Vascular Injury After Stenting - Insights of Systemic Mechanisms of Vascular Repair

BACKGROUND

The role of circulating progenitor cells (CPC) in vascular repair following everolimus-eluting stent (EES) implantation is largely unknown. The aim of the study was to investigate the relationship between temporal variation in CPC levels following EES implantation and the degree of peri-procedural vascular damage, and stent healing, as measured by optical coherence tomography (OCT).Methods and Results:CPC populations (CD133+/KDR+/CD45low) included patients with stable coronary artery disease undergoing stent implantation, and were evaluated using a flow cytometry technique both at baseline and at 1 week. OCT evaluation was performed immediately post-implantation to quantify the stent-related injury and at a 9-month follow up to assess the mid-term vascular response. Twenty patients (mean age 66±9 years; 80% male) with EES-treated stenoses (n=24) were included in this study. Vascular injury score was associated with the 1-week increase of CD133+/KDR+/CD45low (β 0.28 [95% CI 0.15; 0.41]; P<0.001) and with maximum neointimal thickness at a 9-month follow up (β 0.008 [95% CI 0.0004; 0.002]; P=0.04). Inverse relationships between numbers of uncoated and apposed struts for the 9-month and the 1-week delta values of CD133+/KDR+/CD45low (β -12.53 [95% CI -22.17; -2.90]; P=0.011), were also found.

CONCLUSIONS

The extent of vessel wall injury influences early changes in the levels of CPC and had an effect on mid-term vascular healing after EES implantation. Early CPC mobilisation was associated with mid-term strut coverage.

COVID-19 anosmia and gustatory symptoms as a prognosis factor: a subanalysis of the HOPE COVID-19 (Health Outcome Predictive Evaluation for COVID-19) registry

Olfactory and gustatory dysfunctions (OGD) are a frequent symptom of coronavirus disease 2019 (COVID-19). It has been proposed that the neuroinvasive potential of the novel SARS-CoV-2 could be due to olfactory bulb invasion, conversely studies suggest it could be a good prognostic factor. The aim of the current study was to investigate the prognosis value of OGD in COVID-19. These symptoms were recorded on admission from a cohort study of 5868 patients with confirmed or highly suspected COVID-19 infection included in the multicenter international HOPE Registry (NCT04334291). There was statistical relation in multivariate analysis for OGD in gender, more frequent in female 12.41% vs 8.67% in male, related to age, more frequent under 65 years, presence of hypertension, dyslipidemia, diabetes, smoke, renal insufficiency, lung, heart, cancer and neurological disease. We did not find statistical differences in pregnant (p = 0.505), patient suffering cognitive (p = 0.484), liver (p = 0.1) or immune disease (p = 0.32). There was inverse relation (protective) between OGD and prone positioning (0.005) and death (< 0.0001), but no with ICU (0.165) or mechanical ventilation (0.292). On univariable logistic regression, OGD was found to be inversely related to death in COVID-19 patients. The odds ratio was 0.26 (0.15-0.44) (p < 0.001) and Z was - 5.05. The presence of anosmia is fundamental in the diagnosis of SARS.CoV-2 infection, but also could be important in classifying patients and in therapeutic decisions. Even more knowing that it is an early symptom of the disease. Knowing that other situations as being Afro-American or Latino-American, hypertension, renal insufficiency, or increase of C-reactive protein (CRP) imply a worse prognosis we can make a clinical score to estimate the vital prognosis of the patient. The exact pathogenesis of SARS-CoV-2 that causes olfactory and gustative disorders remains unknown but seems related to the prognosis. This point is fundamental, insomuch as could be a plausible way to find a treatment.

Accuracy of 18F-FDG PET/CT in patients with the suspicion of cardiac implantable electronic device infections: good for pocket, not so good for endocarditis

Introduction

The usefulness of 18F-FDG PET/CT in the diagnosis of infective endocarditis (IE) associated with cardiac implantable electronic devices (CIED) is not well established.

Purpose

To assess the diagnostic yield of 18F-FDG PET/CT in patients with suspected CIED infections, placing special emphasis on differentiating between pocket infection (PI) and CIED-IE.

Methods

From 2013 to 2018, all patients (n=63) admitted to a tertiary care hospital with suspected CIED infection were prospectively recruited, undergoing a thorough diagnostic work-up that included blood cultures extraction, transthoracic (TTE) and transoesophageal echocardiography (TEE) and a PET/CT. When device explantation was required, material from the pocket, generator and leads were also cultured. The gold standard for the diagnosis of CIED-IE was a positive lead culture in the absence of PI when percutaneous extraction was performed or a positive culture from a surgically removed lead. In spite of negative lead cultures, the presence of typical TEE images of vegetations in a clinical context of positive blood cultures was also considered as CIED-IE.

