Gadoxetic acid-enhanced MRI-derived functional liver imaging score (FLIS) and spleen diameter predict outcomes in ACLD.

BACKGROUND & AIMS: Functional liver imaging score (FLIS) - derived from gadoxetic acid-enhanced MRI - correlates with liver function and independently predicts liver-related mortality in patients with chronic liver disease (CLD), while splenic craniocaudal diameter (SCCD) is a marker of portal hypertension. The aim of this study was to investigate the accuracy of a combination of FLIS and SCCD for predicting hepatic decompensation, acute-on-chronic liver failure (ACLF), and mortality in patients with advanced CLD (ACLD). METHODS: We included 397 patients with CLD who underwent gadoxetic acid-enhanced liver MRI. The FLIS was calculated by summing the points (0-2) of 3 hepatobiliary-phase features: hepatic enhancement, biliary excretion, and portal vein signal intensity. Patients were stratified into 3 groups according to liver fibrosis severity and presence/history of hepatic decompensation: non-ACLD, compensated ACLD (cACLD), and decompensated ACLD (dACLD). RESULTS: SCCD showed excellent intra- and inter-reader agreement. Importantly, SCCD was an independent risk factor for hepatic decompensation in patients with cACLD (per cm; adjusted hazard ratio [aHR] 1.13; 95% CI 1.04-1.23; p = 0.004). Patients with cACLD and a FLIS of 0-3 points and/or a SCCD of >13 cm were at increased risk of hepatic decompensation (aHR 3.07; 95% CI 1.43-6.59; p = 0.004). In patients with dACLD, a FLIS of 0-3 was independently associated with an increased risk of ACLF (aHR 2.81; 95% CI 1.16-6.84; p = 0.02), even after adjusting for other prognostic factors. Finally, a FLIS and SCCD-based algorithm was independently predictive of transplant-free mortality and stratified the probability of transplant-free survival (TFS) in ACLD (p <0.001): FLIS 4-6 and SCCD ≤13 cm (5-year TFS of 84%) vs. FLIS 4-6 and SCCD >13 cm (5-year TFS of 70%) vs. FLIS 0-3 (5-year TFS of 24%). CONCLUSION: The FLIS and SCCD are simple imaging markers that provide complementary information for risk stratification in patients with compensated and decompensated ACLD. LAY SUMMARY: Magnetic resonance imaging (MRI) can be used to assess the state of the liver. Previously the functional liver imaging score, which is based on MRI criteria, was developed as a measure of liver function and to predict the risk of liver-related complications or death. By combining this score with a measurement of spleen diameter, also using MRI, we generated an algorithm that could predict the risk of adverse liver-related outcomes in patients with advanced chronic liver disease.

Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain.

OBJECTIVE: Early diagnosis or rule-out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE-ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high-sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule-out and prolonged observation with repeated hsTnt testing at a high-volume tertiary care emergency department. PATIENTS AND METHODS: We conducted a pre- and post-changeover analysis 3 months before and 3 months after transition from less (hsTnt cut-off 30 ng/L, 3-hour rule-out) to more conservative (hsTnt cut-off 14 ng/L, 1-hour rule-out) guidelines in 2015, comparing proportions of patients requiring repeated testing. RESULTS: We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early-rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision. CONCLUSION: The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.

Pacemaker lead-associated tricuspid regurgitation in patients with or without pre-existing right ventricular dilatation.

