Heart Failure Readmission in Patients With ST-Segment Elevation Myocardial Infarction and Active Cancer.

Background: Although numerous studies have examined readmission with heart failure (HF) after acute myocardial infarction (AMI), limited data are available on HF readmission in cancer patients post-AMI. Objectives: This study aimed to assess the rates and factors associated with HF readmission in cancer patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: A nationally linked cohort of STEMI patients between January 2005 and March 2019 were obtained from the UK Myocardial Infarction National Audit Project registry and the UK national Hospital Episode Statistics Admitted Patient Care registry. Multivariable Fine-Gray competing risk models were used to evaluate HF readmission at 30 days and 1 year. Results: A total of 326,551 STEMI indexed admissions were included, with 7,090 (2.2%) patients having active cancer. The cancer group was less likely to be admitted under the care of a cardiologist (74.5% vs 81.9%) and had lower rates of invasive coronary angiography (62.2% vs 72.7%; P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%). There was a significant prescription gap in the administration of post-AMI medications upon discharge such as an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (49.5% vs 71.1%) and beta-blockers (58.4% vs 68.0%) in cancer patients. The cancer group had a higher rate of HF readmission at 30 days (3.2% vs 2.3%) and 1 year (9.4% vs 7.3%). However, after adjustment, cancer was not independently associated with HF readmission at 30 days (subdistribution HR: 1.05; 95% CI: 0.86-1.28) or 1 year (subdistribution HR: 1.03; 95% CI: 0.92-1.16). The opportunity-based quality indicator was associated with higher rates of HF readmission independent of cancer diagnosis. Conclusions: Cancer patients receive care that differs in important ways from patients without cancer. Greater implementation of evidence-based care may reduce HF readmissions, including in cancer patients.

Characteristics and Outcomes of Patients Who Underwent Coronary Atherectomy in Centers With and Without On-Site Cardiac Surgery.

We aimed to describe the clinical characteristics and outcomes of patients who underwent atherectomy at the time of percutaneous coronary intervention in centers with on-site surgical centers (SCs) versus nonsurgical centers (NSCs). Patients treated with coronary atherectomy between January 1, 2006, to December 31, 2019, from the British Cardiovascular Society Intervention (BCIS) registry were included. Primary outcomes were in-hospital all-cause mortality and major adverse cardiovascular and cerebrovascular events. A total of 20,833 patients were treated with coronary atherectomy, of which 7,983 (38%) were performed at NSC. The proportion of coronary atherectomies performed in NSC increased from 12.5% in 2006 to 42% in 2019. Compared with patients treated at SC, patients treated in NSC were older (mean age 75.1 ± SD years vs 74.2 ± SD, p <0.001), but had comparable prevalence of hypertension (NSC 73.9% vs SC 72.8%, p = 0.085), diabetes mellitus (NSC 32.2% vs SC 31.6%, p = 0.43) and renal disease (NSC 6.0% vs SC 6.0%, p = 0.99). Intracoronary imaging was used more often in NSC than SC (22.3% vs 19.4%, p <0.001). After adjustment, the odds of in-hospital mortality (odds ratios [OR] 0.76, 95% confidence intervals [CI] 0.50 to 1.16), major adverse cardiovascular and cerebrovascular events (OR 0.80, 95% CI 0.53 to 1.21), emergency coronary artery bypass graft (OR 0.49, 95% CI 0.15 to 1.57), major bleeding (OR 0.67, 95% CI 0.36 to 1.24) and coronary perforation (OR 1.07, 95% CI 0.97 to 1.43) in NSC were comparable with SC. In conclusion, coronary atherectomy in hospitals with off-site surgical cover has become more frequent, with no association with poorer outcomes, compared with hospitals with on-site surgical cover.

Ethnic Disparities in ST-Segment Elevation Myocardial Infarction Outcomes and Processes of Care in Patients With and Without Standard Modifiable Cardiovascular Risk Factors: A Nationwide Cohort Study.

