The association of oxidative stress and pro-inflammatory cytokines in diabetic patients with hyperglycemic crisis

AimsTo investigate the relationship between oxidative stress and serum levels of pro-inflammatory cytokines in diabetic patients with hyperglycemic crisis.MethodsSeventy-three patients presenting to hospital with diabetic ketoacidosis or non-ketotic hyperglycemia were studied. Superoxide dismutase (SOD) activity, malondialdehyde (MDA) content, total antioxidant capacity (TAC), 8-iso-prostaglandin F2α (8-iso-prostaglandinF2α, 8-iso-PGF2α), tumor necrosis factor receptor-I (TNF-RI), interleukin -1β (IL-1β), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels were measured in all patients. The patients were then given an intravenous infusion of insulin 0.1U • kg-1 • h-1, as well as fluids, symptomatic therapy and parenteral and intravenous nutrition.Results

• 1.Before treatment, SOD and TAC were significantly lower (P < 0.05), whereas MDA and 8-iso-PGF2α were significantly higher (P < 0.05) in patients with hyperglycemic crises compared to controls. After treatment, SOD and TAC significantly increased (P < 0.05), while MDA and 8-iso-PGF2α significantly decreased (P < 0.05).
• 2.TNF-RI, IL-1β, TNF-α and IL-6 were significantly higher, both before and after treatment, in patients with hyperglycemic crises compared to controls (P < 0.05).
• 3.Before treatment, IL-6 and TNF-α were positively correlated with 8-iso-PGF2α (r = 0.32, r = 0.36, P < 0.05) in patients with hyperglycemic crises. After treatment, IL-6 and SOD were negatively correlated within patients (r = − 0.33, P < 0.05). Multiple regression analysis indicated that 8-iso-PGF2α affects the level of serum IL-6.

ConclusionPatients with hyperglycemic crises have significantly increased oxidative stress and dysregulated serum pro-inflammatory cytokines that can be effectively treated by intensive insulin therapy.     

Effects of virgin coconut oil consumption on metabolic syndrome components and asymmetric dimethylarginine: A randomized controlled clinical trial

Background and aimsThere is some promising evidence regarding the beneficial effect of coconut oil on cardiometabolic risk factors. This study aimed to assess the effects of virgin coconut oil (VCO) consumption on metabolic syndrome (MetS) components, as well as, asymmetric dimethylarginine (ADMA) in adults with MetS.Methods and resultsIn this randomized controlled trial, 48 subjects, aged 20–50 years, with MetS were allocated into two groups; the intervention group was given 30 ml of VCO per day to substitute the same amounts of fat in their usual diet for four weeks. The control group was advised to follow their usual diet. VCO consumption significantly reduced serum levels of triglyceride (TG) (P = 0.001), very low-density lipoprotein (VLDL) (P = 0.001), and fasting blood sugar (FBS) (P = 0.015) compared to the control group. The levels of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC) were significantly increased in the VCO group when compared to the control group (P = 0.001). Circulatory ADMA also increased in the VCO group compared to the control group (P = 0.003). No significant differences were observed in the LDL-C/HDL-C ratio, anthropometric parameters, and blood pressure measurements between the two groups at the end of the study (P > 0.05).ConclusionVCO consumption increased the values of HDL-C while reduced TG and FBS levels. Blood pressure and waist circumference did not change. However, levels of TC, LDL-C, and ADMA elevated by VCO consumption. Caution is warranted until the results of further studies become available to explain the long-term effects of VCO consumption.Registration numberIRCT20131125015536N11.     

Risk factors for bleeding in patients with acute necrotizing pancreatitis undergoing endoscopic necrosectomy

