Spinal cord injury is associated with an increased risk of atrial fibrillation: A population-based cohort study

Spinal cord injury and risk of overall and type specific cardiovascular diseases: A meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is a growing concern among people with spinal cord injury (SCI). This meta-analysis aims to explore the risk of overall CVD and specific types of cardiovascular events among SCI patients.

METHODS

This meta-analysis is registered on PROSPERO (CRD CRD42024537888). The data sources comprised PubMed, Embase, the Cochrane Library, and reference lists of the included studies. The literature collection span is from database establishment until April 17, 2024. This meta-analysis encompassed observational studies investigating the association between SCI and the risk of overall types of CVD or specific CVD types. Risk of bias was evaluated utilizing the Newcastle-Ottawa Quality Assessment Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) Scale. Odds ratios (ORs) with 95% confidence intervals (CIs) were aggregated using a random-effects model.

RESULTS

Our initial search generated 5357 relevant records form these international databases. This meta-analysis encompassed 9 observational studies involving 2,282,691 individuals, comprising 193,045 patients with SCI and 2,209,646 controls. We observed a 1.56-fold [OR = 1.56, 95% CI (1.43, 1.70), I2 = 91.3%, P < 0.001] rise in the risk of overall types of CVD among SCI patients, with a 1.82-fold increase in males and a 1.76-fold increase in females. SCI patients without comorbidities exhibited a 2.10-fold elevated risk of overall CVD types, while those with comorbidities had a 1.48-fold increased risk. Concerning specific CVD types, SCI patients showed a 1.58-fold [OR = 1.57, 95% CI (1.22, 2.03), I2 = 92.4%] higher risk of myocardial infarction, a 1.52-fold [OR = 1.52, 95% CI (1.07, 2.16), I2 = 88.7%] increase in atrial fibrillation, a 1.64-fold [OR = 1.64, 95% CI (1.22, 2.20), I2 = 95.5%] elevation in heart failure risk, and 2.38-fold [OR = 2.38, 95% CI (1.29, 4.40), I2 = 92.5%] increments in stroke risk. But there was no statistically significant difference in the risk of hypertension [OR = 1.54, 95% CI (0.98, 2.42), I2 = 96.6%].

CONCLUSIONS

The risk of overall CVD in SCI patients surpassed that of the non-SCI control group, with elevated risks of specific cardiovascular events like myocardial infarction, atrial fibrillation, heart failure, and stroke. Clinicians should prioritize awareness of CVD risks in SCI patients.

Traumatic brain injury is associated with the subsequent risk of atrial fibrillation or atrial flutter

BACKGROUND

Traumatic brain injury (TBI) is associated with a variety of adverse long-term outcomes and increases sympathetic nervous system activation, which could increase the risk of arrhythmias including atrial fibrillation or atrial flutter (AF/AFL).

OBJECTIVE

We examined episodes of TBI and subsequent AF/AFL in a large cohort of post-9/11 servicemembers and veterans.

METHODS

The variable of interest was TBI, stratified by severity (mild, moderate/severe, and penetrating). The outcome was a subsequent diagnosis of AF/AFL. We used Fine-Gray competing risks models to evaluate the potential risk imparted by TBI on subsequent AF/AFL.

RESULTS

Of the 1,924,900 participants included in the analysis, 369,891 (19.2%) experienced an episode of documented TBI. Most were young (63% <35 years), male (81.7%), and non-Hispanic White (62.7%). AF/AFL was diagnosed in 22,087 patients. On univariate analysis, only penetrating TBI (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.84-2.23; P < .001) was associated with AF/AFL compared with veterans without TBI. After adjustment in the full multivariable model (adjusted for age, sex, race and ethnicity, service branch, rank, component, and comorbidities), mild (HR 1.27, 95% CI 1.22-1.32; P < .001), moderate/severe (HR, 1.34; 95% CI, 1.24-1.44; P < .001), and penetrating TBI (HR, 1.82; 95% CI, 1.65-2.02; P < .001) were significantly associated with AF/AFL compared with no TBI. Post hoc analyses demonstrated that the risk of AF/AFL was concentrated in female and younger patients.