Results

After the whole diagnostic process, 14 (22.2%) cases corresponded to isolated PI and 13 (20.6%) were categorized as CIED-IE. Considering radionuclide uptake in the intracardiac portion of the lead, values of sensitivity, specificity and global diagnostic accuracy of PET/CT for CIED-IE were 38.5%, 98.0% and 85.7%, respectively. Positive and negative likelihood ratio values, 19.2 and 0.6 respectively, suggest that a positive PET/CT is much more probable to correspond to a patient with CIED-IE, whereas it is not possible to exclude this diagnosis in case of a negative result. In the case of PI, fair sensitivity (72.2%) and good specificity values (95.6%) were obtained. Extracardiac lead SUVmax and SUVratio in PI were good, with an area under the ROC curve (AUC) of 0.870 and 0.879, respectively. However, semiquantitative analysis was not useful for the diagnosis of CIED-IE.

Conclusions

In patients with suspected CIED infection, the yield of 18F-FDG PET/CT differs depending on the site of infection, showing a very high specificity but poor sensitivity in CIED-IE; so negative studies must be interpreted with caution if the suspicion of CIED-IE is high.

ROC curves SUVmax and SUV ratio for PI

Funding Acknowledgement

Type of funding source: None

Trends in hospitalization and in-hospital mortality of patients with heart failure in Spain. A population-based study (2003–2015)

Background

Heart failure (HF) is one of the most pressing current public health concerns. However, in Spain there is a lack of population data.

Purpose

To investigate trends in HF hospitalization and in-hospital mortality rates.

Methods

We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospitals during 2003–2015. The source of the data was the Minimum Basic Data Set of the Ministry of Health, Consumer and Social Welfare. We analyzed trends in hospital discharge rates for HF (discharge rates were weighted by age and gender) an in-hospital mortality. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality (which individually considers the performance of the hospital where the patient is attended) and expected mortality (which considers a standard performance according to the average of all hospitals) multiplied by the crude rate of mortality. RSMR was calculated using a risk adjustment multilevel logistic regression models developed by the Medicare and Medicaid Services. Temporal trend during the observed period was modelled using Poisson regression analysis with year as the only independent variable. In this model, the incidence rate ratio (IRR) and their 95% confidence intervals (95% CI) was calculated.

Results

A total of 1 254 830 episodes of HF were selected. Throughout 2003–2015 the number of hospital discharges with principal diagnosis of HF increased by 61% (IRR: 1.04; CI: 1.03–1.04; p&lt;0.001), meanwhile the crude mortality rate and the mean length of stay (LOS) diminished significantly (IRR: 0.99; CI: 0.98–1; and IRR: 1.04; CI: 0.99–0.99; p&lt;0.001, for both). Discharge rates weighted by age and sex showed a statistically significant increase during the period (IRR: 1.03; CI: 1.03–1.03; p&lt;0.001); however, whereas discharge rates increased significantly in older groups of age (≥75 years old) (IRR: 1–1.02; p&lt;0.001) they diminished in younger groups of age (45–74 years old) (IRR: 0.99; p&lt;0.001 and there was not a significant trend in the discharge rates for the group of 35–44 years old (Figure). The risk-standardized in-hospital mortality ratio did not significantly change throughout 2003–2015 (IRR: 0.997; CI: 0.992–1; p=0.32), however the risk-standardized LOS ratio diminished from 1.07 in 2003 to 0.97 in 2015 (IRR: 0.98: IC: 0.98–0.99; p&lt;0.001).

Conclusions

From 2003 to 2015, HF admission rate increased significantly in Spain as a consequence of the sustained increase of hospitalization in the population over 75. The crude in-hospital mortality rate diminished significantly for the same period, but the risk-standardized in-hospital mortality ratio did not significantly change.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of hospital volume on in-hospital mortality and 30-day cardiac readmission of hospitalized patients with heart faliure. A population based study

Background

Heart failure (HF) is a major health care problem. Epidemiological data from hospitalized patients are scarce and the association between hospital volume and patient outcomes is largely unknown.

Purpose

The aim of this study was to analyze the relationship between hospital volume and outcomes (in-hospital mortality and 30-day cardiac readmission).

Methods

We conducted an observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospitals during 2015. The source of the data was the Minimum Basic Data Set of the Ministry of Health, Consumer and Social Welfare. We calculated risk-standardized mortality rates (RSMR) at the index episode and risk-standardized cardiac diseases readmissions rates (RSRR) within 30 days after discharge by using a risk adjustment multilevel logistic regression models developed by the Medicare and Medicaid Services. Information on the number of HF discharges at each hospital in 2015 was analysed to classify centres into 2 categories (high- and low-volume hospitals). To discriminate between high- and low-volume centers, a K-means clustering algorithm was used. The association between volume and RSMR or RSRR was tested with the Pearson correlation coefficient and linear regression models.

Results

A total of 117 233 episodes of HF were selected during 2015. The mean age was 80±10 years and 46% were women. The crude in-hospital mortality rate was 12.1% and 30-day cardiac readmission rate was 18%. The cut-off point was set at 517 HF discharges per hospital during 2015. High volume hospitals had a statistically lower RSMR (10.3±2.8 vs 11.3±3.6; p&lt;0.001) and higher RSRR (10.7±1.9 vs 9.2±1.6; p&lt;0.001) than low volume hospitals. Low-volume hospitals showed higher dispersion of outcomes than high-volume, both for RSMR and RSRR (Figure).

