In-hospital mortality for pulmonary embolism: relationship with chronic kidney disease and end-stage renal disease. The hospital admission and discharge database of the Emilia Romagna region of Italy

The impact of chronic kidney disease (CKD) on the outcome of acute pulmonary embolism (PE) is uncertain. We aimed to evaluate the effect of renal dysfunction (defined by ICD-9-CM codification) on in-hospital mortality for PE. We considered all cases of PE (first event) recorded in the database of hospital admissions for the Emilia-Romagna region, Italy, from 1999 to 2009. The inclusion criterion was the presence, as a main discharge diagnosis, of acute PE codes according to ICD-9-CM. Diagnoses of immobilization, dementia, sepsis, skeletal fractures, hypertension, heart failure, myocardial infarction, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic pulmonary disease, pneumonia, malignancy, CKD and end-stage renal disease (ESRD) were also considered to evaluate comorbidity. The outcome was in-hospital mortality for PE, and multivariate logistic regression analyses was performed. We considered 24,690 cases of first episode of PE. In-hospital mortality for PE was not different in patients without renal dysfunction, with CKD, or ESRD (23.6 vs. 24 vs. 18 % p = ns). In-hospital mortality for PE was independently associated with age (OR 1.045, 95 % CI 1.042–1.048, p < 0.001), female sex (OR 1.322, 95 % CI 1.242–1.406, p < 0.001), hypertension (OR 1.096, 95 % CI 1.019–1.178, p = 0.013), diabetes mellitus (OR 1.120, 95 % CI 1.001–1.253, p = 0.049), dementia (OR 1.171, 95 % CI 1.020–1.346, p = 0.025), peripheral vascular disease (OR 1.349, 95 % CI 1.057–1.720, p = 0.016) and malignancy (OR 1.065, 95 % CI 1.016–1.116, p = 0.008). Age and comorbidity are associated with in-hospital mortality for PE, whereas CKD does not appear to be an independent predictor of adverse outcomes in patients hospitalized for PE.     

Influence of pre-hydration and pharmacogenetics on plasma methotrexate concentration and renal dysfunction following high-dose methotrexate therapy

High-dose methotrexate therapy (HD-MTX) has been well established for the treatment of childhood acute lymphoblastic leukemia (ALL). The aims of this study were to investigate whether clinical and pharmacogenetic factors influence plasma MTX concentration and renal dysfunction in patients treated with HD-MTX. In a total of 127 courses of HD-MTX in 51 patients with childhood ALL, influence of clinical and pharmacogenetic factors on plasma MTX concentration and HD-MTX-related renal dysfunction was evaluated. Clinical factors included age, gender, duration of HD-MTX continuous-infusion and duration of pre-hydration before HD-MTX. Pharmacogenetic factors included 5 gene polymorphisms within the MTX pathway genes, namely, SLC19A1, MTHFR, ABCC2 and ABCG2. Short duration of pre-hydration before HD-MTX is the most important risk factor for prolonged high MTX concentration (p < 0.001, OR 6.40, 95 % CI 2.39–17.16) and renal dysfunction (p = 0.013, OR 3.15, 95 % CI 1.27–7.80). The T allele at MTHFR C677T was the risk factor for prolonged high MTX concentration (p = 0.009, OR 5.54, 95 % CI 1.54–19.85), but not for renal dysfunction. We found the influence of MTHFR C677T polymorphism on prolonged high MTX concentration. We reconfirmed the importance of adequate pre-hydration before HD-MTX to prevent prolonged high MTX concentration and MTX-related renal dysfunction.     

Association of glucokinase regulatory gene polymorphisms with risk and severity of non-alcoholic fatty liver disease: an interaction study with adiponutrin gene

Background

Recent genome-wide association studies demonstrated an association between single nucleotide polymorphisms (SNPs) on the glucokinase regulatory gene (GCKR) with hepatic steatosis. This study attempted to investigate the association of GCKR rs780094 and rs1260326 with susceptibility to non-alcoholic fatty liver disease (NAFLD) and its severity.

