Δευτέρα, 5 Αυγούστου 2019

Oncology

The Heterogeneous Landscape of Head & Neck Squamous Cell Carcinomas
imageNo abstract available

Finding a Cure for Children With CNS Neuroblastoma
imageNo abstract available

EHR Tool Finds Pediatric Leukemia Patients for Clinical Studies
imageNo abstract available

In Search of an Immunotherapy Innovation for Ovarian Cancer
imageNo abstract available

Childhood Leukemia Cannot Hide From Immune System
imageNo abstract available

UpToDate®
No abstract available

Enzalutamide Improved Survival in Metastatic Prostate Cancer
imageNo abstract available

Olaparib Improved Outcomes in BRCA-Mutated Metastatic Pancreatic Cancer
imageNo abstract available

Dual Targeted Immune Activation in Gynecological Cancer
imageNo abstract available

Targeted Therapies in Elderly Patients With Metastatic Renal Cell Carcinoma
imageNo abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Surgical Laparoscopy Endoscopy & Percutaneous Techniques

Endoscopic Transgastric Versus Surgical Approach for Infected Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis
imageSurgical approach (SA) is the standard treatment for infected necrotizing pancreatitis (INP) and endoscopic transgastric approach (ETA) is a promising alternative treatment. This systematic review and meta-analysis aimed to compare the effectiveness and safety of ETA versus SA in INP. Several databases were systematically searched for eligible studies that compared ETA with SA for INP. Predefined criteria were used for study selection. Three reviewers independently assessed the risk of bias. Primary outcomes included clinical resolution rate, short-term mortality, major complications, and hospital stay. Study-specific effect sizes and their 95% confidence interval (CI) were combined to calculate the pooled value using fixed-effects or random-effects model. Six studies were included with 295 patients. Major complication rate [odds ratio (OR), 0.13; 95% CI, 0.06-0.29], new-onset organ failure rate (OR, 0.26; 95% CI, 0.12-0.54), postoperative pancreatic fistula rate (OR, 0.09; 95% CI, 0.03-0.28), and incisional hernia rate (OR, 0.10; 95% CI, 0.01-0.85) were lower in the ETA group. There was a shorter hospital stay (mean difference, −17.72; 95% CI, −21.30 to −14.13) in the ETA group. No differences were found in clinical resolution, short-term mortality, postoperative bleeding, perforation of visceral organ, and endocrine or exocrine insufficiency. Compared with SA, ETA showed comparable effectiveness and safety for the treatment of INP based on current evidence.

The Influence of Etoricoxib on Pain Control for Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Trials
imageIntroduction: The efficacy of etoricoxib on pain control for laparoscopic cholecystectomy remains controversial. We conduct a systematic review and meta-analysis to explore the impact of etoricoxib on pain intensity after laparoscopic cholecystectomy. Materials and Methods: We searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2018 for randomized controlled trials assessing the effect of etoricoxib versus placebo on pain management after laparoscopic cholecystectomy. This meta-analysis was performed using the random-effect model. Results: Four randomized controlled trials involving 351 patients are included in the meta-analysis. Overall, compared with control group for laparoscopic cholecystectomy, etoricoxib has no important impact on pain scores within 4 hours [mean difference (MD)=−1.48; 95% confidence interval (CI)=−3.54 to 0.58; P=0.16] and 8 hours (MD=−0.65; 95% CI=−1.43 to 0.12; P=0.10), but can significantly decrease pain intensity within 12 hours (MD=−1.16; 95% CI=−1.93 to −0.38; P=0.003) and 24 hours (MD=−1.10; 95% CI=−1.98 to −0.22; P=0.01), as well as postoperative analgesic consumption (standard MD=−1.21; 95% CI=−2.19 to −0.23; P=0.02), with no increase in nausea and vomiting (risk ratio=0.68; 95% CI=0.42-1.10; P=0.11), and headache (risk ratio=0.96; 95% CI=0.44-2.09; P=0.92). Conclusions: Etoricoxib can substantially reduce pain intensity in patients with laparoscopic cholecystectomy.

Omentopexy in Sleeve Gastrectomy Reduces Early Gastroesophageal Reflux Symptoms
imageIntroduction: Laparoscopic sleeve gastrectomy (LSG) is one of the surgical procedures indicated in the treatment of obesity. The occurrence of gastroesophageal reflux (GER) in the postoperative period of this surgery is related to a reduction in the lower esophageal sphincter (LES) tone and the presence of gastric residual fundus (RF) associated with increased gastric intraluminal pressure. Fixation of the remaining gastric reservoir to the gastrosplenic and gastrocolic ligaments (omentopexy) has emerged as a technical option to avoid or decrease GER in the postoperative period of LSG. Objective: To evaluate the presence of GER symptoms, alterations in LES tone, and the presence of RF in obese subjects submitted to LSG with omentopexy. Methods: Twenty obese patients were submitted to LSG with omentopexy from July 2016 to July 2017 at the Hospital Unimed de Teresina, Brazil and was studied prospectively. Clinical evaluations, including a specific questionnaire (clinical score), upper digestive endoscopy and esophageal manometry, were performed preoperatively and on the 90th postoperative day. Contrast x-ray of the esophagus, stomach, and duodenum were performed after the 90th postoperative day. The Fischer exact test was used to evaluate the correlation between GER symptoms and changes in LES tone or the presence of RF. Analysis of variance was used to evaluate the correlation of GER symptoms with the 2 variables together. All analyses adopted a level of significance for α errors >5% (P-value <0.05). Results: The mean clinical score of GER reduced from 6.7 in the preoperative period to 2.7 in the postoperative period. By manometry, there were no significant changes in the LES tone with mean values of 26.04 and 27.07 mm Hg before and after the procedure. RF was identified in 3 cases by contrast radiology. There was no statistical correlation between the changes in the LES tone or the presence of RF with the increase in the clinical score of GER (in cases where this occurred), even when the variables were evaluated together. Conclusions: LSG with omentopexy improved the clinical score of GER in most cases and did not cause significant changes in the LES tone. The presence of RF did not exacerbate the clinical score of GER.

Impact of Sleep Deprivation on Surgical Laparoscopic Performance in Novices: A Computer-based Crossover Study
imageObjective: The 24-hour work shifts are newly permitted to first-year surgical residents in the United States. Whether surgery novices' motor activity is affected by sleep deprivation is controversial. Materials and Methods: This study assesses sleep deprivation effects in computer-simulated laparoscopy in 20 surgical novices following 24 hours of sleep deprivation and after resting using a virtual-reality trainer. Participants were randomly assigned to perform simulator tests either well rested or sleep deprived first. Results: Of 3 different tasks performed, no significant differences in total time to complete the procedure and average speed of instruments were found. Instrument path length was longer following sleep deprivation (P=0.0435) in 1 of 3 tasks. Error rates (ie, noncauterized bleedings, perforations, etc.), as well as precision, and accuracy rates showed no difference. None of the assessed participants' characteristics affected simulator performance. Conclusions: Twenty-four hours of sleep deprivation does not affect laparoscopic performance of surgical novices as assessed by computer-simulation.

Complications After Endoscopic Stenting for Malignant Gastric Outlet Obstruction: A Cohort Study
imageBackground: Gastric stenting has become a common place in clinical practice. The aim of our study was to evaluate the factors influencing the clinical outcome in patients who received endoscopic stenting for malignant gastric outlet obstruction (GOO). Materials and Methods: We prospectively evaluated the clinical course of 87 patients who presented to our attention with malignant GOO. Results: There was neither mortality nor major morbidity after endoscopic stenting. Survival was reduced (average, 2 mo) in patients with an obstruction due to no resectable pancreatic cancer. In patients with primary no resectable pyloric adenocarcinoma, the crude survival was >1 year. Almost half of the patients required a new endoscopy. Food obstruction was common after 6 months from stent placement, limiting the quality of life of the patients. Conclusions: Endoscopic stenting represents a valid treatment in patients with symptoms of GOO from metastatic cancer. Patients with metastatic pyloric adenocarcinoma and normal liver function tests have survival rates longer than 1 year. In this selected group of patients, laparoscopic surgical gastrojejunostomy can be a valid alternative to avoid a close and exhausting follow-up, with the possibility of a better quality of life (res Registry 808).

Iatrogenic Colonic Perforations: Changing the Paradigm
imagePurpose: The purpose of our study was to investigate the clinical outcomes of colonoscopic perforations in patients. Materials and Methods: We retrospectively studied patients with perforations secondary to diagnostic/therapeutic colonoscopy between 2009 and 2015 at the Pontevedra Hospital Complex. We analyzed age, closure method, length of hospitalization, and long-term progress. Results: Of the 34 perforations detected, 67.6% occurred in patients aged below 75 years. Most perforations occurred in the descending colon (55%). Perforations occurred in 55.9% of outpatients and 45% of inpatients. Diagnostic and therapeutic colonoscopies caused perforations in 20.6% and 79.4% of patients, respectively. Conservative treatment alone was performed in 5.9%, complete or partial endoscopic closure in 14.7%, and surgery in 79.4% of patients. Patients treated only conservatively or with concomitant endoscopic closure showed no mortality. The mortality rate was 14.8% in those treated surgically, and 55% of these patients required a subsequent ostomy. Conclusions: Conservative management with antibiotics and parenteral nutrition concomitant with complete/partial endoscopic closure effectively treats perforations, provided intraprocedural diagnosis is possible with immediate administration of antibiotics after the procedure. Nevertheless, studies with larger number of patients and statistical analysis are necessary in the near future.

