Cardioprotective Potential of Sodium-Glucose Co-Transporter-2 Inhibitors in Cancer Patients Treated With Anthracyclines: An Observational Study

Anthracyclines are pivotal in cancer treatment, yet their clinical utility is hindered by the risk of cardiotoxicity. Preclinical studies highlight the effectiveness of sodium-glucose co-transporter-2 inhibitors (SGLT2i) in mitigating anthracycline-induced cardiotoxicity. Nonetheless, the translation of these findings to clinical practice remains uncertain. This study aims to evaluate the safety and potential of SGLT2i for preventing cardiotoxicity in cancer patients, without pre-existing heart failure (HF), receiving anthracyclines therapy. Using the TriNetX Global Research Network, cancer patients without prior HF diagnosis, receiving anthracycline therapy were identified and classified into two groups based on SGLT2i usage. A 1:1 propensity score matching was used to control for baseline characteristics between the two groups. Patients were followed for 2 years. The primary endpoint was new-onset HF and secondary endpoints were HF exacerbation, new-onset arrhythmia, myocardial infarction, all-cause mortality, and all-cause hospitalization. Safety outcomes included acute renal failure and creatinine levels. A total of 79,074 patients were identified and 1,412 were included post-matching (706 in each group). They comprised 53% females, 62% White, with a mean age of 62.5 ± 11.4 years. Over the 2-year follow-up period, patients on SGLT2i had lower rates of new-onset HF (HR 0.147, 95% CI [0.073 - 0.294]) and arrhythmia (HR 0.397, 95% CI [0.227 - 0.692]) compared to those not on SGLT2i. The incidence of all-cause mortality, myocardial infarction, all-cause hospitalization, and safety outcomes were similar between both groups. In conclusion, amidst cancer patients receiving anthracycline therapy without preexisting HF, SGLT2i use demonstrates both safety and effectiveness in reducing anthracycline-induced cardiotoxicity, with a decreased incidence of new-onset HF, HF exacerbation, and arrhythmias.

Association Between Clinical Trial Participation Status and Outcomes With Mitral Transcatheter Edge-to-Edge Repair

BACKGROUND

Clinical trials have demonstrated the efficacy and safety of mitral transcatheter edge-to-edge repair (M-TEER) for selected patients with severe mitral regurgitation. However, the generalizability of trial results to real-world patients remains uncertain.

OBJECTIVES

The authors aimed to compare baseline characteristics and in-hospital outcomes among trial participants with nonparticipants undergoing M-TEER.

METHODS

Using the National Inpatient Sample database years 2016-2020, M-TEER admissions were identified and categorized into trial participants vs none. We also identified a cohort of trial noneligible patients based on clinical exclusion criteria from pivotal trials. Multivariate regression analysis was performed to compare in-hospital outcomes. The primary outcome was in-hospital mortality, and secondary outcomes included in-hospital complications, length of stay, and hospitalization cost.

RESULTS

Among 38,770 M-TEER admissions from 2016 to 2020, 11,450 (29.5%) were trial participants, 22,975 (59.3%) were eligible nonparticipants, and 2,960 (7.6%) were noneligible. Baseline characteristics and comorbidity profiles were mostly similar between trial participants vs eligible nonparticipants. In-hospital mortality (adjusted OR [aOR]: 0.98; 95% CI: 0.60-1.62), cardiogenic shock (aOR: 1.06; 95% CI: 0.80-1.42), mechanical circulatory support (aOR: 0.91; 95% CI: 0.58-1.41), mechanical ventilation (aOR: 1.03; 95% CI: 0.74-1.42), and conversion to mitral valve surgery (aOR: 1.08; 95% CI: 0.57-2.03) were not different between both groups. Conversely, M-TEER for noneligible patients was associated with higher rates of mortality (aOR: 6.27; 95% CI: 3.75-10.45) and complications.

CONCLUSIONS

The majority of real-world M-TEER patients would have been eligible for clinical trial participation and had comparable clinical profiles and in-hospital outcomes to trial participants. However, noneligible patients had worse in-hospital outcomes compared with trial participants.

