Alarmingly Rising Trends in Venous Thromboembolic Events and Respiratory Failure in Takotsubo Syndrome-Related Hospitalizations in the United States

Background There is very scarce data about the shifting landscape of complications like venous thromboembolic events (VTE) and respiratory failure in Takotsubo syndrome (TTS). We have assessed the rates and trends of these complications in (TTS)-related hospitalizations. Methods The National Inpatient Sample (2007-2014) was queried to identify adult hospitalizations for TTS and subsequent VTE and respiratory failure using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. Trends were assessed using discharge weights and the linear-by-linear association test for the overall cohort and subgroups based on age, sex, and race. Results Of 156,506 admissions for TTS from 2007-2014, 3.5% (N=5,550) of admissions revealed VTE whereas 17.4% (N=27,252) of admissions revealed respiratory failure. There were significantly rising trends in VTE (from 2.2% to 4.2%) and respiratory failure (10% to 20.7%) with TTS (p<0.05) from 2007-2014. On subgroup analysis, all subgroups showed rising trends in VTE and respiratory failure. However, young (18-44 years), male patients admitted with TTS demonstrated a greater surge in VTE as compared to other groups. In contrast, the frequency of respiratory failure rose more significantly in young, male, non-white TTS patients compared to older, female and white TTS patients. Conclusion There were alarming trends in the VTE and respiratory failure despite the improved understanding of TTS etiopathogenesis and advanced diagnostic modalities among TTS-related admissions, mostly comprising of young, male, and non-white patients. Introduction.

Admission Hyperglycemia in Non-diabetics Predicts Mortality and Disease Severity in COVID-19: a Pooled Analysis and Meta-summary of Literature

In the latter part of 2019, a cluster of unexplained pneumonia cases were reported in Wuhan, China. In less than a year, SARS-CoV-2 has infected over 27 million people and claimed more than 800,000 deaths worldwide. Diabetes is a highly prevalent chronic metabolic disease, and recent reports have suggested a possible existence of COVID-19 related new-onset diabetes. Hyperglycemia induces an inflammatory state in the body, which coupled with coronavirus associated immune response is a possible explanation for clinical worsening of patients. We present a summary and pooled analysis of available evidence to ascertain the relationship between hyperglycemia in undiagnosed diabetics and outcomes of COVID-19 disease. Our results showed that hyperglycemia in non-diabetics was associated with higher risk of severe/critical illness (OR 1.837 (95% CI 1.368–2.465, P < 0.001) and mortality (2.822, 95% CI 1.587–5.019, P < 0.001) compared with those with normal values of blood glucose. The management of hyperglycemia in COVID-19 poses significant challenges in clinical practice, and the need to develop strategies for optimal glucose control in these patients cannot be overlooked.

Takotsubo Syndrome in Patients with COVID-19: a Systematic Review of Published Cases

Takotsubo syndrome (TTS) is caused by catecholamine surge, which is also observed in COVID-19 disease due to the cytokine storm. We performed a systematic literature search using PubMed/Medline, SCOPUS, Web of Science, and Google Scholar databases to identify COVID-19-associated TTS case reports and evaluated patient-level demographics, clinical attributes, and outcomes. There are 12 cases reported of TTS associated with COVID-19 infection with mean age of 70.8 ± 15.2 years (range 43–87 years) with elderly (66.6% > 60 years) female (66.6%) majority. The time interval from the first symptom to TTS was 8.3 ± 3.6 days (range 3–14 days). Out of 12 cases, 7 reported apical ballooning, 4 reported basal segment hypo/akinesia, and 1 reported median TTS. Out of 12 cases, during hospitalization, data on left ventricular ejection fraction (LVEF) was reported in only 9 of the cases. The mean LVEF was 40.6 ± 9.9% (male, 46.7 ± 5.7%, and female, 37.7 ± 10.6%). Troponin was measured in all 12 cases and was elevated in 11 (91.6%) without stenosis on coronary angiography except one. Out of 11 cases, 6 developed cardiac complications with 1 case each of cardiac tamponade, heart failure, myocarditis, hypertensive crisis, and cardiogenic shock in 2. Five patients required intubation, 1 patient required continuous positive airway pressure, and 1 patient required venovenous extracorporeal membrane oxygenation. The outcome was reported in terms of recovery in 11 (91.6%) out of 12 cases, and a successful recovery was noted in 10 (90.9%) cases. COVID-19-related TTS has a higher prevalence in older women. Despite a lower prevalence of cardiac comorbidities in COVID-19 patients, direct myocardial injury, inflammation, and stress may contribute to TTS with a high complication rate.

