Statins and risks of dementia among patients with heart failure: a population-based retrospective cohort study in Hong Kong

Background

Heart failure (HF) and dementia frequently co-exist with shared pathological mechanisms and risk factors. Our study aims to investigate the association between statin therapy and the risks of dementia and its subtypes among patients with HF.

Methods

The Hong Kong Clinical Data Analysis and Reporting System database was interrogated to identify patients with incident HF diagnosis from 2004 to 2018, using ICD 9/ICD 10 codes. Inverse probability of treatment weighting (IPTW) was used to balance baseline covariates between statin users (N = 54,004) and non-users (N = 50,291). The primary outcomes were incident all-cause dementia, including subtypes of Alzheimer's disease, vascular dementia, and unspecified dementia. Cox proportional-hazard model with competing risk regression was performed to estimate the sub-distribution hazards ratio (SHR) with corresponding 95% confidence intervals (CI) of the risks of all-cause dementia and its subtypes that are associated with statin use.

Findings

Of all eligible patients with HF (N = 104,295), the mean age was 74.2 ± 13.6 years old and 52,511 (50.3%) were male. Over a median follow-up of 9.9 years (interquartile range [IQR]: 6.4-13.0), 10,031 (9.6%) patients were diagnosed with dementia, among which Alzheimer's disease (N = 2250), vascular dementia (N = 1831), and unspecified dementia (N = 5950) were quantified separately. After IPTW, statin use was associated with a 20% lower risk of incident dementia compared with non-use (multivariable-adjusted SHR 0.80, 95% CI 0.76-0.84). Stratified by subtypes of dementia, statin use was associated with a 28% lower risk of Alzheimer's disease (SHR 0.72, 95% CI 0.63-0.82), 18% lower risk of vascular dementia (SHR 0.82, 95% CI 0.70-0.95), and a 20% lower risk of unspecified dementia (SHR 0.80, 95% CI 0.75-0.85).

Interpretation

In patients with HF, statin use was associated with a significantly lower risk of all-cause dementia and its subtypes, including Alzheimer's disease, vascular dementia, and unspecified dementia. Both randomized trials and experimental studies to validate the potential neuroprotective effect of statin are warranted.

Funding

No funding was provided for this study.

[Study on revision of standard limits for benzene in"Standards for indoor air quality（GB/T 18883-2022）"in China]

Benzene, as a major indoor pollutant, has received widespread attention. In order to better control indoor benzene pollution and protect people's health, the limit value of benzene in the"Standards for indoor air quality (GB/T 18883-2022)'' was reduced from 0.11 mg/m3 to 0.03 mg/m3. This study reviewed and discussed the relevant technical contents of the determination of benzene limit value, including the exposure status of benzene, health effects, and derivation of the limit value. It also proposed prospects for the future direction of formulating indoor air benzene standards.

Morphological and functional types of tricuspid regurgitation: prognostic value in patients undergoing tricuspid annuloplasty during left-sided valvular surgery

BACKGROUND

The nonuniform benefit of tricuspid annuloplasty may be explained by the proportionality of tricuspid regurgitation (TR) severity to right ventricular (RV) area. The purpose of this study was to delineate distinct morphological phenotypes of functional TR and investigate their prognostic implications in patients undergoing tricuspid annuloplasty during left-sided valvular surgery.

METHODS

The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) were retrospectively assessed in 290 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from penalized splines and maximally selected rank statistics, patients were stratified into proportionate (EROA/RVDA ratio ≤ 1.74) and disproportionate TR (EROA/RVDA ratio > 1.74).

RESULTS

Overall, 59 (20%) and 231 (80%) patients had proportionate and disproportionate TR, respectively. Compared to those with proportionate TR, patients with disproportionate TR were older, had a higher prevalence of atrial fibrillation, lower pulmonary pressures, more impaired RV function, and larger tricuspid leaflet tenting area. Over a median follow-up of 4.1 years, 79 adverse events (47 heart failure hospitalizations and 32 deaths) occurred. Patients with disproportionate TR had higher rates of adverse events than those with proportionate TR (32% vs 10%; P = 0.001) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based classification of TR severity in outcome prediction and provided incremental prognostic value to both the EuroSCORE II and STS score (incremental χ2 = 6.757 and 9.094 respectively; both P < 0.05).

CONCLUSIONS

Disproportionate TR is strongly associated with adverse prognosis and may aid patient selection and risk stratification for tricuspid annuloplasty with left-sided valvular surgery.

Clinical Value of Computational Angiography-derived Fractional Flow Reserve in Stable Coronary Artery Disease

The utilization of FFR remains low. Our study evaluated the per-vessel prognostic value of computational pressure-flow dynamics-derived FFR (caFFR) among patients with stable coronary artery disease. A total of 3329 vessels from 1308 patients were included and analysed. They were stratified into ischaemic (caFFR ≤ 0.8) and non-ischaemic (caFFR > 0.8) cohorts, and the associations between PCI and outcomes were evaluated. The third cohort comprised all included vessels, and the associations between treatment adherent-to-caFFR (PCI in vessels with caFFR ≤ 0.8 and no PCI in vessels with caFFR > 0.8) and outcomes were evaluated. The primary outcome was VOCE, defined as a composite of vessel-related cardiovascular mortality, non-fatal myocardial infarction, and repeat revascularization. PCI was associated with a lower 3-year risk of VOCE in the ischaemic cohort (HR, 0.44; 95% CI, 0.26-0.74; P = 0.002) but not in the non-ischaemic cohort. The risk of VOCE was lower in the adherent-to-caFFR group (n = 2649) (HR, 0.69; 95% CI, 0.48-0.98; P = 0.039). A novel index that uses coronary angiography images to estimate FFR may have substantial clinical value in guiding management among patients with stable coronary artery disease.

[The impact of human umbilical cord-derived mesenchymal stem cells on the pancreatic function of type 2 diabetic mice and their regulatory role on NLRP3 inflammasomes]

Objective: To investigate the effect and regulation of umbilical cord-derived mesenchymal stem cells (UC-MSCs) on islets function and NOD-like receptor family, pyrin domain containing 3 (NLRP3) and autophagy in type 2 diabetic mellitus (T2DM) mice. Methods: Experimental study. Twenty, 8-week-old, male C57BL/6J mice were selected and divided into a normal control group (n=5) and a high-fat feeding modeling group (n=15). The model of T2DM was established by high-fat feeding combined with intraperitoneal injection of low-dose streptozotocin. After successful modeling, those mice were divided into a diabetes group (n=7) and a UC-MSCs treatment group (n=7). The UC-MSCs treatment group was given UC-MSCs (1×106/0.2 ml phosphate buffer solution) by tail vein infusion once a week for a total of 4 weeks; the diabetes group was injected with the same amount of normal saline, and the normal control group was not treated. One week after the treatment, mice underwent intraperitoneal glucose tolerance tests and intraperitoneal insulin tolerance tests, and then the mice were sacrificed to obtain pancreatic tissue to detect the expressions of interleukin-1β (IL-1β) and pancreatic and duodenal homeobox 1 (PDX-1) by immunofluorescence. The bone marrow-derived macrophages were stimulated with lipopolysaccharide and adenosine triphosphate (experimental group) in vitro, then co-cultured with UC-MSCs for 24 h (treatment group). After the culture, enzyme-linked immunosorbent assay was used to detect the secretion level of IL-1β in the supernatant, and immunofluorescence staining was used to detect the expression of NLRP3 inflammasome, and related autophagy proteins. Statistical analysis was performed using unpaired one-way analysis of variance, repeated measure analysis of variance. Results: In vivo experiments showed that compared with the diabetes group, the UC-MSCs treatment group partially repaired islet structure, improved glucose tolerance and insulin sensitivity (all P<0.05), and the expression of PDX-1 increased and IL-1β decreased in islets under confocal microscopy. In vitro experiments showed that compared with the experimental group, the level of IL-1β secreted by macrophages in the treatment group was decreased [(85.9±74.6) pg/ml vs. (883.4±446.2) pg/ml, P=0.001], the expression of NLRP3 inflammasome and autophagy-related protein P62 was decreased, and the expressions of microtubule-associated protein 1 light chain 3β (LC3) and autophagy effector Beclin-1 were increased under confocal microscopy. Conclusions: UC-MSCs can reduce the level of pancreatic inflammation in T2DM mice, preserving pancreatic function. This might be associated with the ability of UC-MSCs to inhibit the activity of NLRP3 inflammasomes in macrophages and enhance autophagy levels.

Chronic kidney disease begets heart failure and vice versa: temporal associations between heart failure events in relation to incident chronic kidney disease in type 2 diabetes

AIM

To investigate the interplay of incident chronic kidney disease (CKD) and/or heart failure (HF) and their associations with prognosis in a large, population-based cohort with type 2 diabetes (T2DM).

METHODS

Patients aged ≥18 years with new-onset T2DM, without renal disease or HF at baseline, were identified from the territory-wide Clinical Data Analysis Reporting System between 2000 and 2015. Patients were followed up until December 31, 2020 for incident CKD and/or HF and all-cause mortality.

RESULTS

Among 102 488 patients (median age 66 years, 45.7% women, median follow-up 7.5 years), new-onset CKD occurred in 14 798 patients (14.4%), in whom 21.7% had HF. In contrast, among 9258 patients (9.0%) with new-onset HF, 34.6% had CKD. The median time from baseline to incident CKD or HF (4.4 vs. 4.1 years) did not differ. However, the median (interquartile range) time until incident HF after CKD diagnosis was 1.7 (0.5-3.6) years and was 1.2 (0.2-3.4) years for incident CKD after HF diagnosis (P < 0.001). The crude incidence of CKD was higher than that of HF: 17.6 (95% confidence interval [CI] 17.3-17.9) vs. 10.6 (95% CI 10.4-10.9)/1000 person-years, respectively, but incident HF was associated with a higher adjusted-mortality than incident CKD. The presence of either condition (vs. CKD/HF-free status) was associated with a three-fold hazard of death, whereas concomitant HF and CKD conferred a six to seven-fold adjusted hazard of mortality.

CONCLUSION

Cardiorenal complications are common and are associated with high mortality risk among patients with new-onset T2DM. Close surveillance of these dual complications is crucial to reduce the burden of disease.

Effect of Collagen-Reactive Functional Monomer on Etch-and-Rinse Adhesives

In this study, we evaluated a novel functional monomer (4-formylphenyl acrylate [FA]) that can specifically and covalently bind to the dentin collagen matrix as a potential alternative hydrophobic diluent-like monomer for improving the durability of dentin bonding. Experimental adhesives with different FA contents (0%, 10%, 20%, and 30%) were evaluated as partial substituents for the hydrophilic monomer 2-hydroxyethyl methacrylate, with the commercial adhesive One-Step (Bisco, Inc.) employed as the positive control. Their degree of conversion, viscosity, hydrophobicity, mechanical properties, and water absorption/solubility were measured as the comprehensive characterization. In situ zymographic assays were performed to determine the extent to which FA inhibits the endogenous hydrolytic activity of dentin. Finally, the bonding performances of the novel adhesives were evaluated with microtensile strength tests and scanning electron microscopy. The results showed that the incorporation of FA significantly improved the mobility of experimental adhesives attributable to the dilution property of FA. In contrast to the possible compromised rate of polymerization by hydroxyethyl methacrylate, FA exhibited typical characteristics of favorable copolymerization with polymerizable monomers in adhesives and improved the degree of conversion of experimental adhesives. The rigidity and hydrophobic properties of the phenyl framework of the FA molecule conferred superior mechanical properties and hydrolysis resistance to the novel experimental adhesives. An inhibitory effect on gelatinolytic activities within the hybrid layer was also observed in the in situ zymographic assays, even at a low FA concentration (10%). In conjunction with the significantly improved infiltration found via scanning electron microscopy, the experimental adhesives containing FA possessed significantly better-maintained microtensile strength, even after aging. Thus, the incorporation of this novel monomer endowed the experimental adhesives with multiple enhanced functionalities. These remarkable advantages highlight the suitability of the monomer for further applications in clinical practice.