BackgroundThis study investigated risk factors for bleeding in patients with acute necrotizing pancreatitis (ANP) undergoing endoscopic necrosectomy (EN) and the effect of endoscopic haemostasis.Methods145 patients with ANP who underwent EN were recruited from January 2014 to December 2018. Patients with and without bleeding were allocated to the bleeding and nonbleeding groups, respectively. Multivariable logistic regression models were used to assess independent risk factors for bleeding.Results39 patients (26.9%) experienced bleeding. The body mass index and culture-confirmed infectious pancreatic necrosis (IPN), renal failure and continuous renal replacement therapy rates were significantly higher in the bleeding group (all P < 0.01). In addition, the number of debridement procedures was significantly higher in the bleeding group (P = 0.004), accompanied by a higher mortality rate and greater hospitalization costs (all P < 0.05). Most cases of bleeding during EN were successfully stopped by endoscopic haemostasis (94.1%), but this was difficult to achieve after EN. Multivariate analysis revealed that renal failure (odds ratio [OR]: 3.77, P = 0.02), culture-confirmed IPN (OR: 3.19, P = 0.02), and ≥3 debridement procedures (OR: 12.92, P = 0.001) were associated with an increased bleeding risk.ConclusionRenal failure, culture-confirmed IPN, and multiple debridement procedures were independent risk factors for bleeding in patients with ANP who underwent EN.     

Arrhythmias in congenital heart disease

Opinion statement  

A machine learning approach identifies modulators of heart failure hospitalization prevention among patients with type 2 diabetes: A revisit to the ACCORD trial

BackgroundTo examine patient characteristics that may modulate the heterogeneous treatment effect of intensive systolic blood pressure control (SBP) and intensive glycemic control on incident heart failure (HF) risk in people with type 2 diabetes.MethodsWe analyzed 10,251 participants from the ACCORD glucose trial, and 4733 from the SBP sub-trial separately. We applied a robust machine-learning (ML) algorithm, namely the causal forest/causal tree analysis, to each trial to identify participants' characteristics that modulate the effectiveness of each trial intervention.ResultsDiastolic blood pressure (DBP) was found to interact with intensive glycemic control and impact outcomes. An increased HF risk associated with intensive glycemic control (absolute risk change (ARC): 2.28 %, 95 % confidence interval (CI): 0.69 % to 3.90 %; relative risk (RR):1.57, 95 % CI: 1.15 to 2.20; P < 0.05) was observed in individuals with baseline DBP at the lowest tertile (45–69 mmHg), while no changes in HF risk associated with intensive glycemic control were observed in individuals with baseline DBP at the middle (70–79 mmHg) and the highest tertiles (80–100 mmHg). Liver function was identified as a modulator of intensive BP control, and baseline Alanine transaminase (ALT) level was a sensitive marker for the modulating effect. Only individuals with baseline ALT at the lowest tertile (8–19 mg/dl) benefited from the intensive BP control for HF prevention (ARC: ?1.95 %, 95 % CI: ?4.06 % to 0.11 %; RR:0.62. 95 % CI: 0.27 to 0.94; P < 0.05).ConclusionsOur study is the first to observe and quantify the potential synergistic harmful effect when low DBP was combined with an intensive blood glucose intervention. Recognizing these may help clinicians develop a more precise approach to such treatments, thus increasing the efficiency and outcomes of diabetes treatments.     

Improving the efficacy of nutritional supplementation in the hospitalised elderly

Background: Protein‐energy malnutrition delays wound healing, extends length of stay, and increases complication rates. Identification of patients at risk of malnutrition, together with early intervention, may prevent further deterioration of nutritional status. Objectives: Through the use of nutrition screening and assessment, prioritise nutrition intervention to those at greatest nutritional risk. To improve the consumption rate of nutritional supplements, using a ‘nutrition as medication’ program. Methods: We assessed 200 acute aged care patients for malnutrition risk using the Mini Nutritional Assessment (MNA) tool (Nestle SA, Vevey, Switzerland) within 72 h of hospital admission. Patients ‘at risk’ or malnourished, received either mid meal supplements (control group) or 60 mL of a 2 kcal per ml supplement, given four times daily (trial group). Outcome measures included comparison of supplement consumption changes in MNA scores on fortnightly reassessment or discharge. Results: Thirty per cent of patients were malnourished on admission, with a further 42%‘at risk’. Patient compliance with the ‘nutrition as medication’ program was excellent (95%) compared with current practice (48%). On reassessment patients in the trial group showed a trend towards a greater improvement in score for appetite (P = 0.065), number of meals consumed (P = 0.01) and protein intake (P = 0.007). Improvement in score for weight was significant in the trial group (P = 0.027). Length of stay was shorter in the trial group (P = 0.044). Conclusion: Routine use of a validated assessment tool is essential for early identification of malnutrition risk. A ‘nutrition as medication’ program is effective in attenuating deterioration in nutritional status.     

