Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis.

BACKGROUND: Discontinuation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) surveillance after 5 years of no change remains controversial. Long-term outcomes of BD-IPMN without significant changes in the first 5 years were evaluated. METHODS: We performed a multi-center retrospective analysis of patients with BD-IPMN diagnosis from 2005 to 2011 (follow-up until 2017). Significant changes were defined as pancreatic cancer (PC), pancreatectomy, high-risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). RESULTS: Of 982 patients who had no significant changes, 5 (0.5%), 7 (0.7%), 99 (10.1%), 4 (0.4%) patients developed PC, HRS, WF, WEUS, respectively, post-5 years. PC and HRS/WF/WEUS incidences at 12 years were 1.0% and 29.0%, respectively. Patients that developed HRS/WF/WEUS had larger cyst size in first 5 years compared to those that did not [16 (12-23) vs. 12 (9-17) mm, p = 0.0001], cyst size of >15 mm having higher cumulative incidence of HRS/WF/WEUS. PC mortality was 0.8%; all-cause mortality was 32%. Incidence of mortality due to PC was higher in HRS/WF/WEUS group, p < 0.0001. The mortality rate at 12 years for ACCI (age-adjusted Charlson Comorbidity Index) of ≤3, 4-6, and ≥7 were 3.5%, 19.9%, and 57.6% (p < 0.0001), respectively. CONCLUSIONS: Incidence of PC in patients with BD-IPMN without significant changes in first 5 years of diagnosis remains low at 1.0%. Incidence of HRS/WF/WEUS was higher at 29.0%. PC-related mortality was higher in HRS/WF/WEUS group. These risks should be weighed against patients' overall mortality (utilizing scoring systems such as ACCI) when making surveillance decision of BD-IPMN beyond 5 years.

Prolonged Opioid Use After Primary Total Knee and Total Hip Arthroplasty: Prospective Evaluation of Risk Factors and Psychological Profile for Depression, Pain Catastrophizing, and Aberrant Drug-Related Behavior.

BACKGROUND: Forty percent of patients continue to use opioids at 3 months after joint arthroplasty. We sought to identify clinical and psychological risk factors associated with prolonged opioid use. METHODS: In this prospective study, psychological profile data were collected preoperatively. Prolonged use was defined as dispensation of an opioid after 90 days. Logistic regressions were used for univariate and multivariate modeling and to create receiver operating characteristic curves. A backward stepwise regression analysis was used to select significant factors in the multivariable model. RESULTS: The study included 258 patients (163 total knee arthroplasty, 95 total hip arthroplasty). 29.84% of patients were on preoperative opioids and 14% (37 of 258) of patients had prolonged use of opioids. In the univariate analysis, age <65, associated back pain, chronic pain syndrome or fibromyalgia, prior opioid use, drug potency of more than 10 morphine equivalent, and total score on Opioid Risk Tool of more than 7 were associated with prolong use. In the multivariate analysis, age <65, associated back pain, chronic pain, and preoperative use of opioids were significant risk factors for prolonged use (combined area under the curve = 0.83). Preoperative opioid use had the highest area under the curve = 0.72 (P = .0005). Psychological profile tests did not predict prolonged opioid use. CONCLUSION: Preoperative opioid use was the strongest predictor of postoperative prolonged opioid use. Younger age, associated backpain, and chronic pain syndrome were the other identified risk factors. Screening tools to detect aberrant drug-related behavior may be more helpful than those for depression or pain catastrophizing.

Postoperative Risk of Hepatic Decompensation after Orthopedic Surgery in Patients with Cirrhosis.