Pre-admission and In-Hospital Statin Use is Associated With Reduced Short-Term Mortality in Infective Endocarditis

OBJECTIVE

To investigate for potential protective effects of statin use among patients with infective endocarditis (IE) with consideration for underlying diseases and bacterial culture - variables which have prognostic implications and show considerable geographic variation yet are unappreciated in previous pharmacoepidemiological studies.

PATIENTS AND METHODS

Patients diagnosed with IE between January 1, 1996, and December 31, 2019, were identified. We estimated the effect on mortality of pre-admission statin use (≥90 cumulative days of use before index date) and in-hospital use (use beginning within 2 days of admission), compared with nonusers and discontinued users, respectively, through propensity score analytics.

RESULTS

Of 6700 IE patients (mean age, 58.0 years; 63.3% male [n=4251]), 776 patients had pre-admission statin use, with 626 continuing statin use following admission (in-hospital users). Pre-admission statin users had a 31% lower risk of 1-year mortality (HR, 0.69; 95% CI, 0.58 to 0.82) compared with nonusers. In-hospital users had a 48% lower risk of 1-year mortality (HR, 0.52; 95% CI, 0.34 to 0.78) compared with discontinued users. Subgroup analyses showed significant protective effects of statin use for patients with varying causative agents, underlying diseases, and with or without prosthetic valves. Results were consistent across different statins, and were dose-dependent.

CONCLUSION

In patients with IE, pre-admission and in-hospital use of statin, when compared with statin nonusers and discontinued users, respectively, were associated with a lower risk of 1-year mortality.

Incidence, Clinical Correlates, and Prognostic Impact of Dementia in Heart Failure: A Population-Based Cohort Study

Background

Heart failure (HF) may increase the risk of dementia via shared risk factors.

Objectives

The authors investigated the incidence, types, clinical correlates, and prognostic impact of dementia in a population-based cohort of patients with index HF.

Methods

The previously territory-wide database was interrogated to identify eligible patients with HF (N = 202,121) from 1995 to 2018. Clinical correlates of incident dementia and their associations with all-cause mortality were assessed using multivariable Cox/competing risk regression models where appropriate.

Results

Among a total cohort aged ≥18 years with HF (mean age 75.3 ± 13.0 years, 51.3% women, median follow-up 4.1 [IQR: 1.2-10.2] years), new-onset dementia occurred in 22,145 (11.0%), with age-standardized incidence rate of 1,297 (95% CI: 1,276-1,318) per 10,000 in women and 744 (723-765) per 10,000 in men. Types of dementia were Alzheimer's disease (26.8%), vascular dementia (18.1%), and unspecified dementia (55.1%). Independent predictors of dementia included: older age (≥75 years, subdistribution hazard ratio [SHR]: 2.22), female sex (SHR: 1.31), Parkinson's disease (SHR: 1.28), peripheral vascular disease (SHR: 1.46), stroke (SHR: 1.24), anemia (SHR: 1.11), and hypertension (SHR: 1.21). The population attributable risk was highest for age ≥75 years (17.4%) and female sex (10.2%). New-onset dementia was independently associated with increased risk of all-cause mortality (adjusted SHR: 4.51; P < 0.001).

Conclusions

New-onset dementia affected more than 1 in 10 patients with index HF over the follow-up, and portended a worse prognosis in these patients. Older women were at highest risk and should be targeted for screening and preventive strategies.

Comparison of risk of hyperkalemia between SGLT2 inhibitors and DPP4-inhibitors in patients with type 2 diabetes

Funding Acknowledgements

Type of funding sources: None.

Background

Hyperkalemia is a common complication and increases the risk of cardiac arrhythmias and mortality in patients with type 2 diabetes (T2DM), especially in those with diabetic nephropathy. We investigated the risk of hyperkalemia in patients initiated on SGLT2 inhibitors versus DPP-4 inhibitors among patients with T2DM.

Methods

This study included patients with T2DM who initiated on SGLT2 inhibitors or DPP-4 inhibitors between January 01, 2015 and December 31, 2019 from a territory-wide clinical registry in Hong Kong (Clinical Data Analysis and Reporting System [CDARS]). A multivariable cox proportional hazards analysis, adjusting for key confounders, was used to compare the risk of central laboratory-determined hyperkalemia (serum potassium ≥6.0mmol/L) and hypokalemia (serum potassium &lt;3.5mmol/L), respectively, between SGLT2 inhibitors and DPP-4 inhibitors.

Results

10193 new users of SGLT2 inhibitors were matched to 17305 new users of DPP-4 inhibitors. During the 2-year follow-up, there were 104 hyperkalemia events (incident rate [IR] = 5.17 per 1000 person-years) among SGLT2 inhibitors and 306 events (IR = 9.09 per 1000 person-years) among DPP-4 inhibitors, of which SGLT2 inhibitors were associated with a lower risk of incident hyperkalemia (Adjusted HR: 0.66 [95%CI 0.53-0.83], p&lt;0.001), compared to DPP-4 inhibitors. The incident hypokalemia was similar between SGLT2 inhibitors and DPP-4 inhibitors (Adjusted HR: 0.91 [95%CI 0.81-1.03], P=0.13).

Conclusion

SGLT2 inhibitors reduced incident hyperkalemia, but without increasing incident hypokalemia compared to DPP-4 inhibitors.

Prediabetes Is Associated With Increased Risk of Heart Failure Among Patients With Atrial Fibrillation

OBJECTIVE

To evaluate the association between prediabetes and heart failure (HF) and the association of HF with changes in glycemic status.

RESEARCH DESIGN AND METHODS

Patients newly diagnosed with atrial fibrillation (AF) between 2015 and 2018 were divided into three groups (normoglycemia, prediabetes, and type 2 diabetes) according to their baseline glycemic status. The primary outcome was incident HF. The Fine and Gray competing risks model was applied, with death defined as the competing event.

RESULTS

Among 17,943 patients with AF (mean age 75.5 years, 47% female), 3,711 (20.7%) had prediabetes, and 10,127 (56.4%) had diabetes at baseline. Over a median follow-up of 4.7 years, HF developed in 518 (14%) patients with normoglycemia, 646 (15.7%) with prediabetes, and 1,795 (17.7%) with diabetes. Prediabetes was associated with an increased risk of HF compared with normoglycemia (subdistribution hazard ratio [SHR] 1.12, 95% CI 1.03-1.22). In patients with prediabetes at baseline, 403 (11.1%) progressed to diabetes, and 311 (8.6%) reversed to normoglycemia at 2 years. Compared with remaining prediabetic, progression to diabetes was associated with an increased risk of HF (SHR 1.50, 95% CI 1.13-1.97), whereas reversion to normoglycemia was associated with a decreased risk (SHR 0.61, 95% CI 0.42-0.94).

CONCLUSIONS

Prediabetes was associated with an increased risk of HF in patients with AF. Compared with patients who remained prediabetic, those who progressed to diabetes at 2 years experienced an increased risk of HF, whereas those who reversed to normoglycemia incurred a lower risk of HF.

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Pneumonia and Septic Shock

CONTEXT

Individuals with type 2 diabetes mellitus (DM) have an increased risk of pneumonia and septic shock. Traditional glucose-lowering drugs have recently been found to be associated with a higher risk of infections. It remains unclear whether sodium-glucose cotransporter 2 inhibitors (SGLT2is), which have pleiotropic/anti-inflammatory effects, may reduce the risk of pneumonia and septic shock in DM.

METHODS

MEDLINE, Embase, and ClinicalTrials.gov were searched from inception up to May 19, 2022, for randomized, placebo-controlled trials of SGLT2i that included patients with DM and reported outcomes of interest (pneumonia and/or septic shock). Study selection, data extraction, and quality assessment (using the Cochrane Risk of Bias Assessment Tool) were conducted by independent authors. A fixed-effects model was used to pool the relative risk (RRs) and 95% CI across trials.

RESULTS

Out of 4568 citations, 26 trials with a total of 59 264 patients (1.9% developed pneumonia and 0.2% developed septic shock) were included. Compared with placebo, SGLT2is significantly reduced the risk of pneumonia (pooled RR 0.87, 95% CI 0.78-0.98) and septic shock (pooled RR 0.65, 95% CI 0.44-0.95). There was no significant heterogeneity of effect size among trials. Subgroup analyses according to the type of SGLT2i used, baseline comorbidities, glycemic control, duration of DM, and trial follow-up showed consistent results without evidence of significant treatment-by-subgroup heterogeneity (all Pheterogeneity > .10).

CONCLUSION

Among DM patients, SGLT2is reduced the risk of pneumonia and septic shock compared with placebo. Our findings should be viewed as hypothesis generating, with concepts requiring validation in future studies.

Prospective associations of circulating thrombospondin-2 level with heart failure hospitalization, left ventricular remodeling and diastolic function in type 2 diabetes

Background

Circulating thrombospondin-2 (TSP2) levels were associated with the development of heart failure (HF) in recent studies. However, these studies included only a minority of patients with type 2 diabetes, which is associated with an increased HF risk. As hyperglycemia induces TSP2 expression and its tissue expression increases in type 2 diabetes, we investigated the prospective association of circulating TSP2 with incident HF hospitalization (HHF), and its associations with longitudinal changes of echocardiographic parameters in type 2 diabetes.

Methods

Baseline serum TSP2 levels were measured in 4949 patients with type 2 diabetes to determine its association with incident HHF using multivariable Cox regression analysis. In the echocardiographic study, baseline serum TSP2 levels were measured in another 146 patients with type 2 diabetes but without cardiovascular diseases who underwent detailed transthoracic echocardiography at baseline and after 1 year.

Results

Over a median follow-up of 7.8 years, 330 of 4949 patients (6.7%) developed incident HHF. Baseline serum TSP2 levels were independently associated with the development of HHF (HR 1.31, 95%CI 1.06–1.62, p = 0.014) after adjustments for baseline conventional cardiovascular risk factors, atrial fibrillation, estimated glomerular filtration rate, albuminuria and high-sensitivity C-reactive protein level, use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop-diuretics, aspirin, insulin, metformin and sodium-glucose co-transporter 2 inhibitors. Moreover, baseline serum TSP2 levels were independently associated with increase in average E/e’ and left atrial volume index (p = 0.04 and < 0.01, respectively).

Conclusion

Serum TSP2 levels were independently associated with both incident HHF and deterioration in diastolic function in type 2 diabetes.

Trial registration

Not Applicable

Supplementary information

The online version contains supplementary material available at 10.1186/s12933-022-01646-x.

