Impact of malnutrition and frailty on mortality and major amputation in patients with CLTI.

OBJECTIVES: To understand the prevalence of malnutrition and its association with chronic limb-threatening ischemia (CLTI) outcomes; to clarify the differential impact of revascularization methods on outcomes; to assess the ability of the CLTI Frailty Risk Score (CLTI-FRS) to predict adverse events in patients hospitalized with CLTI. BACKGROUND: Despite advances in the management of CLTI, a majority still undergo major amputation, and a minority heal within 6 months. There is a lack of validated assessment tools for the identification and management of frailty and malnutrition in these patients. METHODS: Using the National Inpatient Sample from January 2012 to September 2015, we identified all patients with CLTI using International Classification of Diseases Ninth Edition Clinical Modification codes. The cohort was divided into three groups according to nutritional status. Multivariable regression analysis was used to analyze the interaction between malnutrition and outcomes of interest. RESULTS: Of 1,414,080 CLTI-related hospitalizations, 163,835 (11.6%) were malnourished, 332,855 (23.5%) patients were frail, 917,390 (64.9%) were well-nourished. In-hospital mortality, major amputation, the average length of stay, and hospital costs were highest among malnourished or frail patients and lowest in well-nourished patients (p < 0.001). Malnourished and frail patients were observed to have lower rates of mortality with endovascular revascularization as compared to surgical (adjusted odds ratios: 0.675 [0.533-0.854; p = 0.001]). CONCLUSION: Many patients with CLTI are malnourished or frail, and this is associated with mortality and amputation. Both malnourished and frail patients were observed to have a mortality benefit with a less invasive approach to revascularization. Better assessment of nutritional and frailty status of CLTI patients may guide therapy and help prevent amputation and death.

Epidemiology of Diverticulitis and Prevalence of First-Ever Colorectal Cancer Postdiverticulitis in Adults in the United States: A Population-Based National Study.

BACKGROUND: The incidence of acute diverticulitis is increasing, and previous studies showed a wide range of prevalence of colorectal cancer after diverticulitis. There is a lack of high-quality evidence to support performing colonoscopy after diverticulitis. OBJECTIVE: We aimed to describe the incidence of first-ever diverticulitis and prevalence of first-ever colorectal cancer postdiverticulitis in the United States. DESIGN: This is a retrospective cohort study. SETTINGS: We queried a national database that contains data from 26 major integrated healthcare systems in the United States. PATIENTS: We identified an aggregated patient cohort aged ≥18 years with a diagnosis of first-ever diverticulitis from February 2015 to February 2020, followed by first-ever colorectal cancer diagnosis, at least 1 day after and within 1 year of diverticulitis. MAIN OUTCOME MEASURES: The incidence of first-ever diverticulitis was calculated. The prevalence and OR of first-ever colorectal cancer after diverticulitis were analyzed. RESULTS: Among 31,778,290 individuals, we found the incidence of first-ever acute diverticulitis to be 2.9%. The prevalence of colorectal cancer within 1 year of first-ever acute diverticulitis was 0.57%, whereas the prevalence of colorectal cancer without a history of diverticulitis was 0.31% (OR = 1.8 (95% CI, 1.76-1.86)). The majority (92.3%) of the postdiverticulitis colorectal cancer were diagnosed within the first 6 months. The risk of colorectal cancer postdiverticulitis was higher in women (OR = 1.9), African Americans (OR = 2.0), and adults aged 18 to 65 years (OR = 2.3). LIMITATIONS: We are unable to validate the diagnostic code because patient information in our database is deidentified. CONCLUSIONS: Individuals are twice as likely to be diagnosed with colorectal cancer within 1 year of their first episode of acute diverticulitis compared with individuals without diverticulitis. We advocate for colonoscopy after the first occurrence of acute diverticulitis to screen for colorectal cancer, particularly for patients without a recent colonoscopy. See Video Abstract at http://links.lww.com/DCR/B412.