Conclusions

We found that patients hospitalized for HF in 2105 had lower in-hospital mortality if they were admitted to a high-volume hospital. We have also found that high-volume hospitals had higher 30-day cardiac readmission rates.

Funding Acknowledgement

Type of funding source: None

Diagnostic validity of optic nerve head colorimetric assessment and optical coherence tomography angiography in patients with glaucoma

Background/Aims

The aim of this study was to assess the optic nerve head (ONH) and macular vessel density with optical coherence tomography angiography (OCT-A) and the ONH haemoglobin (ONH Hb) amount with Laguna ONhE program in open-angle glaucoma (OAG) patients.

Methods

In this prospective observational cross-sectional study, 67 OAG patients and 41 healthy age-sex frequency matched subjects were examined with OCT-A and retinal photos. The circumpapillary (wcpVD), optic nerve head (iVD) and macular (wmVD) capillary vessel density of OCT-A and ONH colorimetric assessment to determine the ONH Hb amount using the Laguna ONhE program were evaluated.

Results

Significant differences between normal subjects and glaucoma patients in the wcpVD (22.18±3.42 vs 16.03±2.89%; p<0.001), iVD (18.31±5.56 vs 12.52±4.67%; p<0.001), wmVD (15.60±2.34 vs 13.34±2.32%; p<0.001) and amount of ONH Hb (71.10±1.67 vs 68.86±2.46%; p<0.001) and in the papillary cup (68.14±5.25 vs 64.77±5.08%; p=0.001) were found. The Laguna ONhE glaucoma discriminant function (GDF) index had a negative value in the OAG patients and normal values in healthy subjects (−18.76±13.31 vs 7.98±14.09; p<0.001). The area under the receiver operating characteristic (ROC) curve (AUROC) for discriminating between healthy and glaucomatous eyes was highest for wcpVD (0.93; 95% CI 0.86 to 0.97, p<0.0001), followed by GDF (0.92; 95% CI 0.86 to 0.97, p<0.0001), iVD (0.79; 95% CI 0.70 to 0.86; p<0.0001) and ONH Hb (0.78; 95% CI 0.69 to 0.85, p<0.0001). Pair wise comparisons showed that the AUROC of wcpVD (0.93) was not significantly different than GDF (0.92) (p=0.855).

Conclusion

Laguna ONhE program and OCT-A have similar diagnostic validity in open-angle glaucoma patients.

Gender-related Influences on Superficial Papillary Microcirculation Measured with Optical Coherence Tomography Angiography in Patients with Glaucoma

Purpose: To evaluate the optic nerve head (ONH), macular vessel density, and retinal nerve fiber layer (RNFL) thickness differences between the genders. Material and methods: In this prospective case-control cross-sectional study 111 healthy subjects and 130 primary open-angle glaucoma (OAG) patients were examined with optical coherence tomography angiography (OCT-A (RS-3000 Advance (Nidek, Gamagori, Japan))). The vessel density in the peripapillary and macular area as well as the RNFL thickness was evaluated. Results: Men appeared to have less RNFL thickness compared with women in early glaucomatous group, being significant at the whole circumpapillary retinal nerve fiber layer (cpRNFL) thickness and inferior and nasal quadrants: (cpRNFL) (71.01 ± 9.32 vs 77.64 ± 9.95 μm; P = .001), superior quadrant (89.10 ± 16.63 vs 92.97 ± 17.53 μm; P = .284), inferior quadrant (83.03 ± 19.17 vs 95.07 ± 21.70 μm; P = .006), temporal quadrant (57.11 ± 10.36 vs 61.78 ± 11.37 μm; P = .043), nasal quadrant (54.81 ± 11.42 vs 60.73 ± 11.62 μm; P = .016). Circumpapillary (wcpVD) and macular (wmVD) vessel density values were lower in men than women in the early stage OAG group, being wmVD significantly lower: wcpVD (15.53 ± 2.45% vs 16.81 ± 3.17%, P = .032) and wmVD values (12.51 ± 2.21 vs 13.63 ± 2.28%, P = .019), but not in the moderate OAG group (wcpVD 14.46 ± 2.20% vs 16.61 ± 3.10%, P = .056 and wmVD 12.61 ± 2.40% vs 12.74 ± 2.54%, P = .870). There were no significant differences between men and women for RNFL thickness and the vessel density parameters in normal group. Conclusion: Both, the thickness of the nerve fiber layer and peripapillary and macular vessel density are lower in men than in women with glaucoma, more markedly in early stage glaucomatous patients.

Prevalence of Food Sensitization and Food Allergy in Children Across Europe

BACKGROUND

For adults, prevalence estimates of food sensitization (FS) and food allergy (FA) have been obtained in a standardized manner across Europe. For children, such estimates are lacking.

OBJECTIVES

To determine the prevalence of self-reported FA, FS, probable FA (symptoms plus IgE sensitization), and challenge-confirmed FA in European school-age children.

