The timing of last hemodialysis influences the prognostic value of serum lactate levels in predicting mortality of end-stage renal disease patients with sepsis in the emergency department

Sepsis is a life-threatening condition, and serum lactate levels have been used to predict patient prognosis. Studies on serum lactate levels in patients undergoing regular hemodialysis who have sepsis are limited. This study aimed to determine the predictive value of serum lactate levels for sepsis-related mortality among patients who underwent last hemodialysis at three different times before admission to the emergency department (ED).This retrospective cohort study was conducted from January 2007 to December 2013 in southern Taiwan. All hemodialysis patients with sepsis, receiving antibiotics within 24 hours of sepsis confirmation, admitted for at least 3 days, and whose serum lactate levels were known were examined to determine the difference in the serum lactate levels of patients who underwent last hemodialysis within 4 hours (Groups A), in 4–12 hours (Group B), and beyond 12 hours (Group C) before visited to the ED. All the continuous variables, categorical variables and mortality were compared by using Kruskal-Wallis test or Mann-Whitney test, the χ² or Fisher exact tests, and multiple logistic regression model, respectively.A total of 490 patients were enrolled in the study, and 8.0% (39), 21.5% (84), and 74.9% (367) of the patients were in Group A, Group B and Group C, respectively; the serum lactate levels (2.91 vs 2.13 vs 2.79 mmol/L, respectively; P = .175) and 28-day in-hospital mortality (17.9% vs 14.6% vs 22.9%) showed no statistically significant difference between 3 groups. The association between serum lactate levels and 28-day in-hospital mortality was reliable in Group B (P = .002) and Group C (P < .001), but it was unreliable in Group A (P = .629).Serum lactate level has acceptable sensitivity in predicting 28-day in-hospital mortality among patients with sepsis who undergo last hemodialysis after 4 hours, but is not reliable when the last hemodialysis takes place within 4 hours.     

The prognostic value of peak arterial lactate levels within 72 h of lung transplantation in identifying patient outcome

BackgroundLactic acidosis is often seen in lung transplantation (LTx). Postoperative lactate is frequently associated with poor outcome in postoperative and critically ill patients. Our aim was to evaluate the predictive value of postoperative peak lactate levels within 72 h of LTx for 30-day and late mortality.MethodsWe evaluated patients who underwent LTx from January 2015 to September 2017. All admitted patients were classified according to the peak lactate level (PL) within 72 h of surgery: PL <5 mmol/L (Group 1); PL =5–10 mmol/L (Group 2), and PL >10 mmol/L (Group 3). We performed logistic regression analysis and used Cox regression models to identify the peak lactate level as a predictive factor for 30-day and late mortality, respectively.ResultsOf 255 eligible patients, mean age 55.61±12.16, mean lactate 4.99±2.93 and 80% male, and 40% had hyperlactatemia (PL >5 mmol/L) after LTx. The 30-day mortality rate was 17.9%, 28.9% and 68.8% in the three groups, respectively (P<0.05). Multivariate regression analyses revealed postoperative PL as a notable predictor of 30-day mortality [odds ratio =2.62 (1.42–4.84), P=0.002] as well as for late mortality [hazard ratio =2.70 (1.13–6.42), P=0.025].ConclusionsThe postoperative peak lactate level within 72 h of surgery was an independent predictor for 30-day and late mortality in LTx patients.     

Relationship between serum lactate dehydrogenase and mortality after cardiac arrest: A retrospective cohort study

Serum lactate dehydrogenase (LDH) has been identified as an independent risk factor for predicting all-cause mortality in patients with multiple diseases. However, the prognostic value of LDH levels in post-cardiac arrest patients remains uncertain. This study aimed to assess the association between LDH and mortality in intensive care unit (ICU) patients after cardiac arrest. This retrospective observational study is based on data from the Dryad Digital Repository, which included 374 consecutive adult patients after cardiac arrest. Patients were divided into 2 groups based on median LDH values. A multivariate Cox proportional hazards model was established to assess the independent relationship between LDH and ICU mortality. Cumulative mortality was compared using Kaplan–Meier curves. The cohort included 374 patients, of which 51.9% (194/374) died in the ICU. The overall death rate from cardiac arrest was significantly higher for patients with LDH ≥ 335 IU/L (59.6%) than for those with LDH < 335 IU/L (44.1%). In multiple Cox regression models, hazard ratios (HR) and corresponding 95% confidence intervals (CI) for logLDH and the 2 LDH groups were 1.72 (1.07, 2.78) and 1.42 (1.04, 1.93), respectively. Participants with LDH ≥ 335IU/L had a higher incidence of ICU mortality than LDH < 335 IU/L, as shown by the Kaplan–Meier curves (P = .0085). Subgroup analysis revealed that the association between LDH and ICU mortality was vitally stable, with all P interactions from different subgroups >.05. Serum LDH levels are positively associated with ICU mortality in patients after cardiac arrest, especially for patients with LDH ≥ 335 IU/L.     