BACKGROUND: Transcatheter tricuspid valve intervention became an option for pacemaker lead-associated tricuspid regurgitation. This study investigated the progression of tricuspid regurgitation (TR) in patients with or without pre-existing right ventricular dilatation (RVD) undergoing pacemaker implantation. METHODS: Patients were included if they had implantation of transtricuspid pacemaker lead and completed echocardiography before and after implantation. The cohort was divided in patients with and without RVD (cut-off basal RV diameter ≥ 42 mm). TR was graded in none/mild, moderate, and severe. Worsening of one grade was defined as progression. Survival analyses were plotted for 10 years. RESULTS: In total, 990 patients were analyzed (24.5% with RVD). Progression of TR occurred in 46.1% of patients with RVD and in 25.6% of patients without RVD (P < 0.001). Predictors for TR progression were RV dilatation (OR 2.04; 95% CI 1.27-3.29; P = 0.003), pre-existing TR (OR 4.30; 95% CI 2.51-7.38; P < 0.001), female sex (OR 1.68; 95% CI 1.16-2.43; P = 0.006), single RV lead (OR 1.67; 95% CI 1.09-2.56; P = 0.018), mitral regurgitation (OR 2.08; 95% CI 1.42-3.05; P < 0.001), and enlarged left atrium (OR 1.98; 95% CI 1.07-3.67; P = 0.03). Survival-predictors were pacemaker lead-associated TR (HR 1.38; 95% CI 1.04-1.84; P = 0.028), mitral regurgitation (HR 1.34; 95% CI 1.02-1.77; P = 0.034), heart failure (HR 1.75; 95% CI 1.31-2.33; P < 0.001), kidney disease (HR 1.62; 95% CI 1.25-2.11; P < 0.001), and age ≥ 80 years (HR 2.84; 95% CI 2.17-3.71; P < 0.001). CONCLUSIONS: Patients with RVD receiving pacemaker suffered from increased TR progression, leading to decreased survival.

Soluble urokinase-type plasminogen activator receptor predicts peripheral artery disease severity and outcomes.

Soluble urokinase-type plasminogen activator receptor (suPAR) is associated with chronic kidney disease (CKD) severity and peripheral artery disease (PAD). We hypothesize an association of PAD severity and suPAR in patients without advanced CKD and further risk stratification according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. For study purposes, suPAR was measured in 334 PAD patients (34% women, age 69 (62-78) years, eGFR 68 ± 20 mL/min/1.72 m2) by commercial ELISA. Patients were followed for 10 years to assess long-term all-cause survival by Cox regression. Higher suPAR levels were associated with lower ankle-brachial index (R = -0.215, p = 0.001) in patients with PAD without media-sclerosis (n = 236). suPAR levels inversely correlated with decreased glomerular filtration rate (R = -0.476, p < 0.001) and directly correlated with urinary albumin-to-creatinine ratio (R = 0.207, p < 0.001). Furthermore, higher suPAR levels associated with a higher KDIGO risk score (p < 0.001). Baseline suPAR was significantly associated with all-cause mortality (HR 1.40 (95% CI 1.16-1.68), p < 0.001) over 10 years. suPAR remained associated with mortality (HR 1.29 (1.03-1.61), p = 0.026) after multivariable adjustment for age, sex, cardiovascular risk factors, and eGFR. Future research may define a standard role for suPAR assessment in PAD's work-up and treatment, especially in patients with CKD.

Sex Differences and Long-Term Outcome in Patients With Pacemakers.

Introduction: Evidence of sex-related differences in patients with pacemakers regarding comorbidities is insufficiently investigated. The aim of this study was to determine the relationship of cardiovascular comorbidities and sex category with properties of pacemaker implantation, pacemaker follow-up, and long-term survival. Methods: This retrospective, single-center cohort study consisted of 6,362 pacemaker-patients (39.7% female) enrolled between May 2000 and April 2015. Functional pacemaker parameters were registered at regular pacemaker controls. Survival status and cause of death were analyzed in relation to comorbidities, implanted pacing devices, and echocardiography. Survival analyses were plotted for a 10-year follow-up. Results: Patients with hypertension or hyperlipidemia had higher rates of implantations due to sick sinus syndrome (28.6 vs. 25.5% without hypertension, P < 0.001; 30.7 vs. 25.7% without hyperlipidemia, P < 0.001), while endocarditis was associated with higher rates of implantations due to AV block (46.7 vs. 33.4%, P < 0.001). Patients with valvular heart disease had higher rates of pacemaker implantation due to bradycardic atrial fibrillation (24.9 vs. 21.0% without valvular heart disease, P < 0.001). Ventricular pacing threshold increased in both sexes during the follow-up and was higher in women in the final follow-up (0.94 vs. 0.91 V in men, P = 0.002). During the 10-years follow-up, 6.1% of women and 8.6% of men underwent lead replacement (P = 0.054). Device and lead replacement rates were increased if the comorbidities coronary artery disease, heart failure, hypertension, hyperlipidemia, valvular heart disease, previous stroke/TIA, atrial arrhythmias, chronic kidney disease, or endocarditis were present. Diabetes and previous CABG increase the rates of device replacement, but not the rate of lead replacement. Severe tricuspid regurgitation after implantation of pacemaker was present in more men than women (14.4 vs. 6.1%, P < 0.001). In a multivariate COX regression, the following variables were associated with independent decrease of 10-year survival: hypertension (HR 1.34, 95% CI 1.09-1.64), chronic kidney disease (HR 1.83, 95% CI 1.53-2.19), tricuspid regurgitation after pacemaker implantation (HR 1.48, 95% CI 1.26-1.74). Survival was independently increased in female sex (HR 0.83, 95% CI 0.70-0.99) and hyperlipidemia (HR 0.81, 95% CI 0.67-0.97). Conclusions: Cardiovascular comorbidities influenced significantly pacemaker implantations and long-term outcome. Trial Registration: ClinicalTrials.gov Unique identifier: NCT03388281.

