Association of distal hyperintense vessel sign and recurrent stroke in patients with symptomatic intracranial stenosis.

OBJECTIVE: The distal hyperintense vessel sign (DHV) on fluid-attenuated inversion recovery magnetic resonance image (MRI) is an imaging biomarker of slow leptomeningeal collateral flow in the presence of large artery stenosis or occlusion reflecting impaired cerebral hemodynamics. In this study, we aim to investigate the significance of the DHV sign in patients with symptomatic ≥ 70% intracranial atherosclerotic stenosis. METHODS: We retrospectively reviewed patients with ischemic stroke or transient ischemic attack admitted to a single center from January 2010 to December 2017. Patients were included if they had symptomatic ≥ 70% atherosclerotic stenosis of the intracranial internal carotid artery or middle cerebral artery. The presence of the DHV sign was evaluated by blinded neuroradiologist and vascular neurologists. Recurrent ischemic stroke in the vascular territory of symptomatic intracranial artery was defined as new neurological deficits with associated neuroimaging findings during the follow up period. RESULTS: A total of 109 patients were included in the study, of which 55 had DHV sign. Average duration of follow up was 297 ± 326 days. Four patients were lost during follow up. Patients with the DHV sign had a higher rate of recurrent ischemic stroke (38%), compared to patients without the DHV sign (17%; p=0.018). In multivariate regression analysis, the presence of DHV sign was an independent predictor of recurrent ischemic stroke. A DHV score of ≥ 2 had a 63% sensitivity and 69% specificity for recurrent ischemic stroke. INTERPRETATION: In patients with severe symptomatic intracranial atherosclerotic stenosis, those with a DHV sign on MRI are at higher risk of recurrent ischemic stroke.

Co-morbidities and mortality associated with intracranial bleeds and ischaemic stroke.

Stroke is a leading cause of mortality and acquired disability; however, there has been no comprehensive comparison of co-morbid risk factors between different stroke subtypes. The aim of this study was to compare risk factors and mortality for subdural haematoma (SDH), subarachnoid haemorrhage (SAH) and ischaemic and haemorrhagic stroke. We compiled a database of all patients admitted with these conditions to a large teaching hospital in Birmingham, United Kingdom during the period 2000-2007 using the International Classification of Disease (ICD) 10th revision codes. Generalised linear models were constructed to calculate relative risks (RRs) associated with co-morbidities. In total, 4804 patients were admitted with diagnoses of SDH (1004), SAH (807), ischaemic stroke (2579) and haemorrhagic stroke (414). Patients with SDH were less likely to have pneumonia (0.492, 95% CI, 0.330-0.734; p < 0.001), whereas alcohol abuse (4.21, 95% CI, 2.82-6.28; p < 0.001) was more common. In SAH, ischaemic heart disease (0.56, 95% CI, 0.40-0.79; p < 0.001) was less common. As expected, a range of cardiovascular risk factors were associated with ischaemic stroke. Epilepsy was positively associated with ischaemic stroke (1.94, 95% CI, 1.36-2.76; p < 0.001), indicating a role for targeted primary prevention in patients with epilepsy. Five-year survival was lower in ischaemic and haemorrhagic strokes (41% and 40% respectively, vs. 73% in SDH and 64% in SAH; p < 0.001). These findings may guide clinical risk stratification, and improve the prognostic information given to patients.

Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions.

Schizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ≥1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). Schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.

Hospital admission with non-alcoholic fatty liver disease is associated with increased all-cause mortality independent of cardiovascular risk factors.

Non-alcoholic fatty liver disease (NAFLD) is common and strongly associated with the metabolic syndrome. Though NAFLD may progress to end-stage liver disease, the top cause of mortality in NAFLD is cardiovascular disease (CVD). Most of the data on liver-related mortality in NAFLD derives from specialist liver centres. It is not clear if the higher reported mortality rates in individuals with non-cirrhotic NAFLD are entirely accounted for by complications of atherosclerosis and diabetes. Therefore, we aimed to describe the CVD burden and mortality in NAFLD when adjusting for metabolic risk factors using a 'real world' cohort. We performed a retrospective study of patients followed-up after an admission to non-specialist hospitals with a NAFLD-spectrum diagnosis. Non-cirrhotic NAFLD and NAFLD-cirrhosis patients were defined by ICD-10 codes. Cases were age-/sex-matched with non-NAFLD hospitalised patients. All-cause mortality over 14-years follow-up after discharge was compared between groups using Cox proportional hazard models adjusted for demographics, CVD, and metabolic syndrome components. We identified 1,802 patients with NAFLD-diagnoses: 1,091 with non-cirrhotic NAFLD and 711 with NAFLD-cirrhosis, matched to 24,737 controls. There was an increasing burden of CVD with progression of NAFLD: for congestive heart failure 3.5% control, 4.2% non-cirrhotic NAFLD, 6.6% NAFLD-cirrhosis; and for atrial fibrillation 4.7% control, 5.9% non-cirrhotic NAFLD, 12.1% NAFLD-cirrhosis. Over 14-years follow-up, crude mortality rates were 14.7% control, 13.7% non-cirrhotic NAFLD, and 40.5% NAFLD-cirrhosis. However, after adjusting for demographics, non-cirrhotic NAFLD (HR 1.3 (95% CI 1.1-1.5)) as well as NAFLD-cirrhosis (HR 3.7 (95% CI 3.0-4.5)) patients had higher mortality compared to controls. These differences remained after adjusting for CVD and metabolic syndrome components: non-cirrhotic NAFLD (HR 1.2 (95% CI 1.0-1.4)) and NAFLD-cirrhosis (HR 3.4 (95% CI 2.8-4.2)). In conclusion, from a large non-specialist registry of hospitalised patients, those with non-cirrhotic NAFLD had increased overall mortality compared to controls even after adjusting for CVD.

Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002-2007.

BACKGROUND: There is a lack of evidence to explain why patients with dementia are admitted to a general hospital. METHODS: Main reasons for hospitalisation were investigated in all patients admitted to a multi-ethnic general hospital during 2002-2007, by analysis of type of admission and primary diagnosis on admission. Anonymised data from the Hospital Activity Analysis Register was used to trace these patients; 505 were diagnosed with Alzheimer's disease (AD), 283 with vascular dementia (VD) and 1,773 patients were classified as unspecified dementia (UnD). Logistic regression analysis was used to compare these groups to 53,123 age-matched controls. Statistical significance of p < 0.001 was accepted. RESULTS: More dementia patients were admitted as emergency cases compared to controls (AD = 95.8%, VD = 95.4%, UnD = 96.7%, controls = 54.4%; p < 0.001 for all comparisons). The proportion of patients admitted for dementia as their primary diagnosis was small (AD = 5.9%, VD = 10.6%, UnD = 6.0%). Primary diagnoses such as syncope and collapse, bronchopneumonia, urinary tract infection and dehydration were more frequent in all dementia patients than controls. CONCLUSION: Dementia patients are frequently admitted as emergency cases, but dementia itself is often not the primary diagnosis. Earlier detection of the specific conditions mentioned above may reduce emergency hospital admissions amongst dementia patients.

The interplay between atrial fibrillation and heart failure on long-term mortality and length of stay: Insights from the, United Kingdom ACALM registry.

BACKGROUND: There is concern that the development of heart failure and atrial fibrillation has a detrimental influence on clinical outcomes. The aim of this study was to assess all-cause mortality and length of hospital stay in patients with chronic and new-onset concomitant AF and HF. METHODS: Using the ACALM registry, we analysed adults hospitalised between 2000 and 2013 with AF and HF and assessed prevalence, mortality and length of hospital stay. Patients with HF and/or AF at baseline (study-entry) were compared with patients who developed new-onset disease during follow-up. RESULTS: Of 929,552 patients, 31,695 (3.4%) were in AF without HF, 20,768 (2.2%) had HF in sinus rhythm, and 10,992 (1.2%) had HF in AF. Patients with HF in AF had the greatest all-cause mortality (70.8%), followed by HF in sinus rhythm (64.1%) and AF alone (45.1%, p<0.0001). Patients that developed new-onset AF, HF or both had significantly worse mortality (58.5%, 70.7% and 74.8% respectively) compared to those already with the condition at baseline (48.5%, 63.7% and 67.2% respectively, p<0.0001). Patients with HF in AF had the longest length of hospital stay (9.41days, 95% CI 8.90-9.92), followed by HF in sinus rhythm (7.67, 95% CI 7.34-8.00) and AF alone (6.05, 95% CI 5.78-6.31). CONCLUSIONS: Patients with HF in AF are at a greater risk of mortality and longer hospital stay compared to patients without the combination. New-onset AF or HF is associated with significantly worse prognosis than long-standing disease.

The impact of psychiatric comorbidities on the length of hospital stay in patients with heart failure.

BACKGROUND: Heart failure (HF) is a major healthcare problem contributing significantly to hospital admission stays and National Health Service (NHS) spending. Reducing length of hospital stay (LoS) in HF is paramount in reducing this burden and is influenced by factors relating to the condition, sociodemographics and comorbidities. Psychiatric comorbidities are being increasingly identified amongst HF patients but their impact on LoS has not been studied in the UK. METHODS: We investigated the impact of psychiatric comorbidities on LoS amongst 31,760 HF patients admitted to hospitals in North England between 1st January 2000 and 31st March 2013 from the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study. The ACALM protocol uses ICD-10 and OPCS-4 coding to trace HF patients, psychiatric comorbidities and demographics including LoS. RESULTS: Amongst 31,760 HF patients mean LoS in the absence of psychiatric comorbidities was 11.2days. The presence of a psychiatric comorbidity increased LoS by 3.3days. Logistic regression accounting for age, gender and ethnicity showed that LoS was significantly longer in patients suffering from depression (3.4days, p<0.001), bipolar disorder (8.8days, p<0.001) and all types of dementia (4.2days, p<0.001). CONCLUSIONS: Our results demonstrate that psychiatric comorbidities have a significant and clinically important impact on LoS in HF patients in the UK. Clinicians should be actively aware of psychiatric conditions amongst HF patients and manage them to reduce LoS and ultimately the risk for patients and financial burden for the NHS.

