Correlates and prognostic impact of acute heart failure at the acute stage of ST-elevation and non-ST-elevation myocardial infarction according to diabetic status: the FAST-MI registries

Background

Diabetes mellitus (DM) predisposes to cardiovascular diseases including acute myocardial infarction (AMI) and acute heart failure (AHF).

Purpose

Analysing the French Registries of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 and 2010, we assessed correlates of AHF occurring at the acute stage of ST-elevation AMI (STEMI) and non-ST-elevation AMI (NSTEMI), as well as the prognostic impact of AHF on 5-year mortality according to diabetic status.

Methods

The FAST-MI 2005 and 2010 registries included 7,839 consecutive patients admitted for AMI (4,250 STEMI and 3,589 NSTEMI). Vital status at 5 years was available in >96% of the patients. Binary logistic regression analysis was used to determine independent correlates of AHF and Cox multivariate analysis was used to determine independent correlates of 5-year mortality. Long-term survival curves were estimated using the Kaplan Meier method and comparisons were made using log-rank tests.

Results

2,151 patients presented with DM (27,4%) and 629 patients (8,0%) were treated by insulin (DMi). DM patients were older (70.0 vs. 64.6 years; p<0.001), with more comorbidities and more severe coronary artery disease. AHF (pulmonary edema or cardiogenic shock) was the most frequent in-hospital complication (12.5%) and was twice as frequent in DM patients (20.2% vs. 9.6%; adjusted OR=1.66; 95% confidence interval: 1.43–1.94; P<0.001). AHF was more frequently observed in DM patients on insulin therapy compared with DM patients not receiving insulin (29.1% vs 16.6%; adjusted OR=1.53; 95% CI: 1.20–1.96; P=0.001). The significant difference in AHF between DM patients and patients without DM was found in both STEMI (18.8% vs 8.0%; P=0.001) and in NSTEMI (21.3% vs 11.9%; P=0.001) patients.

After multivariate analysis on confounders (risk factors, previous medical history, type of AMI, year of survey and medications used before the index AMI), compared with patients without DM nor AHF, those with AHF without DM and those with DM without AHF had a 50% increase in 5-year mortality (adjusted HR=1.50; 95% CI: 1.32–1.69; P<0.001 and adjusted HR=1.46; 95% CI: 1.23–1.74; P<0.001) while the risk of 5-year death was doubled in those with both DM and AHF (adjusted HR=1.97; 95% CI: 1.66–2.34; P<0.0001).

Conclusion

AHF is the most frequent complication of AMI and is twice as common in DM patients. It is associated with reduced 5-year survival in non-diabetic and DM patients, with the worst outcomes in patients with both conditions (AHF and DM). In AMI, new management strategies are needed to prevent AHF and improve survival in DM patients with AHF.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The FAST-MI 2005 and 2010 registries are the propriety of the French Society of Cardiology and were funded by grants from the following companies: Amgen, AstraZeneca, Bayer, BMS, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, Pfizer, Sanofi, and Servier, and by a grant from the French National Health Insurance body (CNAM-TS).

A multistage process leading to the development of a structured consent form and patient information leaflet for complex abdominal wall reconstruction (CAWR)

PURPOSE

Informed consent is vital in surgery. The General Medical Council, UK and Royal College of Surgeons of England provide clear guidance on what constitutes the process of informed patient consent. Despite this, evidence suggests that the consent process may not be performed well in surgery. We utilised a staged patient-centred approach and rigorous methodology to develop a standardised patient information leaflet (PIL) and pre-written structured consent form for complex abdominal wall reconstruction (CAWR).

METHODS

We utilised the principles of Deming's Plan-Do-Study-Act (PDSA) cycles to approach the process. Buzan's mind maps were used to identify the stakeholders and deficiencies in the consent process ('Plan' phase). The content of the PIL and pre-written consent form was then developed in collaboration with stakeholders ('Do' phase). Multidisciplinary and multidepartmental feedback was obtained on the proposed content and amendments were made ('Study' and 'Act' phases).

RESULTS

We successfully produced a clear, focused PIL and structured consent form, in Plain English, presenting accurate, relevant and detailed information in a highly understandable way. The PIL had a Flesch Reading Ease score of > 80, demonstrating a high level of readability and comprehensibility, with positive implications for informed patient decision making and preparedness for surgery.

