A simplified clinical risk score predicts the need for early endoscopy in non-variceal upper gastrointestinal bleeding

BackgroundPre-endoscopic triage of patients who require an early upper endoscopy can improve management of patients with non-variceal upper gastrointestinal bleeding.AimsTo validate a new simplified clinical score (T-score) to assess the need of an early upper endoscopy in non variceal bleeding patients. Secondary outcomes were re-bleeding rate, 30-day bleeding-related mortality.MethodsIn this prospective, multicentre study patients with bleeding who underwent upper endoscopy were enrolled. The accuracy for high risk endoscopic stigmata of the T-score was compared with that of the Glasgow Blatchford risk score.ResultsOverall, 602 patients underwent early upper endoscopy, and 472 presented with non-variceal bleeding. High risk endoscopic stigmata were detected in 145 (30.7%) cases. T-score sensitivity and specificity for high risk endoscopic stigmata and bleeding-related mortality was 96% and 30%, and 80% and 71%, respectively. No statistically difference in predicting high risk endoscopic stigmata between T-score and Glasgow Blatchford risk score was observed (ROC curve: 0.72 vs. 0.69, p = 0.11). The two scores were also similar in predicting re-bleeding (ROC curve: 0.64 vs. 0.63, p = 0.4) and 30-day bleeding-related mortality (ROC curve: 0.78 vs. 0.76, p = 0.3).ConclusionsThe T-score appeared to predict high risk endoscopic stigmata, re-bleeding and mortality with similar accuracy to Glasgow Blatchford risk score. Such a score may be helpful for the prediction of high-risk patients who need a very early therapeutic endoscopy.     

Hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt: A retrospective case–control study

BackgroundAn association between Transjugular Intrahepatic Porto-Systemic Shunt (TIPS) and the development of hepatocellular carcinoma in patients with cirrhosis has been suggested, but not confirmed.AimTo evaluate the potential role of TIPS in hepatocellular carcinoma development.MethodsWe performed a retrospective case–control study among patients with cirrhosis; all cases had undergone TIPS placement. Cases and controls were followed as outpatients at a single liver care centre in the same timeframe.ResultsOverall, 101 patients with cirrhosis (mean age 58 ± 9 years, 64.3% male) were included in each group. Median duration of follow-up was 56.7 months (range 8.2–174.5) for TIPS patients and 67.8 months (range 8.3–183.1) for controls (p = 0.08). In both groups 94% of patients had Child–Pugh Class A or B cirrhosis. The cumulative incidence of hepatocellular carcinoma at 1, 3, 5, and 10 years was 2%, 7%, 18%, and 46% among TIPS patients, and 3%, 10%, 19%, and 39% among controls (log rank test p = 0.19). Compared to controls, hepatocellular carcinoma nodules in TIPS patients were more frequently situated in the right lobe (p < 0.05).ConclusionsTIPS does not seem to increase the risk of hepatocellular carcinoma in patients with Child–Pugh Class A or B cirrhosis; for these patients ultrasound surveillance should not be modified.     

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.     

Clinical outcome of portal vein thrombosis in patients with digestive cancers: A large AGEO multicenter study

IntroductionManagement of portal vein thrombosis (PVT) in cancer patients remains discussed.AimsThe objective of this multicenter retrospective study was to investigate the management and outcome of PVT in patients with digestive cancers other than hepatocellular carcinoma (HCC).MethodMain inclusion criteria were trunk or branch PVT in patients with locally advanced or metastatic digestive cancers. Predictive factors of bleeding and overall survival (OS) were evaluated in univariate and multivariate analysis.ResultsBetween 2012 and 2016, 118 patients with PVT and digestive cancers were identified. The majority had a pancreatic cancer (50%). Sixty-six percent of patients had trunk PVT location. Endoscopic screening of portal hypertension was performed in only 7 patients (1%) and 5 had esophageal varices. Gastrointestinal bleeding occurred in 22 patients (19%) and 12 patient deaths (17%) were related to a gastrointestinal hemorrhage. Metastatic disease (HR = 2.83 [95%CI 1.47–5.43], p < 0.01) and gastrointestinal hemorrhage (HR = 1.68 [95%CI 1.01–2.78], p = 0.04) were associated with OS in multivariate analysis. Only trunk PVT location was significantly associated with gastrointestinal hemorrhage in multivariate analysis (HR = 5.56 [95%CI 1.18–26.32], p = 0.03).ConclusionA high rate of variceal bleeding leading to death was found in this cohort. Endoscopic screening and the efficacy of prophylactic treatment of variceal bleeding remain to be evaluated in a prospective study.     

