Effect of CPAP therapy on cardiovascular events and mortality in patients with obstructive sleep apnea: a meta-analysis

Purpose

Continuous positive airway pressure (CPAP) therapy may decrease the risk of mortality and cardiovascular events in patients with obstructive sleep apnea. However, these benefits are not completely clear.

Methods

We undertook a meta-analysis of randomized clinical trials identified in systematic searches of MEDLINE, EMBASE, and the Cochrane Database.

Results

Eighteen studies (4146 patients) were included. Overall, CPAP therapy did not significantly decrease the risk of cardiovascular events compared with the control group (odds ratio (OR), 0.84; 95 % confidence intervals (CI), 0.62–1.13; p = 0.25; I ² = 0 %). CPAP was associated with a nonsignificant trend of lower rate of death and stroke (for death: OR, 0.85; 95 % CI, 0.35–2.06; p = 0.72; I ² = 0.0 %; for stroke: OR, 0.56; 95 % CI, 0.18–1.73; p = 0.32; I ² = 12.0 %), a significantly lower Epworth sleepiness score (ESS) (mean difference (MD), ?1.78; 95 % CI, ?2.31 to ?1.24; p < 0.00001; I ² = 76 %), and a significantly lower 24 h systolic and diastolic blood pressure (BP) (for 24 h systolic BP: MD, ?2.03 mmHg; 95 % CI, ?3.64 to ?0.42; p = 0.01; I ² = 0 %; for diastolic BP: MD, ?1.79 mmHg; 95 % CI, ?2.89 to ?0.68; p = 0.001; I ² = 0 %). Daytime systolic BP and body mass index were comparable between the CPAP and control groups. Subgroup analysis did not show any significant difference between short- and mediate-to-long-term follow-up groups with regard to cardiovascular events, death, and stroke.

Conclusions

CPAP therapy was associated with a trend of decreased risk of cardiovascular events. Furthermore, ESS and BP were significantly lower in the CPAP group. Larger randomized studies are needed to confirm these findings.

     

A meta-analysis of the clinicopathological characteristics and survival outcomes of inflammatory bowel disease associated colorectal cancer

Purpose

The current study aims to use meta-analytical techniques to compare the clinicopathological characteristics and survival outcomes of inflammatory bowel disease (IBD) associated and sporadic colorectal carcinoma (CRC). Patients with IBD have an established increased risk of developing CRC. There is no consensus, however, on the clinicopathological characteristics and survival outcomes of IBD associated CRC when compared to sporadic CRC.

Methods

A comprehensive search for published studies comparing IBD associated and sporadic CRC was performed. Random effect methods were used to combine data. This study adhered to the recommendations of the MOOSE guidelines.

Results

Data were retrieved from 20 studies describing 571,278 patients. IBD associated CRC had an increased rate of synchronous tumors (OR 4.403, 95% CI 2.320–8.359; p < 0.001), poor differentiation (OR 1.875, 95% CI 1.425–2.466; p < 0.001), and a reduced rate of rectal cancer (OR 0.827, 95% CI 0.735–0.930; p = 0.002). IBD associated CRC however did not affect the frequency of T3/T4 tumors (OR 0.931, 95% CI 0.782–1.108; p = 0.421), lymph node positivity (OR 1.061, 95% CI 0.929–1.213; p = 0.381), metastasis at presentation (OR 0.970, 95% CI 0.776–1.211; p = 0.786), sex distribution (OR 0.978, 95% CI 0.890–1.074; p = 0.640), or 5-year overall survival (OR 1.105, 95% CI 0.414–2.949; p = 0.842).

Conclusions

In this large analysis of available data, IBD associated CRC was characterized by less rectal tumors and more synchronous and poorly differentiated tumors compared with sporadic cancers, but no discernable difference in sex distribution, stage at presentation, or survival could be identified.

     

Colchicine in addition to conventional therapy for pericarditis recurrence

Background

Randomized controlled trials (RCTs) have investigated the use of colchicine and conventional therapy for reducing the recurrence of pericarditis in patients with acute pericarditis or post-pericardiotomy syndrome. However, the benefits of these treatments are variable.

Methods

Studies were retrieved from PubMed, the Cochrane Library, and the EMBASE database.

