The Use of Inflammatory Markers for Treatment Response Monitoring in Acute Cholangitis: A Retrospective Cohort Study.

INTRODUCTION: In acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection. METHODS: This was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements. RESULTS: The discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%). CONCLUSIONS: CLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.

The association of socioeconomic deprivation with access and survival after hematopoietic stem cell transplantation in New Zealand.

BACKGROUND: Socioeconomic deprivation (SED) is a risk factor for reduced survival of hematopoietic stem cell transplant (HSCT) recipients. This study aimed to evaluate access and long-term survival of HSCT recipients. METHODS: This was a hospital HSCT Registry-based retrospective cohort study. Patients who underwent HSCT from January 2010 to June 2020 were identified. HSCT recipients younger than 16 years of age, patients who reported their residential address as a post office box or the Department of Corrections, and those who left the country after HSCT were excluded from the study. HSCT recipients with the 2018 New Zealand deprivation index (NZDep2018) deciles 8, 9, and 10 were assigned to the higher SED group and those with NZDep2018 deciles from 1 to 7 were allocated to the lower SED group. The total number of New Zealanders in the higher and lower SED strata was obtained from the 2018 Census. RESULTS: Eight hundred fifty-one HSCT recipients met the eligibility criteria. HSCT recipients from the higher and lower SED strata of the New Zealand population had similar access to HSCT (odds ratio = .9; 95% confidence interval (CI): .77-1.04; p = .155). Mortality in the higher and lower SED groups of HSCT recipients was 9.6/100 person-years (95% CI: 7.7-12/100 person-years) and 8.1/100 person-years (95% CI: 6.9-9.4/100 person-years), respectively. The mortality ratio was 1.2 (95% CI: .9-1.6), p = .098. Both groups had similar survival. CONCLUSION: New Zealand residents from the higher and lower SED strata have similar access to HSCT. SED is not associated with reduced survival in adult HSCT recipients.

The combination of Euroscore II with a new variable "Nongraftable coronary artery lesions" improves the discriminating power of the test in surgical patients with postinfarction ventricular septal defect and ventricular aneurysm.

BACKGROUND: We aimed to establish whether Euroscore II can be used for the prediction of hospital mortality in surgical patients with postinfarction intraventricular septal defect (PIVSD) and ventricular aneurysm (VA), and coexisting coronary artery lesions (CALs), and identify perioperative mortality risk factors to improve the discriminating power of Euroscore II. METHODS: This was a retrospective observational study. The inclusion criterion was PIVSD. Exclusion criteria were previous CABG, conservative treatment, percutaneous transcatheter closure of PIVSDs, and PIVSDs with normal coronary arteries on coronary angiography. RESULTS: Among 53 patients with PIVSDs and VAs who met eligibility criteria, 12 (22.6%) patients died in the hospital. Logistic regression demonstrated that Euroscore II was associated with in-hospital mortality (odds ratio [OR] = 1.13; 95% confidence interval [CI]: 1.03-1.23; p = .006), well-calibrated (Hosmer-Lemeshow χ2 (8) = 9.75; p = .283), and had fair discriminating power, area under receiver operating characteristic curve (AUC) = 77% (95% CI: 58%-96%). A newly identified variable "Nongraftable CALs" was associated with in-hospital mortality (OR = 6.65; 95% CI: 1.24-35.53; p = .027), and had a fair discriminating power, AUC = 70% (95% CI: 54%-85%). When Euroscore II and Nongraftable CALs were combined, the discriminating power of the test increased to 83% (95% CI: 71%-95%), p = .036. CONCLUSION: Euroscore II has adequate discriminating power and good calibration in predicting in-hospital mortality of surgical patients with PIVSDs and VAs. The combination of Euroscore II with a new variable "Nongraftable CALs" significantly improves the performance of the model.

Complete anatomic surgical myocardial revascularisation during postinfarction ventricular septal defect and ventricular aneurysm repair is associated with improved short- and long-term outcomes.

BACKGROUND: Coronary artery bypass grafting (CABG) is recommended during acute postinfarction ventricular septal defect (PIVSD) repair, but clinical benefits of surgical revascularization in patients with subacute PIVSD have not been established. We aimed to evaluate the association of primary complete anatomic surgical myocardial revascularization (CASMR) during PIVSD and ventricular aneurysm (VA) repair on patients' short- and long-term outcomes. METHODS: This was a retrospective observational study. The inclusion criterion was PIVSD. Patients with previous CABG and those with PIVSD due to vasospasm and normal coronary arteries on angiography were excluded. RESULTS: From March 2002 to April 2021, 53 patients met the eligibility criteria. The median patient age was 65 years, and 28 (53%) were male. Compared to the non-CABG group, CABG patients had higher values of the median postoperative left ventricular (LV) end-diastolic volume, 100 ml, and 128.5 ml, respectively (p = .012), and the mean LV stroke volume, 49 ml, and 61 ml, respectively (p = .048). The mortality rates in the CABG and non-CABG groups were 3.6/100 person-years (95% confidence interval [CI]: 1.5-8.6/100 person-years) and 16.3/100 person-years (95% CI: 8.5-31.3/100 person-years), respectively. Cox regression adjusted for between groups imbalances demonstrated a 4-fold greater mortality risk (hazard ratio = 4.3; 95% CI: 1.1-16.7; p = .036) among the non-CABG patients than in the CABG patients. Kaplan-Meier survival analysis yielded a poorer overall survival of the non-CABG patients (p = .011). CONCLUSION: Primary CASMR during PIVSD and VA repair is associated with improved postoperative cardiac function, lower hospital mortality, and better long-term survival. We recommend CASMR during PIVSD and VA repair.

