Four-year incidence of major adverse cardiovascular events in patients with atherosclerosis and atrial fibrillation

Background

There is a paucity of contemporary data assessing the implications of atrial fibrillation (AF) on major adverse cardiovascular events (MACE) in patients with or at high‐risk for atherosclerotic disease managed in routine practice.

Hypothesis

We sought to evaluate the 4‐year incidence of MACE in patients with or at risk of atherosclerotic disease in the presence of AF.

Methods

Using US MarketScan data, we identified AF patients ≥45 years old with billing codes indicating established coronary artery disease, cerebrovascular disease, or peripheral artery disease or the presence of ≥3 risk factors for atherosclerotic disease from January 1, 2013 to December 31, 2013 with a minimum of 4‐years of available follow‐up. We calculated the 4‐year incidence of MACE (cardiovascular death or hospitalization with a primary billing code for myocardial infarction or ischemic stroke). Patients were further stratified by CHA₂DS₂‐VASc score and oral anticoagulation (OAC) use at baseline.

Results

We identified 625,951 patients with 4‐years of follow‐up, of which 77,752 (12.4%) had comorbid AF. The median (25%, 75% range) CHA₂DS₂‐VASc score was 4 (3, 5) and 64% of patients received an OAC at baseline. The incidence of MACE increased as CHA₂DS₂‐VASc scores increased (P‐interaction<.0001 for all). AF patients receiving an OAC were less likely to experience MACE (8.9% vs 11.6%, P < .0001) including ischemic stroke (5.4% vs 6.7%, P < .0001).

Conclusion

Comorbid AF carries a substantial risk of MACE in patients with or at risk of atherosclerotic disease. MACE risk increases with higher CHA₂DS₂‐VASc scores and is more likely in patients without OAC.

In-hospital mortality among incident hemodialysis older patients in Peru

BACKGROUND

Understanding the pattern of mortality linked to end stage renal disease (ESRD) is important given the increasing ageing population in low- and middle-income countries.

METHODS

We analyzed older patients with ESRD with incident hemodialysis, from January 2012 to August 2017 in one large general hospital in Peru. Individual and health system-related variables were analyzed using Generalized Linear Models (GLM) to estimate their association with in-hospital all-cause mortality. Relative risk (RR) with their 95% confidence intervals (95% CI) were calculated.

RESULTS

We evaluated 312 patients; mean age 69 years, 93.6% started hemodialysis with a transient central venous catheter, 1.7% had previous hemodialysis indication and 24.7% died during hospital stay. The mean length of stay was 16.1 days (SD 13.5). In the adjusted multivariate models, we found higher in-hospital mortality among those with encephalopathy (aRR 1.85, 95% CI 1.21-2.82 vs. without encephalopathy) and a lower in-hospital mortality among those with eGFR ≤7 mL/min (aRR 0.45, 95% CI 0.31-0.67 vs. eGFR>7 mL/min).

CONCLUSIONS

There is a high in-hospital mortality among older hemodialysis patients in Peru. The presence of uremic encephalopathy was associated with higher mortality and a lower estimated glomerular filtration rate with lower mortality.

Incidence and Predictors of Major Adverse Cardiovascular Events in Patients With Established Atherosclerotic Disease or Multiple Risk Factors

Background

There is a paucity of contemporary data estimating the incidence of major adverse cardiovascular events (MACE) in patients with established atherosclerotic disease or multiple risk factors managed in routine practice. We estimated 1‐ and 4‐year incidences of MACE and the association between MACE and vascular beds affected in these patients.

Methods and Results

Using US IBM MarketScan data from January 1, 2013 to December 31, 2017, we identified patients ≥45 years old with established coronary artery disease, cerebrovascular disease, peripheral artery disease, or the presence of ≥3 risk factors for atherosclerosis during 2013 with a minimum of 4 years of follow‐up. We calculated 1‐ and 4‐year incidences of MACE (cardiovascular death or hospitalization for myocardial infarction or ischemic stroke). A Cox proportional hazards regression model adjusted for age and sex was used to evaluate the association between vascular bed number/location(s) affected and MACE. We identified 1 302 856 patients with established atherosclerotic disease or risk factors for atherosclerosis. Coronary artery disease was present in 16.9% of patients, cerebrovascular disease in 7.6%, peripheral artery disease in 13.6%, and risk factors for atherosclerosis only in 66.0%. The 1‐ and 4‐year incidences of MACE were 1.4% and 6.9%, respectively. At 4 years, MACE was more frequent in patients with atherosclerotic disease in a single (hazard ratio=1.51, 95% CI=1.48–1.55), 2‐(hazard ratio=2.35, 95% CI=2.27–2.44), or all 3 vascular beds (hazard ratio=3.30, 95% CI=2.97–3.68) compared with having risk factors for atherosclerosis.