Predictors of early re-bleeding and mortality after acute variceal haemorrhage

Background and study aims: Oesophageal variceal haemorrhage is a devastating complication of portal hypertension (PHT). This study was done to determine the risk factors for re-bleeding within 5 days and mortality up to 6 weeks in patients with cirrhosis and acute variceal haemorrhage (AVH).Patients and methods: The study included 100 patients presenting with haematemesis and/or melena due to bleeding varices. All patients were subjected to full clinical assessment, routine laboratory investigations, calculation of the Child-Turcotte-Pugh (CTP) and model for end stage liver disease (MELD) scores, abdominal ultrasound and emergency upper gastrointestinal endoscopy.The patients were followed up since admission and up to 6 weeks for the occurrence of rebleeding (in the first 5 days) and mortality (up to 6 weeks) after the acute attack.ResultsThe patients were grouped into three groups: Group I: patients who survived more than 6 weeks following endoscopic management and did not rebleed during this period (75 patients). Group II: patients who died within 6 weeks of AVH (10 patients). Group III: patients who rebled or died within 5 days of AVH (15 patients). The mean MELD score was significantly higher in group II (18.29 ± 0.66) and group III (18.73 ± 0.89) as compared to group I (12.8 ± 2.1) (p = 0.001). Active bleeding at time of endoscopy was present in 8% of group I, 70% of group II and 53.3% of group III and the difference was statistically significant (p = 0.003), while white nipple sign was present in 10.6% of group I, 90% of group II and 73.3% of group III and the difference was statistically significant (p = 0.05).In conclusion high MELD score (>18), presence of active bleeding or white nipple sign at time of endoscopy are significant predictors for early rebleeding and mortality after AVH.     

Eficacia del octreótido sobre la recurrencia hemorrágica de las angiectasias del intestino delgado. Estudio comparativo

IntroductionFifty percent of small bowel bleeding is caused by angioectasia and the rebleeding rate due to small bowel angioectasia (SBA) is 80%. Its endoscopic treatment is difficult. Beneficial effects of octreotide on gastrointestinal angioectasia have been described, but no studies have reported its efficacy in SBA.AimOur aim was to investigate the effectiveness of octreotide in the prevention of rebleeding due to SBA.Material and methodsSixteen patients with bleeding caused by SBA were assigned to treatment with octreotide 100 μg/24 h SC, for at least 6 months, and compared with a non-treatment group of 36 patients. The primary outcome was the rebleeding rate, and the secondary outcomes were the number of hospital readmissions, bleeding-related death, and adverse effects.ResultsOctreotide was administered for 10.5 ± 8.4 months. Follow-up was 12.9 ± 17.3 months and 15.3 ± 17.7 months, in the treatment and non-treatment groups, respectively (p = 0.09). At the end of follow-up, 4 (25%) treatment group patients and 26 (72.2%) non-treatment group patients presented with rebleeding (p = 0.002). In the treatment group and non-treatment group, the cumulative probability of remaining rebleeding-free at one year was 79% vs 44.2%, and 79% vs 34.6% at 2 years, respectively (p = 0.05). Through the multiple logistic regression analysis, treatment was the protective variable. Six patients presented with adverse events. One of those patients (6.25%) had a major adverse event.ConclusionsOur results suggest that treatment with octreotide could be efficacious in the prevention of rebleeding due to SBA.     

Prospective randomized trial: Endoscopic follow up 3 vs 6 months after esophageal variceal eradication by band ligation in cirrhosis

