Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

A new single-layer structure of MBene family: Ti2B

In this manuscript, we have carried out a combined study of density functional theory and Monte Carlo (MC) simulations for a thorough examination of a single-layer (SL) Ti₂B structure. On the basis of first-principles, spin-polarized density functional calculations, we showed that a free standing SL-Ti₂B structure is dynamically and thermally stable. The atomic structure, phonon spectrum, electronic and magnetic properties of the SL-Ti₂B structure are analyzed. In order to determine ground state, the structure of Ti₂B is optimized for four types of spin oriented configurations, namely ferromagnetic (FM), antiferromagnetic Néel, antiferromagnetic Zigzag and antiferromagnetic Stripy and non-magnetic states. We found that the spin configuration FM corresponds to the ground state for SL-Ti₂B. We also found that the Raman-active modes are softening in the antiferromagnetic cases. On the basis of these results, MC simulations show that the magnetic susceptibility, thermal variations of magnetization, and specific heat curves of Ti₂B exhibit a phase transition between paramagnetic and FM phases at the Curie temperature of 39.06 K. While SL-Ti₂B possess a little out-of-plane magnetic anisotropy, it has not any in plane magnetic anisotropy energy.

Results of Real-time Multiplex Polymerase Chain Reaction Assay in Renal Transplant Recipients With Sterile Pyuria

Urinary tract infections are a major cause of morbidity and hospitalization after renal transplantation. Patients treated with immunosuppressive drugs suffer not only from common uropathogens but also from opportunistic infections caused by unusual uropathogens. Sterile pyuria is associated with numerous infectious agents including viruses, fungi, and atypical or fastidious organisms. The objective of this study was to investigate the pathogens using real-time multiplex polymerase chain reaction (rtMPCR) assay in sterile pyuria of renal transplant recipients. In this prospective controlled study, pathogen detection was performed with rtMPCR assay on October 2016 in 60 patients with sterile pyuria who had undergone kidney transplantation. A total of 40 renal transplant patients were determined as the control group. Male-to-female ratio was same. The mean age of the subjects with sterile pyuria was 45.7 ± 12.1 (25-74). The mean duration after transplantation was 28.8 ± 3.97 (3-102) months. Pathogens were detected with rtMPCR in 61.7% of sterile pyuria group. This rate was significantly higher compared with the control group (P < .001). Two or more different pathogens were found in 13 (21.7%) patients in sterile pyuria group. The pathogens found included cytomegalovirus in 10 patients (19%), Gardnerella vaginalis and obligate anaerobes in 20 patients (38%), Ureaplasma spp in 17 patients (33%), Candida spp in 2 patients (4%), Mycoplasma hominis in one patient (2%), herpes simplex virus-2 in one patient (2%), and Trichomonas vaginalis in one patient (2%). Sterile pyuria may indicate the presence of genitourinary pathogens that cannot be detected with conventional urine culture method in renal transplantation patients. rtMPCR is an accurate and convenient method for detection of multiple potential pathogens of sterile pyuria in renal transplant patients.

Pregnancy and Delivery in the Sequel of Kidney Transplantation: Single-Center Study of 8 Years' Experience

BACKGROUND

Depending on hyphothalamic, hyphophyseal, and gonadal axis dysfunction, anovulatory irregular cycles occur and the probability of pregnancy decreases in the patients with chronic kidney disease (CKD). Maternal mortality and morbidity rates are increased in CKD patients; the risk of premature delivery is 70% and the risk of preeclampsia is 40% more than normal among those with a creatine level of >2.5 mg/dL.

METHODS

If a pregnancy is expected in the sequel of kidney transplantation (KT), a multidisciplinary team approach should be adopted and both the gynecologist and the nephrologist should follow the patient simultaneously. Among 3883 patients who underwent KT at Antalya Medical Park Hospital Transplantion Department between November 2009 and October 2016, the records of 550 female patients between the ages of 18 and 40 years were examined retrospectively; 31 patients who complied with these criteria were included in the study group. In 6 of these patients who had an unplanned pregnancy, medical abortion was performed after the families were informed about the possible fetal anomalies caused by the use of everolimus in the first trimester, and they were excluded from the study (pregnant group). The control group consisted of 43 patients who had a KT and became pregnant, and of those who had recently undergone KT and shared similarities regarding age, CKD etiology, duration of dialysis, and number of transplants.