Psychopharmacological Medication Has No Influence on Vitamin Status After Bariatric Surgery in Long-term Follow-up.

CONTEXT: A substantial number of patients undergoing bariatric surgery are prescribed psychopharmacological medication. However, the impact of concomitant psychopharmacological medication on the frequency of relevant vitamin deficiencies in postoperative follow-up is not known. METHODS: Five hundred twenty-four patients with obesity who underwent bariatric surgery (January 2004 to September 2018) with follow-up of at least 12 months, were included in retrospective analysis. Postoperative follow-up visits between January 2015 and September 2019 were analyzed. Anthropometric and laboratory data were analyzed at the first documented follow-up visit after on average 39.5 ± 37.3 months and at every following visit during the observation period. Patients with prescribed psychopharmacological drugs (PD) were compared with patients without (control group, CON). RESULTS: Psychopharmacological medication was documented in 25% (132) of patients. In 59 patients documented prescription of more than one psychiatric drug was found, whereas psychopharmacological monotherapy was found in 73 patients. Frequencies of vitamin deficiencies were comparable between PD and CON (vitamin A: p = 0.852; vitamin D: p = 0.622; vitamin E: p = 0.901; folic acid: p = 0.941). Prevalence of vitamin B12 deficiency was rare (6% CON, 1% PD) but was significantly higher in CON (p = 0.023). A comparison of CON and POLY also showed no significant differences between the groups concerning prevalence of vitamin deficiencies. CONCLUSIONS: Intake of psychopharmacological medication is highly prevalent in patients after bariatric surgery. Patients with psychopharmacological medication, who participate in structured follow-up care after bariatric surgery, are not at higher risk for vitamin deficiencies compared with controls.

Peripheral arterial disease and type 2 diabetes: Older patients still exhibit a survival benefit from glucose control.

OBJECTIVE: To investigate a possible beneficial effect of strict glycaemic control on all-cause mortality in patients with peripheral arterial disease and type 2 diabetes mellitus. METHODS: A total of 367 mainly older peripheral arterial disease patients [age: 69 (62-78) years, 34% women, Fontaine stage I-II] were categorized according to glycaemic control, that is, (a) no type 2 diabetes mellitus, (b) strict glucose control (HbA1c < 53 mmol/mol) and (c) lenient glucose control (HbA1c ⩾ 53 mmol/mol) at inclusion and by mean HbA1c over the first study year. Mortality was analysed using Kaplan-Meier and Cox-regression analyses after 7 years. RESULTS: The combination of type 2 diabetes mellitus and peripheral arterial disease reduced survival from 78.8% to 68.9% in comparison to patients without type 2 diabetes mellitus (p = 0.023). Patients with strict glucose control (75%) were associated with increased survival in comparison to patients with lenient glucose control (58.9%) stratified by mean HbA1c (p = 0.042). Baseline cardiovascular risk factors were similar in those type 2 diabetes mellitus patients. In this peripheral arterial disease cohort HbA1c (hazard ratio: 1.3, 1.04-1.63), age (hazard ratio: 1.7, 1.3-2.3) and C-reactive protein (hazard ratio: 1.5, 1.2-2.0) remained independent associates for mortality adjusted for cardiovascular risk factors and diabetes duration. CONCLUSION: Older patients with peripheral arterial disease and type 2 diabetes mellitus still benefit from strict glucose control in a cohort of patients with similar distribution of cardiovascular risk factors.

