25; 95 % CI?=??39.25 to ?1.24; p?=?0.037), and more lymph nodes harvested (pooled WMD?=?1.75; 95 % CI?=?0.12 to 3.38; p?=?0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio?=?0.83; 95 % CI?=?0.57 to 1.20; p?=?0.33) or operative time (pooled WMD?=?5.06; 95 % CI?=??2.91 to 13.03; p?=?0.21).

Conclusion

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.     

Fructose malabsorption is not uncommon among patients with irritable bowel syndrome in India: A case–control study

Background

Fructose malabsorption (FM) is reported in 38 % to 75 % patients with irritable bowel syndrome (IBS). Most of these studies, however, had limitations due to use of variable dose of fructose, small sample size, and lack of control population. Moreover, there is no study on this issue from India. Hence, in this prospective study, we evaluated the frequency of FM on an adequately powered sample of patients with IBS and healthy controls (HC) from India.

Methods

Ninety-seven patients with IBS (diagnosed using Rome III criteria) and 41 healthy controls were evaluated for FM by fructose hydrogen breath test (FHBT) using 25 g fructose. Persistent rise (at least two readings) in breath hydrogen 20 parts per million (PPM) above basal was considered diagnostic of FM.

Results

Patients and controls were comparable in age (37 years [21–66] vs. 33 years [15–56]; p?=?0.1) and gender (76/97 [78.4 %] vs. 29/41 [70.7 %] male; p?=?0.3). Of 70 patients reporting data on Bristol’s stool forms, 10 (14 %), 43 (61 %), and 17 (25 %) had constipation, diarrhea predominant and unclassified IBS (Asian classification), respectively. Patients with IBS more often had FM than controls on FHBT (14/97 [14.4 %] vs. 1/41 [2.4 %]; p?=?0.04). Patients with FM more often had diarrhea-predominant IBS than those without FM (10/11 [91 %] vs. 33/59 [56 %]; p?=?0.02).

Conclusion

Though FM was not very common among Indian patients with IBS, it was higher among them than controls. Patients with FM more often had diarrhea-predominant IBS.     

Angiotensin-converting enzyme gene polymorphism in north Indian population with obstructive sleep apnea

Background

A deletion of 287-bp Alu repeat of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene is associated with hypertension.

Purpose

The aim of this study is to determine the frequency of ACE (I/D) polymorphism in patients with obstructive sleep apnea (OSA).

Methods

Genotyping of ACE (I/D) gene polymorphism and estimation of serum angiotensin-converting enzyme (SACE) activity were done in 813 subjects who underwent polysomnography. Of these, 395 were apneics and 418 were non-apneics.

Results

The frequencies of II genotype (OR = 1.8, 95 % CI 1.26–2.60, p?=?0.001) and I allele (OR = 1.4, 95 % CI 1.13–1.69, p?=?0.001) of ACE gene were found to be significantly increased in patients with OSA as compared to patients without OSA. Frequency of II genotype was significantly decreased (OR = 0.46, 95 % CI 0.28–0.77, p?=?0.003) in OSA patients with hypertension. In contrast, the frequencies of ID (OR?=?1.80, 95 % CI 1.08–2.99, p?=?0.024) and DD genotypes (OR?=?2.15, 95 % CI 1.30–3.57, p?=?0.003) were significantly increased in this group. The activity of SACE was significantly decreased in the apneic group as compared to the non-apneic group (OR?=?0.99, 95 % CI 0.98–1.00, p?=?0.04).

Conclusions

The findings suggest that II genotype confers susceptibility towards development of OSA whereas DD genotype confers susceptibility towards hypertension irrespective of OSA.     

Doublet Versus Single Cytotoxic Agent as First-Line Treatment for Elderly Patients with Advanced Non-Small-Cell Lung Cancer: A Systematic Review and Meta-Analysis

Background

The aim of this study was to perform a systematic review and meta-analysis of all randomized controlled trials that compared the efficacy of doublet versus single third-generation cytotoxic agent as first-line treatment for elderly patients with advanced non-small-cell lung cancer (NSCLC).