Sex differences in myocarditis hospitalizations: Rates, outcomes, and hospital characteristics in the National Readmission Database

Inflammation of the myocardium, or myocarditis, presents with varied severity, from mild to life-threatening such as cardiogenic shock or ventricular tachycardia storm. Existing data on sex-related differences in its presentation and outcomes are scarce. Using the Nationwide Readmission Database (2016-2019), we identified myocarditis hospitalizations and stratified them according to sex to either males or females. Multivariable regression analyses were used to determine the association between sex and myocarditis outcomes. The primary outcome was in-hospital mortality, and the secondary outcomes included sudden cardiac death (SCD), cardiogenic shock (CS), use of mechanical circulatory support (MCS), and 90-day readmissions. We found a total of 12,997 myocarditis hospitalizations, among which 4,884 (37.6 %) were females. Compared to males, females were older (51 ± 15.6 years vs. 41.9 ± 14.8 in males) and more likely to have connective tissue disease, obesity, and a history of coronary artery disease. No differences were noted between the two groups with regards to in-hospital mortality (adjusted odds ratio [aOR] 1.20; confidence interval [CI] 0.93-1.53; P = 0.16), SCD (aOR:1.18; CI 0.84-1.64; P = 0.34), CS (aOR: 1.01; CI 0.85-1.20;P = 0.87), or use of MCS (aOR: 1.07; CI:0.86-1.34; P = 0.56). In terms of interventional procedures, females had lower rates of coronary angiography (aOR: 0.78; CI 0.70-0.88; P < 0.01), however, similar rates of right heart catheterization (aOR 0.93; CI:0.79-1.09; P = 0.36) and myocardial biopsy (aOR: 1.16; CI:0.83-1.62; P = 0.38) compared to males. Additionally, females had a higher risk of 90-day all-cause readmission (aOR: 1.25; CI: 1.16-1.56; P < 0.01) and myocarditis readmission (aOR:1.58; CI 1.02-2.44; P = 0.04). Specific predictors of readmission included essential hypertension, congestive heart failure, malignancy, and peripheral vascular disease. In conclusion, females admitted with myocarditis tend to have similar in-hospital outcomes with males; however, they are at higher risk of readmission within 90 days from hospitalization. Further studies are needed to identify those at higher risk of readmission.

Transcatheter Aortic Valve Replacement: Variations in Use, Charges, and Geography in the United States

The use of transcatheter aortic valve replacement (TAVR) in the United States has been increasing but with variability. We used a 100% sample of Medicare beneficiaries (MBs), from the Centers for Medicare and Medicaid Services database, who underwent TAVR by cardiologists between 2015 and 2019. We stratified data by geographic region, rural/urban areas, and provider's gender. We examined the average number of TAVRs performed per 100,000 MBs, the average number of TAVRs performed per individual cardiologist, and the average submitted charge (ASC) per procedure. The number of TAVR per 100,000 MBs was significantly variable among regions in all years (all P≤0.028), except in 2015 (P=0.103), with the highest rates being in the Northeast and the lowest being in the West. The number of TAVRs per cardiologist was significantly different among regions only in 2019 (P=0.04), with the Northeast showing the highest numbers and the South showing the lowest. The ASC was also significantly variable among regions in all years (all P≤0.01). The highest ASC was in the Midwest for all years, whereas the lowest was in the West in 2015 to 2016 and in the South in 2017 to 2019. In all years, the number of TAVRs per cardiologist was higher in urban areas than in rural areas (all P<0.05); however, rural cardiologists had higher ASCs (all P<0.05). The number of TAVR procedures per cardiologist was not significantly different between male and female cardiologists (all P>0.1). Female cardiologists had a significantly higher ASC only in 2015 (P=0.034). In conclusion, there are variations in TAVR use and charges for MBs according to geographic, urban, and rural regions and the performing cardiologist's gender.