Empagliflozin in posttransplantation diabetes mellitus: A prospective, interventional pilot study on glucose metabolism, fluid volume, and patient safety.

The safety and efficacy of sodium-glucose cotransporter 2 inhibitors in posttransplantation diabetes mellitus is unknown. We converted stable kidney transplant patients to 10 mg empagliflozin, aiming at replacing their insulin therapy (<40 IU/d). N = 14 participants (the required sample size) completed the study visits through 4 weeks and N = 8 through 12 months. Oral glucose tolerance test (OGTT)-derived 2-hour glucose (primary end point) increased from 232 ± 82 mg/dL (baseline) to 273 ± 116 mg/dL (4 weeks, P = .06) and to 251 ± 71 mg/dL (12 months, P = .41). Self-monitored blood glucose and hemoglobin A1c were also clinically inferior with empagliflozin monotherapy, such that insulin was reinstituted in 3 of 8 remaining participants. Five participants (2 of them dropouts) vs nine of 24 matched reference patients developed bacterial urinary tract infections (P = .81). In empagliflozin-treated participants, oral glucose insulin sensitivity decreased and beta-cell glucose sensitivity increased at the 4-week and 12-month OGTTs. Estimated glomerular filtration rate and bioimpedance spectroscopy-derived extracellular and total body fluid volumes decreased by 4 weeks, but recovered. All participants lost body weight. No participant developed ketoacidosis; 1 patient developed balanitis. In conclusion, although limited by sample size and therefore preliminary, these results suggest that empagliflozin can safely be used as add-on therapy, if posttransplant diabetes patients are monitored closely (NCT03113110).

Automated tube voltage selection in pediatric non-contrast chest CT.

BACKGROUND: Modern CT scanners provide automatic dose adjustment systems, which are promising options for reducing radiation dose in pediatric CT scans. Their impact on patient dose, however, has not been investigated sufficiently thus far. OBJECTIVE: To evaluate automated tube voltage selection (ATVS) in combination with automated tube current modulation (ATCM) in non-contrast pediatric chest CT, with regard to the diagnostic image quality. MATERIALS AND METHODS: There were 160 non-contrast pediatric chest CT scans (8.7±5.4 years) analyzed retrospectively without and with ATVS. Correlations of volume CT Dose Index (CTDIvol) and effective diameter, with and without ATVS, were compared using Fisher's z-transformation. Image quality was assessed by mean signal-difference-to-noise ratios (SDNR) in the aorta and in the left main bronchus using the independent samples t-test. Two pediatric radiologists and a general radiologist rated overall subjective Image quality. Readers' agreement was assessed using weighted kappa coefficients. A p value <0.05 was considered significant. RESULTS: CTDIvol correlation with the effective diameter was r = 0.62 without and r = 0.80 with ATVS (CI: -0.04 to -0.60; p = 0.025). Mean SDNR was 10.88 without and 10.03 with ATVS (p = 0.0089). Readers' agreement improved with ATVS (weighted kappa between pediatric radiologists from 0.1 (0.03-0.16) to 0.27 (0.09-0.45) with ATVS; between general and each pediatric radiologist from 0.1 (0.06-0.14) to 0.12 (0.05-0.20), and from 0.22 (0.11-0.34) to 0.36 (0.24-0.49)). CONCLUSION: ATVS, combined with ATCM, results in a radiation dose reduction for pediatric non-contrast chest CT without a loss of diagnostic image quality and prevents errors in manual tube voltage setting, and thus protecting larger children against an unnecessarily high radiation exposure.

YKL-40 levels increase with declining ankle-brachial index and are associated with long-term cardiovascular mortality in peripheral arterial disease patients.

