Which laboratory malnutrition markers best predict 1-year mortality in hospitalized older adults?

PURPOSE: To study which laboratory malnutrition markers best predict 1-year mortality in the general population of hospitalized older adults as well as among patients at risk for malnutrition. METHODS: A historical prospective study. All older adults (age ≥ 65 years) hospitalized in one geriatric department during 9 months were included. Malnutrition Universal Screening Tool (MUST) was used to determine malnutrition risk. Laboratory malnutrition markers included albumin serum levels, transferrin serum levels, total cholesterol serum levels, vitamin D serum levels, and lymphocyte count. A receiver operating characteristic (ROC) curve analysis was used to study which markers best predict 1-year mortality. RESULTS: Overall, 437 patients (63.2% women; mean age 84.7 years) were included. Overall, 126 (28.8%) patients died in the year following admission. ROC curve analysis showed that low albumin serum levels best predict 1-year mortality (AUC 0.721, p < 0.001), followed by low transferrin serum levels (AUC 0.661, p < 0.001) and low lymphocyte count (AUC 0.575, p = 0.016). Among 178 (40.7%) patients at risk for malnutrition, 63 (35.4%) patients died in the year following admission. ROC curve analysis showed that albumin serum levels best predict 1-year mortality in patients at risk for malnutrition (AUC 0.720, p < 0.001), followed by transferrin serum levels (AUC 0.659, p = 0.001). Regression analysis showed that low albumin serum levels were also independently associated with 1-year mortality among the whole cohort and among patients at risk for malnutrition (OR 0.2, 95% CI 0.1-0.4, p < 0.001, for both). CONCLUSIONS: Low albumin serum levels best predict 1-year mortality in hospitalized older adults, followed by low transferrin serum levels.

Anemia and inflammation have an additive value in risk stratification of patients undergoing coronary interventions.

AIMS: Anemia and inflammation are both associated with unfavorable outcomes in patients with ischemic heart disease and might be pathophysiologically linked. We aimed to analyze the additive value of anemia and inflammation on the outcomes of patients undergoing percutaneous coronary intervention. METHODS: Cox regression models were fitted for hemoglobin and C-reactive protein (CRP) cut-offs and performed separately for myocardial infarction (MI) and angina pectoris patients undergoing catheterization at a tertiary hospital between 2006 and 2011. Major adverse cardiovascular events (MACEs) were defined as all-cause mortality, MI and stroke. RESULTS: Included were 1976 patients (825 with angina pectoris and 1151 with MI). The median follow-up in the MI and the angina pectoris groups was 14 and 13 months, respectively (maximal follow-up of 4 years). In the MI group, the risk of MACE during follow-up was increased with the presence of either anemia (hazard ratio 2.1, P = 0.07) or of elevated CRP (hazard ratio 1.9, P = 0.04), whereas the presence of both increased the risk even further (hazard ratio 3.4, P < 0.01). In the angina pectoris group, the risk of MACE was increased only in patients who had both anemia and elevated CRP (hazard ratio 2.9, P < 0.01). CONCLUSION: Inflammation and anemia are independently and additively associated with MACE in MI patients.

Prevalence and predictors of slow flow in angiographically normal coronary arteries.

BACKGROUND: One out of 5 patients undergoing coronary angiography has angiographically normal coronary arteries (ANCA). Some of them have abnormally slow coronary flow (SCF). The prevalence and causes of SCF in these patients are not clear. METHODS: We studied 114 consecutive patients with ANCA. Each angiogram was independently evaluated by 2 physicians unaware of all other clinical features of the case. Coronary flow (CF) was graded using the corrected TIMI Frame Count (cTFC) and Coronary Clearance Frame Count (CCFC) methodologies. SCF was defined as a cTFC exceeding the reported normal (mean cTFC + 2 SD) in each of the three major coronary arteries. The association between SCF and various clinical, inflammatory, and metabolic variables was tested using a multivariable analysis model. RESULTS: Thirty-nine (34%) patients had SCF. Inter-individual CF varied substantially among them (range 10-143 frames/sec, mean: 37 ± 22 frames/sec). The intra-individual CF did not vary: CF correlated well in the three major epicardial coronary arteries of a given individual (r = 0.7, p = 0.0001). Multivariable analysis revealed that current smoking was the most significant variable related to SCF (odds ratio = 4.7, p = 0.006, CI 95% 1.6-13.3). The SCF group included significantly more smokers (41% versus 15%, p = 0.002). CONCLUSIONS: SCF is a common finding (34%) among patients with angiographically normal coronary arteries. In these patients, slow flow is a systemic phenomenon that involves all three coronary arteries rather than a local event and is associated with current smoking.

Depressive symptoms and erectile dysfunction in men with coronary artery disease.

