Hypertensive disorders of pregnancy and future heart failure risk: A nationwide population-based retrospective cohort study

OBJECTIVE

To assess whether hypertensive disorders of pregnancy (HDP) increased the risk of subsequent heart failure (HF) and identify possible risk factors.

STUDY DESIGN

A nationwide population-based retrospective cohort study.

MAIN OUTCOME MEASURES

Incidence of heart failure.

RESULTS

Among the 23.3 million individuals registered in the National Health Insurance Research Database in Taiwan, 29,186 patients with HDP and 116,744 matched controls were identified. The overall incidence of HF was greater in the HDP group than it was in the control group (9.83 vs. 1.67 per 10,000 person-years), with a significant incidence rate ratio (IRR = 5.88, 95% confidence interval [CI] 5.84-5.92, p < 0.0001). When stratified by age, parity, gestational age, gestational number, and follow-up years, the IRR for subsequent HF remained significantly higher in the HDP group in all stratifications. Additionally, the Kaplan-Meier analysis indicated that the cumulative incidence rate of HF was higher in the HDP group than it was in the control group. The Cox proportional-hazard model analysis showed that in addition to HDP, single parity, preterm and hypertension were independent risk factors for developing HF. Moreover, HF was more likely to develop within 5 years post-partum. Among patients with a history of HDP, the Cox proportional-hazard model showed that severe forms of HDP and increased HDP occurrences were independently associated with the subsequent development of HF.

CONCLUSIONS

Patients who have experienced HDP presented an increased risk for developing HF later in life. Moreover, among individuals with a history of HDP, those with severe forms of HDP or recurrent HDP displayed an increased subsequent risk of HF.

Ciguatera fish Poisoning: a Challenge to Emergency Physicians

Seven patients from two families presented with ciguatera poisoning after fish consumption. They suffered most of the typical clinical features of ciguatera poisoning and were given supportive treatments. Three of them were given mannitol infusion and showed improvement in symptoms. All of them were discharged within two days.

A 6-Year Epidemiological Study of Pulmonary Embolism in an Emergency Department

Objective

To identify the epidemiology and early clinical features of patients with pulmonary embolism with a view to facilitate making the correct diagnosis.

Methodology

A retrospective study of patients admitted through the emergency department with a discharge diagnosis of pulmonary embolism in the computerised Clinical Management System from 1st January 1999 to 31st December 2004 in a public emergency general hospital in Hong Kong.

Results

Twenty-two patients were newly diagnosed to have pulmonary embolism and included in the study. The patients' clinical features and investigation findings were analysed. Old age and immobilisation were the most common risk factors identified. Nine patients were found to have deep vein thrombosis but none of them complained of calf pain during consultation in the emergency department. Most patients had symptoms of shortness of breath and chest pain on presentation. Fourteen patients had type 1 respiratory failure. The electrocardiogram and chest X-ray findings were non-specific. All the patients with D-dimer done showed positive results. CT scans were used in all patients to make the final diagnosis. Nineteen patients received low molecular weight heparin followed by warfarin and three patients had thrombolytic therapy.

Conclusion

Pulmonary embolism is not a commonly diagnosed disease in Hong Kong. The symptoms are non-specific and it is difficult to make the correct diagnosis in the emergency department.

An Analysis of Emergency Department Visits and the Survival Rate for Colorectal Cancer Patients: A Nationwide Population-based Study

Objective We examined the general characteristics, survival rate, and most common reasons for visiting the emergency department (ED) among colorectal cancer patients in Taiwan. We performed a population-based retrospective study and used data sourced from the National Health Insurance Research Database (NHIRD). Methods The colorectal cancer patient population, their diagnosis, and their medical management at the ED were identified using the Longitudinal Health Insurance Database 2000 (HV) codes and International Classification of Diseases, Ninth Revision, Clinical Modification system. We investigated their reasons for visiting the ED and the medications used there, analyzed their cumulative survival curves using the Kaplan-Meier method, and compared the survival curves with other colorectal cancer patients who had never visited the ED. Results Between 2000 and 2012, there were 6,532 ED visits by 3,347 colorectal patients, and the number per year increased gradually. The top three most common reasons for visiting ED were ill-defined conditions, abdominal pain, and intestinal obstruction. The overall survival rates of colorectal patients in the ED visit group at 3, 5, and 10 years, were 0.65, 0.56, and 0.47, respectively, without significant differences from the rates among colorectal cancer patients who did not visit the ED (p=0.2072). Conclusion We described the circumstances of ED visitation by colorectal cancer patients in Taiwan. Health care providers and researchers should pay more attention to improve medical care quality and investigate more details to predict the outcome among colorectal cancer patients.

