Metabolic syndrome vs. its components for prediction of cardiovascular mortality: A cohort study in Chinese elderly adults

Objectives The predictive value of the metabolic syndrome (MetS) for mortality from all-cause and cardiovascular disease (CVD) in the Chinese population is unclear. The aim of this present study was to compare MetS with its individual components as predictors of mortality in Chinese elderly adults. Methods A cohort of 1,535 subjects (994 men and 541 women) aged 50 years or older was selected from employees of a machinery factory in 1994 and followed until 2009. Cox models were used to estimate the hazard ratios (HRs) predicted by MetS according to the harmonized definition and by its individual components. Results The baseline prevalence of MetS was 28.0% in men and 48.4% in women. During a median follow-up of 15 years, 414 deaths occurred, of these, 153 participants died from CVD. Adjusted for age and gender, the HRs of mortality from all-cause and CVD in participants with MetS were 1.47 (95% confidence interval (CI): 1.20–1.80) and 1.96 (95%CI: 1.42–2.72), respectively, compared with those without MetS. Non-significant higher risk of CVD mortality was seen in those with one or two individual components (HR = 1.22, 95%CI: 0.59–2.50; HR = 1.82, 95%CI: 0.91–3.64, respectively), while a substantially higher risk of CVD mortality only appeared in those with 3, 4, or 5 components (HR = 2.81–3.72), compared with those with no components. On evaluating the MetS components individually, we found that, independent of MetS, only hypertension and impaired glucose predicted higher mortality. Conclusions The number of positive MetS components seems no more informative than classifying (dichotomous) MetS for CVD risks assessment in this Chinese cohort.     

Serum bicarbonate and mortality in stage 3 and stage 4 chronic kidney disease

Summary

Background and objectives

The incidence and prevalence of metabolic acidosis increase with declining kidney function. We studied the associations of both low and high serum bicarbonate levels with all-cause mortality among stage 3 and 4 chronic kidney disease (CKD) patients.

Design, setting, participants, & measurements

We examined factors associated with low (<23 mmol/L) and high (>32 mmol/L) serum bicarbonate levels using logistic regression models and associations between bicarbonate and all-cause mortality using Cox-proportional hazard models, Kaplan–Meier survival curves, and time-dependent analysis.

Results

Out of 41,749 patients, 13.9% (n = 5796) had low and 1.6% (n = 652) had high serum bicarbonate levels. After adjusting for relevant covariates, there was a significant association between low serum bicarbonate and all-cause mortality (hazard ratio [HR] 1.23, 95% CI 1.16, 1.31). This association was not statistically significant among patients with stage 4 CKD and diabetes. The time-dependent analysis demonstrated a significant mortality risk associated with a decline from normal to low bicarbonate level (HR 1.59, 95% CI 1.49, 1.69). High serum bicarbonate levels were associated with death irrespective of the level of kidney function (HR 1.74, 95% CI 1.52, 2.00). When serum bicarbonate was examined as a continuous variable, a J-shaped relationship was noted between serum bicarbonate and mortality.

Conclusions

Low serum bicarbonate levels are associated with increased mortality among stage 3 CKD patients and patients without diabetes. High serum bicarbonate levels are associated with mortality in both stage 3 and stage 4 CKD patients.     

Serum uric acid as a prognostic marker in the setting of advanced vascular disease: a prospective study in the elderly

Background Many epidemiological studies analyze the relationship between hyperuricemia and cardiovascular outcomes. This observational prospective study investigates the association of serum uric acid (SUA) levels with adverse cardiovascular events and deaths in an elderly population affected by advanced atherosclerosis. Methods Two hundred and seventy six elderly patients affected by advanced atherosclerosis (217 males and 59 females; aged 71.2 ± 7.8 years) were included. All patients were assessed for history of cardiovascular disease, cancer, obesity and traditional risk factors. Patients were followed for approximately 31 ± 11 months. Major events were recorded during follow-up, defined as myocardial infarction, cerebral ischemia, myocardial and/or peripheral revascularization and death. Results Mean SUA level was 5.47 ± 1.43 mg/dL; then we further divided the population in two groups, according to the median value (5.36 mg/dL). During a median follow up of 31 months (5 to 49 months), 66 cardiovascular events, 9 fatal cardiovascular events and 14 cancer-related deaths have occurred. The patients with increased SUA level presented a higher significant incidence of total cardiovascular events (HR: 1.867, P = 0.014, 95%CI: 1.134–3.074). The same patients showed a significant increased risk of cancer-related death (HR: 4.335, P = 0.025, 95%CI: 1.204–15.606). Conclusions Increased SUA levels are independently and significantly associated with risk of cardiovascular events and cancer related death in a population of mainly elderly patients affected by peripheral vasculopathy.     