Improving Medication Adherence in Patients with Hypertension: A Randomized Trial

Background and Purpose

In patients with hypertension, medication adherence is often suboptimal, thereby increasing the risk of ischemic heart disease and stroke. In a randomized trial, we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients. Motivational interviewing was a key element of the intervention.

Methods

Patients (n = 532) were recruited from 3 hospital outpatient clinics and randomized to usual care or a 6-month pharmacist intervention comprising collaborative care, medication review, and tailored adherence counseling including motivational interviewing and telephone follow-ups. The primary outcome was composite medication possession ratio (MPR) to antihypertensive and lipid-lowering agents, at 1-year follow-up, assessed by analyzing pharmacy records. Secondary outcomes at 12 months included persistence to medications, blood pressure, hospital admission, and a combined clinical endpoint of cardiovascular death, stroke, or acute myocardial infarction.

Results

At 12 months, 20.3% of the patients in the intervention group (n = 231) were nonadherent (MPR <0.80), compared with 30.2% in the control group (n = 285) (risk difference −9.8; 95% confidence interval [CI], −17.3, −2.4) and median MPR (interquartile range) was 0.93 (0.82-0.99) and 0.91 (0.76-0.98), respectively, P = .02. The combined clinical endpoint was reached by 1.3% in the intervention group and 3.1% in the control group (relative risk 0.41; 95% CI, 0.11-1.50). No significant differences were found for persistence, blood pressure, or hospital admission.

Conclusions

A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension. The intervention had no significant impact on blood pressure and secondary clinical outcomes.     

Hemodynamic Profiles and Clinical Response to Transcatheter Mitral Repair

BackgroundPrediction of the clinical response to transcatheter edge-to-edge repair (TEER) remains a vexing challenge.ObjectivesThis study sought to examine the relation between hemodynamic profiles and outcomes following mitral TEER.MethodsAmong 378 patients (median age 82 years; 43.9% women), 3 hemodynamic profiles using residual left atrial pressure (LAP) and mitral regurgitation (MR) were defined: type I (optimal), grade ≤1 MR and mean LAP (mLAP) ≤15 mm Hg; type II (mixed), MR grade >1 or mLAP >15 mm Hg; and type III (poor), MR grade >1 and mLAP >15 mm Hg. The discrimination of these profiles for predicting outcomes was examined. A positive clinical response to TEER was defined as improvement in New York Heart Association functional class ≥I grade at 1 year without heart failure rehospitalization or death.ResultsThere were 148 (39.0%) patients classified as optimal (type I), 187 (49.0%) patients as mixed (type II), and 43 (11.0%) patients as poor (type III). For all-cause mortality, survival at 1 year was 91.6%, 82.6%, and 67.9% for types I, II, and III, respectively (HR: 2.13; 95% CI: 1.44-3.15; P < 0.001). For the composite endpoint of all-cause mortality and rehospitalization for heart failure, event-free survival at 1 year was 84.1%, 70.7%, and 53.2% for types I, II, and III, respectively (HR: 1.93; 95% CI: 1.41-2.65; P < 0.001). Hemodynamic profiling was strongly associated with a positive response to TEER, occurring in 73.9%, 57.0%, 35.0%, for types I, II, and III, respectively (P < 0.001).ConclusionsIn patients undergoing mitral TEER, hemodynamic profiling is prognostic, with superior survival occurring among patients with optimal reduction in MR and normal postprocedural LAP.     

Effects of moderate-intensity resistance exercise on blood glucose and pregnancy outcome in patients with gestational diabetes mellitus: A randomized controlled trial

