Association Rule Mining and Prognostic Stratification of 2-Year Longevity in Octogenarians Undergoing Endovascular Therapy for Lower Extremity Arterial Disease: Observational Cohort Study

A systematic review of the neutrophil to lymphocyte and platelet to lymphocyte ratios in patients with lower extremity arterial disease

Lower extremity arterial disease (LEAD) is caused by atherosclerotic plaque in the arterial supply to the lower limbs. The neutrophil to lymphocyte and platelet to lymphocyte ratios (NLR, PLR) are established markers of systemic inflammation which are related to inferior outcomes in multiple clinical conditions, though remain poorly described in patients with LEAD. This review was carried out in accordance with PRISMA guidelines. The MEDLINE database was interrogated for relevant studies. Primary outcome was the prognostic effect of NLR and PLR on clinical outcomes following treatment, and secondary outcomes were the prognostic effect of NLR and PLR on disease severity and technical success following revascularisation. There were 34 studies included in the final review reporting outcomes on a total of 19870 patients. NLR was investigated in 21 studies, PLR was investigated in two studies, and both NLR & PLR were investigated in 11 studies. Relating to increased levels of systemic inflammation, 20 studies (100%) reported inferior clinical outcomes, 13 (92.9%) studies reported increased disease severity, and seven (87.5%) studies reported inferior technical results from revascularisation. The studies included in this review support the role of elevated NLR and PLR as key components influencing the clinical outcomes, severity, and success of treatment in patients with LEAD. The use of these easily accessible, cost effective and routinely available markers is supported by the present review.

Effectiveness and pharmacological mechanisms of Chinese herbal medicine for coronary heart disease complicated with heart failure

ETHNOPHARMACOLOGICAL RELEVANCE

Chinese herbal medicine (CHM) is widely used for treating coronary heart disease complicated with heart failure (CHD-HF). However, the exact mechanisms involved are still not fully understood.

AIM OF THE STUDY

To assess the clinical effectiveness and potential pharmacological mechanisms of CHM for treating CHD-HF.

METHODS

Eight databases were retrieved for Randomized Controlled Trials of CHM for CHD-HF published from their inception to March 2023. Quality assessment of include studies was performed by the Cochrane risk-of-bias. Meta-analysis was used to assess the effectiveness of CHM for CHD-HF, and then core drugs and active ingredients were selected by data mining and network pharmacology. Finally, cluster and enrichment analysis were adopted to explore the potential targets and signaling pathways.

RESULTS

A total of 52 studies enrolling 5216 patients were included. Meta-analysis revealed that CHM treatment groups significantly improved left ventricular ejection fraction (LVEF), 6-min walk test (6-MWT), left ventricular end-diastolic dimension (LVEDD) and left ventricular end systolic diameter (LVESD) than control groups: [LVEF: SMD = 0.7, 95%CI (0.54, 0.87), p < 0.00001, I2 = 80%; 6-MWT: SMD = 0.72, 95%CI (0.58, 0.86), p < 0.0001, I2 = 67%; LVEDD: SMD = -0.79, 95%CI (-0.89, -0.69), p < 0.0001, I2 = 49%; LVESD: SMD = -0.6 (-0.74, -0.46), p < 0.0001, I2 = 0%]. The results of various biological information analysis showed the internal relationship between prescriptions, core drugs, active ingredients and therapeutic targets. Twelve core herbs with the most commonly use and high correlation were selected from 110 CHMs of 52 prescriptions for CHD-HF treatment, and further 65 effective components were screened out according to the most strength value, which were divided into 12 compounds such as terpenoids, flavonoids, steroids and alkaloids and etc. At the same time, 67 therapeutic targets of active ingredients in CHD-HF were filtrated. On these bases, cluster and enrichment analysis of the components and targets were used to explore relevant pharmacological mechanisms, mainly including anti-myocardial cell damage, anti-inflammation, anti-apoptosis, anti-fibrosis, regulation of oxidative stress, anticoagulation and angiogenesis, and improvement of glucose and fatty acid metabolism.

CONCLUSION

CHM are effective in treating CHD-HF compared with conventional treatment. Some of the included studies have high risks in the implementation of blinding, so more high-quality studies are needed. The active ingredients of CHM could protect the myocardium and improve pathological environment of CHD-HF in various ways. And CHM has the advantage of multi-component and multi-target treatment for complex diseases.

Association between corrected QT interval and long-term cardiovascular outcomes in elderly patients who had undergone endovascular therapy for lower extremity arterial disease

Background

Population-based studies have reported the association between prolonged corrected QT (QTc) intervals and an increased risk of adverse cardiovascular events. Data regarding the association between longer QTc intervals and incident cardiovascular outcomes in patients with lower extremity arterial disease (LEAD) are scarce.