ANTECEDENTES: La incidencia de diverticulitis aguda está aumentando y los estudios anteriores mostraron una amplia gama de prevalencia de cáncer colorrectal después de diverticulitis. Hay una falta de evidencia de alta calidad para apoyar la realización de una colonoscopia después de la diverticulitis. OBJETIVOS: Nuestro objetivo fue describir la incidencia de la primera diverticulitis y la prevalencia del cáncer colorrectal posterior a la primera diverticulitis en los Estados Unidos.DISEÑO:Este es un estudio de cohorte retrospectivo. AJUSTES: Consultamos una base de datos nacional que contiene datos de 26 sistemas de salud integrados importantes en los Estados Unidos. PACIENTES: Identificamos una cohorte agregada de pacientes mayores de 18 años con un diagnóstico de diverticulitis por primera vez entre febrero de 2015 y febrero de 2020, seguido de un diagnóstico de cáncer colorrectal por primera vez, al menos 1 día después y dentro de 1 año de diverticulitis. PRINCIPALES MEDIDAS DE RESULTADO: Se calculó la incidencia de la primer diverticulitis. Se analizaron la prevalencia y el odds ratio del primer CCR después de la diverticulitis. RESULTADOS: Entre 31,778,290 individuos, encontramos que la incidencia de la primera diverticulitis aguda fue del 2.9%. La prevalencia de cáncer colorrectal dentro de 1 año de la primera diverticulitis aguda fue del 0,57%, mientras que la prevalencia del cáncer colorrectal sin antecedentes de diverticulitis fue del 0,31% (OR 1,8; IC del 95%: 1,76-1,86). La mayoría (92,3%) de los pacientes con cáncer colorrectal posterior a diverticulitis se diagnosticaron dentro de los primeros 6 meses. El riesgo de CCR después de diverticulitis fue mayor en mujeres (OR 1,9), afroamericanos (OR 2,0) y adultos de 18 a 65 años (OR 2,3). LIMITACIONES: No podemos validar el código de diagnóstico debido a que la información del paciente en nuestra base de datos no está identificada. CONCLUSIONES: Las personas tienen el doble de probabilidades de ser diagnosticadas con cáncer colorrectal dentro del primer año de su primer episodio de diverticulitis aguda en comparación con las personas sin diverticulitis. Abogamos por la colonoscopia después de la primera aparición de diverticulitis aguda para detectar cáncer colorrectal, particularmente en pacientes sin una colonoscopia reciente.

Influence of Influenza Infection on In-Hospital Acute Myocardial Infarction Outcomes.

Influenza is associated with significant morbidity in the United States but its influence on in-hospital outcomes in patients with AMI has not been well studied. The Nationwide Readmission Database (NRD) from 2010 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥18 years who were admitted for AMI with and without concurrent influenza. Propensity score matching was used to adjust patients' baseline characteristics and co-morbidities. In-hospital mortality, 30-day readmission rates, in-hospital complications, and resource utilization were analyzed. We identified a total of 2,428,361 patients admitted with AMI, of whom 3,006 (0.12%) had coexisting influenza. We noted significantly higher in-hospital mortality (7.7% vs 5.6%, p <0.01) and 30-day readmission rates (15.8% vs 14.1%, p <0.01) in patients with influenza compared with those without it. After propensity matching, the differences in in-hospital mortality and 30-day readmission were no longer statistically significant between the groups. Patients with influenza had a higher incidence of acute kidney injury (30.9% vs 24.6%, p <0.01), acute respiratory failure (50.2% vs 32.2%, p <0.01), need for mechanical ventilation (13.9% vs 9.2%, p <0.01), and sepsis (10% vs 3.8%, p <0.01) in the matched cohort. Patients with influenza had longer hospital stays (8.4 days vs 6.4 days, p <0.01) and mean costs of care (26,200USD vs 23,400USD, p <0.01). In conclusion, AMI patients with concomitant influenza infection had higher in-hospital mortality, 30-day readmission, in-hospital complications, and higher resource utilization compared with those without influenza.

Association of Acute Venous Thromboembolism With In-Hospital Outcomes of Coronary Artery Bypass Graft Surgery.