The impact of DPP-4 inhibitors on long-term survival among diabetic patients after first acute myocardial infarction

Background

Previous studies regarding the cardioprotective effects of dipeptidyl peptidase 4 (DPP-4) inhibitors have not provided sufficient evidence of a relationship between DPP-4 inhibition and actual cardiovascular outcomes. This study aimed to evaluate the impact of DPP-4 inhibitors on the survival of diabetic patients after first acute myocardial infarction (AMI).

Methods

This was a nationwide, propensity score-matched, case–control study of 186,112 first AMI patients, 72,924 of whom had diabetes. A propensity score, one-to-one matching technique was used to match 2672 controls to 2672 patients in the DPP-4 inhibitor group for analysis. Controls were matched based on gender, age, and a history of hypertension, dyslipidemia, diabetes, peripheral vascular disease, heart failure, cerebrovascular accident, end-stage renal disease, chronic obstructive pulmonary disease, and percutaneous coronary intervention.

Results

DPP-4 inhibitors improve the overall 3-year survival rate (log rank P < 0.0001), whether male or female. Cox proportional hazard regression showed DPP-4 inhibitor is beneficial in diabetes patients after AMI (HR = 0.86; 95% CI 0.78–0.95), especially in those patients with hypertension (HR = 0.87; 95% CI 0.78–0.97; P = 0.0103) and cerebrovascular disease (HR = 0.83; 95% CI 0.72–0.97; P = 0.018), but without dyslipidemia (HR = 0.78; 95% CI 0.67–0.92; P = 0.0029), without peripheral vascular disease (HR = 0.86; 95% CI 0.78–0.96; P = 0.0047), without heart failure (HR = 0.84; 95% CI 0.73–0.96; P = 0.0106), without end stage renal disease (HR = 0.86; 95% CI 0.77–0.95; P = 0.0035), and without chronic obstructive pulmonary disease (HR = 0.87; 95% CI 0.78–0.97; P = 0.0096).

Conclusions

DPP-4 inhibitor therapy improved long-term survival in diabetic patients after first AMI, regardless of gender.

Comparison of gram-negative and gram-positive hematogenous pyogenic spondylodiscitis: clinical characteristics and outcomes of treatment

Background

To the best of our knowledge, no study has compared gram-negative bacillary hematogenous pyogenic spondylodiscitis (GNB-HPS) with gram-positive coccal hematogenous pyogenic spondylodiscitis (GPC-HPS) regarding their clinical characteristics and outcomes.

Methods

From January 2003 to January 2013, 54 patients who underwent combined antibiotic and surgical therapy in the treatment of hematogenous pyogenic spondylodiscitis were included.

Results

Compared with 37 GPC-HPS patients, the 17 GNB-HPS patients were more often found to be older individuals, a history of cancer, and a previous history of symptomatic urinary tract infection. They also had a less incidence of epidural abscess formation compared with GPC-HPS patients from findings on magnetic resonance imaging (MRI). Constitutional symptoms were the primary reasons for initial physician visits in GNB-HPS patients whereas pain in the affected spinal region was the most common manifestation in GPC-HPS patients at initial visit. The clinical outcomes of GNB-HPS patients under combined surgical and antibiotic treatment were not different from those of GPC-HPS patients. In multivariate analysis, independent predicting risk factors for GNB-HPS included a malignant history and constitutional symptoms and that for GPC-HPS was epidural abscess.

Conclusions

The clinical manifestations and MRI presentations of GNB-HPS were distinguishable from those of GPC-HPS.