The Impact of Creatinine Clearance Rate,Daily Urinary Albumin,and Their Joint Effect on Predicting Death in Diabetic Inpatients After Discharge: An Observational Study

Renal clearance function and urinary albumin excretion are important markers for diabetic nephropathy. We assessed whether the creatinine clearance rate (CCR) and daily urinary albumin (DUA) excretion, which both require 24-hour urine data, are better predictors of mortality in diabetic inpatients compared with the estimated glomerular filtration rate (eGFR) and urine albumin–creatinine ratio (ACR).We enrolled 1011 patients who were hospitalized due to poor glucose control, and collected clinical information, including 24-hour urine data, from their medical records. We determined the mortality rate after discharge by examining the national registry data in Taiwan.The subjects had a median follow-up of 6.5 years (interquartile range between 3.5 and 9.6 years). Subjects with a CCR < 60 mL/min and a DUA ≥ 300 mg/d had the highest mortality rate, with a hazard ratio of 3.373 (95% confidence interval = 2.469–4.609), compared with the mortality rate in subjects with a CCR ≥ 60 mL/min and a DUA < 300 mg/d. In terms of predicting mortality in diabetic inpatients, ACR had a similar sensitivity to DUA (40.3% versus 38.0%), but eGFR provided lower sensitivity than CCR (54.5% versus 66.5%).Creatinine clearance rate and DUA have an additive effect on predicting mortality in diabetic inpatients after discharge. Moreover, CCR is a more sensitive predictor of mortality than eGFR. Therefore, determining CCR using 24-hour urine data, as well as either ACR or DUA, should provide better prediction of mortality in diabetic nephropathy patients.     

Association of Admission Glycaemia With High Grade Atrioventricular Block in ST-Segment Elevation Myocardial Infarction Undergoing Reperfusion Therapy: An Observational Study

Several studies have demonstrated the association between elevated admission glycaemia (AG) and the occurrence of some arrhythmias such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation after myocardial infarction. However, the impact of elevated AG on the high grade atrioventricular block (AVB) occurrence after ST-segment elevation myocardial infarction (STEMI) remains unclear.Included were 3359 consecutive patients with STEMI who received reperfusion therapy. The primary endpoint was the development of high grade AVB during hospital course. Patients were divided into non-diabetes mellitus (DM), newly diagnosed DM, and previously known DM according to the hemoglobin A1c level. The optimal AG value was determined by receiver operating characteristic curves analysis with AG predicting the high grade AVB occurrence.The best cut-off value of AG for predicting the high grade AVB occurrence was 10.05 mmol/L by ROC curve analysis. The prevalence of AG ≥ 10.05 mmol/L in non-DM, newly diagnosed DM, and previously known DM was 15.7%, 34.1%, and 68.5%, respectively. The incidence of high grade AVB was significantly higher in patients with AG ≥ 10.05 mmol/L than <10.05 mmol/L in non-DM (5.7% vs. 2.1%, P < 0.001) and in newly diagnosed DM (10.2% vs.1.4%, P < 0.001), but was comparable in previously known DM (3.6% vs. 0.0%, P = 0.062). After multivariate adjustment, AG ≥ 10.05 mmol/L was independently associated with increased risk of high grade AVB occurrence in non-DM (HR = 1.826, 95% CI 1.073–3.107, P = 0.027) and in newly diagnosed DM (HR = 5.252, 95% CI 1.890–14.597, P = 0.001). Moreover, both AG ≥ 10.05 mmol/L and high grade AVB were independent risk factors of 30-day all cause-mortality (HR = 1.362, 95% CI 1.006–1.844, P = 0.046 and HR = 2.122, 95% CI 1.154–3.903, P = 0.015, respectively).Our study suggested that elevated AG level (≥10.05 mmol/L) might be an indicator of increased risk of high grade AVB occurrence in patients with STEMI.     