Background While venous thromboembolism (VTE) prophylaxis is a strong recommendation after most surgeries, it is controversial in cardiac surgeries such as coronary artery bypass grafting (CABG), because of perceived low VTE incidence and increased bleeding risk. Prior studies may not have been adequately powered to study outcomes of VTE in this population. We sought to investigate the postoperative incidence and outcomes of CABG patients using a large national inpatient database. Methods and Results We utilized the 2013 to 2014 National Inpatient Sample to identify all patients >18 years of age who underwent CABG (without concomitant valvular procedures), and had VTE during the hospital stay. We then compared clinically relevant outcomes in patients with and without VTE. We identified 331 950 CABG procedures. Of these, 1.3% (n=4205) had VTE. Patients with VTE were more likely to be older (mean 67.2±10.4 years versus 65.2±10.4 years, P<0.001). VTE was associated with higher incidence of inpatient mortality (6.8% versus 1.7%; adjusted odds ratio 1.92 [95% CI 1.40-2.65]; P<0.001) and complications. VTE was also associated with higher cost (mean±SE $81 995±$923 versus $48 909±$55) and longer length of stay (mean±SE 17.06±0.16 days versus 8.52±0.01 days). Conclusions Our analysis of >330 000 CABG procedures suggests that while postoperative VTE after CABG is rare, it is associated with increased morbidity and mortality. Randomized controlled trials are needed to identify optimal strategies for VTE prophylaxis in these patients.

Waitlist Mortality of Patients With Amyloid Cardiomyopathy who Are Listed for Heart Transplantation and Implications for Organ Allocation.

BACKGROUND: Outcomes of patients with amyloid cardiomyopathy (ACM) undergoing heart transplantation have been reported, but there are scant data concerning the waitlist mortality (WLM) of these patients. AIM: The aim of this study was to investigate whether patients with ACM have higher waitlist mortality compared to those with other types of cardiomyopathies. METHODS: We queried the United Network for Organ Sharing registry for all patients (age ≥ 18 years) listed for heart transplantation between 2008 and 2015. We compared patients with ACM to those with dilated cardiomyopathy (DCM) or idiopathic restrictive cardiomyopathy (RCM) for WLM and waitlist mortality or delisting for deterioration (WLM/D). We identified 306 patients with ACM, 183 with RCM and 8416 with DCM. Patients with ACM were older (ACM 61 vs RCM 49 vs DCM 51 years, P < .001), were more likely to be male (82% vs 60% vs 73%, P < .001) but less likely to be listed as status 1A (16% vs 18% vs 23%, P< .001). After adjusting for baseline characteristics, ACM was associated with increased risk of mortality and mortality/delisting compared with DCM (HR 2.03 [1.36-3.04], P = .001 for WLM; HR 2.07 [1.55-2.78], P < .001 for WLM/D) but not with other RCMs (HR 1.28 [0.54-3.02], P = .58 for WLM; HR 0.97 [0.56-1.69], P = .91 for WLM/D). RESULTS: Patients with ACM are listed with lower acuity and have higher waitlist mortality compared with those with dilated cardiomyopathies. Further studies are needed to identify whether special prioritization should be considered for patients with ACM listed for heart transplantation.

Effect of Influenza on Outcomes in Patients With Heart Failure.

