Renal Transplantation and Outcome.

Emergency surgery represents an independent risk factor for death and postoperative complications. The aim of this study was to investigate the literature data regarding outcome of daytime or nighttime renal transplantation surgery. Relevant papers, focused on renal transplantation surgery, time of the day, and complications, were searched across the PubMed database. We used the following search terms: "renal", "transplantation", "surgery", "daytime", "nighttime", and "outcome". A total of five papers, including 6,991 adult patients were evaluated. All patients received renal transplantation from deceased donor. Daytime or nighttime surgery do not seem to negatively impact on graft survival in renal transplantation. However, two out five studies reported higher odds of complications after nighttime operation. Since it is not possible to predict the availability of a deceased donor, nighttime surgery remains a valid option when necessary, maybe deserving a higher level of caution to reduce or avoid complications.

Renal disease and accidental falls: a review of published evidence.

BACKGROUND: The pathogenesis of falling is complex, and identification of risk factors may be essential for prevention. The relationship between renal disease and falls is unclear, and the goal of this study was to collect the available evidence and investigate the relationship between accidental falls and renal dysfunction. METHODS: Electronic searches were performed in the MEDLINE, Scopus, Ovid SP and Web of Science databases to identify the appropriate literature. The themes used were: falls (combined in the title/abstract fall or falls or falling or faller* or fallen or slip* or trip* or (MeSH) accidental falls) and renal insufficiency (chronic or renal insufficiency or kidney diseases combined in title/abstract renal disease* or kidney disease* or renal insufficiency or kidney insufficiency or kidney failure or renal failure or MeSH renal insufficiency, chronic or renal insufficiency or kidney diseases). The incidence, risk factors, complications, and characteristics of the falls were analyzed. RESULTS: Eight prospective cohorts including five cross-sectional studies, and one case-control study were identified. No randomized controlled studies were found. The incidence of falls in chronic kidney disease patients ranged between 1.18 and 1.60 fall/patient year. These were frequent in frail older adults on hemodialysis treatment. Falling relapses in the same group of patients caused serious consequences. Data on pre-end stage renal disease (ESRD) were scarce. CONCLUSIONS: The risk of falling appears to be common in patients with renal dysfunction especially in older adults undergoing hemodialysis. On the other hand, we could not find any conclusive data on pre-ESRD patients.

Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUND: Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic. METHODS: Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA2DS2VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA2DS2VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg. RESULTS: We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA2DS2VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA2DS2VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not. CONCLUSIONS: ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

Temporal variation of heart failure hospitalization: does it exist?

Congestive heart failure (CHF) is the end stage of many cardiac diseases, and one of the leading causes of mortality and morbidity around the world. Coronary heart disease and hypertension (either singly or together) are the main etiology for CHF. It has been reported that major acute cardiovascular events (myocardial infarction, sudden death, cardiac arrest, ischemic and hemorrhagic stroke, pulmonary embolism, rupture/dissection of aortic aneurysms) do not occur randomly through time, but exhibit a specific temporal periodicity characterized by seasonal (winter), weekly (Monday), and circadian (morning) patterns of onset. Thus, because the major causes of CHF present a temporal pattern, in the past several years some studies have investigated the temporal variation of CHF hospitalization and mortality, with results indicating the possibility of a preference for winter months, Mondays, and nighttime, respectively.

Evidence-based statin prescription for cardiovascular protection in renal impairment.

Dyslipidemia is a well-known risk factor for cardiovascular disease in the general population, and the cardioprotective role of statins is well established. However, although cardiovascular disease is the major cause of morbidity and mortality in chronic kidney disease (CKD), the role of statin therapy is still under investigation. In CKD the atherosclerotic burden is high and pathophysiology of dyslipidemia is complex; however, the majority of large-scale statin trials excluded patients with CKD. Statins could have different effects in the different stages of CKD. Two large trials involving haemodialysis patients showed unfavourable results, whereas in renal transplant subjects as well as in early CKD subjects, statins reduced cardiovascular risk. The studies involving early CKD patients are post-hoc analyses of large trials and they showed that statins are more effective in secondary than in primary prevention. The aim of this study was to evaluate the effectiveness of statins for prevention of cardiovascular events by calculating the number of patients needed to be treated in different interventional trials. We conclude that dyslipidemia is a modifiable cardiovascular risk and statins appear to be an effective treatment especially in the early stages of CKD. Patients on renal replacement therapy could obtain an advantage from this treatment; however, the patient's clinical prognosis should be taken into account when evaluating treatment.