Methods

Several databases including PubMed, Embase, and Cochrane databases were searched. The endpoints were overall survival (OS), time to progression (TTP), 1-year survival rate (1-year SR), overall response rate (ORR), and grade 3 or 4 adverse event (AE). We performed a meta-analysis of the randomized controlled trials using a fixed-effects model and an additional random-effects model when applicable. The results of the meta-analysis were expressed as hazard ratio (HR) or risk ratio (RR), with their corresponding 95?% confidence intervals (95?% CI). A subgroup meta-analysis was performed based on chemotherapy regimens.

Results

Ten eligible trials involving 2,510 patients were identified. The intention-to-treatment (ITT) analysis demonstrated that doublet therapy was superior to single agent in terms of OS (HR?=?0.84, 95?% CI?=?0.71–1.00, p?=?0.053), TTP (HR?=?0.76, 95?% CI?=?0.60–0.96, p?=?0.022), 1-year SR (RR?=?1.17, 95?% CI?=?1.02–1.35, p?=?0.03), and ORR (RR?=?1.54, 95?% CI?=?1.36–1.73, p?=?0.000). Subgroup analysis also favored platinum-based doublet therapy in terms of 1-year SR (RR?=?1.40, 95?% CI?=?1.09–1.81, p?=?0.009) and ORR (RR?=?1.64, 95?% CI?=?1.38–1.96, p?=?0.000). Though gemcitabine-based doublet significantly increased ORR compared with single agent (RR?=?1.45, 95?% CI?=?1.23–1.71, p?=?0.000), it did not translate into an increase in survival benefits. In addition, more incidences of grade 3 or 4 anemia, thrombocytopenia, and neurotoxicity were observed in the doublet combination group. With respect to grade 3 or 4 neutropenia and nonhematologic toxicities such as diarrhea, fatigue, nausea, and vomiting, equivalent frequencies were found between the two groups.

Conclusions

Our results indicated that doublet therapy was superior to a single third-generation cytotoxic agent for elderly patients with advanced NSCLC. The optimal dosage and schedule of platinum-based doublet should be investigated in future prospective clinical trials. Gemcitabine-based doublet could be considered for elderly patients who were not suitable for platinum-based chemotherapy.     

Early cardiovascular remodelling in Fabry disease

Aims

Fabry disease (FD) is a rare X-linked genetic disorder caused by the deficiency or absent activity of lysosomal α-galactosidase A. Cardiovascular remodelling is a hallmark of FD. The present study aimed to comprehensively evaluate the cardiac, vascular and microvascular status in a population of patients with genetic mutations for FD without left ventricular hypertrophy (LVH).

Methods and results

This study includes subjects carrying genetic mutations for FD (Fabry disease mutation-carrier, FDMC) without LVH (n?=?19). A group of control subjects (n?=?19) matched for age, sex, body mass index and cardiovascular risk factors were also included. All subjects underwent echocardiography, carotid ultrasound scan, endothelial flow-mediated dilatation (FMD) and nailfold capillaroscopy (NFC) assessment. When compared to the subjects in the control group, FDMC patients showed significantly lower mean values of systolic myocardial velocity (7.33?±?1.28 vs. 10.08?±?1.63 cm/s, p?<?0.0001), longitudinal systolic strain (?18.07?±?1.72 vs. ?21.15?±?2.22 %, p?<?0.0001), significantly higher E/E’ mean values (7.15?±?1.54 vs. 5.98?±?1.27, p?=?0.016) and intima-media thickness mean values (0.80?±?0.20 vs. 0.61?±?0.19 mm, p?=?0.005), significantly lower FMD (8.3?±?4.6 vs. 12.2?±?5.0 %, p?=?0.02), more atypical capillaries and irregular NFC architecture in FDMC than control subjects (52.6 vs. 0 %, p?<?0.0001; 78.9 vs. 36.8 %, p?=?0.02 respectively).

Conclusions

FD progressively involves cardiac, macrovascular and microvascular systems in an early stage. These features are present even in asymptomatic mutation carriers without LVH.     