BACKGROUND AND AIMS: Previous studies have shown increased hepatic decompensation in patients with cirrhosis undergoing surgery. However, there are little data available in cirrhotics undergoing orthopedic surgery compared to cirrhotics who did not undergo surgery. The aim of this study was to examine the demographics, comorbid conditions, and clinical factors associated with hepatic decompensation within 90 days in cirrhotics who underwent orthopedic surgery. METHODS: This is a retrospective matched cohort study. Inclusion criteria were cirrhosis diagnosis, age > 18 years, ≥ 6 months continuous health plan membership, and a procedure code for orthopedic surgery. Up to five cirrhotic controls without orthopedic surgery were matched on age, gender, and cirrhosis diagnosis date. Data abstraction was performed for demographics, socioeconomics, clinical, and decompensation data. Chart review was performed for validation. Multivariable analysis estimated relative risk of decompensation. RESULTS: Eight hundred fifty-three orthopedic surgery cases in cirrhotics were matched with 4,263 cirrhotic controls. Among the cases and matched controls, the mean age was 60.5 years, and 52.2% were female. Within 90 days after surgery, cases had more decompensation compared to matched controls (12.8% vs 4.9%). Using multivariable analysis, orthopedic surgery, a 0.5 g/dL decrease in serum albumin, and a 1-unit increase in Charlson Comorbidity Index were associated with a significant increase in decompensation within 90 days of surgery. Diabetes, chronic obstructive pulmonary disease, and chronic kidney disease were seen with increased frequency in cases vs. matched controls. CONCLUSIONS: Cirrhotics who underwent orthopedic surgery had a significant increase in hepatic decompensation within 90 days of surgery compared to matched controls. An incremental decrease in serum albumin and an incremental increase in the Charlson Comorbidity Index were significantly associated with hepatic decompensation after surgery.

Blood pressure categories, hypertensive subtypes, and the metabolic syndrome.

BACKGROUND: Elevated blood pressure (BP) is one element of metabolic syndrome (MetS); however, the relation of various BP categories and hypertension subtypes to the likelihood of having MetS is not well defined. METHODS: We determined the odds of MetS, defined by the National Cholesterol Education Program, in various BP categories from a cross-sectional study of 5968 individuals aged at least 18 years and untreated for hypertension (weighted to 124.7 million) in the National Health and Nutrition Examination Survey, 1999-2002. Nonhypertensive BP categories were optimal, normal, and high-normal BP, according to JNC-VI classification. Hypertension consisted of three subtypes: isolated diastolic hypertension (IDH), systolic-diastolic hypertension (SDH), and isolated systolic hypertension (ISH). RESULTS: Among those with hypertension and MetS, 25.3% had IDH, 20.2% had SDH, and 54.5% had ISH. The MetS prevalence in nontreated persons was 5.8% for optimal BP, 9.1% for normal BP, 38.2% for high-normal BP, 45.9% for IDH, 44.3% for SDH, and 43.9% for ISH. Risk factor odds ratios (95% confidence intervals; reference group, optimal BP), adjusted for age, sex, total cholesterol, and smoking, were 1.6 (1.2-2.2) for normal BP, 9.4 (6.9-12.7) for high-normal BP, 14.7 (8.9-24.0) for IDH, 12.2 (7.2-20.8) for SDH, and 10.2 (7.0-14.9) for ISH (all P < 0.01); odds ratios were higher for women in all categories. CONCLUSIONS: Despite having the lowest mean age, IDH subtype is associated with greatest likelihood of MetS. The high frequency of ISH in the hypertensive population, however, makes ISH the most common hypertensive subtype in persons with MetS.

Impact of C-reactive protein on the likelihood of peripheral arterial disease in United States adults with the metabolic syndrome, diabetes mellitus, and preexisting cardiovascular disease.