Do Sex-Related Differences of Comorbidity Burden and/or In-Hospital Mortality Exist in Cancer Patients? A Retrospective Study in an Internal Medicine Setting.

Cancer represents important comorbidity, and data on outcomes are usually derived from selected oncologic units. Our aim was to evaluate possible sex-related differences and factors associated with in-hospital mortality (IHM) in a consecutive cohort of elderly patients with cancer admitted to internal medicine. We included all patients admitted to our department with a diagnosis of cancer during 2018. Based on the International Classification of Diseases, 9th Revision, Clinical Modification, demography, comorbidity burden, and diagnostic procedures were evaluated, with IHM as our outcome. We evaluated 955 subjects with cancer (23.9% of total hospital admissions), 42.9% were males, and the mean age was 76.4 ± 11.4 years. Metastatic cancer was diagnosed in 18.2%. The deceased group had a higher modified Elixhauser Index (17.6 ± 7.7 vs. 14 ± 7.3, p < 0.001), prevalence of cachexia (17.9% vs. 7.2%, p < 0.001), and presence of metastasis (27.8% vs. 16.3%, p = 0.001) than survivors. Females had a higher age (77.4 ± 11.4 vs. 75.5 ± 11.4, p = 0.013), and lower comorbidity (10.2 ± 5.9 vs. 12.0 ± 5.6, p < 0.001) than males. IHM was not significantly different among sex groups, but it was independently associated with cachexia and metastasis only in women. Comorbidities are highly prevalent in patients with cancer admitted to the internal medicine setting and are associated with an increased risk of all-cause mortality, especially in female elderly patients with advanced disease.

Chromosome 14q32 translocations involving the immunoglobulin heavy chain locus in chronic lymphocytic leukaemia identify a disease subset with poor prognosis.

Immunophenotypic studies, fluorescence in situ hybridization (FISH) and conventional karyotyping were used to define the clinicobiological significance of 14q32 translocations involving the immunoglobulin gene locus (14q32/IGH) in 252 chronic lymphocytic leukaemia (CLL) patients. The following regions were studied: 13q14, centromere 12, 6q21; 11q22/ATM; 17p13/TP53, 14q32/IGH. Patients were classified as group 1 (favourable, i.e. 13q-single or normal), group 2 (intermediate risk, i.e. +12, 6q-, 1-2 anomalies), group 3 (unfavourable, i.e. 17p-, 11q-, complex karyotype), or group 4 (14q32/IGH translocation). Endpoints were treatment-free survival (TFS) and overall survival (OS). One hundred and ten patients were included in group 1, 99 in group 2, 25 in group 3 and 18 in group 4. 14q32/IGH translocation partners were identified in eight cases (BCL2 in five cases, BCL11A, CCND3 and CDK6 in one case each). group 4 showed shorter TFS versus groups 2 and 1 (25% patients treated at 2 months vs. 12 (P = 0.02) and 20 months (P = 0.002), respectively) and shorter OS (25% patients dead at 18 months versus 50 (P = 0.0003) and >60 months (P < 0.0001) respectively. The 14q32/IGH translocation maintained prognostic significance at multivariate analysis on TFS (P = 0.025) and OS (P < 0.001), along with advanced stage and CD38+. These findings show that the 14q32/IGH translocation predicts for an unfavourable outcome in CLL and that this cytogenetic subset might be included as a separate entity in a hierarchical cytogenetic classification of CLL.

Pulmonary embolism and internal jugular vein thrombosis as evocative clues of Lemierre's syndrome: A case report and review of the literature.

Lemierre's syndrome (LS) is an uncommon condition with oropharyngeal infections, internal jugular vein thrombosis, and systemic metastatic septic embolization as the main features. Fusobacterium species, a group of strictly anaerobic Gram negative rod shaped bacteria, are advocated to be the main pathogen involved. We report a case of LS complicated by pulmonary embolism and pulmonary septic emboli that mimicked a neoplastic lung condition. A Medline search revealed 173 case reports of LS associated with internal jugular vein thrombosis that documented the type of microorganism. Data confirmed high prevalence in young males with Gram negative infections (83.2%). Pulmonary embolism was reported in 8.7% of cases mainly described in subjects with Gram positive infections (OR = 9.786; 95%CI: 2.577-37.168, P = 0.001), independently of age and gender. Only four fatal cases were reported. LS is an uncommon condition that could be complicated by pulmonary embolism, especially in subjects with Gram positive infections.