OBJECTIVES: This study sought to determine whether influenza infection increases morbidity and mortality in patients hospitalized with heart failure (HF). BACKGROUND: Patients with HF may be at increased risk of morbidity and mortality from influenza infection. However, there are limited data for the associated hazards of influenza infection in patients with HF. METHODS: We queried the 2013 to 2014 National Inpatient Sample database for all adult patients (18 years of age or older) admitted with HF with and without concomitant influenza infection. Propensity score matching was used to match patients across age, race, sex, and comorbidities. Outcomes included in-hospital mortality, in-hospital complications, length of stay, and average hospital costs. RESULTS: Of 8,189,119 all-cause hospitalizations in patients with HF, 54,590 (0.67%) had concomitant influenza infection. Patients with concomitant influenza had higher incidence of in-hospital mortality (6.2% vs. 5.4%, respectively; odds ratio [OR]: 1.15 [95% confidence interval [CI]: 1.03 to 1.30]; p = 0.02), acute respiratory failure (36.9% vs. 23.1%, respectively; OR: 1.95 [95% CI: 1.83 to 2.07]; p < 0.001), acute respiratory failure requiring mechanical ventilation (18.2% vs. 11.3%, respectively; OR: 1.75 [95% CI: 1.62 to 1.89]; p < 0.001), acute kidney injury (AKI) (30.3% vs. 28.7%, respectively; OR: 1.08 [95% CI: 1.02 to 1.15]; p = 0.01), and AKI requiring dialysis (2.4% vs. 1.8%, respectively; OR: 1.37 [95% CI: 1.14 to 1.65]; p = 0.001). Patients with influenza had longer mean lengths of stay (5.9 days vs. 5.2 days, respectively; p <0.001) but similar average hospital costs ($12,137 vs. $12,003, respectively; p = 0.40). CONCLUSIONS: Influenza infection is associated with increased in-hospital morbidity and mortality in patients with HF. Our results emphasize the need for efforts to mitigate the incidence of influenza, specifically in this high-risk patient cohort.

Outcomes Among Patients With Heart Failure With Reduced Ejection Fraction Undergoing Transcatheter Aortic Valve Replacement: Minimally Invasive Strategy Versus Conventional Strategy.

OBJECTIVES: To investigate the effect of TAVR technique on in-hospital and 30-day outcomes in patients with aortic stenosis (AS) and reduced ejection fraction (EF). BACKGROUND: Patients with AS and concomitant low EF may be at risk for adverse hemodynamic effects from general anesthesia utilized in transcatheter aortic valve replacement (TAVR) via the conventional strategy (CS). These patients may be better suited for the minimally invasive strategy (MIS), which employs conscious sedation. However, data are lacking that compare MIS to CS in patients with AS and concomitant low EF. METHODS: In this retrospective study, we identified all patients with low EF (<50%) undergoing transfemoral MIS-TAVR vs CS-TAVR between March 2011 and May 2018. Our primary endpoint was defined as the composite of in-hospital mortality and major periprocedural bleeding or vascular complications. RESULTS: Two hundred and seventy patients had EF <50%, while 154 patients had EF ≤35%. Overall, a total of 236 patients were in the MIS group and 34 were in the CS group. Baseline characteristics between the two groups were similar except for Society of Thoracic Surgeons (STS) score (MIS 8.4 ± 5.1 vs CS 11.7 ± 6.8; P<.01). There were no differences between the two groups in incidence of the primary endpoint (MIS 5.5% vs CS 8.8%; odds ratio for MIS, 0.60; 95% confidence interval, 0.16-2.23; P=.45). CONCLUSIONS: In patients with severe AS and reduced EF, MIS was not associated with adverse in-hospital or 30-day clinical outcomes compared with CS. In these patients, MIS may be a suitable alternative to CS without compromising clinical outcomes.

The ER-associated degradation adaptor protein Sel1L regulates LPL secretion and lipid metabolism.

Sel1L is an essential adaptor protein for the E3 ligase Hrd1 in the endoplasmic reticulum (ER)-associated degradation (ERAD), a universal quality-control system in the cell; but its physiological role remains unclear. Here we show that mice with adipocyte-specific Sel1L deficiency are resistant to diet-induced obesity and exhibit postprandial hypertriglyceridemia. Further analyses reveal that Sel1L is indispensable for the secretion of lipoprotein lipase (LPL), independent of its role in Hrd1-mediated ERAD and ER homeostasis. Sel1L physically interacts with and stabilizes the LPL maturation complex consisting of LPL and lipase maturation factor 1 (LMF1). In the absence of Sel1L, LPL is retained in the ER and forms protein aggregates, which are degraded primarily by autophagy. The Sel1L-mediated control of LPL secretion is also seen in other LPL-expressing cell types including cardiac myocytes and macrophages. Thus, our study reports a role of Sel1L in LPL secretion and systemic lipid metabolism.