Hemodynamic impact of percutaneous left atrial appendage closure in patients with paroxysmal atrial fibrillation

Purpose

Percutaneous left atrial appendage (LAA) closure has become a valid alternative to anticoagulation therapy for the prevention of thromboembolic events in patients with atrial fibrillation (AF). However, scarce data exist on the impact of LAA closure on left atrial and ventricular function. We sought to assess the acute hemodynamic changes associated with percutaneous LAA closure in patients with paroxysmal AF.

Methods

The study population consisted of 31 patients (mean age 73?±?10 years; 49% women) with paroxysmal AF who underwent successful percutaneous LAA closure. All patients were in sinus rhythm and underwent 2D transthoracic echocardiography at baseline and the day after the procedure. A subset of 14 patients underwent preprocedural cardiac computed tomography (CT) with 3D LA and LAA reconstruction.

Results

Left ventricular systolic function parameters and LA volumetric indexes remained unchanged after the procedure. No significant changes in left ventricular stroke volume (72.4?±?16.0 vs. 73.3?±?15.7 mL, p?=?0.55) or LA stroke volume (total 15.6?±?4.2 vs. 14.6?±?4.2 mL, p?=?0.21; passive 9.0?±?2.8 vs. 8.3?±?2.6 mL, p?=?0.31; active 10.3?±?5.6 vs. 10.0?±?6.4 mL, p?=?0.72) occurred following LAA closure. Mean ratio of LAA to LA volume by 3D CT was 10.2?±?2.3%. No correlation was found between LAA/LA ratio and changes in LA stroke volume (r?=?0.35, p?=?0.22) or left ventricular stroke volume (r?=?0.28, p?=?0.33).

Conclusions

The LAA accounts for about 10% of the total LA volume, but percutaneous LAA closure did not translate into any significant changes in LA and left ventricular function.

     

Oncologic outcome of colorectal cancer patients over age 80: a propensity score-matched analysis

Purpose

It remains unclear whether old age is a poor prognostic factor in colorectal cancer (CRC). We compared oncologic outcomes in CRC patients according to age, using 80 as the dividing point.

Methods

CRC patients who underwent radical surgery from 2000 to 2011 were evaluated. We performed matched and adjusted analyses comparing oncologic outcomes between patients with ≥?80 and <?80 years old.

Results

Among 9562 patients, 222 were elderly. The median age was 82.0 years in elderly patients and 59.0 years in young patients. Elderly patients received less neoadjuvant or adjuvant therapy compared to young patients (p?<?0.001). After recurrence, significantly fewer elderly patients received additional treatments (p?<?0.001). Before matching, disease-free survival (DFS) and cancer-specific survival (CSS) were significantly lower for elderly patients compared to those for young patients (p?<?0.001 and p?<?0.001, respectively). After matching, DFS and CCS were not significantly different between the two groups (p?=?0.400 and p?=?0.267, respectively). In a multivariate analysis for prognostic factors, old age was not an independent poor prognostic factor of DFS and CCS (p?=?0.619 and p?=?0.137, respectively).

Conclusions

Elderly patients aged ≥?80 years with CRC had similar oncologic outcome to young patients, and age was not an independent prognostic factor.

     

Side-to-end vs. straight stapled colorectal anastomosis after low anterior resection: results of randomized clinical trial

Aim

The aim of this study is to compare surgical, functional, physiologic outcomes and QOL after low anterior resection (LAR) with andside-to-end or straight colorectal anastomosis.

Method

Between 2012 and 2015, 86 patients with mid and low rectal tumors were enrolled into randomized trial. Wexner score, number of defecations, use of antidiarrheal medicine or laxatives, enemas, pads, episodes of nocturnal incontinence, and urgency were recorded. The Fecal Incontinence Quality of Life (FIQL) scale was used for assessment of QOL. Anal manometry and volumetric examination were performed.

