Characteristics, outcomes, and predictors of 1-year mortality in patients hospitalized for acute heart failure.

AIMS: Acute heart failure (AHF) is associated with poor prognosis and requires recurrent hospitalizations. However, studies on AHF characteristics, treatment, and prognostic factors are few. Our aim was to investigate the characteristics, treatment, and 1-year prognosis of AHF and identify prognostic factors in different clinical groups. METHODS AND RESULTS: We conducted a prospective multicentre study with 620 patients hospitalized due to AHF; mean age 75.1 (10.4) years, 50% male. Half of the patients had new-onset heart failure. Acute congestion (63.5%) and pulmonary oedema (26.3%) were the most common clinical presentations. Left ventricular ejection fraction (LVEF) was reported in two-thirds of patients. Half of these had preserved systolic function (LVEF> or =45%). At discharge, 86% of patients had beta-blockers and 76% either ACE-inhibitors or angiotensin receptor blockers in use. The 12-month all-cause mortality was 27.4%. We identified several clinical and biochemical prognostic risk factors in univariate analysis. Independent predictors of 1-year mortality were older age, male gender, lower systolic blood pressure (SBP) on admission, C-reactive protein, and serum creatinine >120 micromol/L. CONCLUSION: We present the characteristics and prognosis of an unselected population of AHF patients. One-year mortality is high, and independent clinical risk factors include age, male gender, lower SBP on admission, C-reactive protein, and renal dysfunction.     

Functional impairment in spondyloarthropathy and fibromyalgia

OBJECTIVE: To compare the functional ability of patients with spondyloarthropathy (SpA) and fibromyalgia (FM) using the Bath Ankylosing Spondylitis Functional Index (BASFI), the Dougados Functional Index (DFI), and and the Health Assessment Questionnaire for Spondyloarthropathy (HAQ-S), to establish whether these indicators can differentiate between these patient groups, and to ascertain how well the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) functions in patients with FM. METHODS: Twenty-four patients with SpA and 70 with FM, all female, filled in 4 self-administered questionnaires: BASFI, DFI, HAQ-S, and the BASDAI; results were compared between the 2 groups. RESULTS: The decline in functional ability was similar in patients with SpA and FM when assessed by BASFI, but slightly greater in the SpA group when assessed by DFI and HAQ-S. BASDAI was significantly (p = 0.018) greater in the FM group. CONCLUSION: An almost similar functional decline was observed in both SpA and FM patients when measured by the indices developed for patients with AS and SpA. The specificity of BASDAI in measuring disease activity in SpA was poor, as disease activity in FM was rated higher than in SpA.     

Effect of coronary arterial occlusion on vagal control of heart rate

Diminished variation in heart rate as a sign of impaired vagal control is common in coronary arterial disease. To evaluate the effect of short-term myocardial ischaemia induced by coronary arterial occlusion during therapeutic percutaneous transluminal coronary angioplasty we measured the variation in heart rate during controlled deep breathing in 50 patients before and during arterial occlusion. Variation in heart rate diminished from 11.1 ± 4.5 to 9.5 ± 5.1 beats/min (P < 0.01) during occlusion. No change occurred in heart rate, blood pressure or levels of noradrenaline and adrenaline. The attenuation of variation in the heart rate was not significantly associated with the site or duration of arterial occlusion nor concomitant chest pain. Thus, brief coronary arterial occlusion seems to be associated with impairment of the vagal control of heart rate in patients with coronary arterial disease.     

Updated Electrocardiographic Classification of Acute Coronary Syndromes

The electrocardiogram (ECG) findings in acute coronary syndrome should always be interpreted in the context of the clinical findings and symptoms of the patient, when these data are available. It is important to acknowledge the dynamic nature of ECG changes in acute coronary syndrome. The ECG pattern changes over time and may be different if recorded when the patient is symptomatic or after symptoms have resolved. Temporal changes are most striking in cases of ST-elevation myocardial infarction. With the emerging concept of acute reperfusion therapy, the concept ST-elevation/non-ST elevation has replaced the traditional division into Q-wave/non-Q wave in the classification of acute coronary syndrome in the acute phase.

Keypoints:

In acute coronary syndrome, in addition to the traditional electrocardiographic risk markers, such as ST depression, the 12-lead ECG contains additional, important diagnostic and prognostic information. Clinical guidelines need to acknowledge certain high-risk ECG patterns to improve patient care.     

Withdrawal from long‐term use of zopiclone,zolpidem and temazepam may improve perceived sleep and quality of life in older adults with primary insomnia

Long‐term use of benzodiazepines or benzodiazepine receptor agonists is widespread, although guidelines recommend short‐term use. Only few controlled studies have characterized the effect of discontinuation of their chronic use on sleep and quality of life. We studied perceived sleep and quality of life in 92 older (age 55‐91 years) outpatients with primary insomnia before and after withdrawal from long‐term use of zopiclone, zolpidem or temazepam (BZDA). BZDA was withdrawn during 1 month, during which the participants received psychosocial support and blindly melatonin or placebo. A questionnaire was used to study perceived sleep and quality of life before withdrawal, and 1 month and 6 months later. 89 participants completed the 6‐month follow‐up. As melatonin did not improve withdrawal, all participants were pooled and then separated based solely on the withdrawal results at 6 months (34 Withdrawers. 55 Nonwithdrawers) for this secondary analysis. At 6 months, the Withdrawers had significantly (P < 0.05) shorter sleep‐onset latency and less difficulty in initiating sleep than at baseline and when compared to Nonwithdrawers. Compared to baseline, both Withdrawers and Nonwithdrawers had at 6 months significantly (P < 0.05) less fatigue during the morning and daytime. Stress was alleviated more in Withdrawers than in Nonwithdrawers (P < 0.05). Satisfaction with life and expected health 1 year later improved (P < 0.05) in Withdrawers. In conclusion, sleep disturbances, daytime fatigue and impaired quality of life may resolve within 6 months of BZDA withdrawal. These results encourage withdrawal from chronic use of benzodiazepine‐type hypnotics, particularly in older subjects.     

