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Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that may complicate hematologic malignancies. HLH and malignancies have common clinical features, and HLH diagnostic criteria (HLH-2004/Hscore) were not validated in this specific population. We describe a case of a 72-year-old patient with a history of chronic lymphocytic leukemia stable for over 10 years who presented with fever and cytopenia. After excluding infectious etiologies and the progression of her disease, HLH was diagnosed. The patient was treated with etoposide, dexamethasone, intravenous immunoglobulin, and rituximab. Despite initial clinical improvement, the patient deteriorated and developed pulmonary aspergillosis and CNS involvement that reflected uncontrolled HLH. The patient died 45 days after her presentation. An unusual feature of this case was that HLH was not triggered by infection, disease transformation, or treatment. This case emphasizes the challenges of differentiating the development of overwhelming HLH from other complications associated with hematologic malignancy.
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Leucemia Linfocítica Crônica de Células B , Linfo-Histiocitose Hemofagocítica , Idoso , Etoposídeo/uso terapêutico , Feminino , Febre , Humanos , Imunidade , Leucemia Linfocítica Crônica de Células B/complicações , Leucemia Linfocítica Crônica de Células B/diagnóstico , Leucemia Linfocítica Crônica de Células B/tratamento farmacológico , Linfo-Histiocitose Hemofagocítica/complicações , Linfo-Histiocitose Hemofagocítica/diagnósticoRESUMO
INTRODUCTION: While there is evidence of the presence of the coronavirus in the kidneys and resultant acute kidney injury (AKI), information on the effect of chronic kidney disease (CKD) on COVID-19 outcomes and its pathogenesis is currently lacking. METHODS: This retrospective, observational study evaluated the outcomes of all consecutive patients hospitalized during COVID-19 outbreaks in Meir Medical Center. Serum creatinine level was assessed before hospitalization ("baseline serum creatinine") and at admission, as well as minimum and maximum serum creatinine levels during hospitalization. RESULTS: Among 658 patients, 152 had eGFR < 60 ml/min (termed the CKD group), 506 patients served as controls. Patients in the CKD group were older, with higher prevalence of hypertension, diabetes mellitus and atherosclerosis. Disease severity and clinical presentation of CKD group were comparable to that of control group. Odds ratio for AKI was 5.8 (95%CI 3.8-8.7; p < 0.001) in CKD group vs. control group and 3.4 (95%CI 1.1-10.8) for renal replacement therapy (p < 0.026). Among the CKD group, 32.2% died after COVID-19 infection versus 14.8% of the controls (p < 0.001). Mortality increased as CKD stage increased (14.8% in controls, 29.6% in CKD stage 3, and 39.3% in CKD stages 4 and 5, p < 0.001). CONCLUSION: Despite comparable disease severity at presentation, patients with CKD had significantly more AKI events and required more renal replacement therapy during hospitalization than control patients did. Mortality increased as CKD stage increased.
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Injúria Renal Aguda , COVID-19 , Insuficiência Renal Crônica , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/terapia , COVID-19/complicações , Creatinina , Feminino , Humanos , Rim , Masculino , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Patients with end-stage renal disease (ESRD) undergoing chronic hemodialysis are at high mortality and cardiovascular risk. This study was aimed to assess whether the CHA2DS2-VASc score may be used for risk stratification of this population. METHODS: Included were patients undergoing chronic hemodialysis at Meir Medical Center. The CHA2DS2-VASc score was calculated for each patient at the initiation of hemodialysis. Patients were classified into 3 groups according to the CHA2DS2-VASc score: 0-3 (low), 4-5 (intermediate), and ≥6 (high). The primary endpoint was the composite of all-cause mortality, myocardial infarction, and stroke during the first year of hemodialysis. RESULTS: Of the 457 patients with ESRD, 181 (40%) had low, 193 (42%) intermediate, and 83 (18%) high CHA2DS2-VASc scores. During the first year of hemodialysis, 109 (23.8%) patients died, 17 (3.7%) had a stroke, and 28 (6.1%) had a myocardial infarction. Compared to patients in the low CHA2DS2-VASc score group, those in the intermediate and high score groups had higher risk for the composite endpoint (OR: 2.6, 95% CI: 1.6-4.2, p < 0.01 and OR: 4.2, 95% CI: 2.3-7.5, p < 0.01, respectively). Each 1-point increase in CHA2DS2-VASc score was associated with a 38% increased risk for the composite endpoint, a 19% increased risk for 1-year myocardial infarction, and a 29% increased risk for 1-year stroke. CONCLUSIONS: Patients with ESRD are at an extremely high mortality and cardiovascular risk within the first year of hemodialysis. The CHA2DS2-VASc score was strongly associated with adverse outcomes and may be used for risk stratification of these patients.