Results

We identified nine RCTs with 1832 patients and a mean follow-up of 13.1 months. Overall, colchicine therapy significantly decreased the risk of pericarditis recurrence (odds ratio, OR 0.42; 95?% confidence interval, CI 0.33–0.52; P?<?0.001; I²?=?17.0?%). Colchicine therapy was associated with significantly lower rates of pericarditis-associated rehospitalization (OR 0.29; 95?% CI 0.16–0.53; P?<?0.0001; I²?=?0.0?%) and persistence of symptoms (OR 0.29; 95?% CI, 0.21–0.41; P?=?0.000; I²?=?0.0?%) at 72 h. Adverse events were higher in the colchicine group (relative risk, RR 1.48; 95?% CI, 1.06–2.07; P?=?0.02; I²?=?0.0?%). Subgroup analysis showed that recurrence of pericarditis was significantly lower in the colchicine therapy group, irrespective of prednisone use and the cause of pericarditis.

Conclusion

Colchicine significantly decreases the rate of pericarditis recurrence, regardless of prednisone use and the cause of pericarditis. Larger studies are needed to confirm this effect.

     

Magnetic resonance defecography versus clinical examination and fluoroscopy: a systematic review and meta-analysis

Background

Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques.

Methods

A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients.

Results

Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21–4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01–0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30–0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16–0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17–0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34–46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25–34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38–44.76, p = 0.0001).

Conclusions

MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.

     

The correlation between diverticulosis and redundant colon

Background

Diverticulosis and redundant colon are colonic conditions for which underlying pathophysiology, management and prevention are poorly understood. Historical papers suggest an inverse relationship between these two conditions. However, no further attempt has been made to validate this relationship. This study set out to assess the correlation between diverticulosis and colonic redundancy.

Methods

Redundant colon, diverticulosis and patient demographics were recorded during colonoscopy. Multivariate binary logistic regression was performed with redundant colon as the dependent variable and age, gender and diverticulosis as independent variables. Nagelkerke R ² and a receiver operator curve were calculated to assess goodness of fit and internally validate the multivariate model.

Results

Redundant colon and diverticulosis were diagnosed in 31 and 113 patients, respectively. The probability of redundant colon was increased by female gender odds ratio (OR) 8.4 (95% CI 2.7–26, p = 0.00020) and increasing age OR 1.7 (95% CI 1.1–2.6, p = 0.017). Paradoxically, diverticulosis strongly reduced the probability of redundant colon with OR of 0.12 (95% CI 0.42–0.32, p = 0.000039). The Nagelkerke R ² for the multivariate model was 0.29 and the area under the curve at ROC analysis was 0.81 (95% CI 0.73–0.90 p–value 3.1 × 10^?8).

Conclusions

This study found an inverse correlation between redundant colon and diverticulosis, supporting the historical suggestion that the two conditions rarely occur concurrently. The underlying principle for this relationship remains to be found. However, it may contribute to the understanding of the aetiology and pathophysiology of these colonic conditions.

     

Fostamatinib,an oral spleen tyrosine kinase inhibitor,in the treatment of rheumatoid arthritis: a meta-analysis of randomized controlled trials

Fostamatinib is a selective inhibitor of spleen tyrosine kinase which has a role in the pathogenesis of RA. Multiple RCTs have been performed to study the effects of fostamatinib. The objective of this study was to perform a meta-analysis to analyze the efficacy and safety of fostamatinib in the management of RA. We searched PubMed, EMBASE and Cochrane CENTRAL through 11/9/15. Random effect model was used to estimate odds ratio (OR) and 95 % confidence interval. We measured outcomes with efficacy analysis using ACR20/50/70 response criteria and safety with adverse events. Five studies were included in the meta-analysis with total of 2105 patients including 1419 in fostamatinib group and 686 in placebo. Fostamatinib was effective in achieving ACR20, ACR50 and ACR70 responses compared to placebo (48 vs. 32.8 %, OR 1.86, 95 % CI 1.32–2.62, P = 0.0004, I ² 63 %; 26.4 vs. 12.5 %, OR 2.50, 95 % CI 1.93–3.23, P < 0.00001, I ² 0 % and 12.7 vs. 4.4 %, OR 3.00, 95 % CI 1.99–4.51, P < 0.00001, I ² 0 %, respectively). Response to fostamatinib was rapid and significant effect on ACR20 response was seen by week 1 (OR 3.70, 95 % CI 2.33–5.87, P < 0.00001, I ² 42 %). Safety analysis showed an increased risk of infection (OR 1.59, 95 % CI 1.2–2.11; P = 0.001; I ² 0 %), diarrhea (OR 3.54; 95 % CI 2.43–5.16; P < 0.00001; I ² 2 %), hypertension (OR 2.55, 95 % CI 1.54–4.22, P = 0.0003; I ² 42 %) and neutropenia (OR 5.68, 95 % CI 1.97–16.42, P = 0.001, I ² 35 %) and showed a trend toward the increase in ALT ≥3 times ULN (OR 1.76, 95 % CI 0.99–3.13; P = 0.05; I ² 0 %). This meta-analysis concludes that fostamatinib has moderate effect in the treatment of RA with mostly mild-to-moderate adverse events and dose-dependent, transient neutropenia and hypertransaminasemia.     