Methods

The genotypes were assessed on 144 histologically confirmed NAFLD patients and 198 controls using a Sequenom MassARRAY platform.

Results

The GCKR rs1260326 and rs780094 allele T were associated with susceptibility to NAFLD (OR 1.49, 95 % CI 1.09–2.05, p = 0.012; and OR 1.51, 95 % CI 1.09–2.09, p = 0.013, respectively), non-alcoholic steatohepatitis (NASH) (OR 1.55, 95 % CI 1.10–2.17, p = 0.013; and OR 1.56, 95 % CI 1.10–2.20, p = 0.012, respectively) and NASH with significant fibrosis (OR 1.50, 95 % CI 1.01–2.21, p = 0.044; and OR 1.52, 95 % CI 1.03–2.26, p = 0.038, respectively). Following stratification by ethnicity, significant association was seen in Indian patients between the two SNPs and susceptibility to NAFLD (OR 2.64, 95 % CI 1.28–5.43, p = 0.009; and OR 4.35, 95 % CI 1.93–9.81, p < 0.0001, respectively). The joint effect of GCKR with adiponutrin rs738409 indicated greatly increased the risk of NAFLD (OR 4.14, 95 % CI 1.41–12.18, p = 0.010). Histological data showed significant association of GCKR rs1260326 with high steatosis grade (OR 1.76, 95 % CI 1.08–2.85, p = 0.04).

Conclusion

This study suggests that risk allele T of the GCKR rs780094 and rs1260326 is associated with predisposition to NAFLD and NASH with significant fibrosis. The GCKR and PNPLA3 genes interact to result in increased susceptibility to NAFLD.     

Association between self-reported snoring and arterial stiffness: data from the Brisighella Heart Study

The correlation of both obstructive sleep apnoea syndrome (OSAS) and snoring with cardiovascular risk is well known, but its investigation is complex and not suitable for studying large cohorts of subjects. Thus, we prospectively evaluated 1476 non-pharmacologically treated subjects selected from the last survey of the Brisighella Heart Study. Snoring and sleep apnoea were investigated asking the subjects if they were aware of snoring during the night, and if this was associated with episodes of apnoea. A full set of clinical and laboratory parameters were evaluated, while augmentation index (AIx), and pulse wave velocity (PWV) were recorded with the Vicorder^® apparatus. A logistic regression analysis identifies as main independent predictors of AIx age (OR 1.058, 95 % CI 1.043–1.065, p < 0.001), Body Mass Index (OR 1.046, 95 % CI 1.014–1.079, p = 0.005), and apolipoprotein B (OR 1.014, 95 % CI 1.004–1.023, p = 0.001). The main independent predictors of PWV are snoring (OR 1.215, 95 % CI 1.083–1.390, p < 0.001), and snoring with apnoea (OR 1.351, 95 % CI 1.135–1.598, p = 0.014), age (OR 1.078, 95 % CI 1.052–1.089, p < 0.001), serum uric acid [SUA] (OR 1.093, 95 % CI 1.026–1.151, p < 0.001) and mean arterial pressure (OR 1.042, 95 % CI 1.024–1.056, p < 0.001). In conclusion, in our cohort of overall healthy subjects, self-reported snoring and sleep apnoea are independently associated with a higher PVW, and AIx is statistically significantly higher in snorers with or without sleep apnoea than in non-snorers. Body Mass Index and apolipoprotein B are associated with AIx, while SUA and mean arterial pressure are related to PWV.     