BACKGROUND AND AIMS: YKL-40 is an inflammatory marker secreted by macrophages and is expressed in atherosclerotic plaques. YKL-40 increases in coronary artery disease (CAD) with poor coronary collateral vessel development. Higher levels are linked to reduced survival in CAD patients. Studies evaluating YKL-40 in patients with peripheral arterial disease (PAD) are scarce. This study aims to elucidate a possible link between YKL-40 and PAD severity as well as cardiovascular long-term mortality. METHODS: YKL-40 was measured at baseline in 365 elderly PAD patients (age 69 ±â€¯10.4, 33.7% women, Fontaine stage I-II) by bead-based multiplex assay. Patients were followed for seven years to assess long-term cardiovascular and all-cause survival by Kaplan-Meier and Cox regression. RESULTS: YKL-40 levels were associated with declining ankle-brachial index (ABI) in PAD patients without Moenckeberg's mediasclerosis (R = -0.189, p=0.002). PAD patients with mediasclerosis exhibited higher YKL-40 levels (p=0.002). Baseline YKL-40 levels were significantly associated with cardiovascular mortality (HR 1.52 (1.21-1.91), p < 0.001) and all-cause mortality (HR 1.45 (1.20-1.75), p < 0.001) over a seven-year observation period. After multivariable adjustment for gender, patient age, known carotid artery disease, known coronary artery disease, smoking status, systolic blood pressure, HbA1c, low density lipoprotein cholesterol, estimated glomerular filtration rate, aspartate aminotransferase, and C-reactive protein, YKL-40 remained significantly associated with cardiovascular (HR 1.34 (1.02-1.75), p=0.033) and all-cause mortality (HR 1.25 (1.01-1.55), p=0.039). CONCLUSIONS: Increased YKL-40 levels are independently associated with poor long-term cardiovascular survival in peripheral arterial disease patients. Furthermore, YKL-40 correlates with patients' ABI in PAD in the absence of mediasclerosis.

Epidemiology of Urinary Tract Infections in HIV Positive Patients at a Tertiary Care University Hospital in Central Europe (2011 - 2016).

OBJECTIVES: There is limited published data concerning the recent epidemiology of urinary tract infections (UTI) in HIV-patients, thus we analysed independent risk factors for UTI in HIV positive individuals and antimicrobial resistance rates of E. coli to antimicrobial agents commonly used in UTI. To determine the prevalence of symptomatic urinary tract infections (UTI) in HIV-patients, we performed a retrospective case-control study. METHODS: We included 313 HIV-patients, 101 with UTI and 212 age and gendermatched controls, attending the HIV outpatient clinic at the Vienna University Hospital (VUH) over a period from January 2011 to September 2016. The patients' specific data was gathered from the electronic database of the VUH. The statistical analysis was performed using SPSS Software Version 20.0. RESULTS: HIV infected individuals with CD4 count >200 cells/mm3 were less likely than HIV infected individuals with CD4 count <200 cells/mm3 to experience UTI (OR 0.811, 95% CI 0.712-0.923 vs. OR 2.555, 95% CI 1.553 - 4.205, respectively). The in vitro resistance rate of E. coli to antimicrobial agents was as follows: ciprofloxacin (41%), mecillinam (20.5%), trimethoprim (61%), ampicillin (67%), ampicillin/ clavulanic acid (23%), cefuroxime (17%), nitrofurantoin (2%), amikacin (0%) and gentamicin (9.5%). CONCLUSION: Immunological status (CD4 count) is an important parameter for risk assessment of UTIs in HIV-patients. The increased resistance rate of E. coli to commonly used antimicrobial agents needs to be considered when it comes to the management of UTI, additionally, surveillance strategies should be implemented in HIV-patients.

Angiopoietin-2 and Survival in Peripheral Artery Disease Patients.

Survival of peripheral arterial disease (PAD) patients increased over the last decade due to increased use of secondary preventive medication and rapid revascularization of PAD patients. Angiogenetic markers such as vascular endothelial growth factor (VEGF), angiopoietin-2 (Ang-2) and its receptor Tie-2 might be useful markers to assess the residual risk for mortality in PAD patients. The aim of this study was to evaluate angiogenetic markers for the prediction of mortality in a PAD cohort. For this purpose, 366 patients (mean age: 69 ± 10 years) with PAD Fontaine stage I or II were included and followed up over a 5-year study period. Serum Ang-2, Tie-2 and VEGF levels were measured by bead-based multiplex assay. All-cause mortality and major cardiovascular events (MACE) including all-cause death, non-fatal stroke and non-fatal myocardial infarction were analysed by Kaplan-Meier and Cox regression analyses after 5 years. Ang-2 was associated with Tie-2 (R = 0.151, p = 0.006) and VEGF levels (R = 0.160, p = 0.002). However, only Ang-2 was linked to all all-cause mortality in PAD patients (hazard ratio [HR]: 1.55 [1.23-2.15], p = 0.008) even after adjustment for age and gender, haemoglobin A1c, low-density lipoprotein cholesterol, systolic blood pressure and glomerular filtration rate (HR: 1.44 [1.03-2.00], p = 0.032). Furthermore, an association of Ang-2 and MACE in PAD patients (HR: 1.36 (1.03-1.78), p = 0.028) was found. This result implies that Ang-2 might be used as an additional marker to stratify PAD patients to predict poor mid-term life expectancy.