METHODS

Data on self-reported FA were collected through a screening questionnaire sent to a random sample of the general population of 7- to 10-year-old children in 8 European centers in phase I of the EuroPrevall study. Data on FS and probable FA were obtained in phase II, comprising an extensive questionnaire on reactions to 24 commonly implicated foods, and serology testing. Food challenge was performed in phase III.

RESULTS

Prevalence (95% CI) of self-reported FA ranged from 6.5% (5.4-7.6) in Athens to 24.6% (22.8-26.5) in Lodz; prevalence of FS ranged from 11.0% (9.7-12.3) in Reykjavik to 28.7% (26.9-30.6) in Zurich; and prevalence of probable FA ranged from 1.9% (0.8-3.5) in Reykjavik to 5.6% (3.6-8.1) in Lodz. In all centers, most food-sensitized subjects had primary (non-cross-reactive) FS. However, FS due to birch pollen related cross-reactivity was also common in Central-Northern Europe. Probable FA to milk and egg occurred frequently throughout Europe; to fish and shrimp mainly in the Mediterranean and Reykjavik. Peach, kiwi, and peanut were prominent sources of plant FA in most countries, along with notably hazelnut, apple, carrot, and celery in Central-Northern Europe and lentils and walnut in the Mediterranean.

CONCLUSIONS

There are large geograhical differences in the prevalence of FS and FA in school-age children across Europe. Both primary and cross-reactive FS and FA occur frequently.

Oncologic outcomes in 408 consecutive patient cohort treated with da Vinci robot-assisted radical prostatectomy

The objective of this study is to evaluate the general characteristics and oncological results in a cohort of 408 cases submitted to da Vinci Standard 4-armed robot-assisted radical prostatectomy (RARP), performed between October 2006 and February 2015 at Clínico San Carlos hospital. Statistical analysis was performed with the SPSS 20.0 program. Qualitative variables are presented with their frequency distribution and quantitative variables with their mean and standard deviation or median and interquartile range. The χ² test was used to analyze the association of qualitative variables. The disease-free survival outcome variable was evaluated with a Kaplan-Meier curve analysis, and the differences were contrasted with the Breslow test. A Cox regression model was adjusted. Among the results, we highlight the follow-up of 47 months (32-68.75m), recurrence-free survival of 90 months (95% CI, 86-94), median time to recurrence of 23 months (10.5-37 m), recurrence 16'6% (68/408), biochemical recurrence (62/498, 15'2%) and 22% of complications, mostly Clavien I-II. The results are summarized in Tables 1 to 7 and Figure 1. CONCLUSIONS: 1) RARP is a safe technique with an acceptable percentage of complications, mostly minor (Clavien grades iandii), 2) We found a higher probability of remaining recurrence-free in the lower grades of the ISUP classification and a higher probability of recurrence in high-risk cases, and 3) The multivariate model showed that the ISUP grade was significantly related to survival and the ISUP and PSM classification grades were independent prognostic variables.

Prognostic Impact of Hyponatremia and Hypernatremia in COVID-19 Pneumonia. A HOPE-COVID-19 (Health Outcome Predictive Evaluation for COVID-19) Registry Analysis

Dysnatremia is associated with increased mortality in patients with community-acquired pneumonia. SARS-COV2 (Severe-acute-respiratory syndrome caused by Coronavirus-type 2) pneumonia can be fatal. The aim of this study was to ascertain whether admittance dysnatremia is associated with mortality, sepsis, or intensive therapy (IT) in patients hospitalized with SARS-COV2 pneumonia. This is a retrospective study of the HOPE-COVID-19 registry, with data collected from January 1^th through April 31^th, 2020. We selected all hospitalized adult patients with RT-PCR-confirmed SARS-COV2 pneumonia and a registered admission serum sodium level (SNa). Patients were classified as hyponatremic (SNa <135 mmol/L), eunatremic (SNa 135-145 mmol/L), or hypernatremic (SNa >145 mmol/L). Multivariable analyses were performed to elucidate independent relationships of admission hyponatremia and hypernatremia, with mortality, sepsis, or IT during hospitalization. Four thousand six hundred sixty-four patients were analyzed, median age 66 (52-77), 58% males. Death occurred in 988 (21.2%) patients, sepsis was diagnosed in 551 (12%) and IT in 838 (18.4%). Hyponatremia was present in 957/4,664 (20.5%) patients, and hypernatremia in 174/4,664 (3.7%). Both hyponatremia and hypernatremia were associated with mortality and sepsis. Only hyponatremia was associated with IT. In conclusion, hyponatremia and hypernatremia at admission are factors independently associated with mortality and sepsis in patients hospitalized with SARS-COV2 pneumonia.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04334291, NCT04334291.

Long-term impact of diabetes in patients with ST-segment elevation myocardial infarction: Insights from the EXAMINATION randomized trial

BACKGROUND

Long-term outcomes of diabetic patients suffering from ST-segment elevation myocardial infarction (STEMI) and treated with second-generation drug-eluting stent have been scarcely evaluated. The aim of this posthoc subanalysis of the EXAMINATION trial was to compare 5-year outcomes according to the presence of diabetes mellitus.