Results

Six patients were excluded from the study. There was no mortality. The morbidity rate was 6 (14.6 %) for side-to-end vs. 8 (20.0 %) for straight anastomosis (p?=?0.57). The median Wexner score was 5 vs. 6 (p?=?0.033), 4 vs. 5 (p?=?0.006), and 2 vs. 3 (p?=?0.1) at 1, 3, and 6 months after stoma reversal, respectively. Side-to-end anastomosis resulted in a fewer mean numbers of bowel movements per day at the same check points of follow-up: 5.8?±?0.14 vs. 6.4?±?0.15 (p?=?0.006), 3.7?±?0.1 vs. 4.2?±?0.1 (p?=?0.003), and 2.5?±?0.1 vs. 3.0?±?0.10 (p?=?0.0002), correspondingly. Maximal tolerated volume was higher for side-to-end anastomosis at 3 and 6 months of follow-up: 152.0 vs. 137.8 cm³ (p?=?0.002) and 180.5 vs. 167.0 cm³ (p?=?0.006), respectively. Better FIQL score was found at 1 and 3 months in the side-to-end group.

Conclusion

Better functional outcomes and QOL were observed in a short period after stoma closure, but at 6 months of follow-up, the only benefit of side-to-end anastomosis was a lower number of bowel movements.

     

The number of metastatic lymph nodes exhibiting poorly differentiated clusters predicts survival in patients with pStage III colorectal cancer

Purpose

Many studies have proposed alternative designations for lymph node (LN) status in colorectal cancer (CRC); however, knowledge of histopathological features in metastatic lymph nodes (MLNs) is limited. This study investigated the clinicopathological significance of poorly differentiated clusters (PDCs) in MLNs.

Methods

Slides from 159 patients with pathological Stage III CRC were reviewed. Those with <12 dissected LNs (DLNs) were ineligible. PDCs composed of ≥5 cancer cells lacking full glandular formation and ≥10 PDCs under ×20 objective lens were defined as positive, and the number of MLNs with positive PDCs (MLNs-PDCs) was counted. Results were correlated with patient survival and comparisons made with other indications of LN status.

Results

The mean numbers of MLNs and MLNs-PDCs were 2.8 and 1.0, respectively, and were moderately and positively correlated with each other. Univariate analysis identified cutoffs of ≥5 MLNs (86 vs. 55 %, p?=?0.024), ≥2 MLNs-PDCs (85 vs. 63 %, p?=?0.008), and ≥30 % LN ratio (85 vs. 44 %, p?=?0.036) to indicate a positive LN status. However, no cutoff for DLNs was obtained. MLNs-PDCs (≥2) were associated with pT4 tumor (p?=?0.0035), open surgery (p?=?0.016), greater number of MLNs (p?<?0.0001), and positive-PDC primary tumor (p?<?0.0001). In multivariate analysis, a prognostic model incorporating ≥2 MLNs-PDCs provided the lowest Akaike information criterion value; consequently, both pT4 tumors (p?<?0.001) and ≥2 MLNs-PDCs (p?=?0.038) were revealed to be significant prognosticators.

Conclusion

Results showed that applying the number of MLNs-PDCs could improve stratification in pStage III CRC and may be a valuable candidate for LN status.

     

Social Function and Cognitive Status: Results from a US Nationally Representative Survey of Older Adults

BACKGROUND

An early sign of cognitive decline in older adults is often a disruption in social function, but our understanding of this association is limited.

OBJECTIVE

We aimed to determine whether those screening positive for early stages of cognitive impairment have differences across multiple dimensions of social function and whether associations differ by gender.

DESIGN

United States nationally representative cohort (2010), the National Social life, Health, and Aging Project (NSHAP).

PARTICIPANTS

Community-dwelling adults aged 62–90 years (N?=?3,310) with a response rate of 76.9 %.

MAIN MEASURES

Cognition was measured using a survey adaptation of the Montreal Cognitive Assessment categorized into three groups: normal, mild cognitive impairment (MCI), and dementia. We measured three domains of social relationships, each comprised of two scales: network structure (size and density), social resources (social support and social strain), and social engagement (community involvement and socializing). We used multiple linear regression to characterize the relationship of each social relationship measure to cognition.

