The modified Rajan's heart failure risk score predicts all-cause mortality in patients hospitalized for heart failure with reduced ejection fraction: a retrospective cohort study.

Background: The dimensionless Rajan's heart failure (R-hf) risk score was proposed to predict all-cause mortality in patients hospitalized with chronic heart failure (HF) and reduced ejection fraction (EF) (HFrEF). Purpose: To examine the association between the modified R-hf risk score and all-cause mortality in patients with HFrEF. Methods: Retrospective cohort study included adults hospitalized with HFrEF, as defined by clinical symptoms of HF with biplane EF less than 40% on transthoracic echocardiography, at a tertiary centre in Dalian, China, between 1 November 2015, and 31 October 2019. All patients were followed up until 31 October 2020. A modified R-hf risk score was calculated by substituting brain natriuretic peptide (BNP) for N-terminal prohormone of BNP (NT-proBNP) using EF× estimated glomerular filtration rate (eGFR)× haemoglobin (Hb))/BNP. The patients were stratified into tertiles according to the R-hf risk score. The measured outcome was all-cause mortality. The score performance was assessed using C-statistics. Results: A total of 840 patients were analyzed (70.2% males; mean age, 64±14 years; median (interquartile range) follow-up 37.0 (27.8) months). A lower modified R-hf risk score predicted a higher risk of all-cause mortality, independent of sex and age [1st tertile vs. 3rd tertile: adjusted hazard ratio (aHR), 3.46; 95% CI: 2.11-5.67; P<0.001]. Multivariate Cox regression analysis indicated that a lower modified R-hf risk score was associated with increased cumulative all-cause mortality [univariate: (1st tertile vs. 3rd tertile: aHR, 3.45; 95% CI: 2.11-5.65; P<0.001) and multivariate: (1st tertile vs. 3rd tertile: aHR 2.21, 95% CI: 1.29-3.79; P=0.004)]. The performance of the model, as reported by C-statistic was 0.67 (95% CI: 0.62-0.72). Conclusion: The modified R-hf risk score predicted all-cause mortality in patients hospitalized with HFrEF. Further validation of the modified R-hf risk score in other cohorts of patients with HFrEF is needed before clinical application.

Interpretable machine learning models for predicting in-hospital and 30 days adverse events in acute coronary syndrome patients in Kuwait.

The relationships between acute coronary syndromes (ACS) adverse events and the associated risk factors are typically complicated and nonlinear, which poses significant challenges to clinicians' attempts at risk stratification. Here, we aim to explore the implementation of modern risk stratification tools to untangle how these complex factors shape the risk of adverse events in patients with ACS. We used an interpretable multi-algorithm machine learning (ML) approach and clinical features to fit predictive models to 1,976 patients with ACS in Kuwait. We demonstrated that random forest (RF) and extreme gradient boosting (XGB) algorithms, remarkably outperform traditional logistic regression model (AUCs = 0.84 & 0.79 for RF and XGB, respectively). Our in-hospital adverse events model identified left ventricular ejection fraction as the most important predictor with the highest interaction strength with other factors. However, using the 30-days adverse events model, we found that performing an urgent coronary artery bypass graft was the most important predictor, with creatinine levels having the strongest overall interaction with other related factors. Our ML models not only untangled the non-linear relationships that shape the clinical epidemiology of ACS adverse events but also elucidated their risk in individual patients based on their unique features.

Clinical features, socioeconomic status, management, short and long-term outcomes of patients with acute myocardial infarction: Phase I results of PEACE MENA registry.