CONCLUSION

We found that an episode of TBI, particularly penetrating TBI, significantly increased the risk for AF/AFL. Further work is needed to delineate the long-term risk of arrhythmias after TBI.

Atrial fibrillation and heart failure with preserved ejection fraction "twindemic"-Shared root causes and treatment targets

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are comorbid conditions that are increasingly prevalent and have a high socioeconomic burden. This article discusses their shared pathophysiology, focusing on the triad of hypertension, obesity, and aging. We highlight the misperception that pharmacological heart rate lowering is beneficial, which has resulted in an overprescription of β-blockers in HFpEF and AF. In contrast, heart rate modulation through accelerated pacing provides hemodynamic and structural advantages, which have yielded significant improvements in quality of life, physical activity, and AF burden in the personalized pacing for diastolic dysfunction and heart failure with preserved ejection fraction (myPACE) trial of patients with preclinical or overt HFpEF.

Increased Risk of Myocardial Infarction, Heart Failure, and Atrial Fibrillation After Spinal Cord Injury

BACKGROUND

Heart diseases are a growing concern for the spinal cord injury (SCI) population.

OBJECTIVES

This study aims to compare the incidence of heart diseases between SCI survivors and the general non-SCI population.

METHODS

We identified 5,083 SCI survivors and 1:3 age- and sex-matched non-SCI controls. Study outcomes were myocardial infarction (MI), heart failure (HF), and atrial fibrillation (AF). The cohort was followed up from the index date (diagnosis date for SCI or corresponding date for matched controls) until 2019.

RESULTS

SCI survivors showed a higher risk for MI (adjusted HR [aHR]: 2.41; 95% CI: 1.93-3.00), HF (aHR: 2.24; 95% CI: 1.95-2.56), and AF (aHR: 1.84; 95% CI: 1.49-2.28) compared to controls. The risks were further increased for those who were registered in the National Disability Registry within 1 year from the index date (SCI survivors with disability): SCI survivors with severe disability had the highest risks of MI (aHR: 3.74; 95% CI: 2.43-5.76), HF (aHR: 3.96; 95% CI: 3.05-5.14), and AF (aHR: 3.32; 95% CI: 2.18-5.05). Cervical and lumbar SCI survivors had an increased risk of heart disease regardless of disability compared to matched controls; these risks were slightly higher in those with disability. Thoracic SCI survivors with disability had significantly increased risk of heart disease compared to matched controls.

CONCLUSIONS

SCI survivors at all levels were at significantly greater risk for heart disease than non-SCI controls, particularly those with severe disability. Clinicians must be aware of the importance of heart disease in SCI survivors.

Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation

Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.

Risk of non-typhoidal Salmonella infection in patients with cholecystectomy: Results from a nationwide matched cohort study in Taiwan

BACKGROUND

The current study was designed to investigate the association between cholecystectomy and the risk of non-typhoidal Salmonella (NTS) infection.

METHODS

We obtained claims-based data from the Taiwan National Health Insurance Research Database (NHIRD) to perform a nationwide cohort study. A propensity score (PS)-matching analysis was performed with a ratio of 1:2 in the cholecystectomy cohort and cholecystectomy-free group to reduce selection bias. Both groups were followed until NTS diagnosis, a dropout from the insurance programme or the end of 2013. Cox proportional hazard regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the risk of NTS infection between the cholecystectomy and cholecystectomy-free groups.

RESULTS

Our study enrolled 197 444 patients who had undergone cholecystectomy and 394 888 patients who did not receive cholecystectomy. The adjusted HR (aHR) of NTS infection was 1.34 (95% CI, 1.13-1.58; P < .001) for the cholecystectomy group after adjusting for demographical characteristics and relevant comorbidities. The study population is predominantly female patients (55%) and older (58% older than 50 years). The subgroup analysis revealed that both sexes and notably, patients aged >50, who underwent cholecystectomy had a higher risk of NTS infection than the matched controls. Follow-up of patients who underwent cholecystectomy showed that they had a significantly higher risk of NTS infection for more than 6 months after the procedure.

CONCLUSIONS

Our study showed that cholecystectomy might be an independent risk factor for subsequent NTS infection.