KEY RESULTS

Individuals screened as at risk for MCI and early dementia had smaller network sizes by 0.3 and 0.6 individuals (p?<?0.001), and a 10 % and 25 % increase in network density (p?<?0.001), respectively. For social resources, individuals at risk for MCI and dementia had 4 % and 14 % less social strain (p?=?0.01), but only women had 3 % and 6 % less perceived social support (p?=?0.013), respectively. For social engagement, individuals screened positive for MCI and dementia had 8 % and 19 % less community involvement (p?=?0.01), but only men had 8 % and 13 % increased social involvement with neighbors and family members (p?<?0.001), respectively.

CONCLUSION

Changes in social functioning provide an early indication to screen for cognitive loss. Recognition that early cognitive loss is associated with differences in social function can guide counseling efforts and help identify social vulnerabilities to ease the transition to overt dementia for both patients and caregivers.

     

Statin Use,Diabetes Incidence and Overall Mortality in Normoglycemic and Impaired Fasting Glucose Patients

BACKGROUND

The association between the use of statins and the risk of diabetes and increased mortality within the same population has been a source of controversy, and may underestimate the value of statins for patients at risk.

OBJECTIVE

We aimed to assess whether statin use increases the risk of developing diabetes or affects overall mortality among normoglycemic patients and patients with impaired fasting glucose (IFG).

DESIGN AND PARTICIPANTS

Observational cohort study of 13,508 normoglycemic patients (n?=?4460; 33 % taking statins) and 4563 IFG patients (n?=?1865; 41 % taking statin) among residents of Olmsted County, Minnesota, with clinical data in the Mayo Clinic electronic medical record and at least one outpatient fasting glucose test between 1999 and 2004. Demographics, vital signs, tobacco use, laboratory results, medications and comorbidities were obtained by electronic search for the period 1999–2004. Results were analyzed by Cox proportional hazards models, and the risk of incident diabetes and mortality were analyzed by survival curves using the Kaplan–Meier method.

MAIN MEASURES

The main endpoints were new clinical diagnosis of diabetes mellitus and total mortality.

KEY RESULTS

After a mean of 6 years of follow-up, statin use was found to be associated with an increased risk of incident diabetes in the normoglycemic (HR 1.19; 95 % CI, 1.05 to 1.35; p?=?0.007) and IFG groups (HR 1.24; 95%CI, 1.11 to 1.38; p?=?0.0001). At the same time, overall mortality decreased in both normoglycemic (HR 0.70; 95 % CI, 0.66 to 0.80; p?<?0.0001) and IFG patients (HR 0.77, 95 % CI, 0.64 to 0.91; p?=?0.0029) with statin use.

CONCLUSION

In general, recommendations for statin use should not be affected by concerns over an increased risk of developing diabetes, since the benefit of reduced mortality clearly outweighs this small (19–24 %) risk.

     

Macroscopic serosal invasion and small tumor size as independent prognostic factors in stage IIA colon cancer

Background

This study aimed to investigate the prognostic factors of patients with stage IIA (T3N0M0) colon cancer in terms of macroscopic serosal invasion and small tumor size.

Methods

We enrolled 375 stage IIA colon cancer patients who underwent curative resection between January 2004 and December 2011. Macroscopic serosal invasion was defined as tumor nodules or colloid changes protruding the surface of the serosa. The clinicopathologic characteristics were analyzed to identify independent prognostic factors.

Results

The median follow-up was 47 months (range, 1–90 months). On multivariate survival analysis, macroscopic serosal invasion (adjusted hazard ratio [HR]?=?4.750; p?=?0.013), tumor size <?5 cm (adjusted HR?=?3.112, p?=?0.009), perineural invasion (adjusted HR?=?3.528; p?=?0.002), <?12 retrieved lymph nodes (adjusted HR?=?4.257; p?=?0.002), and localized perforation (adjusted HR?=?7.666; p?=?0.008) were independent risk factors for recurrence.