Thromboembolic events among adult patients with primary immune thrombocytopenia in the United Kingdom General Practice Research Database

Background

The risk of thromboembolic events in adults with primary immune thrombocytopenia has been little investigated despite findings of increased susceptibility in other thrombocytopenic autoimmune conditions. The objective of this study was to evaluate the risk of thromboembolic events among adult patients with and without primary immune thrombocytopenia in the UK General Practice Research Database.

Design and Methods

Using the General Practice Research Database, 1,070 adults (≥18 years) with coded records for primary immune thrombocytopenia first referenced between January 1^st 1992 and November 30^th 2007, and having at least one year pre-diagnosis and three months post-diagnosis medical history were matched (1:4 ratio) with 4,280 primary immune thrombocytopenia disease free patients by age, gender, primary care practice, and pre-diagnosis observation time. The baseline prevalence and incidence rate of thromboembolic events were quantified, with comparative risk modelled by Cox’s proportional hazards regression.

Results

Over a median 47.6 months of follow-up (range: 3.0–192.5 months), adjusted hazard ratios of 1.58 (95% CI, 1.01–2.48), 1.37 (95% CI, 0.94–2.00), and 1.41 (95% CI, 1.04–1.91) were found for venous, arterial, and combined (arterial and venous) thromboembolic events, respectively, when comparing the primary immune thrombocytopenia cohort with the primary immune thrombocytopenia disease free cohort. Further event categorization revealed an elevated incidence rate for each occurring venous thromboembolic subtype among the adult patients with primary immune thrombocytopenia.

Conclusions

Patients with primary immune thrombocytopenia are at increased risk for venous thromboembolic events compared with patients without primary immune thrombocytopenia.     

Survival Trends of US Dialysis Patients with Heart Failure: 1995 to 2005

Summary

Background and objectives

Congestive heart failure (CHF) is a major risk factor for death in end-stage kidney disease; however, data on prevalence and survival trends are limited. The objective of this study was to determine the prevalence and mortality effect of CHF in successive incident dialysis cohorts.

Design, setting, participants, & measurements

This was a population-based cohort of incident US dialysis patients (n = 926,298) from 1995 to 2005. Age- and gender-specific prevalence of CHF was determined by incident year, whereas temporal trends in mortality were compared using multivariable Cox regression.

Results

The prevalence of CHF was significantly higher in women than men and in older than younger patients, but it did not change over time in men (range 28% to 33%) or women (range 33% to 36%). From 1995 to 2005, incident death rates decreased for younger men (≤70 years) and increased for older men (>70 years). For women, the pattern was similar but less impressive. During this period, the adjusted mortality risks (relative risk [RR]) from CHF decreased in men (from RR = 1.06 95% Confidence intervals (CI) 1.02–1.11 in 1995 to 0.91 95% CI 0.87–0.96 in 2005) and women (from RR = 1.06 95% CI 1.01–1.10 in 1995 to 0.90 95% CI 0.85–0.95 in 2005 compared with referent year 2000; RR = 1.00). The reduction in mortality over time was greater for younger than older patients (20% to 30% versus 5% to 10% decrease per decade).

Conclusions

Although CHF remains a common condition at dialysis initiation, mortality risks in US patients have declined from 1995 to 2005.     

General Practitioners’ Judgment of their Elderly Patients’ Cognitive Status

Background

General practitioners (GP) play an important role in detecting cognitive impairment among their patients.

