Hyponatraemia at hospital admission is a predictor of overall mortality

BACKGROUND

Hyponatraemia is a prognostic marker of increased mortality and morbidity in selected groups of hospitalised patients. The aim of the present study was to examine the prevalence and prognostic significance of hyponatraemia at hospital admission in an unselected population with a broad spectrum of medical and surgical diagnoses.

METHODS

Consecutive patients >40 years of age admitted to a general district hospital in Greater Copenhagen between 1 April 1998 and 31 March 1999. Median follow-up time was 5.16 years (range 0-4372 days). Plasma sodium measurements were available in 2960 patients, and hyponatraemia defined as P-Na(+) <137 mmol/L at hospital admission was present in 1105 (37.3 %) patients.

RESULTS

One-year mortality was higher for hyponatraemic patients than for normonatraemic patients: 27.5% versus 17.7%. Moreover, hyponatraemia was an independent predictor of short and long-term all-cause mortality after 1 year and after the entire observation period respectively: hazard ratio (HR) 1.6 (95 % confidence interval (CI) 1.4-1.9, P < 0.0001) and HR 1.4 (95 % CI 1.3-1.6, P < 0.0001). Patients with hyponatraemia had longer hospitalisations than patients with normonatraemia: 7.6 (±0.38) days vs 5.6 (±0.21) days, P < 0.001. There was no interaction between hyponatraemia at admission and any admission diagnoses (P > 0.05 for all interaction analyses).

CONCLUSION

Hyponatraemia is associated with increased all-cause mortality and longer admission length independently of diagnosis and clinical variables.

The inflammatory biomarker YKL-40 at admission is a strong predictor of overall mortality

OBJECTIVES

YKL-40 is an inflammatory biomarker associated with disease activity and mortality in patients with diseases characterized by inflammation and tissue remodelling. The aim of this study was to describe the prognostic value of YKL-40 in an unselected patient population.

DESIGN

In consecutive patients admitted to hospital during a 1-year period, blood was collected and information regarding final diagnosis and mortality was collected. Median follow-up time was 11.5 years.

SETTING

District hospital, Copenhagen, Denmark.

PATIENTS

A total of 1407 patients >40 years of age were admitted acutely.

MAIN OUTCOME MEASURE

All-cause mortality.

RESULTS

Median YKL-40 was increased in patients (157 μg L(-1) , range 13-7704 μg L(-1) ) compared to healthy controls (40 μg L(-1) , range 29-58 μg L(-1) ; P < 0.001). Patients with YKL-40 in the highest quartile had a hazard ratio (HR) of 7.1 [95% confidence interval (CI) 4.2-12.0] for all-cause mortality in the first year and 3.4 (95% CI 2.8-4.2) in the total study period, compared to those in the lowest quartile (HR = 1). The HR for death for all patients with YKL-40 above the normal age-corrected 95th percentile was 2.1 (95% CI 1.6-2.7) after 1 year and 1.5 (95% CI 1.3-1.7) during the total study period, compared to patients with YKL-40 below the age-corrected 95th percentile. The results of multivariable analysis showed that YKL-40 was an independent biomarker of mortality; this was most significant in the first year. YKL-40 was a marker of prognosis in all disease categories. The HR for death was increased in patients with YKL-40 above the normal age-corrected 95th percentile in healthy subjects independent of type of disease (all P < 0.001).

CONCLUSION

The level of YKL-40 at admission is a strong predictor of overall mortality, independent of diagnosis and could be useful as a biomarker in the acute evaluation of all patients.

Prevalence and risk factors associated to chronic kidney disease in HIV-infected patients on HAART and undetectable viral load in Brazil

Background

To determine the prevalence and associated factors with chronic kidney disease (CKD) in a cohort of HIV-positive individuals with undetectable viral load on HAART.