Background and objectivesEndoscopic variceal ligation (EVL) is recommended to treat esophageal varices (EV) in cirrhosis and portal hypertension. A program of endoscopic surveillance is not clearly established. The aim of this prospective randomized trial was to assess the most effective timing of endoscopic monitoring after variceal eradication and its impact on the patient's outcome and on the costs.MethodsA hundred and two cirrhotic patients with esophageal varices treated by EVL were evaluated. After variceal eradication patients were randomized to receive first endoscopic control at 3 (Group 1) and 6 (Group 2) months respectively.ResultsVariceal obliteration was achieved in all patients. Variceal recurrence was observed in 28 cases at the first control (29.1%) without difference between the two groups (32% vs 29% in group 1 and 2 respectively, p = 0.75). The incidence of large varices is similar in the two groups (33% vs 38% respectively). Using a multivariate analysis, medical therapy with B blockers was the only independent predictor of lowest risk of variceal recurrence [OR 2.30, 95% CI (1.68–3.26)]. Bleeding related to recurrent varices occurred in 3.1% of cases and was associated with portal thrombosis. Child Pugh score ≥ 8 was the only predictor of mortality (p = 0.0002).ConclusionsRecurrence of varices after banding ligation is not rare but it is associated with a low risk of variceal progression and bleeding. Accordingly, a first endoscopic control at 6 months after variceal eradication associated with a good risk stratification might be a cost-effective strategy of monitoring.     

Comparison of outcomes in new-generation versus early-generation heart valve in transcatheter aortic valve implantation: A systematic review and meta-analysis

BackgroundNew-generation (NG) valves for transcatheter aortic valve implantation (TAVI) has recently been widely used in real-world practice, yet its comparative outcomes with early-generation (EG) valves remain under-explored.MethodsAn electronic literature search using PUBMED and EMBASE was conducted from inception to April 2017 for matched-cohort studies. Articles that compared the outcomes of NG vs. EG valves post TAVI with at least one of the following clinical outcome reported were included: all-cause mortality, major or life-threatening bleeding, major vascular complications (MVC), significant (more than moderate) paravalvular regurgitation (PVR), cerebrovascular events, significant (stage 2 or 3) acute kidney injury (AKI) and new permanent pacemaker implantation (PPI) that occurred either in-hospital or within 30-days.ResultsA total of 6 observational matched-cohort studies with 585 and 647 patients included in NG and EG valves, respectively, were included. EG valves were associated with a lower incidence of major or life-threatening bleeding (5.7% vs. 15.7%, p < 0.00001), significant paravalvular regurgitation (5.3% vs. 14.4%, p = 0.001), and significant AKI (4.4% vs. 7.5, p = 0.03). All-cause mortality (3.5% vs. 5.0, p = 0.43), cerebrovascular events (3.4% vs. 2.3%, p = 0.34) and new PPI (11.0% vs. 14.6%, p = 0.52) were similar between the two groups. NG demonstrated lower tendency of MVC (2.5% vs. 7.2, p = 0.09) compared to EG valves.ConclusionsNG demonstrated lower rates of significant AKI, significant PVR and major or life-threatening bleeding while all-cause mortality, new PPI, and cerebrovascular events remained similar compared to EG valves.     

STEMI vs NSTEACS management trends in non-invasive hospital

ObjectivesTo compare the clinical features, management, and in-hospital outcomes of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTEACS), in the Western Region of Saudi Arabia.MethodsA total of 71 patients were enrolled in a longitudinal study at a tertiary hospital without cardiac catheterization facility. These data were collected from Saudi Project for Assessment of Coronary Events registry.ResultsTwenty-three patients with STEMI were compared to 48 patients with NSTEACS. Mean age for STEMI was younger, 57.4 ± 13.7 years compared to 63.2 ± 13.9 years respectively (p = 0.19). Forty-four percent arrived at the hospital by ambulance. History of hypertension and hyperlipidemia were more frequent in NSTEACS (p = 0.05), while both groups showed no difference in diabetes mellitus, 17% vs 22% and smoking, 30% vs 17%. In-hospital medications were: Aspirin (100%) both groups, Clopidogrel (91% vs 100%) (p = 0.03). There was more aggressive use of beta-blockers (74% vs 95%) (p = 0.01) and statins (87% vs 100%) (p = 0.01) in NSTEACS.In-hospital outcomes showed one recurrent myocardial infarction and one death in NSTEACS group (2%). Other outcome in the two groups showed recurrent ischemia (13% vs 29%) (p = 0.14) and cardiogenic shock (9% vs 2%) (p = 0.17). No stroke or major bleeding was reported in both groups.ConclusionNSTEACS patients in western province of KSA present at an older age are mostly males and have higher prevalence of hypertension and hyperlipidemia compared with STEMI patients. It is therefore important to identify patients with high-risk profile and put implement measures to reduce these factors.     