FABP4 and Cardiovascular Events in Peripheral Arterial Disease.

Fatty acid-binding protein 4 (FABP4) is a possible biomarker of atherosclerosis. We evaluated FABP4 levels, for the first time, in patients with peripheral artery disease (PAD) and the possible association between baseline FABP4 levels and cardiovascular events over time. Patients (n = 327; mean age 69 ± 10 years) with stable PAD were enrolled in this study. Serum FABP4 was measured by bead-based multiplex assay. Cardiovascular events were analyzed by FABP4 tertiles using Kaplan-Meier and Cox regression analyses after 5 years. Serum FABP4 levels showed a significant association with the classical 3-point major adverse cardiovascular event (MACE) end point (including death, nonlethal myocardial infarction, or nonfatal stroke) in patients with PAD ( P = .038). A standard deviation increase of FABP4 resulted in a hazard ratio (HR) of 1.33 (95% confidence interval [95% CI]: 1.03-1.71) for MACE. This association increased (HR: 1.47, 95% CI: 1.03-1.71) after multivariable adjustment ( P = .020). Additionally, in multivariable linear regression analysis, FABP4 was linked to estimated glomerular filtration rate ( P < .001), gender ( P = .005), fasting triglycerides ( P = .048), and body mass index ( P < .001). Circulating FABP4 may be a useful additional biomarker to evaluate patients with stable PAD at risk of major cardiovascular complications.

Clinical characteristics of a large cohort of patients with positive culture of Fusobacterium necrophorum.

Background: Fusobacterium necrophorum is a rare pathogen, mostly affecting young adults, causing infections of the head and neck, typically described as the Lemierre's syndrome. Today this symptom complex has become increasingly rare and has almost turned to a 'forgotten disease'. Methods: We performed a retrospective, descriptive study to identify the clinical features of patients with positive culture of F. necrophorum. Additionally, the antibiotic susceptibility profile of the pathogens was analysed. Results: During a period of 22 years 36 patients with at least one isolate of F. necrophorum were identified. Mostly tonsillar and peritonsillar abscesses were found, 10 patients were identified with bacteraemia, but only 4 patients presented with symptoms like sore throat, fever and swollen cervical lymph nodes, which may suggest Lemierre's. Most of the isolates (33/35) showed sensitivity to all tested antibiotics. Conclusion: Appropriate techniques are needed to detect F. necropho rum, especially from throat swabs, in the microbiological laboratory. Current clinical and microbiological practice may lead to under-diagnosis of infections caused by F. necrophorum. Further research is needed to define the colonization rate and to optimize methods for detection as well as identification of virulence.

Hypothyroidism and Hyponatremia: Rather Coincidence Than Causality.

BACKGROUND: Hypothyroidism is referred to be a rare but possible cause of hyponatremia. However, there is only poor evidence supporting this association. Since hyponatremia and hypothyroidism are both common conditions themselves, co-occurrence does not have to be causal. METHODS: To address a potential relationship, a retrospective analysis of data from the Division of Endocrinology of the Medical University of Vienna from April 2004 to February 2016 was performed. A total of 8053 hypothyroid patients (48 ± 18 years of age; 71% female) with thyrotropin >4.0 µIU/mL and available blood tests for free thyroxine and sodium (Na+) within maximal ± seven days were included and screened for hyponatremia. Patients' records were searched for concomitant disease and medication when Na+ concentration was <135 mmol/L. RESULTS: Hyponatremia was present in 448/8053 (5.56%) patients. Analysis of medical history revealed potential alternative causes of hyponatremia in 442/448 (98.88%) patients (i.e., side effects of medication, concomitant underlying disease, or other endocrine disorders). This distribution did not differ between patients suffering from clinical or subclinical hypothyroidism. No case of clinically relevant hyponatremia (Na+ < 130 mmol/L), present in 111/448 (24.78%) patients could be attributed only to hypothyroidism. There was a very weak but statistically significant trend toward a positive association between thyroid function and serum Na+ levels (Na+/thyrotropin: R = 0.022, p = 0.046; Na+/free thyroxine: R = -0.047, p < 0.001). CONCLUSION: The results suggest that hypothyroid patients with moderate to severe hyponatremia often have other potential explanations for their low serum Na+ concentrations in routine care.