ObjectivesTo investigate the effects of a structured moderate-intensity resistance exercise program on blood glucose levels and other health-related indicators in patients with GDM.MethodsA total of 99 patients with GDM in a tertiary class A general hospital were randomly divided into an experimental group and a control group. GDM patients in the control group received routine prenatal care, online education, and a personalized diabetes diet intervention. The experimental group was treated in the same way as the control group with the addition of a moderate intensity resistance exercise program.ResultsThe blood glucose levels in both groups were lower after the intervention compared with before intervention (P < 0.05). After intervention, the average fasting blood glucose, the 2 h postprandial blood glucose, the utilization rate of insulin, the amount of insulin, gestational weight gain and blood pressure (P < 0.05) in the experimental group were lower than the control group. In addition, there was no statistical significance in the incidence of adverse pregnancy outcomes between the two groups after intervention (P > 0.05).ConclusionsModerate intensity resistance exercise was helpful for improvement of blood glucose control and insulin use, gestational weight gain and blood pressure in patients with GDM. In the future, long-term follow-up of both maternal and newborn infants should be performed to assess the long-term effects of exercise intervention on maternal and child health. The impact on the risk of obesity and diabetes may need to be further clarified.The trial was approved by the registration of the Chinese Clinical Trial Registry, and registration number: ChiCTR1900027929.     

Progression from biochemical leak to pancreatic fistula after distal pancreatectomy. Don't cry over spilt amylase

BackgroundPostoperative pancreatic fistula (POPF) is a frequent complication after distal pancreatectomy (DP), but its upgrading from biochemical leak (BL) still represents an unexplored phenomenon. This study aims at identifying risk factors of the clinical evolution from BL to grade-B POPF after DP.MethodsPatients who underwent DP between 2015 and 2019 and who developed either BL (n = 89,56%) or BL upgraded to late B fistula (LB) after postoperative day 5 (n = 71,44%) were included. Preoperative, surgical, postoperative predictors were compared between the two groups.ResultsPatients with LB were significantly older (61 vs 56 years, P < 0.025) and received neoadjuvant chemotherapy more frequently (22.5% vs 8.5%,P = 0.017). Extended lymphadenectomy (52.8% vs 31.0%,P = 0.006), longer operative times (OT) (307 vs 250 min,P = 0.002), greater estimated blood loss (250 vs 150 ml, P = 0.021), and the appearance of purulent fluid in surgical drains (58.4% vs 21.1%; P < 0.001) were more frequently observed in LB group. Only purulent fluid in surgical drains and longer OT were confirmed as independent predictors of BL clinical progression.ConclusionsPurulent fluid from surgical drains should be suspicious of BL upgrading. Frail patients undergoing longer interventions may represent key targets of mitigation strategies to minimize the magnitude of an incipient fistula and its increase in morbidity.     

The impact of inspiratory pressure level on prevention of ventilator-associated pneumonia: A double-blind,randomized clinical trial

BackgroundAtelectasis and pneumonia are highly prevalent in patients under mechanical ventilation. Studies indicate that using ventilation with an open lung concept improves recovery, decreases ventilator-related pneumonia, decreases mortality and leads to faster weaning from the ventilator. Therefore, this study investigated the effect of higher airway pressure on ventilator-associated pneumonia.MethodsThis randomized clinical trial was conducted on 120 patients under mechanical ventilation. The patients were divided into two groups based on ventilator pressure: the control group (pressure level 20) and the intervention group (pressure level 30). Demographic data, disease severity, the incidence of ventilator-associated pneumonia, organ damage, days connected to the ventilator, length of hospitalization in ICU, and mortality were compared between the two groups.ResultsThere was no significant difference in demographic data and disease severity between the two groups. The average Clinical Pulmonary Infection Score in the intervention group was significantly lower than the control group (P = 0.02). The intervention group's average Sequential Organ Failure Assessment score was significantly lower than the control group (p = 0.016).ConclusionsHigh-pressure levels can decrease ventilator-associated pneumonia and organ failure. It is recommended that the study be repeated with a larger, more diverse population.     

Food anthocyanins decrease concentrations of TNF-α in older adults with mild cognitive impairment: A randomized,controlled, double blind clinical trial