Diagnostic accuracy of liver and spleen stiffness measured by fibroscan® in the prediction of esophageal varices in HCV-related cirrhosis patients treated with oral antivirals

IntroductionThe aim of this study was to investigate the accuracy of liver and spleen stiffness measurement by transient elastography for the prediction of gastroesophageal varices in patients with HCV-associated cirrhosis treated with new direct-acting antiviral agents.Patients and methodsThis cross-sectional observational study included patients with compensated HCV-related cirrhosis and sustained virological response after direct-acting antiviral therapy. Patients underwent liver and spleen stiffness measurement, abdominal ultrasound and oesophago-gastroduodenoscopy. Clinical and laboratory data and non-invasive markers such as the liver stiffness–spleen diameter to platelet ratio score, variceal risk index and platelet count to spleen diameter ratio were analyzed.ResultsNinety-seven consecutive patients were included. Liver stiffness measurement (12.2 vs 16; p = 0.02), spleen stiffness measurement (39.4 vs 46.05; p = 0.04), liver stiffness–spleen diameter to platelet ratio score (1.21 vs 2.02; p = 0.008), platelet count to spleen diameter ratio (1102.19 vs 829.7; p = 0.04) and variceal risk index (?3.4 vs ?1.02; p = 0.01) showed significant differences between patients without/with gastroesophageal varices. The best cut-off value to discard the presence of gastroesophageal varices was 12.3 kPa for liver stiffness measurement and 27 kPa for spleen stiffness measurement. However, diagnostic accuracy was moderate (AUROC: 0.671 and 0.624 respectively). Combining different non-invasive parameters did not significantly improve the overall performance.DiscussionLiver and spleen stiffness measurement showed suboptimal results for non-invasive assessment of gastroesophageal varices in HCV cirrhotic patients treated with direct-acting antiviral agents. Our results suggest that non-invasive methods cannot substitute standard procedures for predicting gastroesophageal varices in this population.     

Clinical profile and management of patients with chronic ischemic heart disease according to age in the population daily attended by cardiologists in Spain: The ELDERCIC study

ObjectivesThis study was aimed to evaluate the differences according to age in the clinical profile and management of outpatients with chronic ischemic heart disease attended by cardiologists in Spain.MethodsPatients with an established diagnosis of chronic ischemic heart disease were included in this cross-sectional multicenter study. The age of 65 years was considered as the cut-off point for the present analysis.ResultsA total of 1038 subjects were included, 524 of them (50.5%) > 65 years. Patients > 65 years had a lesser prevalence of smoking, a longer history of hypertension, a worse left ventricular ejection fraction and a higher prevalence of heart failure and renal insufficiency than younger subjects. The number of prescribed drugs was higher in patients > 65 years (6.1 ± 1.9 vs 5.7 ± 2.1, p = 0.004). Blood pressure control rate was lower in older patients (38.1% vs 46.5%, p = 0.008). No significant differences were found either in LDL-cholesterol (42.4% vs 46.5%), or glycemic control rates (42.4% vs 41.4%), both p = NS. Diagnostic and therapeutic procedures were also compared in > 65 vs ≤ 65 years, exercise test was performed in 51.5% vs 62.8% (p < 0.0001); stress echocardiography in 18.3% vs 13.2% (p = 0.027); coronary angiography in 38.6% vs 53.5% (p < 0.0001); and coronary revascularization in 37.2% vs 46.9% (p = 0.002), without significant differences in electrocardiogram, echocardiogram, or isotopic exams.ConclusionsOlder patients exhibited a worse clinical profile and a worse blood pressure control rate than the younger. However, diagnostic and therapeutic procedures appear to be frequently underused in the old patients.     