Conclusions

Patients with established atherosclerotic disease or who have multiple risk factors and are treated in contemporary, routine practice carry a substantial risk for MACE at 1‐ and 4‐ years of follow‐up. MACE risk was shown to vary based on the number and location of vascular beds involved.

Effects of preeclampsia and eclampsia on maternal metabolic and biochemical outcomes in later life: a systematic review and meta-analysis

OBJECTIVE

To evaluate the association between preeclampsia (PE) and eclampsia (E) on subsequent metabolic and biochemical outcomes.

METHODS

Systematic review and meta-analysis of observational studies. We searched five engines until November 2018 for studies evaluating the effects of PE/E on metabolic and biochemical outcomes after delivery. PE was defined as presence of hypertension and proteinuria at >20 weeks of pregnancy; controls did not have PE/E. Primary outcomes were blood pressure (BP), body mass index (BMI), metabolic syndrome (MetS), blood lipids and glucose levels. Random effects models were used for meta-analyses, and effects reported as risk difference (RD) or mean difference (MD) and their 95% confidence interval (CI). Subgroup analyses by time of follow up, publication year, and confounder adjustment were performed.

RESULTS

We evaluated 41 cohorts including 3300 PE/E and 13,967 normotensive controls. Women were followed up from 3 months after delivery up to 32 years postpartum. In comparison to controls, PE/E significantly increased systolic BP (MD = 8.3 mmHg, 95%CI 6.8 to 9.7), diastolic BP (MD = 6.8 mmHg, 95%CI 5.6 to 8.0), BMI (MD = 2.0 kg/m²; 95%CI 1.6 to 2.4), waist (MD = 4.3 cm, 95%CI 3.1 to 5.5), waist-to-hip ratio (MD = 0.02, 95%CI 0.01 to 0.03), weight (MD = 5.1 kg, 95%CI 2.2 to 7.9), total cholesterol (MD = 4.6 mg/dL, CI 1.5 to 7.7), LDL (MD = 4.6 mg/dL; 95%CI 0.2 to 8.9), triglycerides (MD = 7.7 mg/dL, 95%CI 3.6 to 11.7), glucose (MD = 2.6 mg/dL, 95%CI 1.2 to 4.0), insulin (MD = 19.1 pmol/L, 95%CI 11.9 to 26.2), HOMA-IR index (MD = 0.7, 95%CI 0.2 to 1.2), C reactive protein (MD = 0.05 mg/dL, 95%CI 0.01 to 0.09), and the risks of hypertension (RD = 0.24, 95%CI 0.15 to 0.33) and MetS (RD = 0.11, 95%CI 0.08 to 0.15). Also, PE/E reduced HDL levels (MD = -2.15 mg/dL, 95%CI -3.46 to -0.85). Heterogeneity of effects was high for most outcomes. Risk of bias was moderate across studies. Subgroup analyses showed similar effects as main analyses.

CONCLUSION

Women who had PE/E have worse metabolic and biochemical profile than those without PE/E in an intermediate to long term follow up period.

Association between social determinants of health and trends in prevalence of hypertension in patients of the Peruvian Ministry of Health

OBJECTIVE

To evaluate the association between social determinants of health and trends in the prevalence of hypertension among patients of the Peruvian Ministry of Health 2007-2016.

METHODS

We conducted an ecological study with secondary data sources using health care and death records obtained from the Peruvian Ministry of Health, data from the Peruvian National Household Survey and data from the Regional Information System for Decision Making. We determined the standardised prevalence of hypertension at national and region level, conducted a geospatial exploratory analysis at region level, and applied generalised linear mixed models to evaluate the association between social determinants of health and the prevalence of HT, according to the domains suggested by Healthy People 2020.

