Association between vitamin D receptor gene variants and neonatal sepsis: A systematic review and meta-analysis

The objective of this systematic review and meta-analysis was elucidating the association of VDR SNPs (FokI, TaqI, BsmI, BgII, and ApaI) with neonatal sepsis. Literature search was performed to retrieve records published until August 2nd, 2023 (PROSPERO registration: CRD42023451355). Meta-analysis was carried out to determine the pooled estimates for Odds Ratio (OR). A total of four studies were included with 500 neonates (250 sepsis cases and 250 healthy controls). There was an association observed between TaqI SNP with neonatal sepsis for CT vs. CC+TT (OR=1.95) and TT vs CT+CC (OR=0.40). Moreover, the pooled estimates also suggested that CC vs. CT+TT (OR= 0.37) and C vs. T (OR=0.66) of FokI SNP were significantly associated with neonatal sepsis. SNP of BgII was found to be significantly associated with neonatal sepsis, but only reported in a single study.

Genetic polymorphisms associated with sepsis incidence, severity, and outcomes among neonates: A mini-review

Genetic variation remains a topic of great interest due to its potential as a risk factor for various diseases. Interactions between genes contribute to diverse phenotypes in response to factors such as infection. The impact of genetic background on susceptibility and clinical outcomes, particularly in neonatal sepsis, has gained recognition. The variability in sepsis susceptibility and outcomes can be attributed to the genetic diversity in coding regions and regulatory elements of genes related to innate immune response. Recent advances in genomics and technology have shed light on genetic polymorphisms among humans, often represented by single-nucleotide polymorphisms (SNPs). These SNPs encode proteins crucial for recognizing and responding to pathogenic bacteria, including Toll-like receptor 4, CD14, tumor necrosis factor-alpha, as well as interleukin-1-10. This literature review specifically discusses the involvement of genetic polymorphism during the pathogenesis stage of sepsis, with an emphasis on previous research findings in neonatal sepsis cases, aiming to discuss the implications of polymorphism in sepsis susceptibility and outcomes.

A choledochal cyst type IVa in a child treated with Roux-en-Y hepaticojejunostomy

A choledochal cyst is a bile duct anomaly that disrupts the transportation of bile from the liver to the gallbladder and small intestine. Choledochal cysts are rare, occurring in approximately one out of every 100,000 to 150,000 children in Western countries, with a girls-to-boys ratio of 4:1. Immediate surgery to excise the cyst and construct a biliary-enteric continuity is necessary to treat this condition. This case-report aimed to present a child with choledochal cyst type IVa who underwent a Roux-en-Y hepaticojejunostomy. A 3-year-11-month-old girl with an abdominal mass experienced jaundice, nausea, and vomiting over the past two years, which worsened in the last month. Abdominal ultrasonography indicated intrahepatic biliary dilatation. Abdominal computed tomography scan results confirmed a choledochal cyst type IVa, characterized by fusiform cyst dilatation at the bilateral intrahepatic bile duct, common hepatic duct, cystic duct, and common bile duct. The cyst exerted pressure on the pancreas and small intestine. Before the surgery, the patient was treated with ceftriaxone 100 mg/kg/day and gentamicin 5 mg/kg/day. Roux-en-Y hepaticojejunostomy was performed, involving the complete excision of the extrahepatic bile duct to reconstruct the biliary system. During the surgery, a retroperitoneal cyst measuring 20 cm x 10 cm with a volume of 200 ml was discovered. Following the surgery, the patient showed clinical improvement. Patient follow-ups indicated that no complications such as wound infection, acute pancreatitis, and the formation of pancreatic or biliary fistula occurred. This case highlights that Roux-en-Y hepaticojejunostomy proves to be an effective surgical approach for managing choledochal cyst type IVa in children, helping to prevent further complications.

A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

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Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

Vitamin D supplementation and adverse skeletal and non-skeletal outcomes in individuals at increased cardiovascular risk: Results from the International Polycap Study (TIPS)-3 randomized controlled trial

BACKGROUND AND AIMS

Vitamin D has mostly been tested in Western populations. We examined the effect of high dose vitamin D in a population drawn predominantly from outside of Western countries.

METHODS AND RESULTS

This randomized trial tested vitamin D 60,000 IU monthly in 5670 participants without vascular disease but at increased CV risk. The primary outcome was fracture. The secondary outcome was the composite of CV death, myocardial infarction stroke, cancer, fracture or fall. Death was a pre-specified outcome. Mean age was 63.9 years, and 3005 (53.0%) were female. 3034 (53.5%) participants resided in South Asia, 1904 (33.6%) in South East Asia, 480 (8.5%) in South America, and 252 (4.4%) in other regions. Mean follow-up was 4.6 years. A fracture occurred in 20 participants (0.2 per 100 person years) assigned to vitamin D, and 19 (0.1 per 100 person years) assigned to placebo (HR 1.06, 95% CI 0.57-1.99, p-value = 0.86). The secondary outcome occurred in 222 participants (1.8 per 100 person years) assigned to vitamin D, and 198 (1.6 per 100 person years) assigned to placebo (HR 1.13, 95% CI 0.93-1.37, p = 0.22). 172 (1.3 per 100 person years) participants assigned to vitamin D died, compared with 135 (1.0 per 100 person years) assigned to placebo (HR 1.29, 95% CI 1.03-1.61, p = 0.03).

CONCLUSION

In a population predominantly from South Asia, South East Asia and South America, high-dose vitamin D did not reduce adverse skeletal or non-skeletal outcomes. Higher mortality was observed in the vitamin D group.

REGISTRATION NUMBER

NCT01646437.

Factors associated with health-related quality of life in heart failure in 23,000 patients from 40 countries: results of the global congestive heart failure research program

Background

Poor health-related quality of life (HRQL) is common in heart failure (HF) and strongly predicts death and HF hospitalization in all regions of the world. Understanding facors associated with HRQL could therefore lead to improved prognosis in HF patients. Despite that the majority of HF occurs in low- and middle-income countries, there are limited data characterizing self-perceived health HRQL and its correlates in these settings.

Purpose

To examine clinical and social correlates of HRQL in patients with HF from high- (HIC), upper middle- (UMIC), lower middle-(LMIC) and low-income (LIC) countries.