RESULTS

In both groups, the ages of the patients, their follow-up span and dialysis duration, tissue compatibility, age of the donor, and time elapsed until the pregnancy was analyzed, whereas in the control group, creatinine levels in the first, second, third, and fourth years after the KT were reviewed. Additionally, in the pregnant group, creatinine levels of the first, second, and third trimesters; delivery week; birth weight of the baby; APGAR scores of the first minute; postnatal creatinine levels of first, second, and third years; and prenatal, maternal, and postnatal acute rejections were reviewed. We measured the creatine clearance by use of the Cockcroft-Gault formula in the pregnancy group before pregnancy and during delivery [Cockcroft-Gault formula: (140 - age) × body weight (kg)/72 × plasma creatine level (mg/dL) × 0.85].

CONCLUSIONS

Pregnancy after KT is risky both for the mother and the baby; however, if planned and followed in coordination within an experienced center, both the pregnancy period and the birth process can occur without distress.

Optimal Timing for Removal of the Double-J Stent After Kidney Transplantation

BACKGROUND

Urologic complications (UC) have gradually decreased in recent years after advanced surgical experience. The incidence of urologic complications varies between 0.22% and 30% in different medical studies. There is no routine usage of double-J stenting (DJS) during renal transplantation (RT) in the literature. It is a necessity, and optimal timing for stent removal is an important question for many transplantation centers.

METHODS

This study includes 818 renal transplant patients whose ureteroneocystostomy anastomoses were completed by use of the Lich-Gregorie procedure during a 2-year period at a transplantation center. We performed 926 renal transplantations at Antalya Medical Park Hospital Renal Transplantation Center between January 2014 and January 2016. The patients were divided into four groups according to the timing of DJS removal.

RESULTS

For group 1, removal time for DJS was between 5 and 7 days; group 2, Removal time for DJS was between 8 and 14 days; group 3, removal time for DJS was between 15 and 21 days; and group 4, removal time for DJS was later than 22 days. The patients were divided into two groups according to removal time of stent as 5 to 14 days and >15 days. DJS was performed again in the patients whose urine output was reduced during the first 5 days after removal of the DJS, whose creatine level increased, and whose graft ureter and collecting tubules were extended as an ultrasonographic finding.

CONCLUSIONS

There is no declared optimal time for the removal of DJS. The removal time was reported between postoperative first week and 3 months in some of the reports of RT centers, according to their protocols. We emphasize that the optimal time for the removal of DJS is 14 to 21 days after RT, based on the findings of our large case report study.

Effects of MMP-1 and MMP-3 gene polymorphisms on gene expression and protein level in lumbar disc herniation

The aim of this study was to identify the possible correlation between polymorphisms in matrix metalloproteinase (MMP)-1 and MMP-3 and their corresponding protein levels in disc tissues obtained from patients with lumbar disc herniation (LDH) using biochemical and immunohistochemical analyses. Blood and disc samples were obtained from 100 patients with LDH who underwent a lumbar microdiscectomy. Based on the radiological degeneration, the patients were diagnosed with grade 2, 3, or 4 LDH. MMP-1 -1607 1G/2G and MMP-3 -1171 5A/6A were analyzed by real-time polymerase chain reaction. The expressions of MMP-1 and MMP- 3 were detected by biochemical and immunohistochemical analyses. We found no association between the MMP-1 polymorphism and disc degeneration and MMP-1 expression. However, patients expressing the 6A/6A and 5A/6A alleles of MMP-3 -11715A/6A showed higher MMP-3 expression, compared to those expressing the 5A/5A genotype. Additionally, the radiological degeneration grades were correlated with the histological degeneration scoring. Protein levels and immunopositive cell rates of MMP-1 and MMP-3 were associated with disc degeneration grades. Moreover, the MMP-1 and MMP-3 expression and the histological and radiological scores were positively correlated and the MMP-3 -11715A/6A polymorphism was associated with MMP-3 expression in herniated disc tissues. This study is the first to investigate polymorphisms in MMP-1 and MMP-3, as well as their corresponding protein expressions. We also quantified an association between the radiological degeneration grades and MMP-1 and MMP- 3 expression. Further genomic studies on MMPs could focus on the utilization of MMP-1 and MMP-3 as markers for the prevention and treatment of this disease.

Middle Hepatic Vein Tributary Reconstruction of a Right Hepatic Graft in Adult Living Donor Liver Transplantation: A Case Report

In adult living donor (right liver) lobe transplantations (LDLT), the removal of the middle hepatic vein (MHV) with the graft and reconstruction carried out in the donor are of great importance. Here a 44-year-old male patient with hepatitis B-related end-stage liver failure is reported of whom his 34-year-old brother was evaluated as a donor candidate. At routine preoperative screening tests, neither the patient nor the donor candidate was found to have any pathological findings that might interfere with the transplantation. The donor candidate was assessed using multislice computed tomography for a standard liver volume measurement and anatomical structure evaluation and extended right hepatectomy including MHV was planned. MHV of the donor removed together with the graft was reconstructed to the common orifice of MHV-left hepatic vein using a cryopreserved aortic graft. In conclusion, if the MHV is removed with the graft in adult LDLT, appropriate reconstruction in the donor is also an important issue. Reconstruction carried out without creating tension and folding in the right hepatic vein is crucial for avoiding congestion and of great importance for the prevention of graft dysfunction.