RESULTS

The prevalence of hypertensive patients of the Peruvian Ministry of Health increased from 966.8/100 000 in 2007 to 1619.1/100 000 in 2016. The prevalence of hypertension rose by 17.7/100 000 per 1% increase of insurance coverage and by 2.2/100 000 per 1% increase in the number of hospitals. In contrast, it decreased by 12.3/100 000 per 1% increase of the poverty rate, by 9.8/100 000 per 1% increase of the proportion of people with native language, by 3.6/100 000 per 1% increase of GDP per capita and by 3/100 000 per 1% increase in the number of local health centres.

CONCLUSIONS

The growing trend of HT prevalence in Peru is directly associated with insurance coverage and number of hospitals, and inversely associated with poverty rate, proportion of people with native language, GDP per capita and number of local health centres.

Association of statin use and clinical outcomes in heart failure patients: a systematic review and meta-analysis

BACKGROUND

The role of statins in patients with heart failure (HF) of different levels of left ventricular ejection fraction (LVEF) remains unclear especially in the light of the absence of prospective data from randomized controlled trials (RCTs) in non-ischemic HF, and taking into account potential statins' prosarcopenic effects. We assessed the association of statin use with clinical outcomes in patients with HF.

METHODS

We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until August 2018 for RCTs and prospective cohorts comparing clinical outcomes with statin vs non-statin use in patients with HF at different LVEF levels. We followed the guidelines of the 2009 PRISMA statement for reporting and applied independent extraction by multiple observers. Meta-analyses of hazard ratios (HRs) of effects of statins on clinical outcomes used generic inverse variance method and random model effects. Clinical outcomes were all-cause mortality, cardiovascular (CV) mortality and CV hospitalization.

RESULTS

Finally we included 17 studies (n = 88,100; 2 RCTs and 15 cohorts) comparing statin vs non-statin users (mean follow-up 36 months). Compared with non-statin use, statin use was associated with lower risk of all-cause mortality (HR 0.77, 95% confidence interval [CI], 0.72-0.83, P < 0.0001, I2 = 63%), CV mortality (HR 0.82, 95% CI: 0.76-0.88, P < 0.0001, I2 = 63%), and CV hospitalization (HR 0.78, 95% CI: 0.69-0.89, P = 0.0003, I2 = 36%). All-cause mortality was reduced on statin therapy in HF with both EF < 40% and ≥ 40% (HR: 0.77, 95% Cl: 0.68-0.86, P < 0.00001, and HR 0.75, 95% CI: 0.69-0.82, P < 0.00001, respectively). Similarly, CV mortality (HR 0.86, 95% CI: 0.79-0.93, P = 0.0003, and HR 0.83, 95% CI: 0.77-0.90, P < 0.00001, respectively), and CV hospitalizations (HR 0.80 95% CI: 0.64-0.99, P = 0.04 and HR 0.76 95% CI: 0.61-0.93, P = 0.009, respectively) were reduced in these EF subgroups. Significant effects on all clinical outcomes were also found in cohort studies' analyses; the effect was also larger and significant for lipophilic than hydrophilic statins.

CONCLUSIONS

In conclusion, statins may have a beneficial effect on CV outcomes irrespective of HF etiology and LVEF level. Lipophilic statins seem to be much more favorable for patients with heart failure.

45Association of types of dietary fats and all-cause and cause-specific mortality: a prospective cohort study and meta-analysis of prospective studies with 1,148,117 participants

Background

The associations between dietary fats with mortality are poorly delineated.

Purpose

Using a large prospective cohort we evaluated the link between total fat, mono-unsaturated (MUFA), polyunsaturated (PUFA) and saturated fatty acid (SFA) consumption and all-cause, coronary heart disease (CHD), stroke, and diabetes (T2D)-associated mortality in a representative sample of US adults. We then added our results to a systematic review and meta-analysis.

Methods

We evaluated 35,080 participants from the National Health and Nutrition Examination Surveys (NHANES) 1988–1999 (19.2 years follow-up) and 1999–2010 (12 years follow-up), with vital status available through December 31, 2011. Cox proportional hazard regression models were used to evaluate the association between baseline quartiles of fat consumption (g/day, 24h recall) and all-cause or cause-specific mortality. For the systematic review, selected databases were searched up to November 2018 and 29 prospective cohorts (n=1,148,117) met inclusion criteria. The DerSimonian-Laird method and generic inverse variance methods were used for random effects meta-analyses.