Marital Status, Cardiovascular Diseases, and Cardiovascular Risk Factors: A Review of the Evidence.

BACKGROUND: There is evidence showing that marital status (MS) and marital disruption (i.e., separation, divorce, and being widowed) are associated with poor physical health outcomes, including for all-cause mortality. We checked for the available evidence on the association between MS and cardiovascular (CV) diseases, outcomes, and CV risk factors. METHODS: A search across the PubMed database of all articles, including the term "marital status" in their title, was performed. All articles were then manually checked for the presence of the following terms or topic: CV diseases, acute myocardial infarction, acute coronary syndrome, coronary artery disease, cardiac arrest, heart failure, heart diseases, and CV mortality. Moreover, other search terms were: CV risk factors, hypertension, cholesterol, obesity, smoking, alcohol, fitness and/or physical activity, and health. Systematic reviews, meta-analyses, controlled trials, cohort studies, and case-control studies were potentially considered pertinent for inclusion. Case reports, comments, discussion letters, abstracts of scientific conferences, articles in other than English language, and conference abstracts or proceedings were excluded. RESULTS: In total, 817 references containing the title words "marital status" were found. After elimination of articles dealing with other topics, 70 records were considered pertinent. Twenty-two were eliminated for several reasons, such as old articles, no abstract, full text unavailable, other than English language, comments, and letters. Out of the remaining 48 articles, 13 were suitable for the discussion, and 35 (accounting for 1,245,967 subjects) were included in this study. CONCLUSIONS: Most studies showed better outcomes for married persons, and men who were single generally had the poorest results. Moreover, being married was associated with lower risk factors and better health status, even in the presence of many confounding effects.

Reducing the risk of venous thromboembolism using apixaban - patient perspectives and considerations. Should more attention be given to females?

BACKGROUND: New oral anticoagulant agents, such as apixaban, rivaroxaban, dabigatran, or endoxaban, have recently become for patients an alternative option to conventional treatment in the therapy of venous thromboembolism (VTE). Thus, we aimed to review the available information on adverse events (AEs) of apixaban compared to conventional therapy (heparin or vitamin K antagonists) in randomized controlled trials (RCTs) on patients treated for VTE, with a particular attention to sex subgroups. METHODS: An electronic search in MEDLINE and Embase was performed by using the keywords "apixaban" and "venous thromboembolism". All RCTs focused on apixaban in the treatment and prevention of VTE were evaluated for the presence of AEs. AEs were classified as serious, bleeding, and cause of discontinuation. Moreover, we also searched by using the keywords "gender" and "venous thromboembolism" and "anticoagulants". RESULTS: Considering all subjects enrolled in the eleven RCTs as a whole to investigate the occurrence of AEs, we extrapolated an events/subjects rate of 57.8% for AEs (6,445/11,144), 7.7% for serious AEs (975/12,647), 9.1% for bleeding events (1,229/13,454), and 3.2% for discontinuation of apixaban (421/13,039). The percentage of AEs was lower in subjects treated with apixaban than in those treated with conventional VTE therapy (53% vs 56.3%, respectively). However, only one study provided data on separate analysis by sex of either efficacy or safety of apixaban. CONCLUSION: Under the patient's perspective, apixaban could represent a good choice in the treatment of VTE, due to its pharmacological, economical, and safety profile. These positive aspects are certainly present in both sexes, since the available studies include a correct percentage of women, but data with separate analyses by sex are extremely limited. Future clinical trials should include in their results on clinical impact and outcomes a stratification by sex, and studies aimed to evaluate possible sex-related differences for these drugs should be strongly encouraged.

Chronotype, gender and general health.