Percutaneous Ventricular Assist Device vs. Intra-Aortic Balloon Pump for Hemodynamic Support in Acute Myocardial Infarction-Related Cardiogenic Shock and Coexistent Atrial Fibrillation: A Nationwide Propensity-Matched Analysis'

BACKGROUND

Patients suffering an acute myocardial infarction complicated by cardiogenic shock (AMICS) may experience clinical deterioration with concomitant atrial fibrillation (AF). Recent data suggest that percutaneous ventricular assist devices (pVADs) provide superior hemodynamic support over intra-aortic balloon pump (IABP) in AMICS. In patients with AF+AMICS, however, outcomes data comparing these two devices remain limited.

METHODS

Using the National Inpatient Sample datasets (2008-2014) and a propensity-score matched analysis, we compared the outcomes of AMICS+AF hospitalized patients undergoing PCI with pVAD vs. IABP support.

RESULTS

A total of 12,842 AMICS+AF patients were identified (pVAD=468, IABP=12,374). The matched groups (pVAD=443, IABP=443) were comparable in terms of mean age (70.3 ± 12.0 vs. 70.4 ± 11.0yrs, p = 0.92). The utilization of pVAD was higher in whites but lower in Medicare/Medicaid beneficiaries as compared to IABP. The pVAD group demonstrated higher rates of obesity (13.6% vs. 7.8%, p = 0.006) and dyslipidemia (48.4% vs. 41.8%, p = 0.05). There was no difference in the in-hospital mortality (40.5% vs. 36.8%, p = 0.25); however, pVAD group had a lower incidence of post-procedural MI and higher incidences of stroke (7.8% vs. 4.4%, p = 0.03), hemorrhage (5.6% vs. 2.3%, p = 0.01), discharges to home health care (13.5% vs. 10.1%, p<0.001) and to other facilities (29.1% vs. 24.9%, p<0.001) as compared to IABP group. There was no difference between the groups in terms of mean length of stay or hospital charges.

CONCLUSIONS

All-cause inpatient mortality was similar in AMICS+AF patients undergoing PCI who were treated with either pVAD or IABP. The pVAD group, however, experienced more complications while consuming greater healthcare resources.

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study

BACKGROUND

While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

METHODS

In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

RESULTS

GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

CONCLUSIONS

GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017

BACKGROUND

Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries.

METHODS

We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs).

FINDINGS

In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505).

INTERPRETATION

Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.

Higher odds and rising trends in arrhythmia among young cannabis users with comorbid depression

BACKGROUND

Cannabis (marijuana) use and depression are known to be strongly interconnected. However, amid alarming rates of mental health problems in the United States young population, the risk of arrhythmia among young cannabis users with comorbid depression has never been studied.

METHODS

In-hospital encounters of arrhythmia were identified among young cannabis users (18-39 years) with or without depression using the National Inpatient Sample (2007-2014) databases and apposite ICD-9 codes. Baseline characteristics and trends in prevalence of arrhythmia were evaluated among inpatient young cannabis users with or without depression. A multivariable regression was performed after adjusting for baseline demographics, comorbidities and parallel history of substance abuse.

RESULTS

Of 2,011,598 young cannabis users (59.6% male) admitted from 2007-2014, 190,146 (9.5%) of patients had comorbid depression, of which 6.9% of patients experienced arrhythmias with atrial fibrillation being most common. Cannabis users with depression were more likely older, white, females and frequently hospitalized in Midwest and rural hospitals. We observed a steadily rising trend in prevalence of arrhythmia in both groups, but a more rapid rise in cannabis users with depression (4.9% in 2007 to 8.5% in 2014 vs. 3.7% in 2007 to 5.7% in 2014). Correspondingly, young depressed cannabis users had higher odds of arrhythmia compared to non-depressed even after controlling for demographics and comorbidities (OR: 1.41, 95% CI: 1.38-1.44, p<0.001).

CONCLUSION

Rampant recreational use of marijuana may increase the risk of arrhythmia by 40% in young cannabis users with depression as compared to non-depressed.