BACKGROUND: The Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa (PEACE MENA) is a prospective registry program in Arabian countries that involves in patients with acute myocardial infarction (AMI) or acute heart failure (AHF). METHODS: This prospective, multi-center, multi-country study is the first report of the baseline characteristics and outcomes of inpatients with AMI who were enrolled during the first 14-month recruitment phase. We report the clinical characteristics, socioeconomic, educational levels, and management, in-hospital, one month and one-year outcomes. RESULTS: Between April 2019 and June 2020, 1377 patients with AMI were enrolled (79.1% males) from 16 Arabian countries. The mean age (± SD) was 58 ± 12 years. Almost half of the population had a net income < $500/month, and 40% had limited education. Nearly half of the cohort had a history of diabetes mellitus, hypertension, or hypercholesterolemia; 53% had STEMI, and almost half (49.7%) underwent a primary percutaneous intervention (PCI) (lowest 4.5% and highest 100%). Thrombolytics were used by 36.2%. (Lowest 6.45% and highest (90.9%). No reperfusion occurred in 13.8% of patients (lowest was 0% and highest 72.7%).Primary PCI was performed less frequently in the lower income group vs. high income group (26.3% vs. 54.7%; P<0.001). Recurrent ischemia occurred more frequently in the low-income group (10.9% vs. 7%; P = 0.018). Re-admission occurred in 9% at 1 month and 30% at 1 year, whereas 1-month mortality was 0.7% and 1-year mortality 4.7%. CONCLUSION: In the MENA region, patients with AMI present at a young age and have a high burden of cardiac risk factors. Most of the patients in the registry have a low income and low educational status. There is heterogeneity among key performance indicators of AMI management among various Arabian countries.

Correction: Acute Myocardial Infarction and Acute Heart Failure in the Middle East and North Africa: Study Design and Pilot Phase Study Results from the PEACE MENA Registry.

[This corrects the article DOI: 10.1371/journal.pone.0236292.].

Acute myocardial infarction and acute heart failure in the Middle East and North Africa: Study design and pilot phase study results from the PEACE MENA registry.

BACKGROUND: This pilot study describes the overall design and results of the Program for the Evaluation and Management of the Cardiac Events registry for the Middle East and North Africa (MENA) Region. METHODS: This prospective, multi-center, multi-country study included patients hospitalized with acute myocardial infarction (AMI) and/or acute heart failure (AHF). We evaluated the clinical characteristics, socioeconomic and educational levels, management, in-hospital outcomes, and 30-day mortality rate of patients that were admitted to one tertiary-care center in each of 14 Arab countries in the MENA region. RESULTS: Between 22 April and 28 August 2018, 543 AMI and 381AHF patients were enrolled from 14 Arab countries (mean age, 57±12 years, 82.5% men). Over half of the patients in both study groups had low incomes with limited health care coverage, and limited education. Nearly half of the cohort had a history of diabetes mellitus, hypertension, or hypercholesterolemia. Among patients with ST-elevation myocardial infarctions, 56.4% received primary percutaneous interventions, 24% received thrombolysis, and 19.5% received no acute reperfusion therapy. The main causes of AHF were ischemic heart diseases (55%) and primary valvular heart diseases (15%). The in-hospital and 30-day mortality rates were 2.0% and 3.5%, respectively, for AMI, and 5.4% and 7.0%, respectively, for AHF. CONCLUSIONS: This pilot study revealed a high prevalence of cardiovascular risk factors in patients with AMI and AHF in Arab countries, and low levels of socioeconomic and educational status. Future phases of the study will improve our understanding of the impact that these factors have on the management and outcomes of cardiac events in these patient populations.

Implementation of Guideline-Recommended Therapies for Patients With Heart Failure and Reduced Ejection Fraction: A Regional Arab Middle East Experience.