First International Paired Exchange Kidney Transplantations of Turkey

OBJECTIVE

We estimated that many patients on the waiting list for kidney transplantation in Turkey have immunologicaly incompatible suitable living donors. Paired exchange kidney transplantation (PETx) is superior to desensitization for patients with incompatible donors. Recently we decided to begin an international PETx program.

METHODS

We report three international living related paired kidney transplantations which occurred between May 14,2013, and March 7, 2014. The international donor and recipient operations were performed at Medical Park Hospital, Antalya, Turkey. All pairs were living related and written proofs were obtained according to Turkish laws. As with the donor procedures, the transplantation procedures were performed at the same time.

RESULTS

The uniqueness of these transplantations was that they are the first international exchange kidney transplantations between Turkey and Kirghizia. Currently all recipients are alive with wel-functioning grafts.

CONCLUSION

In our institute, a 5% increase was obtained in living-related kidney transplantations by the help of PETx on a national basis. We believe that international PETx may also have the potential to expand the donor pool.

Renal Transplantation in Recipients Older Than 65 Years: Retrospective Analysis of the Results of a 4-year (2008-2012) Experience

BACKGROUND

We analyze the results of renal transplantation among recipients older than 65 years old over a 4-year period (2008-2012) from a single renal transplantation unit and compare results with younger recipients.

METHODS

We retrospectively analyzed the outcomes of 2018 renal transplantations performed between November 2008 and December 2012. The χ(2) test was used for the comparison of categorical data, and the Student t test was used for the analysis of continuous variables. Patient and graft cumulative actuarial survivals were calculated using the Kaplan-Meier analysis and we tested for differences with the Mantel-Cox log-rank test.

RESULTS

Seventy-five (3.7%) recipients were aged ≥ 65 years with a median age of 68 (range, 65 to 82) years. Actuarial graft survivals at 1, 2, and 3 years were 93.8%, 92.5%, and 90.3%, respectively, for the <65 group and 89.7%, 88.1%, and 83.1%, respectively, for the ≥ 65 group (P < .03). Actuarial patient survivals at 1, 2, and 3 years were 96.3%, 95.5%, and 94.7%, respectively, for the younger and 91.8%, 90.2%, and 88%, respectively, for the older samples (P < .03). When graft survival was censored for patient death with a functioning kidney at 1, 2, and 3 years, the results were similar between groups with 95.5%, 94%, and 92.8%, respectively, for recipients aged <65 years and 94.7%, 89.2%, and 89.2%, respectively, for recipients aged ≥ 65 years (P = .213).

CONCLUSIONS

Our results showed that renal transplantation in selected patients older than 65 years was associated with good outcomes; this indicates that it seems safe and effective to treat end-stage renal disease in the elderly knowing there are acceptable rates of graft and patient survival.

Changes in indications for endoscopic sinonasal surgery over 14 years

OBJECTIVE

To assess how surgical indications for endoscopic sinonasal surgery have changed over time.

MATERIAL AND METHODS

The surgical indications of 1173 patients who underwent endoscopic sinonasal surgery between 1994 and 2007 were reviewed retrospectively.

RESULTS

Preoperative diagnoses were chronic sinusitis without nasal polyps in 511 patients (43.6%), chronic sinusitis with nasal polyps in 434 (36.9%), concha bullosa in 113 (9.6%), nasal mass in 66 (5.6%), and others in 49 patients (4.1%). Over 60% of patients had surgery for chronic sinusitis without nasal polyps between 1994 and 1999, whereas nearly 60% of patients who underwent surgery between 2001 and 2007 had chronic sinusitis with nasal polyps.

CONCLUSIONS

Reasons for the decrease in the number of the patients with chronic sinusitis without nasal polyps and the increase in the number of patients with chronic sinusitis with nasal polyps might include: 1) Administration of maximal medical therapy; 2) Increased recognition of the possibility for false positive opacifications in computed tomography and increased understanding that not all anatomical variations predispose to sinusitis; 3) More careful "profit and loss" discussions with patients as our postoperative experience increased; 4) More patients with nasal polyps underwent endoscopic sinonasal surgery as surgical skills improved, and recurrences remained common.