OBJECTIVES: To study the association between erectile dysfunction (ED) and depressive symptoms in men with coronary artery disease (CAD). A cross-sectional analysis of data obtained during a prospective study was carried out. METHODS: A cohort of men undergoing coronary angiography filled-out the sexual health inventory for males (SHIM) and the mental health inventory 5 (MHI5) questionnaires for detection and severity assessment of both ED and depressive symptoms. CAD documented by coronary angiography was defined as > or = 50% stenosis in at least one of the major epicardial coronary arteries. RESULTS: Overall, 242 men, with a mean age of 63.7 +/- 12.0 years, were included in the study. ED and depressive symptoms were found in 76% and 47.9% of men, respectively, whereas 94 (38.8%) men suffered from both. The prevalence of diabetes mellitus and the mean age were significantly higher, whereas the mean MHI5 scores were significantly lower, in the group with ED than that without. ED was associated independently with age (P <.0001) and depressive symptoms (P = .007), but not with the number of obstructed coronary arteries, history of diabetes mellitus, hypertension, or smoking. After controlling for age and diabetes mellitus, the scores of SHIM were positively correlated with MHI5 scores (r = .14; P = .03). CONCLUSIONS: These results validate the high prevalence of both ED and depressive symptoms in men with CAD. ED in men with CAD might be associated with age and depressive symptoms.

C-reactive protein to distinguish pneumonia from acute decompensated heart failure.

BACKGROUND: Patients with acute decompensated heart failure (ADHF) are frequently treated with unnecessary antibiotics since they are confused with pneumonia patients. AIM: To study the efficacy of measuring C-reactive protein (CRP) levels on admission and CRP velocity in differentiating ADHF from pneumonia. METHODS: A retrospective observational study of ADHF and pneumonia patients admitted to a tertiary hospital during 2 years. Patients who were already treated with antibiotics on admission were excluded. Efficacy of CRP as a diagnostic marker was evaluated by using receiver operator curves (ROC). RESULTS: Overall, 72 ADHF and 50 pneumonia patients were included in the study. The mean CRP levels on admission were 13.5+/-13.5 mg/L for the ADHF patients and 127+/-84 mg/L for the pneumonia patients (p<0.001). CRP increases of > or =0.56 mg/L/h were diagnostic of pneumonia. CRP levels on admission together with CRP increases had a sensitivity of 0.96 and a specificity of 0.972 (p<0.001) as markers to distinguish pneumonia from ADHF. CONCLUSIONS: This study emphasizes the dynamic nature of biomarkers. Demonstrating the efficiency of repeated CRP measurements in an acute setting will provide clinicians with a valuable tool for establishing the correct diagnosis and refraining from unnecessary use of antibiotics.

C-reactive protein velocity following antibiotics in patients with chronic obstructive pulmonary disease exacerbation and community acquired pneumonia.

INTRODUCTION: Distinguishing community acquired pneumonia (CAP) from chronic obstructive pulmonary disease (COPD) exacerbation is a challenging task, since fever, productive cough, dyspnea, and leukocytosis are all common features of both conditions. Moreover, chest X-ray might not be sensitive enough. It is therefore quite common for physicians to prescribe unnecessary antibiotics for COPD exacerbation, leading to resistant bacteria and other related adverse affects. AIM: To study whether CRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment, could provide an efficient tool for distinguishing CAP from COPD exacerbation. METHODS: The study group included 36 COPD exacerbation and 49 CAP patients, admitted to a single Internal Medicine department during the years 2004-2006. All patients were treated with cephalosporins and macrolides upon admission. RESULTS: CRP levels upon admission were significantly higher among CAP patients than among COPD exacerbation patients (111.5+/-104.4 vs. 34.9+/-28.6 mg/l, p<0.0001). CRP levels on the second day of hospitalization, following antibiotic administration to all patients, made a sharp incline in 36.7% of CAP patients compared to only 5.9% of COPD exacerbation patients (p=0.005), and remained unchanged in 61.8% of COPD patients compared to 16.3% of CAP patients (p=0.0006). CONCLUSIONS: CRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment could provide an efficient tool for distinguishing CAP from COPD exacerbation.

Takotsubo cardiomyopathy and QT interval prolongation: who are the patients at risk for torsades de pointes?