Clinical Significance of Preoperative Serum High Density Lipoprotein Cholesterol Levels in Soft Tissue Sarcoma

The prognostic value of lipid profile remains unclear in soft tissue sarcoma. The aim of the present study was to validate the prognostic value of preoperative plasma lipid profile (high density lipoprotein-cholesterol [HDL-C], low density lipoprotein-cholesterol [LDL-C], cholesterol, and triglycerides) levels on disease-free survival (DFS) and overall survival (OS) in soft tissue sarcoma (STS) patients undergoing extensive and radical surgical resection.The preoperative plasma lipid profile levels of 234 STS patients, who were operated on between 2000 with 2010, were retrospectively evaluated. Kaplan-Meier curves and multivariate Cox proportional models were calculated for DFS and OS.In univariate analysis, a decreased HDL-C level was significantly associated with decreased OS (hazard ratio [HR], 3.405; 95% confidence interval (CI), 1.445–8.021, P = 0.005) and remained significant in the multivariate analysis (HR, 5.615; 95% CI, 1.243–25.378, P = 0.025). Patients with HDL-C < 1.475 mmol/L showed a median OS of 71 months. In contrast, patients with HDL-C ≥1.475 mmol/L had a median OS of 101 months. In univariate analysis, a decreased HDL-C level was significantly associated with decreased DFS (HR, 2.085; 95% CI, 1.271–3.422, P = 0.004) and remained significant in the multivariate analysis (HR, 1.808; 95% CI, 1.118–2.924, P = 0.016). Patients with HDL-C <1.475 mmol/L presented with a median DFS of 47 months, whereas patients with HDL-C ≥1.475 mmol/L had a median DFS of 78 months. In univariate analysis and multivariate analyses regarding OS and DFS, there was no significant association between the groups in terms of LDL-C, CHO and TG.Our study investigated the potential prognostic utility of preoperative plasma HDL-C levels as an independent factor in STS patients who had undergone radical surgical resection.     

The relationship between pre-procedural elevated arterial lactate and contrast-induced nephropathy following primary percutaneous coronary intervention

BackgroundRisk stratification has been one of the main steps in preventing contrast-induced nephropathy (CIN), which is a common complication after percutaneous coronary intervention (PCI). Elevated arterial lactate is a biomarker indicating severe disease condition and post-intervention complications. The relationship between lactate and CIN has not been established. This study is performed to investigate the relationship between elevated arterial lactate level and contrast-induced nephropathy (CIN).MethodsPatients diagnosed with ST-segment elevated myocardial infarction (STEMI) were prospectively enrolled, with lactate measured within 0.5–1 hours before primary percutaneous coronary intervention (PCI). Patients with cardiopulmonary resuscitation, any forms of severe anaerobic condition, or end-stage renal disease undergoing dialysis were excluded. CIN was defined as an increase in serum creatinine ≥0.5 mg/dL or 25% within 72 hours after PCI. The Mehran Risk Score (MRS) is widely regarded as a classic risk model for CIN and the risk factors of MRS were applied in our multivariate regression analysis.ResultsOf the 227 enrolled patients, 47 (20.7%) developed CIN according to the definition. The mean lactate level was higher in the CIN group than in the non-CIN group (2.68±2.27 vs. 1.74±1.94, P<0.001). The arterial lactate level ≥2.0 mmol/L had 57.5% sensitivity and 75.6% specificity in predicting CIN. The performance of the lactate level in discriminating CIN was similar to that of the MRS (AUC_lac =0.707 vs. AUC_MRS =0.697, P=0.86). After adjusting for other risk factors, lactate ≥2.0 mmol/L still significantly predicted CIN (odds ratio =3.77, 95% CI, 1.77–7.99, P=0.001).ConclusionsAn arterial lactate level of ≥2.0 mmol/L is associated with CIN in STEMI patients after primary PCI.     

Monitoring the Sequential Organ Failure Assessment score in nonocclusive mesenteric ischemia increases the survival rate: A single-center observational study

Several large-scale studies have assessed the endovascular and surgical treatments for nonocclusive mesenteric ischemia (NOMI); nonetheless, the prognostic factors for NOMI remain unclear.In this single-center study, we retrospectively reviewed the electronic medical records of 197, 149 patients were retrieved from the inpatient database of our hospital from January 2011 to January 2020; 79 patients with NOMI were observed. A total of 44 patients who underwent laparotomy were statistically analyzed and divided into the survivor and non-survivor groups. Prognostic factors were compared between the 2 groups. Exploratory laparotomy based on a second-look surgery was the first treatment choice.The overall mortality rate was 61.3%, with a male-to-female ratio of 1.6:1. The median Sequential Organ Failure Assessment (SOFA) score was 11.06 [5.75-17.25]. The median SOFA score was 5 [interquartile range: 3-8] in the survivor group and 14.8 [interquartile range: 10.5-19] in the non-survivor group. The log-rank test showed a significant difference in the presence of diabetes mellitus (P = .025), hypoglycemia (P = .001), SOFA score ≥10 (P < .001), hemoglobin levels ≥11 g/dL (P = .003), platelet count ≥12.9 × 10⁴/μL (P = .01), lactate levels ≥2.6 mmol/L (P = .005), and base excess <-3.0 (P < .023). Multivariate analysis using the factors with significant differences revealed that SOFA score ≥10 (hazard ratio for death, 1.199; 95% confidence interval, 1.101-1.305; P < .001) was an independent prognostic factor.The SOFA score can be used to assess disease severity. A SOFA score of ≥10 may be associated with increased mortality.     