Background & aimsVascular function, blood pressure and inflammation are involved in the pathogenesis of major chronic diseases, including both cardiovascular disease (CVD) and mild cognitive impairment (MCI). This study investigated the effects of food anthocyanins on microvascular function, 24-h ambulatory blood pressure (ABP) and inflammatory biomarkers in older adults with MCI.Methods and resultsThirty-one participants with MCI [19 female, 12 male, mean age 75.3 (SD 6.9) years and body mass index 26.1 (SD 3.3) kg/m²], participated in a randomized, controlled, double-blind clinical trial (Australian New Zealand Clinical Trials Registry: ACTRN12618001184268). Participants consumed 250 mL fruit juice daily for 8 weeks, allocated into three groups: a) high dose anthocyanins (201 mg); b) low dose anthocyanins (47 mg); c) control. Microvascular function (Laser Speckle Contrast Imaging combined with a post-occlusive reactive hyperaemia test), 24h ABP and serum inflammatory biomarkers were assessed before and after the nutritional intervention.ResultsParticipants in the high anthocyanins group had a reduction in serum tumor necrosis factor alpha (TNF-α) (P = 0.002) compared to controls and the low anthocyanins group (all P's > 0.05). Serum IL-6, IL-1β, c-reactive protein, and parameters of microvascular function and 24h ABP were not altered by any treatment.ConclusionA daily high dose of fruit-based anthocyanins for 8 weeks reduced concentrations of TNF-α in older adults with MCI. Anthocyanins did not alter other inflammatory biomarkers, microvascular function or blood pressure parameters. Further studies with a larger sample size and longer period of follow-up are required to elucidate whether this change in the immune response will alter CVD risk and progression of cognitive decline.     

Effects of fish oil and curcumin supplementation on cerebrovascular function in older adults: A randomized controlled trial

Background and aimsChronic conditions such as obesity, which contribute to endothelial dysfunction in older adults, can cause impairments in cerebrovascular perfusion, which is associated with accelerated cognitive decline. Supplementing the diet with bioactive nutrients that can enhance endothelial function, such as fish oil or curcumin, may help to counteract cerebrovascular dysfunction.Methods and resultsA 16-week double-blind, randomized placebo-controlled trial was undertaken in 152 older sedentary overweight/obese adults (50–80 years, body mass index: 25–40 kg/m²) to investigate effects of fish oil (2000 mg docosahexaenoic acid + 400 mg eicosapentaenoic acid/day), curcumin (160 mg/day) or a combination of both on cerebrovascular function (measured by Transcranial Doppler ultrasound), systemic vascular function (blood pressure, heart rate and arterial compliance) and cardiometabolic (fasting glucose and blood lipids) and inflammatory (C-reactive protein) biomarkers. The primary outcome, cerebrovascular responsiveness to hypercapnia, was not affected by the interventions. However, cerebral artery stiffness was significantly reduced in males following fish oil supplementation (P = 0.007). Furthermore, fish oil reduced heart rate (P = 0.038) and serum triglycerides (P = 0.006) and increased HDL cholesterol (P = 0.002). Curcumin did not significantly affect these outcomes either alone or in combination with fish oil.ConclusionRegular supplementation with fish oil but not curcumin improved biomarkers of cardiovascular and cerebrovascular function. The combined supplementation did not result in additional benefits. Further studies are warranted to identify an efficacious curcumin dose and to characterize (in terms of sex, BMI, cardiovascular and metabolic risk factors) populations whose cerebrovascular and cognitive functions might benefit from either intervention.Clinical trial registrationACTRN12616000732482p.     

The prognostic role of fatigue,depression and anxiety on postoperative outcomes after pancreatectomy for pancreatic cancer. A prospective observational study (FAT-PRO study)

ObjectivesThis study aims to assess the prevalence of preoperative fatigue, depression and anxiety among patients undergoing pancreatic surgery for pancreatic cancer (PC), and possible relationship with postoperative outcomes.MethodsProspective data from 162 consecutive patients undergoing pancreatectomy for PC at a third-level referral centers for pancreatic surgery were collected. All patients preoperatively completed four questionnaires assessing depression (PHQ-9), anxiety (STAI-Y2), chronic illness fatigue (FACIT-F) and cancer therapy fatigue (FACT-G).ResultsForty patients (25%) where in the first quartile for chronic illness (FACIT-F ≤34) and/or cancer therapy (FACT-G ≤78) fatigue, 26 patients (16%) met the criteria for major depression (PHQ-9 ≥10) and 34 patients (21%) had anxiety symptoms (STAI-Y2 ≥40). Cancer therapy fatigue was significantly associated with higher rates of morbidity (70% vs 49%), major morbidity (Clavien-Dindo ≥3) (28% vs 11%), post-pancreatectomy hemorrhage (18% vs 4%), pulmonary complications (20% vs 9%) and mortality (8% vs null) (all P ≤ 0.01). Major depression was associated with higher rates of post-pancreatectomy hemorrhage and readmission (23% vs 5%). Multivariable logistic regression analysis of preoperative factors confirmed diabetes (OR 2.71, 95%CI 1.01–7.20; P = 0.04), ASA score ≥3 (OR 4.12, 95%CI 1.52–11.21; P < 0.01) and cancer therapy fatigue (OR 2.95, 95%CI 1.01–8.74; P = 0.04) to be independent predictors of major morbidity.ConclusionsHigher levels of fatigue (in particular cancer therapy fatigue) strongly correlates with worse postoperative outcomes.     