Results

In fully adjusted models from our prospective study, there was a negative association between total fat (hazard ratio [HR]:0.90, 95% confidence interval [CI]: 0.82, 0.99, Q4 vs. Q1) and PUFA (0.81,95% CI: 0.78–0.84) consumption and all-cause mortality (Figure), whereas SFA were positively associated with mortality (1.08, 95% CI: 1.04–1.11). In the meta-analysis we found a significant negative association between total fat (HR: 0.89, 95% CI: 0.82–0.97, I2:27%), MUFA (0.93, 95% CI: 0.87–0.99, I2:56%) and PUFA (0.86, 95% CI: 0.80–0.93, I2:63%) consumption and all-cause mortality. No significant association was observed between total fat and both CVD and CHD mortality (0.92, 95% CI: 0.79–1.08, I2:46%, and 1.03, 95% CI: 0.99–1.09, I2:42%, respectively), while a positive association between SFA intake and CHD mortality (1.10, 95% CI: 1.01–1.20, I2:52.6%) was observed. Neither MUFA nor PUFA were associated with CVD and CHD mortality. Inverse associations were observed between MUFA (0.80, 95% CI: 0.67–0.96, I2:0%) and PUFA (0.84, 95% CI: 0.80–0.90, I2:0%) intakes and stroke mortality.

All-cause death and total fat intake.

Conclusions

Our results highlight differential associations of total fat, MUFA and PUFA intake with all-cause mortality, but no association of them with CVD and CHD mortalities. SFA intake was significantly associated with higher all-cause mortality inNHANES and with CHD mortality in our meta-analysis. The type of fat intake appears to be associated with important health outcomes.

Acknowledgement/Funding

None

Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting

Objectives: The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting. Methods: We searched MEDLINE^®, Embase^®, and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE). Results: We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, there is no evidence of a clinically important difference in the change of pain scores with opioids vs. ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE). Opioids may cause fewer adverse events than ketamine (low SOE) when primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but there is no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), both administered primarily IV. Conclusions: As initial analgesia, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Combining an opioid and ketamine may reduce acute pain more than an opioid alone but comparative harms are uncertain. When initial morphine is inadequate, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, strength of evidence is generally low, and future research in the prehospital setting is needed.

Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016

Background

There has been an increase in the prevalence of drug abuse (DA) in the national opioid epidemic. With increasing DA, there is an increased risk of infective endocarditis (IE). There are limited recent data evaluating national trends on the incidence and geographical distribution of DA‐IE. We aim to investigate those numbers as well as the determinants of outcome in this patient population.

Methods and Results

Hospitalized patients with a primary or secondary diagnosis of IE based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD‐9, ICD‐10) were included. We described the national and geographical trends in DA‐IE. We also compared DA‐IE patients’ characteristics and outcomes to those with IE, but without associated drug abuse (non‐DA‐IE) using Poisson regression models. Incidence of DA‐IE has nearly doubled between 2002 and 2016 All US regions were affected, and the Midwest had the highest increase in DA‐IE hospitalizations (annual percent change=4.9%). Patients with DA‐IE were younger, more commonly white males, poorer, had fewer comorbidities, and were more likely to have human immunodeficiency virus, hepatitis C, concomitant alcohol abuse, and liver disease. Their length of stay was longer (9 versus 7 days; P<0.001) and were more likely to undergo cardiac surgery (7.8% versus 6.2%; P<0.001), but their inpatient mortality was lower (6.4% versus 9.1%; P<0.001).

Conclusions

DA‐IE is rising at an alarming rate in the United States. All regions of the United States are affected, with the Midwest having the highest increase in rate. Young‐adult, poor, white males were the most affected.

Outcomes of patients with severe tricuspid regurgitation and congestive heart failure

Objectives

A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not.

Methods

Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes.

Results

Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71).