Variations in Atrial Fibrillation Ablation Use and Charges in a Modern Cohort of Medicare Beneficiaries

Catheter ablation of atrial fibrillation (CAF) is increasingly being used in the United States. This study aimed to identify variations in CAF use among Medicare beneficiaries (MBs) over a 6-year period (2013 to 2019). Using the Center of Medicare and Medicaid Services database, a 100% sample of MBs who underwent CAF from 2013 to 2019 was included. We stratified CAF use data geographically (Northeast, South, West, and Midwest) and identified the number of CAFs per 100,000 MBs, number of electrophysiologists performing CAFs per 100,000 MBs, number of CAFs per individual electrophysiologist, and average submitted charge for CAF. In addition, we stratified the data per urban versus rural areas and gender of the operator. We found that the mean atrial fibrillation (AF) prevalence, rates of CAFs, number of electrophysiologists performing CAFs, and number of CAFs per electrophysiologist have increased steadily in all regions. The mean AF prevalence was different among regions, with the highest prevalence in the Northeast (p <0.001); however, there was a pattern of higher CAFs rates in the West and the South (p ≥0.057). The number of electrophysiologists performing CAFs was not different among regions; however, the number of CAFs per electrophysiologist was higher in the West and the South (p <0.001). The average submitted charge for CAF has decreased over years and was the lowest in the West and the South (p <0.001). There was no major difference in these variables regarding operator gender. In conclusion, there are significant variations in CAF use among MBs in the United States according to geographic and urban versus rural regions. These variations have the potential to impact the outcomes in MBs diagnosed with AF.

Disparities in Acute Coronary Syndrome Outcomes in Individuals With Intellectual Disabilities: A Propensity-Matched Analysis of National Inpatient Sample

BACKGROUND

Individuals with intellectual disabilities (IDs) are at similar risk of acute coronary syndrome (ACS) as compared to general population. However, there is a paucity of real-world data evaluating outcomes of ACS in this population. We sought to study ACS outcomes in individuals with IDs using a large national database.

METHODS

Adult admissions with a primary diagnosis of ACS were identified from the national inpatient sample of years 2016-2019. Cohort was stratified according to presence of IDs. A 1 to 1 nearest neighbor propensity score matching using 16 patient variables. Outcomes evaluated were in-hospital mortality, coronary angiography (CA), timing of CA (early [day 0] vs. late [>day0]), and revascularization.

RESULTS

A total of 5110 admissions (2555 in each group) were included in our matched cohort. IDs admissions had higher rates of in-hospital mortality (9 % vs. 4 %, aOR: 2.84, 95 % CI [1.66-4.86], P < 0.001), and were less likely to receive CA (52 % vs. 71 %, aOR: 0.44, 95 % CI [0.34-0.58], P < 0.001) and revascularization (33 % vs. 52 %, aOR: 0.45, 95 % CI [0.35-0.58], P < 0.001). In-Hospital mortality was higher in the ID admissions whether invasive coronary treatment (CA or revascularization) was performed (6 % vs. 3 %, aOR: 2.34, 95 % CI [1.09-5.06], P = 0.03) or not (13 % vs. 5 %, aOR: 2.56, 95 % CI [1.14-5.78], P = 0.023).

CONCLUSION

Significant disparities exist in ACS outcomes and management in individuals with IDs. More research is needed to understand the reasons for these disparities and develop interventions to improve quality of care in this population.

Personal and community-level exposure to air pollution and daily changes in respiratory symptoms and oxygen saturation among adults with COPD

Background

Air pollution exposure is associated with hospital admissions for Chronic Obstructive Pulmonary Disease (COPD). Few studies have investigated whether daily personal exposure to air pollutants affects respiratory symptoms and oxygenation among COPD patients.

Methodology

We followed 30 former smokers with COPD for up to 4 non-consecutive 30-day periods in different seasons. Participants recorded worsening of respiratory symptoms (sub-categorized as breathing or bronchitis symptoms) by daily questionnaire, and oxygen saturation by pulse oximeter. Personal and community-level exposure to fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃) were measured by portable air quality monitors and stationary monitors in the Boston area. We used generalized and multi-level linear mixed-effects models to estimate associations of the 24-hour average of each pollutant in the previous day with changes in respiratory symptoms and oxygen saturation.