Objectives

To explore factors associated with GPs’ judgment of their elderly patients’ cognitive status.

Design

Cross-sectional data from an observational cohort study (AgeCoDe study); General practice surgeries in six German metropolitan study centers; home visits by interviewers.

Participants

138 GPs, 3,181 patients (80.13 ± 3.61 years, 65.23% female).

Measurements

General practitioner questionnaire for each patient: familiarity with the patient, patient morbidity, judgment of cognitive status. Home visits by trained interviewers: sociodemographic and clinical data, psychometric test performance. Multivariate regression analysis was used to identify independent associations with the GPs’ judgment of “cognitively impaired” vs. “cognitively unimpaired.”

Results

Less familiar patients (adjusted odds ratio [aOR] 2.42, 95% CI 1.35–4.32, for poor vs. very high familiarity), less mobile patients (aOR 1.29, 95% CI 1.13–1.46), patients with impaired hearing (aOR 5.46, 95% CI 2.35–12.67 for serious vs. no problems), and patients with greater comorbidity (aOR 1.15, 95% CI 1.08–1.22) were more likely to be rated as “cognitively impaired” by their GPs.

Conclusions

The associations between GPs’ assessments of cognitive impairment and their familiarity with their patients and patients’ mobility, hearing, and morbidity provide important insights into how GPs make their judgments.KEY WORDS: general practice, cognition, dementia, clinical judgment     

Glycated Hemoglobin Level and Mortality in a Nondiabetic Population with CKD

Background and objectives

Glycated hemoglobin (HbA_1c) is used to diagnose diabetes mellitus (DM) and guide its management. The association between higher HbA_1c and progression to ESRD and mortality has been demonstrated in populations with DM. This study examined the association between HbA_1c and these end points in a population with CKD and without DM.

Design, setting, participants, & measurements

In the hospital-based NephroTest cohort study, measured GFR (mGFR) was taken by ⁵¹Cr-EDTA renal clearance and HbA_1c in 1165 adults with nondialysis CKD stages 1–5 and without DM between January 2000 and December 2010. The median follow-up was 3.48 years (interquartile range, 1.94–5.82) for the competing events of ESRD and pre-ESRD mortality. Time-fixed and time-dependent Cox models were used to estimate hazard ratios (HRs) for ESRD and mortality according to HbA_1c, treated continuously or in tertiles.

Results

At inclusion, the mean mGFR was 42.2±19.9 ml/min per 1.73 m², and the mean HbA_1c value was 5.5%±0.5%. During follow-up, 109 patients died, and 162 patients reached ESRD. Pre-ESRD mortality was significantly associated with HbA_1c treated continuously: for every 1% higher HbA_1c, the crude HR was 2.16 (95% confidence interval [95% CI], 1.27 to 3.68), and it was 1.85 (95% CI, 1.05 to 3.24) after adjustment for mGFR and other risk factors of death. After excluding incident diabetes over time, the updated mean of HbA_1c remained significantly associated with higher mortality risk: adjusted HR for the highest (5.7%–6.4%) versus the lowest tertile (<5.3%) was 2.62 (95% CI, 1.16 to 5.91). There was no association with ESRD risk after adjustment for risk factors of CKD progression.

Conclusions

In a CKD cohort, HbA_1c values in the prediabetes range are associated with mortality. Such values should be therefore included among the risk factors for negative outcomes in CKD populations.     

Unresectable pancreatic adenocarcinoma: do we know who survives?

Background

This study attempts to define clinical predictors of survival in patients with unresectable pancreatic adenocarcinoma (UPA).

Methods

A retrospective study of 94 consecutive patients diagnosed with UPA from 2001 to 2006 was performed. Using data for these patients, a symptom score was devised through a forward stepwise Cox proportional hazards model based on four weighted criteria: weight loss of >10% of body weight; pain; jaundice, and smoking. The symptom score was subsequently validated in a distinct cohort of 32 patients diagnosed with UPA in 2007.