Conclusion

We found novel prognostic factors of stage IIA colon cancer, including macroscopic serosal invasion and small tumor size (<?5 cm). Further studies are needed to evaluate the benefit of adjuvant chemotherapy in patients with these prognostic factors.

     

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial

Background

Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.

Objective

To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students’ counseling skills.

Design

A group-randomized controlled trial (2010–2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).

Setting/Participants

Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N?=?1345) completed objective structured clinical examinations (OSCEs), and 50 % (N?=?660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N?=?1096) from the class of 2014 completed an OSCE and 69.7 % (N?=?1047) completed pre and post surveys.

Interventions

The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.

Measurements

The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.

Results

Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean?8.0 [SE 0.6], p?=?0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p?<?0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p?<?0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps?≤0.05).

Limitations

Inclusion of only ten schools limits generalizability.

Conclusions

Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools.NIH Trial Registry Number: NCT01905618

     

Time from colorectal cancer diagnosis to laparoscopic curative surgery—is there a safe window for prehabilitation?

Background

There is a growing interest in the adoption of formal prehabilitation programmes prior to elective surgery but regulatory targets mandate prompt treatment following cancer diagnosis. We aimed to investigate if time from diagnosis to surgery is linked to short- and long-term outcomes.

Methods

An exploratory analysis was performed utilising a dedicated, prospectively populated database. Inclusion criteria were biopsy-proven colorectal adenocarcinoma undergoing elective laparoscopic surgery with curative intent. Demographics, date of diagnosis and surgery was captured with patients dichotomised using 4-, 8- and 12-week time points. All patients were followed in a standardised pathway for 5 years. Overall survival was assessed with the Kaplan-Meier log-rank method.

Results

Six hundred sixty-eight consecutive patients met inclusion criteria. Mean time from diagnosis to surgery was 53 days (95% CI 48.3–57.8). Identified risk factors for longer time to surgery were males (OR 1.92 [1.2–3.1], p?=?0.008), age?≤?65 (OR 1.9 [1.2–3], p?=?0.01), higher ASA scores (p?=?0.01) stoma formation (OR 6.9 [4.1–11], p?<?0.001) and neoadjuvant treatment (OR 5.06 [3.1–8.3], p?<?0.001). There was no association between time to surgery and BMI (p?=?0.36), conversion (16.3%, p?=?0.5), length of stay (p?=?0.33) and readmission or reoperation (p?=?0.3). No differences in five-year survival were seen in those operated within 4, 8 and 12 weeks (p?=?0.397, p?=?0.962 and p?=?0.611, respectively). Multivariate analysis showed time from diagnosis to surgery was not associated with five-year overall survival (HR 0.99, p?=?0.52).

Conclusion

Time from colorectal cancer diagnosis to curative laparoscopic surgery did not impact on overall survival. This finding may allow preoperative pathway alteration without compromising safety.

     

Neuromuscular comorbidity,heart failure,and atrial fibrillation as prognostic factors in left ventricular hypertrabeculation/noncompaction

Background

There is some controversy concerning the prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT). LVHT is frequently associated with neuromuscular disorders (NMDs). The aim of this study was to assess cardiac and neurological findings as predictors of mortality in patients with LVHT.

Patients and methods

The study included patients with LVHT diagnosed between June 1995 and January 2014 in one echocardiographic laboratory. They underwent a baseline cardiologic examination and were invited for a neurological examination. Between January and February 2014, their survival status was assessed.

Results

LVHT was diagnosed in 220 patients (68 female, aged 52?±?17 years) with a prevalence of 0.35?%/year. During a follow-up of 72?±?61 months, 65 patients died. The mortality was 5?%/year. A neurological investigation was performed on 173 patients (79?%) and revealed specific NMDs in 31 (14?%), NMD of unknown etiology in 103 (47?%), and normal findings in 39 (18?%) patients. In multivariate analysis, the predictors of mortality were increased age (p?=?0.0001), presence of a specific NMD (p?=?0.0062) or NMD of unknown etiology (p?=?0.0062), heart failure NYHA III (p?=?0.0396), atrial fibrillation (p?=?0.0022), and sinus tachycardia (p?=?0.0395).