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Falência Renal Crônica/complicações , Infarto do Miocárdio/epidemiologia , Diálise Renal/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Feminino , Seguimentos , Humanos , Falência Renal Crônica/mortalidade , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Prognóstico , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Acidente Vascular Cerebral/etnologiaRESUMO
BACKGROUND: Cardiac resynchronization therapy (CRT) is a non-pharmacological option for patients with heart failure and interventricular dyssynchrony. Elevated red cell distribution width (RDW) reflects higher size and heterogeneity of erythrocytes and is associated with poor outcome in patients with chronic heart failure. OBJECTIVES: To examine the association between RDW levels and outcomes after CRT implantation. METHODS: We conducted a cohort analysis of 156 patients (126 men, median age 69.0 years) who underwent CRT implantation in our institution during 2004-2008. RDW was measured at three time points before and after implantation. Primary outcome was defined as all-cause mortality, and secondary outcome as hospital re-admissions. We investigated the association between RDW levels and primary outcome during a median follow-up of 61 months. RESULTS: Ninety-five patients (60.9%) died during follow-up. Higher baseline RDW levels were associated with all-cause mortality (unadjusted HR 1.35, 95% CI 1.20-1.52, P < 0.001). On multivariate analysis adjusted for clinical, electrocardiographic and laboratory variables, baseline RDW levels were associated with mortality (HR 1.33, 95%CI 1.16-1.53). RDW levels 6 months and 12 months post-implantation were also associated with mortality (HR 1.22, 95%CI 1.08-1.38, P = 0.001; and HR 1.15, 95% CI 1.01-1.32, P = 0.02, respectively). Patients who were re-admitted to hospital during follow-up (n = 78) had higher baseline RDW levels as compared to those who were not (14.9%, IQR 14.0, 16.0% vs. 14.3%, IQR 13.7, 15.0%, respectively, P = 0.03). CONCLUSION: An elevated RDW level before and after CRT implantation is independently associated with all-cause mortality.
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Índices de Eritrócitos , Eritrócitos/metabolismo , Insuficiência Cardíaca , Idoso , Terapia de Ressincronização Cardíaca/métodos , Doença Crônica , Feminino , Seguimentos , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Análise de SobrevidaRESUMO
BACKGROUND: The skin of the scalp is relatively thick, minimally mobile, with distinct hair distribution. TopClosure® is a novel device for skin stretching and secure wound closure. OBJECTIVES: To evaluate the efficacy of the TopClosure® system in primary closure of moderate and large scalp defects, as a substitute for skin grafts, flaps, and tissue expanders. METHODS: We report a retrospective series of 8 patients requiring resection of 9 scalp tumors resulting with moderate to large size defects that otherwise would have required reconstruction with skin grafts, flaps, or tissue expanders. TopClosure® was applied for intraoperative cycles of stress-relaxation, followed, when indicated, by additional steps of mechanical creep and scar secure. RESULTS: Skin defects, averaging 3.5 cm, were managed by TopClosure®, enabling, primary closure in all wounds. Immediate wound edge approximation was reached through stress-relaxation in 2 wounds by heavy tension sutures within one hour. Further skin stretching by mechanical creep was required in 7 wounds, achieving staged primary closure in an outpatient setting. TopClosure® was further applied to secure the skin for up to 3 weeks following surgery. CONCLUSIONS: The TopClosure system, effectively, aided closure of moderate and large scalp defects by stress-relaxation and mechanical creep and serving as a topical tension-relief platform for tension sutures, allowing mobilization of skin and subcutaneous tissue without undermining or need of drainage, for early, direct wound closure. Local complications were minimal and donor site morbidity was eliminated. Surgical time, hospital stay and costs were reduced, and post-operative wound aesthetics were improved.