A simple method for discrimination of carcinomatous meningitis using CEA,total protein,and total cell count in the cerebrospinal fluid of primary lung cancer patients

Carcinomatous meningitis (CM) is a critical issue for physicians. However, no study has reported a simple and useful diagnostic or predictive marker for CM.This study aimed to elucidate the potential markers for diagnosing CM derived from cerebrospinal fluid (CSF).We retrospectively enrolled 78 lung cancer patients with suspected CM during the clinical course, including 42 CM and 36 non-CM patients. We compared the clinical and CSF findings, including carcinoembryonic antigen (CEA), between CM and non-CM patients, and explored the diagnostic markers for early identification of CM as well as the contributing factors for mortality.On CSF analysis, with cutoff values of CEA ≥5 ng/ml, total protein (TP) in CSF ≥45 g/dl, and total cell count (TCC) ≥7 cells/μL, the sensitivity, specificity, and area under the curve (AUC) for CM were 85.7%, 84.6%, and 0.887 (95% CI: 0.758–1.0, P < .001); 80.5%, 69.4%, and 0.755 (95% CI: 0.646–0.865, P < .001); and 56.1%, 100%, and 0.817 (95% CI: 0.722–0.912, P < .001), respectively. TP levels in CSF ≥the patients’ age had a sensitivity, specificity, and an AUC of 48.8%, 77.8%, and 0.633 (95% CI: 0.722–0.912, P = .045) for CM, respectively. Among CM patients, patients with ‘TP in CSF (>patients’ age)” (n = 19, P = .008) showed significantly shorter 90-day survival probability than the residual patients (n = 20). None of the CSF parameters could predict the risk of mortality on Cox regression analysis.The cutoff value of CEA ≥5 ng/ml in CSF is a simple and useful method with a high diagnostic value for CM diagnosis, but not a suitable predicting factor for mortality. ‘TP in CSF >patients’ age” might be a novel factor for assessing short-term mortality.     

Relationships between serum levels of lactate dehydrogenase and neurological outcomes of patients who underwent targeted temperature management after out-of-hospital cardiac arrest

This study aimed to evaluate times for measuring serum lactate dehydrogenase levels (SLLs) to predict neurological prognosis among out-of-hospital cardiac arrest (OHCA) survivors.This retrospective study examined patients who experienced OHCA treated with targeted temperature management (TTM). The SLLs were evaluated at the return of spontaneous circulation (ROSC) and at 24, 48, and 72 hours later. Neurological outcomes after 3 months were evaluated for relationships with the SLL measurement times.A total of 95 comatose patients with OHCA were treated using TTM. Seventy three patients were considered eligible, including 31 patients (42%) who experienced good neurological outcomes. There were significant differences between the good and poor outcome groups at most time points (P < .001), except for ROSC (P = .06). The ROSC measurement had a lower area under the receiver operating characteristic curve (AUC: 0.631, 95% confidence interval [CI]: 0.502–0.761) than at 48 hours (AUC: 0.830, 95% CI: 0.736–0.924), at 24 hours (AUC: 0.786, 95% CI: 0.681–0.892), and at 72 hours (AUC: 0.821, 95% CI: 0.724–0.919).A higher SLL seemingly predicted poor neurological outcomes, with good prognostic values at 48 hours and 72 hours. Prospective studies should be conducted to confirm these results.     

Combined immune score predicts the prognosis of newly diagnosed multiple myeloma patients in the bortezomib-based therapy era

To investigate the effect of a combined immune score including the lymphocyte-to-monocyte ratio (LMR) and uninvolved immunoglobulin (u-Ig) levels on the prognosis of newly diagnosed multiple myeloma (NDMM) patients treated with bortezomib.Clinical data of 201 NDMM patients were retrospectively analyzed. Patients with LMR ≥ 3.6 and LMR < 3.6 were scored 0 and 1, respectively. Patients with preserved u-Ig levels, suppression of 1 u-Ig, and suppression of at least 2 u-Igs were scored 0, 1, and 2, respectively. The immune score, established from these individual scores, was used to separate patients into good (0–1 points), intermediate (2 points), and poor (3 points) risk groups. The baseline data, objective remission rate (ORR), whether receive maintenance treatment regularly and overall survival of patients before treatment were analyzed.The ORR of the good-risk group was significantly higher than that of the intermediate-risk group (75.6% vs 57.7%, P = .044) and the poor-risk group (75.6% vs 48.2%, P = .007). The multivariate analysis results showed that age ≥ 65 years, International Staging System stage III, platelet count ≤ 100 × 109/L, lactate dehydrogenase (LDH) > 250 U/L, serum calcium > 2.75 mmol/L, no receipt of regular maintenance treatment, LMR < 3.6, suppressed u-Igs = 1, suppressed u-Igs ≥ 2, intermediate-risk group and poor-risk group were independent predictors of poor overall survival.In the bortezomib era, the LMR, u-Ig levels, and the immune score play an important role in the prognosis of NDMM patients. Among them, the immune score showed the strongest prognostic value, and it could be a beneficial supplement for the early identification of high-risk patients.     