Spinal cord infarction in a young patient with methamphetamine abuse

We report a case of a 20-year-old man who was diagnosed with spontaneous spinal cord infarction after abusing methamphetamine for a year. He presented with sudden onset of bilateral upper and lower limb weakness. His MRI spine showed a long segment of high signal intensity seen predominantly in the anterior spinal cord from medulla to mid thoracic level as well as a pencil-like hyperintensity seen postcontrast suggestive of spinal cord ischaemia or infarct. Thus, he was empirically treated for presumed anterior spinal cord infarction. He then developed autonomic dysfunction and went into respiratory distress, which required invasive mechanical ventilation support. Subsequently, he developed cardiac arrythmia with supraventricular tachycardiac followed by asystole and succumbed to illness on day 9 despite maximal resuscitative efforts. This case report illustrates a rare spinal cord infarction caused by methamphetamine intoxication and the importance of identifying and treating it early.

32-year-old with Paroxysmal Atrial Fibrillation after Traumatic Spinal Cord Injury

A 32-year-old man presented with sudden loss of consciousness after passing urine with resultant trauma to the back of his neck. There were no palpitations prior. Examination revealed flaccid paralysis of all 4 limbs with priapism. Electrocardiogram demonstrated atrial fibrillation with rapid ventricular response. Laboratory showed normal potassium, magnesium, calcium, thyroid stimulating hormone and troponin I levels. Magnetic resonance imaging of the cervical spine demonstrated left C4 facet dislocation with grade 1 spondylolisthesis of C4 over C5, with moderate to severe narrowing of the spinal canal with cord compression and oedema. Transthoracic echocardiogram demonstrated an ejection fraction of 60% and no valvular abnormalities. Left atrium size was normal. The atrial fibrillation subsequently spontaneously reverted to sinus rhythm without treatment. Clinicians should be aware that atrial fibrillation can occur in the context of traumatic spinal cord injury due to disruption of the autonomic pathways in the cervical spine.

The Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment: Methodology, Cohort Demographics, and Initial Results

OBJECTIVE

The aim of the study was to present the methodology, cohort demographics, and initial results of the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA).

DESIGN

The SPICA is based on the Swedish CArdioPulmonary BioImage Study, a study on cardiopulmonary diseases in a cohort of 30,000 people. The assessments in the SPICA cover the structure and function of the cardiopulmonary and autonomic systems using bioimaging and functional analyses, together with a study-specific questionnaire and generic and spinal cord injury-specific assessment tools. The inclusion criteria were as follows: age 50-65 yrs, traumatic spinal cord injury of 5 yrs or more, and injury levels C1-T6, American Spinal Injury Association Impairment Scale A-C.

RESULTS

Of 38 potential participants, 25 comprised the final sample (20% women, mean age 58 yrs, mean time since injury 28 yrs). Eight percent had sustained a cardiovascular event, and 72% were classified as a high risk for cardiovascular disease. Asthma was previously diagnosed in only 8%, and none had chronic obstructive pulmonary disease.

CONCLUSIONS

The risk for cardiovascular disease in people with severe high-level spinal cord injury is a major clinical concern. Forthcoming studies in the SPICA will provide new knowledge of cardiopulmonary health in this cohort, which can guide future research and be used to develop long-term management.

Risk of biliary tract disease in living liver donors: A population-based cohort study

BACKGROUND & AIMS

Whether living liver donors have a higher risk of biliary tract disease compared with non-donors remains unknown.

METHODS

Data were collected from the Taiwan Longitudinal Health Insurance Database for the 2003-2011 period. The study cohort comprised 1,446 patients aged ≥ 18 years who had served as living liver donors. The primary outcome was the incidence of biliary tract disease. Cox proportional hazards modeling was used to determine the hazard ratios.

RESULTS

The incidence density rate of biliary tract disease was 13.9-fold higher in the liver donor (LD) cohort than in the non-LD cohort (10.2 vs. 0.71 per 1,000 person-years), with an adjusted hazard ratio (HR) of 14.2 (95% confidence interval [CI] = 7.73-26.1). Stratified by comorbidity, the relative risk of biliary tract disease was higher in the LD cohort than in the non-LD cohort for both patients with or without comorbidity. The incidence density rate of biliary tract disease was significantly higher in the first 3 years (13.5 per 1,000 person-years in the LD cohort). The highest adjusted HR of biliary tract disease for LD patients compared with the non-LD cohort was 22.4 (95% CI = 10.8-46.1) in the follow-up ≤ 3 years.