Trials suggest patients with ST-elevation myocardial infarction (STEMI) without 'standard modifiable cardiovascular risk factors' (SMuRFs) have poorer outcomes, but the role of ethnicity has not been investigated. We analyzed 118,177 STEMI patients using the Myocardial Ischaemia National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analyzed using hierarchical logistic regression models; patients with ≥1 SMuRF (n = 88,055) were compared with 'SMuRFless' patients (n = 30,122), with subgroup analysis comparing outcomes of White and Ethnic minority patients. SMuRFless patients had higher incidence of major adverse cardiovascular events (MACE) (odds ratio, OR: 1.09, 95% CI 1.02-1.16) and in-hospital mortality (OR: 1.09, 95% CI 1.01-1.18) after adjusting for demographics, Killip classification, cardiac arrest, and comorbidities. When additionally adjusting for invasive coronary angiography (ICA) and revascularisation (percutaneous coronary intervention (PCI) or coronary artery bypass grafts surgery (CABG)), results for in-hospital mortality were no longer significant (OR 1.05, 95% CI .97-1.13). There were no significant differences in outcomes according to ethnicity. Ethnic minority patients were more likely to undergo revascularisation with ≥1 SMuRF (88 vs 80%, P < .001) or SMuRFless (87 vs 77%, P < .001. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status.

Outcomes of ST elevation myocardial infarction in patients with cancer: a nationwide study.

AIMS: To assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type. METHODS AND RESULTS: This is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P < 0.001] and had higher in-hospital death [odd ratio (OR) 1.39, 95% confidence interval (CI) 1.25-1.54] and bleeding (OR 1.23, 95% CI 1.03-1.46). Cancer patients had higher mortality at 30 days (HR 2.39, 95% CI 2.19-2.62) and 1 year (HR 3.73, 95% CI 3.58-3.89). Lung cancer was the cancer associated with the highest risk of death in the hospital (OR 1.75, 95% CI 1.39-2.22) and at 1 year (OR 8.08, 95% CI 7.44-8.78). Colon cancer (OR 1.98, 95% CI 1.24-3.14) was the main cancer associated with major bleeding. All common cancer types were associated with higher mortality at 1 year. Cardiovascular death (62%) was the main cause of death in the first 30 days, while cancer (52%) was the main cause of death within 1 year. CONCLUSION: STEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.

Comparison of care and outcomes for myocardial infarction by heart failure status between United Kingdom and Japan.

AIMS: Prognosis for ST-segment elevation myocardial infarction (STEMI) is worse when heart failure is present on admission. Understanding clinical practice in different health systems can identify areas for quality improvement initiatives to improve outcomes. In the absence of international comparison studies, we aimed to compare treatments and in-hospital outcomes of patients admitted with ST elevation myocardial infarction (STEMI) by heart failure status in two healthcare-wide cohorts. METHODS AND RESULTS: We used two nationwide databases to capture admissions with STEMI in the United Kingdom (Myocardial ischemia National Audit Project, MINAP) and Japan (Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination, JROAD-DPC) between 2012 and 2017. Participants were stratified using the HF Killip classification into three groups; Killip 1: no congestive heart failure, Killip 2-3: congestive heart failure, Killip 4: cardiogenic shock. We calculated crude rate and case mix standardized risk ratios (CSRR) for use of treatments and in-hospital death. Patients were younger in the United Kingdom (65.4 [13.6] vs. 69.1 [13.0] years) and more likely to have co-morbidities in the United Kingdom except for diabetes and hypertension. Japan had a higher percentage of heart failure and cardiogenic shock patients among STEMI during admission than that in the United Kingdom. Primary percutaneous coronary intervention (pPCI) rates were lower in the United Kingdom compared with Japan, especially for patients presenting with Killip 2-3 class heart failure (pPCI use in patients with Killip 1, 2-3, 4: Japan, 86.2%, 81.7%, 78.7%; United Kingdom, 79.6%, 58.2% and 79.9%). In contrast, beta-blocker use was consistently lower in Japan than in the United Kingdom (61.4% vs. 90.2%) across Killip classifications and length of hospital stay longer (17.0 [9.7] vs. 5.0 [7.4] days). The crude rate of in-hospital mortality increased with increasing Killip class group. Both the crude rate and CSRR was higher in the United Kingdom compared with Japan for Killip 2-3 (15.8% vs. 6.4%, CSRR 1.80 95% CI 1.73-1.87, P < 0.001), and similar for Killip 4 (36.9% vs. 36.3%, CSRR 1.11 95% CI 1.08-1.13, P < 0.001). CONCLUSIONS: Important differences in the care and outcomes for STEMI with heart failure exist between the United Kingdom and Japan. Specifically, in the United Kingdom, there was a lower rate of pPCI, and in Japan, fewer patients were prescribed beta blockers and hospital length of stay was longer. This international comparison can inform targeted quality improvement programmes to narrow the outcome gap between health systems.

Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study.

OBJECTIVE: To assess the impact of patient's sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA). PATIENTS AND METHODS: We conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy. RESULTS: Of 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40). CONCLUSION: Women were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.

Impact of pre-existing vascular disease on clinical outcomes.

AIMS: Little is known about the outcomes and processes of care of patients with non-ST-segment myocardial infarction (NSTEMI) who present with 'polyvascular' disease. METHODS AND RESULTS: We analysed 287 279 NSTEMI patients using the Myocardial Ischaemia National Audit Project registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed-coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD)-with comparison to a historically disease-free control group, comprising 167 947 patients (59%). After adjusting for demographics and management, polyvascular disease was associated with increased likelihood of major adverse cardiovascular events (MACEs) [CAD odds ratio (OR): 1.06; 95% confidence interval (CI): 1.01-1.12; P = 0.02] (CeVD OR: 1.19; 95% CI: 1.12-1.27; P < 0.001) (PVD OR: 1.22; 95% CI: 1.13-1.33; P < 0.001) and in-hospital mortality (CeVD OR: 1.24; 95% CI: 1.16-1.32; P < 0.001) (PVD OR: 1.33; 95% CI: 1.21-1.46; P < 0.001). Patients without vascular disease were less frequently discharged on statins (PVD 88%, CeVD 86%, CAD 90%, and control 78%), and those with moderate [ejection fraction (EF) 30-49%] or severe left ventricular systolic dysfunction (EF < 30%) were less frequently discharged on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (CAD 82%, CeVD 77%, PVD 77%, and control 74%). Patients with polyvascular disease were less likely to be discharged on dual antiplatelet therapy (DAPT) (PVD 78%, CeVD 77%, CAD 80%, and control 87%). CONCLUSION: Polyvascular disease patients had a higher incidence of in-hospital mortality and MACEs. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Temporal patterns, characteristics, and predictors of clinical outcomes in patients undergoing percutaneous coronary intervention for stent thrombosis.

BACKGROUND: There are limited data on the outcomes of percutaneous coronary intervention (PCI) following stent thrombosis (ST) and differences exist based on timing. AIMS: Our aim was to study the rates of PCI procedures for an ST indication among all patients admitted for PCI at a national level and to compare their characteristics and procedural outcomes based on ST timing. METHODS: All PCI procedures in England and Wales (2014-2020) were retrospectively analysed and stratified by the presence of ST into four groups: non-ST, early ST (0-30 days), late ST (>30-360 days), very late ST (>360 days). Multivariable logistic regression models were performed to assess the odds ratios (OR) of in-hospital MACCE (major adverse cardiovascular and cerebrovascular events, a composite of mortality, acute stroke and reinfarction) and mortality. RESULTS: Overall, 7,923 (1.4%) procedures were for ST indication, most commonly for early ST (n=4,171; 52.6%), followed by very late ST (n=2,801; 35.4%) and late ST (n=951; 12.0%). The rate of PCI for ST declined between 2014 and 2020 (1.7 to 1.4%; p<0.001). Early ST was the only subgroup associated with increased odds of MACCE (OR 1.22, 95% CI: 1.05-1.41), all-cause mortality (OR 1.21, 95% CI: 1.07-1.36) and reinfarction (OR 2.48, 95% CI: 1.48-4.14), compared with non-ST indication. The odds of mortality were significantly reduced in ST patients with the use of intravascular imaging (OR 0.66, 95% CI: 0.48-0.92) and newer P2Y12 inhibitors (ticagrelor: OR 0.69, 95% CI: 0.49-0.95; prasugrel: OR 0.54, 95% CI: 0.30-0.96). CONCLUSIONS: PCI for ST has declined in frequency over a 7-year period, with most procedures performed for early ST. Among the different times of ST onset, only early ST is associated with worse clinical outcomes after PCI. Routine use of intravascular imaging and newer P2Y12 inhibitors could further improve outcomes in this high-risk procedural group.