Short stature and gestational diabetes in Brazil

Aims/hypothesis. To examine the association between maternal stature and gestational diabetes mellitus.¶Methods. We studied a sample of 5564 consecutive Brazilian women 20 or more years old, who were pregnant for approximately 21–28 weeks, had no history of diabetes outside pregnancy and were attending general prenatal care units in six state capitals in Brazil from 1991 to 1995. We did a 2-h, 75-g oral glucose tolerance test, defining gestational diabetes by World Health Organisation criteria.¶Results. Those in the shortest quartile of height ( ≤ 151 cm) had a 60 % increase in the odds of having gestational diabetes, independently of prenatal clinic, age, global obesity, family history of diabetes, skin colour, referral pattern, waist circumference, parity, previous gestational diabetes, education, ambient temperature and gestational age compared with the tallest quartile [odds ratio (OR) = 1.60, p = 0.005]. This association was observed for those with above median values of skinfold thickness (OR = 1.74, p = 0.006) but not for those with below median values (OR = 1.22, p = 0.51). Associations of short stature with high 2-h glycaemia ( ≥ 7.8 mmol/l) (OR = 1.61, p = 0.005) were essentially the same as those for gestational diabetes. There was, however, no association between short stature and gestational hyperglycaemia when the latter was defined exclusively by fasting values (OR = 0.97, p = 0.90).¶Conclusion/interpretation. In Brazil short stature associates with gestational diabetes, principally in women with greater fat mass. This difference in glycaemic levels is present postprandially but not in the fasting state. [Diabetologia (2000) 43: 848–851]     

Prevalence of irritable bowel syndrome and functional dyspepsia,overlapping symptoms,and associated factors in a general population of Bangladesh

Background

This community-based survey aimed to find out the prevalence of irritable bowel syndrome (IBS), functional dyspepsia (FD), overlapping symptoms, and associated factors for overlap.

Method

By cluster sampling method, 3,000 (1,523 male) randomly selected adult subjects in the Sylhet district of Bangladesh were interviewed by a questionnaire based on ROME III criteria. Multivariate logistic regression analyses were done to find out the factors for overlap with significance level set at ≤0.05.

Results

The mean age of the study population was 33.9?±?16.4 years. Prevalence of IBS and FD and IBS-FD were 12.9 % (n?=?387), 8.3 % (n?=?249), and 3.5 % (n?=?105), respectively. Approximately 27.1 % of IBS patients and 42.1 % of FD patients had overlapping IBS-FD. The odds ratio for IBS-FD overlap was 6.3 (95 % CI, 4.8–8.4). Mean age (p?=?0.011) and epigastric pain (p?=?0.002) were more in overlap patients than FD alone, whereas epigastric pain syndrome subtype (p?<?0.009) was more prevalent in lone FD subjects. In the multivariate logistic analysis, early satiety (OR, 3.0; 95 % CI, 1.2–7.5; p?=?0.018) and epigastric pain (OR, 14.5; 95 % CI, 5.0–42.1; p?=?0.000) in FD patients appeared as independent risk factors for overlap. Bloating (p?=?0.026), <3 stools per week (p?=?0.050), abdominal pain reduced by defecation (p?=?0.002), abdominal pain severity score (p?=?0.004), and overall symptom frequency score (p?=?0.000) were more in overlap patients than IBS-alone patients. In IBS patients, bloating (OR, 3.6; CI, 2.0–6.5; p?=?0.000) was found as potential symptom associated with IBS-FD overlap.

Conclusion

FD was a less prevalent disorder than IBS in our community, and significant overlap existed between the two disorders. Early satiety, epigastric pain, and bloating were important factors associated with overlap.     

Influence of gender on the risk of death and adverse events in patients with acute myocardial infarction undergoing pharmacoinvasive strategy