Intra-stent tissue evaluation within bare metal and drug-eluting stents > 3 years since implantation in patients with mild to moderate neointimal proliferation using optical coherence tomography and virtual histology intravascular ultrasound

ObjectiveWe aimed to compare neointimal tissue characteristics between bare-metal stents (BMS) and drug-eluting stents (DES) at long-term follow-up using optical coherence tomography (OCT) and virtual histology intravascular ultrasound (VH-IVUS).BackgroundNeoatherosclerosis in neointima has been reported in BMS and in DES.MethodsThirty patients with 36 stented lesions [BMS (n = 17) or DES (n = 19)] > 3 years after implantation were prospectively enrolled. OCT and VH-IVUS were performed and analyzed independently. Stents with ≥ 70% diameter stenosis were excluded.ResultsThe median duration from implantation was 126.0 months in the BMS group and 60.0 months in the DES group (p < 0.001). Lipid-laden intima (58.8% vs. 42.1%, p = 0.317), thrombus (17.6% vs. 5.3%, p = 0.326), and calcification (35.3% vs. 26.3%, p = 0.559) did not show significant differences between BMS and DES. When divided into 3 time periods, the cumulative incidence of lipid-laden neointima from > 3 years to < 9 years was similar between BMS and DES (42.9% vs. 42.1%, p = 1.000). Furthermore, it continued to gradually increase over time in both groups. OCT-derived thin-cap fibroatheroma (TCFA) was observed in 17.6% of BMS- and 5.3% of DES-treated lesions (p = 0.326). No stents had evidence of intimal disruption. The percentage volume of necrotic core (16.1% [9.7, 20.3] vs. 9.7% [7.0, 16.5], p = 0.062) and dense calcium (9.5% [3.8, 13.6] vs. 2.7% [0.4, 4.9], p = 0.080) in neointima tended to be greater in BMS-treated lesions. Intra-stent VH-TCFA (BMS vs. DES 45.5% vs. 18.2%, p = 0.361) did not differ significantly.ConclusionAt long-term follow-up beyond 3 years after implantation, the intra-stent neointimal tissue characteristics appeared similar for both BMS and DES.     

Antifungal treatment administered in OPAT programs is a safe and effective option in selected patients

IntroductionOutpatient parenteral antimicrobial therapy (OPAT) has been recognised as a useful, cost-effective and safe alternative to inpatient treatment. Nevertheless, the most common antimicrobials used are antibiotics, and there is less information about the use of antifungal therapy (AT). The aim of this study is to analyse a cohort of patients treated with AT administered via OPAT and to compare them with patients from the rest of the cohort (RC) treated with antibiotics.MethodsProspective observational study with post hoc (or retrospective) analysis of a cohort of patients treated in the OPAT program. We selected the patients treated with antifungals between July 2012 and December 2018. We recorded demographic and clinical data to analyse the validity of the treatment and to compare the differences between the AT and the RC.ResultsOf the 1101 patients included in the OPAT program, 24 (2.18%) were treated with AT, 12 Liposomal Amphotericin B, 6 echinocandins and 6 fluconazole. This result is similar to other cohorts. There were differences between the AT vs RC in the number of patients with neoplasia (58.3% vs 28%; p = 0.001), IC Charlson > 2 (58.3% vs 38.8; p = 0.053), duration of treatment (15 days vs 10.39 days; p = 0.001) and patients with central catheters (54.2% vs 21.7%; p = 0.0001). These differences are justified because there were more hematologic patients included in the AT group. Nevertheless, there were no differences in adverse reactions (25% vs 32.3%; p = 0.45) or re-admissions (12.5% vs 10%; p = 0.686) and OPAT with AT was successful in 21/24 patients (87.5%).ConclusionsAT can be successfully administered in OPAT programs in selected patients, that are clinically stable and monitored by an infectious disease physician.     

Combined oral and rectal mesalazine for the treatment of mild-to-moderately active ulcerative colitis: Rapid symptom resolution and improvements in quality of life

Background and aimsMesalazine (5-aminosalicylic acid) is the standard first-line therapy for mild-to-moderate ulcerative colitis. In the PINCE study, remission rates were significantly greater with combined oral/enema vs. oral/placebo treatment at 8 weeks (64% vs. 43%, respectively; p = 0.030). In this analysis, we explored early response, mucosal healing rates, cessation of rectal bleeding, and quality of life in PINCE.MethodsPatients with extensive mild-to-moderately active ulcerative colitis received 8 weeks of oral mesalazine 4 g/day, plus 4 weeks of daily active (1 g mesalazine) or placebo enema. Early response was assessed using the abbreviated ulcerative colitis disease activity index. Mucosal healing was assessed by disease activity index endoscopic mucosal appearance score. Cessation of bleeding (patient diaries), quality of life (EQ-5D), and patient acceptability (questionnaire) were also assessed.ResultsCombined mesalazine oral/enema treatment achieved a significantly higher rate of improvement in abbreviated ulcerative colitis disease activity index (score decrease ≥ 2) within 2 weeks, compared with oral-only treatment (p = 0.032). Bleeding ceased significantly more quickly with combination vs. oral therapy (p = 0.003). More patients showed mucosal healing (disease activity index endoscopic mucosal appearance score 0/1) with combination vs. oral therapy, which was significantly different between groups at week 4 (p = 0.052). Both groups showed quality of life improvements, with a significant benefit for combination vs. oral therapy at week 4 in multiple domains. Most patients reported finding the treatment acceptable.ConclusionsRapid cessation of symptoms was seen with combination therapy, which is particularly important to patients and may improve quality of life.     