Predictive value of total atrial conduction time measured with tissue Doppler imaging for postoperative atrial fibrillation after coronary artery bypass surgery

Objective

Postoperative atrial fibrillation (POAF) complicating coronary artery bypass grafting surgery (CABG) increases morbidity and stroke risk. Total atrial conduction time (PA-TDI duration) has been identified as an independent predictor of new-onset atrial fibrillation (AF). We aimed to assess whether PA-TDI duration is a predictor of AF after CABG.

Methods

In 128 patients who had undergone CABG, preoperative clinical and echocardiographic data were compared between patients with and without POAF. The PA-TDI duration was assessed by measuring the time interval between the beginning of the P wave on the surface ECG and point of the peak A wave on TDI from left atrium (LA) lateral wall just over the mitral annulus.

Results

Patients with POAF (38/128, 29.6 %) were older (68.1?±?11.1 vs. 59.3?±?10.2 years; p?<?0.001), had higher LA maximum volume, had prolonged PA-TDI duration, and had lower ejection fraction compared with patients without POAF. PA-TDI duration was found to be significantly increased in POAF group (134.3?±?19.7 vs. 112.5?±?17.7 ms; p?=?0.01). On multivariate analysis, age (95 % CI?=?1.03–1.09; p?=?0.003), LA maximum volume (95 % CI?=?1.01–1.06; p?=?0.03), and prolonged PA-TDI duration (95 % CI, 1.02–1.05; p?=?0.001) were found to be the independent risk factors of POAF.

Conclusions

In this study, LA maximum volume and PA-TDI duration were found to be the independent predictors of the development of POAF after CABG. Echocardiographic predictors of left atrial electromechanical dysfunction may be useful in risk stratifying of patients in terms of POAF development after CABG.     

Genetic polymorphisms of SCN10A are associated with functional dyspepsia in Japanese subjects

Background

Visceral sensory impulses are transmitted via C-fibers from the gastrointestinal tract to the central nervous system. The tetrodotoxinresistant (TTX-r) sodium channel, Na(V) 1.8/SNS (sensory-neuron specific), encoded by SCN10A, has been identified on C-fibers. We attempted to clarify the association between functional dyspepsia (FD) and SCN10A non-synonymous polymorphisms (2884 A>G, 3218 C>T and 3275 T>C).

Methods

The study was performed in 642 subjects (345 with no symptoms and 297 with FD). We employed a multiplex polymerase chain reaction single-strand confirmation polymorphism (PCR-SSCP) method to detect the gene polymorphisms.

Results

The 3218 CC homozygotes had a reduced risk for the development of FD [odds ratio (OR) 0.589; 95 % confidence interval (CI) 0.402–0.864; p = 0.0067]. In addition, both 2884 A>G and 3275 T>C, which were in linkage disequilibrium, were also associated with the development of FD (p = 0.039 and 0.028, respectively). Each 2884 G carrier, 3218 CC homozygote, and 3275 C carrier had a reduced risk for the development of both epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS). The subjects with the 2884 G allele, 3275 C allele, and no 3218 T allele had a reduced risk for FD (OR 0.618; 95 % CI 0.448–0.853; p = 0.0034). This haplotype was associated with a reduced risk for both EPS and PDS (p = 0.0011 and 0.0056, respectively). In addition, there was a significant association between FD and this haplotype in Helicobacter pylori-negative subjects (OR 0.463; 95 % CI 0279–0.9768; p = 0.0029).

Conclusion

We conclude that genetic polymorphisms of SCN10A are closely associated with FD (both EPS and PDS), especially in H. pylori-negative subjects, in Japanese.     

The short- and long-term outcomes of laparoscopic versus open surgery for colorectal cancer: a meta-analysis

Purpose

The aim of the study was to compare short- and long-term outcomes of laparoscopic surgery and conventional open surgery for colorectal cancer.

Methods

Published randomized controlled trial (RCT) reports of laparoscopic surgery and open surgery for colorectal cancer were searched, and short- and long-term factors were extracted to perform meta-analysis.