Impact of availability of catheter laboratory facilities on management and outcomes of acute myocardial infarction presenting with out of hospital cardiac arrest.

OBJECTIVES: We aimed to identify whether the availability of catheter laboratory affects clinical outcomes of out-of-hospital cardiac arrest (OHCA) complicating myocardial infarction (AMI). METHODS: Patients admitted with a diagnosis of AMI and OHCA from the Myocardial Ischaemia National Audit Project (MINAP) between 2010 to 2017 were stratified into three groups based on initial hospital's catheter laboratory status: hospitals without a catheter laboratory (No-catheter lab hospitals), hospitals with diagnostic catheter laboratory (Diagnostic hospitals), and hospitals with PCI facilities (PCI hospitals). We used multivariable logistic regression to evaluate factors associated with clinical outcomes. RESULTS: We included 12,303 patients of which 9,798 were admitted to PCI hospitals, 1,595 to no-catheter lab hospitals, and 910 to diagnostic hospitals. Patients admitted to PCI hospitals were more frequently reviewed by a cardiologist (96%, p < 0.001) than no-catheter lab hospitals (80%) and diagnostic hospitals (74%), and more likely to receive coronary angiography (PCI hospitals (87%), diagnostic hospitals (31%), no-catheter lab hospitals (54%), p < 0.001). They also were more likely to undergo PCI (PCI hospitals (42%), diagnostic hospitals (17%), no-catheter lab hospitals (17%), p < 0.001). After adjustment, there was no significant difference in the in-hospital mortality (OR 0.76, 95% CI 0.55-1.06) or re-infarction (OR 1.28, 95% CI 0.72-2.26) in patients admitted to PCI hospitals nor in patients admitted to diagnostic hospitals (mortality (OR 1.28, 95% CI 0.72-2.26), re-infarction (OR 1.38, 95% CI 0.68-2.82)). CONCLUSION: There is variation in coronary angiography use between hospitals without a catheter laboratory and PCI centres, which was not associated with better in-hospital survival.

Effect of the Timing of Admission of Out of Hospital Cardiac Arrest Complicating Acute Myocardial Infarction on Management and Outcome.

There is limited data regarding the impact of time of admission on clinical outcomes of out of hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI). We investigated the patient characteristics, management, and outcomes of OHCA complicating AMI according to the time of admission. Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischemia National Audit Project (MINAP) were studied. All patients were stratified into out-of-hours (OOH) and working hours (WH) cohort according to the time of hospital admission. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. 16,118 patients were admitted with AMI and OHCA. The WH cohort consisted of 5,780 patients (35.9%) and OOH cohort consisted of 10,338 patients (64.1%). The OOH cohort was younger (OOH 64 vs WH 66 years, p <0.001). A significantly higher proportion of patients had a final diagnosis of STEMI in OOH cohort (OOH 78.3% vs WH 76.6%, p = 0.012). Whilst the use of coronary angiography was lower in OOH (OOH 80.7% vs WH 82.5%, p = 0.005), PCI rates were similar (OOH 39.7% vs WH 40.5%, p = 0.4). Adjusted in-hospital mortality (OR 0.96, 95%CI 0.86 to 1.07), re-infarction (OR 0.90, 95% CI 0.72 to 1.12) and bleeding (OR 0.93, 95% CI 0.76 to 1.12) were similar in the 2 groups. In conclusion, the majority of OHCA occurred out of working hours. However, the time of hospital admission didn't affect the rate of revascularization by PCI or clinical outcomes.

Effect of Location on Treatment and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in England & Wales.