Increase in COVID-19 inpatient survival following detection of Thromboembolic and Cytokine storm risk from the point of admission to hospital by a near real time Traffic-light System (TraCe-Tic)

IntroductionOur goal was to evaluate if traffic-light driven personalized care for COVID-19 was associated with improved survival in acute hospital settings.MethodsDischarge outcomes were evaluated before and after prospective implementation of a real-time dashboard with feedback to ward-based clinicians. Thromboembolism categories were “medium-risk” (D-dimer >1000 ng/mL or CRP >200 mg/L); “high-risk” (D-dimer >3000 ng/mL or CRP >250 mg/L) or “suspected” (D-dimer >5000 ng/mL). Cytokine storm risk was categorized by ferritin.Results939/1039 COVID-19 positive patients (median age 67 years, 563/939 (60%) male) completed hospital encounters to death or discharge by 21st May 2020. Thromboembolism flag criteria were reached by 568/939 (60.5%), including 238/275 (86.6%) of the patients who died, and 330/664 (49.7%) of the patients who survived to discharge, p < 0.0001. Cytokine storm flag criteria were reached by 212 (22.6%) of admissions, including 80/275 (29.1%) of the patients who died, and 132/664 (19.9%) of the patients who survived, p < 0.0001. The maximum thromboembolism flag discriminated completed encounter mortality (no flag: 37/371 [9.97%] died; medium-risk: 68/239 [28.5%]; high-risk: 105/205 [51.2%]; and suspected thromboembolism: 65/124 [52.4%], p < 0.0001). Flag criteria were reached by 535 consecutive COVID-19 positive patients whose hospital encounter completed before traffic-light introduction: 173/535 (32.3% [95% confidence intervals 28.0, 36.0]) died. For the 200 consecutive admissions after implementation of real-time traffic light flags, 46/200 (23.0% [95% confidence intervals 17.1, 28.9]) died, p = 0.013. Adjusted for age and sex, the probability of death was 0.33 (95% confidence intervals 0.30, 0.37) before traffic light implementation, 0.22 (0.17, 0.27) after implementation, p < 0.001. In subgroup analyses, older patients, males, and patients with hypertension (p ≤ 0.01), and/or diabetes (p = 0.05) derived the greatest benefit from admission under the traffic light system.ConclusionPersonalized early interventions were associated with a 33% reduction in early mortality. We suggest benefit predominantly resulted from early triggers to review/enhance anticoagulation management, without exposing lower-risk patients to potential risks of full anticoagulation therapy.     

Comparison of demographic and clinical characteristics of patients with early vs. adult vs. late onset ulcerative colitis

Background & aimsThere is limited data comparing influence of age on the presentation, clinical course, and therapeutic response of patients with ulcerative colitis. We aimed to compare the demographic and clinical characteristics of patients diagnosed with UC in older age vs. adulthood vs. early age.MethodsFive-hundred sixty one patients with UC seen at our center from 1995 to 2011 were categorized into early onset (EO), adult onset (AO) and late onset (LO) due to age at date of initial diagnosis. Patients diagnosed younger than age 17 were defined as EO, while those diagnosed between 17 and 60 were defined as AO and older than age 60 as LO. All patients were analyzed for demographic and clinical characteristics.ResultsThere was a male predominancy among LO patients (50% vs. 57.7% vs. 78.6%, p = 0.004). Patients with EO UC were more likely to be non-smokers (p < 0.001), and had higher family history of UC (p = 0.02). Patients with EO UC had more steroid use (p = 0.03), total colectomy (p = 0.04), presence of chronic active disease (p = 0.04) rates when compared with AO and LO groups. Patients in EO group had higher overall probability of surgery in 1, 5 and 10 years, when compared with patients in LO group (p = 0.02), but it wasn't different between EO and AO groups (p = 0.09).ConclusionsOur study showed that clinical course of UC was more aggressive in younger ages. Also the difference between the demographic characteristics suggests that different age groups have different risk factors for the disease development.     