Peak atrial longitudinal strain as an independent predictor of composite endpoint in patients received aortic valve replacement for severe aortic stenosis: a prospective cohort study

Objective

Severe aortic stenosis (AS) is the primary valvular heart disease, treatable only by aortic valve replacement (AVR). The prognostic value of pre-operative left atrial (LA) function on post-AVR clinical outcomes is uncertain. The study aims to evaluate the prognostic value of pre-operative peak atrial longitudinal strain (PALS) as a surrogate of LA function on post AVR all-cause mortality and heart failure hospitalisation.

Methods

Patients aged 18 years old or above with severe AS were recruited and assessed using speckle-tracking echocardiography pre-operatively. Severe AS was defined according to 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease. PALS was measured. Based on the median value of PALS, patients were stratified into PALS &lt;15.94% and PALS &gt;15.94%. Patients with underlying pre-operative atrial fibrillation, other moderate to severe valvular heart diseases and cancers were excluded. Patients were followed up until death, heart failure hospitalisation or end of the study. The primary outcome is a composite endpoint of all-cause mortality and heart failure hospitalisation. The association of PALS with the composite endpoint was evaluated by Cox Proportional Hazards analysis.

Results

A total of 128 patients (mean age 65.32±9.42 years, 56.3% male) were prospectively analyzed. Patients were followed up for a mean period of 3.9±2.4 years. A total of 65 of 128 patients (50.8%) belonged to PALS&lt;15.94%. During the study period, 23 patients developed the adverse events. A lower pre-operative PALS, both as a continuous or a categorical variable, were associated with a higher unadjusted risk of adverse events (Continuous; HR, 0.93; 95% CI 0.88–0.98; p=0.011; PALS &lt;15.94%; HR, 4.94; 95% CI, 1.67–14.58; p=0.004).

Conclusion

The study demonstrated a lower pre-operative PALS is associated with all-cause mortality and heart failure admission in patients with severe AS undergoing AVR. Evaluation of LA function by assessing speckle tracking derived PALS may aid in prognostication for patients undergoing AVR.

Funding Acknowledgement

Type of funding sources: None.

Risk of sepsis and pneumonia in patients initiated on SGLT2 inhibitors and DPP-4 inhibitors

AIM

The organ protective effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors may be beneficial against infectious complications. This real-world study aims to compare the risk of pneumonia and sepsis between SGLT2 inhibitors and dipeptidyl peptidase 4 (DPP-4) inhibitors in patients with type 2 diabetes.

METHODS

Using a territory-wide clinical registry in Hong Kong (Clinical Data Analysis and Reporting System [CDARS]), we included patients initiated on SGLT2 inhibitors or DPP-4 inhibitors between January 01, 2015 and December 31, 2019 through 1:2 propensity score matching. The primary outcomes were incident events of pneumonia, sepsis and the related mortality. Cox proportional hazards analysis was used to compare the risk of incident pneumonia and sepsis for SGLT2 inhibitors versus DPP-4 inhibitors.

RESULTS

After propensity score matching, 10,706 new users of SGLT2 inhibitors and 18,281 new users of DPP-4 inhibitors were included. The mean age of all eligible subjects were 60 years (SD 11.07) and 61.1% were male. There were 309 pneumonia events [incidence rate per 1000 person-years (IR) = 11.38] among SGLT2 inhibitors users and 961 events (IR = 20.45) among DPP-4 inhibitors users, with lower risk of pneumonia among SGLT2 inhibitors users (adjusted HR 0.63 [95%CI 0.55-0.72], p<0.001). Similarly, SGLT2 inhibitors users had lower incidence of sepsis [164 (IR=6.00) vs. 610 (IR=12.88) events] as well as associated risk of incident sepsis (HR 0.52 [95% CI 0.44-0.62], p<0.001), compared to DPP-4 inhibitors users. Outcome analyses showed that SGLT2 inhibitors were associated with lower risk of pneumonia-related death (HR 0.41 [95%CI 0.29-0.58], p<0.001), sepsis-related death (HR 0.39 [95%CI 0.18-0.84], p<0.05), and infection-related death (HR 0.43 [95%CI 0.32-0.57], p<0.001), compared to DPP-4 inhibitors users. Results were consistent when stratified by age, sex, pre-existing cardiovascular disease, and type of SGLT2 inhibitors.

CONCLUSION

We provide real-world evidence that irrespective of age, sex, prior-existing cardiovascular disease, or type of SGLT2 inhibitors used, patients with type 2 diabetes initiated on SGLT2 inhibitors have lower incidence of pneumonia and sepsis as well as mortality risk associated with pneumonia, sepsis, and infectious diseases, compared with those initiated on DPP-4 inhibitors.

Temporal trends and patterns of infective endocarditis in a Chinese population: A territory-wide study in Hong Kong (2002–2019)

Background

The characteristics of infective endocarditis (IE) in Asians are poorly understood. Therefore, we aim to describe the epidemiological trends and clinical features of IE in Hong Kong.

Methods

All patients with incident IE from 2002–2019 in a territory-wide clinical database in Hong Kong were identified. We studied the age- and sex-adjusted and one-year mortality of IE between 2002 and 2019 and identified significant contributors to 1-year all-cause death using the attributable fraction. We used propensity score and inverse propensity of treatment weighting to study the association of surgery with mortality.

Findings

A total of 5139 patients (60.4 ± 18.2years, 37% women) were included. The overall incidence of IE was 4.9 per 100,000 person-year, which did not change over time (P = 0.17). Patients in 2019 were older and more comorbid than those in 2002. The one-year crude mortality rate was 30% in 2002, which did not change significantly over time (P = 0.10). Between 2002 and 2019, the rate of surgery increased and was associated with a 51% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.49 [0.28–0.87], P = 0.015). Advanced age (attributable fraction 19%) and comorbidities (attributable fraction 15%) were significant contributors to death.

Interpretation

The incidence of IE in Hong Kong did not change between 2002 and 2019. Patients with IE in 2019 were older and had more comorbidities than those in 2002. Mortality of IE remains persistently high in Hong Kong. Together, these data can guide public health strategies to improve the outcomes of patients with IE.

Funding

This work was supported by Sanming Project of Medicine in Shenzhen, China [No. SZSM201911020] and HKU-SZH Fund for Shenzhen Key Medical Discipline [No. SZXK2020081].

Role of prenatal cardiovascular magnetic resonance imaging in determining pregnancy risk in repaired Tetralogy of Fallot patients

Funding Acknowledgements

Type of funding sources: None.

Addressing pregnancy risks poses as a new challenge among women with repaired tetralogy of Fallot (TOF). The high-output state of pregnancy may predispose women to late complications of repaired TOF. However, guidelines regarding antenatal and or perinatal cardiovascular assessment has not been outlined. Noninvasive modalities such as cardiac magnetic resonance imaging (CMR) that do not require the utilization of ionizing radiation are feasible methods of assessment. Risk stratification of baseline CMR parameters has been sparsely investigated among repaired TOF cohorts. This study aims to identify baseline CMR parameters that may predict adverse outcomes of pregnancy among women with repaired TOF.

Sixty-five successful pregnancies were recorded from a cohort of 105 pregnant episodes. Patients with CMR studies performed within 5 years prior to delivery events were included. Adverse clinical outcomes of interest included arrhythmia, heart failure admissions, gestational hypertension, pre-eclampsia toxemia and all-cause mortality. Baseline CMR parameters regarding ventricular mechanics such as left and right ventricular end-diastolic and end-systolic volumes, left and right ventricular ejection fractions and pulmonary regurgitant fraction were measured, and their association with adverse clinical outcomes were evaluated using an independent-samples t-test.

Within all 65 successful pregnancies, 26 baseline CMR images were obtained and included in this study. The mean maternal age was 29.7 ± 6.7 years old with a mean birth weight of 2.91 ± 0.49 kg at a mean gestational age of 38.4 ± 2.0 weeks. There was a total of 12 patients with adverse clinical outcome: 5 patients with heart failure hospitalizations, 4 patients with gestational hypertension, 4 patients with arrhythmia and 2 patients with pre-eclampsia toxemia.

Assessment of baseline CMR parameters of ventricular mechanics revealed that increased left ventricular end-diastolic volumes (LVEDV) (144.7mL/m2 ± 4.9; P = 0.011), left ventricular end-systolic volumes (LVESV) (65.1mL/m2 ± 9.4; P = 0.004), right ventricular end-diastolic volumes (RVEDV) (235.2 ± 29.0; P = 0.021) and right ventricular end-systolic volumes (RVESV) (122.2mL/m2 ± 38.1; P = 0.033) were associated with an increased incidence of arrhythmia during pregnancy. Nonetheless, there was no significant association between baseline ventricular mechanics with heart failure, gestational hypertension, and pre-eclampsia toxemia. 

Baseline assessment of cardiac magnetic resonance imaging among pregnant TOF women revealed that larger left and right ventricular volumes were associated with arrythmia development during pregnancy. Further studies with larger cohort sizes evaluating the role of antenatal and perinatal cardiovascular imaging assessment using CMR in predicting the risks of cardiovascular complications during pregnancy are warranted.

Incidence, clinical correlates and associated outcomes of dementia in heart failure: a population-based cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

Dementia, in the setting of heart failure (HF), portends poorer outcomes and poses great challenges in its clinical management.

Purpose

We investigated the incidence, types, clinical correlates, and the prognostic impact of dementia in a population-based cohort of patients with HF. Further, we examined the interactions of age and sex, and education status with dementia incidence.

Methods

The previously validated Hong Kong Clinical Data Analysis Reporting System (CDARS), a territory-wide database was interrogated to identify patients with HF (N= 202,121) from 1995 to 2018. Associations of clinical correlates with incident dementia and its risk with all-cause mortality were assessed using competing risk/multivariable Cox regression models where appropriate.

Results

Among a total cohort aged ≥18 years with HF (mean age: 75.3 ± 13.0 years, 51.3% women), new-onset dementia occurred in 22,145 (11.0%) over a median follow-up of 5.5 years. Alzheimer’s disease occurred in 27.0%; vascular dementia (18.1%) and unspecified dementia (in 55.1%). Age-standardized rate of dementia incidence in women was 1297 (95%CI, 1276-1318) (vs. 744, 95%CI, 723-765) per 10000 population in men. Other independent predictors of dementia include: Increasing age (HR 1.08), Female sex (HR 1.19), Nil/&lt; primary (vs tertiary) education (HR 1.29), Parkinson’s disease (HR 1.73), head injury (HR 1.37), peripheral vascular disease (HR 1.31), stroke (HR 1.29), depression (HR 1.18), alcohol intake (HR1.17), anaemia (HR 1.14), hypertension (HR 1.08), among other common comorbidities in HF (Figure 1A).

Notably, a significant interaction (p &lt; 0.001) between age and sex on dementia incidence was observed, such that women in all age groups were observed to have higher sHR compared to men (Figure 1B). After accounting for competing risk, dementia was not associated with adjusted hazard of all-cause mortality.

Conclusions

Female sex, lower socioeconomic status, increasing age and common comorbidities were associated with higher hazards of incident dementia. Abstract Figure 1A and Figure 1B

Serial echocardiography assessment and clinical outcomes among pregnant women with Tetralogy of Fallot

Funding Acknowledgements

Type of funding sources: None.

