A cost-effectiveness evaluation of a high-sensitivity troponin I guided voluntary cardiovascular risk assessment program for asymptomatic women in Croatia.

Background: To estimate the effectiveness and cost-effectiveness of a high-sensitivity troponin I (hsTnI) guided cardiovascular risk assessment program in women in Croatia. Methods: An observational study of a voluntary program for cardiovascular disease (CVD) risk assessment in women aged above 45 years with no specific symptoms, no confirmed or known coronary artery disease was conducted (WHP). Participants were stratified into three categories according to their hsTnI level. Subjects in the moderate or high-risk class were referred to cardiac work-up and invasive cardiovascular investigation as appropriate. Study information were applied to a discrete-event simulation model to estimate the cost-effectiveness of WHP against current practice. The number of CVD events and deaths, costs, and quality-adjusted life years (QALY) were assessed over 10 years from a societal perspective. Results: Of 1034 women who participated in the program, 921 (89.1%), 100 (9.7%), and 13 (1.3%) subjects fall into the low, moderate, and high-risk class. Of 26 women referred for angiography, significant coronary artery disease (CAD) was diagnosed in 12 women (46.1%). WHP gained 15.8 (95%CI 12.8; 17.2) QALYs per 1000 subjects, increased costs by 490€ (95%CI 487; 500), decreased CVD-related mortality by 40%. At a willingness-to-pay threshold of 45,000 €/QALY, WHP was cost-effective with a probability of 90%. Model results were most sensitive to utility weights and cost of medical prevention. Conclusions: Assessing the cardiovascular risk in asymptomatic women with hsTnI and guiding those at higher risk to further cardiac testing, identified individuals with CAD, could reduce CVD related burden, and would be cost-effective.

Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the most severe complications after cephalic pancreaticoduodenectomy, with mortality as high as 30%. Risk scores may help predict the risk of POPF. Multiple external validations substantially improve generalized clinical acceptability of a scoring system. AIM: The aim of this study was to externally validate previously described fistula risk score in the prediction of clinically relevant POPF. METHODS: All patients who underwent pancreaticoduodenectomy for any indication during a 5-year period were prospectively analyzed. A total of 132 patients were analyzed. RESULTS: Of the 132 patients, 44 (33.3%) developed pancreatic fistula, including 12.9% biochemical leaks, 7.6% grade B fistula, and 12.9% grade C fistula. Cut-off point of 4.5 was determined to best separate patients who developed clinically relevant POPF with area under curve of 78% (p = .00003). Sensitivity and specificity for the prediction of clinically relevant POPF with the cut-off value of 4.5 was 70.4 and 74.3%, respectively. Positive predictive value with cut-off value 4.5 was 57.8%, and negative predictive value was 83.4%. CONCLUSION: Fistula risk score identified low risk patients with false negative rate of 16.6%. Further external validation studies on large cohorts of patients and with wide case-mix may enable additional refinements of the score model.

The Role of Ambulatory Cardiac Rehabilitation in Improvement of Quality of Life, Anxiety and Depression.

BACKGROUND: Psychological reactions may adversely affect recovery after major cardiac events. This study investigates the role and frequently negligible importance of ambulatory cardiac rehabilitation (ACR) in improvement of quality of life (QoL), anxiety and depression at patients with various cardiac pathology. SUBJECTS AND METHODS: This prospective study included subjects treated for acute coronary syndrome (ACS), those with performed elective revascularization, and OTHERS (after valve replacement, implanted pacemaker or other device, with stable heart failure and coronary artery disease). Their anxiety (State Trait Anxiety Inventory (STAI) questionnaire), depression (Beck Depression Inventory (BDI-II) questionnaire) and QoL data (Short Form Health Survey-36 (SF-36) questionnaire, for physical and mental QoL components) were collected initially and after 3-month of ACR. RESULTS: ACR underwent 170 patients, aged 59 (53-66 years), predominately males (74.7%). At both genders, median duration of ACR was 12 weeks, with reduction of anxiety and depression scores and improvement in almost all components of QoL (P<0.05), except in mental health and bodily pain in males and females, respectively. After ACS (63.5%), ACR lasted 12 weeks, with reduction of anxiety and depression scores and improvement in all components of QoL (P<0.05). After elective revascularization (14.1%), ACR lasted 12 weeks, with reduction of anxiety score and improvement in almost all components of QoL (P<0.05), except mental health. At OTHERS (22.4%), ACR lasted 4 weeks, with improvement in almost all components of QoL (P<0.05), except mental health; ACR duration negatively correlated with anxiety and depressive scores (P<0.05). CONCLUSION: ACR during 3-month results with improvement of anxiety, depression and QoL at patients with various cardiac pathology.