CONCLUSION

Through sharing the process that we undertook, we aim to support other abdominal wall units who wish to develop and improve their own consent process.

Evaluation of dual energy CT and iterative metal artefact reduction (iMAR) for artefact reduction in radiation therapy

Metal artefacts pose a common problem in single energy computed tomography (SECT) images used for radiotherapy. Virtual monoenergetic (VME) images constructed with dual energy computed tomography (DECT) scans can be used to reduce beam hardening artefacts. Dual energy metal artefact reduction is compared and combined with iterative metal artefact reduction (iMAR) to determine optimal imaging strategies for patients with metal prostheses. SECT and DECT scans were performed on a Siemens Somatom AS-64 Slice CT scanner. Images were acquired of a modified CIRS pelvis phantom with 6, 12, 20 mm diameter stainless steel rods and VME images reconstructed at 100, 120, 140 and 190 keV. These were post-reconstructed with and without the iMAR algorithm. Artefact reduction was measured using: (1) the change in Hounsfield Unit (HU) with and without metal artefact reduction (MAR) for 4 regions of interest; (2) the total number of artefact pixels, defined as pixels with a difference (between images with metal rod and without) exceeding a threshold; (3) the difference in the mean pixel intensity of the artefact pixels. DECT, SECT + iMAR and DECT + iMAR were compared. Both SECT + iMAR and DECT + iMAR offer successful MAR for phantom simulating unilateral hip prosthesis. DECT gives minimal artefact reduction over iMAR alone. Quantitative metrics are advantageous for MAR analysis but have limitations that leave room for metric development.

Randomized controlled study of the prediction of diminutive/small colorectal polyp histology using didactic versus computer-based self-learning module in gastroenterology trainees

BACKGROUND AND AIM

The aim of this randomized trial was to evaluate the performance of self-training versus didactic training in order to increase the diagnostic accuracy of diminutive/small colonic polyp histological prediction by trainees.

METHODS

Sixteen trainees reviewed 78 videos (48 iSCAN-OE and 30 NBI) of diminutive/small polyps in a pretraining assessment. Trainees were randomized to receive computer-based self-learning (n = 8) or didactic training (n = 8) using identical teaching materials and videos. The same 78 videos, in a different randomized order, were assessed. The NICE (NBI International Colorectal Endoscopic) and SIMPLE (Simplified Identification Method for Polyp Labeling during Endoscopy) classification systems were used to classify diminutive/small polyps.

RESULTS

A higher proportion of high-confidence predictions of polyps was made by the self-training group versus the didactic group using both the SIMPLE classification (77.1% [95% CI 73.4-80.3] vs 69.9% [95% CI 66.1-73.5%] [P = 0.005]) and the NICE classification (77% [95% CI 73.2-80.4%] vs 69.8% [95% CI 66-73.4%] [P = 0.006]). When using NICE, sensitivity of the self-training group compared with the didactic group was 72% versus 83% (P = 0.0005), and the accuracy was 66.1% versus 69.1%. The training improved the confidence of participants and SIMPLE was preferred over NICE.

CONCLUSION

Self-learning for the prediction of diminutive/small polyp histology is a method of training that can achieve results similar to didactic training. Availability of adequate self-learning teaching modules could enable widespread implementation of optical diagnosis in clinical practice.

The consensus recommendations of a group of international experts on the fundamental concepts related to the issues of testosterone deficiency and its treatment

Conference on the development of the international expert consensus to address frequently asked questions related to a medical condition of testosterone deficiency (TD, male hypogonadism) and testosterone therapy was held in Prague (Czech Republic) on October 1, 2015. The included experts were representatives from a variety of medical specialties, including urology, endocrinology, diabetology, internal medicine, as well as representatives of basic medical sciences. An international team of experts came to the following conclusions: TD - an important medical condition that affects the health and well-being of men; TD symptoms is a consequence of low testosterone levels, regardless of whether background etiology installed; TD consequences are global; care must be taken in an attempt to use any uniform threshold levels of testosterone for a decision on the appointment of testosterone therapy; a person does not have any reason to refrain from appointing testosterone therapy only on the basis of age; the existing evidence does not suggest increasing the prostate cancer or cardiovascular disease risk during testosterone therapy; there is evidence conserning the feasibility of a major research initiative to explore possible cardioprotective beneficial effects of testosterone therapy in men with metabolic disorders, including diabetes.