Conclusions

LVHT patients should undergo systematic neurological examinations. Whether an optimal therapy of heart failure and atrial fibrillation will improve the prognosis of LVHT patients needs to be addressed in further studies.

     

Crohn’s disease: is there any link between anal and luminal phenotypes?

Purpose

Perianal Crohn’s disease (CD) encompasses a variety of lesion similar to luminal disease, which are usually not distinctly assessed. Links between luminal and perianal CD phenotype remains therefore underreported, and we aimed to describe both luminal and perianal phenotype and their relationships.

Methods

From January 2007, clinical data of all consecutive patients with CD seen in a referral center were prospectively recorded. Data recorded until October 2011 were extracted and reviewed for study proposal.

Results

A total of 282 patients (M/F, 108/174; aged 37.8?±?16.2 years) were assessed that included 154 cases (54.6 %) with anal ulceration, 118 cases (41.8 %) with fistula, 49 cases (17.4 %) with stricture, and 94 cases without anal lesion (33.3 %). Anal ulcerations were associated with fistulas (N?=?87/154) in more than half of patients (56.5 %) and were isolated in 55 patients (35.7 %). Most of strictures (94 %) were associated with other lesions (N?=?46/49). Harvey-Bradshaw score was significantly higher in patients with ulcerations (p?<?0.001) as compared to those with perianal fistulas (p?=?0.15) or with anal strictures (p?=?0.16). Proportions of complicated behavior (fistulizing or stricturing) of luminal CD were similar according to anal lesions: anal fistulas were not significantly associated to penetrating Montreal phenotype (N?=?4/31 p?=?0.13) as well as anal stricture and stricturing Montreal phenotype (N?=?3/49, p?=?0.53).

Conclusions

The phenotype of luminal disease does not link with the occurrence and the phenotype of perianal Crohn’s disease. Anal ulcerations denote a more severe disease on both luminal and perianal locations and should consequently be taking into account in physician decision-making.

     

Female sexual function and fertility after ileal pouch-anal anastomosis

Purpose

A potential complication in women after ileal pouch-anal anastomosis (IPAA) is sexual impairment and reduced fertility. The aim was to evaluate sexual function and fertility after IPAA.

Methods

All female patients who underwent an IPAA between 2004 and 2013 were retrospectively included. Sexual function, fertility, and continence were explored by the female sexual function index (FSFI), telephonic interview, and Wexner’s score.

Results

Among 127 women included, 93 responded to the questionnaires (73.2 %). Seventy five were sexually active, and 48 (64 %) had normal sexual function (FSFI?>?26). In univariate analysis, there was a significant relationship between ulcerative colitis (p?=?0.0161), age?>?40 years (p?=?0.01311), number of bowel movements (p?=?0.0238), nocturnal pouch activity (p?=?0.0094), use of loperamide (p?=?0.0283), and existence of sexual dysfunction. After multivariate analysis, age and nocturnal pouch activity were associated with a worse sexual function (p?=?0.0235, OR?=?3.3 (1.2–9.9) and p?=?0.0094, OR?=?4.1 (1.4–13.5)). Of 16 patients who wished to have children, 10 (63 %) became pregnant without recourse to in vitro fertilization, of whom 3 had two or more pregnancies. In total, there were 13 children born after IPAA. The mean time between the first pregnancy and surgery was 24.8?±?22 months. At 12 and 24 months after cessation of contraception, 57 and 67 % had at least one pregnancy.

Conclusions

While sexual function is impaired in a limited number of patients, the impact of surgery can be regarded as modest. Age and nocturnal pouch activity were some independent factors of worse sexual function. The risk of infertility should not preclude consideration of IPAA as a treatment option.