CONCLUSION

Living liver donors had a higher risk of biliary tract disease compared with non-donors.

Risk of Dementia in Patients with Leptospirosis: A Nationwide Cohort Analysis

Background: Studies have linked some bacterial infections with an increased likelihood for development of dementia. However, there is a paucity of data on the relationship between dementia and leptospirosis. In view of this, we conducted a retrospective cohort study to determine whether leptospirosis is a risk factor for dementia. Methods: Data were collected from the Taiwan National Health Insurance Research Databases (2000–2010) to investigate the incidence of and risk factors for dementia in patients with leptospirosis. Patients with leptospirosis who did not have a history of dementia were enrolled in the study. For each leptospirosis patient, four controls were randomly selected after frequency matching of age, sex, and index date. Cox proportional hazard regression models were used for the analyses of dementia risk. Results: A greater risk of dementia was observed in the leptospirosis cohort than in the non-leptospirosis cohort both in patients without any comorbidity (adjusted HR (aHR) = 1.23, 95% CI = 1.06–1.43) and with a comorbidity (aHR = 2.06, 95% CI = 1.7–2.5). Compared with the non-leptospirosis cohort without these comorbidities, the leptospirosis cohort with ≥2 comorbidities exhibited a significantly increased risk of dementia (aHR = 6.11, 95% CI = 3.15–11.9), followed by those with any one comorbidity (adjusted HR = 3.62, 95% CI = 1.76–7.46). Conclusions: Patients with leptospirosis were at a 1.89-fold greater risk of subsequent dementia, but potential genetic susceptibility bias in the study group is a major confound.

Risk of Parkinson disease in Sjögren syndrome administered ineffective immunosuppressant therapies: A nationwide population-based study

To determine the incidence and risk of Parkinson disease (PD) in patients with Sjögren syndrome (SS) according to a nationwide population-based database.In total, 12,640 patients in the SS cohort and 50,560 in the non-SS cohort were enrolled from Taiwan's National Health Insurance Research Database from 2000 to 2010. We used the Cox multivariable proportional hazards model to determine the risk factors for PD in the SS cohort.We observed an increased incidence of PD in patients with SS, with a crude hazard ratio (HR) of 1.40 and an adjusted HR (aHR) of 1.23. The cumulative incidence of PD was 1.95% higher in the SS cohort than in the non-SS cohort. The SS cohort had an elevated HR under medication use, namely cevimeline and pilocarpine (crude HR, 1.28), hydroxychloroquine (crude HR, 1.43; aHR, 1.46), and methylprednisolone (crude HR, 2.21; aHR, 1.49). Patients receiving other non-hydroxychloroquine immunosuppressant therapies had a lower risk (aHR, 0.86) of PD. Furthermore, patients with SS aged 20 to 49 years had a 1.93-fold higher risk of PD than did those without SS (aHR, 1.93). The risk of PD was higher (aHR, 2.20) in patients with SS without comorbidities than in those with comorbidities. The aHR of PD significantly increased when the follow-up period exceeded 9 years (aHR, 1.93).We determined an increased risk of PD in patients with SS. Further investigation is warranted to determine the possible underlying mechanisms and the potential role of non-hydroxychloroquine immunosuppressants in ameliorating PD.

Scrub typhus and depression: a nationwide cohort analysis

BACKGROUND

Studies on the relationship between depression and scrub typhus are limited. We conducted a retrospective cohort study to investigate whether scrub typhus is a risk factor for depression.

METHODS

Using Taiwan's National Health Insurance Research Database, this study investigated the incidence of depression, and its risk factors, in patients diagnosed with scrub typhus between 2000 and 2010. Scrub typhus patients who did not have a history of depression before the index date were enrolled. For each patient with scrub typhus, four controls without a history of scrub typhus and depression were randomly selected and frequency matched by sex, age, year of the index date, and comorbidities. The follow-up period was from the time of initial scrub typhus diagnosis to the date of diagnosis of depression, censoring, or December 31, 2010. Cox proportional hazards regression models were used to analyze the risk of depression according to sex, age, and comorbidities.