Methods

Between 2017 and 2020, we enrolled 23,292 patients with HF (32% inpatients, 61% men) from 40 countries in the Global Congestive Heart Failure Study. We recorded HRQL at baseline using Kansas City Cardiomyopathy Questionnaire (KCCQ)-12. In a cross-sectional analysis, we compared age- and sex-adjusted mean KCCQ-12 summary scores (SS: 0–100, higher=better) between patients from different country income levels. We used multivariable linear regression examining correlations (estimates expressed as β-coefficients) of KCCQ-12-SS with sociodemographic-, comorbidity-, treatment- and symptom-covariates. The adjusted model (37 covariates) was informed by univariable findings, clinical importance and backward selection. We used partial R2-estimates to understand the contribution to the variability in KCCQ-12-SS of 4 different groups of covariates. (sociodemographic, comorbidities, treatments and signs and symptoms of congestion).

Results

Mean age was 63 years and 40% were in NYHA class III–IV. Average HRQL was 55± SD 0.5. It was 62.5 (95% CI 62.0–63.1) in HIC, 56.8 (56.1–57.4) in UMIC, 48.6 (48.0–49.3) in LMIC, and 38.5 (37.3–39.7) in LICs (p&lt;0.0001). Strong correlates (β-coefficient [95% CI]) of KCCQ-12-SS were NYHA class III vs class I/II (−12.1 [−12.8 to −11.4] and class IV vs. class I/II (−16.5 [−17.7 to −15.3]), effort dyspnea (−9.5 [−10.2 to −8.8]) and living in LIC vs. HIC (−5.8 [−7.1 to −4.4]). Symptoms explained most of the KCCQ-12-SS variability (partial R2=0.32 of total adjusted R2=0.51), followed by sociodemographic factors (R2=0.12). Results were consistent in populations across income levels.

Conclusion

The most important correlates of HRQL in HF patients relate to HF symptom severity, irrespective of country-income level. Improved symptom control may have a big impact on HRQL, especially in LICs.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer AG

Body mass index from the RE-LY trial: further evidence of the obesity paradox

Background

The obesity paradox has been reported in 3 post-hoc analyses evaluating the direct oral anticoagulants (DOAC) against warfarin (W): apixaban (ARISTOTLE), rivaroxaban (ROCKET), and edoxaban (ENGAGE-AF).

Purpose

To evaluate the obesity paradox in a post-hoc analysis of the RE-LY trial, comparing dabigatran 110 mg BID (D110), 150 mg BID (D150), and W by body mass index (BMI).

Methods

Baseline characteristics were evaluated using World Health Organization (WHO) criteria of overweight and obese (BMI ≥25 kg/m2) and under and normal weight (BMI &lt;25 kg/m2). Stroke and systemic embolism, ischemic stroke, major bleeding, mortality, and intracranial hemorrhage were evaluated using BMI as a continuous variable and by the WHO criteria using a cox proportional hazard model.

Results

BMI was available in 99.9% of patients randomized; 74% had a BMI ≥25. At baseline, patients with a BMI ≥25 were younger (70.9 vs 73.1, p&lt;0.001) and had fewer prior strokes (11.5% vs 15.6%, p&lt;0.001), but higher mean creatinine clearance (78.3 vs 57.0, p&lt;0.001) and rates of diabetes (25.8% vs 16.1%, p&lt;0.001) (Table 1). Independent of drug assignment, patients with a BMI ≥25 had lower rates of stroke and systemic embolism (HR 0.65 [95% CI 0.54–0.79], p&lt;0.001), ischemic stroke (0.75 [95% CI 0.60, 0.94], p=0.01), major bleeding (HR 0.79 [95% CI 0.69,0.89], p&lt;0.001), mortality (HR 0.60 [95% CI 0.53, 0.67], p&lt;0.001) and intracranial hemorrhage (HR 0.53 [95% CI 0.38, 0.73], p&lt;0.001) compared to those with a BMI &lt;25. Using BMI as a continuous variable combining all outcomes at 3 years, endpoint rates declined as BMI approached 25 in all 3 treatment groups. The exceptions were intracranial hemorrhage for D110 and D150 and stroke in D150 patients, where rates were low independent of BMI. No significant interaction between BMI and treatment was observed in individual outcomes except for the D110 vs. D150 comparison for major bleeding, in favor of D110 for patients with BMI ≥25 (HR 0.77 [95% CI 0.65, 0.91] and HR 1.12 [95% CI 0.86, 1.47], interaction p=0.0190).

Conclusions

In RE-LY, independent of drug assignment, patients with a higher BMI had improved outcomes, demonstrating the obesity paradox. As BMI increased towards 25, outcome rates improved except for intracranial hemorrhage rates for both D110 and D150 and ischemic stroke rates for D150, which were low independent of BMI. Patients treated with D110 with a BMI ≥25 kg/m2 had significantly lower rates of bleeding compared to D150.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Sharpe Strumia Foundation

The performance of STRONGkids in the early detection of hospital malnutrition

Background Hospital malnutrition in children can increase morbidity and mortality, regardless of the type of illness. The Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) is a practical and easy nutritional risk screening tool that has been widely validated in several countries. Objective To examine the performance of STRONGkids for the early detection of hospital malnutrition in pediatric inpatients. Methods This cross-sectional study was conducted in the pediatric ward of Dr. Zainoel Abidin General Hospital, Banda Aceh, Indonesia. The pediatric inpatients' STRONGkids scores were calculated within 24 hours of admission. We used the chi-square test to compare the proportion of at-risk children based on STRONGkids scores with the prevalence of hospital malnutrition based on serial weight measurement. We also determined the sensitivity, specificity, as well as positive and negative predictive values of STRONGkids for detecting hospital malnutrition, with percentage of weight loss between admission and discharge as the gold standard. Result Out of 75 subjects, 48% were male. The hospital malnutrition prevalence was 29.3%. STRONGkids score was significantly associated with hospital malnutrition (P=0.023). The sensitivity, specificity, positive predictive value, and negative predictive value of STRONGkids for detecting hospital malnutrition was 77.3%, 54.7%, 41.4%, and 85.2%, respectively. Conclusion With its good sensitivity, the STRONGkids tool is effective in identifying those at risk of hospital malnutrition. In addition, with its high NPV, a “no-risk” score also effectively implies that the child is likely not to have hospital malnutrition.