Results

In the original cohort, the overall median survival was 9.0 months (95% confidence interval [CI] 7.6–10.4). This altered to 10.3 months (95% CI 6.1–14.5) in patients with locally advanced disease, and 6.6 months (95% CI 4.2–9.0) in patients with distant metastasis. Median survival was 14.6 months (95% CI 13.1–16.1) in patients with a low symptom (LS) score and 6.3 months (95% CI 4.1–8.5) in patients with a high symptom (HS) score. A total of 73% of LS score patients survived beyond 9 months, compared with only 38% of HS score patients (P < 0.001). The discrimination of the LS score was greater than that of any conventional method, including imaging. The validation cohort confirmed the discriminative ability of the symptom score for survival.

Conclusions

A simple and clinically meaningful point-based symptom score can successfully predict survival in patients with UPA.     

Self-Rated Health and Adverse Events in CKD

Background and objectives

Little is known about the utility of self-rated general health assessments in persons with moderate-to-severe CKD. This study examined the ability of a single self-rated health measure to predict all-cause mortality and kidney disease progression in a cohort of 443 patients with stages 3–4 CKD, recruited between 2005 and 2011, and followed until the end of 2012. The performance of models incorporating self-rated health measures was compared with previously published predictive models and more complex models comprising a multibiomarker panel.

Design, setting, participants, & measurements

Participants were asked “In general, would you say your health is excellent, very good, good, fair, or poor?” Outcomes examined were time to all-cause mortality, kidney disease progression (initiation of RRT or 30% loss of eGFR), and a composite of these events. Model performances were compared using a nonparametric area under the curve (AUC) analysis.

Results

Over a median follow-up of 3.3 years, 118 (27%) participants died and 138 (31%) had progression of kidney disease. Fair-to-poor self-rated health status was associated with significantly greater risks of mortality (fully adjusted hazard ratio [HR] for relative to good-to-excellent self-rated health, 2.76; 95% confidence interval [95% CI], 1.28 to 5.89), kidney disease progression (HR, 1.94; 95% CI, 1.49 to 2.56), and the combined end point (HR, 2.21; 95% CI, 1.66 to 2.96). For 3-year mortality prediction, the self-rated health model (AUC, 0.80; 95% CI, 0.76 to 0.85) had significantly higher AUCs than the base model (AUC, 0.71; 95% CI, 0.66 to 0.76) and the multibiomarker panel model (AUC, 0.74; 95% CI, 0.68 to 0.80) (P=0.03 and P=0.04, respectively).

Conclusions

A single, easily obtained measure of self-rated health helps identify patients with CKD at high risk of mortality and kidney disease progression. Routine evaluation of self-rated health may help target individuals who might benefit from more intensive monitoring strategies.     

Impact of diabetes mellitus on pneumonia mortality in a senior population: results from the NHANES III follow-up study

Objective To examine whether diabetes mellitus increases the risk of pneumonia mortality among seniors in the U.S. general popula-tion. Methods&Results The NHANES III follow-up study data were used. Af...     

Invasive cardiac procedure use and mortality among South Asian and Chinese Canadians with coronary artery disease

BACKGROUND:

Previous studies evaluated cardiac procedure use and outcome over the short term, with relatively few Asian patients included.

OBJECTIVES:

To determine the likelihood of undergoing percutaneous coronary intervention and coronary artery bypass grafting, and survival during 10.5 years of follow-up after coronary angiography among South Asian, Chinese and other Canadian patients.

METHODS:

Using prospective cohort study data from two large Canadian provinces, 3061 South Asian, 1473 Chinese and 77,314 other Canadian patients with angiographically proven coronary artery disease from 1995 to 2004 were assessed, and their revascularization and mortality rates during 10.5 years of follow-up were determined.