METHODS

From a total of 1,497 patients included in the trial, 258 were diabetics (n = 137, received everolimus-eluting stent (EES) and n = 121 bare-metal stent (BMS); whereas 1,239 were nondiabetics (n = 613 treated with EES and n = 626 with BMS). Patient-oriented combined endpoint (POCE) defined as all-cause death, any MI or any revascularization, and other clinical parameters were collected up to 5-years. All results were adjusted for various potential confounders.

RESULTS

At 5-years, patients with diabetes showed similar rates of POCE between diabetics treated with EES and those treated with BMS (32.8% vs. 32.2%; p = 0.88). However, rates of TLR were significantly lower in the EES group (4.4% vs. 9.9%; HR 0.52 (0.29-0.94); P = 0.03). In non-diabetics, the use of EES was associated with a significant improvement in all-clinical parameters except for MI rate: POCE: [10.0% vs. 12.6%; HR 0.78(0.62-0.98); P = 0.038], all cause death: [7.0% vs. 12.1%; HR 0.62(0.42-0.90); P = 0.014], and [TLR: 4.2 vs. 6.7; HR 0.60 (0.37-0.98); P = 0.04]. Overall, diabetics showed higher rate of POCE at 5-years (32.6% vs. 21.5% in nondiabetics HR1.45[1.03-2.04];p = 0.03) driven by increased rates of MI and the need for revascularization that occurred in coronary segments remote from target lesions [2.7% vs. 1.1%; HR: 2.27 (1.12-5.23); P = 0.02 and 14% vs. 6.2%; HR: 2.11 (1.38-3.22); P = 0.001, respectively].

CONCLUSIONS

Diabetics had worse clinical outcomes than nondiabetics after STEMI mainly due to atherosclerosis progression. At 5-years, the treatment with EES did not reduce the rate of POCE in diabetics but reduced the need for revascularization compared with BMS.

Diffusion Tensor Imaging Measures of Brain Connectivity for the Early Diagnosis of Alzheimer's Disease

The prognostic capacity of the diffusion tensor imaging measures fractional anisotropy (FA) and mean diffusivity (MD) to detect mild cognitive impairment (MCI) progression to Alzheimer's disease (AD) was assessed in 135 MCI patients and 72 healthy subjects over a median follow-up of 40 months. Forty-nine MCI patients (36.3%) developed AD. The factors MD left hippocampus, FA left cingulate, and FA left hippocampus emerged as predictors of progression. Age (hazard ratio [HR] 1.21), delayed text recall (HR 0.89), FA left uncinate (HR 1.90), FA left hippocampus (HR 2.21), and carrying at least one ApoE4 allele (HR 2.86) were associated with a high conversion rate. FA measures revealed the greatest discriminative capacity (Harrell's C = 0.73 versus 0.65 without FA; p = 0.034). The inclusion of FA structural connectivity data in our model improved discrimination between subjects with MCI progressing or not to dementia.

Food Allergy in Adults: Substantial Variation in Prevalence and Causative Foods Across Europe

BACKGROUND

According to the community-based EuroPrevall surveys, prevalence of self-reported food allergy (FA) in adults across Europe ranges from 2% to 37% for any food and 1% to 19% for 24 selected foods.

OBJECTIVE

To determine the prevalence of probable FA (symptoms plus specific IgE-sensitization) and challenge-confirmed FA in European adults, along with symptoms and causative foods.

METHODS

In phase I of the EuroPrevall project, a screening questionnaire was sent to a random sample of the general adult population in 8 European centers. Phase II consisted of an extensive questionnaire on reactions to 24 preselected commonly implicated foods, and measurement of specific IgE levels. Multiple imputation was performed to estimate missing symptom and serology information for nonresponders. In the final phase, subjects with probable FA were invited for double-blind placebo-controlled food challenge.

RESULTS

Prevalence of probable FA in adults in Athens, Reykjavik, Utrecht, Lodz, Madrid, and Zurich was respectively 0.3%, 1.4%, 2.1%, 2.8%, 3.3%, and 5.6%. Oral allergy symptoms were reported most frequently (81.6%), followed by skin symptoms (38.2%) and rhinoconjunctivitis (29.5%). Hazelnut, peach, and apple were the most common causative foods in Lodz, Utrecht, and Zurich. Peach was also among the top 3 causative foods in Athens and Madrid. Shrimp and fish allergies were relatively common in Madrid and Reykjavik. Of the 55 food challenges performed, 72.8% were classified as positive.

CONCLUSIONS

FA shows substantial geographical variation in prevalence and causative foods across Europe. Although probable FA is less common than self-reported FA, prevalence still reaches almost 6% in parts of Europe.

The Effect of Morbidity and Sex on Postnatal Growth of Very Preterm Infants: A Multicenter Cohort Study

BACKGROUND

Extrauterine growth restriction is common in the preterm infant, and it is associated with poor neurodevelopment. Nutrition plays an important role in postnatal growth, but growth is also influenced by other factors like co-morbidity, and, also, there might be sex differences.