Objective

To examine the impact of QTc interval on long-term cardiovascular outcomes in elderly patients with symptomatic LEAD.

Methods

This cohort study extracted data from the Tzu-chi Registry of ENDovascular Intervention for Peripheral Artery Disease (TRENDPAD) and enrolled 504 patients aged ≥ 70 treated with endovascular therapy for atherosclerotic LEAD from July 1, 2005, to December 31, 2019. The main outcomes of interest were all-cause mortality and major adverse cardiovascular events (MACE). Multivariate analysis was conducted using the Cox proportional hazard model to determine independent variables. We performed interaction analysis between corrected QT and other covariates and Kaplan-Meier analysis to compare the outcome of interest among the groups stratified by the tercile of QTc intervals.

Results

A total of 504 patients [235 men (46.6%); mean age, 79.9 ± 6.2 years; mean QTc interval, 459 ± 33 msec] entered the final data analysis. We categorized the baseline patient characteristics according to terciles of QTc intervals. During the median follow-up time of 3.15 (interquartile ranges, 1.65-5.42) years, we noted 264 deaths and 145 MACEs. The 5-year rates of freedom from all-cause mortality (71% vs. 57% vs. 31%, P < 0.001) and MACEs (83% vs. 67% vs. 46%, P < 0.001) were significantly different among the tercile groups. Multivariate analysis showed that a 1-SD increase in the QTc interval increased the risk of all-cause mortality [hazard ratio (HR) 1.49, P < 0.001] and MACEs (HR 1.59, P < 0.001) after adjusting for other covariates. The interaction analysis showed that QTc interval and C-reactive protein levels were most strongly associated with death (HR = 4.88, 95% CI 3.09-7.73, interaction P < 0.001) and MACEs (HR = 7.83, 95% CI 4.14-14.79, interaction P < 0.001).

Conclusions

In elderly patients with symptomatic atherosclerotic LEAD, a prolonged QTc interval is associated with advanced limb ischemia, multiple medical comorbidities, increased risk of MACEs, and all-cause mortality.

Repetition of Paclitaxel-Coated Devices for the Treatment of Lower Extremity Artery Disease: Mortality Outcomes and Predictors

Background

A recent meta-analysis reported late excess mortality in patients treated with paclitaxel-coated devices (PCDs) for symptomatic femoropopliteal disease. However, this finding is controversial.

Objectives

To investigate the impact on mortality and predictors of repeat exposure to PCDs in patients with lower extremity peripheral arterial disease (LE-PAD).

Methods

We analyzed registry patient-level data from two centers. A total of 214 patients were enrolled, and stratified based on terciles of cumulative dose of paclitaxel. We treated 134 patients with a single PCD exposure and 80 with multiple PCD exposures. We used the follow-up index (FUI) in Kaplan-Meier survival estimates to minimize potential selection bias. We used Cox proportional hazard and splines models to determine the predictors of mortality and assess their relationships with mortality.

Results

The mean cumulative dose of paclitaxel was significantly different among groups (6.40 mg vs. 15.06 mg vs. 38.57 mg, p < 0.001). The 5-year FUI (0.93 ± 0.19 vs. 0.94 ± 0.18 vs. 0.95 ± 0.15, p = 0.836) and survival rates were not different (65.4% vs. 51.9% vs. 72.0%, p = 0.148). There was no dose-response association between paclitaxel dosage and death (p = 0.297). The predictors of death were congestive heart failure, stroke, dialysis dependence, neutrophil-lymphocyte ratio (NLR) > 3, age > 71 years, and body mass index (BMI) < 20 kg/m². Spline model analysis validated the non-linear associations between mortality, age, BMI, and NLR.

Conclusions

Repeated PCD exposure for LE-PAD did not result in excess late mortality. Predictors of mortality might change over time, and continuous variables had non-linear relationships with death.

Referral, Diagnosis, and Pharmacological Management of Peripheral Artery Disease: Perspectives from Taiwan

Peripheral artery disease (PAD) imposes a heavy burden of major adverse cardiovascular events that are associated with considerable mortality and morbidity, and major adverse limb events (e.g., thrombectomy, revascularization, amputation) that can substantially impact patients' daily functioning and quality of life. Global registry data have indicated that PAD is an underdiagnosed disease in Taiwan, and its associated risk factors remain inadequately controlled. This review discusses the burden of PAD in Taiwan, major guidelines on PAD management, and the latest clinical trial outcomes. Practical experience, opinions, and the latest trial data were integrated to derive a series of clinical algorithms - patient referral, PAD diagnosis, and the antithrombotic management of PAD. These algorithms can be adapted not only by physicians in Taiwan involved in the clinical management of patients with PAD but also by general practitioners in local clinics and regional hospital settings, with the ultimate aim of improving the totality of PAD patient care in Taiwan.