Results

A total of 15 RCT reports (6,557 colorectal cancer patients) were included in this study. Blood loss of laparoscopic surgery was less by 91.06 ml than open surgery (p?=?0.044). Operation time was longer by 49.34 min (p?=?0.000). The length of hospital stay was shorter by 2.64 days (p?=?0.003). Incisional length was shorter by 9.23 cm (p?=?0.000). Fluid intake was shorter by 0.70 day (p?=?0.001). Bowel movement was earlier by 0.95 day (p?=?0.000). Incidence of complications, blood transfusion, and 30 days death were significantly lower in laparoscopic surgery than in open surgery (p?=?0.011, 0.000, 0.01). But there was no significant difference in lymph nodes (p?=?0.535) and anastomotic leak (p?=?0.924). There was also no significant difference in 3 and 5 years overall survival (p?=?0.298, 0.966), disease-free survival (p?=?0.487, 0.356), local recurrence (p?=?0.270, 0.649), and no difference in 5 years distant recurrence (p?=?0.838).

Conclusions

Laparoscopic surgery is a mini-injured approach which can cure colorectal cancer safely and radically, and it is not different from conventional open surgery in long-term effectiveness, so laparoscopic surgery can be tried to widely use in colorectal cancer.     

Survival comparison between surgical resection and percutaneous radiofrequency ablation for patients in Barcelona Clinic Liver Cancer early stage hepatocellular carcinoma

Aim

To compare the survival outcome between surgical resection (SR) and radiofrequency ablation (RFA) for Barcelona Clinic Liver Cancer (BCLC) early stage hepatocellular carcinoma (HCC).

Methods

The retrospective study enrolled eighty-two patients with newly diagnosed BCLC early HCC (single nodule, size ≦3 cm, and Child-Pugh class A) treated either surgically (n?=?46) or with RFA (n?=?36) from year 2004 to 2009. The patients’ survival outcomes were compared.

Results

There were no significant differences in overall survival (OS) rates between SR and RFA (p?=?0.204). The 3- and 5-year disease-free survival (DFS) rates were 65.8 % and 53.7 % respectively, in the SR group, which were significantly higher than those in the RFA group (34.8 % and 14.9 % respectively) (p?=?0.009 and p?=?0.001). In subgroup analysis, the DFS was similar between RFA and SR in patients with presentation of lower platelet count (≦100,000/mL) and smaller tumor size (tumor size ≦1 cm). Multivariate analysis showed SR as a procedure type was a significant predictive factor for DFS [HR?=?2.26 (CI 1.462–5.227), p?=?0.002].

Conclusion

SR yielded similar OS but better DFS when compared to RFA for patients with BCLC early HCC (single nodule, ≦3 cm and Child-Pugh class A). In subgroup patients with lower platelet count (≦100,000/mL) and smaller tumor size (tumor size ≦1 cm), DFS was similar between both treatments.     

Fecal calprotectin, MMP-9, and human beta-defensin-2 levels in pediatric inflammatory bowel disease

Purpose

Fecal MMP-9 and human beta-defensin-2 (HBD-2) levels, potential markers of intestinal inflammation, are insufficiently explored in pediatric inflammatory bowel disease (IBD). The aim was to study fecal MMP-9 and HBD-2 in pediatric IBD to compare their performance to calprotectin and to study whether they would provide additional value in categorizing patients according to their disease subtype.

Methods

Fecal calprotectin, MMP-9, and HBD-2 levels were measured with ELISA in 110 pediatric patients with IBD (Crohn’s disease, n?=?68; ulcerative colitis (UC), n?=?27; unclassified, n?=?15; median age, 14). To compare the performance of the fecal markers, the area under the receiver operating characteristics curve (±95 % CI) was used. In addition, the best cut-off values of each measure to differentiate IBD patients and controls (n?=?27 presenting with diarrhea, abdominal pain, and/or anemia) were derived by maximizing sensitivity and specificity.

Results

Of the fecal markers studied, calprotectin performed best for separation of IBD and non-IBD patients with the area under curve (AUC) of 0.944 (95 % CI, 0.907 to 0.981). For MMP-9, AUC was 0.837 (95 % CI, 0.766 to 0.909), the levels being significantly higher in active IBD and in UC compared with Crohn’s disease (p?=?0.0013), but categorization of these patient groups did not take place. HBD-2 did not categorize any of the studied groups.