We sought to determine, in United States (US) patients with the metabolic syndrome (MS), diabetes mellitus (DM), or preexisting cardiovascular disease, whether higher levels of C-reactive protein (CRP) would identify those with an increased likelihood of peripheral arterial disease (PAD). In a cross-sectional evaluation of the National Health and Nutrition Examination Survey (NHANES), 1999 to 2000, of 1,600 adults (representing a US population of 62.9 million) aged > or =40 years who had valid ankle-brachial index measurements available, subjects were categorized as having MS (without DM), DM, preexisting cardiovascular disease, or none of these conditions. The presence of PAD was defined as an ankle-brachial index <0.9. Subjects were also divided into groups according to CRP levels that were low (<1 mg/L), intermediate (1 to 3 mg/L), and elevated (>3.0 mg/L). Weighted multiple logistic regression analysis examined the odds of PAD by CRP group and disease category compared with the reference group of subjects who did not have MS, DM, or cardiovascular disease and had a CRP level of <1 mg/L. Those with MS (including DM) had an increased likelihood of PAD (odds ratio 4.8, 95% confidence interval 1.4 to 16.1, p = 0.01) as did those with MS without diabetes and an elevated CRP level (odds ratio 3.9, 95% confidence interval 1.1 to 14.6, p = 0.04); those with DM and an elevated CRP had the highest likelihood of PAD (odds ratio 8.6, 95% confidence interval 2.2 to 34.0, p = 0.001). In conclusion, the likelihood of PAD in US adults with MS and DM is enhanced by elevated CRP levels.

Prevalence and control of dyslipidemia among persons with diabetes in the United States.

OBJECTIVE: We assessed the prevalence, treatment, and control of dyslipidemia among United States (U.S.) adults with diabetes. METHODS: Among 498 adults (projected to 13.4 million) aged >or=18 years with diabetes representative of the U.S. population and surveyed within the cross-sectional National Health and Nutrition Examination Survey 1999-2000, control of lipids was classified according to American Diabetes Association criteria. The extent of low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), and triglyceride (TG) control was examined by gender and ethnicity, in comparison to those without diabetes, and according to lipid-lowering treatment. Analyses were weighted to the U.S. population. RESULTS: Less than one-third of men and only one-fifth of women with diabetes are in control for LDL-C, defined as <2.6 mmol/l (<100mg/dl); over 70% are not at goal. Over half of men and over two-thirds of women have low levels of HDL-C (or=1.7 mmol/l [150 mg/dl]). Low HDL-C was more common in Caucasians (70.1%) than in Hispanics (58.8%) or African-Americans (41.5%) (p<0.001). 28.2% of subjects with diabetes were on lipid-lowering treatment. Control of LDL-C did not differ by treatment status and only 3% of subjects were controlled to target levels for all lipids. CONCLUSION: Many persons with diabetes remain uncontrolled for dyslipidemia. Intensified efforts at screening and treatment according to current guidelines are warranted.

Predictors of new-onset diastolic and systolic hypertension: the Framingham Heart Study.

BACKGROUND: Factors leading differentially to the development of isolated diastolic (IDH), systolic-diastolic (SDH), and isolated systolic (ISH) hypertension are poorly understood. We examined the relations of blood pressure (BP) and clinical risk factors to the new onset of the 3 forms of hypertension. METHODS AND RESULTS: Participants in the Framingham Heart Study were included if they had undergone 2 biennial examinations between 1953 and 1957 and were free of antihypertensive therapy and cardiovascular disease. Compared with optimal BP (SBP <120 and DBP <80 mm Hg), the adjusted hazard ratios (HRs) for developing new-onset IDH over the ensuing 10 years were 2.75 for normal BP, 3.29 for high-normal BP (both P<0.0001), 1.31 (P=0.40) for SDH, and 0.61 (P=0.36) for ISH. The HRs of developing new-onset SDH were 3.32, 7.96, 7.10, and 23.12 for the normal BP, high-normal BP, ISH, and IDH groups, respectively (all P<0.0001). The HRs of developing ISH were 3.26 for normal and 4.82 for high-normal BP (both P<0.0001), 1.39 (P=0.24) for IDH, and 1.69 (P<0.01) for SDH. Increased body mass index (BMI) during follow-up predicted new-onset IDH and SDH. Other predictors of IDH were younger age, male sex, and BMI at baseline. Predictors of ISH included older age, female sex, and increased BMI during follow-up. CONCLUSIONS: Given the propensity for increased baseline BMI and weight gain to predict new-onset IDH and the high probability of IDH to transition to SDH, it is likely that IDH is not a benign condition. ISH arises more commonly from normal and high-normal BP than from "burned-out" diastolic hypertension.