Pharmacoinvasive treatment is an acceptable alternative for patients with ST-segment elevation myocardial infarction (STEMI) in developing countries. The present study evaluated the influence of gender on the risks of death and major adverse cardiovascular events (MACE) in this population. Seven municipal emergency rooms and the Emergency Mobile Healthcare Service in São Paulo treated STEMI patients with tenecteplase. The patients were subsequently transferred to a tertiary teaching hospital for early (<24 h) coronary angiography. A total of 469 patients were evaluated [329 men (70.1 %)]. Compared to men, women had more advanced age (60.2 ± 12.3 vs. 56.5 ± 11 years; p = 0.002); lower body mass index (BMI; 25.85 ± 5.07 vs. 27.04 ± 4.26 kg/m²; p = 0.009); higher rates of hypertension (70.7 vs. 59.3 %, p = 0.02); higher incidence of hypothyroidism (20.0 vs. 5.5 %; p < 0.001), chronic renal failure (10.0 vs. 8.8 %; p = 0.68), peripheral vascular disease (PVD; 19.3 vs. 4.3 %; p = 0.03), and previous history of stroke (6.4 vs. 1.3 %; p = 0.13); and higher thrombolysis in myocardial infarction risk scores (40.0 vs. 23.7 %; p < 0.001). The overall in-hospital mortality and MACE rates for women versus men were 9.3 versus 4.9 % (p = 0.07) and 12.9 versus 7.9 % (p = 0.09), respectively. By multivariate analysis, diabetes (OR 4.15; 95 % CI 1.86–9.25; p = 0.001), previous stroke (OR 4.81; 95 % CI 1.49–15.52; p = 0.009), and hypothyroidism (OR 3.75; 95 % CI 1.44–9.81; p = 0.007), were independent predictors of mortality, whereas diabetes (OR 2.05; 95 % CI 1.03–4.06; p = 0.04), PVD (OR 2.38; 95 % CI 0.88–6.43; p = 0.08), were predictors of MACE. In STEMI patients undergoing pharmacoinvasive strategy, mortality and MACE rates were twice as high in women; however, this was due to a higher prevalence of risk factors and not gender itself.     

The relationship between factor V Leiden, prothrombin G20210A, and MTHFR mutations and the first major thrombotic episode in polycythemia vera and essential thrombocythemia

Arterial and venous thrombosis are the most frequent complications in patients with polycythemia vera and essential thrombocythemia. We sought to demonstrate a possible contribution of the factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase (MTHFR) 677 C?>?T and 1298 A?>?C mutations to the thrombotic risk in patients with polycythemia vera and essential thrombocythemia along with other biological features of these patients. We included 86 patients with polycythemia vera, of which 34 (39.5 %) had major thrombosis and 95 patients with essential thrombocythemia, of which 22 (23.1 %) had major thrombosis. In the whole cohort of patients, only the factor V Leiden mutation was significantly associated with both arterial and venous thrombosis in univariate and multivariate analysis (odds ratio (OR)?=?4.3; 95 % confidence interval (CI)?=?1.5–12.5; p?=?0.008 and OR?=?4.3; 95 % CI?=?1.2–15.9; p?=?0.02, respectively). Other factors significantly associated with thrombosis in both univariate and multivariate analysis were male sex (OR?=?2.8, 95 % CI?=?1.4–5.4, p?=?0.002 and OR?=?3.5, 95 % CI?=?1.6–7.6, p?=?0.002, respectively) and the JAK2 V617F mutation (OR?=?5.5, 95 % CI?=?2.1–15, p?=?0.0001 and OR?=?6.9, 95 % CI?=?2.2–21.2, p?=?0.001, respectively). In conclusion, among the four mutations analyzed (factor V Leiden, prothrombin G20210A, and MTHFR 677 C?>?T and 1298 A?>?C), only factor V Leiden is a major contributor to thrombosis in polycythemia vera and essential thrombocythemia.     

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.

     

Evaluation of central corneal and central retinal thicknesses and intraocular pressure in acromegaly patients

Introduction

Acromegaly is a disorder with increased morbidity which can involve many organs and the eye can be one of them which was investigated in few reports. Herein, we aimed to evaluate CCT, IOP and retinal thickness (RT), and their relationships with serum GH and IGF-1 levels and disease duration, in acromegaly patients. We compared the ocular parameters with those of a control group. This study included the largest number of patients of any comparable investigation to date.