Conclusions

Calprotectin was the best fecal marker in pediatric IBD, but MMP-9 showed almost comparable performance in UC, suggesting applicability as a surrogate marker of inflammation. Fecal HBD-2 did not bring information to the disease characteristics of pediatric IBD patients.     

Metformin treatment is associated with a low risk of mortality in diabetic patients with heart failure: a retrospective nationwide cohort study

Aims/hypothesis

The safety of metformin in heart failure has been questioned because of a perceived risk of life-threatening lactic acidosis, though recent studies have not supported this concern. We investigated the risk of all-cause mortality associated with individual glucose-lowering treatment regimens used in current clinical practice in Denmark.

Methods

All patients aged ≥30 years hospitalised for the first time for heart failure in 1997–2006 were identified and followed until the end of 2006. Patients who received treatment with metformin, a sulfonylurea and/or insulin were included and assigned to mono-, bi- or triple therapy groups. Multivariable Cox proportional hazard regression models were used to assess the risk of all-cause mortality.

Results

A total of 10,920 patients were included. The median observational time was 844 days (interquartile range 365–1,395 days). In total, 6,187 (57%) patients died. With sulfonylurea monotherapy used as the reference, adjusted hazard ratios for all-cause mortality associated with the different treatment groups were as follows: metformin 0.85 (95% CI 0.75–0.98, p?=?0.02), metformin?+?sulfonylurea 0.89 (95% CI 0.82–0.96, p?=?0.003), metformin?+?insulin 0.96 (95% CI 0.82–1.13, p?=?0.6), metformin?+?insulin?+?sulfonylurea 0.94 (95% CI 0.77–1.15, p?=?0.5), sulfonylurea?+?insulin 0.97 (95% CI 0.86–1.08, p?=?0.5) and insulin 1.14 (95% CI 1.06–1.20, p?=?0.0001).

Conclusions/interpretation

Treatment with metformin is associated with a low risk of mortality in diabetic patients with heart failure compared with treatment with a sulfonylurea or insulin.     

A variant in the G6PC2/ABCB11 locus is associated with increased fasting plasma glucose, increased basal hepatic glucose production and increased insulin release after oral and intravenous glucose loads

Aims/hypothesis

An association between elevated fasting plasma glucose and the common rs560887 G allele in the G6PC2/ABCB11 locus has been reported. In Danes we aimed to examine rs560887 in relation to plasma glucose and serum insulin responses following oral and i.v. glucose loads and in relation to hepatic glucose production during a hyperinsulinaemic–euglycaemic clamp. Furthermore, we examined rs560887 for association with impaired fasting glycaemia (IFG), impaired glucose tolerance (IGT), type 2 diabetes and components of the metabolic syndrome.

Methods

rs560887 was genotyped in the Inter99 cohort (n?=?5,899), in 366 young, healthy Danes, in non-diabetic relatives of type 2 diabetic patients (n?=?196), and in young and elderly twins (n?=?159). Participants underwent an OGTT, an IVGTT or a 2 h hyperinsulinaemic–euglycaemic clamp.

Results

The rs560887 G allele associated with elevated fasting plasma glucose (p?=?2?×?10^?14) but not with plasma glucose levels at 30 min (p?=?0.9) or 120 min (p?=?0.9) during an OGTT. G allele carriers had elevated levels of serum insulin at 30 min during an OGTT (p?=?1?×?10^?4) and relatives of type 2 diabetes patients carrying the G allele had an increased acute insulin response (p?=?4?×?10^?4) during an IVGTT. Among elderly twins, G allele carriers had higher basal hepatic glucose production (p?=?0.04). Finally, the G allele associated with the risk of having IFG (OR 1.26, 95% CI 1.08–1.47, p?=?0.002), but not with IGT (OR 0.94, 95% CI 0.82–1.08, p?=?0.4) or type 2 diabetes (OR 0.93, 95% CI 0.84–1.04, p?=?0.2).