Real-world evaluation of follow up strategies after implantable cardiac-defibrillator therapies in patients with ventricular tachycardia (REFINE-VT)

Introduction

Implantable cardiac-defibrillators (ICD) can prevent sudden cardiac death but the risk of recurrent ventricular arrhythmia (VA) and ICD therapies persists. Established strategies to minimize such risks include medication optimization, device reprogramming or ventricular tachycardia (VT) catheter ablation (CA). However, the timing and choice of these strategies at ICD follow-up may not be as consistent in the real-world as the regulated conditions of clinical trials. Furthermore, whether these decisions at follow-up are influenced by the type of arrhythmia, ICD therapy or patient characteristics remain unclear.

Purpose

We evaluated ICD follow-up strategies in patients with ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM) to refine the outpatient management of these complex patients and ultimately improve overall patient outcome.

Methods

REFINE-VT is a retrospective study of 514 patients with ICD/CRT-D who attended ICD follow-up between June 2018 to September 2019 at the University Hospital Coventry & Warwickshire (UHCW) tertiary cardiology department. All follow-ups were face-to-face. Patients were divided into 2 groups according to the absence or presence of sustained VA (e.g. &gt;30 seconds of VT and/or appropriate ICD therapy), described as “negative event” and “positive event” groups respectively. The type of strategy employed in response to a positive event were categorized into 4 groups: (1) Medication change only (2) Device programming +/− medication (3) Referral for VT CA (4) No intervention

Results

514 consecutive patients with ICD (52%) or CRT-D (48%) were analysed. Overall mean age was 67±14 years with 79% male patients. ICM was diagnosed in 329 (64%) patient and NICM in 185 (36%). 437 (85%) patients had no significant VA and/or ICD therapy referred to as the negative group. A total of 77 patients (15%) suffered VA and/or ICD therapies, of whom 22 patients (26%) experienced a second event. 31% (n=24) of this positive event group received no preventative strategy (Table 1). We observed an inconsistent approach to the choice of strategies across different types of arrhythmias and ICD therapies. E.g. the odds of intervening were significantly higher if ICD shock was detected compared to anti-tachycardia pacing (OR 8.4, 95% CI 1.7–39.6, p=0.007). Even in patients with two events, the rate of referral for VT ablation and escalation of antiarrhythmics were similarly as low as patients with a single event (Table 2).

Conclusion

This is the first contemporary study that has evaluated how strategies that reduce the risk of recurrent ICD events are executed in a real-world population. We have demonstrated that the decision to intervene and choices of strategy remain inconsistent and partially biased by the type of arrhythmia and ICD therapy at follow-up. This supports the need for an evidence-driven multi-disciplinary VT clinic to refine and standardize our approach to this heterogeneous population.

Funding Acknowledgement

Type of funding sources: None.

Challenges in the management of kidney transplant recipients in a centre without a kidney transplant program: A single centre experience

Objective: This study is aimed at highlighting the challenges associated with the management of kidney transplant recipients in a centre without a transplant program.Methods: This is a retrospective study that enrolled all post renal transplant patients seen at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, North-western Nigeria between October 2010 and June 2019. Data obtained included cause of renal disease, pre-transplant dialysis details, type of donor, country of the kidney transplant, sponsor, type of maintenance immunosuppression, frequency of follow up, complications and outcome of the kidney transplant. Data obtained was analysed using statistical package for the social sciences software (SPSS) version 25 (IBM Inc. 2010).Results: Of the 16 patients who were enrolled in this study, 10 (62.5%) were males with a mean age of 36.5 ± 13.2 years. Twelve (75%) subjects reported challenges in obtaining their post-transplant immunosuppressants. Only one (6.25%) subject had allograft biopsy despite the fact that 5 (71.4%) out of the 7 patients that died had allograft dysfunction. The majority of the participants (81.3%) had no serum tacrolimus level test done throughout their follow up period.Conclusions: The management of post-transplant recipients in our centre is associated with challenges ranging from difficulty in procurement of post-transplant medications, poor laboratory support for monitoring of drug levels and inadequate facilities for management of allograft dysfunction. Keywords: Kidney transplant; End-stage renal disease; follow-up French Title: Défis dans la prise en charge des receveurs de transplantation rénale dans un centre sans programme de transplantation rénale: Une expérience dans un seul centreIntroduction : Cette étude vise à mettre en évidence les défis associés à la prise en charge des greffés rénaux dans un centre sans programme de transplantation.Méthode de l'étude : Il s'agit d'une étude rétrospective qui a recruté tous les patients après transplantation rénale vus à l'hôpital universitaire Usmanu Danfodiyo (HUUD), Sokoto, dans le nord-ouest du Nigéria entre octobre 2010 et juin 2019. Les données obtenues comprenaient la cause de la maladie rénale, les détails de la dialyse de pré-transplantation, le type du donner, du pays de la  transplantation rénale, du promoteur et d'immunosuppression. Les données obtenues ont été analysées à l'aide du progiciel statistique du logiciel de sciences sociales (PSLSS) version 25 (IBM Inc. 2010).Résultat de l'étude : Sur les 16 patients inclus dans cette étude, 10 (62,5%) étaient des hommes avec un âge moyen de 36,5 ± 13,2 ans. Douze (75%) sujets ont signalé des difficultés à obtenir leurs immunosuppresseurs après la transplantation. Un seul sujet (6,25%) a eu une biopsie d'allogreffe malgré le fait que 5 (71,4%) des 7 patients décédés avaient un dysfonctionnement de l'allogreffe. La majorité des participants (81,3%) n'ont eu aucun test du taux de tacrolimus sérique effectué tout au long de leur période de suivi.Conclusion : La gestion des receveurs post-transplantation dans notre centre est associée à des défis allant de la difficulté à se procurer des médicaments post-transplantation, un soutien de laboratoire médiocre pour la surveillance des niveaux de médicaments et des installations inadéquates pour la gestion du dysfonctionnement des allogreffes. Mots-clés: Greffe de rein, phase terminale de la maladie rénale

Efficacy and safety of low-dose rivaroxaban on top of aspirin in patients with polypharmacy and multimorbidity: an analysis from the COMPASS trial

Background

In patients with coronary or peripheral artery disease, intensified antithrombotic therapy with aspirin plus low dose rivaroxaban reduced cardiovascular outcomes compared with aspirin alone. Polypharmacy and multimorbidity are frequent in patients with vascular disease and are often perceived as barriers to more intensive pharmacotherapy by both patients and physicians.

Purpose

To report cardiovascular outcomes and the efficacy, safety, and net benefit of low dose rivaroxaban plus aspirin in patients with stable vascular disease by the number of concomitant cardiovascular drugs and by the number of comorbidities.