Following advancements in intracardiac repair of Tetralogy of Fallot (TOF), a greater proportion of patients survive well beyond child-bearing age. Pulmonary regurgitation (PR) and subsequent progressive right ventricular dilatation occur frequently as an intrinsic complication of surgical repair of TOF. High-output states such as pregnancy may exacerbate these late complications. The advocation of pre-pregnancy pulmonary valve replacement to mitigate pregnancy-related cardiac burden has remained controversial. This study aims to delineate the outcomes of pregnancy among women with repaired TOF.

105 pregnant episodes among were identified from a cohort of 240 adult female patients with TOF between 1990 to 2021. Patients with echocardiographic studies performed within 1 year prior to and following delivery were included for cardiac functional analysis. A paired sample t-test was performed to compare echocardiographic parameters between pre-delivery and post-delivery periods. Linear regression was used to identify changes to identify significant changes in echocardiographic parameters among patients with a baseline of severe PR.

Within all pregnant episodes (n = 105), 65 successful pregnancies, 16 spontaneous miscarriages, 21 termination of pregnancies and 3 ectopic pregnancies were recorded. The mean maternal age was 28.9 (±6.7) years with deliveries at 37.86 (30-41) gestational weeks. Cardiovascular events occurred in 19 pregnancies with 4 patients having gestational hypertension, 4 patients with pre-eclampsia toxemia, 7 patients with heart failure symptoms and 4 patients with arrhythmias. Other complications included 4 patients with gestational diabetes mellitus, 3 patients with impaired glucose tolerance, 2 patients with anemia, 3 patients with maternal thyroid disease and 1 patients with proteinuria.

Echocardiographic studies demonstrated significant changes in left ventricular ejection fraction (LVEF) (Pre-delivery = 60.69 ±8.73; post-delivery = 59.39 ±9.36) (P = 0.007), left ventricular end diastolic volume (LVEDV) (Pre-delivery: 89.71mL ±18.22mL; Post-delivery: 80.96mL ±12.32mL; P = 0.007), left end systolic volume (LVESV) (Pre-delivery: 35.43 ±12.36; Post-delivery: 32.70 ± 8.83; P = 3.7x10-5) and right ventricular index of myocardial performance score (Pre-delivery: 0.34 ±0.12; Post-delivery: 0.33 ±0.12; P = 0.007). Patients with severe PR was found to have significantly worse right ventricular global longitudinal strain (RV GLS) (P = 0.029). 2 patients progressed to severe PR following delivery.

Adult female patients with TOF can have viable pregnancies with acceptable mortality and morbidity. Deterioration in echocardiographic parameters were identified when comparing between pre-delivery and post-delivery studies. TOF patients should be closely monitored throughout and post-delivery for detection of deterioration of cardiac function and clinical symptoms.

A Novel Chemical Binding Primer to Improve Dentin Bonding Durability

The dentin collagen matrix that is not completely enveloped by resin adhesive is vulnerable to degradation by intrinsic collagenases during the etch-and-rinse process, which contributes to the deterioration of the bonding interface. Current commercial adhesives have no functional components that can form covalent bonds to the dentin collagen matrix. In this study, a photocurable aldehyde, 4-formylphenyl acrylate (FA), was synthesized and for the first time applied as a primer in adhesive dentistry to covalently bind to collagen. Experimental groups with different concentrations of FA (1%, 3%, 5%, 7%, 9%) were prepared as primers. The cytotoxicity was evaluated by live/dead-cell staining and thiazolyl blue tetrazolium bromide assay. The interaction of FA with collagen was examined by attenuated total reflection Fourier transform infrared spectroscopy, hydroxyproline release under the degradation of type I collagenase, and thermogravimetric analysis. An optimal group was selected based on the degree of conversion of 2 universal adhesives and further divided depending on the treatment time (20 s, 30 s, 1 min, 2 min). The bonding performances were evaluated by microtensile strength before and after aging. Finally, the bonding interface was observed under confocal laser scanning microscopy and scanning electron microscope. The results indicated that FA demonstrated good biocompatibility, dentin modification capability, and infiltration. It not only effectively cross-linked dentin collagen to improve its stability against enzymatic hydrolysis and modify the adhesive interface but also potentially acted as a diluting monomer to induce deep penetration of adhesive resin monomers into the dentin. The bonding strength after aging was improved without jeopardizing the degree of conversion of 2 commercial adhesives. Such prominent advantages of using FA to improve the bonding performance promotes its further application in adhesive dentistry.

Prognostic role of right ventricular geometry and function in patients undergoing double valve surgery

Introduction

Multiple valvular heart disease, a combination of stenotic and regurgitant lesions occurring on two or more valves, is a highly prevalent condition. For these patients, surgical correction is the only definitive treatment to improve prognosis, yet concomitant aortic and mitral (double) valve surgery is associated with poor post-operative outcomes. While current guidelines outline left ventricular dimensions and function as surgical triggers, little is known regarding the importance of right ventricular (RV) remodelling in these patients.

Purpose

We sought to evaluate the prognostic value of RV remodelling in patients undergoing double valve surgery.

Methods

RV remodelling was characterised by transthoracic echocardiography in 152 patients undergoing concomitant aortic and mitral valve replacement (n=118) or aortic valve replacement and mitral valve repair (n=34). Four patterns of RV remodelling were defined according to the presence of RV dilation (tricuspid annulus diameter&gt;35mm) and RV systolic dysfunction (percentage RV fractional area change &lt;35%): normal RV size and systolic function (pattern 1); dilated RV with normal systolic function (pattern 2); RV systolic dysfunction with normal RV size (pattern 3); and dilated RV with systolic dysfunction (pattern 4). Adverse events were defined as the composite of all-cause mortality and hospitalisation for heart failure.

Results

Overall, 62 (41%), 31 (20%), 35 (23%), and 24 (16%) patients were classified as RV remodelling patterns 1, 2, 3, and 4, respectively. Patients with advanced RV remodelling patterns were more frequently male, had worse renal function, and a higher EuroSCORE II. During a median follow-up of 43 months, 41 adverse events (22 heart failure hospitalisation and 19 deaths) occurred. Patients with patterns 3 and 4 RV remodelling had an increased risk of adverse events compared to pattern 1 (log-rank χ2 27.42; p&lt;0.001; Figure 1). After adjustments for EuroSCORE II and significant tricuspid regurgitation, RV remodelling patterns 3 (Hazard Ratio [HR] 3.24, 95% Confidence Interval [CI] 1.27–8.24, p=0.014) and 4 (HR 6.18, 95% CI 2.49–15.32, p&lt;0.001) were independently associated with poor post-operative outcomes. Importantly, RV remodelling patterns provided incremental prognostic value to EuroSCORE II (χ2 increased from 18 to 38, p&lt;0.001).

Conclusion

In patients with concomitant aortic and mitral valve disease, RV remodelling is frequent and associated with poorer outcomes. Our study highlights the involvement of the RV in left-sided valvular heart disease and underlines the importance of preoperative assessment of RV geometry and function in patients undergoing double valve surgery.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The evolving characteristics and outcomes of acute myocardial infarction in Hong Kong, 1999–2018

Background

The burden of myocardial infarction (MI) with its assorted comorbid complications is increasing parallel to rising life expectancy. Careful characterisation of patient characteristics and identification of short- and long-term complications is critical to their management. Nonetheless, data on the evolving profiles of patient features and outcomes, particularly in an Asian population, remain sparse.

Purpose

We aim to describe the evolving characteristics and outcomes of MI patients in Hong Kong in the past 2 decades.

Methods

From a well-validated territory-wide database in Hong Kong, we included patients with incident acute MI from 1999/01/01 to 2018/12/31. The primary outcome was 30-day all-cause death, while secondary outcomes include haemorrhagic stroke, and pneumonia, at both 30 days and 5 years. Temporal trends in baseline characteristics were evaluated using Poisson regression, while trends in outcomes were evaluated using Cox proportional hazard model, adjusted with demographics, comorbidities, and baseline medications.

Results

A total of 130,218 patients (age 73.6±13.9 years, 40.0% female) were included. Over time, while there was no change in the proportion of females (P=0.196), the increase in mean age (APC 0.23% [0.21 to 0.24], P&lt;0.001) was concordant with the increase in mean CCI (APC 5.1%, [4.8 to 5.3], P&lt;0.001), with more patients suffering from baseline comorbidities (Figure 1; range of APC 1.7% to 4.3%; all P&lt;0.001). The proportion of ST elevation increased significantly (APC 2.5% [2.4 to 2.5], P&lt;0.001).

The adjusted all-cause 30-day mortality rate decreased increased significantly (APC 0.3% [0.1 to 0.5], P=0.005). The increasing trend was significant in older patients (≥70 years), non-ST elevation, and female, while there was a decreasing trend mortality rate in ST elevation and young patients; no significant trend was observed in male. Strikingly, there is an alarming increase in the rate of haemorrhagic stroke (APC 3.4% [2.3 to 4.4], P&lt;0.001) and pneumonia (APC 1.5% [1.3 to 1.7], P&lt;0.001) at 30 days (Figure 2). Although the rate of 5-year all-cause death declined slightly (APC −0.8% [−0.9 to −0.6], P&lt;0.001), there were increasing rates of haemorrhagic stroke (APC 1.0% [0.3 to 1.7], P=0.004) and pneumonia (APC 3.8% [3.6 to 4.1], P&lt;0.001). Patients who were older, had ST elevation, and more comorbid were more likely to develop pneumonia.

Conclusions

Patients with MI have evolved to be older and more comorbid. Alarmingly, despite reduction in long-term all-cause death over time, the reduction was small; risk of death in short-term significantly increased and patients suffer from more complications including haemorrhagic stroke and pneumonia. These results highlight the emergence of extra-cardiac outcomes that drive poor prognosis and accentuate the need to develop tailored strategies to tackle these potentially lethal complications.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical Discipline; The Sanming Project of HKU-SZH Cardiology

Microbiology of infective endocarditis in Hong Kong from 2000 to 2019: a 20-year analysis

Background

Infective endocarditis (IE) is associated with high mortality and complex microbiological profile. The antibiotic prophylaxis guidelines underwent a major revision in 2009 to reduce unnecessary antibiotic exposure. Substantial geographic variations in microbiological profiles exist, of which the understanding in an Asian population is lacking.

Purpose

We aim to describe the trends in the microbiology of IE in Hong Kong in the past 2 decades.

Methods

All patients aged 20 or above diagnosed with incident IE with blood culture results from 2000–2019 were included from a well-validated territory-wide database in Hong Kong, and were classified as 7 groups of causative organisms as shown in Figure 1. To evaluate the association between microbiology and 1-year all-cause death, a multivariable Cox proportional-hazards model was used, adjusted with demographics and comorbidities. Temporal trends in the proportion of each organism were characterised using Poisson regression. Interrupted time series analysis was used to evaluate the change in the organism-specific incidence after the revision of guidelines.

Results

In a total of 5,657 patients (age 59.9±18.3 years, 37.2% females), there were 2,185 (38.6%) patients with culture-negative endocarditis. Staphylococcus aureus (22.4%) and Streptococci (20.5%) were the most common organisms identified.

Over time, there was a significant reduction in the proportion of culture-negative endocarditis (annual percentage change [APC] −2.3% [−2.8 to −1.7], P&lt;0.001), and a significant increase in the proportion of endocarditis due to Staphylococcus aureus (APC 1.6% [0.7 to 2.4], P&lt;0.001) and Streptococci (APC 2.3% [1.4 to 3.3], P&lt;0.001) (Figure 1). After guidelines revision in 2009, there was no significant change in organism-specific incidence (all P-values for relative change&gt;0.05).