Comorbidity and its relevance on general hospital based mortality in major depressive disorder: a naturalistic 12-year follow-up in general hospital admissions.

Major depressive disorder (MDD) is associated with physical comorbidity, but the risk factors of general hospital-based mortality are unclear. Consequently, we investigated whether the burden of comorbidity and its relevance on in-hospital death differs between patients with and without MDD in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 30 June 2012, 9604 MDD patients were admitted to three General Manchester Hospitals. All comorbidities with a prevalence ≥1% were compared with those of 96,040 age-gender matched hospital controls. Risk factors of in-hospital death were identified using multivariate logistic regression analyses. Crude hospital-based mortality rates within the period under observation were 997/9604 (10.4%) in MDD patients and 8495/96,040 (8.8%) in controls. MDD patients compared to controls had a substantial higher burden of comorbidity. The highest comorbidities included hypertension, asthma, and anxiety disorders. Subsequently, twenty-six other diseases were disproportionally increased, many of them linked to chronic lung diseases and to diabetes. In deceased MDD patients, chronic obstructive pulmonary disease and type-2 diabetes mellitus were the most common comorbidities, contributing to 18.6% and 17.1% of deaths. Furthermore, fifteen physical diseases contributed to in-hospital death in the MDD population. However, there were no significant differences in their impact on mortality compared to controls in multivariate logistic regression analyses. Thus in one of the largest samples of MDD patients in general hospitals, MDD patients have a substantial higher burden of comorbidity compared to controls, but they succumb to the same physical diseases as their age-gender matched peers without MDD.

The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting.

INTRODUCTION: Angioplasty has changed the management of acute coronary syndrome (ACS). However, in patients with previous coronary artery bypass grafting (CABG), the role of angioplasty in the management of ACS is widely debated. Lack of clear guidelines leads to subjective and often stereotypical assessments based on clinician preferences. We sought to investigate if angioplasty affected all cause mortality in ACS patients with previous CABG. METHODS: Completely anonymous information on patients with ACS with a background of previous CABG, co-morbidities and procedures attending three multi-ethnic general hospitals in the North West of England, United Kingdom in the period 2000-2012 was traced using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol using ICD-10 and OPCS-4 coding systems. Predictors of mortality and survival analyses were performed using SPSS version 20.0. RESULTS: Out of 12,227 patients with ACS, there were 1172 (19.0%) cases of ACS in patients with previous coronary artery bypass grafting. Of these 83 (7.1%) patients underwent angioplasty. Multi-nominal logistic regression, accounting for differences in age and co-morbidities, revealed that having angioplasty conferred a 7.96 times improvement in mortality (2.36-26.83 95% CI) compared to not having angioplasty in this patient group. CONCLUSIONS: We have shown that angioplasty confers significantly improved all cause mortality in the management of ACS in patients with previous CABG. The findings of this study highlight the need for clinicians to conscientiously think about the individual benefits and risks of angioplasty for every patient rather than confining to age related stereotypes.

Length of hospital stay is shorter in South Asian patients with acute pulmonary embolism.

Pulmonary embolism (PE) is a common diagnosis in UK hospitals and confers a significant hospital stay (LOS). There is very little evidence concerning ethnic variations on LOS in patients with PE. We sought to investigate ethnic variations in LOS in a large sample of 3440 patients with PE from 2000 to 2013 across seven hospitals in the north west of UK. We found that South Asian patients have significantly lower LOS compared with Caucasian patients. We discuss possible reasons for, and implications of, this finding.

Cardiovascular Risk Profiles amongst Women in a Multiethnic Population in Inner City Britain: A Potential Impact of Anaemia.

The risk of diabetes is markedly reduced in men with iron deficiency anaemia (IDA). The nature of this relationship in women is not clear, nor is there information about the influence of ethnicity, given the increased susceptibility of diabetes amongst South Asians and Afro-Caribbeans. We reviewed 3563 patients with a diagnosis of anaemia from 2000 to 2007. The age-adjusted prevalence of vitamin B12 deficiency and IDA was calculated, together with cardiovascular comorbidities amongst Caucasians, South Asians, and Afro-Caribbeans. The prevalence of vitamin B12 deficiency (women only) or IDA was markedly higher in South Asians compared to Caucasians and Afro-Caribbeans. Among women with IDA, diabetes was more prevalent among South Asians (45%, 95% CI 39.0-51.0) compared to Caucasians (3.0%, 2.1-4.0); P < 0.001. Among South Asian women with vitamin B12 deficiency, the prevalence of diabetes was reduced 8.5% (5.2-12.0). South Asian women with vitamin B12 deficiency had a higher prevalence of myocardial infarction (MI) and ischemic heart disease (IHD), but this relationship was reversed in IDA. IDA is associated with a greater prevalence of diabetes in South Asian women, but it is not coordinated by a greater risk of macrovascular complications. Given the cardiovascular impact of diabetes in South Asians, this association merits further study in relation to its pathophysiological implication.