Self-reported obstructive sleep apnea,simple snoring,and various markers of sleep-disordered breathing as predictors of cardiovascular risk

Purpose

Our objective was to investigate whether self-reported obstructive sleep apnea (OSA), simple snoring, and various markers of sleep-disordered breathing (SDB) are associated with cardiovascular risk.

Methods

We examined a representative nationwide cohort of 5177 Finnish adults aged ≥30 years. The participants underwent measurement of traditional cardiovascular risk factors and answered SDB-related questions derived from the Basic Nordic Sleep Questionnaire, which were used to operationalize self-reported OSA. The primary end point was incidence of a cardiovascular event (cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, hospitalization for heart failure, or coronary interventions).

Results

During a median follow-up of 11.2 years and 52,910 person-years of follow-up, 634 participants suffered a cardiovascular event. In multivariable-adjusted Cox models, self-reported OSA (hazard ratio [HR] 1.34; 95 % confidence interval [CI] 1.04–1.73; p?=?0.03) was an independent predictor of cardiovascular events. Self-reported simple snoring by itself was not associated with future cardiovascular events (HR 0.88 versus non-snorers, 95 % CI 0.75–1.04, p?=?0.15). However, among snorers (n?=?3152), frequent breathing cessations (HR 2.19, 95 % CI 1.26–3.81, p?=?0.006) and very loud and irregular snoring (HR 1.82, 95 % CI 1.31–2.54, p?<?0.001) were associated with cardiovascular risk.

Conclusions

Self-reported OSA and SDB-related snoring variables are associated with cardiovascular risk, whereas simple snoring is not. In clinical practice and in surveys, questions concerning only habitual snoring should be amended with questions focusing on respiratory pauses and snoring stertorousness, which can be used to estimate the risk of OSA and cardiovascular events.

     

Gender Differences in Platelet Reactivity in Patients Receiving Dual Antiplatelet Therapy

Background

Cardiovascular risk is still underestimated in women, experiencing higher mortality and worse prognosis after acute cardiovascular events. Gender differences have been reported in thrombotic and hemorrhagic risk during dual antiplatelet therapy (DAPT), thus suggesting a potential variability in platelet reactivity according to sex. The aim of the present study was to assess the role of gender on platelet function and the prevalence of high-on treatment residual platelet reactivity (HRPR) during DAPT in patients with recent acute coronary syndrome or percutaneous coronary revascularization.

Methods

Patients treated with DAPT (ASA and clopidogrel or ticagrelor) were scheduled for platelet function assessment at 30–90 days post-discharge. By whole blood impedance aggregometry, HRPR was considered for ASPI test >862 AU*min (for ASA) and ADP test values ≥417 AU*min (for ADP-antagonists).