     

The short-term outcomes of robotic sphincter-preserving surgery for rectal cancer: comparison with open and laparoscopic surgery using a propensity score analysis

Purpose

The aim of this study is to clarify the short-term outcomes of robotic sphincter-preserving surgery for rectal cancer in a retrospective study.

Methods

The short-term outcomes of robotic sphincter-preserving surgery (n?=?130) were retrospectively compared to open (n?=?234) and laparoscopic surgery (n?=?318) by a propensity score analysis.

Results

Robotic surgery was performed more frequently for patients with lower rectal cancer (55%) than open (30%, p?<?0.0001) or laparoscopic surgery (36%, p?<?0.0001). None of the robotic surgery cases were converted to open surgery. After propensity score matching, robotic surgery was found to be associated with a longer operation time (342 vs. 230 min, p?<?0.0001) and less blood loss (7 vs. 420 mL, p?<?0.0001) than open surgery. The overall complication rate of robotic surgery was lower than that of open surgery (13 vs. 28%, p?=?0.032). Robotic surgery was associated with a lower incidence of surgical site infections (SSIs) than laparoscopic surgery (0 vs. 7%, p?=?0.028). There were no cases of anastomotic leakage after robotic surgery. The circumferential resection margin was involved in 0.8% of the patients who underwent robotic surgery; the incidence did not differ among the treatment groups.

Conclusions

Although robotic surgery for rectal cancer was associated with a longer operation time, it was associated with a very low incidence of SSIs. The degree of safety was comparable to both open and laparoscopic surgery.

     

Diabetes was the only comorbid condition associated with mortality of invasive pneumococcal infection in ICU patients: a multicenter observational study from the Outcomerea research group

Purposes

Streptococcus pneumoniae is a leading pathogen of severe community, hospital or nursing facility infections. We sought to describe characteristics of invasive pneumococcal infection (IPI) and pneumonia (due to the high mortality of intensive care-associated pneumonia) and to report outcomes according to various types of comorbidity.

Methods

Multicenter observational cohort study on the prospective Outcomerea database, including adult patients, with a hospital stay?<?48 h before ICU admission and a documented IPI within the first 72 h of ICU admission. Comorbid conditions were defined according to the Knaus and Charlson classification.

Results

Of the 20,235 patients, 5310 (26.4%) had an invasive infection, including 560/5,310 (10.6%) who had an IPI. The ICU 28-day mortality was 109/560 (19.8%). Four factors were independently associated with mortality: SOFA day 1–2: [hazard ratio (HR) 1.21; 95% confidence interval (95% CI) 1.15–1.27, p?<?0.001]; maximum lactate level day 1–2: (HR 1.07, 95% CI 1.02–1.12, p?=?0.006); diabetes mellitus: (HR 1.91, 95% CI 1.23–3.03, p?=?0.006) and appropriate antibiotics (HR 0.28, 95% CI 0.15–0.50, p?<?0.001). Comparable results were obtained when other comorbid conditions were forced into the model. Diabetes impact was more pronounced in case of micro- or macro-angiopathy (HR 4.17, 95%CI 1.68–10.54, p?=?0.003), in patients?≥?65 years old (HR 2.59, 95% CI 1.56–4.28, <?0.001) and in those with body mass index (BMI)?<?25 kg/m² (HR 2.11, 95% CI 1.10–4.06, p?=?0.025).

Conclusions

Diabetes mellitus was the only comorbid condition which independently influenced mortality in patients with IPI. Its impact was more pronounced in patients with complications, aged?≥?65 years and with BMI?<?25 kg/m².

     

T wave positivity in lead aVR is associated with mortality in patients with cardiac resynchronization therapy

Purpose

Positive T wave polarity in lead aVR (TPaVR) is associated with a poor prognostic indicator in patients with heart failure reduce ejection fraction (HFrEF). Our aim was to investigate the relationship between positive TPaVR and mortality in patients with cardiac resynchronization therapy defibrillator (CRT-D).