METHODS

This is a cohort study including preterm infants < 32 weeks at birth (n = 21,825) from the Spanish Neonatal Network database. The effect of sex and morbidity (patent ductus arteriosus, bronchopulmonary dysplasia, necrotizing enterocolitis and late-onset sepsis) on weight gain as well as linear and head growth from birth to discharge/death was assessed with linear regression models adjusted by gestational age and Z-scores at birth.

RESULTS

The 4 selected morbidities had an independent effect on all 6 growth parameters studied, which was greater in the case of necrotizing enterocolitis: changes in weight, length and head Z-scores were -0.60 (95% CI: -0.66 to -0.55), -0.62 (95% CI: -0.70 to -0.54) and -0.63 (95% CI: -0.71 to -0.56), respectively. Weight gain and linear growth were overall more affected than head growth. Girls lost slightly more weight Z-scores (-0.03; 95% CI: -0.06 to -0.002) than boys after adjustment by morbidity. There were no significant gender differences regarding linear and head growth velocity (cm/week), although girls lost more head Z-scores (-0.14; 95% CI: -0.18 to -0.10).

CONCLUSIONS

Main co-morbidities associated with prematurity have an impact on postnatal growth. Head growth is less affected than length and weight. Girls are at slightly higher risk of postnatal weight and head restriction after adjustment by morbidity.

Retinal Angiomatous Proliferation Reactivation 6 Months after High-Dose Intravitreal Acetonide Triamcinolone and Photodynamic Therapy

Purpose

To describe the incidence of retinal angiomatous proliferation (RAP) reactivation after combined treatment with a high-dose intravitreal triamcinolone acetonide (IVTA) and photodynamic therapy (PDT) at 1-year follow-up.

Methods

All patients had undergone a full ophthalmic examination. High-dose IVTA (20 mg) was injected via pars plana. Four to 7 days later, PDT was delivered.

Results

Fourteen eyes of 13 patients were included. Eight lesions (57%) reopened and needed retreatment with combined therapy at 6 months follow-up. At 1-year follow up, the lesion was obliterated in nine cases (64.2%) and best-corrected visual acuity improved from 0.87 logMar (range, 0.7–1) to 0.79 logMar (range, 0.5–1).

Conclusions

Combined therapy using high-dose IVTA and PDT is beneficial in stabilizing RAP. However, a high incidence of RAP reactivation has been observed at 6 months, even with a high-dose IVTA injection.

RECALMIN: The association between management of Spanish National Health Service Internal Medical Units and health outcomes

Objective

To investigate the association between management of Internal Medical Units (IMUs) with outcomes (mortality and length of stay) within the Spanish National Health Service.

Design

Data on management were obtained from a descriptive transversal study performed among IMUs of the acute hospitals. Outcome indicators were taken from an administrative database of all hospital discharges from the IMUs.

Setting

Spanish National Health Service.

Participants

One hundred and twenty-four acute general hospitals with available data of management and outcomes (401 424 discharges).

Main Outcome Measures

IMU risk standardized mortality rates were calculated using a multilevel model adjusted by Charlson Index. Risk standardized myocardial infarction and heart failure mortality rates were calculated using specific multilevel models. Length of stay was adjusted by complexity.

Results

Greater hospital complexity was associated with longer average length of stays (r: 0.42; P < 0.001). Crude in-hospital mortality rates were higher at larger hospitals, but no significant differences were found when mortality was risk adjusted. There was an association between nurse workload with mortality rate for selected conditions (r: 0.25; P = 0.009). Safety committee and multidisciplinary ward rounds were also associated with outcomes.

Conclusions

We have not found any association between complexity and intra-hospital mortality. There is an association between some management indicators with intra-hospital mortality and the length of stay. Better disease-specific outcomes adjustments and a larger number of IMUs in the sample may provide more insights about the association between management of IMUs with healthcare outcomes.

Trends in respiratory syncytial virus bronchiolitis hospitalizations in children less than 1 year: 2004-2012

OBJECTIVE

To analyze trends in health outcomes and the influence of risk factors in children under 1 year with acute bronchiolitis due to respiratory syncytial virus (RSV bronchiolitis). A risk-adjustment model for RSV bronchiolitis in-hospital mortality was also developed.

RESEARCH DESIGN AND METHODS

Retrospective study of hospitalizations for RSV bronchiolitis in children aged <1 year from 2004 to 2012. We used nationally representative data from the Spanish National Health Service records.

RESULTS

Over the study period, the annual hospital discharges for RSV bronchiolitis ranged between 6390 and 8637. The annual in-hospital mortality rate ranged from 120 (2004) to 69 (2012) per 100,000 hospitalizations and the mean length of stay decreased steadily from 6.5 to 5.2 days (p < 0.001); 98.3% of hospitalizations for RSV bronchiolitis were children without risk factors. The in-hospital mortality rate due to RSV bronchiolitis in children with risk factors was 18.8 times higher than non-high-risk children and, in adjusted analyses, the OR of in-hospital mortality due to RSV bronchiolitis was higher than that due to other causes.

LIMITATIONS

This study is a retrospective analysis, based on administrative data. It does not include data about pre- or in-hospital treatments, and has the limitations inherent in procedures for determining risk-adjusted mortality rates. Socioeconomic and environmental factors have not been considered in this study.

