Adjustment For Known Predictors Research Articles

In-hospital outcomes following an acute coronary syndrome in patients with recent cannabis use

Background: The prevalence and short-term cardiovascular consequences of recent cannabis use in patients admitted to an intensive cardiac care unit for acute coronary syndrome is not well established.Aims: To assess the prevalence of recent cannabis use detected by prospective systematic screening, and its prognostic value in predicting the occurrence of in-hospital major adverse events in consecutive patients with acute coronary syndrome.Methods: From 07 to 22 April 2021, all consecutive patients admitted to an intensive cardiac care unit in 39 centres throughout France were studied prospectively. Systematic recreational drug screening was performed on admission by urine assay in all patients. The primary outcome was the prevalence of recent cannabis use. The secondary outcome was in-hospital major adverse events, defined by death, resuscitated cardiac arrest and cardiogenic shock requiring medical or mechanical haemodynamic support.Results: A total of 772 patients were hospitalized for acute coronary syndrome (mean age 64 ± 13 years; 74% male). Among those, 86 patients (11.1%) had a positive urine test for cannabis. Patients with cannabis detected were younger (53 ± 12 vs 65 ± 12 years, respectively; P < 0.001) and were more frequently male (88% vs 72%, respectively; P = 0.001). After a median hospitalization duration of 2 days, 33 (4.3%) in-hospital major adverse events occurred. The detection of cannabis was associated with a higher rate of in-hospital major adverse events after adjustment for prior co-morbidities (odds ratio 3.28; P = 0.015) and after adjustment for known predictors of severity (odds ratio 3.68; P = 0.009).Conclusions: The prevalence of recent cannabis use in patients hospitalized for acute coronary syndrome was 11.1%. The detection of recent cannabis use was independently associated with a higher occurrence of in-hospital major adverse events.

Circulating CC16 and Asthma: A Population-based, Multicohort Study from Early Childhood through Adult Life.

Rationale: Club cell secretory protein (CC16) is an antiinflammatory protein highly expressed in the airways. CC16 deficiency has been associated with lung function deficits, but its role in asthma has not been established conclusively. Objectives: To determine 1) the longitudinal association of circulating CC16 with the presence of active asthma from early childhood through adult life and 2) whether CC16 in early childhood predicts the clinical course of childhood asthma into adult life. Methods: We assessed the association of circulating CC16 and asthma in three population-based birth cohorts: the Tucson Children's Respiratory Study (years 6-36; total participants, 814; total observations, 3,042), the Swedish Barn/Children, Allergy, Milieu, Stockholm, Epidemiological survey (years 8-24; total participants, 2,547; total observations, 3,438), and the UK Manchester Asthma and Allergy Study (years 5-18; total participants, 745; total observations, 1,626). Among 233 children who had asthma at the first survey in any of the cohorts, baseline CC16 was also tested for association with persistence of symptoms. Measurements and Main Results: After adjusting for covariates, CC16 deficits were associated with increased risk for the presence of asthma in all cohorts (meta-analyzed adjusted odds ratio per 1-SD CC16 decrease, 1.20; 95% confidence interval [CI], 1.12-1.28; P < 0.0001). The association was particularly strong for asthma with frequent symptoms (meta-analyzed adjusted relative risk ratio, 1.40; 95% CI, 1.24-1.57; P < 0.0001), was confirmed for both atopic and nonatopic asthma, and was independent of lung function impairment. After adjustment for known predictors of persistent asthma, children with asthma in the lowest CC16 tertile had a nearly fourfold increased risk for having frequent symptoms persisting into adult life compared with children with asthma in the other two CC16 tertiles (meta-analyzed adjusted odds ratio, 3.72; 95% CI, 1.78-7.76; P < 0.0001). Conclusions: Circulating CC16 deficits are associated with the presence of asthma with frequent symptoms from childhood through midadult life and predict the persistence of asthma symptoms into adulthood. These findings support a possible protective role of CC16 in asthma and its potential use for risk stratification.