Risk factors for death in patients with sepsis admitted to an obstetric intensive care unit: A cohort study

Improving understanding of the prognostic factors associated with death resulting from sepsis in obstetric patients is essential to allow management to be optimized. This retrospective cohort study aimed to determine the risk factors for death in patients with sepsis admitted to the obstetric intensive care unit of a tertiary teaching hospital in northeastern Brazil between April 2012 and April 2016.The clinical, obstetric, and laboratory data of the sepsis patients, as well as data on their final outcome, were collected. A significance level of 5% was adopted. Risk factors for death in patients with sepsis were evaluated in a multivariate analysis.During the period analyzed, 155 patients with sepsis were identified and included in the study, representing 5.2% of all obstetric intensive care unit (ICU) admissions. Of these, 14.2% (n = 22) died. The risk factors for death were septic shock at the time of hospitalization (relative risk [RR] = 3.45; 95% confidence interval [CI]: 1.64–7.25), need for vasopressors during hospitalization (RR = 17.32; 95% CI: 4.20–71.36), lactate levels >2 mmol/L at the time of diagnosis (RR = 4.60; 95% CI: 1.05–20.07), and sequential organ failure assessment score >2 at the time of diagnosis (RR = 5.97; 95% CI: 1.82–19.94). Following multiple logistic regression analysis, only the need for vasopressors during hospitalization remained as a risk factor associated with death (odds ratio [OR] = 26.38; 95% CI: 5.87–118.51).The need for vasopressors during hospitalization is associated with death in obstetric patients with sepsis.     

Relationship of MTHFR Gene 677C→T Polymorphism,Homocysteine, and Estimated Glomerular Filtration Rate Levels With the Risk of New-Onset Diabetes

East Asian patients with diabetes have a higher risk for renal complications and strokes than Europeans. We aimed to evaluate the effect of methylenetetrahydrofolate reductase (MTHFR) gene 677C→T polymorphism, which was associated with a higher stroke risk and was common in the Chinese population, as well as homocysteine and estimated glomerular filtration rate (eGFR) levels on the risk of new-onset diabetes (NOD).A total of 2422 subjects without diabetes were followed-up for 7 years. NOD was defined as fasting plasma glucose ≥7.0 mmol/L or self-reported physician diagnosis of diabetes.Compared with subjects with MTHFR 677CC genotype, those with TT genotype had a higher risk of NOD in females (odds ratio 2.78, 95% confidence interval 1.39–5.56) but not in males (0.80, 0.40–1.61, P for interaction = 0.008). Furthermore, MTHFR 677C→T polymorphism was more strongly associated with the risk of NOD among females with higher body mass index (BMI, ≥23 vs <23 kg/m², P for interaction = 0.009) or lower high-density lipoprotein-cholesterol (HDL-C, <1.3 vs ≥1.3 mmol/L, P for interaction = 0.015) levels. Hyperhomocysteinemia (≥16 vs <10 μmol/L) was not significantly associated with NOD in males (0.88, 0.42–1.85) or females (1.52, 0.65–3.57). However, mildly decreased eGFR (<90 vs 90–120 mL/min/1.73 m²) was associated with NOD mainly in males (1.96, 1.01–3.78; females, 0.74, 0.32–1.72, P for interaction = 0.134).Females with MTHFR 677TT genotype had a significantly higher risk of NOD, particularly those with higher BMI or low HDL-C levels. The higher risk of NOD associated with mildly decreased eGFR also warrants more investigation. Our results provide insights into the ethnic differences of diabetic complications between East Asian patients and Europeans.     