Compared to patients with culture-negative endocarditis, those infected with Staphylococcus aureus (hazard ratio [HR] 2.19 [1.94–2.47], P&lt;0.001), other Staphylococci (HR 1.56 [1.20–2.01], P&lt;0.001), Enterococci (HR 1.60 [1.25–2.05], P&lt;0.001), other microorganisms (HR 1.30 [1.05–1.60], P=0.015), and mixed microorganisms (HR 2.40 [2.02–2.84], P&lt;0.001) had a higher risk of 1-year all-cause death (Figure 2).

There was a significant increase in the proportion of methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (APC 4.1% [1.9 to 6.3], P&lt;0.001), with no significant interval change after 2009. Patients infected with MRSA had a higher all-cause death (HR 2.00 [1.70–2.36], P&lt;0.001).

Conclusions

Different causative organisms carry variable mortality signals in infective endocarditis. Over time, there were fewer cases of culture-negative endocarditis, and the revision of antibiotic prophylaxis guidelines did not result in a significant change in the microbiological profile. There was an increasing trend for MRSA endocarditis, which was associated with a higher risk of death.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Epidemiology of infective endocarditis in Hong Kong, 2000–2019

Background/Introduction

Despite improvements in diagnostic and therapeutic strategies, the mortality and morbidity of infective endocarditis (IE) remain high. The incidence, outcomes, and surgical intervention of IE, particularly in an Asian population, are poorly understood and characterised, and the effect of antibiotic prophylaxis guidelines revision on the incidence of IE remains unexplored.

Purpose

We aim to describe temporal changes in the epidemiology and surgical intervention for IE in Hong Kong in the past 2 decades.

Methods

From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. The temporal trends in the incidence of IE, rate of surgical intervention, and mean Charlson Comorbidity Index (CCI) were characterised using Poisson regression analysis and expressed in annual percentage change (APC [95% CI]). Interrupted time series analysis was used to evaluate the change in incidence after the revision of antibiotic prophylaxis guidelines. The association between surgical intervention and mortality was evaluated using propensity score analytics. Temporal trends in 1-year all-cause mortality were evaluated using multivariable Cox regression.

Results

A total of 5,657 patients (59.9±18.3 years, 37.2% females) were included. The crude incidence remained was stable from 2000 to 2019 (APC 0.1% [−0.5 to 0.7], P=0.675), and remained unchanged following the revision of antibiotic prophylaxis guidelines in 2008 (relative risk of change 0.90 [0.64 to 1.00], P=0.065) (Figure 1). Concordant with an increase in the mean age of IE patients (APC 0.9% [0.8 to 1.1], P&lt;0.001), the comorbidity burden grew substantially from 2000 (CCI 0.55±1.27) to 2019 (CCI 1.09±1.66).

The rate of surgical intervention significantly increased from 5.3% in 2000 to 17.8% in 2019 (APC 2.7% [1.1 to 4.3], P=0.004), and surgical intervention at 1 year was associated with a 45% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.55 [0.46 to 0.65], P&lt;0.001). Nevertheless, the crude all-cause mortality rate at 1 year increased from 27.4% in 2000 to 31.5% in 2019, with no significant trend after adjustment for demographics and comorbidities (APC −0.7% [−1.6 to 0.1], P=0.087).

Conclusions

In this large cohort of Asian patients, the incidence of IE remained static and did not change following the revision of antibiotic prophylaxis guidelines. Over time, patients with IE have evolved to be older and more comorbid. Despite an increasing rate of surgical intervention that conferred improved survival, the mortality of IE remained irresistibly high.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Prognostic value of longitudinal assessment of hepatorenal function and nutritional status in patients undergoing valvular heart surgery

Background

Hepatorenal dysfunction and malnutrition are frequent extracardiac consequences of valvular heart disease (VHD) and have emerged as prominent drivers of adverse prognosis in selected valvular interventions. Nonetheless, data in a general VHD population is sparse, and their interaction and changes following valvular surgery remain unexplored.

Purpose

We aim to characterise the temporal changes, interaction, and prognostic implications of hepatorenal dysfunction and malnutrition before and after valvular surgery.

Methods

Baseline and temporal changes in hepatorenal dysfunction (assessed by the modified model for end-stage liver disease [MELD-XI] score) and nutritional status (assessed by Controlling Nutritional Status [CONUT] score) were correlated with adverse events (composite of all-cause mortality and hospitalisation for heart failure) using Cox proportional hazards model, adjusted with clinical and echocardiographic covariates, medications, type of valvular procedure, and cardiac surgery risk-stratification models (EuroSCORE II and STS score).

Results

Our study included 909 patients who underwent valvular surgery. At baseline, 216 (24%) and 554 (61%) had hepatorenal dysfunction (MELD-XI &gt;12.43) and malnutrition (CONUT ≥2), respectively. MELD-XI scores were modestly correlated with CONUT scores (R=0.36, p&lt;0.001), with concomitant hepatorenal dysfunction and malnutrition present in 177 (19%) patients.

Over a median follow-up of 4.1 years, 101 (11%) patients died and 119 (13%) were hospitalised for heart failure. There was a stepwise increase in mortality (χ2 89.1, p&lt;0.001) and adverse events (χ2 92.9, p&lt;0.001) from patients with normal hepatorenal function and nutrition to concomitant hepatorenal dysfunction and malnutrition (Figure 1). This association remained consistent in fully adjusted models. MELD-XI and CONUT scores significantly improved the discriminatory accuracy of EuroSCORE II (area under the curve [AUC]: 0.80 vs 0.73, p&lt;0.001) and STS score (AUC: 0.79 vs 0.72, p=0.004) for all-cause mortality.

In patients with MELD-XI and CONUT scores 1 year after surgery (n=707), ΔMELD-XI (follow-up MELD-XI minus baseline MELD-XI score) and ΔCONUT scores were significantly associated with adverse events (HR 1.08, 95% CI 1.03–1.14, p=0.001 for ΔMELD-XI; HR 1.18, 95% CI 1.02–1.35, p=0.02 for ΔCONUT). Patients remaining with hepatorenal dysfunction and malnutrition experienced worse survival (log-rank χ2 65.2, p&lt;0.001) and adverse events (log-rank χ2 90.4, p&lt;0.001) (Figure 2).

Conclusions

In patients undergoing valvular surgery, hepatorenal function and nutritional status at baseline, and their temporal changes, are strongly linked to clinical outcomes. These results highlight the role of hepatorenal and nutritional assessment for risk-stratification in valvular surgery.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Survival benefits and optimal timing for surgical intervention for infective endocarditis

Background

Surgery is often indicated in patients with infective endocarditis (IE), but the survival benefits of surgical intervention have not been validated in large-scale studies. Although previous studies appeared to support early surgical intervention, the optimal timing of intervention remains uncertain.

Purpose

We aim to evaluate the benefits of surgery and identify the optimal timing of surgical intervention for patients with IE.

Methods

From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. Patients were divided into those who received surgical intervention within 1 year of IE (surgical cohort) and those who did not (control cohort). The two cohorts were then compared using inverse probability weighting of the covariate balancing propensity score, which included demographics, comorbidities, and causative organism as covariates. Outcomes of interest include, at 1 year, all-cause death, and the development of complications. A Cox proportional hazards model was used to evaluate the association between surgical intervention and death, with “doubly-robust estimation” used to minimise the effect of confounders. For complications, a Fine-Gray model was used to account for competing risk.

The surgical cohort was subdivided into early (≤7 days of hospitalisation) or late surgical intervention; a similar propensity score analytic approach was used to evaluate the effects of early vs. late intervention, with those who died within the 7 days excluded to ensure a fair comparison.

Results

A total of 5,657 patients (age 59.9±18.3 years, 37.2% females) were included, of which 930 (16.4%) received surgical intervention in 1 year. Overall, the surgical cohort had a 45% risk reduction in all-cause death (hazard ratio [HR] 0.55, 95% CI [0.46 to 0.65], P&lt;0.001) (Figure). This association remained consistent in subgroup analysis stratified by age, sex, and causative organisms (Table 1).

The surgical cohort also had a lower risk of complications, including acute kidney injury (HR 0.61, 95% CI 0.43 to 0.87, P=0.006), systemic embolism (HR 0.35 [0.23 to 0.55], P&lt;0.001), ischaemic stroke (HR 0.37 [0.24 to 0.55], P&lt;0.001), cardiac dysrhythmia (HR 0.79 [0.66 to 0.95], P=0.011), and pneumonia (HR 0.36 [0.26 to 0.49], P&lt;0.001).

In the surgical cohort, compared to those who had early surgery (N=181), those with delayed surgery had a lower risk of all-cause death (HR 0.58 [0.34 to 0.99], P=0.045) (Figure) and complications (Table 2) at 1 year. In those who had early surgery, patients who received ultra-early surgery (≤3 days of hospitalisation, N=104) did not have a significantly different risk of death (HR 1.19 [0.47 to 3.34], P=0.654).

Conclusions

Surgical intervention significantly reduced the risk of death and complications in patients with infective endocarditis. Delayed surgical intervention appeared to be more protective.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

Trends and sex differences in characteristics and outcomes in myocardial infarction: a 20-year analysis

Background

There are considerable sex differences in patients with myocardial infarction (MI). However, the recent temporal trends in characteristics and outcomes in women vs. men, particularly in an Asian population, remain poorly understood.

Purpose

We aim to evaluate the sex differences in characteristics and outcomes, and how have these differences evolved over the past 2 decades in patients with MI.

Methods

From a well-validated territory-wide database in Hong Kong, we included patients with incident acute MI from 1999/01/01 to 2018/12/31. Outcomes of interest include, at 30 days, all-cause death, new-onset heart failure (HF), and ischaemic stroke. Trends in sex differences in baseline characteristics were evaluated using linear and Poisson regression, while differences in outcomes were evaluated using Cox proportional hazard model, adjusted with demographics, comorbidities, and baseline medications. A Fine-Gray model was used to evaluate HF and ischaemic stroke to account for competing risk, with all-cause death defined as competing event.

Results

A total of 130,218 patients (age 73.6±13.9 years, 40.0% female) were included. Women were older (79.5±11.7 vs. 69.6±13.8 years, P&lt;0.001) and had a more pronounced increasing trend in age over time (interaction P&lt;0.001). Women were also more comorbid overall (Charlson Comorbidity Index [CCI] 1.25 vs 0.85, age-adjusted P&lt;0.001), but the rising trend in CCI over time was less pronounced than in men (interaction P&lt;0.001) (Figure 1). Women had more baseline hypertension, diabetes, and severe renal disease than men (age-adjusted P&lt;0.001), while the increasing trends in these comorbidities were all more pronounced in men than in women (all interaction P&lt;0.001). Women were more likely to have ST-elevation overall (P&lt;0.001).

Although the crude 30-day mortality rate was higher in women (32.6% vs 23.9%), after adjustment for confounders, they had a lower risk of death (hazard ratio [HR] 0.97, 95% CI [0.96 to 0.99], P=0.003). There was no significant difference in the decreasing trend in 30-day mortality between both sexes (interaction P=0.787) (Figure 1). Women had a higher risk of developing HF (HR 1.04 [1.01 to 1.08], P=0.012) and ischemic stroke (HR 1.36 [1.24 to 1.48], P&lt;0.001) in 30 days.