Laparoscopic Splenectomy Versus Open Splenectomy In Massive and Giant Spleens: Should we Update the 2008 EAES Guidelines?
imageThe objective of this study was to derive some useful parameters to define the feasibility of laparoscopic splenectomy (LS) in massive [spleen longitudinal diameter (SLD)>20 cm] and giant spleens (SLD>25 cm). Between December 1996 and May 2017, 175 patients underwent an elective splenectomy. A laparoscopic approach was used in 133 (76%) patients. Massive spleens were treated in 65 (37.1%) patients, of which 24 were treated laparoscopically. In this subset of massive spleens, the results of laparoscopic splenectomy in massive spleens (LSM) and open splenectomy in massive spleens (OSM) were compared. The clinical outcome of a subgroup of patients with giant spleens was also analyzed. The LSM group resulted in significant longer operative times (143±31 vs. 112±40 min; P=0.001), less blood loss (278±302 vs. 575±583 mL; P=0.007), and shorter hospital stay (6±3 vs. 9±4 d; P=0.004). No conversions were experienced in the LSM group, and the morbidity rate was similar in both the LSM and OSM groups (16.6% vs. 20%; P=0.75). When considering the subset of 9 LSM patients and 26 OSM patients with giant spleens, the same favorable tendency of the laparoscopic group as regards surgical conversion, blood loss, and hospital stay was maintained. The laparoscopic approach can be successfully proposed in the presence of massive splenomegaly also after a careful preoperative evaluation of the expected abdominal "working space." In experienced hands, LS is safe, feasible, and associated with better outcomes than open splenectomy for the treatment of massive and giant spleen, with a maximum SLD limit of 31 cm.

Symptomatic, Radiological, and Quality of Life Outcome of Paraesophageal Hernia Repair With Urinary Bladder Extracellular Surgical Matrix: Comparison With Primary Repair
imageIntroduction: Paraesophageal hernia repairs are prone to recurrence and mesh reinforcement is common. Both biologic and prosthetic meshes have been used. We report a comparison of a new type of biologically derived graft, Gentrix Surgical Urinary Bladder Matrix (UBM). Methods: The medical records of 65 patients who underwent paraesophageal hernia repair (PEHR) were reviewed. Primary data points included demographics, first-time or recurrent hernia, operative approach, graft or primary repair, operative time, and postoperative complications. Patients then underwent upper gastrointestinal series, completed the GERD-HRQL symptom severity questionnaire, and the SF-36 generic quality of life instrument. Results: A total of 32 patients underwent graft-reinforced repair, 33 underwent primary repair. More patients in the UBM group were being treated for recurrent PEH. Demographic data and postoperative complications were similar. There was no difference in recurrence rates, size of recurrence, postoperative symptomatic or quality of life improvement. Patients who suffered recurrence in the primary repair group had more severe symptoms and a higher rate of dissatisfaction. Of the 3 patients with recurrences after Gentrix placement, reoperation demonstrated anterior failure where no reinforcement had occurred because of the posteriorly placed U-shaped graft. Conclusions: The use of UBM was not associated with an increased complications despite use in more difficult patients. Although there appeared to be no difference in recurrence rate or size, it was associated with less severe symptomatic recurrences. The U-shape configuration is prone to recurrence at the site of the repair not covered by the graft, suggesting that a keyhole configuration may be superior.

Laparoscopic Multiple Parenchyma-sparing Concomitant Liver Resections for Colorectal Liver Metastases
imageBackground: Parenchyma-sparing concept in liver surgery has received a new incitement with the introduction of laparoscopic techniques. Multiple concomitant liver resections are a major component in the parenchyma-sparing concept. Materials and Methods: In total, 689 patients underwent laparoscopic liver resection for colorectal liver metastases from August 1998 to 2017, and 171 patients were eligible for this study. Patients were divided into 3 groups: group I with single liver resection (36 patients); group II with multiple concomitant liver resections (104 patients); group III with liver resection(s) combined with concomitant liver ablation (31 patients). Perioperative outcomes and survival were compared between the groups I and II, whereas variables of group III were presented as complementary information, avoiding statistically exigent multiple comparisons. Results: There were 6 conversions, 0, 3 (2.9%), and 2 (6.5%), respectively in the groups I, II, and III. Median operative time was 161, 186, and 224 minute in the groups I, II, and III, respectively. Median blood loss was 300 mL in groups I and II, and 200 mL in group III. It was a tendency to higher rate of postoperative complications in the group of single resections with morbidity rate of 31%, 19%, and 23% in group I, II, and III, respectively. Median postoperative stay was 3 days in all groups. Tumor-free margin resection was achieved in 92%, 86%, and 93%, respectively in the groups I, II, III. The median weight of resected specimen was significantly lower in group II (90 vs. 257 g; P<0.001). There were no significant differences in survival between the groups. The 5-year overall survival was 31%, 42%, and 43% for groups I, II, and III, respectively. Conclusions: Laparoscopic multiple concomitant parenchyma-sparing liver resections provide surgical and oncologic outcomes comparable with single greater resections for multiple lesions. This approach could be recommended for a wide application in specialized hepatopancreatobiliary centers.

Diaphragmatic Hernia After Totally Laparoscopic Total Gastrectomy for Gastric Cancer
imageThis study aimed to investigate the occurrence of diaphragmatic hernia (DH) after totally laparoscopic total gastrectomy (TLTG) for gastric cancer. We reviewed retrospectively collected data from 490 consecutive patients who underwent TLTG (functional method, 365; overlap method, 125) for upper body gastric cancer, between January 2011 and May 2017, performed by a single surgeon. The median follow-up period was 40.6 months. Of 490 patients, 8 (1.63%) developed DH at a mean interval after TLTG of 7.3 (range, 3.4 to 12.8) months. All 8 patients were from the functional group, and presented with abdominal pain or vomiting. They were managed with emergency surgery (5 laparoscopic hernia reduction, 3 open hernia reduction). The grade of complication according to Clavien-Dindo classification (CDC) was CDC-III in 7 cases and CDC-IV in 1 case. There was no death associated with DH complications. None of the patients in the overlap group developed DH. The incidence of DH after TLTG is negligible in the overlap method. Therefore, the overlap method may be a safe reconstruction technique that can reduce the occurrence of DC after TLTG for gastric cancer.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Gastroenterology & Hepatology

Norfloxacin, ciprofloxacin, trimethoprim–sulfamethoxazole, and rifaximin for the prevention of spontaneous bacterial peritonitis: a network meta-analysis
imageFor the prevention of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites, prophylactic antibiotics are recommended as a standard regimen. This study aimed to assess the efficacy of norfloxacin (N), ciprofloxacin (C), trimethoprim–sulfamethoxazole (T-S), and rifaximin (R) in the prevention of SBP. We searched the electronic databases including PubMed, Cochrane Library, Embase, and Web of Science from inception till 1 August 2018. The randomized-controlled trials that compared N, C, T-S, R, and placebo (P) were identified. A network meta-analysis (NMA) was carried out using the software STATA 14.0 and Revman 5.3. We included 16 studies involving 1984 participants in the NMA for SBP prevention. The NMA results showed that, compared with those treated with P (reference), patients treated with C, N, or R had a lower incidence of SBP and mortality. Similarly, the incidences of SBP and mortality for R were lower than those for N. The probabilities of ranking results showed that R ranked first with respect to the outcomes of the incidence of SBP and mortality. According to our results, R seemed to be the optimal regimen for protecting against SBP in patients with cirrhosis and ascites. However, considering the limitations of our study, additional high-quality studies are required in this respect.

The association between functional dyspepsia and depression: a meta-analysis of observational studies
imageConcomitant functional dyspepsia (FD) and psychosocial stressors have been reported; however, the association between FD and depression remains controversial and no quantitative meta-analysis exists. Published articles were identified through a comprehensive review of PubMed, Embase, and Web of Science from inception to the 8 July 2018. The pooled odds ratios (ORs) with 95% confidence intervals and subgroup analyses were calculated using a random-effects model. Findings for a total of 59 029 individuals were pooled across 23 studies and examined. Our analyses showed a positive association between FD and depression, with an OR of 2.28 (95% confidence interval: 2.02–3.81; I2=100%). In the subgroup analysis, FD patients in Europe (OR=6.19) were more likely to have depression compared with Asians (OR=2.47); the overall significance results decreased the most in subgroup which the overall significance of the subgroup analyses results decreased the most in studies that adjusted for BMI (OR=1.42). Our meta‐analysis showed a positive association between FD and depression. Further large‐scale prospective cohort studies are needed to investigate the causality between FD and depression.