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Neoplasias Encefálicas/cirurgia , Procedimentos Cirúrgicos Dermatológicos/instrumentação , Procedimentos Cirúrgicos Dermatológicos/métodos , Complicações Pós-Operatórias/cirurgia , Dermatoses do Couro Cabeludo/cirurgia , Couro Cabeludo/cirurgia , Neoplasias Cutâneas/cirurgia , Adolescente , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Dermatoses do Couro Cabeludo/etiologia , Fenômenos Fisiológicos da Pele , Transplante de Pele , Tela Subcutânea/fisiologia , Retalhos Cirúrgicos , Suturas , Tinha do Couro Cabeludo/cirurgia , Dispositivos para Expansão de Tecidos , Resultado do Tratamento , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/cirurgiaRESUMO
Background: The assessment and identification of elderly patients with proximal femur fractures (PFF) who are at high risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to determine whether the neutrophil-to-lymphocyte ratio (NLR) could be used to predict postoperative mortality in the elderly population. Methods: A four-year retrospective cohort study of electronic medical records was conducted at a single tertiary care hospital between 2015 and 2018. Data from 1551 patients aged 65 years and older who underwent surgical treatment for PFF were collected and analyzed. The data included complete blood counts at admission, demographic information, underlying illnesses, type of surgery, and postoperative mortality and complications during the first year of follow-up. A survival analysis model was utilized. Results: The mean age was 90.76 ± 1.88 years, 1066 (68.7%) women. Forty-four (2.8%) patients experienced postoperative infection. A higher NLR0 was independently associated with higher all-cause mortality rates in patients who underwent surgical treatment for PFF (p = 0.041). Moreover, the mean NLR0 value was higher when the death occurred earlier after surgery (p < 0.001). Conclusions: When combined with other clinical and laboratory findings, NLR0 levels may serve as a potentially valuable, inexpensive, and reliable prognostic biomarker to improve risk stratification for elderly patients who are candidates for PFF surgery. Furthermore, with additional research, we could potentially develop a treatment algorithm to identify patients at high risk of postoperative mortality.
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BACKGROUND: Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections. OBJECTIVES: The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction. METHODS: The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy. RESULTS: A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA. CONCLUSIONS: CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).
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Desfibriladores Implantáveis , Marca-Passo Artificial , Infecções Relacionadas à Prótese , Humanos , Antibacterianos , Marca-Passo Artificial/efeitos adversos , Desfibriladores Implantáveis/efeitos adversos , Estudos de Casos e Controles , Remoção de Dispositivo , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Identifying elderly patients with proximal femoral fractures (PFF) who are at risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to examine whether red blood cell distribution width (RDW) can serve as a predictor of postoperative mortality in these patients. METHODS: A retrospective cohort study of electronic medical records at a single tertiary care hospital over a 3-year period between 2015 and 2018. We reviewed the records of 1574 patients aged > 65 years who underwent surgical treatment for PFF and who's preoperative RDW levels were available. Data collected consisted of patient demographics, underlying illnesses at the time of admission, type of procedure performed as well as postoperative mortality and complications over the course of a 1-year follow-up period. The cohort was then divided into two groups based on their RDW levels at the time of admission: low (<14.5%) and high (>14.5%). RESULTS: The mean age was 90.77±1.87 years; 68.7% were women. Majority of patients (69.1%) underwent closed reduction internal fixation; 414 (26.4%) underwent hemiarthroplasty, and 71 (4.5%) had total hip arthroplasty. At admission, 576 patients (36.6%) had high RDW levels and 998 (63.4%) had low RDW levels. There were no statistically significant differences between the groups with regard to age, gender, type of surgery, or duration. Patients with high RDW had more co-morbidities (p<0.001) and more abnormal laboratory test results when compared to patients with low RDW. Overall mortality rate within 1-year post-surgery was 17.5% (276 patients). All-cause mortality was greater for patients with high baseline RDW, at 3 months (p = 0.001), 6 months (p<0.0001), and 1-year post-surgery (p<0.0001). Forty-four (2.8%) patients had surgical site infection (SSI) without any significant association to baseline RDW levels. CONCLUSIONS: Preoperative RDW levels, when combined with clinical and laboratory findings, may help to improve the risk stratification of older patients who are candidates for PFF. With further research, a treatment algorithm could be developed to potentially identify patients at high risk of preoperative mortality, allowing for more conservative management.