Methods

From March, 2009 to September 2009, 213 individuals between 18-70 years, period on HAART ≥12 months, viral load < 50 copies/mm³, and CD4 ≥ 200 cells/mm³, were consecutively enrolled at the outpatient clinic of Hospital de Clínicas, Porto Alegre, Brazil. Exclusion criteria were obesity, malnourishment, amputee, paraplegic, previous history of renal disease, pregnancy and hepatic insufficiency. Renal function was determined by estimated glomerular filtration rate (eGFR) assessed by the modification of diet in renal disease. CKD was defined as an eGFR less or equal than 60 ml/min/1.73 m², for a period of at least 3 months. Poisson regression was used to determine factors associated with CKD.

Results

CKD was diagnosed in 8.4% of the population, and after adjustment, the risk factors were hypertension (RR = 3.88, 95%CI, 1.84 - 8.16), time on HAART (RR = 1.15, 95%CI,1.03–1.27) and tenofovir exposure (RR = 2.25, 95%CI, 1.04–4.95). Higher weight (RR = ,0.88 95%CI, 0.82–0.96) was associated to normal function.

Conclusions

CKD was a common finding in this cohort of patients and was related to hypertension, time on HAART and tenofovir exposure. We suggest a more frequent monitoring of renal function, especially for those with risk factors to early identify renal impairment.

N-terminal proBNP and mortality in hospitalised patients with heart failure and preserved vs. reduced systolic function: data from the prospective Copenhagen Hospital Heart Failure Study (CHHF)

Preserved systolic function among heart failure patients is a common finding, a fact that has only recently been fully appreciated. The aim of the present study was to examine the value of NT-proBNP to predict mortality in relation to established risk factors among consecutively hospitalised heart failure patients and secondly to characterise patients in relation to preserved and reduced systolic function.

MATERIAL

At the time of admission 2230 consecutively hospitalised patients had their cardiac status evaluated through determinations of NT-proBNP, echocardiography, clinical examination and medical history. Follow-up was performed 1 year later in all patients.

RESULTS

161 patients fulfilled strict diagnostic criteria for heart failure (HF). In this subgroup of patients 1-year mortality was approximately 30% and significantly higher as compared to the remaining non-heart failure population (approx. 16%). Using univariate analysis left ventricular ejection fraction (LVEF), New York Heart Association classification (NYHA) and plasma levels of NT-proBNP all predicted mortality independently. However, regardless of systolic function, age and NYHA class, risk-stratification was provided by measurements of NT-proBNP. Having measured plasma levels of NT-proBNP, LVEF did not provide any additional prognostic information on mortality among heart failure patients (multivariate analysis).

CONCLUSION

The results show that independent of LVEF, measurements of NT-proBNP add additional prognostic information. It is concluded that NT-proBNP is a strong predictor of 1-year mortality in consecutively hospitalised patients with heart failure with preserved as well as reduced systolic function.

NT-proBNP: a new diagnostic screening tool to differentiate between patients with normal and reduced left ventricular systolic function

OBJECTIVE

To evaluate whether measurements of N-terminal pro-brain natriuretic peptide (NT-proBNP) can be used to differentiate patients with normal and reduced left ventricular ejection fraction (LVEF) in an unselected consecutive group of hospital inpatients.

SETTING

City general hospital, Copenhagen, Denmark.

PATIENTS AND DESIGN

During a 10 month period 2230 admissions to a city general hospital (80% of targeted patients) had an echocardiographic evaluation of left ventricular function, a comprehensive clinical evaluation, and blood analysis of N-terminal-pro-brain natriuretic peptide (NT-proBNP) within 24 hours of admission. Exclusions resulted from lack of informed consent or failure to obtain the required evaluations before death or discharge from hospital. Echocardiography was unsatisfactory in 37 patients, so the final number studied was 2193.