Methods

We reported ischemic events (cardiovascular death, stroke, or MI), major bleeding (ISTH modified criteria), and a prespecified net clinical outcome in participants from the randomised, double-blind COMPASS study by number of cardiovascular medications (0–2, 3, 4, 5–7) and by number of concomitant medical conditions. We compared rates and hazard ratios of patients treated with rivaroxaban plus aspirin vs aspirin alone by category of number of medications and concomitant conditions and tested for interaction between polypharmacy and multimorbidity and antithrombotic regimen.

Results

Although patients with polypharmacy and multimorbidity have a higher risk of cardiovascular events (Figure) those who required many cardiovascular drugs derived the largest absolute reduction in the net clinical outcome when adding rivaroxaban on top of aspirin. The relative efficacy, safety, and net clinical benefit of adding low-dose rivaroxaban to aspirin in patients with stable vascular diseases were not affected by the number of cardiovascular drugs or by the number of comorbidities. Multimorbidity, but not polypharmacy, was related with a higher risk of major bleeding.

Conclusion

Addition of low-dose rivaroxaban conveyed a benefit irrespective of the number of concomitant drugs or comorbid conditions. Multiple comorbidities and/or polypharmacy should not dissuade the addition of low-dose rivaroxaban to aspirin in otherwise eligible patients.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The COMPASS trial was funded by Bayer AG.

CHA2DS2-VASc and CHADS2 scores for risk stratification of major adverse cardiovascular events in the COMPASS trial

Background

The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial demonstrated that the combination therapy of rivaroxaban and aspirin reduced major adverse cardiovascular events (MACE) compared to aspirin alone in patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD).

Purpose

We assessed whether the CHA2DS2-VASc (congestive heart failure (CHF), hypertension, age ≥75 years, diabetes, stroke/transient ischemic attack (TIA)/thromboembolism, vascular disease, age 65–75 years, and sex category) and CHADS2 (CHF, hypertension, age ≥75 years, diabetes, stroke/TIA) scores used to predict the risk of stroke in patients with atrial fibrillation, can be used identify vascular patients at highest risk of recurrent events who may derive greatest benefits of treatment.

Methods

In COMPASS patients, the predictive accuracy of CHA2DS2-VASc and CHADS2 scores were assessed for MACE, bleeding and net clinical benefit using Cox proportional hazards model. Kaplan-Meier estimates of cumulative risk and absolute risk differences were used to examine the effects of rivaroxaban plus aspirin compared with aspirin alone over 30 months according to risk score categories.

Results

In 27,395 participants with CAD and/or PAD, a high CHA2DS2-VASc score (6–9) was associated with 3 times greater absolute risk of MACE compared to a low score (1–2) (hazard ratio=3.39, 95% CI: 2.54–4.51, p&lt;0.0001). The effects of combination therapy with rivaroxaban and aspirin on MACE, bleeding and net clinical benefit were consistent across CHA2DS2-VASc and CHADS2 score categories, with the greatest benefit in those with the highest risk scores (Figure 1). The greatest reduction in MACE with rivaroxaban and aspirin compared to aspirin only was observed in patients treated for 30 months with highest CHA2DS2-VASc score (6–9) (23 events per 1000 patients prevented) or highest CHADS2 score (3–6) (25 events per 1000 patients prevented). There was increased bleeding in patients with higher CHA2DS2-VASc and CHADS2 scores, but net clinical benefit was preserved across all risk categories and was greatest in those with the highest risk scores.

Conclusion

The CHA2DS2-VASc or CHADS2 scores can be used in patients with chronic CAD and/or PAD to identify patients who are at highest risk of MACE, and therefore likely to achieve the greatest benefit of dual pathway inhibition with the combination of rivaroxaban and aspirin compared with aspirin alone.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This study was sponsored by Bayer AG.

Hubungan Karakteristik Klinis dan Laboratoris Terhadap Kejadian Miokarditis Difteri pada Anak di RSUD Dr. Zainoel Abidin Banda Aceh

Latar belakang. Difteri merupakan penyakit infeksi yang disebabkan oleh Corynebacterium diphtheriae. Komplikasi terberat penyakit ini yaitu terjadinya miokarditis yang dapat mengakibatkan kematian.Tujuan. Mengetahui hubungan antara karakteristik klinis dan laboratoris terhadap kejadian miokarditis difteri pada anak di RSUDZA Banda Aceh.Metode. Jenis penelitian ini adalah observasional analitik dengan pendekatan cross sectional yang menggunakan data rekam medik pasien difteri periode Januari 2017 hingga Desember 2019. Sampel 101 pasien difteri dengan metode purposive sampling. Analisis data menggunakan univariat dan bivariat dengan Chi-square test. Hasil. Berdasarkan hasil analisis bivariat antara karakteristik klinis dengan terjadinya miokarditis difteri didapatkan hasil (CI=95%; p<0,05) untuk stridor dan (CI=95%; p>0,05) untuk variabel letak membran, demam, nyeri tenggorokan, suara parau, bull neck dan derajat difteri. Analisis antara karakteristik laboratoris (leukosit, Troponin I, CK-MB, SGOT dan SGPT) dengan terjadinya miokarditis difteri didapatkan hasil (CI = 95%; p >0,05)Kesimpulan. Terdapat hubungan antara variabel karakteristik klinis, yaitu stridor dengan terjadinya miokarditis difteri. Sementara variabel lain, seperti letak membran, demam, nyeri tenggorokan, suara parau, bull neck dan derajat difteri tidak ada hubungan dengan terjadinya miokarditis difteri. Tidak ada hubungan antara variabel karakteristik laboratoris (leukosit, Troponin I, CK-MB, SGOT dan SGPT) dengan terjadinya miokarditis difteri pada anak di RSUDZA Banda Aceh.