RESULTS:

Compared with other Canadian patients, South Asian and Chinese patients were slightly less likely to undergo revascularization (risk-adjusted HR 0.94, 95% CI 0.90 to 0.98 for South Asian patients; and HR 0.94, 95% CI 0.88 to 1.00 for Chinese patients). However, South Asian patients underwent coronary artery bypass grafting (HR 1.00, 95% CI 0.94 to 1.07) and Chinese patients underwent percutaneous coronary intervention (HR 0.96, 95% CI 0.89 to 1.04) as frequently as other Canadian patients. Although the 30-day mortality rate was similar across the three ethnic groups, the mortality rate in the follow-up period was significantly lower for South Asian patients (HR 0.76, 95% CI 0.61 to 0.95) and marginally lower for Chinese patients (HR 0.80, 95% CI 0.60 to 1.07) compared with other Canadian patients.

CONCLUSIONS:

South Asian and Chinese patients used revascularization slightly less but had better survival outcomes than other Canadian patients. The factors underlying the better outcomes for South Asian and Chinese patients warrant further study.     

Nephrolithiasis as a Risk Factor for CKD: The Atherosclerosis Risk in Communities Study

Background and objectives

Previous studies demonstrated a higher risk of CKD in persons with a history of kidney stones, but these studies examined mostly white populations and did not evaluate important potential interactions such as race and plasma uric acid.

Design, setting, participants, & measurements

In 10,678 Atherosclerosis Risk in Communities (ARIC) study participants free of CKD at baseline (ARIC visit 4 in 1996–1998), we assessed the association between a history of nephrolithiasis (a time-varying variable, defined by a combination of self-report and diagnostic codes) and incident CKD (defined by diagnostic codes from linkage to hospitalizations and US Centers for Medicare and Medicaid Services’ records).

Results

At baseline, 856 participants had a history of nephrolithiasis; 322 developed nephrolithiasis during follow-up. Over a mean follow-up of 12 years, there were 1037 incident CKD events. Nephrolithiasis history was associated with a 29% (hazard ratio [HR], 1.29; 95% confidence interval [95% CI], 1.07 to 1.54) higher risk of CKD in demographic-adjusted analyses, but the association was no longer statistically significant after multivariable adjustment (HR, 1.09; 95% CI, 0.90 to 1.32). The multivariable-adjusted association was stronger among participants with plasma uric acid levels ≤6 mg/dl (HR, 1.34; 95% CI, 1.05 to 1.72) compared with those with levels >6 mg/dl (HR, 0.94; 95% CI, 0.70 to 1.28; P_interaction=0.05). There was no interaction of stone disease and race with incident CKD.

Conclusions

In this community-based cohort, nephrolithiasis was not an independent risk factor for incident CKD overall. However, risk of CKD was unexpectedly elevated in participants with stone disease and lower plasma uric acid levels.     

Acute kidney injury episodes and chronic kidney disease risk in diabetes mellitus

Summary

Background and objectives

Prior studies have examined long-term outcomes of a single acute kidney injury (AKI) event in hospitalized patients. We examined the effects of AKI episodes during multiple hospitalizations on the risk of chronic kidney disease (CKD) in a cohort with diabetes mellitus (DM).

Design, setting, participants, & measurements

A total of 4082 diabetics were followed from January 1999 until December 2008. The primary outcome was reaching stage 4 CKD (GFR of <30 ml/min per 1.73 m²). AKI during hospitalization was defined as >0.3 mg/dl or a 1.5-fold increase in creatinine relative to admission. Cox survival models examined the effect of first AKI episode and up to three episodes as time-dependent covariates, on the risk of stage 4 CKD. Covariates included demographic variables, baseline creatinine, and diagnoses of comorbidities including proteinuria.

Results

Of the 3679 patients who met eligibility criteria (mean age = 61.7 years [SD, 11.2]; mean baseline creatinine = 1.10 mg/dl [SD, 0.3]), 1822 required at least one hospitalization during the time under observation (mean = 61.2 months [SD, 25]). Five hundred thirty of 1822 patients experienced one AKI episode; 157 of 530 experienced ≥2 AKI episodes. In multivariable Cox proportional hazards models, any AKI versus no AKI was a risk factor for stage 4 CKD (hazard ratio [HR], 3.56; 95% confidence interval [CI], 2.76, 4.61); each AKI episode doubled that risk (HR, 2.02; 95% CI, 1.78, 2.30).