Results

Higher community-level exposure to air pollutants was associated with worsening respiratory symptoms. An interquartile range (IQR) higher community-level O₃ was associated with a 1.35 (95%CI: 1.07-1.70) higher odds of worsening respiratory symptoms. The corresponding ORs for community-level PM_2.5 and NO₂ were 1.18 (95%CI: 1.02-1.37) and 1.06 (95%CI: 0.90-1.25), respectively. Community-level NO₂ was associated with worsening bronchitis symptoms (OR=1.25, 95%CI: 1.00-1.56), but not breathing symptoms. Personal PM_2.5 exposure was associated with lower odds of worsening respiratory symptoms (OR=0.91; 95%CI: 0.81-1.01). Personal exposure to NO₂ was associated with 0.11% lower oxygen saturation (95%CI: -0.22, 0.00) per IQR.

Conclusions

In this COPD population, there was a pattern of worsening respiratory symptoms associated with community-level exposure to O₃ and PM_2.5, and worsening oxygenation associated with personal exposure to NO₂.

Non-Small Cell Lung Cancer Presenting as Anterior Nasal Mass and Epistaxis

Lung malignancy presentation with an uncommon metastatic site is a diagnostic challenge and often associated with poor prognosis. Nasal cavity is a rare metastatic site for any type of lung cancer. We report an unusual case of poorly differentiated adenosquamous carcinoma of the lung with widespread metastasis presenting as a right vestibular nasal mass with epistaxis. A 76-year-old male patient with chronic obstructive pulmonary disease and 80 pack-year smoking history presented with spontaneous epistaxis. He reported a new rapidly growing right-sided nasal vestibular mass first noticed 2 weeks prior. Physical examination showed fleshy mass with crusting in right nasal vestibule along with a left nasal domus mass. Imaging revealed an ovoid mass in the right anterior nostril and a large mass in the right upper lobe of the lung (RULL) along with thoracic vertebral sclerotic metastasis and large left frontal lobe hemorrhagic lesion with severe vasogenic edema. Positron emission tomography scan showed large right upper lobe mass and suspected to be the primary malignancy along with widespread metastasis. Biopsy of the nasal lesion revealed poorly differentiated non-small cell carcinoma with squamous and glandular features. The diagnosis of very poorly differentiated adenosquamous carcinoma of the lung with widespread metastasis was made. In conclusion, unusual metastatic sites with unknown primary lesions require a thorough diagnostic workup involving biopsy and extensive imaging. Lung cancer with unusual metastatic sites is inherently aggressive and associated with poor prognosis. Multidisciplinary treatment modalities should be employed keeping in view the functional status and comorbidities of the patient.

Variations in atrial fibrillation ablation utilization and reimbursement among medicare beneficiaries: an observational study from 2013 to 2019

Background

Atrial fibrillation (AF) pulmonary vein isolation ablation has been utilized increasingly yet variably in the USA.

Purpose

To identify variations in AF ablation utilization and reimbursement among Medicare beneficiaries (MB).

Methodology

We used a 100% sample of MB who underwent AF ablation from 2013 to 2019. We stratified data geographically (Northeast, South, West, and Midwest), identified the mean AF prevalence and the number of AF ablations per 100,000 MB, and examined the correlation between AF prevalence and ablation. We also examined the number of cardiologists performing AF ablation per 100,000 MB and the average number of AF ablation per individual cardiologist (ablation/cardiologist), as well as average submitted charge (ASC) for AF ablation. Additionally, we stratified data per urban versus rural areas as well as the gender of performing cardiologists and examined ablation/cardiologist and the ASC.