Budesonide treatment for microscopic colitis: systematic review and meta-analysis
imageMicroscopic colitis (MC), encompassing lymphocytic and collagenous colitis, is a common cause for chronic nonbloody diarrhoea, which impacts significantly on the quality of life for patients. Despite increasing awareness of the condition and its treatment, there is considerable variation in therapeutic approaches. To conduct a systematic review and meta-analysis on the efficacy and safety of budesonide in the treatment of MC. We searched Medline, Embase and Central databases using predefined search methodology for randomised trials using budesonide in the treatment of MC. We extracted data, on the efficacy and safety of budesonide, from studies identified that met the feasibility for analysis criteria. These data were pooled with a fixed effects model. Nine studies met the inclusion criteria for analysis. The pooled odds ratios (ORs) for a response to budesonide therapy at induction and maintenance were 7.34 [95% confidence interval (CI): 4.08–13.19] and 8.35 (95% CI: 4.14–16.85) respectively. Histological response rates were superior in budesonide-treated patients compared to placebo following induction (OR: 11.52; 95% CI: 5.67–23.40) and maintenance treatment (OR: 5.88; 95% CI: 1.90–18.17). There was no difference in adverse events. Significant relapse rates (>50%) were observed following treatment cessation with no difference noted between the budesonide or the placebo-treated patients. Budesonide is an effective treatment option for MC for achieving induction and maintenance of both clinical and histological response. High relapse rates on treatment cessation were observed.

Prevalence of dyspepsia in patients with cholecystolithiasis: a systematic review and meta-analysis
imageCholecystolithiasis and functional gastrointestinal disorders are both highly prevalent in the industrialized world and may exist concomitantly. The presence of both conditions impedes identification of the source of symptoms, leading to a risk of ineffective cholecystectomies with lack of symptom resolution. We carried out a systematic review and meta-analysis to determine the prevalence of dyspepsia in patients with uncomplicated cholecystolithiasis. The electronic databases Medline, Embase, and Web of Science were searched for articles reporting the prevalence of dyspepsia in adults (≥18 years) with uncomplicated cholecystolithiasis. Pooled prevalence and 95% confidence interval were calculated. I2 statistics were used to determine heterogeneity and the Methodological Evaluation of Observational Research criteria were applied for quality assessment. The study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Of the 1696 studies evaluated, 13 reported the prevalence of dyspepsia in a total of 1227 cholecystolithiasis patients seeking medical care. The pooled prevalence of dyspepsia in patients with cholecystolithiasis was 65.7% (95% confidence interval: 51–79%). However, heterogeneity was large across studies. Overall, three studies used validated diagnostic criteria. Variation in diagnostic measures significantly influenced the prevalence of dyspepsia. In conclusion, symptoms similar to those of functional gastrointestinal disorders are common in patients with cholecystolithiasis, obscuring the source of abdominal complaints. Tools to select patients who will benefit from cholecystectomy are paramount to prevent ineffective surgery.

Peroral cholangioscopy with cholangioscopy-directed biopsies in the diagnosis of biliary malignancies: a systemic review and meta-analysis
imageBackground and aim Accurate diagnosis is essential in the appropriate management of biliary strictures. Our aim is to evaluate the efficacy of cholangioscopy-directed biopsies in differentiating biliary intraductal malignancies from benign lesions. Materials and methods Articles were searched in Medline, PubMed, and Ovid journals. Pooling was performed by both fixed-effects and random-effects models. Only studies from which a 2×2 table could be constructed for true-positive, false-negative, false-positive, and true-negative values were included. Results Initial search identified 2110 reference articles for peroral cholangioscopy; of these, 160 relevant articles were selected and reviewed. Data were extracted from 15 studies (N=539) that fulfilled the inclusion criteria. Pooled sensitivity of cholangioscopy-directed biopsies in diagnosing malignancy was 71.9% [95% confidence interval (CI): 66.1–77.1] and pooled specificity was 99.1% (95% CI: 96.9–99.9). The positive likelihood ratio of cholangioscopy-directed biopsies was 18.1 (95% CI: 9.1–35.8), whereas the negative likelihood ratio was 0.3 (95% CI: 0.2–0.4). The pooled diagnostic odds ratio was 71.6 (95% CI: 32.8–156.4). All the pooled estimates calculated by fixed-effects and random-effect models were similar. Summary receiver operating characteristic curves showed an area under the curve of 0.98. The χ2 heterogeneity for all the pooled accuracy estimates was 5.62 (P=0.96). Conclusion Peroral cholangioscopy with cholangioscopy-directed biopsies has a high specificity in differentiating intraductal malignancies from benign lesions. Cholangioscopy-directed biopsies should be strongly considered for biliary stricture evaluation.

How to best measure quality of life in coeliac disease? A validation and comparison of disease-specific and generic quality of life measures
imageObjective Health-related quality of life (HRQoL) is an important outcome in chronic disease. Generic HRQoL questionnaires may not adequately reflect disease-specific challenges in coeliac disease. We investigated whether disease-specific HRQoL questionnaires add relevant information to generic measures that will better help to identify patients experiencing problems. Patients and methods We performed a cross-cultural validation of the Celiac Disease Quality Of Life-survey (CD-QOL), next we developed and validated a new disease-specific HRQoL questionnaire, and finally compared their predictive validity with the disease-generic RAND SF-36/SF-12 in 825 patients (mean age: 56.1±15.8 years) with (reported) biopsy-proven coeliac disease. Internal consistency and convergent, discriminative and predictive validity of the questionnaires was determined. Results Two Dutch versions of the CD-QOL were validated, consisting of 14 and six items, respectively (CD-QOL-14-NL, CD-QOL-6-NL). We developed and validated the CeliacQ-27, which has 27-items across three subscales (Limitations, Worries and Impact on daily life), and a short seven-item version, the CeliacQ-7. All questionnaires had excellent psychometric properties and differentiated well between active disease and clinical remission and strict versus poor dietary adherence. The added value of the disease-specific questionnaires to the generic HRQoL measure to the explained variance of symptom burden and dietary adherence was limited. Conclusion HRQoL in patients with coeliac disease can easily be assessed by brief generic as well as disease-specific measures. Disease-specific questionnaires, however, provide more explicit information on disease-relevant areas of functioning.

Young age and tobacco use are predictors of lower medication adherence in inflammatory bowel disease
imageBackground Medication adherence is crucial in the management of patients with inflammatory bowel disease (IBD) because medication nonadherence in these patients is associated with an increased risk of flare-up, relapse, recurrence, loss of response to anti-tumour necrosis factor agents, morbidity and mortality, and poor quality of life. Data on risk factors are very controversial in the literature. Aim To assess the prevalence of medication nonadherence and to identify predictors of low medication adherence in Spanish patients with IBD. Patients and methods We carried out a cross-sectional study that included consecutive outpatients with IBD attending in our adult tertiary clinic in a 3-month period. Morisky 8-Item Medication Adherence Scale questionnaire as well as a survey of sociodemographic data were used. Results A total of 181 patients were evaluated. Almost half of the patients (46.4%) had high medication adherence, 30.9% had medium adherence, and 22.7% had low adherence. In relation to predictive factors of medication adherence, multivariate analysis showed that age was associated with high adherence [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.01–1.06; P=0.002]. However, being a smoker and presence of Crohn's disease were associated with low adherence (OR: 3.47; 95% CI: 1.36–8.90; P<0.01 and OR: 2.54; 95% CI: 1.12–5.79; P<0.05, respectively). Conclusion Only half of patients were high medication adherers. Young age, active smoking, and Crohn's disease seems to be predictors of low medication adherence. On the basis of these data, efforts for reinforce medication adherence should be especially directed to young patients and smokers.

Impact of occupational stress on irritable bowel syndrome pathophysiology and potential management in active duty noncombat Greek military personnel: a multicenter prospective survey
imageIntroduction Irritable bowel syndrome (IBS) is one of the gut–brain axis interaction disorders. It has global distribution with varying prevalence and particular financial and psychological consequences. IBS has been associated with stress and anxiety, conditions that are usually prevalent in the army. There are scarce data investigating the impact of IBS on noncombat active duty military without reports of Greek military or stress in the occupational environment. Materials and methods The main exclusion criteria in our noncombat military multicenter prospective survey were gastrointestinal pathologies, malignancies, hematochezia, recent infections and antibiotics prescription, and pregnancy. Questionnaires included a synthesis of baseline information, lifestyle, and diet, psychological and stress-investigating scales and the IBS diagnosis checklist. Hospital Anxiety and Depression Scale and Rome IV criteria were utilized. Results Among 1605 participants included finally, the prevalence of IBS was 8% and 131 cases were identified. Women were more vulnerable to IBS, although male sex was prevalent at a ratio of 3.5 : 1 (male:female) in the entire sample. The mean age of all participants was 23.85 years; most of the IBS patients were older than thirty. Abnormal anxiety scores and high levels of occupational stress were related to an IBS diagnosis. Discussion This prospective multicenter survey showed, for the first time, the potential impact of occupational stress on IBS in active duty noncombat Greek Military personnel. The diagnosis of IBS by questionnaire is a quick, affordable way that can upgrade, by its management, the quality of life and relieve from the military burden. Our results are comparable with previous studies, although large-scale epidemiological studies are required for the confirmation of a possible causative relationship.