We investigated the incidence, management, and outcomes of acute myocardial infarction (AMI) patients according to cardiac arrest location. Patients admitted with a diagnosis of AMI between January 1, 2010 to March 31, 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. We used logistic regression models to evaluate predictors of the clinical outcomes and treatment strategy. The study population consisted of 580,796 patients admitted with AMI stratified into three groups: out of hospital cardiac arrest (OOHCA) (16,278[2.8%]), in-hospital cardiac arrest (IHCA) (21,073[3.7%]), plus a reference group consisting of those without cardiac arrest (non-cardiac arrest (543,418[93.5%]). IHCA declined steadily (from 666 per 1000 in 2010 to 477 per 1000 AMI with cardiac arrest admissions in 2017) with a commensurate rise in OOHCA (from 344 per 1000 to 533 per 1000 AMI with cardiac arrest admissions). Coronary angiography utilization (OOHCA 81.1% vs IHCA 60.3% vs non-cardiac arrest 70.4%, p < 0.001) and PCI (OOHCA 40% vs IHCA 32.8% vs non-cardiac arrest 45.2%, p < 0.001) were higher in OOHCA. In-hospital mortality odds were greatest for IHCA (OR 35.3, 95% CI 33.4-37.2) compared to OOHCA (OR 12.7, 95% CI 11.9-13.6), with the worse outcomes seen in patients on medical wards (OR 97.37, 95% CI 87.02-108.95) and the best outcomes seen in the emergency department (OR 8.35, 95% CI 7.32-9.53). In conclusion, outcomes of AMI complicated by cardiac arrest depended on cardiac arrest location, especially the outcomes of the IHCA.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales.

BACKGROUND: Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. METHODS: Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. RESULTS: From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. CONCLUSIONS: BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

INTRODUCTION: Les études sur les inégalités raciales en matière de soins aux patients admis en raison d'un arrêt cardiaque hors de l'hôpital (ACHO) dans le cadre d'un infarctus aigu du myocarde (IAM) ont montré des résultats contradictoires. On ignore si ces différences en matière de soins existent dans le système de soins de santé universel de l'Angleterre. MÉTHODES: Les patients admis en raison d'un diagnostic d'IAM et d'ACHO entre 2010 et 2017 du Myocardial Ischaemia National Audit Project (MINAP) ont fait l'objet de l'étude. Nous avons réparti tous les patients selon l'origine ethnique dans le groupe BAME (de l'anglais Black, Asian and minority ethnic, c.-à-d. Noirs, Asiatiques ou d'une minorité ethnique) vs le groupe des Blancs. Nous avons utilisé les modèles multivariés de régression logistique pour évaluer les prédicteurs des résultats cliniques et la stratégie de traitement. RÉSULTATS: Parmi les 14 287 patients admis en raison d'un IAM compliqué par l'ACHO, les patients du BAME constituaient une minorité de patients (1 185 [8,3 %]) par rapport au groupe des Blancs (13 102 [91,7 %]). Les patients du groupe BAME étaient plus jeunes (âge médian [écart interquartile]), 58 [50-70] ans que le groupe des Blancs, 65 [55-74] ans). Le choc cardiogénique (groupe BAME, 33 %; groupe des Blancs, 20,7 %; P < 0,001) et l'insuffisance ventriculaire gauche grave (groupe BAME, 21 %; groupe des Blancs, 16,5 %; P < 0,003) étaient plus fréquents au sein des patients du BAME. Il était plus probable que les patients du BAME soient vus par un cardiologue (groupe du BAME, 95,9 %; groupe des Blancs, 92,5 %; P < 0,001) et qu'ils passent une angiographie coronarienne que le groupe des Blancs (ratio d'incidence approché [RIA] 1,5, intervalle de confiance [IC] à 95 % 1,2-1,88). Le groupe BAME avait une mortalité intrahospitalière (RIA 1,26, IC à 95 % 1,04-1,52) et une récidive d'infarctus (RIA 1,52, IC à 95 % 1,06-2,18) plus élevées que le groupe des Blancs. CONCLUSIONS: Il était plus probable que les patients du BAME soient vus par un cardiologue et qu'ils passent une angiographie coronarienne que les patients blancs. Malgré cette différence, la mortalité intrahospitalière des patients du BAME, particulièrement de la population asiatique, était significativement plus élevée.