Results

We included 541 patients on DAPT, 122 (22.6 %) of whom were females. Females were older (p < 0.001), displayed more frequently hypercholesterolemia (p = 0.003), renal failure (p = 0.04), acute presentation (p < 0.001), higher cholesterol levels and platelets count (p < 0.001). Inverse association was demonstrated with smoking (p < 0.001), previous PCI (p = 0.04) and statin use (p = 0.03), creatinine and haemoglobin (p < 0.001). Female gender did not influence mean platelet reactivity or the prevalence of HRPR for ASA (1.7 % vs 1.4 %, OR[95%CI] = 1.14[0.17–4.36], p = 0.99, adjusted OR[95%CI] = 1.54[0.20–11.6], p = 0.68) or ADP-antagonists (26.3 % vs 22.8 %, OR[95%CI] = 1.17[0.52–1.34], p = 0.45, adjusted OR[95%CI] = 1.05[0.59–1.86], p = 0.87). Results did not change when considering separately the 309 patients treated with clopidogrel (34 % vs 31.3 %, OR[95%CI] = 1.13[0.62–2.07], p = 0.76, adjusted OR[95%CI] = 1.35[0.63–2.9], p = 0.44 for females vs males), or patients (n = 232) on ticagrelor (20.4 % vs 11.1 %, OR[95%CI] = 2.27[0.99–5.17], p = 0.06 for females vs males), confirmed after correction for baseline differences (adjusted OR[95%CI] = 1.21[0.28–2.29], p = 0.68).

Conclusion

In patients receiving dual antiplatelet therapy, gender does not impact on the prevalence of high-on treatment residual platelet reactivity (HRPR) with the major antiplatelet agents ASA, clopidogrel or ticagrelor.

     

Contrast-induced acute kidney injury and adverse clinical outcomes risk in acute coronary syndrome patients undergoing percutaneous coronary intervention: a meta-analysis

Background

Recent studies have shown associations between contrast-induced acute kidney injury (CI-AKI) and increased risk of adverse clinical outcomes in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI); however, the estimates are inconsistent and vary widely. Therefore, this meta-analysis aimed to evaluate the precise associations between CI-AKI and adverse clinical consequences in patients undergoing PCI for ACS.

Methods

EMBASE, PubMed, Web of Science? and Cochrane Library databases were systematically searched from inception to December 16, 2016 for cohort studies assessing the association between CI-AKI and any adverse clinical outcomes in ACS patients treated with PCI. The results were demonstrated as pooled risk ratios (RRs) with 95% confidence intervals (CI). Heterogeneity was explored by subgroup analyses.

Results

We identified 1857 articles in electronic search, of which 22 (n?=?32,781) were included. Our meta-analysis revealed that in ACS patients undergoing PCI, CI-AKI significantly increased the risk of adverse clinical outcomes including all-cause mortality (18 studies; n?=?28,367; RR?=?3.16, 95% CI 2.52–3.97; I²?=?56.9%), short-term all-cause mortality (9 studies; n?=?13,895; RR?=?5.55, 95% CI 3.53–8.73; I²?=?60.1%), major adverse cardiac events (7 studies; n?=?19,841; RR?=?1.49, 95% CI: 1.34–1.65; I² =?0), major adverse cardiovascular and cerebrovascular events (3 studies; n?=?2768; RR?=?1.86, 95% CI: 1.42–2.43; I² =?0) and stent restenosis (3 studies; n?=?130,678; RR?=?1.50, 95% CI: 1.24–1.81; I² =?0), respectively. Subgroup analyses revealed that the studies with prospective cohort design, larger sample size and lower prevalence of CI-AKI might have higher short-term all-cause mortality risk.

Conclusions

CI-AKI may be a prognostic marker of adverse outcomes in ACS patients undergoing PCI. More attention should be paid to the diagnosis and management of CI-AKI.

     

Postoperative ileus in an enhanced recovery pathway—a retrospective cohort study

Purpose

Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI.

Methods

This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed.

Results

The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3–4 (odds ratio (OR) 1.3; 95% CI 1–1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1–1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5–0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6–1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications.

Conclusions

POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.

     

Risk factors of surgical site infections in patients with Crohn’s disease complicated with gastrointestinal fistula

Purpose

Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn’s disease (CD) complicated with gastrointestinal fistula.

Methods

This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI.

Results

A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m². The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273–26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131–10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086–43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073–0.920).

Conclusion

Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.

     

Risk factors for delayed colonic post-polypectomy bleeding: a systematic review and meta-analysis

Purpose

Delayed post-polypectomy bleeding (PPB) is an infrequent but serious adverse event after colonoscopic polypectomy. Several studies have tried to identify risk factors for delayed PPB, with inconsistent results. This meta-analysis aims to identify significant risk factors for delayed PPB.