Advances for the treatment of lower extremity arterial disease associated with diabetes mellitus

Lower extremity arterial disease (LEAD) is a major vascular complication of diabetes. Vascular endothelial cells dysfunction can exacerbate local ischemia, leading to a significant increase in amputation, disability, and even mortality in patients with diabetes combined with LEAD. Therefore, it is of great clinical importance to explore proper and effective treatments. Conventional treatments of diabetic LEAD include lifestyle management, medication, open surgery, endovascular treatment, and amputation. As interdisciplinary research emerges, regenerative medicine strategies have provided new insights to treat chronic limb threatening ischemia (CLTI). Therapeutic angiogenesis strategies, such as delivering growth factors, stem cells, drugs to ischemic tissues, have also been proposed to treat LEAD by fundamentally stimulating multidimensional vascular regeneration. Recent years have seen the rapid growth of tissue engineering technology; tissue-engineered biomaterials have been used to study the treatment of LEAD, such as encapsulation of growth factors and drugs in hydrogel to facilitate the restoration of blood perfusion in ischemic tissues of animals. The primary purpose of this review is to introduce treatments and novel biomaterials development in LEAD. Firstly, the pathogenesis of LEAD is briefly described. Secondly, conventional therapies and therapeutic angiogenesis strategies of LEAD are discussed. Finally, recent research advances and future perspectives on biomaterials in LEAD are proposed.

Effect of physiotherapy on the promotion of bone mineralization in preterm infants: a randomized controlled trial

Preterm infants have a low level of bone mineralization compared to those born at term. The purpose of the present study was to investigate the effect of reflex locomotion therapy (RLT) on bone mineralization and growth in preterm infants and compare its effect to other physiotherapy procedures. Forty-six preterm infants born at 29–34 weeks were randomized into three groups: one group received RLT (n = 17); the other group received passive movements with gentle joint compression (n = 14); and the control group received massages (n = 15). All the treatments were performed at the neonatal unit for one month. The main outcome measure was bone mineralization, which was measured using the tibial speed of sound (Tibial-SOS). All the groups were similar in terms of gestational age (31.8 ± 1.18), birth weight (1,583.41 ± 311.9), and Tibia-SOS (1,604.7 ± 27.9) at the beginning of the intervention. At the end of the study, significant differences were found among the groups in the Tibial-SOS [F(4,86) = 2.77, p = 0.049, η_p² = 0.114] in terms of the benefit to the RLT group. In conclusion, RLT has been effective at improving Tibial-SOS levels and has been more effective than other physical therapy modalities; therefore, it could be considered an effective physiotherapeutic modality for the prevention and treatment of osteopenia from prematurity.

Triglycerides as Biomarker for Predicting Systemic Lupus Erythematosus Related Kidney Injury of Negative Proteinuria

Fewer biomarkers can be used to predict systemic lupus erythematosus (SLE) related kidney injury. This paper presents an apriori algorithm of association rules to mine the predictive biomarkers for SLE-related kidney injury of negative proteinuria. An apriori algorithm of association rules was employed to identify biomarkers, and logistic regression analysis and spearman correlation analysis were used to evaluate the correlation between triglycerides and SLE-related kidney injury of negative proteinuria. Triglycerides were mined out by the apriori algorithm of association rules. The level of triglycerides was significantly higher, and it was an independent risk factor for SLE-related kidney injury. In the high-triglycerides group, the number of patients with SLE-related kidney injury, SLEDAI-2K, urine P-CAST, the level of blood urea nitrogen, serum creatinine, and proteinuria were increased. Triglycerides level was positively correlated with proteinuria and P-CAST and negatively correlated with albumin and IgG. The area under the ROC curve of triglycerides and triglycerides combined proteinuria was 0.72 and 0.82, respectively. Significantly, 50% of SLE-related kidney injuries of negative proteinuria could be identified by high triglycerides levels. High triglycerides level was found at the time of onset of kidney injury, and it was opposite to glomerular filtration rate. Triglycerides may be a potential marker for predicting SLE-related kidney injury, especially in SLE-related kidney injury of negative proteinuria. Triglycerides combined proteinuria could predict SLE-related kidney injury effectively.