Conclusion

Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

Systematic review and meta-analysis of the effects of treatment modalities for vestibulodynia in women

Objective: To quantify the effects of available treatments of vestibulodynia. Methods: Systematic review of randomised controlled trials (RCTs) in six search engines until December 2018, comparing any intervention vs. placebo or sham in women with vestibulodynia. Primary outcome was dyspareunia assessed with visual analogue (VAS) or numeric rating (NRS) scales. Secondary outcomes were daily vestibular symptoms (DVS), McGill Pain Questionnaire (MPQ) and Index of Sexual Satisfaction (ISS). Effects were described as mean differences (MDs) with their 95% confidence intervals (CIs). Traditional and frequentist network meta-analyses (NMA) were performed using random effect models. Results: Four RCTs (n = 275) were included evaluating vaginal cream of conjugated oestrogens, oral desipramine with or without topical lidocaine, topical lidocaine, laser therapy and transcranial direct current. In traditional MA, interventions did not reduce dyspareunia (MD = 0.08; 95%CI = -0.49 to 0.64), DVS (MD = -0.04; 95%CI = -0.31 to 0.24; 4 interventions), or MPQ (MD = -0.17; 95%CI = -2.16 to 1.81; 4 interventions). ISS was significantly improved (MD = -5.14; 95%CI = -9.52 to -0.75). In NMA, oral desipramine with or without lidocaine significantly improved ISS vs. other treatments. Conclusions: Several existing interventions were not associated with improvements in vestibulodynia. There only was improvement of sexual function with oral desipramine with or without lidocaine.

Safe and Efficacious Use of 1-Month Triple Therapy in Patients with Atrial Fibrillation and High Bleeding Risk Undergoing PCI

BACKGROUND

The impact of short or prolonged use of triple therapy (TT) on outcomes in patients with atrial fibrillation (AF) and high risk of bleeding undergoing percutaneous coronary intervention (PCI) is unclear. We compared clinical outcomes according to the duration of TT in patients with AF and HAS-BLED ≥ 3 at 1 year of follow-up.

METHODS

A prospective observational cohort enrolled 735 patients with AF between 2010 and 2015. Of these, 521 (70.9%) had HAS-BLED ≥ 3 and 380 (72.9%) were discharged on TT. TT was prescribed for 1 month in 233 patients (61.3%). The primary endpoint was the incidence of Bleeding Academic Research Consortium (BARC ≥ 3). The secondary endpoint was the occurrence of ischemic events (cardiac death, MI, stroke, or stent thrombosis).

RESULTS

Patients on 1-month TT had a higher median HAS-BLED. Intracraneal hemorrhage was twofold more frequently in patients on > 1-month TT but without statistical significance (0.9% vs 2.1%, p = 0.20). Rates of the primary endpoint (bleeding BARC ≥ 3) were 8.2% vs 10.9% and did not differ between groups, while secondary endpoint did not occur more frequently in the 1-month TT group compared with the > 1-month TT group (26.6% vs 23.1%). In adjusted multivariate analyses, patients receiving 1-month TT had a similar risk of the primary endpoint compared to those with > 1-month TT (HR 1.47; 95% CI 0.48-4.47, p = 0.50). No difference was found in the secondary ischemic endpoint (HR 1.24; 95% CI 0.77-2.00, p = 0.38).

CONCLUSIONS

In patients with AF undergoing PCI at lower ischemic risk and higher bleeding risk, 1 month of TT seems safe and efficacious. Further studies are warranted in patients at high ischemic risk.

Effect of vegetarian diets on the presentation of metabolic syndrome or its components: A systematic review and meta-analysis

BACKGROUND & AIMS

Several studies have examined the effect of vegetarian diets (VD) on metabolic syndrome (MetS) or its components, but findings have been inconsistent. The aim of this study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies to assess the association between VD and MetS or its components (systolic blood pressure [SBP], diastolic blood pressure [DBP], fasting glucose triglycerides, waist circumference [WC], HDL-cholesterol (HDL-C)) in adults.

METHODS

The Cochrane Library, EMBASE, PubMed, Web of Science, and Scopus were searched. RCTs, cohort studies and cross-sectional studies evaluating the effects of VD on MetS or its components in adults, with omnivore diet as control group, were included. Random effects meta-analyses stratified by study design were employed to calculate pooled estimates.

RESULTS

A total of 71 studies (n = 103 008) met the inclusion criteria (6 RCTs, 2 cohorts, 63 cross-sectional). VD were not associated with MetS in comparison to omnivorous diet (OR 0.96, 95% CI 0.50-1.85, p = 0.9) according to meta-analysis of five cross-sectional studies. Likewise, meta-analysis of RCTs and cohort studies indicated that consumption of VD were not associated with MetS components. Meta-analysis of cross-sectional studies demonstrated that VD were significantly associated with lower levels of SBP (mean difference [MD] -4.18 mmHg, 95%CI -5.57 to -2.80, p < 0.00001), DBP (MD -3.03 mmHg, 95% CI -4.93 to -1.13, p = 0.002), fasting glucose (MD -0.26 mmol/L, 95% CI -0.35to -0.17, p < 0.00001), WC (MD -1.63 cm, 95% CI -3.13 to -0.13, p = 0.03), and HDL-C (MD -0.05 mmol/L, 95% CI -0.07 to -0.03, p < 0.0001) in comparison to omnivorous diet. Heterogeneity of effects among cross-sectional studies was high. About, one-half of the included studies had high risk of bias.