High prevalence of subclinical cardiovascular abnormalities in patients with systemic lupus erythematosus in spite of a very low clinical damage index

Background and aimTo evaluate the prevalence of subclinical cardiovascular (CV) abnormalities in systemic lupus erythematosus (SLE) stratified according to SLE-related organ damage using the Systemic Lupus International Collaborating Clinics (SLICC) damage index.Methods and resultsWe selected SLE patients without clinically overt CV events (n = 45, 56% with SLICC = 0, 44% with SLICC = 1–4). CV evaluation was performed using cardiac and vascular echo-Doppler techniques. Post-ischemic flow-mediated dilation (FMD) over nitroglycerine-mediated dilation (NMD) of the brachial artery <0.70 defined endothelial dysfunction.The prevalence of preclinical CV abnormalities (CVAbn, including at least one of the following—carotid atherosclerosis, left ventricular (LV) hypertrophy, low arterial compliance, LV wall motion abnormalities, aortic regurgitation, FMD/NMD < 0.70)—was 64% (16/25) in patients with SLICC = 0 and 80% (16/20) in those with SLICC > 0 (p = not significant (NS)). In particular, the prevalence of carotid atherosclerosis (28% vs. 16%), of LV hypertrophy (12% vs. 6%) and of LV wall motion abnormalities (15% vs. 12%), of low global arterial compliance (18% vs. 10%), prevalence of aortic regurgitation (30% vs. 18%) and/or aortic valve fibrosclerosis (10% vs. 8%), FMD < 10% (14 ± 5% vs. 14% ± 6) and prevalence of FMD/NMD < 0.70 (53% vs. 52%) were comparable in SLE patients with SLICC > 0 and in those with SLICC = 0 (all p = NS). Of the SLE patients without carotid atherosclerosis, LV hypertrophy, low arterial compliance, LV wall motion abnormalities and aortic regurgitation (n = 17), endothelial dysfunction was detected in 50% of those with SLICC = 0 (6/12) and in 40% of those with SLICC > 0 (2/5, p = NS).ConclusionsSLE patients with SLICC = 0 often have an elevated CV risk profile due to subclinical manifestations of CV disease detectable by cardiac and vascular echo-Doppler evaluations.     

Trends in epidemiology and the treatment of acute coronary syndromes in the Czech Republic: Comparison of the CZECH-1 and CZECH-2 registries

BackgroundThe clinical spectrum of acute coronary syndrome (ACS) has changed due to a progressively ageing population over the last two decades.AimWe analysed the changes in the epidemiological and treatment strategies between two large registries that were performed in 2005 and 2012 in well-defined populations of the Czech Republic.Methods and resultsThe CZECH-1 and CZECH-2 registries enrolled all consecutive hospitalized patients with an initial diagnosis of ACS during a 1 or 2-month period, respectively. Thirty-six and 32 hospitals participated in the CZECH-1 and CZECH-2 registries, respectively. A total of 1921 patients were enrolled in the CZECH-1 registry and 1221 patients participated in the CZECH-2 registry. Patients enrolled in the CZECH-2 registry were older than those in CZECH-1 (68 ± 12 vs. 66 ± 12 years; p < 0.001). ACS was not confirmed during hospitalization in 30.5 and 30.1% (p > 0.05) of the patients in the CZECH-1 and CZECH-2 registries, respectively. Urgent angiography in patients with ST segment elevation myocardial infarction (STEMI) was performed in 92 and 94% of the patients (p > 0.05), respectively; of these, 87 and 89% subsequently underwent primary PCI. There were no signifiant differences in in-hospital (4.2 vs. 4.4%, p=0.805) or in the mortality of patients with a final diagnosis of Q-myocardial (10.3 vs. 10.7%; p = 0.870) or non-Q-myocardial infarction (4.7 vs. 3.8%; p = 0.497) between the two registries. The estimated incidence of confirmed ACS and STEMI in a representative population from both registries was 3248 and 661 cases/million individuals/year in the CZECH-1 registry and 2149 and 652 cases/million individuals/year in the CZECH-2 registry. The fall in ACS incidence was almost exclusively due to a significant decrease in the incidence of unstable angina as the final diagnosis. At discharge, the patients with confirmed ACS were administered the following medications: aspirin (95 vs. 94%; p > 0.05), clopidogrel (60 vs. 76.4%; p < 0.001), beta-blockers (78 vs. 78%; p > 0.05), angiotensin-converting enzyme (ACE) inhibitors (50 vs. 78%; p = <0.001) and statins (75 vs. 90%; p < 0.001) in the CZECH-1 and CZECH-2 registries, respectively.ConclusionIn the Czech Republic, the age of the patients hospitalized with ACS increased between 2005 and 2012. Invasive reperfusion strategy for patients with STEMI was very high in both registries. The overall outcome in patients with confirmed ACS did not change between 2005 and 2012. The estimated incidence of ACS decreased due to the fall in unstable angina pectoris.     