Profil Penyakit Kritis di Ruang Rawat Intensif Anak RSUD Dr. Zainoel Abidin Banda Aceh

Latar belakang. Angka morbiditas dan mortalitas pada anak yang disebabkan penyakit kritis masih tinggi, terutama pada usia di bawah 5 tahun. Hingga saat ini belum ada data mengenai profil pasien anak dengan penyakit kritis yang dirawat di ruang rawat intensif anak RSUD Dr. Zainoel Abidin (RSUDZA), Banda Aceh.Tujuan. Untuk mengetahui bagaimana profil pasien anak dengan penyakit kritis yang dirawat di ruang rawat intensif anak RSUD Zainoel Abidin (RSUDZA), Banda Aceh pada tahun 2019.Metode. Penelitian deskriptif retrospektif di ruang rawat intensif anak RSUDZA, Banda Aceh. Data dari rekam medis usia 1 bulan - 18 tahun sejak Januari 2019 sampai Desember 2019.Hasil. Diperoleh data pasien anak dengan sakit kritis yang dirawat di ruang intensif anak RSUDZA berjumlah 316 subjek. Mayoritas usia di bawah 5 tahun. Penyakit utama terbanyak adalah disfungsi organ respirasi (28,5 %). Jumlah Skor PELOD-2 terbanyak pada studi ini < 7 (69,6%) dengan lama rawat 2-7 hari (64,9%) dan angka mortalitas 21,8%.Kesimpulan. Profil penyakit kritis pada anak di RSUDZA Banda Aceh Tahun 2019 menunjukkan mayoritas subjek berusia di bawah 5 tahun, skor PELOD-2 < 7 dengan disfungsi organ terbanyak adalah respirasi.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

No UHC without medicines: out-of-pocket payments for non-communicable diseases in 18 countries

Background

In 2014 the United Nations agreed on a goal to reduce premature mortality from NCDs by improving financial risk protection. We are far from achieving this: households with NCDs are at an increased risk of catastrophic health spending and impoverishment, particularly in lower middle- and low-income countries. There is a need to better understand the drivers of health spending among households with NCDs, to inform interventions aimed at achieving universal health coverage.

Methods

Using data from the Prospective Urban and Rural Epidemiology Study, we analyse out-of-pocket expenditure (OOP) among households with NCDs (cancer, cardiovascular disease, hypertension, diabetes, respiratory disease or kidney disease) in 18 countries: Canada, Sweden, Brazil, Chile, Malaysia, Poland, South Africa, Turkey, China, the Philippines, Colombia, Iran, the Occupied Palestinian Territory (OPT), Bangladesh, India, Pakistan, Zimbabwe and Tanzania.

Results

The leading driver of OOP on health care in almost all countries included is medicine. For example, the monthly OOP on medicines among NCD households in Iran, where roughly 18% of NCD households experience catastrophic spending, is USD 13.50, representing 36% of OOP on health. In Brazil this figure is USD 25.85, representing 46% of OOP on health. A large proportion of OOP is also made up by consultation fees, particularly in Sub-Saharan African countries. In Poland, 63% of OOP on health is spent on alternative medicine consultation fees.

Conclusions

Our findings echo the message shared by the Director General of the World Health Organization in 2018, that there is “no Universal Health Coverage without access to quality medicines”. Medicine costs impose a significant economic burden on NCD households in countries at all levels of development, highlighting the need to include essential medicines for NCDs in universal health coverage benefit packages.

Key messages

To achieve the goal of improved financial risk protection for NCDs we need to understand drivers of out-of-pocket spending among households with NCDs. Medicines are by far the largest driver of OOP in countries at all levels of development and require urgent attention to ensure universal health coverage.

2387Recurrent cardiovascular events and mortality in relation to antiplatelet therapy in patients with myocardial infarction without obstructive coronary artery disease (MINOCA)

Background

Approximately 10% of patients presenting with myocardial infarction (MI) do not have obstructive coronary artery disease (MINOCA). The role of antiplatelet therapy and outcomes in this group remain unclear. We assessed prognosis and the effect of an intensified clopidogrel regimen in MINOCA patients.

Methods

We analyzed data from the CURRENT-OASIS 7 trial, which randomized 25,086 patients with acute coronary syndromes (ACS) referred for early intervention to receive either double-dose (600mg day 1; 150mg days 2–7; then 75mg daily) or standard-dose (300mg day 1; then 75mg daily) clopidogrel. We evaluated clinical outcomes at 30-days in patients with versus without obstructive CAD and in relation to standard versus double-dose clopidogrel.

Results

Overall, 23,783 MI patients were included, of which 1,599 (6.7%) had MINOCA. MINOCA patients were younger, more frequently presented with non-ST-segment elevation MI and had fewer comorbidities. Rates of all-cause mortality (0.7% versus 2.4%, p=0.0046), cardiovascular mortality (0.6 versus 2.2%, p=0.0056), repeat MI (0.5% versus 2.3%, p=0.0009) and major bleedings (0.7% versus 2.5%, p=0.0001) were significantly lower among patients with MINOCA versus those with obstructive CAD. Compared with the standard-dose clopidogrel regimen, the double-dose regimen appeared to increase the risk of cardiovascular death, MI or stroke in MINOCA patients (0.8% versus 2.1%, hazard ratio (HR) 2.74, P=0.033). There was no difference in those with obstructive CAD (4.7% versus 4.4%, HR 0.93, P=0.226; P-for-interaction=0.023) (see Figure 1A). Major bleeding did not occur more frequently in MINOCA patients with double- versus standard-dose clopidogrel regimen (0.7% versus 0.6%, (HR 1.16 (95% CI 0.35–3.80), p=0.805), but their rate was higher In MI patients with obstructive CAD (2.7% versus 2.2% (HR 1.26 (95% CI 1.06–1.49), p=0.008) (Figure 1B).

Figure 1A & B

Conclusions

Compared to MI patients with obstructive CAD, patients presenting with MINOCA represent a distinct cohort, which is generally younger, has a higher NSTEMI prevalence and fewer comorbidities. Their risk for adverse events, especially repeat MI, stroke, death, and bleeding, is low (<1%) at 30 days. Applying an intensified clopidogrel regimen in MINOCA patients appears to be related to a higher risk for CV death, MI and stroke. Accordingly, more potent antiplatelet regimens might be harmful among MINOCA patients and should not be administered routinely. Nevertheless, there is a need for more prospective studies evaluating the role of dual antiplatelet therapies in MINOCA patients.

Acknowledgement/Funding

The CURRENT-OASIS 7 trial was sponsored by Sanofi-Aventis and Bristol-Myers Squibb.

P2837Day-case complex left atrial ablation is safe and cost-effective: experience from a UK tertiary centre

Background

Day-case standard catheter ablation is becoming routine. However, patients having complex left atrial ablation for atrial fibrillation (AF) or left atrial tachycardia (LAT) often stay overnight. We have been performing day-case complex left atrial ablation since 2015.