Results

Geographic analysis: The mean AF prevalence, the rates AF ablation per 100,000 MB, the number of cardiologists per 100,000 MB, and ablation/cardiologist have shown a steady increase in all regions across years. In all years, the mean AF prevalence was significantly different among regions with the highest prevalence in the Northeast and the lowest in the West (all P&lt;0.001), however, there was no significant difference in the rates of AF ablation per 100,000 MB (all P≥0.056). There was significant correlation between AF prevalence and ablation only in the Midwest and the West, with 46.4% and 43.4% positive correlation respectively (P≤0.0001). The number of cardiologists performing AF ablation per 100,000 MB was not significantly different among regions in all years (All P≥0.48), however, ablation/cardiologist was significantly higher in the West and the South compared to the Northeast and the Midwest (All P&lt;0.0001). On the contrary, the ASC has shown steady decrease in all regions. The ASC was significantly different among regions in all year (all P≤0.003) with higher ASC in the Midwest and the Northeast compared to the south and the West.

Urban vs rural analysis: Ablation/cardiologist was not significantly different between urban and rural areas in all years (all P≥0.068) except in 2013 when it was significantly higher in urban areas (P=0.004). The ASC was significantly higher in rural areas only in 2015 and 2019 (P=0.037 and P=0.029 respectively) however, there was no significant difference in the rest of the years (P≥0.07).

Gender analysis: Ablation/cardiologist was not significantly different between male and female cardiologists in all years (P≥0.056) except in 2017 when the average was significantly higher per male cardiologists (P=0.007). The ASC was not significantly different in all years (P≥0.362).

Conclusion

There are variations in AF ablation utilization and reimbursement among MB in the USA according to geographic, urban and rural regions, and the gender of performing cardiologists.

Funding Acknowledgement

Type of funding sources: None.

Systemic anti-inflammatory effects of mesenchymal stem cells in burn: A systematic review of animal studies

Background

Despite the advances in burn care, severe burns still impose significant morbidity and mortality. Severe burns are associated with an inflammatory response that ranges from alterations in vital signs to shock, multiorgan failure, and death. Mesenchymal stem cells (MSCs) are known for their anti-inflammatory and immunomodulatory effects. Therefore, MSCs were investigated for their potential benefits in modulating burn-induced inflammation and organ damage in several studies.

Aim

We have conducted a systematic review of the literature to evaluate the efficacy of MSCs in modulating burn-induced systemic inflammation and organ damage in animal models.

Methods

Four databases were searched: PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization.

Results

Eight studies were included in the study. Bone marrow derived MSCs, umbilical cord derived MSCs (UC-MSCs), and UC-MSCs exosomes were used to modulate the burn-induced inflammation. MSCs therapy reduced serum levels of pro-inflammatory cytokines, improved renal function, inhibited tissue damage, and improved survival after burn. Furthermore, MSCs reversed all the burn-induced pathological changes in blood brain barrier (BBB).

Conclusion

MSCs may attenuate the burn-induced inflammation by decreasing serum levels of inflammatory cytokines. However, the effect on anti-inflammatory cytokines is conflicting and mandates more substantial evidence. Furthermore, MSCs reduce tissue inflammation, tissue damage, and apoptosis in the lungs and kidneys. In addition, MSCs reversed the burn-induced pathophysiologic changes in the BBB. The underlying mechanisms of these effects are poorly understood and should be the focus of future stem cell research.

Relevance to Patients

Severe burn patients are liable to systemic inflammation due to the release of inflammatory cytokines into the circulation. This inflammatory response has a broad spectrum of severity that ranges from alterations in vital signs to multiorgan failure and death. Despite the advances in burn care, burn-induced inflammation still imposes significant morbidity and mortality. This systematic review evaluates the potential benefits of stem cells in modulating burn-induced systemic inflammation in animal burn models.