“Assessing the hemodynamic impact of various inotropes combination in patients with cardiogenic shock with Non-ST elevation myocardial infarction –the ANAPHOR study”

BackgroundVarious inotropic agents/vasopressors combinations are used in patients of cardiogenic shock. We performed this study to observe hemodynamic effects of various inotrope/vasopressor combinations in patients with NSTEMI cardiogenic shock (CS) at tertiary cardiac centreMethods and materialsOf 3832 NSTEMI, we studied 59 consecutive such patients with CS who hadn't undergone revascularization in the first 24 h in a prospective, open label, observational study. Group 1 comprised of background Dopamine with Noradrenaline titration(N = 38), Group 2 had background Dobutamine and Noradrenaline titration(N = 15) and Group 3 comprised of triple combination of Dopamine, Noradrenaline & Adrenaline(N = 6).ResultsThe mean change in hemodynamic parameters between these groups from baseline to 24 h showed no statistical difference. Cardiac output(CO), mean arterial pressure(MAP), central venous pressure(CVP) and cardiac power output(CPO) in group 2 were favorable at 6 and 24 h compared to baseline but mean change was insignificant as compared to others. In group 3, the increase in MAP was significant. IABP use did not change CO, CPO or SVR in any group except lower dosages of Dobutamine (49%) in IABP group. Lower in-hospital mortality in group 2 compared to others (P = 0.004) may be reflective of sicker patients in group 1 and 3.ConclusionThe mean changes in hemodynamic parameters were not significant between all groups. All regimes of inotropes when selected as per clinical indication in CS with ACS resulted in similar hemodynamic effects. The mortality difference may not truly be reflective of regimes rather reflect sicker patients in the higher mortality group.     

The impact of a telehealth intervention on the metabolic profile of diabetes mellitus patients during the COVID-19 pandemic - A randomized clinical trial

ObjectivesThe objective of this study was to evaluate the impact of a telehealth intervention on metabolic outcomes and self-perceptions of the patients regarding their management of diabetes during the COVID-19 pandemic.MethodsThis is a non-blind randomized controlled clinical trial to assess a telehealth intervention. We included adults with diabetes mellitus. The outcomes assessed were the level of HbA1c, lipid profile, blood pressure levels, weight, body mass index and self-perceptions about diabetes management.ResultsA total of 150 individuals with diabetes participated in the study and at the end of telehealth intervention there were no changes in the patient’s HbA1c levels between intervention and control groups for neither type 1 (8.1% vs. 8.6%; p = 0.11) nor type 2 diabetes (8.6% vs. 9.0%; p = 0.09), respectively. From the rest of the metabolic profile, triglyceride levels from type 1 diabetes group was the only variable that demonstrated improvement with telehealth intervention (66.5% intervention group vs. 86.5% control group; p = 0.05).ConclusionsAfter 4 months of telehealth intervention, no statistically significant results were observed in HbA1c nor in secondary outcomes (with the exception of triglycerides for the type 1 diabetes group).     