CONCLUSIONS

VD in comparison with omnivorous diet is not associated with a lower risk of MetS based on results of meta-analysis of cross-sectional studies. The association between VD and lower levels of SBP, DBP, HDL-C, and fasting glucose is uncertain due to high heterogeneity across the cross-sectional studies. Larger and controlled studies are needed to evaluate the association between VD and MetS and its components.

Glycemia upon admission and mortality in a pediatric intensive care unit

Objectives

To analyze the association between glycemia levels upon pediatric intensive care unit admission and mortality in patients hospitalized.

Methods

A retrospective cohort of pediatric intensive care unit patients admitted to the Instituto Nacional de Salud del Niño between 2012 and 2013. A Poisson regression model with robust variance was used to quantify the association. Diagnostic test performance evaluation was used to describe the sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios for each range of glycemia.

Results

In total, 552 patients were included (median age 23 months, age range 5 months to 79.8 months). The mean glycemia level upon admission was 121.3mg/dL (6.73mmol/L). Ninety-two (16.6%) patients died during hospitalization. In multivariable analyses, significant associations were found between glycemia < 65mg/dL (3.61mmol/L) (RR: 2.01, 95%CI 1.14 - 3.53), glycemia > 200mg/dL (> 11.1mmol/L) (RR: 2.91, 95%CI 1.71 - 4.55), malnutrition (RR: 1.53, 95%CI 1.04 - 2.25), mechanical ventilation (RR: 3.71, 95%CI 1.17 - 11.76) and mortality at discharge. There was low sensitivity (between 17.39% and 39.13%) and high specificity (between 49.13% and 91.74%) for different glucose cut-off levels.

Conclusion

There was an increased risk of death at discharge in patients who developed hypoglycemia and hyperglycemia upon admission to the pediatric intensive care unit. Certain glucose ranges (> 200mg/dL (> 11.1mmol/L) and < 65mg/dL (3.61mmol/L)) have high specificity as predictors of death at discharge.

Oral turmeric/curcumin effects on inflammatory markers in chronic inflammatory diseases: A systematic review and meta-analysis of randomized controlled trials

Turmeric extract or active component curcumin may have anti-inflammatory effects in people with chronic inflammatory diseases. The effect of turmeric or curcumin on a wide range of inflammatory markers has not been evaluated in a systematic review. We performed a systematic review of randomized controlled trials (RCTs) evaluating the effects of oral turmeric or curcumin on inflammatory markers (CRP, hsCRP, IL-1, IL-6, TNF) in patients with a wide range of chronic inflammatory diseases. Pubmed, EMBASE, Scopus, the Web of Science, and the Cochrane library were evaluated until June 2018. Random effects meta-analyses with inverse variance methods and stratified by turmeric or curcumin were performed. Effects were expressed as mean differences (MD) and their 95% confidence intervals (CI). Risk of bias of RCTs was evaluated with the Cochrane tool. Nineteen RCTs were identified; included patients had rheumatic diseases, advanced chronic kidney disease with hemodialysis, metabolic syndrome, and cardiovascular diseases. Turmeric was the intervention in 5 RCTs (n = 356) and curcumin/curcuminoids in 14 RCTs (n = 988). Follow up times ranged between 4 and 16 weeks. One RCT had high risk of bias. In comparison to controls, turmeric or curcumin did not significantly decrease levels of CRP (MD -2.71 mg/L, 95%CI -5.73 to 0.31, p = 0.08, 5 studies), hsCRP (MD -1.44 mg/L, 95%CI -2.94 to 0.06, p = 0.06, 6 studies), IL-1 beta (MD -4.25 pg/mL, 95%CI -13.32 to 4.82, p = 0.36, 2 studies), IL-6 (MD -0.71 pg/mL, 95%CI -1.68 to 0.25, p = 0.15), and TNF alpha (MD -1.23 pg/mL, 95%CI -3.01 to 0.55, p = 0.18, 7 studies). There were no differences between turmeric and curcumin interventions. High heterogeneity of effects was observed for all markers across studies, except hsCRP. Other inflammatory markers such as IL-1 alpha, TNF beta, IL-17, and IL-22 had scarce data. Turmeric or curcumin did not decrease several inflammatory markers in patients with chronic inflammatory diseases.