Premedication with corticosteroids does not impact the pharmacokinetics of infliximab in inflammatory bowel disease irrespective of azathioprine cotreatment
imageObjective Loss of infliximab (IFX) effect is a clinical challenge in the management of patients with Crohn's disease (CD), but this can potentially be reduced with azathioprine (AZA) or with corticosteroids (CS). We aimed to study whether CS premedication with or without cotreatment with AZA could reduce antibody formation and affect the IFX elimination rate. Patients and methods A cross-sectional observational study was conducted at two centers with CD patients receiving maintenance IFX therapy for 12–18 months. In addition to IFX, patients received either CS premedication or not, with or without concominant AZA. Results Fifty-seven patients were included in the study. Thirty-one patients received premedication with CSs, and 11 (35.5%) of these also received AZA, whereas this was the case for 22 of 26 (84.6%) patients in the non-CS group. No difference in IFX trough level (P=0.10) or halftime elimination (P=0.31) was observed with or without CS premedication. Concomitant AZA was associated with significantly longer mean half-life of IFX (P=0.04). Total IFX antibody concentrations were 15.8 and 12.9 with and without CS, respectively, in those not receiving AZA versus 4.3 and 6.1 AU/ml with and without CS, respectively, in those receiving AZA (P=0.004). Premedication with CS did not have any effect on the frequency of antibody formation (P=0.28). Conclusion In patients with CD and in maintenance IFX therapy, premedication with CS did not influence antibody formation, IFX trough levels or IFX halftime elimination, irrespective of concomitant AZA use. However, the use of AZA was associated with higher IFX trough levels and lower total IFX antibody concentrations.

Acute pancreatitis in end-stage renal disease patients in the USA: a nationwide, propensity score-matched analysis
imageBackground Limited data exist regarding the effects of end-stage renal disease (ESRD) on acute pancreatitis (AP). This study aimed to evaluate the association between ESRD and outcomes and resource utilization of AP. Materials and methods The 2014 National Inpatient Sample database was used to identify all hospitalized patients with a principal diagnosis of AP. Propensity score matching was performed to create a matched cohort of ESRD and non-ESRD patients. The in-hospital mortality, morbidity, resource utilization and expenditures of AP in ESRD patients were compared to non-ESRD patients. Multivariate analysis was performed for further adjustment for potential confounders. Results Of 382 595 AP patients, 7380 ESRD patients and 8050 non-ESRD patients were created after propensity score matching. ESRD patients had more tendency to have hypercalcemia-related or AP-related to other/unspecified causes, whereas non-ESRD patients had more tendency to have alcohol-related, gallstone-related, and hypertriglyceridemia-related AP. In multivariate analysis, ESRD was associated with increased in-hospital mortality, increased length of hospital stay, and increased hospitalization costs and charges. No differences were observed in inpatient morbidity, imaging study use, and procedures performed during hospitalization. Conclusion In this large nationwide study using inpatient USA database, we demonstrate higher AP-related mortality, and resource utilization among ESRD patients when compared with non-ESRD patients.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Epidemiology

Sponsorship by Big Oil, Like the Tobacco Industry, Should be Banned by the Research Community
No abstract available

Fine Particulate Air Pollution and Birthweight: Differences in Associations Along the Birthweight Distribution
imageBackground: Maternal exposure to fine particulate air pollution (PM2.5) during pregnancy is associated with lower newborn birthweight, which is a risk factor for chronic disease. Existing studies typically report the average association related with PM2.5 increase, which does not offer information about potentially varying associations at different points of the birthweight distribution. Methods: We retrieved all birth records in Massachusetts between 2001 and 2013 then restricted our analysis to full-term live singletons (n = 775,768). Using the birthdate, gestational age, and residential address reported at time of birth, we estimated the average maternal PM2.5 exposure during pregnancy of each birth. PM2.5 predictions came from a model that incorporates satellite, land use, and meteorologic data. We applied quantile regression to quantify the association between PM2.5 and birthweight at each decile of birthweight, adjusted for individual and neighborhood covariates. We considered effect modification by indicators of individual and neighborhood socioeconomic status (SES). Results: PM2.5 was negatively associated with birthweight. An interquartile range increase in PM2.5 was associated with a 16 g [95% confidence interval (CI) = 13, 19] lower birthweight on average, 19 g (95% CI = 15, 23) lower birthweight at the lowest decile of birthweight, and 14 g (95% CI = 9, 19) lower birthweight at the highest decile. In general, the magnitudes of negative associations were larger at lower deciles. We did not find evidence of effect modification by individual or neighborhood SES. Conclusions: In full-term live births, PM2.5 and birthweight were negatively associated with more severe associations at lower quantiles of birthweight.

Associations Between Ambient Air Pollutant Concentrations and Birth Weight: A Quantile Regression Analysis
imageIntroduction: We investigated the extent to which associations of ambient air pollutant concentrations and birth weight varied across birth weight quantiles. Methods: We analyzed singleton births ≥27 weeks of gestation from 20-county metropolitan Atlanta with conception dates between January 1, 2002 and February 28, 2006 (N = 273,711). Trimester-specific and total pregnancy average concentrations for 10 pollutants, obtained from ground observations that were interpolated using 12-km Community Multiscale Air Quality model outputs, were assigned using maternal residence at delivery. We estimated associations between interquartile range width (IQRw) increases in pollutant concentrations and changes in birth weight using quantile regression. Results: Gestational age-adjusted associations were of greater magnitude at higher percentiles of the birth weight distribution. Pollutants with large vehicle source contributions (carbon monoxide, nitrogen dioxide, PM2.5 elemental carbon, and total PM2.5 mass), as well as PM2.5 sulfate and PM2.5 ammonium, were associated with birth weight decreases for the higher birth weight percentiles. For example, whereas the decrease in mean birthweight per IQRw increase in PM2.5 averaged over pregnancy was -7.8 g (95% confidence interval = −13.6, −2.0 g), the quantile-specific associations were: 10th percentile −2.4 g (−11.5, 6.7 g); 50th percentile −8.9 g (−15.7, −2.0g); and 90th percentile −19.3 g (−30.6, −7.9 g). Associations for the intermediate and high birth weight quantiles were not sensitive to gestational age adjustment. For some pollutants, we saw associations at the lowest quantile (10th percentile) when not adjusting for gestational age. Conclusions: Associations between air pollution and reduced birth weight were of greater magnitude for newborns at relatively heavy birth weights.

Advancing Substantive Knowledge by Asking New Questions, Best Done in the Light of Answers to Older Questions
No abstract available

Increased Risk of Opioid Overdose Death Following Cold Weather: A Case–Crossover Study
imageBackground: The United States is in the midst of an opioid overdose crisis. Little is known about the role of environmental factors in increasing risk of fatal opioid overdose. Methods: We conducted a case–crossover analysis of 3,275 opioid overdose deaths recorded in Connecticut and Rhode Island in 2014–2017. We compared the mean ambient temperature on the day of death, as well as average temperature up to 14 days before death, to referent periods matched on year, month, and day of week. Results: Low average temperatures over the 3–7 days before death were associated with higher odds of fatal opioid overdose. Relative to 11°C, an average temperature of 0°C over the 7 days before death was associated with a 30% higher odds of death (odds ratio: 1.3; 95% confidence interval, 1.1, 1.5). Conclusions: Low average temperature may be associated with higher risk of death due to opioid overdose.

Human Health and the Social Cost of Carbon: A Primer and Call to Action
imageNo abstract available

The Interaction Continuum
imageA common reason given for assessing interaction is to evaluate "whether the effect is larger in one group versus another". It has long been known that the answer to this question is scale dependent: the "effect" may be larger for one subgroup on the difference scale, but smaller on the ratio scale. In this article, we show that if the relative magnitude of effects across subgroups is of interest then there exists an "interaction continuum" that characterizes the nature of these relations. When both main effects are positive then the placement on the continuum depends on the relative magnitude of the probability of the outcome in the doubly exposed group. For high probabilities of the outcome in the doubly exposed group, the interaction may be positive-multiplicative positive-additive, the strongest form of positive interaction on the "interaction continuum". As the probability of the outcome in the doubly exposed group goes down, the form of interaction descends through ranks, of what we will refer to as the following: positive-multiplicative positive-additive, no-multiplicative positive-additive, negative-multiplicative positive-additive, negative-multiplicative zero-additive, negative-multiplicative negative-additive, single pure interaction, single qualitative interaction, single-qualitative single-pure interaction, double qualitative interaction, perfect antagonism, inverted interaction. One can thus place a particular set of outcome probabilities into one of these eleven states on the interaction continuum. Analogous results are also given when both exposures are protective, or when one is protective and one causative. The "interaction continuum" can allow for inquiries as to relative effects sizes, while also acknowledging the scale dependence of the notion of interaction itself.