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Artroplastia de Quadril , Fraturas do Fêmur , Fraturas do Quadril , Idoso , Idoso de 80 Anos ou mais , Índices de Eritrócitos , Feminino , Fraturas do Quadril/cirurgia , Humanos , Masculino , Prognóstico , Estudos RetrospectivosRESUMO
INTRODUCTION: Arterial calcification is an integral component of active atherosclerosis and is an independent risk factor for cardiovascular disease. Atherosclerosis is a systemic, life-threating disease that may occur at different sites and in various clinical presentations. Intracranial and valvular calcifications are common among dialysis patients and have been associated with poor cardiovascular outcomes. The aim of this study was to assess the clinical impact of valvular and intracranial arterial calcifications on mortality among chronic hemodialysis patients. METHODS: A blinded neuroradiologist graded intracranial calcifications (ICC) of all hemodialysis patients who underwent brain computerized tomography (CT) from 2015 to 2017 in our institution. Valvular calcifications were assessed by echocardiography. Only hemodialysis patients with available echocardiography and brain CT were included. FINDINGS: This study included 119 patients (mean age 70.6 ± 12.6 years, 57.1% men, and mean dialysis vintage 25.8 ± 42.6 months). Among the cohort, 19 (16%) had no cardiac or brain calcifications and 65 (54.6%) had both valvular and intracranial calcifications. Considering the patients with no calcification as the reference group yielded adjusted odds ratios for all-cause mortality of 3.68 (95%CI 1.55-8.75) among patients with any brain calcifications, p = 0.002. While valvular calcifications alone did not increase the 1-year mortality rate, ICC was the most important predictor of all-cause 1-year mortality in the study cohort. DISCUSSION: We found an independent association between ICC and the risk of death among hemodialysis patients. Assessing ICC may contribute to the risk stratification of hemodialysis patients. These calcifications are no less important than valvular calcifications.
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Aterosclerose , Calcinose , Doenças das Valvas Cardíacas , Idoso , Idoso de 80 Anos ou mais , Calcinose/diagnóstico por imagem , Calcinose/etiologia , Feminino , Doenças das Valvas Cardíacas/complicações , Valvas Cardíacas , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversosRESUMO
The CHA2DS2-VASc score incorporates several comorbidities which have prognostic implications in COVID-19. We assessed whether a modified score (M-R2CHA2DS2-VASc), which includes pre-admission kidney function and male sex, could be used to classify mortality risk among people hospitalized with COVID-19. This retrospective study included adults admitted for COVID-19 between March and December 2020. Pre-admission glomerular filtration rate (GFR) was calculated based on serum creatinine and used for scoring M-R2CHA2DS2-VASc. Participants were categorized according to the M-R2CHA2DS2-VASc categories as 0-1 (low), 2-3 (intermediate), or ≥ 4 (high), and according to initial COVID-19 severity score. The primary outcome was 30-day mortality rates. Secondary outcomes were mortality rates over time, and rates of mechanical ventilation, hemodynamic support, and renal replacement therapy. Eight hundred hospitalizations met the study criteria. Participants were 55% males, average age was 65.2 ± 17 years. There were similar proportions of subjects across the M-R2CHA2DS2-VASc categories. 30-day mortality was higher in those in higher M-R2CHA2DS2-VASc category and with severe or critical COVID-19 at admission. Subjects in the low, intermediate, and high M-R2CHA2DS2-VASc categories had 30-day mortality rates of 4.7%, 17% and 31%, respectively (p < 0.001). Higher category was also associated with increased need for mechanical ventilation and renal replacement therapy. All-cause 90-day mortality remained significantly associated with M-R2CHA2DS2-VASc. The M-R2CHA2DS2-VASc score is associated with 30-day mortality rates among patients hospitalized with COVID-19, and adds predictive value when combined with initial COVID-19 severity.