Among patients aged ≤55 (N=15,324), women (N=2,161, 14.1%) had higher risks of all-cause death (HR 1.61 [1.40 to 1.85], P&lt;0.001), HF (HR 1.64 [1.17 to 2.32], P=0.004), and ischemic stroke (HR 1.69 [1.14 to 2.51], P=0.010) in 30 days, even after adjustment for covariates. The excess mortality in women declined over time (interaction P=0.002).

Conclusions

Women MI patients were older and more comorbid compared to men, which contributed to the higher risk of death, HF, and ischemic stroke among women. Among young MI patients, the increased risk for adverse outcomes among women was particularly pronounced, though the sex differences in mortality reduced over time.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

[Risk factors of perivalvular leakage after transcatheter aortic valve replacement with Venus-A valve]

Objective: To investigate the risk factors of moderate or severe perivalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) with Veneus-A valve. Methods: This study was a single-center case-control study. The clinical data of patients with severe aortic stenosis, who underwent TAVR in the Department of Cardiology of Second Affiliated Hospital of Army Medical University from October 2017 to January 2021, were analyzed. According to the circumferential extent of prosthetic valve paravalvular regurgitation measured by transthoracic echocardiography before discharge (patients who died in hospital were referred to transesophageal echocardiography results after valve implanted), the patients were divided into moderate or severe PVL group and mild or non-PVL group. The clinical features, CT scan and analysis results of aortic root were compared between the two groups. Multivariate logistic regression analysis was used to identify the independent risk factors of postoperative moderate or severe PVL, and receiver operating characteristic (ROC) curve was used to explore the predictive value of related factors. Results: Eighty-two patients (mean age: (70.9±6.5) years, 46 males) were included in the analysis, there were 16 patients in the moderate or severe PVL group and 66 patients in the mild or non-PVL group. The proportion of male gender, depth of valve implantation, size of valve annulus and left ventricular outflow tract (LVOT), and coverage index of LVOT were significantly higher in moderate or severe PVL group than those in mild or non-PVL group (Pall<0.05). As there was a strong collinearity among the valve annular short diameter, LVOT short diameter and LVOT coverage index (partial correlation coefficient R 0.251-0.779, P<0.05), these parameters were not entered in regression model. Multivariate logistic regression analysis showed that valve implantation depth(OR=1.239,95%CI 1.036-1.442,P=0.023), aortic angulation(OR=1.128, 95%CI 1.044-1.312,P=0.038)and LVOT tract coverage index (OR=1.123, 95%CI1.003-1.315, P=0.032) were independent risk factors for moderate or severe PVL after TAVR. The ROC curve showed that the valve implantation depth could predict the occurrence of moderate or severe PVL after TAVR (area under ROC curve (AUC)=0.697, 95%CI 0.554-0.851, P=0.039). Conclusion: Among patients with severe aortic stenosis who undergo TAVR with Venus-A valve, the implantation depth, aortic angulation and LVOT coverage index are independent risk factors of moderate/severe PVL after TAVR, among which valve implantation depth could be used to predict the occurrence of moderate/severe PVL after TAVR.

Statin associated lower cancer risk and related mortality in patients with heart failure

Aims 

Patients with heart failure (HF) have an increased risk of incident cancer. Data relating to the association of statin use with cancer risk and cancer-related mortality among patients with HF are sparse.

Methods and results 

Using a previously validated territory-wide clinical information registry, statin use was ascertained among all eligible patients with HF (n = 87 102) from 2003 to 2015. Inverse probability of treatment weighting was used to balance baseline covariates between statin nonusers (n = 50 926) with statin users (n = 36 176). Competing risk regression with Cox proportional-hazard models was performed to estimate the risk of cancer and cancer-related mortality associated with statin use. Of all eligible subjects, the mean age was 76.5 ± 12.8 years, and 47.8% was male. Over a median follow-up of 4.1 years (interquartile range: 1.6–6.8), 11 052 (12.7%) were diagnosed with cancer. Statin use (vs. none) was associated with a 16% lower risk of cancer incidence [multivariable adjusted subdistribution hazard ratio (SHR) = 0.84; 95% confidence interval (CI), 0.80–0.89]. This inverse association with risk of cancer was duration dependent; as compared with short-term statin use (3 months to <2 years), the adjusted SHR was 0.99 (95% CI, 0.87–1.13) for 2 to <4 years of use, 0.82 (95% CI, 0.70–0.97) for 4 to <6 years of use, and 0.78 (95% CI, 0.65–0.93) for ≥6 years of use. Ten-year cancer-related mortality was 3.8% among statin users and 5.2% among nonusers (absolute risk difference, −1.4 percentage points [95% CI, −1.6% to −1.2%]; adjusted SHR = 0.74; 95% CI, 0.67–0.81).

Conclusion 

Our study suggests that statin use is associated with a significantly lower risk of incident cancer and cancer-related mortality in HF, an association that appears to be duration dependent.

[Clinical value of carbon nanoparticles tracer in gastric cancer surgery to increase the number of lymph nodes retrieval]

Objective: To investigate the clinical value of carbon nanoparticles zonal tracer technique in lymph node retrieval of gastric cancer (GC). Methods: A retrospective cohort study was carried out. Clinicopathological data of GC patients who underwent radical D2 resection with carbon nanoparticles tracer in The First Affiliated Hospital of Hainan Medical University and Hainan Cancer Hospital from December 2015 and February 2019 were collected. Those with postoperative pathology of T1-2, Borrmann IV type GC, distant metastasis, preoperative neoadjuvant chemotherapy and incomplete data were excluded. A total of 181 patients were enrolled in this study, including 113 cases from the First Affiliated Hospital of Hainan Medical University and 68 cases from Hainan Cancer Hospital. Patients were categorized into two groups based on the methods of carbon nanoparticles tracer: zonal tracer group and traditional tracer group. In the traditional tracer group, 0.1-0.3 ml of carbon nanoparticle was injected subserously at the upper, lower, left and right 4 injection points 0.5 cm away from the edge of the tumor in the normal serous membrane. In the zonal tracer group, on the basis of the traditional tracer group, 0.1-0.3 ml of carbon nanoparticle was injected subserously at the first branch of the suprapyloric right gastric artery into the stomach, the first branch of the subpyloric right gastroepiploic artery into the stomach, the first branch of the minor curvature left gastric artery into the stomach and the first branch of the greater curvature left gastroepiploic artery into the stomach, respectively. The display of lymphatic vessels in each location and lymph nodes in each group by the tracing method was observed. The number of black-stained lymph nodes, the black staining rate of lymph nodes, the total number of detected lymph nodes, the total number of positive lymph nodes, and the metastatic rate of lymph node were compared between the two groups. Results: Eighty-nine patients were assigned to zonal tracer group, and 92 patients to traditional tracer group. There were no significant differences in baseline information between the two groups (all P>0.05). The median number of black-stained lymph nodes (median: 25.0 vs. 13.5, Z=-7.158, P<0.001) and the black staining rate of lymph nodes [(70.8±12.0)% vs. (47.1±15.7)%, t=11.399, P<0.001) in the zonal tracer group were significantly higher than those in the traditional tracer group. The total detected number of lymph nodes (37.5±11.5 vs. 29.6±11.8, t=4.581, P<0.001) and the total number of negative lymph nodes (31.3±12.5 vs. 24.9±11.1, t=3.621, P<0.001) were significantly higher in the zonal tracer group than those in the traditional tracer group. There were no significant differences in the total number of positive lymph nodes (median: 4.0 vs. 3.0, Z=-1.485, P=0.137), lymph node metastatic rate [78.7% (70/89) vs. 72.8% (67/92), χ(2)=0.834, P=0.361] and metastatic degree [median: 11% vs. 10%, Z=-0.483, P=0.629] between the two groups. Conclusion: The carbon nanoparticles zonal tracer method can increase the black-staining rate of lymph nodes and the detected number of lymph nodes, thus improving the accuracy of gastric cancer staging.

[Clinical application effect of modified nasopharyngeal swab sampling for 2019 novel coronavirus nucleic acid detection]

Objective: To study the clinical application effect of modified nasopharyngeal swab sampling for 2019 novel coronavirus nucleic acid detection. Methods: This study covered the period from January 14 to March 1, 2020.The supine position method and the protective face screen were used to collect nasopharyngeal swabs from February 24 onwards, before which, the nasopharyngeal swabs were collected by sitting position method. All the patients who were diagnosed with suspected/confirmed 2019 novel coronavirus infection were admitted from February 19 with the nasopharyngeal swabs collected outside the hospital before admission. (1) Thirty-four swabbing operators meeting the inclusion criteria of the study were recruited in this retrospective cohort study. They were grouped according to the collection method of nasopharyngeal swabs. Sixteen operators of Wuhan Taikang Tongji Hospital who applied the supine position method and the protective face screen were included in supine position method+ protective face screen group (15 males and 1 female, aged 34-49 years); 18 operators (12 from the First Affiliated Hospital of Army Medical University (the Third Military Medical University), 1 from Wuhan Jiangxia Mobile Cabin Hospital, 5 from the East District of People's Hospital of Wuhan University) who applied the traditional sitting position method were included in sitting position method group (2 males and 16 females, aged 25-49 years). In supine position method+ protective face screen group, when collecting sample, the patient lay flat and wore a special protective face screen for nasopharyngeal swab sampling, with neck slightly extending and face turning to the opposite side of the operator about 10°. The self-designed questionnaire was used to investigate the cooperation, the incidence of nausea, coughing, sneezing, and struggling of patients evaluated by the operators, the operation time for a single swab sample, the fear of operation and the perceived exposure risk of operators in the two groups. (2) Sixty-five patients (22 males and 43 females, aged 25-91 years) admitted to Wuhan Taikang Tongji Hospital who successively received the sitting position method and supine position method+ protective face screen for nasopharyngeal swabs sampling and with complete nucleic acid detection results were included. The positive rates of nucleic acid detection by the two sampling methods of nasopharyngeal swabs of the patients were statistically analyzed. (3) Forty-one patients who could express their feelings accurately were selected out of those 65 patients (12 males and 29 females, aged 27-83 years). The comfort of patients in the process of sampling by the two methods was investigated. (4) Thirty-four patients (10 males and 24 females, aged 25-83 years) with two or more consecutive negative results of nucleic acid detection of nasopharyngeal swabs by sitting position method were selected from the above 65 patients. The positive rate of nucleic acid detection of nasopharyngeal swab of patients by supine position method+ protective face screen, i. e. negative to positive rate was statistically analyzed. Data were statistically analyzed with t test, Wilcoxon signed rank test, and chi-square test. Results: (1) Compared with those of sitting position method group, the cooperation score of patients evaluated by the operators in supine position method+ protective face screen group was significantly higher (Z=-4.928, P<0.01), the incidence of nausea, choking cough, sneezing, and struggling of patients evaluated by the operators, and the fear of operation score and the perceived exposure risk score of operators in supine position method+ protective face screen group were significantly lower (Z=-5.071, -5.046, -4.095, -4.397, -4.174, -5.049, P<0.01), and the operation time for a single swab sample in supine position method+ protective face screen group was significantly longer (t=223.17, P<0.01). (2) The positive rate of nucleic acid detection of nasopharyngeal swabs by supine position method+ protective face screen was 60.00% (39/65), which was obviously higher than 41.54% (27/65) by sitting position method (χ(2)=4.432, P<0.05). (3) The comfort score of the 41 patients during nasopharyngeal swabs sampling by supine position method+ protective face screen was significantly higher than that by sitting position method (Z=-5.319, P<0.01). (4) Of the 34 patients with two or more consecutive negative results of nucleic acid detection of nasopharyngeal swabs by sitting position method, the rate of negative to positive of nucleic acid detection was 26.47% (9/34) after sampling by supine position method+ protective face screen. Conclusions: Compared with the traditional sitting position method, detection of 2019 novel coronavirus nucleic acids of nasopharyngeal swabs collected by supine method combined with protective face screen is worth promoting, because of its better comfort of patients, low exposure risk for operators, in addition to reducing in the false negative result to some extent, which may help reduce false recurrence of discharged patients.