Long-Term Follow-Up of Hypoattenuated Leaflet Thickening After Transcatheter Aortic Valve Replacement

BackgroundEarly hypoattenuated leaflet thickening (HALT) occurs in at least 10% of all transcatheter aortic valve replacement (TAVR) patients. The long-term prognostic impact of HALT is uncertain.ObjectivesThe aim of this study was to assess the long-term risk of early HALT post-TAVR.MethodsWe report outcome data from our prospective observational registry with post-TAVR computed tomography angiography performed between May 2012 and December 2017. The outcomes were survival, cardiovascular mortality, ischemic cerebrovascular events, and symptomatic hemodynamic valve deterioration.ResultsEarly HALT was diagnosed in 115 (16.0%) of 804 patients. During a median follow-up of 3.25 years, survival rates did not differ significantly between patients with and without HALT (Kaplan-Meier 3-year estimates for survival 70.1% vs 74.0%, P = 0.597). The 3-year cardiovascular mortality rate was 13.2% versus 11.3% (with vs without HALT, P = 0.733). The 3-year event rate for cerebrovascular events was 2.0% versus 4.4% (with vs without HALT, P = 0.246), and the 3-year event rate of symptomatic hemodynamic valve deterioration was 9.4% versus 1.5% (with vs without HALT, P < 0.001). Multivariable analysis revealed the following predictors of symptomatic hemodynamic valve deterioration: HALT (HR: 6.10; 95% CI: 2.59-14.29; P < 0.001), the mixed valve–type group (HR: 6.51; 95% CI: 2.38-17.81; P < 0.001), and prosthesis diameter (HR valve size per 3 mm [HR: 0.37; 95% CI: 0.17-0.79]; P = 0.011).ConclusionsDuring a median follow-up of more than 3 years, HALT was not associated with mortality or cerebrovascular events. However, we observed an association of HALT with symptomatic hemodynamic valve deterioration.     

Should associating liver partition and portal vein ligation for staged hepatectomy be applied to hepatitis B virus-related hepatocellular carcinoma patients with cirrhosis? A multi-center study

BackgroundIt is unclear whether associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be performed in hepatitis B virus-related hepatocellular carcinoma (HCC) patients with cirrhosis. We explored the efficacy of ALPPS in HCC patients.MethodsData of 54 patients who underwent ALPPS between August 2014 and July 2020 at three centers were collected. Adverse factors affecting their prognosis were analyzed and subsequently compared with 184 patients who underwent transcatheter arterial chemoembolization (TACE).ResultsOverall survival rates of the ALPPS group at 1, 3, and 5 years were 70.6%, 38.4%, and 31.7%, respectively; corresponding disease-free survival rates were 50.5%, 22.4%, and 19.2%, respectively. The ALPPS group had a significantly greater long-term survival rate than the TACE group (before propensity score matching, P < 0.001; after propensity score matching, P = 0.002). Multivariate analysis demonstrated that multifocal lesions (P = 0.018) and macroscopic vascular invasion (P = 0.001) were prognostic factors for HCC patients who underwent ALPPS. After the propensity score matching, the multifocal lesions (P = 0.031), macroscopic vascular invasion (P = 0.003), and treatment type (ALPPS/TACE) (P = 0.026) were the factors adversely affecting the prognosis of HCC patients.ConclusionALPPS was feasible in hepatitis B virus-related HCC patients with cirrhosis and resulted in better survival than TACE.     

Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy

BackgroundSelect patients with acute cholecystitis (AC) are not candidates for index cholecystectomy. We compared the influence of ERCP-guided transpapillary gallbladder drainage (ERGD) versus percutaneous cholecystostomy (PC) on delayed cholecystectomy outcomes.MethodsConsecutive patients undergoing ERGD or PC for AC from January 2007 to October 2018 were included. Primary outcome was the rate of conversion to open cholecystectomy and perioperative complications in groups.ResultsThe study included 52 patients with ERGD and 140 with PC prior to cholecystectomy (median 68 days [IQR: 47–105.5]). Technical success was higher in the PC group (100% vs 91%; P = 0.0004). There was a nonsignificant trend to lower postoperative complications with ERGD (30.7% vs 43.5%; P = 0.07). No difference in conversion to open cholecystectomy OR: 1.5 (95% CI: 0.68–3.65; P = 0.28) or severity of complications (Clavien-Dindo grade >2) OR: 0.60, (95% CI: 0.19–1.87; P = 0.38) was noted between the ERGD and PC groups. PC was associated with higher rates of unplanned repeat intervention (16.4% vs 7.7%; P = 0.02).ConclusionERGD is suitable for patients with AC who is candidates for delayed cholecystectomy and should be considered for gallbladder drainage in patients with concomitant choledocholithiasis or cholangitis who require ERCP.