CONCLUSIONS

RSV bronchiolitis is a leading cause of hospitalizations for infants under 1 year and has not shown incidence reduction over a 9 year period. Risk factors increase the in-hospital mortality risk and it is higher if the hospitalization cause is RSV bronchiolitis than any other reason.

The prevalence and distribution of food sensitization in European adults

BACKGROUND

Complaints of 'food allergy' are increasing. Standardized surveys of IgE sensitization to foods are still uncommon and multicountry surveys are rare. We have assessed IgE sensitization to food-associated allergens in different regions of Europe using a common protocol.

METHODS

Participants from general populations aged 20-54 years in eight European centres (Zurich, Madrid, Utrecht, Lodz, Sophia, Athens, Reykjavik and Vilnius) were asked whether they had allergic symptoms associated with specific foods. Weighted samples of those with and without allergic symptoms then completed a longer questionnaire and donated serum for IgE analysis by ImmunoCAP for 24 foods, 6 aeroallergens and, by allergen microarray, for 48 individual food proteins.

RESULTS

The prevalence of IgE sensitization to foods ranged from 23.6% to 6.6%. The least common IgE sensitizations were to fish (0.2%), milk (0.8%) and egg (0.9%), and the most common were to hazelnut (9.3%), peach (7.9%) and apple (6.5%). The order of prevalence of IgE sensitization against different foods was similar in each centre and correlated with the prevalence of the pollen-associated allergens Bet v 1 and Bet v 2 (r = 0.86). IgE sensitization to plant allergen components unrelated to pollen allergens was more evenly distributed and independent of pollen IgE sensitization (r = -0.10). The most common foods containing allergens not cross-reacting with pollens were sesame, shrimp and hazelnut.

DISCUSSION

IgE sensitization to foods is common, but varies widely and is predominantly related to IgE sensitization to pollen allergens. IgE sensitization to food allergens not cross-reacting with pollens is rare and more evenly distributed.

Robotic Anderson-Hynes dismembered pyeloplasty: initial experience

INTRODUCTION

The introduction of the da Vinci(®) robotic system in 2000 has been a new step forward in the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study was to analyse our initial experience with robot-assisted dismembered Anderson-Hynes pyeloplasty and to perform a bibliographic review on the topic.

PATIENTS AND METHODS

We performed 11 robot-assisted pyeloplasties between March 2007 and April 2011. UPJO diagnosis was made on clinical presentation and imaging techniques (CT scan and intravenous urography). All patients underwent basal and diuretic isotopic renograms to evaluate the degree of obstruction and impaired renal function. Median follow-up was 10 (range 1-26) months.

RESULTS

Mean patient age was 38.8 (range 23-62) years. There were six women (55%) and five men (45%). All cases were primary surgeries. In four patients the cause of UPJO was a crossing vessel; the other seven patients had intrinsic obstruction. One case was associated with extraction of a calyceal lithiasis. Mean operative time was 189.4 min (125-270 min). Average time from robotic arms docking was 116.5 (range 55-180) min. Average hospital stay was 4.18 (range 2-8) days. Conversion to open or laparoscopic surgery was not necessary in any case and there were no postoperative complications. Postoperative radiological evaluation and renograms showed good results in all cases.

CONCLUSIONS

Robotic surgery offers better ergonomics, enhanced three-dimensional (3D) vision and more precise movements, easing intracorporeal suturing.These advantages make robotic pyeloplasty a reproducible technique that combines the high success rates of open surgery and the benefits of laparoscopic surgery.

Colon cancer molecular subtypes identified by expression profiling and associated to stroma, mucinous type and different clinical behavior

Background

Colon cancer patients with the same stage show diverse clinical behavior due to tumor heterogeneity. We aimed to discover distinct classes of tumors based on microarray expression patterns, to analyze whether the molecular classification correlated with the histopathological stages or other clinical parameters and to study differences in the survival.

Methods

Hierarchical clustering was performed for class discovery in 88 colon tumors (stages I to IV). Pathways analysis and correlations between clinical parameters and our classification were analyzed. Tumor subtypes were validated using an external set of 78 patients. A 167 gene signature associated to the main subtype was generated using the 3-Nearest-Neighbor method. Coincidences with other prognostic predictors were assesed.

Results

Hierarchical clustering identified four robust tumor subtypes with biologically and clinically distinct behavior. Stromal components (p < 0.001), nuclear β-catenin (p = 0.021), mucinous histology (p = 0.001), microsatellite-instability (p = 0.039) and BRAF mutations (p < 0.001) were associated to this classification but it was independent of Dukes stages (p = 0.646). Molecular subtypes were established from stage I. High-stroma-subtype showed increased levels of genes and altered pathways distinctive of tumour-associated-stroma and components of the extracellular matrix in contrast to Low-stroma-subtype. Mucinous-subtype was reflected by the increased expression of trefoil factors and mucins as well as by a higher proportion of MSI and BRAF mutations. Tumor subtypes were validated using an external set of 78 patients. A 167 gene signature associated to the Low-stroma-subtype distinguished low risk patients from high risk patients in the external cohort (Dukes B and C:HR = 8.56(2.53-29.01); Dukes B,C and D:HR = 1.87(1.07-3.25)). Eight different reported survival gene signatures segregated our tumors into two groups the Low-stroma-subtype and the other tumor subtypes.