Postmyocardial infarction ventricular septal defect and ventricular aneurysm repair with a "double-patch frame" technique.

BACKGROUND: Postmyocardial infarction intraventricular septal rupture is a life-threatening medical condition. Surgical management of postmyocardial infarction ventricular septal defects (PIVSDs) is associated with a 60% mortality and a 40% incidence of residual ventricular septal defects (rVSDs). Our study aimed to describe our modification of the "Double-patch" technique of PIVSD repair without using a biological glue and present its postoperative complications and survival. METHODS: This was a retrospective observational study. The Bakoulev's Scientific Center of Cardiac Surgery patient admission and discharge database was reviewed from March 2002 to April 2021. The inclusion criterion was PIVSD. Exclusion criteria were conservative treatment, transcatheter closure of PIVSD, PIVSD closure with an interventricular septum patch, and chronic PIVSDs. The study outcomes were echocardiographic parameters of cardiac function, postoperative complications, and mortality. RESULTS: Forty nine patients met the study eligibility criteria. Comparison of echocardiographic data of cardiac function demonstrated reduction in the postoperative period end-diastolic (201.4 ± 59.6 ml vs. 118 [range: 76-207] ml; p < .0005) and end-systolic volumes (106 [51-208] ml vs. 66 [40-147] ml; p < .0005). One (2%) patient developed hemodynamically significant rVSD that required the second run of cardiopulmonary bypass and rVSD closure. Thirteen (26.5%) patients died in the hospital. The overall mortality rate for the study period was 11.4/100 person-years (95% confidence interval [CI]: 6.9-19.0/100 person-years). In these patients, 1-year survival was 68.2% (95% CI: 52.3%-79.8%) and 5-year survival was 63.1% (95% CI: 45.1%-76.7%). CONCLUSION: The "Double-patch frame" technique restores LV dimensions, has a low rate of hemodynamically significant rVSDs and mortality.

Socioeconomic inequality: accessibility and outcomes after renal transplantation in New Zealand.

BACKGROUND: Socioeconomic deprivation (SED) is a risk factor for worse outcomes after renal transplantation (RTx). This study aimed to evaluate access to RTx in different SED strata of the New Zealand population. We also assessed patient survival, acute cellular allograft rejection (AR) and allograft loss. METHODS: This was an Australian and New Zealand Dialysis and Transplantation and Organ Donation Registries-based retrospective cohort study. Patients who underwent RTx in New Zealand from 2008 to 2018 were identified. Patients younger than 16 years of age and those who left the country after RTx were excluded. RESULTS: In the higher SED stratum of New Zealanders, the rate of RTx was 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval: 1.33-1.76; p < 0.00005). RESULTS: One hundred and thirteen (23%) patients from the lower SED group and 51 (14.8%) patients from the higher SED group underwent living unrelated RTx, p = 0.0033. In 233 (67.5%) patients from the higher SED group and 265 (53.9%) patients from the lower SED group, transplanted kidneys were from deceased donors RTx, p = 0.0001. The incidence of allograft loss and patient survival were similar in these groups. CONCLUSION: Our data demonstrated a lower overall survival in the more socioeconomically deprived patients than in the lower SED group however this was not statistically significant after adjustment for covariates. A larger study is required to determine whether SED is associated with reduced survival.

A giant left internal iliac artery aneurysm in a patient with Loeys-Dietz syndrome.

A 16-year-old female presented with left iliac fossa pain. In January 2021, she was admitted to her local hospital with severe lower abdominal pain and the pelvic ultrasound demonstrated a 13-cm left internal iliac artery dissecting aneurysm with its partial thrombosis. On examination, she had a high-arched palate, multiple skin stretch marks, flat feet and a soft systolic ejection murmur at the left 5th mid-clavicular line. She had a mildly tender abdomen in the left iliac fossa. Computed tomography angiography demonstrated a 12.2 cm × 10.4 cm × 12.5 cm left internal iliac artery aneurysm. During surgery, the aneurysm was incised and the proximal and distal orifices of the internal iliac artery were ligated. Genetic testing yielded 2 mutations in the SMAD3 gene characteristic for Loeys-Dietz syndrome.