RESULTS

A raised NT-proBNP (>or= 357 pmol/l) identified patients with an LVEF of <or= 40% (n = 157) with a sensitivity of 73% and a specificity of 82%. The negative predictive value of having an NT-proBNP concentration below 357 pmol/l was 98%. Concentrations of NT-proBNP increased with increasing age and with decreasing LVEF (p < 0.05). A predicted concentration of NT-proBNP (corrected for age, sex, and serum creatinine) was determined for each patient. In patients with an NT-proBNP value less than predicted, the probability of having an LVEF of > 40% was more than 97%. This probability rapidly decreased to 70% as the measured NT-proBNP increased to 150% of the predicted value.

CONCLUSIONS

A single measurement of NT-proBNP at the time of hospital admission provides important information about LVEF in unselected patients.

In vitro study of human alveolar macrophages inflammatory mediator transcriptions and releases induced by soot FR 101, Printex 90, titandioxide and Chrysotile B

Soot FR 101, Printex 90 and Chrysotile B are frequently found in indoor air pollutants phagocytized by alveolar macrophages (AM) involved in inflammatory pulmonary processes as, e.g. in cytokine secretions. The transcription factor NF-kappaB has a role in the trans-duction pathway of proinflammatory cytokines like IL-1beta, IL-6 and TNF-alpha. We therefore investigated whether the transcription factor NF-kappaB and subsequent inflammatory cytokine secretions by AM are induced by exposure to these particles compared to the inert TiO2. AM were incubated for 90 min at particle concentrations of up to 100 microg/10(6) cells. Sequential reverse transcription and semiquantitative cDNA amplification (RT-PCR) was used to measure NF-kappaB and cytokine mRNA expressions. Compared to control exposures these particles induced an up to 4.6-fold increase in gene expression of the transcription factor NF-kappaB (p < 0.01), resulting in up to 12.9-fold enhanced transcription rates of IL-1beta, IL-6 and TNF-alpha (p <0.05). The particles and fibre dependent increases in mRNA reached maximum levels at 90 min post exposure. After an exposure time of 8 hrs, IL-1beta, IL-6 and TNF-alpha proteins, measured by enzyme-linked immunosorbent assays (ELISA), were significant elevated in supernatants of AM, revealing an up to 30.5-fold increase in TNF-alpha secretion rates (p <0.01). Our results suggest that exposure of human AM to soot FR 101, Printex 90, TiO2 and Chrysotile B induce the transcription and production of proinflammatory cytokines via NF-kappaB and may play an important role in the pathogenesis of airway disease and lung parenchymal injury.

[Ambulatory knee arthroscopy in arthroscopic surgery under local anesthesia]

After introducing knee arthroscopy in local anaesthesia as a standard regime in outpatients, we want to describe our experiences from 403 arthroscopies performed in 401 patients, aged 15-80 years, mean 37 years. Diagnostic arthroscopy was performed successfully in 397 of 403 cases. Arthroscopic surgery was indicated in 203 patients and carried out in 188 cases. It was possible to resect 144 of 158 tears of the meniscus. In conclusion, outpatient arthroscopy of the knee with transarthroscopic surgery in local anaesthesia using high dose lidocaine and no sedation is a valuable tool, and should be used on a larger scale. It is possible to carry out diagnostic arthroscopy and arthroscopic surgery in most patients, especially concerning resections of menisci.

Activity and tolerance of a continuous subcutaneous infusion of interferon-alpha2b in patients with chronic hepatitis C

We administered interferon-alpha2b (IFN-alpha2b) by continuous subcutaneous infusion (60,000 IU/h, or 10 million IU/week) over 3 months to 7 patients with chronic hepatitis C. All had previously responded, as assessed by normalization of transaminases to the same dose of IFN administered by intermittent injection over 6 months, but had relapsed after cessation of therapy. The continuous infusion was tolerated well at the site of infusion, and the systemic side effects were similar in type but were lesser in intensity than with intermittent dosage. Four of 7 subjects had normalization of transaminase at the end of week 12 of therapy. Serum HCV RNA and HCV by PCR decreased with treatment, and there was a prompt and sustained increase in serum beta2-microglobulin and of 2', 5' OAS activity. The level of the latter appeared to correlate with response of the transaminase. Serum IFN concentrations were low but detectable throughout therapy. After stopping IFN administration, the transaminases in responders increased again to pretreatment levels.