Conclusions

We have identified novel molecular subtypes in colon cancer with distinct biological and clinical behavior that are established from the initiation of the tumor. Tumor microenvironment is important for the classification and for the malignant power of the tumor. Differential gene sets and biological pathways characterize each tumor subtype reflecting underlying mechanisms of carcinogenesis that may be used for the selection of targeted therapeutic procedures. This classification may contribute to an improvement in the management of the patients with CRC and to a more comprehensive prognosis.

Intravitreal ranibizumab for myopic choroidal neovascularization: factors predictive of visual outcome and need for retreatment

PURPOSE

To identify predictive factors for visual outcome and need for retreatment after treating myopic choroidal neovascularization (CNV) with ranibizumab.

DESIGN

A prospective interventional case series.

METHODS

Sixty-seven eyes of 67 patients with myopic CNV were treated with 3 intravitreal ranibizumab injections given monthly. Best-corrected visual acuity (BCVA) and optical coherence tomography-determined central macular thickness (CMT) were recorded monthly during follow-up. Fluorescein angiography changes and the number of injections needed were also assessed.

RESULTS

Mean follow-up was 15.9 months. Mean BCVA improved by 7.8 letters after the first injection, 12.5 letters after 3 injections, and 12 letters by end follow-up. In 53 eyes (79.1%), BCVA improved; 40.3% gained more than 15 letters. No differences were detected in visual outcome between treatment-naïve and previously treated patients. Myopic CNV area and greatest linear dimension had diminished at the study end. The mean reduction in CMT was 93.6 μm. The mean number of injections given was 4.2. A total of 53.7% of eyes received only 3 injections. Through regression analysis, baseline BCVA (P = .006) and myopic CNV location (P = .026) were significantly correlated with BCVA at the end of follow-up. Myopic CNV location (P = .023) and prior treatment (P = .047) were significantly linked to the number of injections given. No major complications arose.

CONCLUSION

An initial treatment regimen of 3 monthly ranibizumab injections seems effective and safe to treat myopic CNV. Baseline BCVA and myopic CNV location emerged as predictive factors for visual outcome. A need for retreatment was associated with myopic CNV location and prior treatment.

Improved control of osteoarthritis pain and self-reported health status in non-responders to celecoxib switched to rofecoxib: results of PAVIA, an open-label post-marketing survey in Spain

METHODS

An open-label multicentre study was conducted in primary care centres in Spain to investigate the effect of a switch from celecoxib to rofecoxib among patients with osteoarthritis and to identify factors associated with a good response to rofecoxib treatment. Patients were eligible to participate in this study if their physicians considered that they might benefit from such a change of therapy. A total of 2,228 patients (1481 women) were enrolled in the study: participants' mean age was 66.37 years (SD 9.04). Mean duration of OA was 7.44 (6.38) years. Predominant sites of OA included the knee (1,132 patients, 50.8%), lumbar spine (977 patients, 43.9%) and cervical spine (739 patients, 33.2%). At baseline, most patients (77%) were being prescribed celecoxib 200 mg/day; during the study most (92.5%) received rofecoxib 25 mg/day. The mean interval between switch to rofecoxib and follow-up interview was 33 days.

PRINCIPAL RESULTS

Patients considered the therapeutic response to rofecoxib substantially and significantly superior to that previously obtained with celecoxib for the management of OA-related pain and OA-related health status (p < 0.001). Seventy-two percent of patients classified their response to rofecoxib therapy as 'good' or 'very good' (vs 6.6% of patients at baseline with celecoxib) and 89.3% of patients expressed satisfaction with rofecoxib (vs 28.9% at baseline with celecoxib). Improvements reported in patient self-assessments following rofecoxib therapy were complemented by similar changes in physician perceptions. The number of patients considered by their doctors to have 'good' or 'very good' OA-related health status rose from 10.1% at baseline to 80.0% on completion of rofecoxib therapy. Ancillary indices such as the proportion of patients with self-reported depression were also favourably influenced by the switch to rofecoxib from celecoxib. Determinants of response: Patient characteristics identified in multivariate analysis as predictive of a favourable response to rofecoxib comprised age, obesity, depression, diabetes and OA-related overall health status.

CONCLUSIONS

The results of this observational study indicate that rofecoxib 25 mg/day is likely to be more effective in patients with OA who do not respond well to celecoxib 200 mg/day and satisfies a large proportion of both patients and physicians. These data are of practical interest because they indicate that, at the doses most often used in primary practice in Spain to treat OA, many patients who are dissatisfied with the effects of celecoxib 200 mg/day may benefit from a switch to rofecoxib 25 mg/day. The data obtained in this study also reveal that younger OA patients with relatively uncomplicated clinical circumstances (a population in which use of Coxibs is relatively low at present) are likely to derive substantial benefit from a switch to rofecoxib therapy.