Material and Method

We enrolled 30 acromegaly patients (15 male, 15 female and age: 48.4 ± 12.8 years) and 21 age and gender matched controls. All participants underwent complete hormonal and ophtalmological evaluation including central corneal thickness (CCT), retinal thickness (RT) and intraocular pressure (IOP) values.

Results

There were no significant differences in median right and left CCTs and mean CCT (p = 0.646, p = 0.667 and p = 0.384, respectively). Nor were there statistically significant differences in median right and left RT, or mean central RT, between the acromegaly and control groups (p = 0.977, p = 0.738 and p = 0.811, respectively). However median right, left and mean IOPs were found to be significantly higher in the acromegaly group, despite there being no difference in the CCT values (p = 0.011, p = 0.028 and p = 0.047, respectively). When we analyzed two subgroups of acromegaly patients (active/inactive), we found that the median right, left and mean CCTs and RTs, were not significantly different between the groups. Although there was a significant difference in IOP between the acromegaly and control groups, the two subgroups of acromegaly patients had similar IOPs (p = 0.400, p = 0.621 and p = 0.451 for right, left and mean IOPs, respectively). IOP was not found to be correlated with serum IGF-I, GH or disease duration in acromegaly patients.

Conclusion

Our study results suggest that acromegaly is associated with increased ocular pressures irrespective of disease activity. Therefore detailed ocular evaluation should be a routine component of the follow up visits of acromegaly patients.     

Elevated levels of RDW is associated with non-valvular atrial fibrillation

Red cell distribution width (RDW) and neutrophil/lymphocyte ratio (NLR) have been found to be associated with cardiovascular diseases. Only a few trials have investigated the correlation of these parameters with postoperative atrial fibrillation (AF). However, the correlation of these parameters in non-valvular AF is still unclear. We retrospectively analyzed consecutive AF patients from medical records and included 117 non-valvular AF patients (103 paroxysmal and 14 chronic AF). All subjects underwent physical examination and echocardiographic imaging. Complete blood counts (CBCs) were analyzed for hemoglobin, RDW, neutrophil and lymphocyte counts as well as mean corpuscular volume. Results of CBC tests within the previous year were also included and the averages were used. The demographic and echocardiographic properties of non-valvular AF group were comparable to the control group except for left atrial volumes which were increased in AF (median 33.1, IQR 26.3–41.1 cm³ vs. median 26.4, IQR 24.2–28.9 cm³; p = 0.01). RDW levels were significantly higher in the AF group (median 13.4 %, IQR 12.9–14.1 %) compared to the control (median 12.6 %, IQR 12.0–13.1 %; p = 0.01). NLR was not statistically different in the AF group and the controls (2.04 ± 0.94 vs. 1.93 ± 0.64, respectively; p = 0.32). Hs-CRP levels were higher in the AF group compared to the controls (median 0.84, IQR 0.30–1.43 mg/L vs. median 0.29, IQR 0.18–0.50 mg/L, respectively; p = 0.01). Multivariate logistic regression analysis revealed RDW (OR 4.18, 95 % CI 2.15–8.15; p = 0.01), hs-CRP (OR 3.76, 95 % CI 1.43–9.89; p = 0.01) and left atrial volume (OR 1.31, 95 % CI 1.06–1.21; p = 0.01) as the independent markers of non-valvular AF. Multivariate linear regression analysis revealed that hemoglobin levels (standardized β coefficient = ?0.252; p = 0.01) and the presence of AF (standardized β coefficient = 0.336; p = 0.01) were the independent correlates of RDW levels. Elevated RDW levels, not NLR, may be an independent risk marker for non-valvular AF.     