The utility of 18F-fluorodeoxyglucose positron emission tomography with computed tomography in Mycobacterium chimaera endocarditis: a case series.

BACKGROUND: Infective endocarditis secondary to Mycobacterium chimaera can present with classical constitutional symptoms of infective endocarditis but can be blood culture negative and without vegetations on transthoracic or transoesophageal echocardiogram. Patients with prosthetic valves are at particularly high risk. CASE SUMMARY: We present two patients who were diagnosed with infective endocarditis secondary to M. chimaera infection. They presented similarly with pyrexia of unknown origin and night sweats. Both patients had previously undergone aortic valve replacement; one with a tissue valve and the other with a metallic valve. New cardiac murmurs were evident on auscultation, but clinical examination showed no peripheral stigmata of endocarditis. Transoesophageal echo and transthoracic echo were both unremarkable, as were serial blood cultures. FDG PET CT scan was the key investigation, which showed increased uptake in the spleen beside other areas. Histopathology and mycobacterial cultures confirmed the diagnosis of M. chimaera infection in both cases. The first patient completed medical therapy and is now fit and well. However, the second patient unfortunately developed disseminated infection causing death. DISCUSSION: The management of M. chimaera infective endocarditis is challenging, often with delayed diagnosis and poor outcomes. In the context of negative blood cultures and inconclusive echocardiograms where there remains a high index of suspicion for endocarditis, FDG PET CT scanning can be a crucial diagnostic importance and should be considered early in patients with prosthetic valves.

Monoallelic characteristic-bearing heterozygous L1053X in BRCA2 gene among Sudanese women with breast cancer.

BACKGROUND: Breast cancer (BC) is the most common type of cancer in women. Among many risk factors of BC, mutations in BRCA2 gene were found to be the primary cause in 5-10% of cases. The majority of deleterious mutations are frameshift or nonsense mutations. Most of the reported BRCA2 mutations are protein truncating mutations. METHODS: The study aimed to describe the pattern of mutations including single nucleotide polymorphisms (SNPs) and variants of the BRCA2 (exon11) gene among Sudanese women patients diagnosed with BC. In this study a specific region of BRCA2 exon 11 was targeted using PCR and DNA sequencing. RESULTS: Early onset cases 25/45 (55.6%) were premenopausal women with a mean age of 36.6 years. Multiparity was more frequent within the study amounting to 30 cases (66.6%), with a mean parity of 4.1. Ductal type tumor was the predominant type detected in 22 cases (48.8%) among the reported histotypes. A heterozygous monoallelic nonsense mutation at nucleotide 3385 was found in four patients out of 9, where TTA codon was converted into the stop codon TGA. CONCLUSION: This study detected a monoallelic nonsense mutation in four Sudanese female patients diagnosed with early onset BC from different families. Further work is needed to demonstrate its usefulness in screening of BC.

Risk factors of diabetic cardiac autonomic neuropathy in patients with type 1 diabetes mellitus: a meta-analysis.

OBJECTIVES: We aimed to stratify the possible risk factors for diabetic cardiac autonomic neuropathy (CAN). METHODS: We did a meta-analysis of risk factors of CAN. We did a web-based search for literature in MEDLINE/PubMed, Scopus database and CENTRAL database up to August 2015. We included clinical trials or cohort studies that provide data about relationship between CAN and variables of interest. Our risk factors of interest were age, sex, duration of diabetes, body mass index (BMI), systolic blood pressure (sBP) and diastolic blood pressure (dBP), glycated haemoglobin (HbA1c), high-density lipoprotein and low-density lipoprotein (HDL and LDL), triglycerides, retinopathy and nephropathy. We generated Forest plots, χ2 test and I2 as tests for heterogeneity, risk ratio (RR), mean difference (MD), CIs and p values by ReVMan V.5.3 software. RESULTS: We found a total of 882 related items. We excluded 873 studies from the title and abstract and 4 studies after review of full reports. Four studies were included. Our meta-analysis showed significant association between CAN and age (MD=4.94 (3.46 to 6.42)), duration of diabetes (MD=4.51 (2.51 to 6.52)), HbA1c (MD=0.48 (0.28 to 0.67)), BMI (MD=0.55 (0.08 to 1.01)), serum triglycerides (MD=0.09 (0.01 to 0.17)), proliferative retinopathy (RR=3.69 (1.20 to 11.34)), microalbuminuria (RR=2.47 (1.43 to 4.29)), hypertension (RR=4.18 (2.52 to 6.91)) and sBP (MD=4.10 (2.20 to 6.00)). We neither discovered the absence of significant association between the development of CAN and male sex (RR=1.57 (0.45 to 5.39)), dBP (MD=0.89 (-0.36 to 2.14)), cholesterol level (MD=1.19 (-0.99 to 3.36)), LDL (MD=0.12 (-0.15 to 0.39)), nor HDL level (MD=-0.28 (-0.58 to 0.03)). CONCLUSIONS: Age, duration of diabetes, HbA1c, BMI, serum triglycerides, proliferative retinopathy, microalbuminuria, hypertension and sBP are directly related to the risk of development of diabetic CAN.