Impact of Admission Systolic Blood Pressure and Antecedent Hypertension on Short-Term Outcomes After ST-Segment Elevation Myocardial Infarction: Strobe-Compliant Article

We evaluated the combined effect of admission systolic blood pressure (SBP) and antecedent hypertension on short-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Data were derived from a multicenter survey of 7303 consecutive patients with STEMI. Patients were divided into 4 groups according to different blood pressure status: high SBP without hypertension, high SBP with hypertension, low SBP without hypertension, and low SBP with hypertension. The primary endpoints were 7 and 30-day all-cause mortality. The prevalence of hypertension was 40.7%, and the best cutoff of admission SBP for predicting 30-day mortality was 108 mmHg by receiver-operating characteristic curve. Patients with hypertension were older, more often female, also had longer onset-to-admission time, more comorbidities, and higher Killip class. Patients with both low SBP (≤108 mmHg) and hypertension group had significantly higher 7 and 30-day mortality than those in other groups (all P < 0.001). After multivariate adjustment, low SBP with hypertension group was still an independent risk factor for predicting 7-day mortality (hazard ratios [HR] 1.86, 95% confidence interval [CI] 1.41–2.46; P < 0.001) and 30-day mortality (HR 1.88, 95% CI 1.46–2.43; P < 0.001). In patients with SBP > 108 mmHg, a history of hypertension could increase the risk of 30-day mortality by 27% (HR 1.00 vs 1.27, P = 0.012), while in patients with SBP ≤ 108 mmHg, this increased risk reached to 37% (HR 1.51 vs 1.88, P < 0.001). In conclusion, low admission SBP was the relatively dominant contributor for predicting 7 and 30-day all-cause mortality, and a concurrent antecedent hypertension increased the corresponding risk of mortality.     

Hemoglobin A1c Levels and the Risk of Cardiovascular Disease in People Without Known Diabetes: A Population-Based Cohort Study in Japan

High hemoglobin A_1c (HbA_1c) levels are strongly associated with an increased risk of cardiovascular disease (CVD) in people with and without diabetes. However, information regarding the relationship between low HbA_1c levels and the risk of CVD among people without known diabetes is limited. The aim of this large-scale, prospective, population-based cohort study was to clarify the association between HbA_1c levels and CVD risk among people without known diabetes.We followed-up 10,980 men and 18,079 women (46–80 years old and free of CVD and cancer at baseline) in the Japan Public Health Center-based Prospective Study. Using Cox models, we estimated the hazard ratios for CVD risk with adjustments for age, sex, geographic areas, body mass index, smoking status, sports and physical exercise, alcohol intake, systolic blood pressure, non-high-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.During the median follow-up of 9.4 years, 935 CVD events (770 strokes and 165 coronary heart diseases) occurred. We observed a nonlinear association between HbA_1c levels and CVD risk in participants without known diabetes. Compared with HbA_1c levels of 5.0 to 5.4% (31–36 mmol/mol), the hazard ratios for CVD in participants without known diabetes were 1.50 (95% confidence interval: 1.15–1.95), 1.01 (0.85–1.20), 1.04 (0.82–1.32), and 1.77 (1.32–2.38) for HbA_1c levels of <5.0% (<31 mmol/mol), 5.5 to 5.9% (37–41 mmol/mol), 6.0 to 6.4% (42–47 mmol/mol), and ≥6.5% (≥48 mmol/mol), respectively (P value for nonlinear trend: <0.001). In addition, the hazard ratio for CVD was 1.81 (1.43–2.29) in patients with known diabetes compared with participants with HbA_1c levels of 5.0 to 5.4% and without known diabetes. This nonlinear relation persisted after excluding people with kidney dysfunction, liver dysfunction, anemia, body mass index <18.5 kg/m², or early events within 3 years of follow-up (P value for nonlinear trend: <0.01 for all tests).In conclusion, both low and high levels of HbA_1c were associated with a higher risk of CVD in a Japanese general population without known diabetes.     

Metabolic syndrome in Zambian adults with human immunodeficiency virus on antiretroviral therapy: Prevalence and associated factors

Metabolic syndrome (MetS) is a constellation of factors including hypertension, abdominal obesity, dyslipidemia, and insulin resistance that separately and together significantly increase risk for cardiovascular disease (CVD) and diabetes. In sub-Saharan Africa, with a substantial burden of human immunodeficiency virus (HIV) and increasing prevalence of CVD and diabetes, there is a paucity of epidemiological data on demographic, laboratory, and clinical characteristics associated with MetS among people with HIV (people with human [PWH]). Therefore, this study aimed to determine the burden and factors influencing MetS in antiretroviral therapy (ART)-experienced individuals in Zambia.We collected cross-sectional demographic, lifestyle, anthropometric, clinical, and laboratory data in a cohort of ART-experienced (on ART for ≥6 months) adults in 24 urban HIV treatment clinics of Zambia between August, 2016 and May, 2020. MetS was defined as having ≥3 of the following characteristics: low high density lipoprotein cholesterol (HDL-c) (<1.0 mmol/L for men, <1.3 for women), elevated waist circumference (≥94 cm for men, ≥80 cm for women), elevated triglycerides (≥1.7 mmol/L), elevated fasting blood glucose (≥5.6 mmol/L), and elevated blood pressure (BP) (systolic BP ≥130 or diastolic BP ≥85 mm Hg). Virological failure (VF) was defined as HIV viral load ≥1000 copies/mL. The following statistical methods were used: Chi-square test, Wilcoxon rank-sum test, and multivariable logistic regression.Among 1108 participants, the median age (interquartile range [IQR]) was 41 years (34, 49); 666 (60.1%) were females. The prevalence of MetS was 26.3% (95% confidence interval [CI] 23.9–29.1). Age (adjusted odds ratio [OR] 1.07; 95% CI 1.04–1.11), female sex (OR 3.02; 95% CI 1.55–5.91), VF (OR 1.98; 95% CI 1.01–3.87), dolutegravir (DTG)-based regimen (OR 2.10; 95% CI 1.05–4.20), hip-circumference (OR 1.03; 95% CI 1.01–1.05), T-lymphocyte count (OR 2.23; 95% CI 1.44–3.43), high-sensitivity C-reactive protein (hsCRP) (OR 1.14; 95% CI 1.01–1.29), and fasting insulin (OR 1.02; 95% CI 1.01–1.04) were significantly associated with MetS.Metabolic syndrome was highly prevalent among HIV+ adults receiving ART in Zambia and associated with demographic, clinical, anthropometric, and inflammatory characteristics. The association between MetS and dolutegravir requires further investigation, as does elucidation of the impact of MetS on ART outcomes in sub-Saharan African PWH.     