Methods

MEDLINE and EMBASE databases were searched through January 2016 for studies that investigated the risk factors for delayed PPB. Pooled odds ratio (OR) for categorical variables and mean differences (MD) for continuous variables and 95% confidence interval (CI) were calculated using a random-effect model, generic inverse variance method. The between-study heterogeneity of effect size was quantified using the Q statistic and I ².

Results

Twelve articles involving 14,313 patients were included. The pooled delayed PPB rate was 1.5% (95%CI, 0.7–3.4%), I ² = 96%. Cardiovascular disease (OR = 1.55), hypertension (OR = 1.53), polyp size > 10 mm (OR = 3.41), and polyps located in the right colon (OR = 1.60) were identified as significant risk factors for delayed PPB, whereas age, sex, alcohol use, smoking, diabetes, cerebrovascular disease, pedunculated morphology, and carcinoma histology were not.

Conclusions

Cardiovascular disease, hypertension, polyp size, and polyp location were associated with delayed PPB. More caution is needed when removing polyps in patients with these risk factors. Future studies are warranted to determine appropriate preventive hemostatic measures in these patients.

     

Comparative diagnostic accuracy of hepatocyte-specific gadoxetic acid (Gd-EOB-DTPA) enhanced MR imaging and contrast enhanced CT for the detection of liver metastases: a systematic review and meta-analysis

Purpose

This systematic review evaluated the diagnostic accuracy and impact on patient management of hepatocyte-specific gadoxetic acid enhanced magnetic resonance imaging (GA-MRI) compared to contrast enhanced computed tomography (CE-CT) in patients with liver metastases.

Method

Four biomedical databases (PubMed, EMBASE, Cochrane Library, York CRD) were searched from January 1991 to February 2016. Studies investigating the accuracy or management impact of GA-MRI compared to CE-CT in patients with known or suspected liver metastases were included. Bias was evaluated using QUADAS-II. Univariate meta-analysis of sensitivity ratios (RR) were conducted in the absence of heterogeneity, calculated using I ² , Tau values (τ) and prediction intervals.

Results

Nine diagnostic accuracy studies (537 patients with 1216 lesions) and four change in management studies (488 patients with 281 lesions) were included. Per-lesion sensitivity and specificity estimates for GA-MRI ranged from 86.9–100.0 % and 80.2–98.0 %, respectively, compared to 51.8–84.6 % and 77.2–98.0 % for CE-CT. Meta-analysis found GA-MRI to be significantly more sensitive than CE-CT (RR = 1.29, 95 % CI = 1.18–1.40, P < 0.001), with equivalent specificity (RR = 0.97, 95 % CI 0.910–1.042, P = 0.44). The largest difference was observed for lesions smaller than 10 mm for which GA-MRI was significantly more sensitive (RR = 2.21, 95 % CI = 1.47–3.32, P < 0.001) but less specific (RR = 0.92, 95 % CI 0.87–0.98, P = 0.008). GA-MRI affected clinical management in 26 of 155 patients (16.8 %) who had a prior CE-CT; however, no studies investigated the consequences of using GA-MRI instead of CE-CT.

Conclusion

GA-MRI is significantly more sensitive than CE-CT for detecting liver metastases, which leads to a modest impact on patient management in the context of an equivocal CE-CT result.

     

Multicenter analysis of risk factors for anastomotic leakage after middle and low rectal cancer resection without diverting stoma: a retrospective study of 319 consecutive patients

Purpose

The purpose of this study was to evaluate the risk factors for anastomotic leakage (AL) after anterior resection for middle and low rectal cancer in order to help surgeons to decide which patients could benefit from a diverting stoma.

Methods

Data on 319 patients having a middle and low rectal cancer resection with anastomosis between May 2011 and October 2015 from two hospitals were included in the study. The analysis included the following variables: patient-related variables (gender, age, diabetes mellitus, ASA score, preoperative radiochemotherapy, body mass index, blood hemoglobin, and serum albumin level), tumor-related variables (K-ras status, distance of tumor from the anal verge, histopathologic grade, pathological T stage, pathological N stage, pathological M stage, TNM stage, and tumor size), and surgery-related variables (laparoscopic or open surgery, blood loss, and operative time). Univariate and multivariate regression analysis were carried out to identify risk factors for AL.