Center-based patient care enhances survival of elderly patients suffering from peripheral arterial disease.

OBJECTIVES: Recent advances in catheter-based intervention in patients with symptomatic peripheral arterial disease (PAD) have halved mortality. Mortality of PAD patients still remains high compared to other clinical forms of atherosclerosis. Intensified patient care might increase adherence to medical management and benefit the survival of PAD patients. METHODS: Two patient cohorts were compared in a longitudinal prospective follow-up study. 370 PAD patients were included in the intensified center-based vascular medicine group (VMC group) and 332 PAD patients were treated by their usual primary care physician (PCP group). Survival in both groups was compared by Kaplan-Meier and Cox-regression analyses after 5 years. RESULTS: Survival of patients in the VMC group was 90.8% compared to 66% in the PCP group. Thus, survival was improved by 24.9% by center-based care (absolute risk CI: 19-30.7%; 38% relative risk). PCP treatment increased all-cause mortality by a hazard ratio of 3.7 (95% CI: 2.5-5.5; p < .001). Mortality in the VMC group was significantly associated with the non-modifiable risk factors age, C-reactive protein, and nephropathy in multivariable analyses. CONCLUSION: These data imply that multi-morbid elderly PAD patients still benefit by intensified specialist care compared to the usual primary care setting. KEY MESSAGES Center-based patient care improves survival in patients with peripheral arterial disease; mortality was reduced from 82 to 21 events per 1000 patient-years (rate ratio 0.26). Mortality was related to age (HR 1.46), CRP (HR 1.36), and nephropathy (HR 2.7). A multifactorial approach combining adequate drug prescription, accomplishment of agreed goals and repetitive training to initiate, implement, and persist treatment adaptations was applied.

Clinical Decision Support for the Classification of Diabetic Retinopathy: A Comparison of Manual and Automated Results.

The management of diabetic retinopathy, a frequent ophthalmological manifestation of diabetes mellitus, consists of regular examinations and a standardized, manual classification of disease severity, which is used to recommend re-examination intervals. To evaluate the feasibility and safety of implementing automated, guideline-based diabetic retinopathy (DR) grading into clinical routine by applying established clinical decision support (CDS) technology. We compared manual with automated classification that was generated using medical documentation and an Arden server with a specific medical logic module. Of 7169 included eyes, 47% (n=3373) showed inter-method classification agreement, specifically 29.4% in mild DR, 38.3% in moderate DR, 27.6% in severe DR, and 65.7% in proliferative DR. We demonstrate that the implementation of a CDS system for automated disease severity classification in diabetic retinopathy is feasible but also that, due to the highly individual nature of medical documentation, certain important criteria for the used electronic health record system need to be met in order to achieve reliable results.

Outcome after Elective Percutaneous Coronary Intervention Depends on Age in Patients with Stable Coronary Artery Disease - An Analysis of Relative Survival in a Multicenter Cohort and an OCT Substudy.

BACKGROUND: Age is a strong predictor of survival in patients with coronary artery disease. In elder patients with increasing co-morbidities percutaneous coronary intervention (PCI) is associated with more complications and worse outcome. The calculation of relative survival rates adjusts for the "background" mortality in the general population by correcting for age and gender. We analyzed if elder patients after elective PCI have a worse relative survival compared to younger patient groups. METHODS: A total of 8,342 patients who underwent elective PCI at two high volume centers between 1998 and 2009 were analyzed. RESULTS: The survival of our patients after PCI (observed survival) was slightly lower compared to the general population (expected survival) resulting in a slightly decreasing relative survival curve. In a multivariate Cox regression model age amongst others was a strong predictor of survival. Stratifying patients according to their age the relative survival curves of younger patients (Quartile 1: <58 years; 2,046 patients), elder patients (Quartile 3: 66-73 years; 2,090 patients) and very old patients (Quartile 4: >73 years; 2,307 patients) were similar. The relative survival of mid-aged patients (Quartile 2: 58-65 years; 1,899 patients) was better than that of all other patient groups. The profile of cardiovascular risk factors differs between the various groups resulting in different composition and burden of coronary plaques in an optical coherence tomography sub-study. CONCLUSION: Patients after elective PCI have a slightly worse long-term survival compared to the age- and sex-matched general population. This is also true for different groups of age except for mid-aged patients between 58 and 63 years. Elder patients between 66 and 73 years and above 73 years have a similar relative survival compared to younger patients below 58 years, and might therefore have similar benefit from elective PCI.