OBJECTIVES: QT interval prolongation is prevalent among patients with Takotsubo cardiomyopathy (TC), whereas torsades de pointes (TdP) has rarely been reported in these patients. We studied all peer-reviewed reports on TC-associated QT interval prolongation and all peer-reviewed reports on TC-associated TdP to characterize the clinical circumstances leading to TdP in patients with TC. METHODS: The literature search yielded 14 reports on TC-associated TdP and 26 reports on TC-associated QT interval prolongation. Overall, 15 patients with TC-associated TdP and 86 patients with TC-associated QT interval prolongation were reported. We systematically reviewed each report and recorded the risk factors for TdP as well as the clinical circumstances of TC. RESULTS: The prevalence of the male sex was higher among patients with TC-associated TdP relative to patients with TC-associated QT interval prolongation (26.7% vs 5.8%; P = .01). There was a trend in the mean maximal corrected QT interval being longer among patients with TC-associated TdP relative to patients with TC-associated QT interval prolongation (679.9 +/- 230.6 vs 555.9 +/- 63.8 milliseconds; P = .06). There were no differences between patients with TC-associated TdP and patients with TC-associated QT interval prolongation in mean age, maximal troponin levels, and lowest ejection fraction. Overall, 12 (80.0%) patients with TC-associated TdP had risk factors for TdP other than the female sex and systolic dysfunction, including suspicion of congenital long QT syndrome, bradycardia, hypokalemia, recent conversion from atrial fibrillation to sinus rhythm, and using QT prolonging agents. CONCLUSIONS: Men with TC-associated QT interval prolongation are at risk for TdP. Most patients with TC-associated TdP have risk factors for TdP other than the female sex and systolic dysfunction.

Cytomegalovirus-associated splenic infarcts in a female patient with Factor V Leiden mutation: a case report.

INTRODUCTION: Cytomegalovirus-associated thrombosis has rarely been reported in the medical literature, and if so, mainly in immunocompromized patients. CASE PRESENTATION: We report the case of a 36-year-old Caucasian woman with acute cytomegalovirus infection presenting with spontaneous splenic infarcts. Trans-esophageal echocardiography did not show any vegetations or mural thrombi. The patient was also found to be heterozygous for the Factor V Leiden mutation. Anticoagulation treatment was considered but ruled out since cytomegalovirus was the obvious trigger for thrombosis in this patient. To the best of our knowledge, this is only the third report to date of cytomegalovirus-associated splenic infarcts. CONCLUSION: This case report serves as additional evidence for the role of cytomegalovirus in thrombosis.

Screening for erectile dysfunction and associated cardiovascular risk factors in Israeli men.

BACKGROUND: Erectile dysfunction is associated with treatable cardiovascular risk factors; therefore, screening for erectile dysfunction and its cardiovascular risk factors is of clinical importance. OBJECTIVES: To detect erectile dysfunction cases and assess their severity among military personnel. METHODS: The Sexual Health Inventory for Men questionnaire was handed out to military personnel aged 25-55 years during routine examinations. RESULTS: A total of 19,131 men with a mean age of 34.0 +/- 7.1 years participated in routine physical examinations during the years 2001-2005. More than half of them (n=9956, 52%) completed the SHIM questionnaire. No significant differences were found between those who completed the SHIM questionnaire and those who did not, in terms of mean age, mean body mass index, and prevalence of cardiovascular risk factors. One out of every four men (25.2%) suffered from erectile dysfunction, which was mild in 18.9%, mild to moderate in 4.4%, moderate in 1.1%, and severe in 0.7%. Even though treatable cardiovascular risk factors were quite prevalent in the study group (45.2% of them suffered from dyslipidemia, 25.6% smoked, 4.2% suffered from essential hypertension, and 1.6% from diabetes mellitus), erectile dysfunction was significantly associated with age and diabetes mellitus alone (P<0.0001). CONCLUSIONS: There is a high prevalence of erectile dysfunction and associated treatable cardiovascular risk factors in Israeli men aged 25-55, especially those with diabetes.

Drug-induced torsades de pointes in patients aged 80 years or more.

OBJECTIVE: We studied all English-written peer-reviewed reports on drug-induced torsades de pointes (TdP) in patients aged 80 years or more in order to characterize the clinical circumstances leading to this serious complication. METHODS: Our literature search yielded 24 reports on 25 patients aged 80-95 years with drug-induced TdP. We systematically reviewed each report and recorded the non-modifiable risk factors for drug-induced TdP (i.e., female sex and structural heart disease) as well as preventable clinical circumstances, which might have been associated with drug-induced TdP. RESULTS: The most prevalent risk factors for drug-induced TdP were non-modifiable risk factors: 22 (88%) patients were female patients and 19 (76%) patients had structural heart disease. Overall, 16 (64%) patients were female patients with structural heart disease. The literature did not report any elderly male patients without structural heart disease. Among the preventable clinical circumstances, which might have been associated with drug-induced TdP, the most prevalent were: administrating QT prolonging agents despite long QT interval (n=11; 44%) and co-administration of two or more QT prolonging agents (n=9; 36%). The most prevalent QT prolonging agents found to trigger TdP were macrolides and quinolones (n=9; 36%). All but three patients had at least one or more preventable clinical circumstances, which might have been associated with drug-induced TdP. CONCLUSION: Physicians should be more aware of the risk for drug-induced TdP in patients aged 80 years or more while administrating QT prolonging agents despite long QT interval and co- administrating two or more QT prolonging agents, specifically in elderly female patients with structural heart disease.