Bayesian Methods for Exposure Misclassification Adjustment in a Mediation Analysis: Hemoglobin and Malnutrition in the Association Between: Ascaris: and IQ
imageBackground: Soil-transmitted helminth infections have been found to be associated with child development. The objective was to investigate hemoglobin levels and malnutrition as mediators of the association between Ascaris infection and intelligence quotient (IQ) scores in children. Methods: We conducted a longitudinal cohort study in Iquitos, Peru, between September 2011 and July 2016. A total of 1760 children were recruited at 1 year of age and followed up annually to 5 years. We measured Ascaris infection and malnutrition at each study visit, and hemoglobin levels were measured as of age 3. The exposure was defined as the number of detected Ascaris infections between age 1 and 5. We measured IQ scores at age 5 and used Bayesian models to correct exposure misclassification. Results: We included a sample of 781 children in the analysis. In results adjusted for Ascaris misclassification, mean hemoglobin levels mediated the association between Ascaris infection and IQ scores. The natural direct effects (not mediated by hemoglobin) (95% CrI) and natural indirect effects (mediated by hemoglobin) (95% CrI) were compared with no or one infection: −0.9 (−4.6, 2.8) and −4.3 (−6.9, −1.6) for the effect of two infections; −1.4 (−3.8, 1.0) and −1.2 (−2.0, −0.4) for three infections; and −0.4 (−3.2, 2.4) and −2.7 (−4.3, −1.0) for four or five infections. Conclusion: Our results are consistent with the hypothesis that hemoglobin levels mediate the association between Ascaris infection and IQ scores. Additional research investigating the effect of including iron supplements in STH control programs is warranted.

Misclassification of Sex Assigned at Birth in the Behavioral Risk Factor Surveillance System and Transgender Reproductive Health: A Quantitative Bias Analysis
imageBackground: National surveys based on probability sampling methods, such as the Behavioral Risk Factor and Surveillance System (BRFSS), are crucial tools for unbiased estimates of health disparities. In 2014, the BRFSS began offering a module to capture transgender and gender nonconforming identity. Although the BRFSS provides much needed data on the this population, these respondents are vulnerable to misclassification of sex assigned at birth. Methods: We applied quantitative bias analysis to explore the magnitude and direction of the systematic bias present as a result of this misclassification. We use multivariate Poisson regression with robust standard errors to estimate the association between gender and four sex-specific outcomes: prostate-specific antigen testing, Pap testing, hysterectomy, and pregnancy. We applied single and multiple imputation methods, and probabilistic adjustments to explore bias present in these estimates. Results: Combined BRFSS data from 2014, 2015, and 2016 included 1078 transgender women, 701 transgender men, and 450 gender nonconforming individuals. Sex assigned at birth was misclassified among 29.6% of transgender women and 30.2% of transgender men. Transgender and gender nonconforming individuals excluded due to sex-based skip patterns are demographically distinct from those who were asked reproductive health questions, suggesting that there is noteworthy selection bias present in the data. Estimates for gender nonconforming respondents are vulnerable to small degrees of bias, while estimates for cancer screenings among transgender women and men are more robust to moderate degrees of bias. Conclusion: Our results demonstrate that the BRFSS methodology introduces substantial uncertainty into reproductive health measures, which could bias population-based estimates. These findings emphasize the importance of implementing validated sex and gender questions in health surveillance surveys. See video abstract at, http://links.lww.com/EDE/B562.

Prenatal Diethylstilbestrol Exposure and Risk of Depression in Women and Men
imageBackground: Prenatal exposure to diethylstilbestrol (DES), an endocrine-disrupting chemical, may be associated with depression in adulthood, but previous findings are inconsistent. Methods: Women (3,888 DES exposed and 1,729 unexposed) and men (1,021 DES exposed and 1,042 unexposed) participating in the National Cancer Institute (NCI) DES Combined Cohort Follow-up Study were queried in 2011 for any history of depression diagnosis or treatment. Hazard ratios (HRs; 95% confidence intervals [CIs]) estimated the associations between prenatal DES exposure and depression risk. Results: Depression was reported by 993 (26%) exposed and 405 (23%) unexposed women, and 177 (17%) exposed and 181 (17%) unexposed men. Compared with the unexposed, HRs for DES and depression were 1.1 (95% CI = 0.9, 1.2) in women and 1.0 (95% CI = 0.8, 1.2) in men. For medication-treated depression, the HRs (CIs) were 1.1 (0.9, 1.2) in women and 0.9 (0.7, 1.2) in men. In women, the HR (CI) for exposure to a low cumulative DES dose was 1.2 (1.0, 1.4), and for DES exposure before 8 weeks' gestation was 1.2 (1.0, 1.4). In men, the HR for low dose was 1.2 (95% CI = 0.9, 1.6) and there was no association with timing. In women, associations were uninfluenced by the presence of DES-related vaginal epithelial changes or a prior diagnosis of DES-related adverse outcomes. Conclusions: Prenatal DES exposure was not associated overall with risk of depression in women or men. In women, exposure in early gestation or to a low cumulative dose may be weakly associated with an increased depression risk.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Coronary Artery Disease

Beneficial effect of ticagrelor on microvascular perfusion in patients with ST-segment elevation myocardial infarction undergoing a primary percutaneous coronary intervention
imageBackground Ticagrelor significantly reduced the incidence of death, myocardial infarction, and stent thrombosis in patients with ST-segment elevation myocardial infarction (STEMI) intended for reperfusion with a primary percutaneous coronary intervention (pPCI). However, the effects of this drug on microvascular perfusion in patients presenting with STEMI have not been evaluated completely. Patients and methods A total of 298 patients presenting with STEMI were randomized to either ticagrelor 180 mg loading, followed by 90 mg twice daily, or clopidogrel 600 mg loading, followed by 75 mg daily. The primary endpoint was ST-segment resolution at 90 min after pPCI. The secondary endpoints included myocardial blush grade and corrected thrombolysis in myocardial infarction frame count after the procedure. Left ventricular ejection fraction and major adverse cardiac events (MACE) at the 1- and 6-month follow-up time points were also recorded. Results There were no significant differences between the two groups with respect to baseline characteristics. Ticagrelor administration resulted in a higher rate of completed ST-segment resolution (58.67 vs. 39.86%, P=0.001), higher myocardial blush grade (2.63±0.64 vs. 2.41±0.71, P=0.005), and lower corrected thrombolysis in myocardial infarction frame count (19.68±7.38 vs. 22.35±8.30, P=0.004). At 6 months, left ventricular ejection fraction was higher (55.01±8.44 vs. 52.34±9.05%, P=0.009) in the ticagrelor group. Kaplan–Meier analysis showed that MACE-free survival had also improved in the ticagrelor group during the 1- and 6-month follow-up time points. Conclusion Compared with clopidogrel, ticagrelor improves myocardial perfusion and left ventricular ejection fraction, and reduces the incidence of MACE for STEMI patients undergoing pPCI, with no significant increase in major bleeding.

Ticagrelor and microvascular perfusion in patients with acute myocardial infarction: hype or hope?
No abstract available

Outcomes of a routine invasive strategy in elderly patients with non-ST-segment elevation myocardial infarction from 2005 to 2014: results from the PL-ACS registry
imageBackground Elderly patients (≥75 years old) with non-ST-segment elevation myocardial infarction (NSTEMI) represent a large subgroup of all cases. They are rarely included in randomized trials because of comorbidities and concerns about complications. Furthermore, invasive treatments are used less frequently in this patient group. The aim of this study was to analyze trends in invasive procedures and outcomes in elderly patients with NSTEMI from 2005 to 2014. Patients and methods We analyzed 68 978 elderly patients with NSTEMI enrolled in the prospective, nationwide Polish Registry of Acute Coronary Syndromes from 2005 to 2014. Results Elderly patients accounted for 34.9% of all patients with NSTEMI. There was an increase in the rate of coronary angiography from 19.1% in 2005–2007 to 83.5% in 2012–2014 among women (P<0.05) and from 26.0 to 87.5% among men (P<0.05). Simultaneously, there was an increase in percutaneous coronary intervention usage from 12.9% in 2005–2007 to 56.3% in 2012–2014 among women (P<0.05) and from 17.6 to 60.5% among men (P<0.05). On comparing the periods of 2005–2007 and 2012–2014, in-hospital mortality decreased considerably from 9.6 to 5.3% among women (P<0.05) and from 9.1 to 4.7% among men (P<0.05). In the same time period, the 12-month mortality ratio decreased: from 30.5 to 22.0% among women (P<0.05) and from 32.0 to 22.8% among men (P<0.05). In multivariate analysis, age was one of the most important factors associated with poorer outcome. With each increased decade of life, the outcomes worsened – the relative risk of mortality was 1.63 [95% confidence interval (CI): 1.59–1.68] for the in-hospital prognosis and 1.57 (95% CI: 1.55–1.59) for the 12-month prognosis. Invasive treatment strategy was the strongest factor associated with improved outcome, with a relative risk of 0.31 (95% CI: 0.29–0.33) for in-hospital mortality and 0.51 (95% CI: 0.49–0.52) for 12-month mortality, respectively. Conclusion Patients with NSTEMI benefit considerably from invasive procedures independent of age. In-hospital as well as 12-month outcomes in elderly patients improved markedly in the last decade as a result of the wide implementation of an invasive treatment strategy.