The impact of personal and outdoor temperature exposure during cold and warm seasons on lung function and respiratory symptoms in COPD

Rationale

Methodology

Results

Conclusions

Higher temperature, including outdoor exposure during the warm season and personal exposure year-round, may worsen dyspnoea while colder outdoor temperature may trigger cough and phlegm symptoms in COPD patientshttps://bit.ly/3G0bL2c

Distinct Coagulopathy With Myocardial Injury and Pulmonary Embolism in COVID-19

In this article, we report a case of a 61-year-old male who was diagnosed with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), presenting with acute respiratory distress syndrome requiring intubation and hemodynamic support, marked D-Dimer and troponin I elevation, worsening ST-elevation myocardial infarction on repeat electrocardiograms, and a negative coronary angiogram ruling out a coronary artery thrombosis or occlusion. With worsening diffuse ST-segment elevation on electrocardiograms and reduced ejection fraction on echocardiography in the setting of systemic inflammation, fulminant myocarditis was highly suspected. Despite optimal medical treatment, the patient’s condition deteriorated and was complicated by cardiac arrest that failed resuscitation. Although myocarditis was initially suspected, the autopsy revealed no evidence of myocarditis or pericarditis but did demonstrate multiple microscopic sites of myocardial ischemia together with thrombi in the left atrium and pulmonary vasculature. Additionally, scattered microscopic cardiomyocyte necrosis with pathological diagnosis of small vessel micro-thrombotic occlusions. These findings are potentially exacerbated by inflammation-induced coagulopathy, hypoxia, hypotension, and stress, that is, a multifactorial etiology. Further research and an improved understanding are needed to define the precise pathophysiology of the coagulopathic state causing widespread micro-thrombosis with subsequent myocardial and pulmonary injury.

Incidental Finding of a Large Right Atrial Thrombus in a Patient With Cerebral Lymphoma

Right atrial (RA) masses are rare, challenging to diagnose, and potentially life-threatening with high mortality if untreated. We present a patient presenting with diffuse large B-cell lymphoma in the brain that was incidentally found to have a large RA mass. For a better definition of the RA mass, extensive workup using multimodality imaging including chest computed tomography, transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance imaging, and left heart catheterization was warranted. The imaging demonstrated a large RA mass extending through the tricuspid valve into the right ventricle and superior and inferior vena cava without a mobile component. The mass was then successfully resected, and further histology examination was performed to rule out lymphoma and rare subtypes of diffuse large B-cell lymphoma. The comprehensive workup proved the RA mass to be a calcified thrombus rather than a direct metastatic spread of lymphoma.

Chronological Impact of Earthquakes on Blood Pressure: A Literature Review and Retrospective Study of Hypertension in Haiti Before and After the 2010 Earthquake

Objective: We review prior studies on the incidence of hypertension (HTN) after earthquakes and present a retrospective analysis of HTN after the 2010 earthquake in Haiti. Methods: Prior reports on HTN incidence were reviewed and a retrospective chart review for diagnosis of HTN in 4,308 patient charts was performed over a 7 year period (five clinics). A retrospective cohort study (RCS) was then performed on 11 patients with linear follow-up. Results: The Literature review revealed a significant increase in acute and subacute HTN following earthquakes. However, the chronic effects of earthquakes varied. Our chart review uncovered no significant difference in diagnosed HTN in a Fort-Liberté clinic 128 kilometers (km) distant and 4 weeks post-event. A secondary linear RCS for 11 individuals, prior to and after the earthquake, also did not detect a significant change in HTN prevalence. Conclusion: Prior studies demonstrate acute and subacute, increases in HTN after earthquakes, but late changes have varied. Retrospective studies in the Fort-Liberté clinic, 128 km distant and 4 weeks post-event, revealed no significant change in HTN, confirming prior findings that changes in HTN after earthquakes are early and local events. Further work examining HTN after earthquakes is needed to improve early health care after natural disasters.