Retrorenal fat predicts grade C pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula after pancreaticoduodenectomy is one of the most severe complications with mortality rates as high as 45%, and the prediction of most severe form of fistula (grade C) is crucial for successful management of patients who are to undergo cephalic pancreatoduodenectomy. It has been found that the amount of abdominal fat may predict grade C postoperative pancreatic fistula. In this study, we analysed the value of retrorenal fat thickness in the prediction of grade C pancreatic fistula. METHODS: A total of 140 patients who underwent pancreaticoduodenectomy were retrospectively analysed. Retrorenal fat thickness and intra-abdominal fat, expressed as total fat area, visceral fat area and subcutaneous fat area, were determined from computed tomography slices using the known range of attenuation values (-190 to -30). Blood loss, operating time, pancreatic texture and main pancreatic duct diameter as well as body mass index were also analysed. RESULTS: Retrorenal fat thickness (P = 0.0004), duct diameter (P = 0.0008), subcutaneous fat area (P = 0.023) and total fat area (P = 0.014) were found to be significant predictors of grade C pancreatic fistula. CONCLUSION: Although retrorenal fat tissue thickness may seem robust, it is a simple measure that can be used to predict the most severe grade of pancreatic fistula after pancreaticoduodenectomy.

Atypical cause of radiculopathy - Intradural spinal arachnoid cyst.

Intradural spinal arachnoid cysts are a relatively uncommon lesion that may be either intra, or extradural, and intradural spinal arachnoid cysts are even less common. Arachnoid cysts are cerebrospinal fluid collections in the spine that can present with neurological symptoms. The objective of this paper is to describe a rare case of radicular pain due to a spinal arachnoid cyst.

The Influence of Corticosteroids on Heart Rate Variablity in Acute Cervical Spinal Cord Injury.

Heart rate variability (HRV) gives information on the sympathetic-parasympathetic autonomic balance. The aim of the study was to analyze sympathovagal balance after acute spinal cord injury (SCI), demonstrated by linear measures in time and frequency domain of HRV and to analyze the effect of corticosteroids on HRV parameters in SCI. The study included 40 tetraplegic patients with acute SCI and 40 healthy subjects as control group. In the SCI group, 29 patients received and 11 patients did not receive corticosteroid therapy. All patients underwent 24-hour Holter monitoring for evaluation of HRV. Cardiac autonomic balance was evaluated by analysis of HRV in time and frequency domain. Sympathovagal balance (LF/HF) was significantly reduced in the groups of acute SCI patients, both with and without corticosteroid therapy, as compared with controls. However, there was no statistically significant difference between the two SCI groups (1.74 (0524) with and 1.75 (0534) without corticosteroid therapy). This study showed the sympathovagal balance to be altered in the acute phase of cervical spinal cord trauma. Finally, there was no effect of corticosteroid therapy on HRV parameters in SCI patients.

Control of heart rate by the autonomic nervous system in acute spinal cord injury.

Spinal cord injury may cause loss of cardiovascular reflexes mediated by sympathetic drive due to interruption in the supraspinal control of spinal sympathetic motoneurons. The aim of this study was to analyze sympathovagal balance after acute spinal cord injury demonstrated by linear measures in time and frequency domain of heart rate variability (HRV). The study included 40 tatraplegic patients after acute spinal cord injury and 40 healthy subjects as controls. Cardiac autonomic balance was evaluated by HRV analysis in time and frequency domain. The ratio of low to high frequencies (LF/HF) was statistically significantly (Mann-Whitney U = 0.0; Z = -7.7; P < 0.001) different between the group with cervical spine injuries 0.41 (0158) and control group 1.71 (1875). LH/HF was significantly reduced in the group of patients with acute trauma. This study established HRV analysis by linear methods as an objective measure of normal and abnormal function of the autonomic nervous system. In conclusion, spinal cord injury causes dysfunction of the autonomic cardiovascular regulation and leads to disturbances of the modulatory sympathetic activity on the cardiovascular system. The HRV parameters analyzed indicate decreased but still present sympathetic activity and suggest that descending and ascending fibers of the sympathetic nervous system in isolated segment are undamaged, although without supraspinal control after acute spinal cord injury.