Therapeutic Benefits of Induced Pluripotent Stem Cells in Monocrotaline-Induced Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is characterized by progressive increases in vascular resistance and the remodeling of pulmonary arteries. The accumulation of inflammatory cells in the lung and elevated levels of inflammatory cytokines in the bloodstream suggest that inflammation may play a role in PAH. In this study, the benefits of induced pluripotent stem cells (iPSCs) and iPSC-conditioned medium (iPSC CM) were explored in monocrotaline (MCT)-induced PAH rats. We demonstrated that both iPSCs and iPSC CM significantly reduced the right ventricular systolic pressure and ameliorated the hypertrophy of the right ventricle in MCT-induced PAH rats in models of both disease prevention and disease reversal. In the prevention of MCT-induced PAH, iPSC-based therapy led to the decreased accumulation of inflammatory cells and down-regulated the expression of the IL-1β, IL-6, IL-12α, IL-12β, IL-23 and IFNγ genes in lung specimens, which implied that iPSC-based therapy may be involved in the regulation of inflammation. NF-κB signaling is essential to the inflammatory cascade, which is activated via the phosphorylation of the NF-κB molecule. Using the chemical inhibitor specifically blocked the phosphorylation of NF-κB, and in vitro assays of cultured human M1 macrophages implied that the anti-inflammation effect of iPSC-based therapy may contribute to the disturbance of NF-κB activation. Here, we showed that iPSC-based therapy could restore the hemodynamic function of right ventricle with benefits for preventing the ongoing inflammation in the lungs of MCT-induced PAH rats by regulating NF-κB phosphorylation.

Contribution of Hepatitis B to Long-Term Outcome Among Patients With Acute Myocardial Infarction: A Nationwide Study

Although a possible association between hepatitis B and cardiovascular disease has been identified, the impact of viral hepatitis B on long-term prognosis after an acute myocardial infarction (AMI) is uncertain. Therefore, the aim of our study was to evaluate the specific impact of viral hepatitis B on survival after a first AMI through a retrospective analysis of data from the Taiwan National Health Insurance Research Database.This was a nationwide, propensity score-matched case-control study of patients admitted to hospitals between January 2000 and December 2012 with a primary diagnosis of a first AMI. Among the 7671 prospective patients, 244 patients with a confirmed diagnosis of viral hepatitis B infection were identified. A propensity score, one-to-one matching technique was used to match 244 controls to the AMI group for analysis. Controls were matched on the following variables: sex, age, hypertension, dyslipidemia, diabetes, peripheral vascular disease, heart failure, cerebrovascular accidents, end-stage renal disease, chronic obstructive pulmonary disease, and percutaneous coronary intervention (PCI).Overall, viral hepatitis B infection did not influence the 12-year survival rate (P = 0.98). However, survival was lower in female patients with viral hepatitis B infection compared to those without (P = 0.03; hazard ratio, 1.79; 95% confidence interval, 1.08-2.94). Inclusion of percutaneous coronary management improved survival, independent of sex, age, or hepatitis B status.Hepatitis B infection might increase the mortality risk of female patients after a first AMI. PCI may improve the long-term survival of patients after a first AMI, regardless of sex, age, and hepatitis B status.

The effects of zoledronate on the survival and function of human osteoblast-like cells

Background

Prolonged bisphosphonate treatment might suppress bone remodeling to the extent that normal bone repair is impaired. While this adverse side effect is usually ascribed to the negative effects of bisphosphonates on osteoclast survival and function, these effects on osteoblasts are still unclear.

Methods

In the current study, we hypothesized that zoledronate (ZOL) at the μM level might present negative effects on osteoblast survival and function. In vitro analyses of proliferation, migration and differentiation were performed on human osteoblast-like cells.

Results

Our results revealed that ZOL treatment dose- and time-dependently induced apoptosis of osteoblasts after concentrations had reached 10 μM (p < 0.001). The concentrations at which ZOL inhibited osteoblast migration by 50 % were between 10 and 15 μM. Moreover, there was a dose-dependent reduction in the extent of matrix mineralization, but without a concomitant inhibition of osteogenic differentiation in terms of secreted type I collagen and osteocalcin and of alkaline phosphatase activity per viable cell. Analyses of the expression of osteogenic genes confirmed that ZOL at the μM level had no effects on osteogenic differentiation of osteoblasts.

Conclusion

We concluded that ZOL at the μM level affected osteoblast survival and migration, but did not affect differentiation. The pathophysiological implications of ZOL at the μM level on skeletal disorders need to be investigated and clarified in the future researches.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0818-5) contains supplementary material, which is available to authorized users.