Characteristics and outcomes of patients with cancer presenting with acute myocardial infarction
imageBackground Limited data are available regarding the optimal management of patients with cancer in the acute myocardial infarction (AMI) setting. Patients and methods We studied consecutive patients with AMI included in a national registry (years 2010, 2016) with the diagnosis of past or active malignancy and followed them for 1 year. Results Our cohort consisted of 2937 cancer-naive patients and 152 patients with cancer, of whom 35% presented with active malignancies. Compared with cancer-naive patients, patients with cancer were older, with female predominance, and presented more often with a history of hypertension and chronic kidney disease (P<0.001 for all comparisons). The rate of ST-elevation AMI was comparable (P=0.067). GRACE score more than 140 was more common in the cancer group (P<0.001). Most patients with cancer were referred to coronary angiography, though less than cancer-naive patients (87 vs. 93%; P=0.004). The rate of percutaneous coronary intervention was similar (P=0.265). Propensity score matching demonstrated similar rates of in-hospital complications between groups, and no mortality or major cardiac adverse event differences were noted at 30 days. Moreover, short-term mortality was similar between patients with active versus past malignancies, and between patients with solid and nonsolid tumors. However, cancer in patients with AMI was found to predict an increased mortality risk at 1 year by multivariable analysis (hazard ratio=2.52; P<0.001). Conclusion Patients with cancer and AMI have a more complicated clinical presentation, yet their short-term prognosis is similar to cancer-naive patients. Nevertheless, 1-year outcome is worse.

Path analysis for key factors influencing long-term quality of life of patients following a percutaneous coronary intervention
imageObjectives This cross-sectional study aimed to investigate the long-term quality of life (QOL) influencing of patients following a percutaneous coronary intervention (PCI) as well as its influencing factors. Patients and methods From June 2013 to April 2014, 428 PCI patients were enrolled in this questionnaire survey. The demographic and clinical data, Social Support Rating Scale, Medical Coping Modes Questionnaire, Social Disability Screening Schedule, and Short Form 36 Health Status Questionnaire were collected. Statistical analyses for data and path analyses for influencing factors were then carried out. Results PCI patients received considerable social support from family and society, and most PCI patients adopted negative coping styles (avoidance and acceptance-resignation). Approximately 70.3% of PCI patients had a serious functional defect, and 96.97% of patients had an average (79.91%) or better (17.06%) QOL. Multiple linear regression analysis showed that long-term QOL of PCI patients was correlated positively with social support and sleep quality, but correlated negatively with the acceptance-resignation coping style, social function defects, and number of adverse cardiac events. Path analysis further showed that social support, acceptance-resignation coping style, social function defects, number of adverse cardiac events, and sleep quality exerted important effects on long-term QOL of PCI patients in descending order. Conclusion Most PCI patients had an average medium-term or better long-term QOL. Social support, acceptance-resignation coping style, social function defects, number of adverse cardiac events, and sleep quality were key influencing factors.

Ultra-low-contrast angiography in patients with advanced chronic kidney disease and previous coronary artery bypass surgery
imageObjective We sought to describe a technique for ultra-low-contrast angiography (ULCA) in patients with advanced chronic kidney disease (CKD) and previous coronary artery bypass surgery (CABG). Background Patients with advanced CKD and previous CABG are at high risk of developing contrast-induced nephropathy (CIN) because of the additional contrast often required to identify bypass grafts. Apart from hydration, reduced contrast administration is the only established method to minimize the risk of CIN. Patients and methods Ten patients underwent ULCA, whereby an intracoronary injection of saline and coronary guidewires were used instead of test injections of contrast for engagement of bypass grafts with catheters. Estimated glomerular filtration rate (eGFR) before and 30 days following angiography were recorded as was the need for renal replacement therapy 1 year after the procedure. Results All patients completed a diagnostic angiogram without complications. The median volume of contrast delivered was 13.5 ml (interquartile range: 10.5–17.8). The median eGFR was 18.3 ml/min/1.73 m2 (interquartile range: 16.5–28.2). There was no statistically significant difference in eGFR before the procedure and 30 days after the procedure (P=0.79). No patient required dialysis 30 days after the procedure. Two patients required initiation of dialysis at 1 year after the procedure. Conclusion In patients with advanced CKD and previous CABG, ULCA may be performed with high procedural success and without complications, minimizing the risk of CIN in these high-risk patients.

A novel safe method for treatment of giant coronary artery aneurysm: Wire Looping Technique
imageNo abstract available

Off-pump onlay-patch grafting using the left internal mammary artery for a diffusely diseased left anterior descending artery: in-hospital and mid-term outcomes
imageBackground The aims of this study were to evaluate the in-hospital and mid-term outcomes of the off-pump onlay-patch grafting procedure using the left internal mammary artery (LIMA) for a diffusely diseased left anterior descending artery (LAD) and to identify the risk factors for postoperative LIMA graft failure in a single-center retrospective study. Patients and methods A total of 63 patients (52 males, 65.7±9.0 years) undergoing LAD arteriotomy with or without concomitant endarterectomy, followed by reconstruction using LIMA onlay-patch at the time of off-pump coronary artery bypass grafting at our institute from January 2014 to December 2016 were reviewed. The operative mortality, major postoperative morbidity, follow-up all-cause mortality, major adverse cardiac events at follow-up, and postoperative LIMA graft patency were analyzed. The risk factors for postoperative LIMA graft failure on the basis of baseline and surgical characteristics were identified by multivariable logistic regression analysis. Results Eighteen (28.6%) patients underwent concomitant open LAD endarterectomy. The operative mortality rate was 1.6%. Major postoperative morbidity included perioperative myocardial infarction (3.2%), low cardiac output (1.6%), and reoperation for bleeding (1.6%). During the follow-up period of 24.2±9.5 months, all-cause mortality was 1.7% and the incidence of major adverse cardiac events was 6.8%. No repeat revascularization was recorded. In total, 88.1% of LIMA grafts showed FitzGibbon grade A patency determined by noninvasive coronary computed tomography angiography during follow-up. In addition, concomitant LAD endarterectomy and intraoperative LIMA graft flow were found to be independent risk factors for mid-term LIMA graft failure by multivariable logistic regression analysis (odds ratio=2.681, 95% confidence interval: 1.314–9.856, P=0.007 and odds ratio=0.932, 95% confidence interval: 0.791–0.976, P=0.021, respectively). Conclusion Revascularization of a diffusely diseased LAD using the off-pump LIMA onlay-patch technique results in encouraging clinical outcomes with favorable angiographic results. Concomitant LAD endarterectomy and intraoperative LIMA graft flow are associated with the risk of postoperative LIMA graft failure.

Traditional Chinese medicine training for cardiac rehabilitation: a randomized comparison with aerobic and resistance training
imageBackground The aim of this study was to investigate the efficacy and safety of different exercise regimens in the rehabilitation of patients with stable coronary heart disease. Patients and methods This study was a randomized controlled trial to screen 141 patients with stable coronary heart disease who were admitted to the General Administration of Sport of China Sports Medical Science Institute from January 2018 to September 2018. They were randomly divided into the aerobic and resistance training (ART) group for 12 weeks (36 cases), the traditional Chinese medicine training (TCMT) group 12 weeks (37 cases), and the control (CON) group (39 cases). We analyzed the baseline parameters of all participants and the 12-week exercise plate test parameters and related physical and body parameters. Result After 12 weeks of intervention, volume of oxygen (VO2), VO2/kg, metabolic equivalents, VO2/heart rate, stroke volume, and peaked grip strength and flexibility parameters of the ART group and the TCMT group were significantly higher than those of the control group (P<0.05). Resting heart rate of the TCMT group was significantly lower than the CON group, but there was no significant difference between the ART and CON groups (P>0.05). Ventilation/VO2 of the TCMT group was significantly higher than that of the CON group. BMI of the ART group was significantly lower than that of the TCMT group and the CON group, and body fat mass of the TCMT group was significantly smaller than that of the ART group, but there was no difference between the TCMT group and the CON group for BMI and body fat mass. Conclusion Both ART and TCMT can improve the cardiopulmonary aerobic exercise capacity and physical fitness of patients with stable coronary heart disease. Although the degree of improvement is different, they all have certain effects on the rehabilitation of patients with stable coronary heart disease and the application is safe.