Predictive Value of Geriatric Nutritional Risk Index in Patients With Lower Extremity Peripheral Artery Disease: A Meta-Analysis

Background

Conflicting results have been reported on the value of the Geriatric Nutritional Risk Index (GNRI) in predicting adverse outcomes in patients with peripheral artery disease (PAD). The objective of this meta-analysis was to evaluate the association of GNRI with adverse outcomes in patients with lower extremity PAD.

Methods

Relevant studies were comprehensively searched in PubMed and Embase databases until December 31, 2021. Eligible studies should evaluate the value of GNRI in predicting major adverse cardiovascular and leg events (MACLEs), all-cause mortality, and amputation in patients with lower extremity PAD.

Results

Eight studies reporting on 9 articles involving 5,541 patients were included. A fixed-effect model meta-analysis showed that patients with PAD with low GNRI had an increased risk of MACLEs [adjusted risk ratio (RR) 2.26; 95% confidence interval (CI) 1.54–3.31] and all-cause mortality (RR 2.38; 95% CI 1.71–3.31) compared with those with high GNRI. When analysis of GNRI is by continuous data, 10 units of GNRI decrease was associated with 36% and 44% higher risk of MACLEs and all-cause mortality, respectively. However, per 10 units GNRI score decrease was not significantly associated with a higher risk of amputation (p = 0.051).

Conclusion

Low GNRI may be an independent predictor of adverse outcomes in patients with lower extremity PAD. Routine screening of nutritional status using the GNRI may provide important prognostic information in patients with PAD.

A scoping review of malnutrition in patients undergoing interventions for peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is associated with comorbid conditions and frailty. The role of pre-operative nutrition in these patients with PAD is not well characterized. This scoping review sought to describe the prevalence and prognostic implications of pre-operative malnutrition in patients undergoing vascular interventions for claudication or critical limb threatening ischemia (CLTI).

METHODS

Studies were systematically searched across 6 databases from inception to August 2021. Studies focusing on patients with claudication or CLTI undergoing open or endovascular procedures were included if pre-operative nutrition was measured and correlated with a clinical outcome.

RESULTS

Of 4186 records identified, 24 studies addressed the prevalence or prognostic impact of malnutrition in patients undergoing interventions for PAD. The proportion of women included in these studies ranged from 6% to 58%. The prevalence of pre-operative malnutrition ranged from 14.6% to 72%, and notably 7 different malnutrition assessments were used in these studies. Across all scales, pre-operative malnutrition was associated with at least one of the following outcomes: mortality, post-operative complications, length of stay, readmission rates, as well as delayed wound healing.

CONCLUSION

There are a variety of tools used to measure malnutrition in patients undergoing interventions for PAD. Our findings suggest that pre-operative malnutrition is associated with adverse clinical outcomes in patients undergoing open and endovascular procedures for claudication or CLTI, and there is lack of consensus on which tool to use. Clinicians and surgeons should be sensitized to the importance of assessing malnutrition preoperatively in adults undergoing interventions for PAD.

An Association Rule Mining Analysis of Lifestyle Behavioral Risk Factors in Cancer Survivors with High Cardiovascular Disease Risk

We aimed to assess which lifestyle risk behaviors have the greatest influence on the risk of cardiovascular disease in cancer survivors and which of these behaviors are most prominently clustered in cancer survivors, using logistic regression and association rule mining (ARM). We analyzed a consecutive series of 897 cancer survivors from the Korean National Health and Nutritional Exam Survey (2012-2016). Cardiovascular disease risks were assessed using the atherosclerotic cardiovascular disease score (ASCVDs). We classified participants as being in a low-risk group if their calculated ASCVDs was less than 10% and as being in a high-risk group if their score was 10% or higher. We used association rule mining to analyze patterns of lifestyle risk behaviors by ASCVDs risk group, based upon public health recommendations described in the Alameda 7 health behaviors (current smoking, heavy drinking, physical inactivity, obesity, breakfast skipping, frequent snacking, and suboptimal sleep duration). Forty-two percent of cancer survivors had a high ASCVD. Current smoking (common odds ratio, 11.19; 95% confidence interval, 3.66-34.20, p < 0.001) and obesity (common odds ratio, 2.67; 95% confidence interval, 1.40-5.08, p < 0.001) were significant predictors of high ASCVD in cancer survivors within a multivariate model. In ARM analysis, current smoking and obesity were identified as important lifestyle risk behaviors in cancer survivors. In addition, various lifestyle risk behaviors co-occurred with smoking in male cancer survivors.