Methods

We included retrospectively 224 HFrEF patients with CRT-D in sinus rhythm. Laboratory, electrocardiographic (ECG), and echocardiographic data were recorded. T wave polarity was measured in lead DI, DII, and aVR from surface ECG.

Results

The patients were divided as living and deceased. They followed for 2.5?±?0.9 years. Thirty-three patients (14.7%) died. Six patients (18.2%) were TPaVR positive before CRT-D and this number increased to 22 (66.6%) after CRT-D in the deceased group. Pulse (p?=?0.049), hyperlipidemia (p?=?0.022), and NT-proBNP levels were higher in the deceased group (p?=?0.001). TPaVR before CRT-D (p?<?0.001) and TPaVR after CRT-D (p?<?0.001) were significantly positive in the deceased group. Positive TPaVR after CRT-D was the only independent predictor for mortality in binominal logistic regression analysis (OR 1.211, 95% CI 1.105–1.328, p?<?0.001).

Conclusions

In CRT-D patients, a positive TPaVR in surface ECG may be a strong mortality indicator.

     

Type 1 diabetic patients with peripheral neuropathy have pan-enteric prolongation of gastrointestinal transit times and an altered caecal pH profile

Aims/hypothesis

We hypothesised that type 1 diabetic patients with established diabetic sensorimotor polyneuropathy (DSPN) would have segmental and/or pan-enteric dysmotility in comparison to healthy age-matched controls. We aimed to investigate the co-relationships between gastrointestinal function, degree of DSPN and clinical symptoms.

Methods

An observational comparison was made between 48 patients with DSPN (39 men, mean age 50 years, range 29–71 years), representing the baseline data of an ongoing clinical trial (representing a secondary analysis of baseline data collected from an ongoing double-blind randomised controlled trial investigating the neuroprotective effects of liraglutide) and 41 healthy participants (16 men, mean age 49 years, range 30–78) who underwent a standardised wireless motility capsule test to assess gastrointestinal transit. In patients, vibration thresholds, the Michigan Neuropathy Screening Instrument and Patient Assessment of Upper Gastrointestinal Symptom questionnaires were recorded.

Results

Compared with healthy controls, patients showed prolonged gastric emptying (299?±?289 vs 179?±?49 min; p?=?0.01), small bowel transit (289?±?107 vs 224?±?63 min; p?=?0.001), colonic transit (2140, interquartile range [IQR] 1149–2799 min vs 1087, IQR 882–1650 min; p?=?0.0001) and whole-gut transit time (2721, IQR 1196–3541 min vs 1475 (IQR 1278–2214) min; p?<?0.0001). Patients also showed an increased fall in pH across the ileocaecal junction (?1.8?±?0.4 vs ?1.3?±?0.4 pH; p?<?0.0001), which was associated with prolonged colonic transit (r?=?0.3, p?=?0.001). Multivariable regression, controlling for sex, disease duration and glycaemic control, demonstrated an association between whole-gut transit time and total GCSI (p?=?0.02).

Conclusions/interpretation

Pan-enteric prolongation of gastrointestinal transit times and a more acidic caecal pH, which may represent heightened caecal fermentation, are present in patients with type 1 diabetes. The potential implication of delayed gastrointestinal transit on the bioavailability of nutrition and on pharmacotherapeutic and glycaemic control warrants further investigation.

Trial registration

EUDRA CT: 2013-004375-12

     

Prolonged antibiotic prophylaxis after thoracoabdominal esophagectomy does not reduce the risk of pneumonia in the first 30 days: a retrospective before-and-after analysis

Purpose

Thoracoabdominal esophageal resection for malignant disease is frequently associated with pulmonary infection. Whether prolonged antibiotic prophylaxis beyond a single perioperative dose is advantageous in preventing pulmonary infection after thoracoabdominal esophagectomy remains unclear.