Intraoperative computed tomography navigation for transpedicular screw fixation to treat unstable thoracic and lumbar spine fractures: clinical analysis of a case series (CARE-compliant)

Transpedicular screw (TPS) fixation in unstable thoracic and lumbar (TL) spine fractures remains technically difficult because of destroyed anatomical landmarks, unstable gross segments, and discrepancies in anatomic orientation using conventional anatomic landmarks, fluoroscopic guidance, or computed tomography (CT)-based navigation. In this study, we evaluated the safety and accuracy of TPS placement under intraoperative computed tomography (iCT) navigation in managing unstable TL spine fractures.From 2010 to 2013, we retrospectively reviewed the Spine Operation Registry records of patients who underwent posterior instrumented fusion to treat unstable TL spine fractures via the iCT navigation system. An unstable spine fracture was identified as AO/Magerl classification type B or type C.In all, 316 screws in 37 patients with unstable TL spine fractures were evaluated and involved 7 thoracic, 23 thoracolumbar junctional, and 7 lumbar fractures. The accuracy of TPS positioning in the pedicle without breach was 98% (310/316). The average number of iCT scans per patient was 2.1 (range 2-3). The average total radiation dose to patients was 15.8 mSv; the dose per single level exposure was 2.7 mSv. The TPS intraoperative revision rate was 0.6% (2/316) and no neurovascular sequela was observed. TPS fixation using the iCT navigation system obtained a 98% accuracy in stabilizing unstable TL spine fractures. A malplaced TPS could be revised during real-time confirmation of the TPS position, and no secondary operation was required to revise malplaced screws.The iCT navigation system provides accurate and safe management of unstable TL spine fractures. In addition, operating room personnel, including surgeons and nurses, did not need to wear heavy lead aprons as they were not exposed to radiation.

Ankylosing spondylitis associated with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a frequent complication of connective tissue diseases, such as systemic sclerosis, systemic lupus erythematosus and rheumatoid arthritis. However, the occurrence of PAH in a patient with ankylosing spondylitis (AS) has not been previously reported with a detailed clinical description in the English literature. We herein report the first case of AS associated PAH in a 27-year-old Taiwanese man with a chief complaint of intermittent palpitations lasting for two years. To the best of our knowledge, this is the first reported case of AS associated with PAH with a detailed clinical description and findings of right heart catheterization published in the English literature.

2014 Guidelines of Taiwan Society of Cardiology (TSOC) for the Management of Pulmonary Arterial Hypertension

Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic condition, defined as a mean pulmonary arterial pressure exceeding 25 mmHg at rest. According to the recent classifications, it is grouped into pulmonary arterial hypertension (PAH), heart-related, lung-related, thromboembolic, and miscellaneous PH. In the past two decades, tremendous advances have occurred in the field of PH. These include (1) development of clinical diagnostic algorithm and a monitoring strategy dedicated to PAH, (2) defining strong rationales for screening at-risk populations, (3) advent of pulmonary specific drugs which makes PAH manageable, (4) recognition of needs of having proper strategy of combining existing pulmonary specific drugs, and/or potential novel drugs, (5) pursuit of clinical trials with optimal surrogate endpoints and study durations, (6) recognition of critical roles of PH/right ventricular function, as well as interdependence of ventricles in different conditions, especially those with various phenotypes of heart failure, and (7) for rare diseases, putting equal importance on carefully designed observation studies, various registries, etc., besides double blind randomized studies. In addition, ongoing basic and clinical research has led to further understanding of relevant physiology, pathophysiology, epidemiology and genetics of PH/PAH. This guidelines from the working group of Pulmonary Hypertension of the Taiwan Society of Cardiology is to provide updated guidelines based on the most recent international guidelines as well as Taiwan's domestic research on PH. The guidelines are mainly for the management of PAH (Group 1) ; however the majority of content can be helpful for managing other types of PH.

KEY WORDS

Pulmonary arterial hypertension; Taiwan guidelines.