BACKGROUND: Light-dark alternation has always been the strongest external circadian "zeitgeber" for humans. Due to its growing technological preference, our society is quickly transforming toward a progressive "eveningness" (E), with consequences on personal circadian preference (chronotype), depending on gender as well. The aim of this study was to review the available evidence of possible relationships between chronotype and gender, with relevance on disturbances that could negatively impact general health, including daily life aspects. METHODS: Electronic searches of the published literature were performed in the databases MEDLINE and Web of Science, by using the Medical Subject Heading (MeSH), when available, or other specific keywords. RESULTS: Results were grouped into four general areas, i.e. (a) "General and Cardiovascular Issues", (b) "Psychological and Psychopathological Issues", (c) "Sleep and Sleep-Related Issues" and (d) "School and School-Related Issues". (a) E is associated with unhealthy and dietary habits, smoking and alcohol drinking (in younger subjects) and, in adults, with diabetes and metabolic syndrome; (b) E is associated with impulsivity and anger, depression, anxiety disorders and nightmares (especially in women), risk taking behavior, use of alcohol, coffee and stimulants, psychopathology and personality traits; (c) E has been associated, especially in young subjects, with later bedtime and wake-up time, irregular sleep-wake schedule, subjective poor sleep, school performance and motivation, health-related quality of life; (d) E was associated with lowest mood and lower overall grade point average (especially for women). CONCLUSIONS: Eveningness may impact general health, either physical or mental, sleep, school results and achievements, especially in younger age and in women. The role of family support is crucial, and parents should be deeply informed that abuse of technological devices during night hours may lead to the immature adjustment function of children's endogenous circadian pacemakers.

All-cause mortality and estimated renal function in type 2 diabetes mellitus outpatients: Is there a relationship with the equation used?

BACKGROUND: We investigated the relationship between serum creatinine (SCr) and estimated glomerular filtration rate (eGFR), evaluated by different formulae, and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) outpatients. METHODS: This observational cohort study considered 1365 T2DM outpatients, who had been followed up for a period of up to 11 years. eGFR was estimated using several equations. RESULTS: Seventy subjects (5.1%) died after a follow-up of 9.8 ± 3 years. Univariate analysis showed that diagnosis of nephropathy (odds ratio (OR): 2.554, 95% confidence interval (CI): 1.616-4.038, p < 0.001) and microvascular complications (OR: 2.281, 95% CI: 1.449-3.593, p < 0.001) were associated with ACM. Receiving operating characteristic (ROC) curves showed that the areas under the curve for ACM were similar using the different eGFR equations. eGFR values were predictors of ACM, and the hazard ratios (HRs) of the different equations for eGFR estimation were similar. CONCLUSION: In our cohort of T2DM outpatients, different eGFR equations perform similarly in predicting ACM, whereas SCr did not.

Diurnal and twenty-four hour patterning of human diseases: cardiac, vascular, and respiratory diseases, conditions, and syndromes.

Various medical conditions, disorders, and syndromes exhibit predictable-in-time diurnal and 24 h patterning in the signs, symptoms, and grave nonfatal and fatal events, e.g., respiratory ones of viral and allergic rhinorrhea, reversible (asthma) and non-reversible (bronchitis and emphysema) chronic obstructive pulmonary disease, cystic fibrosis, high altitude pulmonary edema, and decompression sickness; cardiac ones of atrial premature beats and tachycardia, paroxysmal atrial fibrillation, 3rd degree atrial-ventricular block, paroxysmal supraventricular tachycardia, ventricular premature beats, ventricular tachyarrhythmia, symptomatic and non-symptomatic angina pectoris, Prinzmetal vasospastic variant angina, acute (non-fatal and fatal) incidents of myocardial infarction, sudden cardiac arrest, in-bed sudden death syndrome of type-1 diabetes, acute cardiogenic pulmonary edema, and heart failure; vascular and circulatory system ones of hypertension, acute orthostatic postprandial, micturition, and defecation hypotension/syncope, intermittent claudication, venous insufficiency, standing occupation leg edema, arterial and venous branch occlusion of the eye, menopausal hot flash, sickle cell syndrome, abdominal, aortic, and thoracic dissections, pulmonary thromboembolism, and deep venous thrombosis, and cerebrovascular transient ischemic attack and hemorrhagic and ischemic stroke. Knowledge of these temporal patterns not only helps guide patient care but research of their underlying endogenous mechanisms, i.e., circadian and others, and external triggers plus informs the development and application of effective chronopreventive and chronotherapeutic strategies.