The subclinical hypothyroid state might predict 30-day readmission in patients admitted with acute heart failure syndrome and reduced left ventricular ejection fraction.

INTRODUCTION: Thyroid hormone (TH) has an essential role on the functional capability of cardiac muscle with its gene modulation and induction of vasodilatory effects. There is considerable evidence to suggest the role of TH in patients with acute coronary syndrome, but less is known about its prognostic role in heart failure (HF) patients. We aim to evaluate the association between subclinical hypothyroid state (SCHS) and event rates including 30-day all-cause and HF readmission in patients with an index hospitalization for acute HF syndrome (AHFS). METHODOLOGY: A retrospective chart review analysis of 2335 patients admitted with the diagnosis of AHFS between 1 January 2007 and 31 December 2017 was conducted. SCHS was defined as thyroid-stimulating hormone (TSH) level >4.50 mIU/L with a normal thyroxine (T4) level. Patients with pre-existing thyroid disease or receiving thyroid replacement therapy were excluded. HF with preserved ejection fraction (HFpEF) was defined as left ventricular ejection fraction (LVEF) >40% and HF with reduced ejection fraction (HFrEF) was defined as having LVEF ⩽40%. Percentage of 30-day, 3-month and 6-month all-cause readmission and mortality rates were calculated in both cohorts of AHFS (HFpEF and HFrEF) with and without SCHS. RESULTS: The mean age of the 2335 AHFS population was 65 (±14.8) years. Of the 2335 patients admitted with AHFS, 1228 (52.6%) patients were found to have HFrEF and 1107 (47.4%) with HFpEF. There were 170 (7.3%) patients with AHFS found to have SCHS. There were more males than females (54% versus 46%). The percentage of hospital readmission within 30 days was higher for patients with SCHS compared with those without SCHS in the HFrEF group (42% versus 30%, p = 0.001). Hospital readmission within 30 days for patients with SCHS compared with those without SCHS in the HFpEF group did not differ (36.5% versus 31%, p = 0.47). Additionally, all-cause mortality was higher among patients with SCHS compared with patients without SCHS in the HFrEF group (18.7% versus 7.0%, p < 0.001). All-cause mortality was found similar in both arms of the HFpEF group (9.5% versus 7.7%, p = 0.73). CONCLUSION: During an index hospital admission for AHFS, SCHS was an independent predictor of readmission in 30 days in patients with HFrEF but not in patients with HFpEF. Additionally, it was related to adverse outcome such as all-cause mortality in HFrEF patients but not in HFpEF patients. Further studies regarding the concept of tissue thyroid and the potential for a therapeutic target are warranted.

Preclinical cardiac disease in nonalcoholic fatty liver disease with and without metabolic syndrome.

BACKGROUND: Metabolic syndrome is associated with preclinical cardiac disease and nonalcoholic fatty liver disease (NAFLD). It is uncertain whether preclinical cardiac disease is present in patients with NAFLD without metabolic syndrome (MetS). OBJECTIVE: To explore preclinical cardiac disease in patients with NAFLD. METHODS: A total of 64 patients with NAFLD, based on computed tomography scans liver attenuation, were identified. A control group, matched to age and gender, comprising of 94 patients was also drafted. Finally, two additional groups of patients with metabolic syndrome, with (n = 40) and without (n = 74) NAFLD, were also identified. Patients with hypertension, diabetes mellitus, and other concomitant liver diseases were excluded from the NAFLD group. Echocardiograms of all groups were reviewed. RESULTS: Severe NAFLD compared to control was associated with a higher left ventricular mass after normalization for height2.7 (LVMHt2.7) (95% CI = 0.39, 12.92) and lower ratio of peak "E" (early) and "A" (late) diastolic ventricular filling velocities (E/A) - 0.39 (95% CI = -0.58, -0.19). Patients with metabolic syndrome (95% CI = 0.02, 0.09), metabolic syndrome with NAFLD (95% CI = 0.02, 0.08), or severe NAFLD (95% CI = 0.02, 0.09) compared to control was associated with a higher relative wall thickness (RWT). CONCLUSION: Healthy adults with NAFLD without metabolic syndrome, after adjusting for body mass index, demonstrated significant echocardiographic changes. Our results show that NAFLD is associated with preclinical cardiac disease, and this association is independent of traditional risk factors like systemic hypertension and diabetes mellitus.

Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach.

BACKGROUND: Various degree of extrinsic compression of the oesophagus and stomach are experienced during upper endoscopy. However, its utility in clinical practice has not been studied. METHODS: Electronic chart review of all upper gastrointestinal endoscopies done at our hospital between 2005 and 2016 was performed. A total of 79 patients with documented extrinsic compression on upper gastrointestinal procedure report who had a preceding or subsequent abdomen/chest CT imaging performed within 6 months were included. RESULTS: 30 (38%) out of 79 patients had abnormal finding on CT scan. 14 (47%) out of 30 patients had an associated malignant lesion, whereas remaining had a benign lesion. Overall, patients with associated gastrointestinal symptoms (60% vs 22%, p=0.001) or history of weight loss (50% vs 16%, p=0.001) had increased odds of having an abnormal finding on CT scan compared with the patients who lacked such symptoms. Pancreatic cancer was the most commonly diagnosed malignancy. On subgroup analysis of patients with extrinsic compression and malignant lesion on imaging study, the likelihood of a malignancy was higher in blacks as compared with Hispanics (71%:29% vs 39%:61%, p=0.031), and with presence of gastrointestinal symptoms (64% vs 22%, p=0.003), presence of weight loss (64% vs 16%, p=0.0001) and hypoalbuminaemia (p=0.001). CONCLUSION: Finding an extrinsic compression of the oesophagus and stomach on an upper endoscopy may suggest malignancy, and hence should prompt further work-up. Posterior wall gastric body compression may signal the presence of pancreatic cancer.