Validity and reliability of Arabic MOS social support survey.

We aimed to generate a valid reliable Arabic version of MOS social support survey (MOS-SSS). We did a cross sectional study in medical students of Faculty of Medicine in Khartoum, Sudan. We did a clustered random sampling in 500 students of which 487 were suitable for analysis. We followed the standard translation process for translating the MOS-SSS. We accomplished factor analysis to assess construct validity, and generated item-scales correlations to evaluate the convergent and discriminant validity. We extracted the Cronbach's α and Spearman Brown coefficient of spit half method to determine internal consistency. We measured stability by correlation between the scores of the MOS survey taken at two different occasions with ten days apart in 252 participants. All items correlated highly (0.788 or greater) with their hypothesized scales. All items in subscales correlated higher by two standard errors with their own scale than with any other scale. Principle component analysis with varimax rotation was conducted on the 19 items and examination of scree plot graphically suggested 4 predominant factors that account for 72 % of variance. It showed high loadings, ranging from 0.720 to 0.84 for items of emotional support, 0.699-0.845 for tangible support, 0.518-0.823 for affectionate support, and 0.740-0.816 for positive social interaction. Cronbach's alpha for overall MOS scale and subscales indicated high internal consistency. The test-retest correlation showed weak correlation between the test and retest (ranges from 0.04 to 0.104). The Arabic MOS-SSS had high validity and internal consistency.

Chemical constituents and antibacterial activity of Melastoma malabathricum L.

The aqueous methanolic extracts of Melastoma malabathricum L. exhibited antibacterial activity when assayed against seven microorganisms by the agar diffusion method. Solvent fractionation afforded active chloroform and ethyl acetate fractions from the leaves and the flowers, respectively. A phytochemical study resulted in the identification of ursolic acid (1), 2α-hydroxyursolic acid (2), asiatic acid (3), ß-sitosterol 3-O-ß-D-glucopyranoside (4) and the glycolipid glycerol 1,2-dilinolenyl-3-O-ß-D-galactopyanoside (5) from the chloroform fraction. Kaempferol (6), kaempferol 3-O-α-L-rhamnopyranoside (7), kaempferol 3-O-ß-D-glucopyranoside (8), kaempferol 3-O-ß-D-galactopyranoside (9), kaempferol 3-O-(2″,6″-di-O-E-p-coumaryl)-ß-D-galactopyranoside (10), quercetin (11) and ellagic acid (12) were found in the ethyl acetate fraction. The structures of these compounds were determined by chemical and spectral analyses. Compounds 1-4, the flavonols (6 and 11) and ellagic acid (12) were found to be active against some of the tested microorganisms, while the kaempferol 3-O-glycosides (7-9) did not show any activity, indicating the role of the free 3-OH for antibacterial activity. Addition of p-coumaryl groups results in mild activity for 10 against Staphylococcus aureus and Bacillus cereus. Compounds 2-5, 7 and 9-12 are reported for the first time from M. malabathricum. Compound 10 is rare, being reported only once before from a plant, without assignment of the double bond geometry in the p-coumaryl moiety.