Empirical Selection of Informative Microsatellite Markers within Co-ancestry Pig Populations Is Required for Improving the Individual Assignment Efficiency

The Lanyu is a miniature pig breed indigenous to Lanyu Island, Taiwan. It is distantly related to Asian and European pig breeds. It has been inbred to generate two breeds and crossed with Landrace and Duroc to produce two hybrids for laboratory use. Selecting sets of informative genetic markers to track the genetic qualities of laboratory animals and stud stock is an important function of genetic databases. For more than two decades, Lanyu derived breeds of common ancestry and crossbreeds have been used to examine the effectiveness of genetic marker selection and optimal approaches for individual assignment. In this paper, these pigs and the following breeds: Berkshire, Duroc, Landrace and Yorkshire, Meishan and Taoyuan, TLRI Black Pig No. 1, and Kaohsiung Animal Propagation Station Black pig are studied to build a genetic reference database. Nineteen microsatellite markers (loci) provide information on genetic variation and differentiation among studied breeds. High differentiation index (FST) and Cavalli-Sforza chord distances give genetic differentiation among breeds, including Lanyu's inbred populations. Inbreeding values (FIS) show that Lanyu and its derived inbred breeds have significant loss of heterozygosity. Individual assignment testing of 352 animals was done with different numbers of microsatellite markers in this study. The testing assigned 99% of the animals successfully into their correct reference populations based on 9 to 14 markers ranking D-scores, allelic number, expected heterozygosity (HE) or FST, respectively. All miss-assigned individuals came from close lineage Lanyu breeds. To improve individual assignment among close lineage breeds, microsatellite markers selected from Lanyu populations with high polymorphic, heterozygosity, FST and D-scores were used. Only 6 to 8 markers ranking HE, FST or allelic number were required to obtain 99% assignment accuracy. This result suggests empirical examination of assignment-error rates is required if discernible levels of co-ancestry exist. In the reference group, optimum assignment accuracy was achievable achieved through a combination of different markers by ranking the heterozygosity, FST and allelic number of close lineage populations.

Comparison of minimal access and traditional anterior spinal surgery in managing infectious spondylitis: a minimum 2-year follow-up

BACKGROUND CONTEXT

Traditional anterior spinal surgery (TASS) for the thoracolumbar spine is associated with significant morbidities. To avoid excessive tissue damage, minimal access spinal surgery (MASS) has been developed to treat a variety of anterior spinal disorders at the authors' institution. No previous reports comparing the outcomes of MASS and TASS for the treatment of infectious spondylitis were noted in the literature, to our knowledge.

PURPOSE

The aim of this study was to investigate the outcomes of MASS in managing infectious spondylitis and compare the results to TASS with a minimum follow-up of 2 years.

STUDY DESIGN

A retrospective comparative cohort study in a single center.

PATIENT SAMPLE

Forty patients with thoracic or lumbar infectious spondylitis who underwent anterior spinal surgery were enrolled.

OUTCOME MEASURES

Perioperative data including operative time, estimated blood loss, packed red blood cell transfusion, postoperative tube drainage, need for intensive care, and length of hospital stay. Postoperative complications were classified according to the Clavien-Dindo system. Fusion grade was assessed by plain radiographs on the basis of Burkus criteria.

METHODS

Between January 2002 and June 2010, all enrolled patients were collected via the Spine Operation Registry of the authors' institution. There were 23 MASS patients and 17 TASS patients. The average follow-up was 4.2 years (range, 2-9 years).

RESULTS

The mean estimated blood loss in MASS and TASS groups was 521.7 versus 979.4 mL (p=.007), intraoperative transfusion of packed red blood cells was 0.9 versus 2.7 units (p=.019), the amount of postoperative tube drainage was 235.2 versus 454.3 mL (p=.005), the number of patients requiring postoperative intensive care was 2 versus 7 (p=.023), and length of hospital stay was 15.4 versus 22.9, respectively (p=.043). The overall complication rate in the MASS group was 17% and 59% in the TASS group (p=.007). No major complications occurred in the MASS group, whereas four occurred in the TASS group (p=.026). Bone graft union was achieved in 38 of 39 survival patients (97%), with no difference between the groups. One patient in TASS had a pseudarthrosis and needed a posterior instrumented fusion.

CONCLUSIONS

Minimal access spinal surgery has been suggested to be an effective and safe technique in treating thoracic and lumbar infectious spondylitis. Minimal access spinal surgery did not need endoscopic equipments or complex surgical instruments. Furthermore, in comparison to TASS, MASS resulted in a reduced blood transfusion amount, decreased intensive care unit stay, reduced overall length of stay, and reduced surgical complication rate. Nevertheless, the risks may be increased in performing MASS on patients with multilevel involvement, which could be associated with high vascularity, alternated vascular anatomy, increased soft-tissue edema, and adhesion.