Modulation of TNF-alpha secretions by alveolar macrophages and blood monocytes after soot-particle or asbestos fibre exposure

Activated monocytes secrete tumor necrosis factor-alpha (TNF-alpha), whose inflammatory and fibroblast activating characteristics may play a role in the maintenance of pulmonary inflammatory processes and subsequent fibrosis. Human alveolar macrophages (AM) and peripheral blood mononuclear cells (PBMNC) were exposed to soot particles or asbestos fibres in concentrations ranging from 5-50 micrograms/1 x 10(6) cells for 8 hrs in RPMI medium. A culture was established with the exposed monocytes and the remaining cells were used to determine TNF-alpha. TNF-alpha was quantified by commercial ELISA-kits. 8 hrs exposure to soot particles and asbestos fibres induced a significant increase in spontaneous TNF-alpha release (p < 0.05). Cytotoxicity of monocytes was checked by trypan blue exclusion and lactate dehydrogenase assay, noted values ranging from 0.5%-16.2%.

Drug disposition and hepatotoxicity in the elderly

Overall, the aged liver seems to function remarkably well in the elderly. Decreased drug disposition is selective and modest and there is no compelling evidence of greater susceptibility to drug-induced or other types of injury. Drug-drug interactions and concurrent derangements accompanying advanced age may, however, contribute to adverse drug effects. Still, the aged, consume about three times as many therapeutic agents as other people. Most of these are metabolized in the liver before excretion. With increasing age, hepatic blood flow falls and so does hepatic volume. Moreover, binding of some agents normally carried on albumin may decrease. In contrast, increasing age has relatively modest effects on hepatic drug metabolism and these are highly selective. In the healthy aged, hepatic drug elimination is only modestly, if at all, impaired and this is likely to especially affect agents dependent on liver blood flow. Other factors that affect drug elimination in the aged are drug-drug interaction and the frailty and functional impairment of many elderly, as a result of poor diet, infection, multiple hospitalizations, or other events. Decreased host defense systems in the aged liver may lead to decreased adaptation to stress and slower regeneration after injury.

Steroid priming of the luteinizing hormone response to luteinizing hormone releasing hormone

Perifusion experiments were performed to study the stimulatory effects of luteinizing hormone releasing hormone (LH-RH) on the release of LH from anterior pituitary tissue. Exposure of pituitary tissue from normal male rats to LH-RH (5 ng/ml for 5 min) induced a small release of LH; in tissue from ovariectomized rats receiving no pretreatment, the release was more than three times greater and in tissue from gonadectomized male or female rats pretreated with oestradiol benzoate and progesterone, the release was six times greater than that observed in normal rats. Further exposure of pituitary tissue from gonadectomized steroid-pretreated male and female rats to LH-RH (5 ng/ml) induced an increase in the level of LH even greater than that seen after the initial exposure (priming action of LH-RH); in tissue from ovariectomized rats receiving no pretreatment, less LH was released than after the first exposure to LH-RH and in tissue from normal male rats the response was unchanged.

On the rapidity with which LRH induces release of LH and FSH from perifused anterior pituitary tissues of the rat

In a series of perifusion (superfusion) experiments, data were obtained which indicated that LRH and K+, when effective, induced increase in LH and/or FSH release within about one minute after arriving in the vicinity of the test rat pituitary tissues. Hormone release stimulating effects of LRH or high K+ continued for some time after washout of test agent. To secure these data perifusion flow was set at 2.5 or more ml/min., each test solution was pulsed for two minutes only, effluent samples were collected at 15 second intervals shortly before, during and after each pulse, and both mixing and dead space time were minimized by introducing each new test solution directly in front of the tissue chamber, via a 4-way or 5-way pulse control stopcock through which two streams of perifusion fluid (Control and Test) passed continually. LH and FSH in effluent samples were estimated by radioimmunoassay.