Anemia Among Patients Undergoing Transcatheter Mitral Valve Repair: From the National Inpatient Sample in the United States

Background The prevalence and impact of anemia on the outcomes of transcatheter mitral valve repair (TMVr) have not been well-studied. Anemia is a commonly encountered comorbidity among patients with cardiovascular disorders and is frequently under-recognized. The study aimed to analyze the prevalence of anemia and its impact on post-TMVr in-hospital outcomes. Methods The National Inpatient Sample (NIS) was queried to identify all patients who underwent TMVr from 2011-2015 in the United States by utilizing suitable International Classification of Diseases, Ninth Revision (ICD-9) codes. The baseline characteristics and in-hospital outcomes were compared among patients with and without anemia. Results A total of 4,382 patients were identified. Out of these, 978 (22.3%) patients had baseline anemia. Anemic patients were noted to have a higher burden of co-morbidities, including chronic kidney disease, hypertension, and diabetes mellitus. The in-hospital mortality was higher but not statistically significant between anemic and non-anemic patients (3.6% vs 2.6%; odds ratio (OR): 1.44; confidence interval (CI): 0.85-2.46, p=0.179). The other adverse outcomes, including the length of stay, the requirement for blood transfusions, the incidence of post-implant acute kidney injury, hemodialysis, and the cost of hospitalization, were higher in anemic patients. Conclusion Anemia was present in one out of five patients undergoing TMVr in this nationally representative cohort. Baseline anemia showed numerically higher but not statistically significant in-hospital mortality and was associated with other in-hospital adverse outcomes. Further larger studies are needed to highlight the importance of anemia in the TMVr procedure.

Epidemiology and Outcomes of Takotsubo Syndrome in Hospitalizations With Systemic Sclerosis

Background

Systemic Sclerosis (SSc) is associated with chronic inflammation which leads to macrophage activation and thus vascular insult and fibrosis. Macrophage activation is shown to precede Takotsubo syndrome (TTS) which may be a common pathophysiologic link to SSc. 

Methods

We queried the National Inpatient Sample (2008-2014) for adult SSc-related hospitalizations and TTS using relevant International Classification of Diseases Clinical Modification, 9th Revision codes. We assessed the prevalence and trends in TTS during this time. We further assessed demographics, comorbidities, and outcomes were in SSc with and without TTS. The primary outcomes of the analysis were all-cause mortality and in-hospital complications including cardiac arrest and acute myocardial infarction (AMI), arrhythmias, and venous thromboembolism, and stroke. 

Results

A total of 213,728 SSc-related hospitalizations were found, of which 357 experienced TTS (0.2%) with rising trends in TTS from 2008-2014 (0.06% to 0.3%, relative increase of 24%, p_trend<0.001). The TTS cohort was older (median age 68 vs 62 years), with 92.8% females and 80.1% white adults with TTS (p<0.001). Co-morbidities were higher in the TTS cohort including hypertension (62.2% vs. 51.5%, p<0.001), dyslipidemia (41.5% vs. 22.8, p<0.001), smoking (28.9% vs. 20.1%, p<0.001), peripheral vascular disease (17.8% vs. 9.1%, p<0.001), uncomplicated diabetes (18.1% vs. 11.9%, p<0.001). The all-cause in-hospital mortality (11% vs. 4.6%; adjusted odds ratio=1.82, 95% confidence interval: 1.21-2.72, p<0.005), cardiovascular complications like AMI (29% vs. 2.9%,p<0.001), arrhythmias (38.9% vs. 21.5%, p<0.001), and median length of stay [6 vs. 4 days] were significantly higher in the TTS cohort as compared to the non-TTS cohort.

Conclusion

This analysis revealed a nearly 10 times higher prevalence of TTS in SSc-related hospitalizations compared to the general inpatient population. Concomitant TTS occurrence in SSc-related hospitalizations led to nearly two times higher odds of all-cause mortality. Cardiovascular co-morbidities in SSc may increase the risk of TTS and worsened outcomes.

Burden of arrythmias in transgender patients hospitalized for gender-affirming surgeries

BACKGROUND

We sought to describe the burden of arrhythmias and their impact on in-hospital outcomes in transgender patients who underwent gender re-assignment surgery.

METHODS

The study utilized data from the National Inpatient Sample from January 2012 to September 2015.

RESULTS

16 555 adult transgender patients were included in this study. A total of 610 adults developed arrhythmia out of which atrial fibrillation (N = 475, 2.87%) was the most frequent arrhythmia. In-hospital mortality increased substantially with arrhythmias.