Conclusions

AKI episodes are associated with a cumulative risk for developing advanced CKD in diabetes mellitus, independent of other major risk factors of progression.     

Associations of Soluble CD14 and Endotoxin with Mortality,Cardiovascular Disease,and Progression of Kidney Disease among Patients with CKD

Background and objectives

CD14 plays a key role in the innate immunity as pattern-recognition receptor of endotoxin. Higher levels of soluble CD14 (sCD14) are associated with overall mortality in hemodialysis patients. The influence of kidney function on plasma sCD14 levels and its relationship with adverse outcomes in patients with CKD not yet on dialysis is unknown. This study examines the associations between plasma levels of sCD14 and endotoxin with adverse outcomes in patients with CKD.

Design, setting, participants, & measurements

We measured plasma levels of sCD14 and endotoxin in 495 Leuven Mild-to-Moderate CKD Study participants. Mild-to-moderate CKD was defined as presence of kidney damage or eGFR<60 ml/min per 1.73 m² for ≥3 months, with exclusion of patients on RRT. Study participants were enrolled between November 2005 and September 2006.

Results

Plasma sCD14 was negatively associated with eGFR (ρ=–0.34, P<0.001). During a median follow-up of 54 (interquartile range, 23–58) months, 53 patients died. Plasma sCD14 was predictive of mortality, even after adjustment for renal function, Framingham risk factors, markers of mineral bone metabolism, and nutritional and inflammatory parameters (hazard ratio [HR] per SD higher of 1.90; 95% confidence interval [95% CI],1.32 to 2.74; P<0.001). After adjustment for the same risk factors, plasma sCD14 was also a predictor of cardiovascular disease (HR, 1.30; 95% CI, 1.00 to 1.69; P=0.05). Although plasma sCD14 was associated with progression of CKD, defined as reaching ESRD or doubling of serum creatinine in models adjusted for CKD-specific risk factors (HR, 1.24; 95% CI, 1.01 to 1.52; P=0.04), significance was lost when adjusted for proteinuria (HR, 1.19; 95% CI, 0.96 to 1.48; P=0.11). There was neither correlation between plasma endotoxin and sCD14 (ρ=–0.06, P=0.20) nor was endotoxin independently associated with adverse outcome during follow-up.

Conclusions

Plasma sCD14 is elevated in patients with decreased kidney function and associated with mortality and cardiovascular disease in patients with CKD not yet on dialysis.     

Vascular Calcification in Patients with Nondialysis CKD over 3 Years

Background and objectives

Vascular calcification (VC) is common in CKD, but little is known about its prognostic effect on patients with nondialysis CKD. The prevalence of VC and its ability to predict death, time to hospitalization, and renal progression were assessed.

Design, setting, participants, & measurements

The Study of Mineral and Bone Disorders in CKD in Spain is a prospective, observational, 3-year follow-up study of 742 patients with nondialysis CKD stages 3–5 from 39 centers in Spain from April to May 2009. VC was assessed using Adragao (AS; x-ray pelvis and hands) and Kauppila (KS; x-ray lateral lumbar spine) scores from 572 and 568 patients, respectively. The primary end point was death. Secondary outcomes were hospital admissions and appearance of a combined renal end point (beginning of dialysis or drop >30% in eGFR). Factors related to VC were assessed by logistic regression analysis. Survival analysis was assessed by Cox proportional models.

Results

VC was present in 79% of patients and prominent in 47% (AS≥3 or KS>6). Age (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 1.02 to 1.07; P<0.001), phosphorous (OR, 1.68; 95% CI, 1.28 to 2.20; P<0.001), and diabetes (OR, 2.11; 95% CI, 1.32 to 3.35; P=0.002) were independently related to AS≥3. After a median follow-up of 35 months (interquartile range=17–36), there were 70 deaths (10%). After multivariate adjustment for age, smoking, diabetes, comorbidity, renal function, and level of phosphorous, AS≥3 but not KS>6 was independently associated with all-cause (hazard ratio [HR], 2.07; 95% CI, 1.07 to 4.01; P=0.03) and cardiovascular (HR, 3.46; 95% CI, 1.27 to 9.45; P=0.02) mortality as well as a shorter hospitalization event–free period (HR, 1.14; 95% CI, 1.06 to 1.22; P<0.001). VC did not predict renal progression.