Plasma Lactate Dehydrogenase Levels Predict Mortality in Acute Aortic Syndromes: A Diagnostic Accuracy and Observational Outcome Study

In acute aortic syndromes (AAS), organ malperfusion represents a key event impacting both on diagnosis and outcome. Increased levels of plasma lactate dehydrogenase (LDH), a biomarker of malperfusion, have been reported in AAS, but the performance of LDH for the diagnosis of AAS and the relation of LDH with outcome in AAS have not been evaluated so far.This was a bi-centric prospective diagnostic accuracy study and a cohort outcome study. From 2008 to 2014, patients from 2 Emergency Departments suspected of having AAS underwent LDH assay at presentation. A final diagnosis was obtained by aortic imaging. Patients diagnosed with AAS were followed-up for in-hospital mortality.One thousand five hundred seventy-eight consecutive patients were clinically eligible, and 999 patients were included in the study. The final diagnosis was AAS in 201 (20.1%) patients. Median LDH was 424 U/L (interquartile range [IQR] 367–557) in patients with AAS and 383 U/L (IQR 331–460) in patients with alternative diagnoses (P < 0.001). Using a cutoff of 450 U/L, the sensitivity of LDH for AAS was 44% (95% confidence interval [CI] 37–51) and the specificity was 73% (95% CI 69–76). Overall in-hospital mortality for AAS was 23.8%. Mortality was 32.6% in patients with LDH ≥ 450 U/L and 16.8% in patients with LDH < 450 U/L (P = 0.006). Following stratification according to LDH quartiles, in-hospital mortality was 12% in the first (lowest) quartile, 18.4% in the second quartile, 23.5% in the third quartile, and 38% in the fourth (highest) quartile (P = 0.01). LDH ≥ 450 U/L was further identified as an independent predictor of death in AAS both in univariate and in stepwise logistic regression analyses (odds ratio 2.28, 95% CI 1.11–4.66; P = 0.025), in addition to well-established risk markers such as advanced age and hypotension. Subgroup analysis showed excess mortality in association with LDH ≥ 450 U/L in elderly, hemodynamically stable and in nonsurgically treated patients.Plasma LDH constitutes a biomarker of poor outcome in patients with AAS. LDH is a rapid and universally available assay that could be used to improve risk stratification and to individualize treatment in patient groups where options are controversial.     

Efficacy of Surgery and Adjuvant Therapy in Older Patients With Colorectal Cancer: A STROBE-compliant article