A national point prevalence study on healthcare-associated infections and antimicrobial use in Austria.

BACKGROUND: The first point prevalence survey performed in Austria had the aim to assess the magnitude of healthcare-associated infections and antimicrobials use in the country. METHODS: A multicentre study was carried out from May until June 2012 in nine acute care hospitals with a mean bed number of 620. Data from 4321 patients' clinical charts were reviewed. RESULTS: The overall healthcare-associated infections prevalence was 6.2% (268/4321) with the highest rate in intensive care departments (20.9%; 49/234). In medical and surgical departments the healthcare-associated infections prevalence was 5.4% (95/1745) and 6.6% (105/1586), respectively. The most frequent healthcare-associated infections were: urinary tract infections (21.3%; 61/287), pneumonia (20.6%; 59/287) and surgical site infections (17.4%; 50/287). The most common isolated microorganisms were: Escherichia coli (14.8%; 26/176), Enterococcus species (13.1%; 23/176) and Pseudomonas aeruginosa (11.4%; 20/176). Thirty-three per cent (1425/4321) of the patients received antimicrobials because of community-acquired infections treatment (14.2%; 615/4321), healthcare-associated infections treatment (6.4%; 278/4321), and surgical (8.2%; 354/4321) and medical prophylaxis (3.2%; 138/4321). Surgical prophylaxis was the indication for 22.0% (394/1792) of the overall prescriptions and was prolonged for more than 1 day in 77.2% (304/394) of the cases. CONCLUSION: The national Austrian survey proved the feasibility of a nation-wide network of surveillance of both healthcare-associated infections and antimicrobial use that will be repeated in the future. Healthcare-associated infections and antimicrobial use have been confirmed to be a grave health problem. The excessive prolongation of perioperative prophylaxis in Austria needs to be limited.

Serum Creatinine Back-Estimation in Cardiac Surgery Patients: Misclassification of AKI Using Existing Formulae and a Data-Driven Model.

BACKGROUND AND OBJECTIVES: A knowledge of baseline serum creatinine (bSCr) is mandatory for diagnosing and staging AKI. With often missing values, bSCr is estimated by back-calculation using several equations designed for the estimation of GFR, assuming a "true" GFR of 75 ml/min per 1.73 m(2). Using a data set from a large cardiac surgery cohort, we tested the appropriateness of such an approach and compared estimated and measured bSCr. Moreover, we designed a novel data-driven model (estimated serum creatinine [eSCr]) for estimating bSCr. Finally, we analyzed the extent of AKI and mortality rate misclassifications. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data for 8024 patients (2833 women) in our cardiac surgery center were included from 1997 to 2008. Measured and estimated bSCr were plotted against age for men and women. Patients were classified to AKI stages defined by the Kidney Disease Improving Global Outcomes (KDIGO) group. Results were compared with data from another cardiac surgery center in Zurich, Switzerland. RESULTS: The Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration formulae describe higher estimated bSCr values in younger patients, but lower values in older patients compared with the measured bSCr values in both centers. The Pittsburgh Linear Three Variables formula correctly describes the increasing bSCr with age, however, it underestimates the overall bSCr level, being in the range of the 25% quantile of the measured values. Our eSCr model estimated measured bSCr best. AKI stage 1 classification using all formulae, including our eSCr model, was incorrect in 53%-80% of patients in Vienna and in 74%-91% in Zurich; AKI severity (according to KDIGO stages) and also mortality were overestimated. Mortality rate was higher among patients falsely classified into higher KDIGO stages by estimated bSCr. CONCLUSIONS: bSCr values back-estimated using currently available eGFR formulae are inaccurate and cannot correctly classify AKI stages. Our model eSCr improves the prediction of AKI but to a still inadequate extent.