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Fibrilação Atrial , COVID-19 , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , COVID-19/complicações , Comorbidade , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
Brain atrophy (BA) is often found in neuroimaging of hemodialysis patients, representing parenchymal cerebral damage. Likely contributing factors to BA are age, chronic hypertension, diabetes mellitus and other cardiovascular risk factors of atherosclerosis that are also common among hemodialysis patients. BA may also occur due to focal ischemia and hypoperfusion during hemodialysis. However, data on optimal blood pressure (BP) in these patients are limited. The goal of this study was to determine whether the prevalence and severity of BA would be higher among hemodialysis patients with lower BP. A blinded neuroradiologist graded BA of all hemodialysis patients who underwent brain non-contrast computerized tomography (CT) from 2015 to 2017 in our institution. Age- and sex-matched patients with normal kidney function who underwent brain CT during the same period and technique served as the control group. A total of 280 patients were included in this retrospective study, with average BP of 140/70 mmHg among hemodialysis patients and 142/75 mmHg in the control group. BA was more common in dialysis patients and its severity increased with age and traditional cardiovascular risk factors. We observed a significant negative correlation between diastolic BP (DBP) at dialysis initiation and BA. Average DBP decreased with increasing severity of BA. These findings were observed in both hemodialysis and non-CKD patients. BA was associated with lower DBP, which may induce cerebral hypoperfusion and ischemia. This finding should discourage over-treatment of hypertension among hemodialysis patients.
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Pressão Sanguínea , Encefalopatias/etiologia , Encefalopatias/patologia , Encéfalo/patologia , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Idoso , Atrofia , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Masculino , Diálise Renal/métodos , Estudos RetrospectivosRESUMO
Chronic kidney disease is associated with an increased risk for cardiovascular and bleeding events. Data regarding the effectiveness and risks of aspirin therapy for primary prevention in the high-risk group of patients with chronic kidney disease are scant and controversial. This retrospective study included patients with chronic kidney disease. Participants were divided according to aspirin use. Outcomes included non-fatal cardiovascular events, major bleeding events and all-cause mortality. Among 10,303 patients, 2169 met the inclusion criteria and 1818 were included after 1:1 propensity-score matching. Our final cohort included patients with mean age of 73.4 ± 11.6 years, estimated glomerular filtration rate of 31.5 ± 10.5 ml/min/1.73m2 with follow up of 4.9 ± 1.5 years. There were no significant differences in all-cause mortality and bleeding events (odds ratio = 1.03, confidence interval [0.62, 1.84], p = .58 and odds ratio = 1.09, confidence interval [0.65, 1.72], p = .87 respectively). The incidence of cardiovascular events was higher in aspirin users versus non-users on univariate analysis (p < 0.01) and was comparable after controlling for possible risk-factors (OR = 1.05, CI [0.61, 3.14], p = .85). Chronic aspirin use for primary prevention of cardiovascular disease was not associated with lower mortality, cardiovascular events or increased bleeding among patients with chronic kidney disease. Those results were unexpected and should prompt further research in this field.