Heart rate variability and nonlinear dynamic analysis in patients with stress-induced cardiomyopathy.

Complexity-based analyses may quantify abnormalities in heart rate variability (HRV). The aim of this study was to investigate the clinical and prognostic significances of dynamic HRV changes in patients with stress-induced cardiomyopathy Takotsubo syndrome (TS) by means of linear and nonlinear analysis. Patients with TS were included in study after complete noninvasive and invasive cardiovascular diagnostic evaluation and compared to an age and gender matched control group of healthy subjects. Series of R-R interval and of ST-T interval values were obtained from 24-h ECG recordings after digital sampling. HRV analysis was performed by 'range rescaled analysis' to determine the Hurst exponent, by detrended fluctuation analysis to quantify fractal long-range correlation properties, and by approximate entropy to assess time-series predictability. Short- and long-term fractal-scaling exponents were significantly higher in patients with TS in acute phases, opposite to lower approximate entropy and Hurst exponent, but all variables normalized in a few weeks. Dynamic HRV analysis allows assessing changes in complexity features of HRV in TS patients during the acute stage, and to monitor recovery after treatment, thus complementing traditional ECG and clinically analysis.

CSM-SD: methodology for contrast set mining through subgroup discovery.

This paper addresses a data analysis task, known as contrast set mining, whose goal is to find differences between contrasting groups. As a methodological novelty, it is shown that this task can be effectively solved by transforming it to a more common and well-understood subgroup discovery task. The transformation is studied in two learning settings, a one-versus-all and a pairwise contrast set mining setting, uncovering the conditions for each of the two choices. Moreover, the paper shows that the explanatory potential of discovered contrast sets can be improved by offering additional contrast set descriptors, called the supporting factors. The proposed methodology has been applied to uncover distinguishing characteristics of two groups of brain stroke patients, both with rapidly developing loss of brain function due to ischemia:those with ischemia caused by thrombosis and by embolism, respectively.

The "Chaos Theory" and nonlinear dynamics in heart rate variability analysis: does it work in short-time series in patients with coronary heart disease?

BACKGROUND: Dynamic analysis techniques may quantify abnormalities in heart rate variability (HRV) based on nonlinear and fractal analysis (chaos theory). The article emphasizes clinical and prognostic significance of dynamic changes in short-time series applied on patients with coronary heart disease (CHD) during the exercise electrocardiograph (ECG) test. METHODS: The subjects were included in the series after complete cardiovascular diagnostic data. Series of R-R and ST-T intervals were obtained from exercise ECG data after sampling digitally. The range rescaled analysis method determined the fractal dimension of the intervals. To quantify fractal long-range correlation's properties of heart rate variability, the detrended fluctuation analysis technique was used. Approximate entropy (ApEn) was applied to quantify the regularity and complexity of time series, as well as unpredictability of fluctuations in time series. RESULTS: It was found that the short-term fractal scaling exponent (alpha(1)) is significantly lower in patients with CHD (0.93 +/- 0.07 vs 1.09 +/- 0.04; P < 0.001). The patients with CHD had higher fractal dimension in each exercise test program separately, as well as in exercise program at all. ApEn was significant lower in CHD group in both RR and ST-T ECG intervals (P < 0.001). CONCLUSIONS: The nonlinear dynamic methods could have clinical and prognostic applicability also in short-time ECG series. Dynamic analysis based on chaos theory during the exercise ECG test point out the multifractal time series in CHD patients who loss normal fractal characteristics and regularity in HRV. Nonlinear analysis technique may complement traditional ECG analysis.