Purpose

To evaluate the safety, efficacy and cost-effectiveness of day-case complex left atrial ablation compared with those who stayed overnight.

Methods

A retrospective analysis of all consecutive complex left atrial ablations performed in a UK tertiary cardiac centre between 2010–2018. Data were collected on baseline parameters, procedure details including mapping technique, ablation strategy, immediate efficacy, and acute complications.

Results

A total of 830 complex left atrial catheter ablations were performed; mean age±SD=60±12 years, 63% male. The majority were AF ablation (n=804, 96.9%), with the rest being LAT/left-atrial flutter. Of the AF cases, 545 were paroxysmal (≤7 days), 212 persistent (>7 days) and 47 long-standing (>1yr); 98% of cases were elective. Pulmonary vein isolation was performed in all; additional LA lines were done in 163, CTI ablation in 129 and CFAEs in 33. 3D-mapping (Carto/Precision)=44.7% (with contact sensing=38.0%), PVAC=18.7%, PVI cryo-balloon=36.6%. Of the cohort 331 (39.9%) were done as day-case. Acute success= 94.9%, acute complications=4.58% (femoral site complications, n=12; pericardial effusion, n=19 (9 needing drain); stroke/cerebral embolus, n=3; phrenic nerve palsy, n=5; first degree heart block, n=1). Comparison of day-case vs non day-case revealed no significant difference in number of complications (Table 1). An overnight stay at out hospital costs £350. During the period of study our institution saved £115.850 (∼140,000 euros).

Day-case vs non day-case ablation Parameters Day-case (n=331) Non day-case (n=499) p-value Mean age ± SD (years) 61.2±11.6 59.1±11.9 0.009 Males (n, %) 205 (61.9%) 321 (64.3%) 0.484 Normal heart (n, %) 243 (73.4%) 383 (76.8%) 0.276 Paroxysmal AF (n, %) 218 (65.9%) 327 (65.5%) 0.928 Fluoroscopy time (mins) 23.8±13.9 27.0±14.5 0.001 Procedure time (mins) 150±89.6 163±68.2 0.025 % with 3D-mapping 30.8% 56.9% <0.001 Acute complications (n, %) 12 (3.63%) 26 (5.21%) 0.285

Conclusions

Day-case complex left atrial cardiac ablation is safe and effective. It is associated with good clinical outcomes and leads to significant cost savings as an overnight stay is not needed.

The effect of zinc supplementation on pro-inflammatory cytokines (TNF-α, IL-1 AND IL-6) in mice with Escherichia coli LPS-induced diarrhea

BACKGROUND AND OBJECTIVES

Inflammation in the intestine causes diarrhea due to an increased release of pro-inflammatory cytokines such as TNF-α, IL-1, and IL-6. These are triggered by the exposure of E. coli-LPS to epithelial cells of the intestinal mucosa as well as low concentration of zinc in plasma such as in infants or children who are experiencing diarrhea. This paper aims to determine the effects of zinc supplementation on pro-inflammatory cytokines (TNF-α, IL-1 and IL-6) in mice with E. coli-LPS-induced diarrhea.

MATERIALS AND METHODS

This study used a controlled trial experimental design in the laboratory. A sample size of 20 mice were randomly divided into 4 groups: 1) Control group was given standard foods, 2) Trial group was given E. coli-LPS 2.5 mg/kg/oral once on day1, 3) Prevention group was given E. coli-LPS + 30 mg/kg/oral of zinc once daily for 12 days, 4) Therapeutic group was given E. coli-LPS, and were then given 30 mg/kg/oral of zinc once daily for 12 days if diarrhea occurred. Blood samples of mice were taken through the orbital sinus on the 0, 5^th, 10^th hour, and on the 4^th, 8^th and 12^th days.

RESULTS

Positive effects of zinc supplementation on levels of pro-inflammatory cytokines were observed, in which the higher levels of zinc were present, the lower levels of pro-inflammatory cytokines, especially TNF-α were observed. However, there was an increase of IL-1 and IL-6 levels on the 8^th day in the prevention and therapeutic groups.

CONCLUSION

Oral zinc supplementation had a significant positive effect on the levels of pro-inflammatory cytokines. Where there were higher levels of zinc, lower levels of pro-inflammatory cytokines TNF-α were present.

P6561Diagnostic yield of implantable loop recorders: a comparison of arrhythmia nurse specialists versus clinicians

Background

Implantable loop recorders (ILR) are recommended in guidelines to determine symptom-rhythm correlation. Arrhythmia Nurse Specialists (ANS) play a critical role in the assessment of such patients. Their effectiveness at risk stratification for ILR implantation is unknown. The ESC 2018 Syncope guidelines recommend more research in this field.

Aim

To evaluate the diagnostic yield of consecutive ILR implants at a tertiary centre over a 2year period and compare ANS versus Clinicians.

Methods

A retrospective study of all patients undergoing ILR implant between April 2016 and April 2018. Data collected included baseline patient demographics, referral source and management changes made by ILR findings.

Results

305 patients had an ILR; median age was 71yrs (interquartile range 52–81), 55% male. Median follow-up time was 15months. Referrals were from general cardiology (GC) = 98 (32%), electrophysiology (EP) = 105 (34%), and ANS-led syncope clinic = 102 (34%). Indications for ILR implant were syncope = 203 (65.9%), palpitation = 21 (6.9%), pre-syncope = 16 (5.2%), cryptogenic stroke = 35 (11.5%) and others 7 (8.9%) (falls, channelopathies). Of the entire cohort, 102 (34.0%) experienced arrhythmias recorded on the ILR that resulted in a change of management. This included: pacemaker implant = 49 (16.1%), complex-device implant = 7 (2.3%), AF=28 (9.2%), SVT=14 (4.6%), VT=1 (0.3%). Of those with a syncope indication (n=203), findings on ILR altered management in 73patients (36.0%) over a median follow-up of 18months; a pacing indication in this syncope group was present in 44 (21.9%) patients (median time to diagnosis: 2.7 months) with 24 receiving a pacemaker indication within 3 months of ILR insertion. ANS had a higher pacemaker implant rate. Overall, an ILR resulted in a diagnostic yield of 34.1% (n=104). Specialist nurse referral resulted in an overall greater trend towards change of management in 38.2% of patients compared with GC (32.7%) and EP (31.0%) (p=0.593 nurse vs. consultant).