We describe the characteristics of ambulatory patients with heart failure with reduced ejection fraction (HFrEF) in the Gulf region (Middle East) and the implementation of guideline-recommended treatments. We included 2427 HFrEF outpatients (mean age 59 ± 13 years, 75% males and median left ventricular ejection fraction [LVEF] of 30%). A high proportion of patients received guideline-recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI] 87%, ß-blocker 91%, mineralocorticoid antagonist [MRA] 64%). However, only a minority of patients received guideline-recommended target doses (ACEI/ARB/ARNI 13%, ß-blocker 27%, and MRA 4.4%). Old age was a significant independent predictor for not prescribing treatment (P < .001 for ACEI/ARB/ARNI and MRA; and P = .002 for ß-blockers). Other independent predictors were chronic kidney disease (for both ACEI/ARB/ARNI and MRA, P < .001) and higher LVEF (P = .014 for ß-blockers and P < .001 for MRA). Patients with HFrEF managed by heart failure specialists more often received recommended target doses of ACEI/ARB/ARNI (40% vs 11%, P < .001) and ß-blockers (56% vs 26%, P < .001) compared to those treated by general cardiologists. Although the majority of our patients with HFrEF received guideline-recommended medications, the doses they were prescribed were suboptimal. Understanding the reasons behind this is important for improved practice.

Design and Rationale of Gulf Documentation of Ambulatory Sick Patients with Heart Failure (Gulf DYSPNEA) Registry.

AIM: The aim of this study is to describe the clinical characteristics of ambulatory patients with chronic heart failure (HF) in the Arabian Gulf and to examine several aspects including types of HF, causes, and adherence to management guidelines. METHODS: Gulf documentation of ambulatory sick patients with HF (Gulf DYSPNEA) registry is a multicenter, cross-sectional study, recruiting adult ambulatory HF patients from 24 hospitals in five Arabian Gulf countries. Consecutive patients are recruited prospectively from participating clinics with no follow-up data collection. Recruitment started on November 07, 2016 and will stop when 3,500 patients are enrolled in this study. Collected data explore demographics, baseline patient characteristics, symptoms, previous medical history, comorbidities, physical signs, presenting electrocardiogram, echocardiographic findings, types of HF, and management. CONCLUSION: This registry is expected to provide useful data on several important aspects and features of ambulatory patients with chronic HF in Arabian Gulf countries. The trial registration number is "ClinicalTrials.gov number, NCT02793180".

Three-Year Follow-Up of Laparoscopic Reduced Port Sleeve Gastrectomy in 808 Consecutive Patients.

BACKGROUND: Sleeve gastrectomy (SG) is a very popular technique for the treatment of morbid obesity. Less and less invasive laparoscopic approaches to SG have been proposed and shown to be safe and feasible. OBJECTIVES: We developed a reduced port laparoscopic approach to sleeve gastrectomy (RLSG) with the aim to further optimize the advantages of laparoscopy. Preliminary and safety profile of RLSG as well as 3 years weight loss outcome are hereby discussed. SETTING: University Hospital, Kuwait. MATERIALS AND METHODS: All patients had morbid obesity with history of failure of conservative treatment. The RLSG procedure was performed using only two skin incisions. RESULTS: The analyzed population comprised 808 patients, including 642 women and 166 men. Mean age and BMI were 28.34 ± 8.37 and 41.09 ± 6.34, respectively. Mean operative time was 43 ± 20 min (range, 31-185). Mortality was nil. Overall morbidity rate was (4.5%). Three patients had postoperative leak (0.4%). Median duration of hospital stay was 2 days (range, 1-5). Mean percentage of excess weight loss (% EWL) was 23.18 ± 17.3% at 1 month, 55.08 ± 22.9% at 6 months, 82.6 ± 22.6% at 1 year, and 84.3 ± 22.4% at 3 years. Mean percentage total weight loss (%TWL) was 9.34% at 1 month, 22.42% at 6 months, and 34.57% at 1 year. CONCLUSION: RLSG is a safe and effective surgical option in patients with morbid obesity. Moreover, 3-year follow-up assessment confirmed adequate % EWL.

Trends in the Use of Evidence-based Therapies Early in the Course of Acute Myocardial Infarction and its Influence on Short Term Patient Outcomes.