Results

The AL rate was 11.91% (38/319). Male (OR 2.898, 95% CI 1.265–6.637, p = 0.012), diabetes mellitus (OR 2.482, 95% CI 1.004–6.134, p = 0.049), K-ras mutation (OR 2.544, 95% CI 1.210–5.348, p = 0.014), distance of tumor from the anal verge (OR 3.445, 95% CI 1.631–7.279, p = 0.001), and preoperative radiochemotherapy (OR 2.790, 95% CI 1.056–7.372, p = 0.039) were independent risk factors of AL. One (2.63%) in 38 patients with AL presented with no risk factor of AL, 6 (15.8%) in 38 patients with 1 risk factor, 16 (42.1%) in 38 patients with 2 risk factors, 9 (23.7%) in 38 patients with 3 risk factors, and 6 (15.7%) in 38 patients with 4 risk factors. No patient with 5 risk factors in our study. AL rate increased with the elevated number of risk factors clustering in individuals.

Conclusions

K-ras mutation is first reported to be an independent risk factor for AL after sphincter-preserving surgery without diverting stoma. A diverting stoma should be performed in sphincter-preserving surgery for middle and low rectal cancer patients with 2 or more risk factors identified in this analysis.

     

Heel quantitative ultrasound in HIV-infected patients: a cross-sectional study

Purpose

HIV infection has been associated with increased risk of osteoporosis and fragility fractures. Dual-energy X-ray absorptiometry (DXA) is the reference standard to assess bone mineral density (BMD); however, it is not easily accessible in several settings. Heel Quantitative ultrasound (QUS) is a radiation-free, easy-to-perform technique, which may help reducing the need for DXA.

Methods

In this cross-sectional study, we used heel QUS (Hologic Sahara^®) to assess bone status in a cohort of HIV-infected patients. A QUS stiffness index (QUI) threshold >83 was used to identify patients with a low likelihood of osteoporosis. Moreover, we compared QUS results with those of 36 sex- and age-matched HIV-negative controls.

Results

244 HIV-positive patients were enrolled. Median heel QUI value was 83 (73–96) vs. 93 (IQR 84–104) in the control group (p = 0.04). 110 patients (45 %) had a QUI value ≤83. Risk factors for low QUI values were age (OR 1.04 per year, 95 % CI 1.01–1.07, p = 0.004), current use of protease inhibitors (OR 1.85, CI 1.03–3.35, p = 0.039), current use of tenofovir (OR 2.28, CI 1.22–4.27, p = 0.009) and the number of risk factors for secondary osteoporosis (OR 1.46, CI 1.09–1.95, p = 0.01). Of note, QUI values were significantly correlated with FRAX score (r = ?0.22, p = 0.004). According to EACS guidelines, 45 % of patients had risk factors for osteoporosis which make them eligible for DXA. By using QUS, we may avoid DXA in around half of them.

Conclusions

As HIV-positive patients are living longer, the prevalence of osteoporosis is expected to increase over time. Appropriate screening, prevention and treatment are crucial to preserve bone health in this population. The use of screening techniques, such as heel QUS, may help reducing the need for DXA. Further studies are needed to define the diagnostic accuracy of this promising technique in the setting of HIV.

     

Surgical Resection for Pulmonary Carcinoid: Long-Term Results of Multicentric Study—The Importance of Pathological N Status,More Than We Thought

Background

Histological subdivision into typical (TC) and atypical (AC) is crucial for treatment and prognosis of lung carcinoids but can be also very challenging, even for experts. In this study, we aimed to strengthen or reduce the prognostic value of several pathological, clinical, or per-operative factors some of which are still controversial.

Methods

We retrospectively reviewed clinical records related to 195 patients affected by TC (159) or AC (36) surgically treated between 2000 and 2014, in three different centers. Survival and subtypes comparison analyses were performed to identify potential prognostic factors.