Conclusions/interpretation

The common rs560887 G allele in the G6PC2/ABCB11 locus is associated with increased fasting glycaemia and increased risk of IFG, associations that may be partly related to an increased basal hepatic glucose production rate.     

Do young patients have different clinical presentation of colorectal cancer causing delay in diagnosis?

Purpose

The incidence of colorectal cancer is increasing among young patients. In these patients, colorectal cancer is believed to have a poorer prognosis because it is more aggressive and diagnosed at later stages; however, the behavior of these tumors in young patients remains to be elucidated. We investigated the impact of time interval between onset of symptoms and diagnosis (TISD) at the pathologic stage of colorectal cancer in young patients.

Methods

The medical records of 215 patients with colorectal adenocarcinoma were reviewed. Patients were divided into two groups according to age. The young group (age?<?50 years) consisted of 66 patients, and the older group (age?≥?50 years) of 149 patients. Clinical variables, TISD, pathologic stage, operative mortality, and oncologic outcomes were compared between groups.

Results

The older group had less abdominal pain (74.0 vs. 56.0 %, p?=?0.0129). In multivariate analysis, the following variables were independently associated with tumor pathologic stage: personal history of inflammatory bowel disease (p?<?0.0001), family history of familial adenomatous polyposis (p?=?0.00100), and smoking (p?=?0.0070). Both groups had similar rates regarding pathologic stage (I, 15 vs. 22 %; II, 22 vs. 24 %; III, 27 vs. 16 %; IV, 37 vs. 38 %, p?=?0.3380). There was no difference in overall survival [45 (69 %) vs. 84 (61 %), p?=?0.2482] and cancer-free survival [36 (63 %) vs. 83 (62 %), p?=?0.9218] between groups.

Conclusions

Young patients with colorectal cancer had clinical and pathological presentation similar to that of older patients.     

Assessment of shoulder pain and shoulder disability in patients with implantable cardioverter–defibrillator

Purpose

Shoulder pain and disability is a common but overlooked disorder in patients with implantable cardioverter–defibrillators (ICD). We aimed to assess chronic shoulder pain and disability in patients with ICD.

Methods

Two hundred fifty-four patients (mean age, 66?±?12 years; 156 men) with ICD were included in the study. The Shoulder Pain and Disability Index (SPADI) was used for assessment of shoulder pain and disability.

Results

Of the patients, 131 (52 %) have shoulder pain and disability. The total mean SPADI score in patients with shoulder pain and disability was 33?±?18 and was significantly higher than in patients without shoulder pain and disability (11?±?2; p?<?0.001). Patients with three-lead ICD have significantly higher SPADI scores than patients with single-lead ICD (p?<?0.001). Number of leads correlated with pain score (p?=?0.001, r?=?0.253), disability score (p?=?0.006, r?=?0.174) and total SPADI score (p?=?0.001, r?=?0.213). In multivariate analysis, significant associates of shoulder pain and disability were evaluated, adjusting for age, sex, body mass index, procedure time, implantation time interval, limitation of shoulder activity and number of leads. Number of leads was the only predictor of shoulder pain and disability (OR 0.518, 95 % CI, 0.372–0.721; p?<?0.001).

Conclusions

Patients with ICD implantation frequently have chronic shoulder pain and disability. Patients with three leads suffer more shoulder pain and disability.     

Key Barriers to Medication Adherence in Survivors of Strokes and Transient Ischemic Attacks

BACKGROUND

Even though medications can greatly reduce the risk of recurrent stroke, medication adherence is suboptimal in stroke survivors.

OBJECTIVE

To identify key barriers to medication adherence in a predominantly low-income, minority group of stroke and transient ischemic attack (TIA) survivors.

DESIGN

Cross-sectional study.

PARTICIPANTS

Six hundred stroke or TIA survivors, age ≥ 40 years old, recruited from underserved communities in New York City.