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Doenças Cardiovasculares , Insuficiência Renal Crônica , Humanos , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Aspirina/uso terapêutico , Estudos Retrospectivos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/induzido quimicamente , Hemorragia/induzido quimicamente , Hemorragia/complicações , Prevenção Primária/métodos , Inibidores da Agregação Plaquetária/efeitos adversosRESUMO
BACKGROUND: Calcium deposits on heart valves are considered a local manifestation of atherosclerosis and are associated with poor cardiovascular outcomes. The clinical significance of cardiac calcifications among heart failure (HF) patients, as assessed by echocardiography, is unknown. This study evaluated associations of cardiac calcifications with mortality and hospital admissions in this specific population. METHODS: Medical records of all patients who initiated ambulatory surveillance at our HF clinic during 2011-2018 were reviewed. Calcifications in the aortic valve, aortic root, or the mitral valve were evaluated. Patients with moderate to severe regurgitation or stenosis of the aortic or mitral valves were excluded. The primary endpoint was the composite of long-term all-cause mortality and HF hospitalizations. Secondary endpoints were long-term all-cause mortality and more than one hospitalization due to HF. RESULTS: This retrospective study included 814 patients (mean age 70.9 ± 13 years, 63.2% male). Of the total cohort, 350 (43%) had no cardiac calcifications and 464 (57%) had at least 1 calcified site. Considering the patients with no calcification as the reference group yielded a higher adjusted odds ratios for the composite endpoint, all-cause death, and recurrent HF hospitalizations, among patients with any cardiac calcification (OR = 1.68, 95%CI = 1.1-2.5, p = 0.01, OR=1.61, 95%CI = 1.1-2.3, p < 0.01, and OR = 1.50, 95%CI = 1.1-2.2, p < 0.01, respectively). CONCLUSIONS: We found an independent association between cardiac calcifications and the risk of death and HF hospitalizations among ambulatory HF patients. Cardiac calcifications evaluated during routine echocardiography may contribute to the risk stratification of patients with HF.
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Calcinose/mortalidade , Cardiomiopatias/mortalidade , Insuficiência Cardíaca/mortalidade , Idoso , Idoso de 80 Anos ou mais , Aorta/patologia , Valva Aórtica/patologia , Calcinose/complicações , Cardiomiopatias/complicações , Causas de Morte , Estudos de Coortes , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/patologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/patologia , Estudos RetrospectivosRESUMO
BACKGROUND: Chest-pain patients with no evidence of acute coronary syndrome might still be at risk for adverse outcomes. Adding renal function to the classic scoring of CHADS and CHA2DS2 VASC may improve risk stratification of chest-pain patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out. METHODS: We accessed medical records of patients admitted to internal medicine wards during 2010-2016 and discharged following ACS rule-out. A R2CHA2DS2-VASc score model that included higher scores as kidney function deteriorated was calculated and compared to CHADS and CHA2DS2 VASC scores. The primary endpoint was the composite of 30-day ACS and mortality. One-year ACS and 1-year mortality were the secondary endpoints. The study included 12,449 patients, stratified into three risk groups according to their R2CHA2DS2-VASc score. RESULTS: Participants were stratified into 3 groups according to R2CHA2DS2-VASc score. R2CHA2DS2-VASc score predicted better the composite outcome of ACS and 30-day and 1-year mortality after discharge (OR: 4, 95%, CI 2.3-7, p < 0.01 and OR: 13.3, 95% CI 7.8-22.7, p < 0.01, respectively). Receiver operating characteristic curve analysis showed better risk stratification of the R2CHA2DS2-VASc compared with both CHADS and CHA2DS2 VASC score. CONCLUSIONS: The R2CHA2DS2-VASc score is a better predictor of short- and long-term cardiovascular morbidity and mortality after hospital discharge.
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Síndrome Coronariana Aguda , Fibrilação Atrial , Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Humanos , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Hyponatremia is the most common electrolyte abnormality observed in clinical practice. Among patients with acute coronary syndrome (ACS), serum sodium levels are inversely associated with mortality risk. We assessed associations of serum sodium level with ACS and mortality in patients with chest pain. METHODS: This retrospective cohort study used clinical data from a large, academic hospital. All adults admitted with chest pain and without hypernatremia and discharged after ACS rule-out from January 2010 through June 2016 were included. The primary endpoint was the composite of 30-day ACS and mortality. Secondary endpoints were a hospital admission due to ACS and mortality in the first year following discharge. RESULTS: Included were 12 315 patients (mean age 58.2 ± 13 years, 60% male). Patients were classified according to the serum sodium (Na) level: hyponatremia, defined as less than 135 mEq/L (n = 289, 2.3%); 140 > Na ≥ 135 mEq/L (n = 8066, 65.5%), and 145 > Na ≥ 140 mEq/L (n = 3960, 32.2%). Patients with serum sodium more than 145 mEq/L were excluded. Among patients with hyponatremia, low-normal, and high-normal levels, rates of the composite outcome of unadjusted 30-day all-cause mortality and ACS admission were 4.5, 1.0, and 0.7%, respectively (P < 0.001). Unadjusted one-year ACS rates were 3.8, 1.5, and 1.4%, respectively (P < 0.01). CONCLUSION: Hyponatremia is associated with higher mortality and ACS risk among patients with chest pain who were discharged from internal medicine wards following ACS-rule-out. Sodium level may be included in the risk stratification of patients with chest pain.