[Time-series analysis on the relationship between ambient PM2.5 and daily outpatient visits due to allergic conjunctivitis among children in Shenzhen]

Objective: To explore the short-term effects of ambient PM_2.5 on the outpatient visits of allergic conjunctivitis among children in Shenzhen. Methods: It was a ecological study. Data on daily visits including date of visit, sex and age from children with allergic conjunctivitis were collected from Shenzhen Eye Hospital and Shenzhen Children's Hospital in 2018. Related data on air pollution (PM_2.5, PM₁₀, SO₂, NO₂, CO and O₃) and meteorology (atmospheric pressure, temperature and relative humidity) were also collected. Pearson correlation analysis was used for normal distribution data and Spearman rank correlation analysis was used for non-normal distribution data. Generalized additive model was used to estimate the impact of PM_2.5 pollution on allergic conjunctivitis outpatients and the lagging effects. Results: In 2018, there were 16 133 allergic conjunctivitis outpatients in the two hospitals. The maximum age was 18 years and the minimum age was 2 months. Males accounted for 49.3%. The daily average concentration of PM_2.5 was 22 (15, 31) μg/m³. Changes of the concentration of PM_2.5 had a positive correlation with the amount of allergic conjunctivitis visits, and the Spearman correlation coefficient was 0.150 (P=0.004). The single pollutant model showed that the strongest effect appeared at 3 days (RR=1.111， 95%CI:1.071-1.152). A 10 μg/m³ increase of PM_2.5 would result in an excessive number of allergic conjunctivitis outpatients as much as 11.112% (95%CI：7.011%-15.212%). In the multiple air pollutants models, after the introduction of NO₂, O₃ and CO, the concentration of PM_2.5 showed an enhanced effect on the number of hospital visits due to allergic conjunctivitis on the same day, and the difference was statistically significant (P<0.05). Conclusion: Changes of the concentration of PM_{2.5 h}ad a positive correlation with daily outpatient visits of allergic conjunctivitis among children in Shenzhen. (Chin J Ophthalmol, 2020, 56: 608-614).

[Experts consensus for the diagnosis, treatment, and prevention of Coronavirus disease 2019 in the elderly]

Coronavirus disease 2019 (COVID-19) can cause great damage to the elderly patients and lead to high mortality. The clinical presentations and auxiliary examinations of the elderly patients with COVID-19 are atypical, due to the physiological ageing deterioration and basal pathological state. The treatment strategy for the elderly patients has its own characteristics and treatment protocol should be considered accordingly. To improve the diagnosis, treatment, and prevention of COVID-19 in the elderly, the Expert Committee of Geriatric Respiratory and Critical Care Medicine, China Society of Geriatrics established the "Expert consensus for the diagnosis, treatment, and prevention of Coronavirus disease 2019 in the elderly" . We focused on the clinical characteristics and key points for better treatment and prevention of COVID-19 in the elderly. (1) For diagnosis, atypical clinical presentation of COVID-19 in the elderly should be emphasized, which may be complicated by underlying disease. (2) For treatment, strategy of multiple disciplinary team (mainly the respiratory and critical care medicine) should be adopted and multiple systemic functions should be considered. (3) For prevention, health care model about integrated management of acute and chronic diseases, in and out of hospital should be applied.

[Electrophysiological features of patients with subacute combined degeneration]

Objective: To investigate the electrophysiological features of patients with subacute combined degeneration (SCD). Methods: The electrophysiological data of 85 hospitalized patients in Department of Neurology, First Medical Centre, Chinese PLA General Hospital from January 2014 to September 2018 were retrospectively analyzed. Results: Abnormality rate of motor nerve conduction (27.4%(93/339)) was lower than that of sensory nerve conduction (45.9%(107/233)) (P<0.001). Abnormality of sensory nerve action potential amplitude was more frequent than conduction velocity abnormality (22.7%(53/233) vs 4.7%(11/233), P=0.001). Abnormality rate of needle electromyogram (EMG) was higher in lower limbs than upper limbs (31.9%(59/185) vs 5.7%(5/87), P<0.001). Spontaneous potentials were unrelated to disease duration or severity. Abnormal somatosensory evoked potential (SEP) results appeared more frequent in lower limbs (80.8%(118/146)) than upper limbs (61.1%(77/126)) (P<0.001). SEP abnormalities (71.7%(195/272)) were more common than nerve conduction abnormalities (35.0%(200/572)). Abnormal findings presented in 15/16 of visual evoked potential (VEP) studies. Neurological severity score were correlated with electrophysiological findings. Conclusions: Posterior funiculus is more likely to be affected than peripheral nerves in SCD patients. The sensory nerves rather than motor nerves, lower limbs rather than upper limbs, axons of sensory nerves rather than myelin, are more severely affected. Electrophysiological tests can provide evidence in early diagnosis, lesions location, and disease severity evaluation for SCD.

[Relationship of body mass index, waist circumference and waist-to-hip ratio with diabetes mellitus in community residents aged 15 years old and above in Pudong new district, Shanghai]

Objective: To analyze the relationship of body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) with diabetes mellitus in community residents aged ≥15 years in Pudong new district of Shanghai, and provide evidence for the prevention and treatment of diabetes mellitus. Methods: Using multi-stage stratified cluster sampling method, a total of 7 194 community residents aged ≥15 years were surveyed by using questionnaire, physical examination and laboratory tests in 2016. The relationship of BMI, waist circumference and waist-hip ratio with diabetes mellitus was analyzed by χ(2) test, single factor linear correlation and logistic regression analyses. Results: In 2016, the crude prevalence rate of diabetes mellitus in Pudong was 27.37%, which was 12.75% after standardization. The prevalence rate of diabetes mellitus was slightly higher in men than in women and was increased with age. The levels of FPG, 2 h plasma glucose and HbA1c were positively correlated with BMI, WC and WHR. After adjusting the confounding factors, multiple logistic regression analysis showed that obesity (OR=1.351, P<0.01), excessive waist circumference (OR=1.255, P<0.01) and high WHR (OR=1.291, P<0.01) were risk factors for diabetes mellitus. Conclusions: The increase of obesity, WC and WHR will increase the risk for diabetes mellitus. It is important to maintain healthy weight, especially the control of WC and WHR, reduce the accumulation of abdominal fat to reduce the risk for diabetes mellitus.

Efficacy and safety of CT-P6 versus reference trastuzumab in HER2-positive early breast cancer: updated results of a randomised phase 3 trial

PURPOSE

Neoadjuvant CT-P6, a trastuzumab biosimilar, demonstrated equivalent efficacy to reference trastuzumab in a phase 3 trial of HER2-positive early-stage breast cancer (EBC) (NCT02162667). We report post hoc analyses evaluating pathological complete response (pCR) and breast pCR alongside additional efficacy and safety measures.

METHODS

Following neoadjuvant treatment and surgery, patients received adjuvant CT-P6 or trastuzumab (6 mg/kg) every 3 weeks for ≤ 1 year.

RESULTS

In total, 271 and 278 patients received CT-P6 and trastuzumab, respectively. pCR and breast pCR rates were comparable between treatment groups regardless of age, region, or clinical stage. Overall, 47.6% (CT-P6) and 52.2% (trastuzumab) of patients experienced study drug-related treatment-emergent adverse events (TEAEs), including 17 patients reporting heart failure (CT-P6: 10; trastuzumab: 7). Two CT-P6 and three trastuzumab patients discontinued adjuvant treatment due to TEAEs.

CONCLUSION

Adjuvant CT-P6 demonstrated comparable efficacy and safety to trastuzumab at 1 year in patients with HER2-positive EBC, supporting CT-P6 and trastuzumab comparability.

[Efficacy and safety of catheter-directed interventional therapy in patients with acute pulmonary embolism]

Objective: To evaluate the efficacy and safety of catheter-directed interventional therapy in patients with acute pulmonary embolism(PE). Methods: PE was diagnosed by CT pulmonary angiography(CTPA). After risk stratification, a total of 79 PE patients (age (58.9±14.9) years old)were treated with catheter-directed interventional therapy via pulmonary vessels. The changes of pulmonary hemodynamics were compared before and after treatment. The risk of complications and side effects were observed. Results: The pulmonary artery pressure was changed followed by interventional therapy. The interventional therapy significantly decreased mean pulmonary arterial pressure (mPAP) from (35.3±11.2)mmHg (1 mmHg=0.133 kPa) to (30.0±10.6)mmHg (t=8.803,P<0.05) and the echocardiographic derived right ventricular dimension to left ventricular dimension (RV/LV) ratio from 0.93±0.16 to 0.83±0.15 (t=6.868,P<0.05). The arterial partial pressure of oxygen was increased from (69.0±8.6)mmHg to (75.1±9.9)mmHg (t=8.561,P<0.05) . The oxygen saturation was also increased from (93.9±2.9)% to (95.1±1.9)% at 24 h after the treatment (t=2.621,P<0.05) . Patients were further grouped as high-risk group (n=28) and intermediate risk group (n=51). mPAP and RV/LV ratio were significantly reduced in the two subgroups (all P<0.05) and the range of reduction was more significant in the high-risk group. Five patients experienced minor bleeding complication, 3 patients suffered worsened dispone post procedure and were treated with mechanical ventilation, 1 patient died, and 1 patient developed recurrent PE. Conclusion: The catheter-directed interventional therapy improves pulmonary hemodynamics and reduces load of right ventricle both in high-risk or intermediate risk PE patients, this therapy strategy is safe and effective for patients with PE.