Conclusion

The overall diagnostic yield of ILR insertion was 34% in our study. ANS had a trend towards a greater diagnostic yield compared with clinicians, and significantly more pacemaker indications. Our data suggests that ANS patient selection for ILR insertion are at least comparable to clinicians.

Comparison of bleeding risk scores in patients with atrial fibrillation: insights from the RE-LY trial

BACKGROUND

Oral anticoagulation is the mainstay of stroke prevention in atrial fibrillation (AF), but must be balanced against the associated bleeding risk. Several risk scores have been proposed for prediction of bleeding events in patients with AF.

OBJECTIVES

To compare the performance of contemporary clinical bleeding risk scores in 18 113 patients with AF randomized to dabigatran 110 mg, 150 mg or warfarin in the RE-LY trial.

METHODS

HAS-BLED, ORBIT, ATRIA and HEMORR₂ HAGES bleeding risk scores were calculated based on clinical information at baseline. All major bleeding events were centrally adjudicated.

RESULTS

There were 1182 (6.5%) major bleeding events during a median follow-up of 2.0 years. For all the four schemes, high-risk subgroups had higher risk of major bleeding (all P < 0.001). The ORBIT score showed the best discrimination with c-indices of 0.66, 0.66 and 0.62, respectively, for major, life-threatening and intracranial bleeding, which were significantly better than for the HAS-BLED score (difference in c-indices: 0.050, 0.053 and 0.048, respectively, all P < 0.05). The ORBIT score also showed the best calibration compared with previous data. Significant treatment interactions between the bleeding scores and the risk of major bleeding with dabigatran 150 mg BD versus warfarin were found for the ORBIT (P = 0.0019), ATRIA (P < 0.001) and HEMORR₂ HAGES (P < 0.001) scores. HAS-BLED score showed a nonsignificant trend for interaction (P = 0.0607).

CONCLUSIONS

Amongst the current clinical bleeding risk scores, the ORBIT score demonstrated the best discrimination and calibration. All the scores demonstrated, to a variable extent, an interaction with bleeding risk associated with dabigatran or warfarin.

Gambaran Derajat Dehidrasi dan Gangguan Fungsi Ginjal pada Diare Akut

Latar belakang. Diare akut merupakan salah satu masalah kesehatan yang cukup banyak ditemukan pada bayi dan anak. Gejala utamanya dehidrasi atau kekurangan cairan dalam tubuh sehingga menyebabkan penurunan volume ekstraselular yang menyebabkan berkurangnya perfusi jaringan memicu gangguan fungsi organ-organ tubuh salah satunya penurunan fungsi ginjal.Tujuan. Mengetahui gambaran derajat dehidrasi dan gangguan fungsi ginjal pada diare akut.Metode. Penelitian deskriptif dengan pendekatan cross sectionalyang ditujukan untuk membuat deskripsi atau gambaran derajat dehidrasi dari diare akut dan gangguan fungsi ginjal pada pasien rawat inap anak Rumah Sakit Umum Daerah Dr. Zainoel Abidin (RSUDZA) Banda Aceh. Penelitian dilakukan pada Agustus sampai dengan bulan Desember 2010 dengan pengumpulan data, klasifikasi, dilanjutkan dengan analisis data.Hasil.Didapatkan 21 pasien diare akut yang memenuhi kriteria penelitian. Jumlah pasien berusia < 2 tahun 17, umur 2-15 tahun 4 anak. Jenis kelamin laki-laki 12 dan perempuan 4. Berdasarkan derajat dehidrasi didapatkan pasien diare akut tanpa dehidrasi 8, dehidrasi ringan sedang 11, dan dehidrasi berat 2. Laju filtrasi glomerulus (LFG) berdasarkan kriteria RIFLE ditemukan pasien diare akut dengan risk 6, dan injury1.Terdapat 2 masuk kriteria riskdari 8 pasien diare akut tanpa dehidrasi, 3 masuk kriteria riskdari 11 pasien diare akut dehidrasi ringan sedang, dan 1 masuk kriteria injurydari 2 pasien diare akut dengan dehidrasi berat.Kesimpulan. Semakin berat derajat dehidrasi maka semakin tinggi risiko terjadi gangguan fungsi ginjal.

Profil Diare di Ruang Rawat Inap Anak

Latar belakang. Data tentang profil pasien diare pada anak di Rumah Sakit - Rumah Sakit pusat rujukan belum lengkap termasuk di Rumah Sakit Umum Daerah Dr. Zainoel Abidin (RSUDZA) Banda Aceh. Tujuan. Mengetahui profil pasien diare di ruang rawat inap anak RSUDZA Banda Aceh.Metode. Studi retrospektif dilakukan pada pasien diare di ruang rawat inap anak RSUDZA Banda Aceh, tanggal 1 Juli 2009 s/d 30 Juni 2010. Pencatatan dilakukan tentang umur, jenis kelamin, jenis diare, derajat dehidrasi, status gizi, penyakit penyerta, dan lama rawatan kemudian disajikan secara deskriptif.Hasil.Jumlah pasien rawat terlama periode penelitian 1279 anak, sedangkan pasien diare 104 anak (8,1%). Proporsi diare berdasarkan umur yaitu 1 bulan - <2 tahun 73,1%, 2 - <5 tahun 18,3%, dan 5 - 16 tahun 8,6%. Jenis diare yaitu, diare akut 80,8%, diare melanjut 12,5% dan diare persisten 6,7%. Derajat dehidrasi yaitu, tanpa dehidrasi 26%, dehidrasi ringan-sedang 62,5%, dan dehidrasi berat 11,5%. Status gizi yaitu, obesitas 5,8%, gizi lebih 2,9%, normal 44,2%, gizi kurang 38,5%, dan gizi buruk 8,6%. Pasien diare disertai penyakit penyerta 55,8% yaitu gizi kurang 68,9%, gizi buruk 15,5%, bronkopneumonia 6,9%, tonsilofaringitis akut 3,5%, kejang demam kompleks 3,5%, dan varisela 1,7%. Lama rawatan 90,4% kurang dari 5 hari. Kesimpulan. Kelompok umur terbanyak pasien diare < 2 tahun, diare persisten 6,7%, diare dengan dehidrasi berat 11,5%, dan lama rawat ≥5 hari 9,6%, serta penyakit penyerta terbanyak adalah gizi kurang dan buruk, serta bronkopneumonia.