Multimodality Imaging Demonstrating an Apical Variant Hypertrophic Cardiomyopathy in an Uncommon Pentad

A 79-year-old man was admitted for a transcatheter aortic valve replacement due to severe aortic stenosis. A preoperative chest computed tomography with angiography revealed an apical variant hypertrophic cardiomyopathy with a prominent apical pouch. In addition, there was near-complete obliteration of the left ventricle in the mid to apical aspect during systole suggesting a midventricular gradient. Postoperative transthoracic echocardiography confirmed the apical variant hypertrophic cardiomyopathy with an apical aneurysm and a gradient with a peak velocity of 2 m/s, and mid-cavitary gradient with a peak velocity of 3 m/s. It also revealed a fusiform aneurysmal dilatation of the ascending aorta.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Bapineuzumab for mild to moderate Alzheimer's disease: a meta-analysis of randomized controlled trials

Background

Alzheimer’s disease (AD) is a globally prevalent neurodegenerative condition, clinically characterized by progressive memory loss and gradual impairment of cognitive functions. Bapineuzumab is a fully humanized monoclonal antibody that binds to neurotoxic amyloid proteins in the brain, enhancing their clearance. We performed this systematic review and meta-analysis to evaluate the safety and efficacy of bapineuzumab in patients with mild to moderate Alzheimer’s disease.

Methods

We performed a web-based literature search of PubMed, Ovid, EBSCO, Scopus, Embase, Cochrane CENTRAL, and web of science using the relevant keywords. Data were extracted from eligible records and pooled as mean difference (MD) or risk ratio (RR) values with their 95% confidence interval (CI), using Review Manager software (version 5.3 for windows). Heterogeneity was measured by Chi-square and I-square tests.

Result

The pooled effect estimate from six randomized clinical trials (n = 2380) showed that bapineuzumab significantly reduced the cerebrospinal fluid concentration of phosphorylated tau proteins (Standardized MD = −5.53, 95% CI [−8.29, −2.76]). However, the bapineuzumab group was not superior to the placebo group in terms of change from baseline in Alzheimer’s disease assessment scale (ADAS)-Cog11 (MD = 0.14, 95% CI [−0.72, 0.99]), disability assessment for dementia (DAD) scale (MD = 1.35, 95% CI [−1.74, 4.43]), and mini-mental state examination (MMSE) scores (MD = 0.08, 95% CI [−0.31, 0.47]). Regarding safety, bapineuzumab increased the risk of serious treatment-emergent adverse events (RR = 1.18, 95% CI [1.02, 1.37]) and cerebral vasogenic edema (RR = 40.88, 95% CI [11.94, 135.95]). All bapineuzumab doses (0.15, 0.5, 1, and 2 mg/kg) were similar to placebo in terms of change from baseline in ADAS-cog11, DAD, and MMSE scores, except for the 0.15 mg/kg dose, which caused a significant worsening on the ADAS-cog11 scale (MD = 5.6, 95% CI [0.22, 10.98]).

Conclusions

Considering the lack of clinical efficacy, combined with the significant association with serious adverse events, bapineuzumab should not be used to treat patients with mild to moderate AD. Future studies should investigate the effect of combining bapineuzumab with other therapeutic strategies and reevaluate the efficacy of targeting amyloid β proteins in AD therapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0850-1) contains supplementary material, which is available to authorized users.

Predictors of suicidality across the life span: the Isle of Wight study

BACKGROUND

Data from a representative community sample were used to explore predictors of lifetime suicidality and to examine associations between distal adolescent and more proximal adult risks.

METHOD

Data are from a midlife follow-up of the Isle of Wight study, an epidemiological sample of adolescents assessed in 1968. Ratings of psychiatric symptoms and disorder, relationships and family functioning and adversity were made in adolescence; adult assessments included lifetime psychiatric history and suicidality, neuroticism and retrospective reports of childhood sexual abuse and harsh parenting.

RESULTS

A wide range of measures of childhood psychopathology, adverse experiences and interpersonal difficulties were associated with adult suicidality; associations were particularly strong for adolescent irritability, worry and depression. In multivariate analyses, substantial proportions of these effects could be explained by their association with adult psychopathology and neuroticism, but additional effects remained for adolescent irritability and worry.

CONCLUSIONS

Factors of importance for long-term suicidality risk are evident in adolescence. These include family and experiential adversities as well as psychopathology. In particular, markers of adolescent worry and irritability appeared both potent risks and ones with additional effects beyond associations with adult disorder and adult neuroticism.