Impact of smoking on all-cause mortality and cardiovascular events in patients after coronary revascularization with a percutaneous coronary intervention or coronary artery bypass graft: a systematic review and meta-analysis
imageAlthough cigarette smoking is an independent risk factor for cardiovascular disease, inconsistent results have been published in the literature on its impacts on the cardiovascular health of patients after coronary revascularization with a percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). We performed a comprehensive electronic database search through July 2018. Studies reporting the risk estimates of all-cause mortality and cardiovascular outcomes in patients after coronary revascularization with PCI or CABG on the basis of smoking status were selected. Multivariate-adjusted relative risks (RRs) and 95% confidence intervals (CIs) were pooled using random-effects models with inverse variance weighting. Data from 37 records including 126 901 participants were finally collected. Overall, the pooled RR (95% CI) associated with cigarette smoking was 1.26 (95% CI: 1.09–1.47) for all-cause mortality, 1.08 (95% CI: 0.92–1.28) for major adverse cardiovascular events, 0.96 (95% CI: 0.69–1.35) for cardiovascular mortality and 1.15 (95% CI: 0.81–1.64) for myocardial infarction. The increased risk of all-cause mortality was also observed in former smokers compared with those who had never smoked (RR: 1.19; 95% CI: 1.03–1.38). Furthermore, the negative effects of cigarette smoking on all-cause mortality were also observed in most subgroups. Cigarette smoking has been shown to increase the likelihood of all-cause mortality in patients after coronary revascularization with PCI or CABG. Smoking cessation is essential for PCI or CABG patients to manage their coronary artery disease.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,