MAIN MEASURES

Medication adherence was measured using the 8-item Morisky Medication Adherence Questionnaire. Potential barriers to adherence were assessed using validated instruments. Logistic regression was used to test which barriers were independently associated with adherence. Models were additionally controlled for age, race/ethnicity, income, and comorbidity.

KEY RESULTS

Forty percent of participants had poor self-reported medication adherence. In unadjusted analyses, compared to adherent participants, non-adherent participants had increased concerns about medications (26 % versus 7 %, p?<?0.001), low trust in their personal doctor (42 % versus 29 %, p?=?0.001), problems communicating with their doctor due to language (19 % versus 12 %, p?=?0.02), perceived discrimination from the health system (42 % versus 22 %, p?<?0.001), difficulty accessing health care (16 % versus 8 %, p?=?0.002), and inadequate continuity of care (27 % versus 20 %, p?=?0.05). In the fully adjusted model, only increased concerns about medications [OR 5.02 (95 % CI 2.76, 9.11); p?<?0.001] and perceived discrimination [OR 1.85 (95 % CI 1.18, 2.90); p?=?0.008] remained significant barriers.

CONCLUSIONS

Increased concerns about medications (related to worry, disruption, long-term effects, and medication dependence) and perceived discrimination were the most important barriers to medication adherence in this group. Interventions that reduce medication concerns have the greatest potential to improve medication adherence in low-income stroke/TIA survivors.     

Impact of continuous positive airway pressure on C-reactive protein in patients with obstructive sleep apnea: a meta-analysis

Purpose

C-reactive protein (CRP) is associated with the development of obstructive sleep apnea (OSA) and cardiovascular diseases. Continuous positive airway pressure (CPAP) is an effective treatment for OSA, but the impact of CPAP therapy on CRP levels in patients with OSA remains unclear. To obtain this information, we performed a meta-analysis to determine whether effective CPAP therapy could reduce serum CRP levels.

Methods

A comprehensive literature search was performed to identify studies that examined the impact of CPAP on serum CRP levels in OSA patients who were treated with CPAP for at least 4 weeks. Standardized mean difference (SMD) was used to analyze the summary estimates for CPAP therapy.

Results

Fourteen self-control design studies involving 1199 patients with OSA met the inclusion criteria. Meta-analysis indicated that the overall SMD for the CRP levels was 0.64 units (95 % confidence interval (CI) 0.40 to 0.88) before and after CPAP therapy; test for overall effect z?=?5.27 (P?=?0.000). Subgroup analysis showed that evolution of CRP decreased non-significantly in less than 3 months (SMD, 0.26, 95 % CI ?0.08 to 0.60, P?=?0.138), significantly decreased after 3 months (SMD, 0.68, 95 % CI 0.34 to 1.02, P?=?0.000), and further declined after 6 months (SMD, 0.74, 95 % CI 0.43 to 1.05, P?=?0.000).

Conclusions

The systemic inflammation, as measured by CRP, was present and significantly reduced by effective CPAP therapy in patients with OSA. The use of CRP levels may be clinically recognized as a valuable predictor for OSA treatment monitoring.     

Comparative-Effectiveness of Revascularization Versus Routine Medical Therapy for Stable Ischemic Heart Disease: A Population-Based Study

BACKGROUND

Randomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.

OBJECTIVE

To evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.

DESIGN

Observational cohort study.

PATIENTS

Stable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.

INTERVENTION

Revascularization, defined as PCI/CABG within 90 days after index angiography.

MAIN MEASURES

Death, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.

KEY RESULTS

We identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI?=?15,604; CABG?=?8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68–0.84; p?<?0.001) ,MIs (HR 0.78; 95 % CI 0.72–0.85; p?<?0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50–0.70; p?<?0.001) than medical therapy. In the propensity-matched analysis of 12,362 well–matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69–0.81; p?<?0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77–0.93 p?<?0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63–0.71; p?<?0.001) occurred in revascularized patients, over the 4.1 years of follow-up. The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p?<?0.001), β-blockers (78.2 % vs 76.7 %; p?=?0.010), and statins (94.7 % vs 91.5 %, p?<?0.001) in the 1-year post-angiogram.

CONCLUSIONS

Stable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.