Proinflammatory HLA-DRB1*01-haplotype predisposes to ST-elevation myocardial infarction

BackgroundMajor histocompatibility complex (MHC) gene region harbours haplotypes that associate with coronary artery disease (CAD). Their role in ST-elevation infarction (STEMI) or on the inflammatory level is not known.MethodsFour candidate MHC markers were analyzed by real-time quantitative PCR and constructed into haplotypes from patients with STEMI (n = 162), matched controls with no CAD (n = 319) and general population sample (n = 149). High sensitivity C-reactive protein (hsCRP) was assessed in a follow-up visit from patients (n = 86) and at inclusion from other study subjects.ResultsThe haplotype with one copy of HLA-DRB1*01, C4A, C4B but no HLA-B*35 doubled the risk of STEMI (OR = 2.15, 95%CI = 1.11–4.15, p = 0.020 for patients vs. controls, and OR = 2.26, 95%CI = 0.97–5.24, p = 0.052 for patients vs. population sample). The association between patients and controls persisted in multivariate analyses. The frequency of the haplotype was 5.86% (n = 19/324) in patients, 2.82% (n = 18/638) in controls and 2.68% (n = 8/298) in population sample. None of the individual MHC markers alone showed significant association with STEMI.In multivariate analyses, the haplotype carriers had higher hsCRP levels in patients (median 3.37 mg/L in carriers vs. 1.14 mg/L in non-carriers, p = 0.019) and in controls (median 2.90 mg/L vs. 1.21 mg/L, p = 0.009, respectively).ConclusionThe MHC haplotype associates with STEMI and elevated baseline hsCRP levels. The results are in concordance with previous data on non-STEMI patients, implying that a HLA-DRB1*01 – related haplotype increases the risk of CAD, possibly though increased inflammation.     

Shortened hospital stay for childhood bone and joint infections: Analysis of 265 prospectively collected culture-positive cases in 1983-2005

Abstract Background: In recent decades the treatment of childhood acute bone and joint infections has shifted towards shorter antibiotic courses and rapid transition to oral therapy. Methods: We prospectively collected 265 culture-positive cases of non-neonatal bone and joint infections in Finnish children during 1983-2005. The duration of antimicrobial treatment and the extent of surgery were defined in the study protocol, but for ethical reasons, the liaison clinician determined the time of discharge using normalization of the serum C-reactive protein (CRP) level as a yardstick. We examined changes during the study in the distribution of causative organisms, severity of disease, and length of hospital stay. Results: Staphylococcus aureus was overwhelmingly the most common causative agent throughout the study, whereas Haemophilus influenzae type b was eliminated soon after the introduction of vaccination. The mean time from initial symptoms to presentation remained the same at 4 days, and no significant change was observed in the severity of disease, CRP, or the rate of sequelae. The mean duration of intravenous antibiotic administration was only 4 days. The average hospital stay shortened significantly from 13 days to 9 days (p =?0.0001). Conclusions: The shortened hospital stay was not due to a change in the anatomical site of these infections, but to simplified treatment. Considerable savings in hospital stay, and thus costs, are feasible in osteoarticular infections of childhood by using CRP in monitoring the disease and shortening intravenous treatment by a swift move to per oral administration.     

Intestinal bacterial translocation and tight junction structure in acute porcine pancreatitis

Background/Aims: To examine whether intestinal bacterial translocation occurs early in acute mild and severe pancreatitis and whether the intestinal expression of tight junction proteins (claudins-2, -3, -4, -5, -7), apoptosis or proliferation would explain the possible translocation. Methodology: Fifteen pigs were randomized to controls (n=5) or to develop mild edematous pancreatitis (n=5, saline infusion to pancreatic duct) or severe necrotic pancreatitis (n=5, taurocholic acid infusion). Translocation was studied by measuring bacterial cultures from portal vein blood and mesenteric lymph nodes. Immunohistochemical expression of the tight junction proteins, apoptosis rate (TUNEL) and Ki-67 were analyzed quantitatively from the epithelium of the jejunum and colon. Results: There was no bacterial translocation during the 6 hours followup, nor changes in the expression of tight junction proteins claudins-2 and -5 in jejunum or colon. Saturation and proportional area of claudin-3 staining decreased in the colon, as did claudins-4 and -7 staining in the jejunum of the necrotic pancreatitis group. Increased apoptosis was found in all samples from controls and the edematous pancreatitis group but not in jejunum in the necrotic pancreatitis group. Ki-67 activity tended to increase in the upper half of the villus in edematous and necrotic pancreatitis. There were no changes in the basic histology. Conclusions: The major finding of this study was that bacterial translocation from the gut is not present at the beginning of acute pancreatitis. Tight junction proteins claudin-2 and -5 do not become altered in the early stages of pancreatitis. Claudin-3 decreases in the colon and claudins-4 and -7 in the jejunum in necrotic pancreatitis. Laparotomy itself causes increased apoptosis in the colon and the jejunum.