Impact of the metabolic syndrome on mortality from coronary heart disease, cardiovascular disease, and all causes in United States adults.

BACKGROUND: Mortality resulting from coronary heart disease (CHD), cardiovascular disease (CVD), and all causes in persons with diabetes and pre-existing CVD is high; however, these risks compared with those with metabolic syndrome (MetS) are unclear. We examined the impact of MetS on CHD, CVD, and overall mortality among US adults. METHODS AND RESULTS: In a prospective cohort study, 6255 subjects 30 to 75 years of age (54% female) (representative of 64 million adults in the United States) from the Second National Health and Nutrition Examination Survey were followed for a mean+/-SD of 13.3+/-3.8 years. MetS was defined by modified National Cholesterol Education Program criteria. From sample-weighted multivariable Cox proportional-hazards regression, compared with those with neither MetS nor prior CVD, age-, gender-, and risk factor-adjusted hazard ratios (HRs) for CHD mortality were 2.02 (95% CI, 1.42 to 2.89) for those with MetS and 4.19 (95% CI, 3.04 to 5.79) for those with pre-existing CVD. For CVD mortality, HRs were 1.82 (95% CI, 1.40 to 2.37) and 3.14 (95% CI, 2.49 to 3.96), respectively; for overall mortality, HRs were 1.40 (95% CI, 1.19 to 1.66) and 1.87 (95% CI, 1.60 to 2.17), respectively. In persons with MetS but without diabetes, risks of CHD and CVD mortality remained elevated. Diabetes predicted all mortality end points. Those with even 1 to 2 MetS risk factors were at increased risk for mortality from CHD and CVD. Moreover, MetS more strongly predicts CHD, CVD, and total mortality than its individual components. CONCLUSIONS: CHD, CVD, and total mortality are significantly higher in US adults with than in those without MetS.

Preventing coronary events by optimal control of blood pressure and lipids in patients with the metabolic syndrome.

We estimated the coronary heart disease (CHD) events that are preventable by treatment of lipids and blood pressure in patients with metabolic syndrome (MetS), a contributor to coronary heart disease (CHD). Among patients aged 30 to 74 years (without diabetes or CHD) in the United States, MetS was defined by National Cholesterol Education Program criteria. CHD events over a period of 10 years were estimated by Framingham algorithms. Events that could be prevented by statistically "controlling" blood pressure, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol to either normal or optimal levels according to national guidelines were calculated. Of 7.5 million men and 9.0 million women aged 30 to 74 years with MetS, approximately 1.5 million men and 0.45 million women, if untreated, developed CHD events in 10 years. In men and women, blood pressure control to normal levels "prevented" 28.1% and 12.5% of CHD events, respectively (p <0.01); control to optimal levels resulted in preventing 28.2% and 45.2% of events, respectively (p <0.01). Control of HDL cholesterol to normal levels resulted in preventing 25.3% of events in men and 27.3% in women; optimal control prevented 51.2% and 50.6% of events, respectively. Control of LDL cholesterol to normal levels prevented 9.3% of events in men and 9.8% of events in women; control to optimal levels prevented 46.2% and 38.1% of events (p <0.05), respectively. Control of all 3 risk factors to normal levels resulted in preventing 51.3% of events for men and 42.6% for women; control to optimal levels resulted in preventing 80.5% and 82.1% of events, respectively. Thus, many CHD events in patients with MetS may be preventable by nominal or optimal control of lipids and/or blood pressure.