Conclusions

VC is highly prevalent in patients with CKD. VC assessment using AS independently predicts death and time to hospitalization. Therefore, it could be a useful index to identify patients with CKD at high risk of death and morbidity as previously reported in patients on dialysis.     

Evaluation of prognostic factors among patients with chronic graft-versus-host disease

Background

Chronic graft-versus-host disease (cGVHD) is a major complication after allogeneic stem cell transplantation with an adverse effect on both mortality and morbidity. In 2005, the National Institute of Health proposed new criteria for diagnosis and classification of chronic graft-versus-host disease for clinical trials. New sub-categories were recognized such as late onset acute graft-versus-host disease and overlap syndrome.

Design and Methods

We evaluated the prognostic impact of the new sub-categories as well as the clinical scoring system proposed by the National Institute of Health in a retrospective, multicenter study of 820 patients undergoing allogeneic stem cell transplantation between 2000 and 2006 at 3 different institutions. Patients were retrospectively categorized according to the National Institute of Health criteria from patients’ medical histories.

Results

As far as the new sub-categories are concerned, in univariate analysis diagnosis of overlap syndrome adversely affected the outcome. Also, the number of organs involved for a cut-off value of 4 significantly influenced both cGVHD related mortality and survival. In multivariate analysis, in addition to NIH score, platelet count and performance score at the time of cGVHD diagnosis, plus gut involvement, significantly influenced outcome. These 3 variables allowed us to develop a simple score system which identifies 4 subgroups of patients with 84%, 64%, 43% and 0% overall survival at five years after cGVHD diagnosis (score 0: HR=15.96 (95% CI: 6.85–37.17), P<0.001; score 1: HR=5.47 (95% CI: 2.6–11.5), P<0.001; score 2: HR=2.8 (95% CI: 1.32–5.93), P=0.007).

Conclusions

In summary, we have identified a powerful and simple tool to discriminate different subgroups of patients in terms of chronic graft-versus-host disease related mortality and survival.     

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

Background

The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones.

Methods

MEDLINE/PubMed and Science Citation Index databases (1990–2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1.

Results

Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65–1.21), mortality (OR, 1.2; 95% CI, 0.32–4.52), total morbidity (OR, 0.75; 95% CI, 0.53–1.06), major morbidity (OR, 0.95; 95% CI, 0.60–1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76–3.30).

Conclusions

Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.     

Patterns of survival and causes of death following a diagnosis of monoclonal gammopathy of undetermined significance: a population-based study

Background

There are limited data on survival patterns among patients with monoclonal gammopathy of undetermined significance.

Design and Methods

We compared the survival of 4,259 patients with monoclonal gammopathy of undetermined significance, collected from hematology outpatient units in Sweden, with the survival of the general population by computing relative survival ratios. We also compared causes of death in these patients with those in 16,151 matched controls.

Results

One-, 5-, 10-, and 15-year relative survival ratios were 0.98 (95% CI 0.97–0.99), 0.93 (0.91–0.95), 0.82 (0.79–0.84), and 0.70 (0.64–0.76), respectively. Younger age at diagnosis of the gammopathy was associated with a significantly lower excess mortality compared to that in older patients (p<0.001). The excess mortality among patients with gammopathy increased with longer follow-up (p<0.0001). IgM (versus IgG/A) gammopathy was associated with a superior survival (p=0.038). Patients with monoclonal gammopathy of undetermined significance had an increased risk of dying from multiple myeloma (hazards ratio (HR)=553; 95% CI 77–3946), Waldenström’s macroglobulinemia (HR=∞), other lymphoproliferative malignancies (6.5; 2.8–15.1), other hematologic malignancies (22.9; 8.9–58.7), amyloidosis (HR=∞), bacterial infections (3.4; 1.7–6.7), ischemic heart disease (1.3; 1.1–1.4), other heart disorders (1.5; 1.2–1.8), other hematologic conditions (6.9; 2.7–18), liver (2.1; 1.1–4.2), and renal diseases (3.2; 2.0–4.9).