CONCLUSIONS

New-onset arrythmias, while infrequent in the inpatient setting is associated with significantly higher in-hospital mortality and resource utilization.

COVID-19 and diabetes mellitus: A need for prudence in elderly patients from a pooled analysis

OBJECTIVE

The objective of this study was to evaluate the pooled estimate of diabetes prevalence in young (<50 years) versus elderly (>50 years) COVID-19 cohorts.

METHODS

Studies published between December-2019 and March-2020 reporting demographic and clinical characteristics of COVID-19 cases were identified. A total of 11 studies included accounting for 2084 COVID-19 patients.

RESULTS

The overall prevalence of diabetes in COVID-19 patients with a mean age>50 years was 13.2%, whereas studies with relatively younger patients (mean age <50 years) had a pooled prevalence of 9.0% CONCLUSION: The overall prevalence of diabetes in COVID-19 patients was found to be 13.2% with studies including relatively elderly patients showing higher rates of diabetes. The intermingled effects of diabetes with other cardiovascular comorbidities warrant age-specific outcomes data including the impact of ongoing antidiabetic treatment.

Nationwide Trends in Prevalent Cardiovascular Risk Factors and Diseases in Young Adults: Differences by Sex and Race and In-Hospital Outcomes

OBJECTIVES

Prevalence and trends in all cardiovascular disease (CVD) risk factors among young adults (18-39 years) have not been evaluated on a large scale stratified by sex and race. The aim of this study was to establish the prevalence and temporal trend of CVD risk factors in US inpatients younger than 40 years of age from 2007 through 2014 with racial and sex-based distinctions. In addition, the impact of these risk factors on inpatient outcomes and healthcare resource utilization was explored.

METHODS

A cross-sectional nationwide analysis of all hospitalizations, comorbidities, and complications among young adults from 2007 to 2014 was performed. The primary outcomes were frequency, trends, and race- and sex-based differences in coexisting CVD risk factors. Coprimary outcomes were trends in all-cause mortality, acute myocardial infarction, arrhythmia, stroke, and venous thromboembolism in young adults with CVD risk factors. Secondary outcomes were demographics and resource utilization in young adults with versus without CVD risk factors.

RESULTS

Of 63 million hospitalizations (mean 30.5 [standard deviation 5.9] years), 27% had at least one coexisting CVD risk factor. From 2007 to 2014, admission frequency with CVD risk factors increased from 42.8% to 55.1% in males and from 16.2% to 24.6% in females. Admissions with CVD risk were higher in male (41.4% vs 15.9%) and white (58.4% vs 53.8%) or African American (22.6% vs 15.9%) patients compared with those without CVD risk. Young adults in the Midwest (23.9% vs 21.1%) and South (40.8% vs 37.9%) documented comparatively higher hospitalizations rates with CVD risk. Young adults with CVD risk had higher all-cause in-hospital mortality (0.4% vs. 0.3%) with a higher average length of stay (4.3 vs 3.2 days) and charges per admission ($30,074 vs $20,124).

CONCLUSIONS

Despite modern advances in screening, management, and interventional measures for CVD, rising trends in CVD risk factors across all sex and race/ethnic groups call for attention by preventive cardiologists.

Nationwide Frequency, Sequential Trends, and Impact of Co-morbid Mental Health Disorders on Hospitalizations, Outcomes, and Healthcare Resource Utilization in Adult Congenital Heart Disease

Despite the growing prevalence of adult congenital heart disease (ACHD), data on trends in prevalence of mental health disorders (MHD) among patients with ACHD remain limited. The National Inpatient Sample (2007 to 2014) was queried to identify the frequency and trends of MHD among ACHD hospitalizations (stratification by age, sex, and race); demographics and co-morbidities for ACHD cohorts, with (MHD+) versus without MHD (MHD-); the rate and trends of all-cause in-hospital mortality, disposition, mean length of stay, and hospitalization charges among both cohorts. A total of 11,709 (13.8%, mean age: 49.1 years, 56.0% females, 78.7% white) out of 85,029 ACHD patient encounters had a coexistent MHD (anxiety, depression, mood disorder, or psychosis). ACHD-MHD+ cohort was more often admitted nonelectively (38.1% vs 32.8%, p <0.001) and had a higher frequency of cardiac/extra-cardiac co-morbidities. The trends in prevalence of coexistent MHD increased from 10.3% to 17.5% (70% relative increase) from 2007 to 2014 with a consistently higher prevalence among females (from 13% to 20.3%) compared to males (from 7.6% to 15.5%) (p_trend <0.001). The hospitalization trends with MHD increased in whites (12.1% to 19.8%) and Hispanics (5.9% to 12.7%). All-cause mortality was lower (0.7% vs 1.1%, p = 0.002) in ACHD-MHD+; however, mean length of stay (∼5.7 vs 4.9 days, p <0.001) was higher without significant difference in charges ($97,710 vs $96,058, p = 0.137). ACHD-MHD+ cohort was less often discharged routinely (declining trend) and more frequently transferred to other facilities and required home healthcare (rising trends). In conclusion, this study reveals increasing trends of MHD, healthcare resource utilization and a higher frequency of co-morbidities in patients with ACHD.