AIM: To evaluate changes in management practices and its influence on short term hospital outcomes in patients with acute myocardial infarction (AMI) admitted during two different time periods, 2007 and 2004. METHODS AND RESULTS: We studied AMI patients from two acute coronary syndrome registries carried out in Kuwait in 2007 and 2004. We included 1872 and 1197 patients from the 2007 and 2004 registries, respectively. When compared with 2004, patients from the 2007 registry had similar baseline clinical characteristics. In 2007 compared to 2004, during the in-hospital period, patients with AMI received significantly more statins (94% vs. 73%%, p<0.0001), Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) (70% vs. 47%, p<0.001), and Clopidogrel (38% vs. 4%, p<0.001), while beta-blockers use dropped in 2007 compared to 2004 (63% vs. 68%, p=0.0066). The rates of in-hospital mortality and recurrent ischemia were significantly lower in the 2007 cohort compared with the 2004 cohort (for mortality 2.2% vs. 3.9%, P=0.0008, for recurrent ischemia 13.7% vs. 20.4%, P=0<0.0001).Higher utilization of angiotensin converting enzyme inhibitors, angiotensin receptor blockers and statins were the main contributors to the improved in-hospital mortality and morbidity. IN CONCLUSION: In the acute management of AMI, there was a significant increase in the use of statins, ACE inhibitors and Clopidogrel in 2007 compared to 2004. This was associated with a significant decrease in the in-hospital mortality and recurrent ischemia. Adherence to guidelines recommended therapies improved in-hospital outcomes.

Clinical characteristics and pathological classification of non-Hodgkin's lymphoma in Kuwait. Results of a collaborative study with the International Lymphoma Study Group (ILSG).

Kuwait was chosen by the International Lymphoma Study Group (ILSG) as one of the sites attending in the project on "Clinical characteristics and pathological classification of non Hodgkin's lymphoma (NHL) in the developing countries". The Kuwait study involved 206 cases of NHL, diagnosed, staged and treated in the Kuwait Cancer Control Center (KCCC). All cases were reviewed and reclassified independently by the pathologists of KCCC and the International Lymphoma Study Group (ISLG) using the latest World Health Organization (WHO) classification of neoplastic disease of the hematopoietic and lymphoid tissues. Immunophenotyping as to B- or T-cell was documented in all cases. Three main pathological entities (diffuse large B-cell lymphoma, follicular lymphoma, peripheral T-cell lymphoma) were identified and studied thoroughly. The intense cooperation between experts of the ISLG and pathologists of the KCCC proved that the WHO classification was fully reproducible in Kuwait. The high incidence of extranodal lymphomas (53%) observed in the KCCC may not be due to special ethnic or environmental conditions in Kuwait but rather be due to a selection of patients coming to our center.

Vascular stroma-derived endothelial colony forming progenitor cells adapt to tumour growth.

Under appropriate nutrient agar culture conditions, primary or xenografted human and animal tumour biopsy-derived cell suspensions will form two types of colony. The first type, consisting of tight colonies of round cells which form tumours when introduced into nude mice, is of neoplastic origin. The second type of colony, the cells of which fail to form tumours on injection into nude mice, consists of loose colonies of larger, inter-connecting elongated bi- or tripolar cells and is thought to originate from vascular stroma-derived endothelial colony forming progenitor cells (V-ECPC). The likely importance of V-ECPC to tumour growth is emphasised by a positive correlation between the VECPC-derived endothelial cell colonies and both tumour vascularity and growth rate. A high cloning efficiency obtained from tumours of particularly intense vascular nature indicates that this cell is of importance in vascular adaptation and therefore tumour growth. In contrast, avascular, fibrotic tumour tissue yielded very low numbers of stromal vascular endothelial cell colonies. The results suggest that stromal vascular endothelial cell colonies do not arise from the mature fibroblastic elements of the tumour stroma, but rather from cells within actively growing regions. Tritiated thymidine uptake studies show that the vascular stroma-derived endothelial colony forming progenitor cells cell are cycling. Cell separation studies have characterized the as yet morphologically unidentified V-ECPC as having a sedimentation rate of 4.7 mm./hr and a mean density of 1.068 g/cm3 and hence a calculated volume of 450 microns 3.