Results

TCs showed a lower rate of nodal involvement than ACs (N0 = 94.9%; N1 = 1.9%; N2 = 3.2% in typical and N0 = 63.8%; N1 = 16.6%; N2 = 19.4% in atypical carcinoids, respectively, p < 0.0001). Long-term oncological results of resected carcinoids were significantly better in TCs than ACs with higher 5- and 10-year overall survival rates (97.2 and 88.2% vs. 77.9 and 68.2%, respectively; p = 0.001) and disease-free survival rates (98.2 and 90.3% in typical and 80.8 and 70.7% atypical carcinoids, respectively; p = 0.001). Risk factors analysis revealed that AC subtype [HR 4.33 (95% CI 1.72–8.03), p = 0.002], pathological nodal involvement [HR 3.05 (95% CI 1.77–5.26), p < 0.0001], and higher SUV_max [HR 4.33 (95% CI 1.03–7.18), p = 0.002] were independently and pejoratively associated with overall survival. Factors associated with a higher risk of recurrence were AC subtype [HR 6.13 (95% CI 1.13–18.86), p = 0.002]; nodal involvement [HR 5.48 (95% CI 2.85–10.51), p < 0.0001]; higher Ki67 expression level [HR 1.09 (95% CI 1.01–1.20), p = 0.047]; and SUV_max [HR 1.83 (95% CI 1.04–3.23), p = 0.035].

Conclusion

Surgery for lung carcinoids allows satisfactory oncological results which mainly depend on carcinoid subtype dichotomy, pathological nodal status, and SUV_max.

     

Influence of pelvic volume on surgical outcome after low anterior resection for rectal cancer

Background

Low anterior resection (LAR) for rectal cancer is a potentially challenging operation due to limited space in the pelvis. CT pelvimetry allows to quantify pelvic space, so that its relationship with outcome after LAR may be assessed. Studies investigating this, however, yielded conflicting results. We hypothesized that a small pelvis is associated with a higher rate of incomplete mesorectal excision, anastomotic leakages, and increased rate of urinary dysfunction in patients operated for rectal cancer.

Methods

In a single-center retrospective analysis, we studied 74 patients that underwent LAR for rectal cancer with primary anastomosis. Thin-layered multi-slice CT datasets were used for slice by slice depiction of the inner pelvic surface, and the inner pelvic volume was automatically compounded. The primary outcome was quality of total mesorectal excision (TME; Mercury grading); secondary outcomes were anastomotic leakage and urinary dysfunction with regard to pelvic dimensions. Univariate analyses and multiple logistic regression analyses were performed for the primary and the secondary outcomes.

Results

Shorter obstetric conjugate diameters were associated with a higher probability of a worse TME quality (110.8 ± 10.2 vs. 105.0 ± 8.6 mm; OR 0.85; 95% CI 0.73–0.99; p = 0.038). Short interspinous distance showed a trend towards an increased risk for deteriorated TME quality (OR 0.88; 95% CI 0.76–1.0; p = 0.06). Anastomotic leakage was associated with anemia (OR 2.77; 95% CI 1.0–7.7; p = 0.047). Association between pelvic diameters or pelvic volume and anastomotic leakage or urinary dysfunction was not observed. Perioperative blood transfusions were administered more often in patients with postoperative urinary dysfunction (OR 17.67; 95% CI 2.44–127.7; p = 0.004).

Conclusion

Shorter obstetric conjugate diameter might be a risk factor for incompleteness of total mesorectal excision. Anastomotic leakage seems to be influenced more by clinical factors such as anemia rather than pelvic dimensions. Further studies have to prove the influence of pelvic diameter on local recurrence of rectal cancer after LAR.

     

Obstructive sleep apnea does not impair cardiorespiratory responses to progressive exercise performed until exhaustion in hypertensive elderly

Background

Elderly people have a high prevalence to systemic arterial hypertension (SAH) and obstructive sleep apnea (OSA). Both comorbidities are closely associated and inflict damage on cardiorespiratory capacity.

Methods

In order to assess cardiorespiratory responses to the cardiopulmonary exercise test (CPET) among hypertensive elderly with OSA, we enrolled 28 subjects into two different groups: without OSA (No-OSA: apnea/hypopnea index (AHI) < 5 events/h; n = 15) and with OSA (OSA: AHI ≥ 15 events/h; n = 13). All subjects underwent CPET and polysomnographic assessments. After normality and homogeneity evaluations, independent t test and Pearson’s correlation were performed. The significance level employed was p ≤ 0.05.