Evaluation of the combined effect of factors influencing bowel preparation and adenoma detection rates in patients undergoing colonoscopy.

BACKGROUND: Colonoscopy is a commonly used modality for screening and surveillance of colorectal cancer (CRC). Therefore, it is essential to have adequate bowel preparation (prep) for the procedure which depends on type of bowel regimens, diet before colonoscopy and timing of the procedure. AIMS: The purpose of this study is to analyse the effect of multiple factors on adenoma detection rate (ADR) and prep quality of colonoscopy. This is the also the first study determining outcomes based on various combinations of diet, timing of the procedure and bowel prep regimens. METHODS: This is a retrospective single-centre observational study. Data about diet before procedure, bowel prepprep regimen and timing of the procedure was collected for patients coming for screening colonoscopy. RESULTS: Patients with split prep had higher good prep rates (73.8% vs 56.2%) and higher ADRs (34.2 % vs 29.9%) as compared with non-split prep. The good prep quality (65.8% vs 62.1%) and ADRs (31.9% vs 31.5%) were comparable in patients who received clear liquid diet as compared with low residue diet. The good results of bowel prep were obtained with split prep with either clear liquids or low residue diet irrespective of the timing of procedure. The poor prep was noticed in patients who underwent procedure in afternoon, with a low restrictive diet and non-split bowel regimen. CONCLUSIONS: The current study adds to our knowledge about the combined effect of multiple variables affecting the bowel prep quality and ADR. It is imperative to opt for the best combination required for colonoscopy, as this will influence the effectiveness of colonoscopies regarding timely cancer detection and prevention.

Fever is associated with higher morbidity and clot burden in patients with acute pulmonary embolism.

BACKGROUND: Fever is considered as a presenting symptom of pulmonary embolism (PE). We aim to evaluate the association between PE and fever, its clinical characteristics, outcomes and role in prognosis. METHODS: A retrospective chart review of patients who were hospitalised with the diagnosis of acute PE was conducted. Patients in whom underlying fever could also be attributable to an underlying infection were also excluded. RESULTS: A total of 241 patients met the study criteria. 63 patients (25.7%) had fever within 1 week of diagnosis of PE of which four patients had fever that could be due to underlying infection and were excluded. Patients in PE with fever group were younger compared with PE without fever group (52.52 vs 58.68, p=0.012) and had higher incidence of smoking (44.1% vs 20.9%, p<0.001). Patients in PE with fever group were more likely to require intensive care admission (69.5% vs 35.7%, p<0.001), had a longer hospital length of stay (19.80 vs 12.20, p<0.001) and higher requirement of mechanical ventilation (30.5% vs 6.6%, p<0.001) compared with those without fever. PE with fever group were more likely to have massive and submassive PE (55.9% vs 36.8%, p=0.015) and had higher incidence of deep vein thrombosis (33.3% vs 17.4%, p=0.0347) compared with PE without fever. In a univariate model, there was higher likelihood of in-hospital mortality in PE with fever group compared with PE without fever (22.0% vs 10.4%, p=0.039). CONCLUSION: Patients with acute PE and fever have higher morbidity and clot burden.

Predicting the presence of adenomatous polyps during colonoscopy with National Cancer Institute Colorectal Cancer Risk-Assessment Tool.

AIM: To evaluate the National Cancer Institute (NCI) Colorectal Cancer (CRC) Risk Assessment Tool as a predictor for the presence of adenomatous polyps (AP) found during screening or surveillance colonoscopy. METHODS: This is a retrospective single center observational study. We collected data of adenomatous polyps in each colonoscopy and then evaluated the lifetime CRC risk. We calculated the AP prevalence across risk score quintiles, odds ratios of the prevalence of AP across risk score quintiles, area under curves (AUCs) and Youden's indexes to assess the optimal risk score cut off value for AP prevalence status. RESULTS: The prevalence of AP gradually increased throughout the five risk score quintiles: i.e., 27.63% in the first and 51.35% in the fifth quintile. The odd ratios of AP prevalence in the fifth quintile compared to the first and second quintile were 2.76 [confidence interval (CI): 1.71-4.47] and 2.09 (CI: 1.32-3.30). The AUC for all patients was 0.62 (CI: 0.58-0.66). Youden's Index indicated the optimal risk score cutoff value discriminating AP prevalence status was 3.60. CONCLUSION: Patients with the higher NCI risk score have higher risk of AP and subsequent CRC; therefore, measures to increase the effectiveness of CRC detection in these patients include longer withdrawal time, early surveillance colonoscopy, and choosing flexible colonoscopy over other CRC screening modalities.

Monetary effects on fear conditioning.

Previous research has found that the loss of money as a negative secondary reinforcer was as effective as a primary reinforcer during fear conditioning. The purpose of the present study was to explore the effect of monetary gain as a positive secondary reinforcer in fear conditioning. Participants were assigned to a high-reward group or low-reward group. Three kinds of squares prompting non-compensation shock, compensation shock, and no shock were presented. Skin conductance responses (SCRs) and self-ratings were recorded. The results revealed that (a) both SCRs and self-ratings in the compensation shock condition were lower than in the non-compensation shock condition, suggesting that money might block the learning stage of fear conditioning; and (b) a higher ratio of fear reduction was present in self-rating when compared to SCRs, suggesting that people might overstate the utility of money, subjectively. Monetary effects, the effects of different amounts of money, and the differences between subjective and physiological levels are discussed.