[Impact of PM2.5 on daily outpatient numbers for respiratory diseases in Shenzhen, China]

Objective: To assess the association between the concentration of the air pollutant PM_2.5 and daily outpatient visits for respiratory disease. Methods: All records of daily outpatient visits to three hospitals in Shenzhen from January 1 to December 31, 2013 were collected. Daily air pollution monitoring and meteorology data from the same period were also collected in Shenzhen. The data were analyzed using a semiparametric generalized additive model with Poisson distribution of time series analysis controlling for long-term and seasonal trends, flu, DOW, public holidays, and meteorological factors. The excess risk(ER)of respiratory disease and its 95% CI value were calculated, along with the incremental increase of 10 μg/m³ in PM_2.5 concentration. Results: Number of outpatient visits for respiratory diseases totaled 1 428 672(daily range: 1 790-5 228). The annual average PM_2.5 concentration was 40.2 μg/m³(daily range: 7.2-137.1 μg/m³). The lag1 factor had the most significant impact on the lag effect. We estimated that a 10 μ g/m³ increase in day-before PM_2.5 concentration was associated with a 1.809%(95% CI: 1.709%-1.909%)ER of visits for respiratory disease. After controlling for other pollutants(NO₂, CO, and O₃), the effect remained stable. When NO₂, CO, and O₃ were introduced separately, for every 10 μg/m³ rise in PM_2.5 concentration, the excess risk of daily outpatient visits for respiratory disease was 1.814%(95% CI: 1.706%-1.923%), 2.780%(95% CI: 2.668%-2.892%), and 1.513%(95% CI: 1.403%-1.624%), respectively. With simultaneous control of NO₂ and O₃, NO₂ and CO, and CO and O₃, for every 10 μg/m³ rise in PM_2.5 concentration, the excess risk of respiratory disease was 1.369%(95% CI: 1.242%-1.497%), 2.709%(95% CI: 2.590%-2.828%), and 2.577%(95% CI: 2.452%-2.702%), respectively. With simultaneous control of NO₂, CO, and O₃, for every 10 μg/m³ rise in PM_2.5 concentration, the excess risk of respiratory disease was 2.370%(95% CI: 2.231%-2.509%). Conclusions: PM_2.5 can increase the risk of outpatient visits for respiratory disease in Shenzhen.

The effects of ginsenoside Rg1 on chronic stress induced depression-like behaviors, BDNF expression and the phosphorylation of PKA and CREB in rats

Depression is a common neuropsychiatric disorder which has been associated with a wide range of structural and functional changes within specific brain regions. Ginsenoside Rg1 has been shown to exert a number of neuroprotective effects as demonstrated in various in vivo and in vitro studies. However, little information is available regarding the site and mechanisms of ginsenoside Rg1 in promoting antidepressant effects. The present study aimed to investigate the neuroprotective and ameliorating effects of ginsenoside Rg1 on depression-like behavior as induced by chronic unpredictable mild stress (CUMS). The results showed that CUMS was effective in producing depression-like behaviors in rats as indicated by decreased responses in sucrose preference and forced swim tests which were associated with ultrastructural changes in neurons within the amygdala. Moreover, levels of PKA and CREB phosphorylation and the expression of brain-derived neurotrophic factor (BDNF) were decreased in the amygdala of CUMS rats. Remarkably, chronic ginsenoside Rg1 (40 mg/kg, i.p., 5 weeks) treatment significantly ameliorated these behavioral and biochemical alterations associated with CUMS-induced depression. Taken together, the results of the present study demonstrate that ginsenoside Rg1 exhibits antidepressant-like effects against CUMS-induced depression. This amelioration of depression-like behaviors by ginsenoside Rg1 appears to be mediated, at least in part, by a CREB-regulated increase of BDNF expression in the amygdala of rats. Therefore, these findings reveal the therapeutic potential of ginsenoside Rg1 for use in clinical trials in the treatment of depression.

THE EFFECT OF DIHYDROARTEMISININ ON THE PROLIFERATION, METASTASIS AND APOPTOSIS OF HUMAN OSTEOSARCOMA CELLS AND ITS MECHANISM

This study aims to research the effect of dihydroartemisinin on the proliferation, metastasis and apoptosis in human osteosarcoma cells 143B and the underlying mechanism. This study designed five groups for experiment and control, using dimethylsulfoxide (DMSO), and docosahexaenoic acid (DHA) at concentrations of 15, 25, 35 μmol.L-1 respectively. Experiments including methyl thiazolyl tetrazolium (MTT) assay, clone formation assay, Hoechst 33258 staining assay, luciferase reporter plasmid assay, Western blot and scratch test were carried out. In addition, SPSS 18.0 software from IBM was used for statistical analysis and all the data obtained from the experiments were expressed as mean ± SD, and variance was used to compare the difference between the groups. DHA is proved to be able to inhibit the proliferation and metastasis of osteosarcoma cells, as well as leaving a positive effect on apoptosis in the cytomorphosis. It achieves regulation over the human osteosarcoma cells by keeping the expression of related protein under control.

Losartan treating podocyte injury induced by Ang II via downregulation of TRPC6 in podocytes

OBJECTIVE

In this study, we investigated the molecule mechanisms of podocyte injury and proteinuria and the protective effects of losartan.

METHODS

This study set up three groups: a control group; an Ang II group (Ang II 10(-6) mol/l, Sigma); and a losartan group (losartan 10(-6) mol/l, Sigma). We used RT-PCR assay to detect TRPC6 mRNA expression, and Western blot to detect TRPC6 protein expression.

RESULTS

TRPC6 overexpression was the basic change of podocyte injury and proteinuria occurrence. Losartan can treat podocyte injury and proteinuria induced by Ang II via downregulation of TRPC6 in podocytes.

CONCLUSION

These findings maybe provide an ideal drug target for the diagnosis and treatment of acquired glomerular diseases.

Impact of Annexin A3 expression in gastric cancer cells

Annexin A3 participates in various biological processes, including tumorigenesis, drug resistance, and metastasis. The aim of this study was to investigate the expression of Annexin A3 in gastric cancer and its relationship with cell differentiation, migration, and invasion of gastric cancer cells. Annexin A3 expression in gastric cancer tissues was detected by quantitative real-time PCR and Western blotting. The proliferation of gastric cancer cells was measured by the MTT assay. Cell migration and invasion were determined via wound healing and transwell assays, respectively. Knock down of endogenous Annexin A3 in gastric cancer BGC823 cells was performed using siRNA technology. The expression of Annexin A3 was significantly upregulated in gastric cancer tissues, and negatively correlated with the differentiation degree. Silencing of endogenous Annexin A3 suppressed the proliferation, migration, and invasion of BGC823 cells. Additionally, the expression of p21, p27, TIMP-1, and TIMP-2 was upregulated, and the expression of PCNA, cyclin D1, MMP-1, and MMP-2 decreased in cells treated with Annexin A3-siRNA. Annexin A3 was upregulated in gastric cancer cells. Deletion of endogenous Annexin A3 significantly inhibited gastric cancer cell proliferation, migration, and invasion.

Role of nephrin phosphorylation inducted by dexamethasone and angiotensin II in podocytes

The phosphorylation of nephrin plays an important role in maintaining the normal structure and function in podocytes. Dexamethasone (Dex) is usually used to treat glomerular diseases with proteinuria. In this study, we observated the effect of Dex and angiotensin II (AngII) on the change of nephrin phosphorylation in cultured podocytes. In vitro, cultured podocytes were exposed to AngII (10(-6) mol/L) pretreated with or without Dex (100 nM) for different time periods. Nck or Fyn were silenced by small interfering RNA (siRNA), nephrin and its phosphorylation expression were analyzed by Western blotting. In vitro, the phosphorylation of nephrin was significantly reduced after AngII stimulation (P < 0.05). Dex significantly resisted podocyte injury inducted by AngII via increasing the phosphorylation of nephrin (P < 0.05), siRNA silencing Nck can partially inhibited nephrin phosphorylation, siRNA silencing Fyn can completely inhibited nephrin phosphorylation. Phosphorylation of nephrin is important for the survival status of podocytes. Glucocorticoid treatment for human glomerulonephritis may exert its function by regulating Nck and Fyn complex to promote phosphorylation of nephrin. These results elucidate a novel mechanism of glucocorticoid treatment for glomerulonephritis.

Losartan reverses glomerular podocytes injury induced by AngII via stabilizing the expression of GLUT1

Podocyte impairment is a key pathogenic even in the initiation and development of glomerular diseases associated with proteinuria. The type 2 diabetic patients is characterized by progressive increases in albuminuria which are associated with the development of characteristic histopathological features. Losartan had a benefit in decreasing albuminuria in type 2 diabetic patients,suggesting that losartan may have another effect other than blockade of the traditional renin-angiotensin system (RAS). However, the mechanism has remained undetermined. Glucose transporter 1 (GLUT1) is the predominant basal glucose transporter. In the kidney, GLUT1 was overexpressed predominantly in glomerular mesangial cells and in small vessels, rather than in podocytes. The increased glomerular GLUT1 mimicked diabetes-induced glomerular GLUT1 expression. In this study, we hypothesized that increased GLUT1 expression induced by angiotensinII (AngII) contributes to the progression of podocytes injury, losartan can block the effect of AngII and protect podocytes via stabilizing the expression of GLUT1, our results strongly suggest that losartan has a direct and protective effect on podocytes. This represents a novel mechanism by which losartan may protect podocyte from apoptotic death and improve podocyte function via stabilizing the expression of GLUT1. This finding underlines the crucial role of GLUT1 in the pathogenesis of podocyte injury and proteinuria.

A clinical study on insomnia in patients with cancer during chemotherapy containing high-dose glucocorticoids

In this prospective, open-labeled study, 240 cancer patients were assigned to either a high-dose glucocorticoids (HDG) group that received chemotherapy containing HDG, or a control group that received chemotherapy without glucocorticoids. The Pittsburgh Sleep Quality Index (PSQI) was chosen to assess insomnia. The results of the study showed that dimensions of sleep latency, sleep duration, and sleep efficiency had the three largest differences in values and numbers of patients, with a score increase in the HDG group compared to the control group (p < 0.001). After chemotherapy in the HDG group, the PSQI score significantly increased in patients with stage II cancer (both p < 0.05), and patients diagnosed with lymphoma (p < 0.01), whereas the complete response and partial response rates (p < 0.05) had the smallest elevations. The average score of each dimension did not significantly decrease after hypnotics (p > 0.05). Our study suggests that the major clinical manifestations of insomnia in cancer patients receiving chemotherapy containing HDG include difficulty falling asleep, short sleep duration, and low sleep efficiency. however, we cannot definitively state that hypnotics can improve poor sleep quality.

Randomised clinical trial: an assessment of acupuncture on specific meridian or specific acupoint vs. sham acupuncture for treating functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a common disease without an established optimal treatment.

AIM

To determine (i) the effect of acupuncture in relieving FD symptoms and improving life quality; (ii) the effect difference between acupoint and non-acupoint; and (iii) the effect difference among different acupoints.

METHODS

A total of 712 eligible patients were included and randomly assigned to six groups (Group A: specific acupoints of the stomach meridian; Group B: non-specific acupoints of the stomach meridian; Group C: specific acupoints of alarm and transport points; Group D: specific acupoints of the gallbladder meridian; Group E: sham acupuncture of non-acupoints; and Group F: itopride). A treatment period of 4 weeks (continuous five sessions per week), and a follow-up period of 12 weeks were arranged. The outcomes were the (i) patients' response, (ii) symptoms improvement measured using the Symptom Index of Dyspepsia and (iii) quality-of-life improvement based on Nepean Dyspepsia Index.

RESULTS

All groups had an improvement in dyspepsia symptoms and the QoL at the end of treatment, and the improvement was sustained for 4 weeks and 12 weeks. The overall response rate was significantly higher in acupuncture group A (70.69%), and lower in sham acupuncture group (34.75%), compared with itopride and other acupuncture groups. Similarly, the difference in symptoms and QoL improvement was significant between group A and the other acupuncture groups.

CONCLUSIONS

Acupuncture is effective in the treatment of functional dyspepsia, and is superior to non-acupoint puncture. The benefit of acupuncture relies on acupoint specificity.