RESULTS

The study comprised a 5238-patient scrub typhus group and a 20,952-patient non-scrub typhus group with similar sex and age distributions. During the follow-up period, the cumulative incidence of depression was higher in the scrub typhus than the non-scrub typhus group (log-rank test P < 0.001). In the scrub typhus group, 45 patients developed depression, yielding an incidence rate of 1.67 per 1000 person-years, and in the non-scrub typhus group, 117 patients developed depression, yielding an incidence rate of 1.08 per 1000 person-years. This yielded a crude hazard ratio (HR) of 1.55 (95% confidence interval [CI] 1.41-1.70) and adjusted HR (aHR) of 1.56 (95% CI 1.42-1.71). Compared with the non-scrub typhus group, the risk of depression in the scrub typhus group was higher in patients of both sexes (men: aHR = 1.46, 95% CI 1.29-1.64; women: aHR = 1.68, 95% CI 1.45-1.96), in patients aged younger than 65 (≤ 49 years: aHR = 1.95, 50-64 years: aHR = 1.73), and in patients without comorbidities (aHR = 2.06, 95% CI 1.85-2.29).

CONCLUSIONS

The risk of depression was 1.56-fold higher in patients with scrub typhus than in the general population.

Risk of pyogenic liver abscess and endoscopic sphincterotomy: a population-based cohort study

OBJECTIVES

To evaluate the risk of pyogenic liver abscess (PLA) in patients receiving endoscopic sphincterotomy (ES).

SETTING

A population-based cohort study using data from Taiwans' National Health Insurance Research Database was conducted. Patients aged 20 or older who had undergone an ES were considered as the ES cohort. The dates for the first hospitalisation of the patients receiving ES were defined as the index dates.

PARTICIPANTS

Patients in the ES and non-ES cohorts were selected by 1:1 matching ratio based on a propensity score. A total of 8174 sex-matched, age-matched and index year-matched (1:1) pairs of patients receiving ES and 8174 patients without ES served as controls. Cox proportional hazards regression was employed to calculate the HRs and 95% CIs for the association between PLA and ES.

RESULTS

The overall incidence of PLA was significantly higher in the ES cohort than in the non-ES cohort (4.20 vs 0.94, respectively, per 1000 person-year) with the adjusted HR (aHR) 4.50 (95% CI 3.38 to 6.58) A stratified analysis during the follow-up years revealed that when the ES cohort was compared with the non-ES cohort, they displayed a higher risk of PLA during the first follow-up year (aHR 4.35, 95% CI 2.26 to 8.39) which continued significantly over the next 4-5 years of follow-up.

CONCLUSIONS

Patients receiving ES are associated with having a higher risk of PLA.

Peptic Ulcer Disease in Living Liver Donors: A Longitudinal Population-Based Study

The objective of this nationwide cohort study was to investigate the risk of peptic ulcer disease (PUD) in living liver donors (LDs). A total of 1333 LDs and 5332 matched nondonors were identified during 2003-2011. Hospitalized patients identified as LDs were assigned to the LD cohort, and the non-LD comparison cohort comprised age- and sex-matched nondonors. Cumulative incidences and hazard ratios (HRs) were calculated. The overall incidence of PUD was 1.74-fold higher in the LD cohort than in the non-LD cohort (2.14 vs. 1.48 per 1000 person-years). After adjustment for age, sex, monthly income and comorbidities, we determined that the LD cohort exhibited a higher risk of PUD than did the non-LD cohort (adjusted HR 1.74, 95% confidence interval [CI] 1.45-2.09). The incidence of PUD increased with age; the risk of PUD was 2.53-fold higher in patients aged ≥35 years (95% CI 2.14-2.99) than in those aged ≤34 years. LDs with comorbidities of osteopathies, chondropathies and acquired musculoskeletal deformities exhibited a higher risk of PUD (adjusted HR 3.93, 95% CI 2.64-5.86) compared with those without these comorbidities. LDs are associated with an increased risk of PUD after hepatectomy.