Prioritising health research in KwaZulu-Natal: has the research conducted met the research needs?

Background

The KwaZulu-Natal (KZN) Health Act of 2009 mandates the Provincial Health Research and Ethics Committee to develop health research priorities for the province. During 2013, the KZN Department of Health embarked on a research prioritisation process for the province. Priority research questions were generated by an inclusive process, in which a variety of stakeholders in health research in the province were engaged. The aim of this study was to determine whether research conducted at public health facilities in KZN between 01 January 2014 and 31 March 2017 met the research priorities of the province developed through the provincial research prioritisation process of 2013.

Methods

This was a mixed methods study. Qualitative thematic analysis was used to categorise priority research questions generated in the priority-setting process and the titles of research projects conducted after that process into themes. Quantitative analysis was used to determine the correlation between themes of the priority questions, and those of the research projects conducted after the prioritisation exercise. Statistical Package for Social Science version 25 was used to analyse the data.

Results

In 72% of thematic areas, there were disproportionately more priority questions than there were research projects conducted. There is thus a large disjuncture between the priorities developed through the provincial research prioritisation process of 2013 and the research projects conducted after that process in terms of major research areas.

Conclusions

Ensuring that research conducted responds to priority questions raised is important because it ensures that research responds to locally important issues and to the concerns of local actors. Local health managers, communities and researchers should work together to ensure that the research conducted in their areas respond to the research priorities of those areas. Health Research Committees and local ethics committees can play important roles in facilitating the responsiveness to research priorities.

Circulating Sex Steroid Measurements of Men by Mass Spectrometry Are Highly Reproducible after Prolonged Frozen Storage

Long-term studies investigating hormone-dependent cancers and reproductive health often require prolonged frozen storage of serum which assumes that the steroid molecules and measurements are stable over that time. Previous studies of reproducibility of circulating steroids have relied upon flawed historical rather than contemporaneous controls. We measured serum testosterone (T), dihydrotestosterone (DHT), estradiol (E2) and estrone (E1) in 150 randomly selected serum samples by liquid chromatography-mass spectrometry (LC-MS) from men 70 years or older (mean age 77 years) in the CHAMP study. The original measurements in 2009 were repeated 10 years later using the identical serum aliquot (having undergone 2-4 freeze-thaw cycles in the interim) in 2019 together with another never-thawed aliquot of the same serum sample. The results of all three sets of measurements were evaluated by Passing-Bablok regression and Bland-Altman difference analysis. Serum androgens (T, DHT) and estrogens (E2, E1) measured by LC-MS display excellent reproducibility when stored for 10 years at -80 C without thawing. Serum T and DHT displayed high level of reproducibility across all three sets of measurements. Multiple freeze-thaw cycles over those storage conditions do not significantly affect serum T, DHT and E1 concentrations but produce a modest increase (21%) in serum E2 measurements.

Risk of Stroke With E-Cigarette and Combustible Cigarette Use in Young Adults

INTRODUCTION

Rising trends in stroke incidence and hospitalizations because of combustible cigarette smoking have been noted among younger adults. However, the association between e-cigarette use and stroke in this population remains largely unknown. This study examines the association between e-cigarette use with or without a history of previous or concurrent combustible cigarette use and stroke among young adults.

METHODS

Pooled data (2016-2017) were analyzed from the Behavior Risk Factor Surveillance System, a nationally representative, cross-sectional telephone survey, in 2019. The sample size was 161,529 participants aged 18-44 years. The association between e-cigarette use and stroke was examined using logistic regression adjusting for patient demographics, relevant comorbidities without or with history, and concurrent use of combustible cigarette use.