Insidens Diare pada Anak dengan Pneumonia, Studi Retrospektif

Latar belakang. Pneumonia dan diare merupakan penyebab utama angka kesakitan dan kematian pada anak. Kedua penyakit dapat terjadi terpisah atau bersamaan. Insidens dari kedua penyakit bersamaan akan menentukan tata laksana kasus tersebut selanjutnya.Tujuan.Mengetahui insidens diare pada anak yang dirawat dengan pneumonia di bangsal anak.Metode.Penelitian dilakukan secara retrospektif dengan menggunakan data dari rekam medis pasien mulai 1 Januari 2008 sampai 31 Desember 2009, yang dirawat di RSUD Dr.Zainoel Abidin Aceh. Hasil.Terdapat 347 anak yang diikutkan dalam penelitian dan 54,2% anak menderita diare, 29,4% menderita pneumonia dan 4,3% menderita diare dengan pneumonia. Selama periode penelitian didapatkan 2035 anak dirawat di bangsal anak RSUD Dr. Zainoel Abidin Banda Aceh; 347 anak di antaranya dilakukan analisis. Dari 347 anak, 54,2% menderita diare, 29,4% pneumonia, dan 4,3% diare ditambah pneumonia. Terbanyak (80%) umur kurang dari 1 tahun, 60% dengan gizi kurang, disertai suhu 380C, muntah (46,7%), dan disertai anemia, terdapat pada anak dengan diare dan pneumonia.Kesimpulan.Pada anak yang dirawat inap dalam dua tahun terakhir didapatkan angka infeksi diare lebih tinggi daripada pneumonia. Insidens diare beserta pneumonia 4,3%.

Cakupan Imunisasi Dasar Anak Usia 1-5 tahun dan Beberapa Faktor yang berhubungan di Poliklinik Anak Rumah Sakit Ibu dan Anak (RSIA) Banda Aceh

Latar belakang. Program pengembangan imunisasi sudah berjalan sejak tahun 1974 untuk penyakit-penyakit yang dapat dicegah dengan imunisasi (PD3I), yaitu satu kali imunisasi BCG, empat kali imunisasi polio, tiga kali imunisasi DPT, tiga kali imunisasi hepatitis B, dan satu kali imunisasi campak sebelum berumur 12 bulan. Sasaran yang hendak dicapai Kementerian Kesehatan Republik Indonesia tahun 2010-2014 adalah meningkatkan cakupan imunisasi dasar lengkap bayi usia 0-11 bulan menjadi 90%. Saat ini berdasarkan Riset Kesehatan Dasar (Riskesdas) tahun 2010, cakupan imunisasi dasar lengkap secara nasional baru mencapai 53,8%, sedangkan Propinsi Aceh baru mencapai 37,0%.Tujuan. Mengetahui cakupan imunisasi dasar anak balita usia 1-5 tahun, alasan imunisasi yang tidak lengkap, serta mengetahui hubungan antara pendidikan orangtua dan pendapatan keluarga dengan kelengkapan imunisasi. Metode. Penelitian potong lintang menggunakan kuesioner dengan subjek orangtua anak usia 1-5 tahun yang berkunjung ke Poliklinik Anak RSIA Banda Aceh selama kurun waktu 8 minggu (12 Desember 2011 sampai 27 Januari 2012). Cakupan bayi dengan imunisasi dasar lengkap adalah persentase bayi umur <12 bulan yang telah mendapat imunisasi dasar lengkap. Hubungan antara 2 kelompok variabel dianalisis dengan uji Chi-squaredan Kolmogorov-Smirnov.Hasil.Seratus tiga anak diikutsertakan dalam penelitian. Cakupan imunisasi dasar pada anak usia 1-5 tahun 86 (83,5%) lengkap, 16 (15,5%) tidak lengkap, dan 1 (1%) tidak pernah diimunisasi. Alasan tidak pernah diimunisasi atau tidak melengkapi imunisasi adalah ibu cemas akan efek samping 12 (70,6%), 4 (23,5%) sering sakit, dan 1 (5,9%) orangtua beralasan imunisasi haram. Terdapat hubungan yang bermakna antara sebaran pendidikan ibu dengan kelengkapan imunisasi dasar (p<0,05). Kesimpulan.Cakupan imunisasi dasar pada subjek penelitian 83,5%. Terdapat hubungan yang bermakna antara sebaran pendidikan ibu dengan kelengkapan imunisasi dasar (p<0,05).

Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies

BACKGROUND

Several studies reported a U-shaped association between urinary sodium excretion and cardiovascular disease events and mortality. Whether these associations vary between those individuals with and without hypertension is uncertain. We aimed to explore whether the association between sodium intake and cardiovascular disease events and all-cause mortality is modified by hypertension status.

METHODS

In this pooled analysis, we studied 133,118 individuals (63,559 with hypertension and 69,559 without hypertension), median age of 55 years (IQR 45-63), from 49 countries in four large prospective studies and estimated 24-h urinary sodium excretion (as group-level measure of intake). We related this to the composite outcome of death and major cardiovascular disease events over a median of 4.2 years (IQR 3.0-5.0) and blood pressure.

FINDINGS

Increased sodium intake was associated with greater increases in systolic blood pressure in individuals with hypertension (2.08 mm Hg change per g sodium increase) compared with individuals without hypertension (1.22 mm Hg change per g; pinteraction<0.0001). In those individuals with hypertension (6835 events), sodium excretion of 7 g/day or more (7060 [11%] of population with hypertension: hazard ratio [HR] 1.23 [95% CI 1.11-1.37]; p<0.0001) and less than 3 g/day (7006 [11%] of population with hypertension: 1.34 [1.23-1.47]; p<0.0001) were both associated with increased risk compared with sodium excretion of 4-5 g/day (reference 25% of the population with hypertension). In those individuals without hypertension (3021 events), compared with 4-5 g/day (18,508 [27%] of the population without hypertension), higher sodium excretion was not associated with risk of the primary composite outcome (≥ 7 g/day in 6271 [9%] of the population without hypertension; HR 0.90 [95% CI 0.76-1.08]; p=0.2547), whereas an excretion of less than 3 g/day was associated with a significantly increased risk (7547 [11%] of the population without hypertension; HR 1.26 [95% CI 1.10-1.45]; p=0.0009).

INTERPRETATION

Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets.

FUNDING

Full funding sources listed at end of paper (see Acknowledgments).