Cardiovascular mortality among patients with non-Hodgkin lymphoma: Differences according to lymphoma subtype

Survival rates of patients with non-Hodgkin lymphoma (NHL) have improved over the last decade. However, cardiotoxicities remain important adverse consequences of treatment with chemotherapy and radiation, although the burden of cardiovascular mortality (CVM) in such patients remains unknown. We conducted a retrospective cohort study of patients greater than or equal to 20 years of age diagnosed with diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) between 2000 and 2013 using data extracted from the United States Surveillance, Epidemiology, and End Results (SEER) database. Our primary endpoint was CVM. The association between NHL and CVM was evaluated using multivariable Cox regression analysis after adjusting for other patient characteristics. We calculated standardized mortality ratios (SMRs) for CVM, comparing NHL patients with the general population. We identified 153 983 patients who met the inclusion criteria (69 329 with DLBCL, 48 650 with CLL/SLL, and 36 004 with FL). The median follow-up was 37 months (interquartile range, 10-78 months); the mean patient age was 66.24 (±14.69) years; 84 924 (55.2%) were men; 134 720 (87.5%) were White, and 131 912 (85.7%) did not receive radiation therapy. Overall, 9017 patients (5.8%) died from cardiovascular disease, and we found that NHL patients had a higher risk of CVM than the general population, after adjusting for age (SMR 15.2, 95% confidence interval: 14.89-15.52). The rates of CVM were 5.1%, 8%, and 4.4% in patients with DLBCL, CLL/SLL, and FL, respectively. Furthermore, across all NHL subtypes, older age, higher stage at the time of diagnosis (particularly stage 4), male sex, and living in the south were associated with higher risks of CVM. Our data suggest that risk assessment and careful cardiac monitoring are recommended for NHL patients, particularly those with the CLL/SLL subtypes.

Abstract WP49: Emboli in New Territory After Mechanical Thrombectomy: Systematic Review and Meta-Analysis

Introduction: As mechanical thrombectomy (MT) for acute ischemic stroke has become standard therapy, interest has grown in treatment of milder strokes. Minor complications might therefore be important in mild strokes. The primary objective of the systematic review was to report the rate of emboli in new territory (ENT) following MT. Secondary objectives included describing rates other non-CNS hemorrhage procedural complications of arterial perforation, dissection, vasospasm and access site complications.

Methods: We searched randomized controlled trials (RCTs) published in MEDLINE/PubMed from 2010 to 2018 supplemented by a hand-search of reference lists and review articles. Random-effects models using the inverse variance method were used to estimate the pooled complication rates. We also performed subgroup analyses by technique (stent retriever first group or other devices) and year of publication (2010-2015 or 2016-2018).

Results: A total 19 RCTs with 2454 procedures for MT were included in our analysis. ENT, perforation, dissection, vasospasm, and access site complications were reported in 9 (47%), 11 (58%), 7 (37%), 7 (37%), 8 (42%) studies, respectively. The pooled ENT rate was 3.5% (95% CI 2.0-5.4), and there was no significant difference in the rate of ENT between stent retriever first group (2.8%, 95% CI 0.4-6.7) and other devices group (4.4%, 95% CI 2.6-6.7, p=0.43). There was no differences in ENT rates by year of publication. Other complication rates were perforation 2.2% (95% CI 0.9-4.0), dissection 2.0% (95% CI 1.1-3.3), vasospasm 10.7% (95% CI 3.8-20.2), and access site complication 2.9% (95% CI 0.9-5.9). There were no differences in the subgroups of perforation, dissection, and vasospasm by procedural methods or year of publication, but the rates of access site complications from 2016-2018 was significant lower compared to 2010-2015 (0.6% vs 5.2%, p<0.001).

Conclusions: The risks of 3.5% rate of ENT and low rates of other complications might become relevant in treatment of mild stroke.