Methods

In this retrospective before-and-after analysis, 173 patients between January 2009 and December 2014 from a prospectively maintained database were included. We evaluated the effect of a 5-day postoperative course of moxifloxacin, which is a frequently used antimicrobial agent for pneumonia, on the incidence of pulmonary infection and mortality after thoracoabdominal esophagectomy.

Results

104 patients received only perioperative antimicrobial prophylaxis (control group) and 69 additionally received a 5-day postoperative antibiotic therapy with moxifloxacin (prolonged-course). 22 (12.7%) of all patients developed pneumonia within the first 30 days after surgery. No statistically significant differences were seen between the prolonged group and control group in terms of pneumonia after 7 (p?=?0.169) or 30 days (p?=?0.133), detected bacterial species (all p?>?0.291) and 30-day mortality (5.8 vs 10.6%, p?=?0.274).

Conclusion

A preemptive 5-day postoperative course of moxifloxacin does not reduce the incidence of pulmonary infection and does not improve mortality after thoracoabdominal esophagectomy.

     

Repeating of local therapy of distant metastases increases overall survival in patients with synchronous metastasized rectal cancer—a monocentric analysis

Purpose

The aim was to evaluate the outcome of treatment-naive patients with synchronous metastatic rectal cancer after chemotherapy with FOLFOXIRI followed by local therapeutic procedures of all tumor lesions as complete as possible.

Methods

We reviewed data of 30 patients with synchronous distant metastatic rectal cancer who underwent chemotherapy with FOLFOXIRI and subsequent local therapy in our institution.

Results

Median follow-up was 28 months (range: 8; 74). Cumulative overall survival (OS) and progression-free survival (PFS) was 93.3, 76.9, 55.6% and 46.2, 29.7, 29.7% after 1, 2, 4 years. Non-response to chemotherapy with FOLFOXIRI was associated with a highly significant decreased OS (p?<?0.0001). The consistent use of local ablative procedures led to a statistically significant increase in OS (p?<?0.0001), but not in PFS (p?=?0.635). Patients with ≤?4 distant metastases showed a better OS (p?=?0.033).

Conclusions

Response to intensified first-line chemotherapy with FOLFOXIRI, treatment of the primary rectal tumor, and repeated thorough local ablative procedures in patients with synchronous metastasized rectal cancer may lead to long-term survival, even in a subset of patients with unresectable disease at initial diagnosis.

     

Association of cardiac implantable electronic devices with survival in bifascicular block and prolonged PR interval on electrocardiogram

Purpose

Bifascicular block and prolonged PR interval on the electrocardiogram (ECG) have been associated with complete heart block and sudden cardiac death. We sought to determine if cardiac implantable electronic devices (CIED) improve survival in these patients.

Methods

We assessed survival in relation to CIED status among 636 consecutive patients with bifascicular block and prolonged PR interval on the ECG. In survival analyses, CIED was considered as a time-varying covariate.

Results

Average age was 76?±?9 years, and 99% of the patients were men. A total of 167 (26%) underwent CIED (127 pacemaker only) implantation at baseline (n?=?23) or during follow-up (n?=?144). During 5.4?±?3.8 years of follow-up, 83 (13%) patients developed complete or high-degree atrioventricular block and 375 (59%) died. Patients with a CIED had a longer survival compared to those without a CIED in the traditional, static analysis (log-rank p?<?0.0001) but not when CIED was considered as a time-varying covariate (log-rank p?=?0.76). In the multivariable model, patients with a CIED had a 34% lower risk of death (hazard ratio 0.66, 95% confidence interval 0.52–0.83; p?=?0.001) than those without CIED in the traditional analysis but not in the time-varying covariate analysis (hazard ratio 1.05, 95% confidence interval 0.79–1.38; p?=?0.76). Results did not change in the subgroup with a pacemaker only.

Conclusions

Bifascicular block and prolonged PR interval on ECG are associated with a high incidence of complete atrioventricular block and mortality. However, CIED implantation does not have a significant influence on survival when time-varying nature of CIED implantation is considered.