Conclusions

Our finding of decreased life expectancy in patients with monoclonal gammopathy of undetermined significance, which was most pronounced in the elderly and explained by both malignant transformation and non-malignant causes, is of importance in the understanding and clinical management of this disease. The underlying mechanisms may be causally related to the gammopathy, but may also be explained by underlying disease that led to the detection of the hematologic disease. Our results are of importance since they give a true estimation of survival in patients with monoclonal gammopathy of undetermined significance diagnosed in clinical practice.     

Trajectories of Cardiovascular Health: Life Course Epidemiology in Brazil

Background

Studies have demonstrated the diagnostic accuracy and prognostic value of physical stress echocardiography in coronary artery disease. However, the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia is limited.

Objective

To evaluate the effectiveness of physical stress echocardiography in the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia.

Methods

This is a retrospective cohort in which 866 consecutive patients with exercise test positive for myocardial ischemia, and who underwent physical stress echocardiography were studied. Patients were divided into two groups: with physical stress echocardiography negative (G1) or positive (G2) for myocardial ischemia. The endpoints analyzed were all‑cause mortality and major cardiac events, defined as cardiac death and non-fatal acute myocardial infarction.

Results

G2 comprised 205 patients (23.7%). During the mean 85.6 ± 15.0-month follow-up, there were 26 deaths, of which six were cardiac deaths, and 25 non-fatal myocardial infarction cases. The independent predictors of mortality were: age, diabetes mellitus, and positive physical stress echocardiography (hazard ratio: 2.69; 95% confidence interval: 1.20 – 6.01; p = 0.016). The independent predictors of major cardiac events were: age, previous coronary artery disease, positive physical stress echocardiography (hazard ratio: 2.75; 95% confidence interval: 1.15 – 6.53; p = 0.022) and absence of a 10% increase in ejection fraction. All-cause mortality and the incidence of major cardiac events were significantly higher in G2 (p < 0. 001 and p = 0.001, respectively).

Conclusion

Physical stress echocardiography provides additional prognostic information in patients with exercise test positive for myocardial ischemia.     

Paradoxical lower postmyocardial infarction mortality among veteran women – does a sex bias exist in the Veterans Affairs medical system?

BACKGROUND:

Outcomes after acute coronary disease are reportedly worse among women in general and more so among women with diabetes compared with men. Sex differences were evaluated in postmyocardial infarction (MI) mortality among veterans (who are predominantly male) to determine whether evaluation and treatment in Veterans Affairs hospitals amplifies sex differences in outcome.

METHODS:

All patients discharged with the primary diagnosis of acute MI from any Veterans hospitals in the United States between October 1990 and September 1997 were identified. Demographic, comorbidity, inpatient, outpatient, mortality and readmission data were extracted. Mortality, revascularization and readmissions were compared between male and female patients using Cox regression models.

RESULTS:

The authors identified 67,889 patients with MI, 17,756 (26%) of whom had diabetes. There were 951 women, 280 (29%) of whom had diabetes, and 66,938 men, 17,476 (26%) of whom had diabetes. Over the entire follow-up period, adjusted mortality was higher in men than women (hazard ratio [HR] 1.5, 95% CI 1.3 to 1.7). Cardiac procedures were significantly higher among men: HR for coronary bypass surgery was 2.1 (95% CI 1.6 to 2.8; P<0.001) for all men, while HR for catheterization and percutaneous coronary intervention were higher for men among non-diabetics only – 1.5 (95% CI 1.2 to 1.8; P<0.001) and 2.0 (95% CI 1.4 to 2.9; P<0.001). Interaction between sex and diabetes was not significant.

CONCLUSIONS:

Contrary to previous observations in the nonveteran population, long-term mortality post-MI was lower among veteran women, despite higher procedure rates in men. The present study also failed to show increased mortality in women with diabetes.