Effects of statins on the development of sepsis and organ dysfunction in hospitalized older patients in China

This study aimed to evaluate the protective role of statins on the development of sepsis and infection-related organ dysfunction and mortality in a hospitalized older Chinese population with bacterial infections. In this retrospective cohort study, 257 older patients with bacterial infection were divided into two groups: a statin group, those who had received statin therapy for ≥1 month before admission and continued receiving statin during hospitalization; and a non-statin group, those who had never received statin or used statin for <1 month prior to admission. A multivariate logistic regression analysis was performed to identify risk and protective factors for severe sepsis. A significantly lower incidence of organ dysfunction was found in the statin group, as compared with the non-statin group (13.3% vs 31.1%, respectively; p = 0.002), corresponding to adjusted rates ratio of 0.32 (95% confidence interval [CI], 0.13–0.75; p = 0.009). No significant difference was found between statin and non-statin groups in 30-day sepsis-related mortality (4.4% vs 10.2%, respectively; p = 0.109), incidence of intensive care unit admission (13.3% vs 16.8%, respectively; p = 0.469), or length of hospital stay (20.5 vs 25.9 days, respectively; p = 0.61). Statins significantly reduced the development of sepsis and infection-related organ dysfunction in hospitalized older Chinese patients but did not reduce 30-day mortality, ICU admission incidence, or length of hospital stay.     

Transcatheter aortic valve implantation and bleeding: incidence, predictors and prognosis

Peri-procedural bleeding complications are feared adverse events in patients undergoing transcatheter aortic valve implantation (TAVI). Little is known about the implications of peri-procedural bleeding on clinical outcome. In a prospective single-center registry of consecutive patients undergoing TAVI, we investigated incidence, predictors and clinical consequences of life-threatening and major bleeding as defined by the Valve Academic Research Consortium. Among 389 consecutive patients undergoing TAVI by a transfemoral (79.2 %), transapical (19.6 %) or trans-subclavian (1.3 %) approach between July 2007 and October 2011, life-threatening or major peri-procedural bleeding events occurred in 64 (16.4 %) and 125 patients (32.1 %), respectively. Patients with peri-procedural bleeding events had a higher logistic EuroSCORE, more advanced renal disease, and were more symptomatic as assessed by New York Heart Association functional class at baseline as compared to patients with no bleeding. Life-threatening bleeding was associated with a higher all-cause (17.2 vs 5.6 vs 3.0 %, p < 0.001) and cardiovascular mortality (10.9 vs 5.6 vs 2.5 %, p = 0.02) at 30 days compared to patients with major bleeding or no bleeding. Multivariate analysis identified transapical access (OR 2.6, 95 % CI 1.4–4.8; p = 0.002), glomerular filtration rate <30 ml/min (OR 2.3, 95 % CI 1.1–4.7, p = 0.031), and diabetes (OR 1.8, 95 % CI 1.001–3.2, p = 0.049) as independent predictors of life-threatening, peri-procedural bleeding. Life-threatening bleeding complications in patients undergoing TAVI are associated with increased mortality. Renal impairment, diabetes, and transapical approach were identified as independent risk factors for life-threatening bleeding events.     

Predictive factors of long-term survival in the octogenarian undergoing surgical aortic valve replacement: 12-year single-centre follow-up