Prospects for pharmacotherapies to treat alcohol use disorder: an update on recent human studies Purpose...
Prospects for pharmacotherapies to treat alcohol use disorder: an update on recent human studiesPurpose of review The aim of this study was to provide an update on medication development efforts for alcohol use disorder (AUD) by reviewing recently published (past 2 years) human studies that evaluated medications' effects on alcohol-related outcomes. Recent findings Forty-five publications were found suitable for this review. A variety of compounds have been tested in the past 2 years as potential...
Αλέξανδρος Γ. Σφακιανάκης
1m
Improved Patient Flow and Provider Efficiency After the Implementation of an Electronic Health Record...
Improved Patient Flow and Provider Efficiency After the Implementation of an Electronic Health RecordElectronic health records are used widely across the nation in many different types of healthcare facilities. Electronic health record systems can provide more accurate and complete information about a patient's health, improve patient safety, and improve patient care. The purpose of this project is to evaluate a provider efficiency and workflow program at a hospital-owned, freestanding urgent care...
Αλέξανδρος Γ. Σφακιανάκης
1m
Cardiovascular Medicine
Routine cardiac troponin assessment after percutaneous coronary intervention: useful or hype?Although the angiographic and procedural success of percutaneous coronary intervention (PCI) is now very high, some severe complications may still develop, including periprocedural myocardial infarction (MI). An accurate diagnosis of this condition is essential for guiding the clinical management, as these patients may need a tailored management. The current recommendations for diagnosing periprocedural myocardial...
Αλέξανδρος Γ. Σφακιανάκης
2m
Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation...
Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress SyndromeIntroduction: Ventilator settings for patients with severe acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation are currently set arbitrarily. The impact on serum and pulmonary biotrauma markers of the transition to ultra-protective ventilation settings following extracorporeal membrane oxygenation implantation,...
Αλέξανδρος Γ. Σφακιανάκης
2m
Routine cardiac troponin assessment after percutaneous coronary intervention: useful or hype? Although...
Routine cardiac troponin assessment after percutaneous coronary intervention: useful or hype?Although the angiographic and procedural success of percutaneous coronary intervention (PCI) is now very high, some severe complications may still develop, including periprocedural myocardial infarction (MI). An accurate diagnosis of this condition is essential for guiding the clinical management, as these patients may need a tailored management. The current recommendations for diagnosing periprocedural myocardial...
Αλέξανδρος Γ. Σφακιανάκης
3m
Responding to the Changing Face of the Social Determinants of Health The social determinants of health...
Responding to the Changing Face of the Social Determinants of HealthThe social determinants of health (SDoH) are at the top of every health care organization's priority list. The ability to respond to these nonclinical client needs is driving the financial sustainability, if not survivability, of facilities and programs across the globe. Although a number of traditional populations have been long identified with the SDoH, the face of those clients and communities is changing. With these demographic...
Αλέξανδρος Γ. Σφακιανάκης
3m
'Googling' anaphylaxis Purpose of review Anaphylaxis is a systemic allergic reaction and without the...
'Googling' anaphylaxisPurpose of review Anaphylaxis is a systemic allergic reaction and without the appropriate treatment can progress fast and may be fatal. Information about allergy and immunology topics including anaphylaxis can be easily found online and are widely searched by patients as well as medical personnel. Social media and search engines not only bring a number of benefits to users but also carry risks for breaches of confidentiality and privacy, unprofessional behaviour, malpractice...
Αλέξανδρος Γ. Σφακιανάκης
4m
Molecular Medicine Reports - Volume:20 Number:3 Spandidos Publications
Current advances in the study of diabetic cardiomyopathy: From clinicopathological features to molecular therapeutics (Review)Lin Sun, Ming Yu, Tong Zhou, Siwen Zhang, Guangyu He, Guixia Wang, Xiaokun GangView Abstract ❯Identification of a thymus microRNA‑mRNA regulatory network in Down syndromeMiao Chai, Liju Su, Xiaolei Hao, Meng Zhang, Lihui Zheng, Jiabing Bi, Xiao Han, Chunbo GaoView Abstract ❯Identification of differentially expressed genes in hip cartilage with femoral head necrosis, based on...
Αλέξανδρος Γ. Σφακιανάκης
6m
Cardiology  A Summary of Recently Published Activity PERSPECTIVE Combating EPA Rollbacks — Health...
Cardiology A Summary of Recently Published ActivityPERSPECTIVECombating EPA Rollbacks — Health Care's Response to a Retreat on ClimateG. McCarthy and A. BernsteinN Engl J Med, July 24, 2019ORIGINAL ARTICLEEffect of Systolic and Diastolic Blood Pressure on Cardiovascular OutcomesA.C. Flint and OthersN Engl J Med 381:243, July 18, 2019A Multicenter Trial of Vena Cava Filters in Severely Injured PatientsK.M. Ho and OthersN Engl J Med 381:328, July 25, 2019CME Quick TakeRituximab or Cyclosporine in the...
Αλέξανδρος Γ. Σφακιανάκης
7m
Dermatology  A Summary of Recently Published Activity IMAGES IN CLINICAL MEDICINE Cutaneous Ulcerations...
Dermatology A Summary of Recently Published ActivityIMAGES IN CLINICAL MEDICINECutaneous Ulcerations in Anti-MDA5 DermatomyositisA. Charrow and R.A. VleugelsN Engl J Med 381:465, August 1, 2019CORRESPONDENCETofacitinib in Amyopathic Dermatomyositis–Associated Interstitial Lung DiseaseZ. Chen and OthersN Engl J Med 381:291, July 18, 2019
Αλέξανδρος Γ. Σφακιανάκης
8m
Emergency Medicine  A Summary of Recently Published Activity PERSPECTIVE Toppling the Ethical Balance...
Emergency Medicine A Summary of Recently Published ActivityPERSPECTIVEToppling the Ethical Balance — Health Care Refusal and the Trump AdministrationE. SepperN Engl J Med, July 31, 2019A "Never Event" That Could Kill MillionsM. BivensN Engl J Med 381:203, July 18, 2019Taking NoteR. RushN Engl J Med 381:9, July 4, 2019ORIGINAL ARTICLEA Multicenter Trial of Vena Cava Filters in Severely Injured PatientsK.M. Ho and OthersN Engl J Med 381:328, July 25, 2019CME Quick TakeREVIEW ARTICLEDrug-Induced Liver...
Αλέξανδρος Γ. Σφακιανάκης
8m
Predicting radiation dosimetric distribution in different regions of the jaw in patients receiving...
Predicting radiation dosimetric distribution in different regions of the jaw in patients receiving radiotherapy for squamous cell carcinoma of the tonsilChiaojung Jillian Tsai MD, PhD  Nipun Verma MD, PhD  Adepitan A. Owosho BChD  Patrick Hilden MS Jonathan Leeman MD  SaeHee Yom DDS, MPH  Joseph M. Huryn DDS … See all authorsFirst published: 05 August 2019 https://doi.org/10.1002/hed.25883Chiaojung Jillian Tsai and Nipun Verma are co‐first authors.Funding information: National Institute of Health...
Αλέξανδρος Γ. Σφακιανάκης
9m
Head & Neck  Early View Online Version of Record before inclusion in an issue ORIGINAL ARTICLESMicroscopic...
Head & Neck Early ViewOnline Version of Record before inclusion in an issueORIGINAL ARTICLESMicroscopic tumor invasion of contralateral mucosa in cancer involving unilateral septumGurston Nyquist MD, Chandala Chitguppi MD, Allison Keane MD, Erin Reilly MD, Ian Koszewski MD, Mehri Mollaee MD, Sanjeet Rangarajan MD, Mindy Rabinowitz MD, Marc Rosen MD, Madalina Tuluc MD, PhDVersion of Record online: 01 August 2019CLINICAL REVIEWSTransoral robotic surgery for head and neck malignancies: Imaging features...
Αλέξανδρος Γ. Σφακιανάκης
9m
The role of rehabilitation in patients with pulmonary arterial hypertension Purpose of review The current...
The role of rehabilitation in patients with pulmonary arterial hypertensionPurpose of review The current review summarizes the latest evidence of the effects of exercise training for pulmonary hypertension patients demonstrated by six randomized controlled trails and 20 further studies. As the availability of exercise training is still limited it is important to raise awareness of the body of evidence showing the benefit for the patients and the limitations. Recent findings The effects of exercise...
Αλέξανδρος Γ. Σφακιανάκης
11m
Endocrinology  A Summary of Recently Published Activity PERSPECTIVE Combating EPA Rollbacks — Health...
Endocrinology A Summary of Recently Published ActivityPERSPECTIVECombating EPA Rollbacks — Health Care's Response to a Retreat on ClimateG. McCarthy and A. BernsteinN Engl J Med, July 24, 2019ORIGINAL ARTICLEC-Type Natriuretic Peptide Analogue Therapy in Children with AchondroplasiaR. Savarirayan and OthersN Engl J Med 381:25, July 4, 2019IMAGES IN CLINICAL MEDICINEMucosal NeuromasA.R. Scott and R.A. ComptonN Engl J Med 381:e5, July 18, 2019INTERACTIVE MEDICAL CASEBad to the BoneJ.L. Crombie and...
Αλέξανδρος Γ. Σφακιανάκης
11m
Gastroenterology  A Summary of Recently Published Activity PERSPECTIVE Taking Note R. Rush N Engl...
Gastroenterology A Summary of Recently Published ActivityPERSPECTIVETaking NoteR. RushN Engl J Med 381:9, July 4, 2019REVIEW ARTICLEDrug-Induced Liver Injury — Types and PhenotypesJ.H. Hoofnagle and E.S. BjörnssonN Engl J Med 381:264, July 18, 2019CMEIMAGES IN CLINICAL MEDICINEPneumoperitoneum from a Gastric PerforationA. Masson and G. CheronN Engl J Med 381:75, July 4, 2019CORRESPONDENCEEuropean Echinococcus multilocularis Identified in Patients in CanadaA. Massolo and OthersN Engl J Med 381:384,...
Αλέξανδρος Γ. Σφακιανάκης
11m
Sarcopenia: looking to muscle mass to better manage pancreatic cancer patients Purpose of review Overall...
Sarcopenia: looking to muscle mass to better manage pancreatic cancer patientsPurpose of review Overall survival of patients with pancreatic cancer is strongly conditioned by tumor biology and the incidence of malnutrition and metabolic disorders. In this landscape, the assessment of body composition is crucial to properly manage the clinical implications of muscle wasting. The pathogenesis of this condition is the result of a complex interplay between cancer and the host. In particular, sarcopenia...
Αλέξανδρος Γ. Σφακιανάκης
12m
Genetics  A Summary of Recently Published Activity ORIGINAL ARTICLE C-Type Natriuretic Peptide Analogue...
Genetics A Summary of Recently Published ActivityORIGINAL ARTICLEC-Type Natriuretic Peptide Analogue Therapy in Children with AchondroplasiaR. Savarirayan and OthersN Engl J Med 381:25, July 4, 2019REVIEW ARTICLEFrontiers in Medicine: Gene TherapyK.A. High and M.G. RoncaroloN Engl J Med 381:455, August 1, 2019Audio | Interactive/Multimedia | CommentsFrontiers in Medicine: Genetic Variation, Comparative Genomics, and the Diagnosis of DiseaseE.E. EichlerN Engl J Med 381:64, July 4, 2019Video | Audio | CommentsIMAGES...
Αλέξανδρος Γ. Σφακιανάκης
12m
Infection in xenotransplantation: opportunities and challenges Purpose of review Posttransplantation...
Infection in xenotransplantation: opportunities and challengesPurpose of review Posttransplantation infections are common. It is anticipated that infection will be no less common in xenotransplantation recipients. Prolonged xenograft survivals have resulted from advances in immunosuppressive strategies and development of swine that decrease host immune responses via genetic manipulation, notably CRISPR/cas9 manipulation. As prospects for clinical trials improve, consideration of the unique infectious...
Αλέξανδρος Γ. Σφακιανάκης
13m
Geriatrics/Aging  A Summary of Recently Published Activity PERSPECTIVE Toppling the Ethical Balance...
Geriatrics/Aging A Summary of Recently Published ActivityPERSPECTIVEToppling the Ethical Balance — Health Care Refusal and the Trump AdministrationE. SepperN Engl J Med, July 31, 2019Combating EPA Rollbacks — Health Care's Response to a Retreat on ClimateG. McCarthy and A. BernsteinN Engl J Med, July 24, 2019Postacute Care — The Piggy Bank for Savings in Alternative Payment Models?M.L. Barnett and OthersN Engl J Med 381:302, July 25, 2019
Αλέξανδρος Γ. Σφακιανάκης
17m
Hematology/Oncology  A Summary of Recently Published Activity PERSPECTIVE Combating EPA Rollbacks...
Hematology/Oncology A Summary of Recently Published ActivityPERSPECTIVECombating EPA Rollbacks — Health Care's Response to a Retreat on ClimateG. McCarthy and A. BernsteinN Engl J Med, July 24, 2019A Most Reckless Proposal — A Plan to Continue Asbestos Use in the United StatesP.J. Landrigan and R.A. LemenN Engl J Med, July 10, 2019ORIGINAL ARTICLERoxadustat for Anemia in Patients with Kidney Disease Not Receiving DialysisN. Chen and OthersN Engl J Med, July 24, 2019Roxadustat Treatment for Anemia...
Αλέξανδρος Γ. Σφακιανάκης
18m
Allergy/Immunology  A Summary of Recently Published Activity ORIGINAL ARTICLE Rituximab or Cyclosporine...
Allergy/Immunology A Summary of Recently Published ActivityORIGINAL ARTICLERituximab or Cyclosporine in the Treatment of Membranous NephropathyF.C. Fervenza and OthersN Engl J Med 381:36, July 4, 2019Brief Report: Kelch-like Protein 11 Antibodies in Seminoma-Associated Paraneoplastic EncephalitisC. Mandel-Brehm and OthersN Engl J Med 381:47, July 4, 2019CLINICAL PRACTICEChronic Rhinosinusitis with Nasal PolypsC. HopkinsN Engl J Med 381:55, July 4, 2019CME | Full Text AudioREVIEW ARTICLEHemolytic...
Αλέξανδρος Γ. Σφακιανάκης
19m
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Molecules, Vol. 24, Pages 2837: Bioavailability and Bioactivity of Encapsulated Phenolics and Carotenoids Isolated from Red Pepper WasteMolecules, Vol. 24, Pages 2837: Bioavailability and Bioactivity of Encapsulated Phenolics and Carotenoids Isolated from Red Pepper Waste Molecules doi: 10.3390/molecules24152837 Authors: Jelena Vulić Vanja Šeregelj Ana Kalušević Steva Lević Viktor Nedović Vesna Tumbas Šaponjac Jasna Čanadanović-Brunet Gordana Ćetković In order to deactivate the health properties...
Αλέξανδρος Γ. Σφακιανάκης
22h
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
Australasian Journal of Dermatology Early View Online Version of Record before inclusion in an issue...Australasian Journal of DermatologyEarly ViewOnline Version of Record before inclusion in an issueLetters to the EditorsCase LetterFlare of palmoplantar psoriasis with ustekinumabBenjamin S. Daniel, Chris Baker, Peter FoleyVersion of Record online: 01 August 2019Original ResearchAtopic dermatitis in adults: An Australian management consensusSaxon Smith, Christopher Baker, Kurt Gebauer, Diana Rubel, Brad...
Αλέξανδρος Γ. Σφακιανάκης
1d
Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,
MDPI JournalsIJERPH, Vol. 16, Pages 2759: Impact of Carers' Smoking Status on Childhood Obesity in the Growing up in Ireland Cohort StudyIJERPH, Vol. 16, Pages 2759: Impact of Carers' Smoking Status on Childhood Obesity in the Growing up in Ireland Cohort Study International Journal of Environmental Research and Public Health doi: 10.3390/ijerph16152759 Authors: Salome Sunday Zubair Kabir Childhood obesity is a growing concern worldwide. The association between childhood obesity and maternal smoking...
Αλέξανδρος Γ. Σφακιανάκης
3d
Cancer Letters
Adoptive CD8+ T cell therapy against cancer:Challenges and opportunitiesPublication date: 10 October 2019Source: Cancer Letters, Volume 462Author(s): Xiaotao Jiang, Jiang Xu, Mingfeng Liu, Hui Xing, Zhiming Wang, Lei Huang, Andrew L. Mellor, Wei Wang, Sha WuAbstractCancer immunotherapy is a new and promising option for cancer treatment. Unlike traditional chemo- and radiotherapy, immunotherapy actives host immune system to attack malignancies, and this potentially offers long-term protection from...
Αλέξανδρος Γ. Σφακιανάκης
4d
Internal and Emergency Medicine
Progressive splenomegaly and mild thrombocytosis in beta-thalassaemia trait and coexisting hereditary hemochromatosis: possible confounders for a subsequent hematological diagnosisAcute pericarditis or a systemic disease with pleuropulmonary involvement?Utility of intestinal ultrasound in the diagnosis and short-term follow-up of non-steroidal anti-inflammatory drug-induced enteropathyIs vitamin D deficiency predictor of complications development in patients with HCV-related cirrhosis?Unusual radiographic...
Αλέξανδρος Γ. Σφακιανάκης
4d
Elafonisi Beach Crete Greece
Alexandros SfakianakisAnapafseos 5 . Agios NikolaosCrete.Greece.7210028410261826948891480alsfakia@gmail.com
Αλέξανδρος Γ. Σφακιανάκης
4d

Δημοφιλείς αναρτήσεις