Assuntos
Síndrome Coronariana Aguda/epidemiologia , Dor no Peito/epidemiologia , Hiponatremia/epidemiologia , Mortalidade , Centros Médicos Acadêmicos , Síndrome Coronariana Aguda/diagnóstico , Idoso , Dor no Peito/sangue , Estudos de Coortes , Feminino , Humanos , Hiponatremia/sangue , Medicina Interna , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Estudos Retrospectivos , Sódio/sangueRESUMO
AIMS: Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and 'torrential TR' based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown. METHODS AND RESULTS: In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P-value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79-3.01), P < 0.0001 per 0.1 cm2 increment] and adjusted [2.6 (1.25-5.0), P = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome (P < 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm2 [P < 0.0001, HR =2.0 (1.5-2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01-2.3); P = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. 'torrential' TR was 0.7 cm2 [P = 0.005, HR =2.6 (1.2-5.1)]. CONCLUSION: TR can be severe and even 'torrential' and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR >0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO > 0.4 cm2 and <0.7 cm2).
Assuntos
Insuficiência da Valva Tricúspide , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Curva ROC , Medição de Risco , Insuficiência da Valva Tricúspide/diagnóstico por imagemRESUMO
BACKGROUND: Currently, there are no clinical scores for risk stratification of low-risk patients with chest pain. We aimed to examine the association between mean platelet volume (MPV) and risk for adverse clinical outcomes in patients with chest pain discharged from internal medicine wards following acute coronary syndrome (ACS) rule-out. PATIENTS AND METHODS: Included were patients who were admitted to internal medicine wards and were discharged following an ACS-rule-out during 2010-2016. The primary endpoint was the composite of all-cause mortality and hospital admission due to ACS at 30-days following hospital discharge. RESULTS: Included in the study were12 440 patients who were divided into three groups according to MPV. The composite endpoint of 30-day all-cause mortality and hospital admission for ACS occurred more frequently among patients with high MPV. Each one-point increase in MPV was associated with an 18% increase in the risk for the composite endpoint (P = 0.02). Considering patients with MPV less than 7.8 fl as the reference group yielded adjusted hazard ratios for the composite endpoint that was significantly higher in patients in the high MPV tertile ( > 8.8 fl) (hazard ratio 1.6; 95% confidence interval = 1.1-2.5; P = 0.04). Each one-point increase in MPV was associated with an 11% increase in the risk for 1-year all-cause mortality (P = 0.01) and a 10% increase in the risk for 1-year ACS (P = 0.04). CONCLUSION: We found an independent association between high MPV and the risk of death and ACS among patients with chest pain who were discharged from internal medicine wards following an ACS-rule-out. MPV may be combined in the risk stratification of patients with chest pain.