The improvement of life expectancy created more surgical candidates with severe symptomatic aortic stenosis and age >80. Therefore, the main objective of this observational, retrospective single-centre study is to compare the long-term survival of octogenarians that have undergone surgical aortic valve replacement (AVR) to the survival of the general population of the same age and to establish whether any perioperative characteristics can anticipate a poor long-term result, limiting the prognostic advantage of the procedure at this age. From 2000 to 2014, 264 octogenarians underwent AVR at our institution. Perioperative data were retrieved from our institutional database and patients were followed up by telephonic interviews. The follow-up ranged between 2 months and 14.9 years (mean 4.1 ± 3.1 years) and the completeness was 99.2 %. Logistic multivariate analysis and Cox regression were respectively applied to identify the risk factors of in-hospital mortality and follow-up survival. Our patient population ages ranged between 80 and 88 years. Isolated AVR (I-AVR) was performed in 136 patients (51.5 %) whereas combined AVR (C-AVR) in 128 patients (48.5 %). Elective procedures were 93.1 %. Logistic EuroSCORE was 15.4 ± 10.6. In-hospital mortality was 4.5 %. Predictive factors of in-hospital mortality were the non-elective priority of the procedure (OR 5.7, CI 1.28–25.7, p = 0.02), cardiopulmonary bypass time (OR 1.02, CI 1.01–1.03, p = 0.004) and age (OR 1.36, CI 1.01–1.84, p = 0.04). Follow-up survival at 1, 4, 8 and 12 years was 93.4 % ± 1.6 %, 72.1 % ± 3.3 %, 39.1 % ± 4.8 % and 20.1 % ± 5.7 %, respectively. The long-term survival of these patients was not statistically different from the survival of an age/gender-matched general population living in the same geographic region (p = 0.52). Predictive factors of poor long-term survival were diabetes mellitus (HR 1.55, CI 1.01–2.46, p = 0.05), preoperative creatinine >200 μmol/L (HR 2.07, CI 1.21–3.53, p = 0.007) and preoperative atrial fibrillation (HR 1.79, CI 1.14–2.80, p = 0.01). In our experience, AVR can be safely performed in octogenarians. After a successful operation, the survival of these patients returns similar to the general population. Nevertheless, the preoperative presence of major comorbidities such as diabetes mellitus, renal dysfunction and atrial fibrillation significantly impact on long-term results.     

Pneumonia After Endoscopic Resection for Gastric Neoplasm

Background

Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay.

Aim

To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm.

Methods

Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects.

Results

Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31–82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2–126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077).

Conclusions

Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.     

The role of statins in the prevention of contrast induced nephropathy: a meta-analysis of 8 randomized trials

Contrast induced nephropathy (CIN) is a common complication of coronary angiography/angioplasty. Prevention is the key to reduce the incidence of CIN and it begins with appropriate pre-procedural management. Statins have been shown to possess pleiotropic effects (anti-oxidant, anti-inflammatory and anti-thrombotic properties) and their effects on CIN were assessed in several studies with conflicting results. Aim of this meta-analysis is to evaluate the efficacy of short-term statins for the prevention of CIN in patients undergoing coronary angiography/percutaneous interventions. We performed formal searches of PubMed, EMBASE, Cochrane central register of controlled trials and major international scientific session abstracts from January 1990 to January 2014 of trials which compares short-term statins versus Placebo for the prevention of CIN in patients undergoing coronary angiography/angioplasty. Data regarding study design, statin dose, inclusion/exclusion criteria, number of patients, and clinical outcome was extracted by 2 investigators. Eight trials were included, with a total of 4734 patients. CIN occurred in 79/2,358 patients (3.3 %) treated with statins versus 153/2,376 patients (6.4 %) of the placebo group [OR 95 % CI 0.50 (0.38–0.66), p < 0.00001; p _het = 0.39]. Benefits were both observed with high-dose short-term statins [OR 95 % CI 0.44 (0.30–0.65), p < 0.0001; p _het = 0.16] and low-dose statins, [OR 95 % CI 0.58 (0.39–0.88), p = 0.010; p _het = 0.90]. By meta-regression analysis, no significant relationship was observed between benefits from statin therapy and patient’s risk profile (p = 0.26), LDL cholesterol (p = 0.4), contrast volume (p = 0.94) or diabetes rate (p = 0.38). This meta-analysis showed that among patients undergoing coronary angiography/percutaneous intervention the use of short-term statins reduces the incidence of CIN, and therefore is highly recommended even in patients with low LDL-cholesterol levels.     