The present study aimed to assess the efficacy of surgery and adjuvant therapy in older patients (age ≥70 years) with colorectal cancer (CRC). Older CRC patients are under-represented in available clinical trials, and therefore their outcomes after receiving surgery and adjuvant therapy are unclear. From two prospective Swedish databases, we assessed a cohort of 1021 patients who underwent curative surgery for stage I, II, or III primary CRC, with or without adjuvant chemotherapy/radiotherapy. Of the patients with colon cancer (n = 467), 182 (39%) were aged <70 years, 162 (35%) aged 70 to 80 years, and 123 (26%) were aged ≥80 years. Of rectal cancer patients (n = 554), 264 (48%) were aged <70 years, 234 (42%) aged 70 to 80 years, and 56 (10%) aged ≥80 years. Older patients with either colon or rectal cancer had higher comorbidity than did younger patients. Older patients with colon cancer had equivalent postoperative morbidity and 30-day mortality to younger patients. Rectal cancer patients aged ≥80 years had a higher 30-day mortality than younger patients (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.6–4.55; P = 0.03). For either colon or rectal cancer, adjuvant chemotherapy compromised the 5-year overall survival (OS) of older patients with stage II disease and had no effect on those with stage III disease. Receiving adjuvant chemotherapy was a poor factor of OS for older patients with either colon (HR 1.88, 95% CI: 1.20–4.35, P = 0.03) or rectal cancer (HR 1.72, 95% CI: 1.05–2.26, P = 0.004). Preoperative short-course radiotherapy improved both OS and local control for older patients with stage III rectal cancer and had no effect on those with stage II disease. Radiotherapy was a favorable factor for the OS of the older patients with rectal cancer (HR 0.42, 95% CI: 0.21–3.57, P = 0.01). In conclusion, Older CRC patients had equal safety of surgery as younger patients, except rectal cancer patients aged ≥80 years that had a higher mortality. Adjuvant 5FU-based chemotherapy did not benefit older CRC patient, while neoadjuvant radiotherapy improved the prognosis of older patients with stage III rectal cancer.     

The risk factors for delayed recovery in patients with cardiopulmonary bypass: Why should we care?

Cardiopulmonary bypass (CPB) is very commonly performed among the cardiovascular surgeries, and delayed recovery (DR) is a kind of serious complications in patients with CPB. It is necessary to assess the risk factors for DR in patients with CPB, to provide evidence into the management of CPB patients.Patients undergoing CPB in our hospital from January 2018 to March 2020 were included. Cases that consciousness has not recovered 12 hours after anesthesia were considered as DR. The preoperative and intraoperative variables of CPB patients were collected and analyzed. Logistic regressions were conducted to analyze the potential influencing factor.A total of 756 CPB patients were included, and the incidence of DR was 9.79%. There were significant differences on the age, aspartate aminotransferase (AST), glutamic pvruvic transaminase (ALT), blood urea nitrogen (BUN), and serum creatinine (SCr) between patients with and without DR (all P < .05); there were no significant differences in the types of surgical procedure (all P > .05); there were significant differences on the duration of CPB, duration of aortic cross clamp (ACC), duration of surgery, minimum nasopharyngeal temperature, and transfusion of packed red blood cells between patients with and without DR (all P < .05). Logistic regression analysis indicated that duration of CPB ≥132 minutes (odds ratio [OR] 4.12, 1.02–8.33), BUN ≥9 mmol/L (OR 4.05, 1.37–8.41), infusion of red blood cell suspension (OR 3.93, 1.25–7.63), duration of surgery ≥350 minutes (OR 3.17, 1.24–5.20), age ≥6 (OR 3.01, 1.38–6.84) were the independent risk factors for DR in patients with CPB (all P < .05).Extra attention and care are needed for those CPB patients with duration of CPB ≥132 minutes, BUN ≥9 mmol/L, infusion of red blood cell suspension, duration of surgery ≥350 minutes, and age ≥60.     

Prognostic value of lactate dehydrogenase for melanoma patients receiving anti-PD-1/PD-L1 therapy: A meta-analysis

Background:Several studies indicate the level of pretreatment lactate dehydrogenase (LDH) may be associated with the prognosis of patients receiving immune checkpoint inhibitors targeting programmed death receptor-1 (PD-1)/programmed death ligand 1 (PD-L1) which had been reported to dramatically improve the survival of patients with advanced or metastatic melanoma; however, no consensus has been reached because the presence of controversial conclusions. This study was to perform a meta-analysis to comprehensively explore the prognostic values of LDH for melanoma patients receiving anti-PD1/PD-L1 monotherapy.Methods:A systematic electronic search in the databases of PubMed, EMBASE and the Cochrane library was performed to identify all related articles up to April, 2020. The pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained to assess the prognostic values of pretreatment LDH in blood for overall survival (OS) and progression-free survival (PFS).Results:A total of 22 eligible studies involving 2745 patients were included. Of them, 19 studies with 20 results assessed the OS and the pooled analysis showed that an elevated pretreatment LDH level was significantly associated with a worse OS (HR = 2.44; 95% CI: 1.95–3.04, P < .001). Thirteen studies reported PFS and meta-analysis also revealed that a higher pretreatment LDH level predicted a significantly shorter PFS (HR, 1.61; 95% CI, 1.34–1.92; P < .001). Although heterogeneity existed among these studies, the same results were acquired in subgroup analyses based on sample size, country, study design, cut-off of LDH, type of PD-1/PD-L1 inhibitors and statistics for HRs (all HRs > 1 and P < .05).Conclusion:This meta-analysis suggests LDH may serve as a potential biomarker to identify patients who can benefit from anti-PD-1/PD-L1 and then schedule treatments.