RESULTS

Current dual use of e-cigarettes and combustible cigarettes was associated with 2.91 times higher odds of stroke versus nonsmokers (AOR=2.91, 95% CI=1.62, 5.25) and 1.83 times higher odds versus current sole combustible cigarette users (AOR=1.83, 95% CI=1.06, 3.17). Compared with nonsmokers, current sole e-cigarette users did not show significantly different odds of stroke (AOR=0.69, 95% CI=0.34, 1.42). However, odds of stroke were lower for sole e-cigarette users versus current sole combustible cigarette users (AOR=0.43, 95% CI=0.20, 0.93).

CONCLUSIONS

Sole e-cigarette use is not associated with greater odds of stroke in young adults. However, if young adults have former or current combustible cigarette use, odds of stroke are significantly increased even compared with current sole combustible cigarette use. Switching from combustible cigarettes to e-cigarettes does not confer stroke benefits.

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Cirrhosis and other chronic liver diseases (collectively referred to as cirrhosis in this paper) are a major cause of morbidity and mortality globally, although the burden and underlying causes differ across locations and demographic groups. We report on results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 on the burden of cirrhosis and its trends since 1990, by cause, sex, and age, for 195 countries and territories.

METHODS

We used data from vital registrations, vital registration samples, and verbal autopsies to estimate mortality. We modelled prevalence of total, compensated, and decompensated cirrhosis on the basis of hospital and claims data. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost due to premature death and years lived with disability. Estimates are presented as numbers and age-standardised or age-specific rates per 100 000 population, with 95% uncertainty intervals (UIs). All estimates are presented for five causes of cirrhosis: hepatitis B, hepatitis C, alcohol-related liver disease, non-alcoholic steatohepatitis (NASH), and other causes. We compared mortality, prevalence, and DALY estimates with those expected according to the Socio-demographic Index (SDI) as a proxy for the development status of regions and countries.

FINDINGS

In 2017, cirrhosis caused more than 1·32 million (95% UI 1·27-1·45) deaths (440 000 [416 000-518 000; 33·3%] in females and 883 000 [838 000-967 000; 66·7%] in males) globally, compared with less than 899 000 (829 000-948 000) deaths in 1990. Deaths due to cirrhosis constituted 2·4% (2·3-2·6) of total deaths globally in 2017 compared with 1·9% (1·8-2·0) in 1990. Despite an increase in the number of deaths, the age-standardised death rate decreased from 21·0 (19·2-22·3) per 100 000 population in 1990 to 16·5 (15·8-18·1) per 100 000 population in 2017. Sub-Saharan Africa had the highest age-standardised death rate among GBD super-regions for all years of the study period (32·2 [25·8-38·6] deaths per 100 000 population in 2017), and the high-income super-region had the lowest (10·1 [9·8-10·5] deaths per 100 000 population in 2017). The age-standardised death rate decreased or remained constant from 1990 to 2017 in all GBD regions except eastern Europe and central Asia, where the age-standardised death rate increased, primarily due to increases in alcohol-related liver disease prevalence. At the national level, the age-standardised death rate of cirrhosis was lowest in Singapore in 2017 (3·7 [3·3-4·0] per 100 000 in 2017) and highest in Egypt in all years since 1990 (103·3 [64·4-133·4] per 100 000 in 2017). There were 10·6 million (10·3-10·9) prevalent cases of decompensated cirrhosis and 112 million (107-119) prevalent cases of compensated cirrhosis globally in 2017. There was a significant increase in age-standardised prevalence rate of decompensated cirrhosis between 1990 and 2017. Cirrhosis caused by NASH had a steady age-standardised death rate throughout the study period, whereas the other four causes showed declines in age-standardised death rate. The age-standardised prevalence of compensated and decompensated cirrhosis due to NASH increased more than for any other cause of cirrhosis (by 33·2% for compensated cirrhosis and 54·8% for decompensated cirrhosis) over the study period. From 1990 to 2017, the number of prevalent cases more than doubled for compensated cirrhosis due to NASH and more than tripled for decompensated cirrhosis due to NASH. In 2017, age-standardised death and DALY rates were lower among countries and territories with higher SDI.