Assuntos
Síndrome Coronariana Aguda/diagnóstico , Angina Pectoris/diagnóstico , Dor no Peito/diagnóstico , Unidades Hospitalares , Medicina Interna , Volume Plaquetário Médio , Alta do Paciente , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Adulto , Idoso , Angina Pectoris/sangue , Angina Pectoris/mortalidade , Causas de Morte , Dor no Peito/sangue , Dor no Peito/mortalidade , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Readmissão do Paciente , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
Background: Red blood cell distribution width (RDW) is a measure of the degree of heterogeneity of erythrocyte volume. Higher RDW levels are associated with increased mortality among patients with acute coronary syndrome (ACS), heart failure and other cardiovascular diseases. The association between RDW levels and clinical outcomes in patients admitted for further evaluation of chest pain is not known. Methods: A retrospective analysis of patients hospitalised with chest pain 2010-2016 was conducted. Patients diagnosed with ACS in the emergency department (ED) were excluded. Patients were divided into tertiles according to baseline ED RDW levels (≤13.1%, 13.1%
Assuntos
Dor no Peito/sangue , Hospitalização , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Dor no Peito/mortalidade , Dor no Peito/terapia , Índices de Eritrócitos , Feminino , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Curva ROC , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto JovemRESUMO
AIM: Regulated negative pressure-assisted wound therapy is a fundamental, nonpharmaceutical technology for acute and chronically infected wounds, yet bacterial clearance and biofilm buildup remain a challenge for healing. Regulated irrigation combined with negative pressure (RI-NPT) is emerging as an alternative therapeutic strategy for reducing bacterial load. Here, we analyzed RI-NPT hydrokinetics and efficacy of bacterial load reduction in wounds. MATERIALS & METHODS: Escherichia coli were loaded with gold nanoparticles, quantified by flame atomic absorption spectroscopy. Computed tomography (CT) imaging tracked bacterial distribution over time in a low-flow rat wound model. Bacterial load was quantified using a novel CT ruler. RESULT: Flame atomic absorption spectroscopy showed loading of 1.7 × 103 ± 0.2 gold nanoparticles/cell. CT tracking revealed that while regulated negative pressure-assisted wound therapy reduced bacterial load to a limited extent (5%), RI-NPT significantly increased bacterial outflow and clearance (by 45%). CONCLUSION: This nanotechnology-based approach demonstrates that RI-NPT is essential for reducing bacterial load and, thus, for promoting wound healing.
Assuntos
Ouro/química , Nanopartículas Metálicas/química , Tratamento de Ferimentos com Pressão Negativa/métodos , Irrigação Terapêutica/métodos , Infecção dos Ferimentos/terapia , Animais , Biofilmes , Rastreamento de Células , Terapia Combinada , Escherichia coli/fisiologia , Masculino , Nanopartículas Metálicas/uso terapêutico , Ratos , Tomografia Computadorizada por Raios X , Cicatrização , Infecção dos Ferimentos/microbiologiaRESUMO
BACKGROUND: Assessment of chest pain is one of the most common reasons for hospital admissions in internal medicine wards. However, little is known regarding predictors for poor prognosis in patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out. OBJECTIVE: To assess the association of kidney function with mortality and hospital admissions due to ACS in patients with chest pain who were discharged from internal medicine wards following ACS rule-out. METHODS: Included were patients admitted to an internal medicine ward who were subsequently discharged following an ACSrule-out during 2010-2016. The primary endpoint was the composite of all-cause mortality and hospital admission due to ACS at 30-days following hospital discharge. RESULTS: Included in the study were12,337 patients who were divided into 3 groups according to renal function. Considering patients with an eGFRâ¯≥â¯60â¯ml/min/1.73m2 as the reference group yielded adjusted hazard ratios for the composite of 30-day all-cause mortality and hospital admission for ACS that increased with reduced eGFR (HRâ¯=â¯2, 95%CIâ¯=â¯1.3-3.3, HRâ¯=â¯4.8, 95%CIâ¯=â¯3-7.6, for patients with eGFR of 45 to 59.9 or <45â¯ml/min/1.73m2, respectively, pâ¯<â¯0.001). Similarly, reduced renal function was associated with increased 1-year all-cause mortality (HRâ¯=â¯1.6, 95%CIâ¯=â¯1.2-2.2, HRâ¯=â¯4.5, 95%CIâ¯=â¯3.4-5.9, for patients with eGFR of 45-59.9 or <45â¯ml/min/1.73m2, respectively, pâ¯<â¯0.001). CONCLUSION: We found an independent graded association between lower eGFR and the risk of death and ACS among patients with chest pain who were discharged from internal medicine wards following an ACS rule-out. The eGFR may be combined in the risk stratification of patients with chest pain.