Safety and feasibility of performing staged non-culprit vessel percutaneous coronary intervention within the index hospitalization in patients with ST-segment elevation myocardial infarction and multivessel disease

ObjectivesTo determine whether staged percutaneous coronary intervention (PCI) within the same hospitalization as primary PCI is safe.BackgroundIn ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary PCI, staged non-culprit vessel PCI at a separate session is recommended.MethodsWe conducted a retrospective analysis of 282 consecutive STEMI patients with multivessel disease who underwent primary PCI followed by staged PCI of the non-culprit vessel. Patients were categorized into staged PCI in the same hospitalization (n = 184) and staged PCI at a separate hospitalization within 8 weeks of primary PCI (n = 98).ResultsBaseline characteristics, presentation of STEMI, and procedural characteristics were similar in both groups. Contrast amount was higher in the separate hospitalization group for both index (175 vs. 153 ml, p = 0.011) and staged (144 vs. 120 ml, p = 0.004) procedures. More staged left main PCI was performed in the separate hospitalization group (3.9 vs. 0.3%, p = 0.008). Angiographic success of staged PCI was similar in both groups, with similar rates of vascular complications and major bleeding. Following staged PCI, in-hospital major adverse cardiac events (3.3 vs. 1.0%, p = 0.43) and mortality (2.7 vs. 0%, p = 0.17) were similar in both groups.ConclusionsOur study supports the safety and feasibility of staged PCI within the same hospitalization as primary PCI, achieving similar procedural success and in-hospital outcomes as staged PCI at a separate hospitalization. Higher contrast amount used during primary PCI and presence of left main lesion in non-culprit vessels may influence the decision to stage the PCI at a separate hospitalization.     

The Japanese experience with sirolimus-eluting stent implantation in the infarct-related artery: Five years of observation from the J-PMS study

BackgroundLong-term outcome and safety concerns regarding drug-eluting stents (DES) for acute myocardial infarction (AMI) treatment is still debated.Methods and resultsWe analyzed data from 1937 patients with complete 5-year follow-up (94.5%) from a multicenter registry of sirolimus-eluting stents (J-PMS). The patients were divided into 2 groups: AMI (n = 133) and non-AMI (n = 1804) by clinical presentation of index procedure, and compared the outcomes. At 5-year follow-up, there were no significant differences in major adverse cardiac events (MACE), death, MI, or stent thrombosis between the groups. However, target vessel related events (TVF; revascularization, cardiac death, MI, thrombosis) were higher in the non-AMI group (p = 0.03). In the early phase (0–6 months), MACE and death/MI were higher in the AMI group (6.0% vs. 3.0%; p = 0.02 and 6.8% vs. 2.1%; p < 0.001). However, in the late phase (6–60 months), there was a difference in TVF between the 2 groups, with a steady increase in the non-AMI group (p = 0.03). Over 60% of patients with AMIs were started on dual antiplatelet therapy after stent implantation or on the same day. However, dual anti-platelet therapy duration was similar (867 ± 18 days in the AMI and 727 ± 57 days in the non-AMI group, p = 0.5). Frequency of bleeding was similar.ConclusionFive-year observation of AMI treatment using drug-eluting stent compared with non-AMI has no clinical disadvantage.