Favorable outcomes of intravenous busulfan, fludarabine, and 400 cGy total body irradiation-based reduced-intensity conditioning allogeneic stem cell transplantation for acute myelogenous leukemia with old age and/or co-morbidities

Traditional transplant conditioning regimens have a limiting factor regarding co-morbidities or old age. Therefore, reduced-intensity conditioning (RIC) regimens have been increasingly used. To define the role of RIC in AML with old age (≥55 years) and/or co-morbidities (HCT-CI scores ≥2), we analyzed patients who received allogeneic stem cell transplantation (SCT) with Flu/Bu/TBI 400 cGy/±antithymocyte globulin (ATG) conditioning regimen. Seventeen men and 15 women were enrolled. The median age was 45 years (range 17–65 years). All patients were in first (n = 25) or second (n = 7) complete remission before undergoing allogeneic SCT. Patients were transplanted from HLA-mismatched unrelated donors (n = 5), matched unrelated donors (n = 10), and matched sibling (n = 17). Calcineurin inhibitor and a short course of standard dose methotrexate were used to prevent graft-versus-host disease (GVHD). All patients achieved engraftment. At a median follow-up of 18 months (range 4–40) for survivors, the estimated 2-year rates of overall survival, event-free survival, transplantation-related mortality, and relapse were 66, 63, 26, and 16%, respectively. The incidence of acute (grades II–IV) and chronic GVHD by NIH consensus criteria was 34.4 and 62.5%. This study suggests that the Flu/Bu/TBI 400 cGy or Flu/Bu/TBI 400 cGy/ATG-based conditioning regimens maybe a feasible therapeutic approach for AML with old age and/or co-morbidities.     

Comparison of PA spine, lateral spine, and femoral BMD measurements to determine bone loss in ankylosing spondylitis

To evaluate bone loss in the early- and late-stage ankylosing spondylitis (AS) patients using posteroanterior (PA) and lateral lumbar and femoral bone mineral density (BMD) measurement methods. Eighty-six AS patients and 50 control subjects were enrolled. PA spine, lateral spine, and femur BMD values of patients and controls were measured. The presence of any syndesmophytes or compression fractures was determined. Patients were divided as early (<10 years) and late stage (≥10 years) according to the onset of the inflammatory pain. Mean PA spinal BMD was similar in patients and controls (p = 0.460). Femoral and lateral spine BMD values were significantly lower in patients (p = 0.012 and p = 0.001). When comparing early- and late-stage AS groups, mean PA spinal BMD was found to be lower in the early group (p = 0.005), while femoral and lateral spinal values were lower (although statistically not significant) in the late group. At least one compression fracture was present in 28 % of patients. Although not statistically significant, mean PA spinal BMD was higher in those with fractures. Femoral and lateral spinal BMD values were significantly lower in the fracture group (p = 0.034 and p = 0.004). Lateral spinal BMD values were significantly lower in patients with syndesmophytes (p = 0.004). Bone loss is increased in AS compared with control subjects. The BMD measurement at the lateral lumbar spine reflects bone loss and fracture risk better than PA spine and femoral measurements.     

Myocardial functional abnormalities and serum N-terminal pro-brain natriuretic peptide in type II diabetes mellitus patients with cardiovascular autonomic neuropathy

The aim was to investigate ventricular myocardial functions in patients with type II diabetes mellitus (DM) with cardiovascular autonomic neuropathy (CAN) in correlation with serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP). We studied 56 patients with type II DM of >5 years’ duration. Thirty healthy subjects matched for age and sex served as control group. The patients with type II DM were divided into two groups according to the outcome of the autonomic nerve function tests as those with CAN (DM + CAN) and without CAN (DM). Echocardiographic studies were performed to assess ventricular functions. NT-pro-BNP levels were measured in all patients. Subclinical left ventricular diastolic dysfunction was not different between diabetic patients with CAN (84 %) and those without CAN (74.2 %); all of them were classified as impaired relaxation pattern (p > 0.05). Subclinical right ventricular diastolic dysfunction was not also different between diabetic patients with CAN (48 %) and those without CAN (32.3 %) (p > 0.05). The NT-pro-BNP levels were not different between patient groups and not significantly increased in patients with diastolic dysfunction. Multivariate logistic regression analysis demonstrated that only diabetes mellitus was associated with diastolic dysfunction (OR 5.8, 95 % CI 1.7–19.2, p = 0.004). NT-pro-BNP is not significantly elevated in diabetic patients with subclinical mild diastolic dysfunction which is not related to CAN.