Results

Hypertensive elderly with OSA presented lower heart rate recovery (HRR) in the second minute (HRR₂) in relation to the No-OSA group. A negative correlation between AHI and ventilation (VE) (r = ?0.63, p = 0.02) was found in polysomnography and CPET data comparisons, and oxygen saturation (O₂S) levels significantly correlated with VE/VCO_2slope (r = 0.66, p = 0.01); in addition, No-OSA group presented a positive correlation between oxygen consumption and O₂S (r = 0.66, p = 0.01), unlike the OSA group.

Conclusions

OSA does not affect the CPET variables in hypertensive elderly, but it attenuates the HRR₂. The association between O₂S during sleep with ventilatory responses probably occurs due to the adaptations in the oxygen transport system unleashed via mechanical respiratory feedback; thus, it has been identified that OSA compromises the oxygen supply in hypertensive elderly.

     

Risk factors and outcomes of acute lower gastrointestinal bleeding in intestinal Behçet’s disease

Background

Intestinal Behçet’s disease (BD) can cause acute lower gastrointestinal bleeding, which is sometimes fatal.

Aim

We aimed to identify the risk factors and outcomes of acute lower gastrointestinal bleeding and factors associated with rebleeding in intestinal BD patients.

Methods

Of the total of 588 intestinal BD patients, we retrospectively reviewed the medical records of 66 (11.2%) patients with acute lower gastrointestinal bleeding and compared them with those of 132 matched patients without bleeding.

Results

The baseline characteristics were comparable between the bleeding group (n = 66) and the non-bleeding group (n = 132). On multivariate analysis, the independent factors significantly associated with lower gastrointestinal bleeding were older age (>52 years) (hazard ratio [HR] 2.2, 95% confidence interval [CI] 1.058–4.684, p = 0.035) and a nodular ulcer margin (HR 7.1, 95% CI 2.084–24.189, p = 0.002). Rebleeding occurred in 23 patients (34.8%). Female patients (p = 0.044) and those with previous use of corticosteroids or azathioprine (p = 0.034) were more likely to develop rebleeding. On multivariate analysis, only use of steroids or azathioprine was significantly associated with rebleeding (HR 3.2, 95% CI 1.070–9.462, p = 0.037).

Conclusions

Age >52 years and the presence of a nodular margin of the ulcer were found to be related to increased risk of bleeding in patients with intestinal BD. Rebleeding is not uncommon and not effectively prevented with currently available medications. Further studies are warranted to identify effective measures to decrease rebleeding in intestinal BD.

     

A radiological and pathological assessment of ileocolic pedicle length as a predictor of lymph node retrieval following right hemicolectomy for caecal cancer

Background

In colon cancer, the number of harvested lymph nodes is critical for pathological staging. It has been proposed that the more central the mesenteric vascular ligation, the greater the nodal yield. The aim of the current study was to determine the association of radiological and pathological ileocolic pedicle length on nodal harvest following right hemicolectomy for caecal cancer.

Methods

A series of 50 patients undergoing right hemicolectomy for adenocarcinoma underwent specimen evaluation. Preoperative computed tomography images were reconstructed and analysed to determine the direct (vessel origin to caecum) ileocolic pedicle length.

Results

The median pathological distance from the tumour to the high vascular tie was 80 mm, and median nodal yield was 16.5 nodes. Radiological pedicle length did not correlate with the pathological distance from the tumour to the high vascular tie or nodal yield; however, the pathological pedicle length did correlate with the total nodal yield (r ²: 0.343, p = 0.015). The median pathologically determined length of colon resected (r ²: 0.153, p = 0.289), ileum resected (r ²: 0.087, p = 0.568) and total specimen length resected (r ²: 0.182, p = 0.205) did not correlate with the total nodal yield. An ileal specimen length ≤25 mm [hazard ratio (HR) 14.8, 95 % confidence interval (CI) 1.1–194.5, p = 0.040] and a well-differentiated tumour (HR 10.5, 95 % CI 1.1–95.9, p = 0.037) increased the likelihood of retrieving <12 lymph nodes.

Conclusions

Based on these data, pathologic pedicle length is a determining factor in lymph node retrieval. Preoperative radiological calculation of pedicle length does not help predict the number of lymph nodes retrieved.