INTERPRETATION

Cirrhosis imposes a substantial health burden on many countries and this burden has increased at the global level since 1990, partly due to population growth and ageing. Although the age-standardised death and DALY rates of cirrhosis decreased from 1990 to 2017, numbers of deaths and DALYs and the proportion of all global deaths due to cirrhosis increased. Despite the availability of effective interventions for the prevention and treatment of hepatitis B and C, they were still the main causes of cirrhosis burden worldwide, particularly in low-income countries. The impact of hepatitis B and C is expected to be attenuated and overtaken by that of NASH in the near future. Cost-effective interventions are required to continue the prevention and treatment of viral hepatitis, and to achieve early diagnosis and prevention of cirrhosis due to alcohol-related liver disease and NASH.

FUNDING

Bill & Melinda Gates Foundation.

National prevalence, trends and outcomes of takotsubo syndrome in hospitalizations with prior history of mediastinal/intrathoracic cancer and radiation therapy

BACKGROUND

Radiation therapy (RT) for cancers in thoracic/mediastinal region has been linked with heart damage following years of radiation exposure. However, prevalence of takotsubo syndrome (TTS) in patients with prior intrathoracic/mediastinal malignancies treated with RT has never been analyzed on a large scale.

METHODS

We identified adult hospitalizations with prior mediastinal/intrathoracic cancer and RT and TTS using ICD-9 CM codes and the National Inpatient Sample (2007-2014) after excluding current admissions for chemotherapy. We then assessed the prevalence, odds, trends and in-hospital outcomes of TTS-related admissions in patients with vs. without prior intrathoracic cancer and RT.

RESULTS

We identified a total of 5,991,314 hospitalizations with prior intrathoracic/mediastinal malignancies and RT (~73 yrs., 85.2% female), of which 7663 (0.13%, 128 per 100,000) were diagnosed with TTS (~74 yrs., 95.8% females, 88.1% white). Higher odds and rising trends in TTS per 100,000 hospitalizations (from 31 to 241) were seen among patients with prior intrathoracic malignancies and RT as compared to those without (from 19 to 104) (p_trend < 0.001). All-cause in-hospital mortality (4.6% vs 2.8%; OR 1.45; 95%CI 1.29-1.63, p < 0.001), cardiogenic shock (4.3% vs 0.2%), cardiac arrest (3.1% vs 0.9%), arrhythmia (34.3% vs 24.6%), stroke (3.6% vs 2.8%), respiratory failure (14.5% vs 4.6%), and median length of stay and hospital charges were significantly higher in the TTS cohort.

CONCLUSIONS

This study showed higher odds and increasing trends in TTS-related admissions with worse in-hospital outcomes among patients with prior intrathoracic/mediastinal cancer and RT, irrespective of the time interval from cancer diagnosis or RT to TTS occurrence.

Abstract WMP37: Burden of Neurological Complications Among Patients With Moyamoya Disease (MMD) Treated With Revascularization

Introduction: Moyamoya disease is a chronic steno-occlusive vasculopathy involving the circle of Willis and typically presents with ischemic or hemorrhagic stroke. Prior studies suggest that either direct or indirect extracranial-intracranial bypass (EC-IC) is an effective treatment for MMD. However, the burden of post-discharge neurological complications after the procedure is unknown. Our study aims to identify the 90 readmission rate (90-DRR) and neurological complications upon readmission in revascularization and untreated MMD patients.

Method: We analyzed the data from the Nationwide Readmission Database (NRD) from 2010-2015. MMD was ascertained by ICD-9 discharge code 437.5 and revascularization (EC-IC) using 39.28. SAS 9.4 was used for data analysis with categorical and continuous variables tested using the Rao Scott Chi-square test and Student’s t-test respectively.

Result: Among total 4,902 MMD index events, 1,840 had a revascularization procedure and 3,062 did not. The 90-DRR for the treatment group was 14.72% (readmitted N=271/Index cases N=1,840) vs. 34.75% (readmitted N=1,064/Index cases N=3,062) for the non-revascularization group (P <0.0001). Baseline characteristics of MMD with revascularization were mean age (Mean±SE) 41±0.6 vs. 40±0.5 (P=0.20), Charlson comorbidity index (CCI) 1.6±0.04 vs. 1.8±0.05 (P=0.0004), female: male 3:1. Cause-specific readmission rate in both groups was reported as per table.

Conclusion: Our analysis shows that patients treated with revascularization had significantly fewer 90-day readmissions when compared to untreated patients. MMD and ischemic stroke were the top reasons for readmission within the 90 days of discharge for both groups. A seizure was reported higher in the treatment group.