Prognostic Impact of the Get-with-the-Guidelines Heart-Failure Risk Score (GWTG-HF) after Transcatheter Aortic Valve Replacement in Patients with Low-Flow–Low-Gradient Aortic Valve Stenosis

This study examined the prognostic value of the get-with-the-guidelines heart-failure risk score (GWTG-HF) on mortality in patients with low-flow-low-gradient aortic valve stenosis (LFLG-AS) after transcatheter aortic valve implantation (TAVI). Data on feasibility of TAVI and mortality prediction in the LFLG-AS population are scarce. Clinical risk assessment in this particular population is difficult, and a score has not yet been established for this purpose. A total of 212 heart failure (HF) patients with real LFLG-AS were enrolled. Patients were classified into low-risk (n = 108), intermediate-risk (n = 90) and high-risk (n = 14) groups calculated by the GWTG-HF score. Clinical outcomes of cardiovascular events according to Valve Academic Research Consortium (VARC-2) recommendations and composite endpoint of death and hospitalization for heart failure (HHF) were assessed at discharge and 1 year of follow-up. Baseline parameters of the groups showed a median age of 81.0 years [77.0; 84.0] (79.0 vs. 82.0 vs. 86.0, respectively p < 0.001), median EuroSCORE II of 6.6 [4.3; 10.7] (5.5 vs. 7.2 vs. 9.1, p = 0.004) and median indexed stroke volume of 26.7 mL/m2 [22.0; 31.0] (28.2 vs. 25.8 vs. 25.0, p = 0.004). The groups significantly differed at follow-up in terms of all-cause mortality (10.2 vs. 21.1 vs. 28.6%; p < 0.035). There was no difference in intrahospital event rate (VARC). Postprocedural mean gradients were lower in high-risk group (7.0 vs. 7.0 vs. 5.0 mmHg, p = 0.011). No differences in postprocedural aortic valve area (1.9 vs. 1.7 vs. 1.9 cm2, p = 0.518) or rate of device failure (5.6 vs. 6.8 vs. 7.7%, p = 0.731) could be observed. After adjustment for known predictors, the GWTG score (HR 1.07 [1.01-1.14], p = 0.030) as well as pacemaker implantation (HR 3.97 [1.34-11.75], p = 0.013) turned out to be possible predictors for mortality. An increase in stroke volume index (SVI) was, in contrast, protective (HR 0.90 [0.83-0.97]; p = 0.006). The GWTG score may predict mortality after TAVI in LFLG-AS HF patients. Interestingly, all groups showed similar intrahospital event and mortality rates, independent of calculated mortality risk. Low SVI and new conduction disturbances associated with PPI after THV implantation had negative impact on mid-term outcome in post-TAVI HF-patients.

Abstract MP35: Hair Cortisol Concentrations Are Associated With Greater Adiposity in Mid-Adolescence

Introduction: Hair cortisol concentration (HCC) is a biomarker of long-term stress. Higher HCC is associated with body mass index (BMI) and other adiposity measures in adults; however, this association is not well characterized in adolescents. Additionally, HCC differs by sex, but associations with adiposity by sex have not been well studied. Hypothesis: Higher HCC levels are associated with greater adiposity in mid-adolescence. Methods: Among 324 participants (49.1% female, mean 17.7 years) in Project Viva, we performed a cross-sectional analysis of HCC with measures of adiposity in mid-adolescence. We used multivariable linear regression models, overall and stratified by sex, to estimate associations of HCC (log2 transformed) with BMI, % body fat, and waist circumference (WC), adjusted for age and known predictors of adiposity, namely maternal education, smoking during pregnancy, pre-pregnancy BMI, age, and household income; and child sex-specific birthweight for gestational age z-scores, secondhand smoke exposure, age, and sex (for overall models). Results: Median (IQR) HCC was 2.1 pm/mg (1.0 – 4.7) and mean (SD) BMI was 23.0 kg/m 2 (3.8), % body fat was 20.1% (9.9), and WC was 80.4 cm (10.8). In adjusted models, HCC (per doubling) was associated with higher BMI (β 0.20 kg/m 2 ; 95% CI 0.01, 0.39), % body fat (β 0.42%; 95% CI 0.04, 0.80), and WC (β 0.45 cm; 95% CI -0.07, 0.96) (Figure). There was no evidence of effect modification by sex (all sex by HCC interaction p-values &gt;0.50). Conclusions: Higher HCC was cross-sectionally associated with greater adiposity in mid-adolescence. Associations were similar among males and females, suggesting a similar impact of long-term stress on adiposity between sexes. Adjustment for known predictors of adiposity does not alter the association of HCC and adiposity measures. Further research is needed to understand the temporal direction of this association.

In-hospital outcomes following an acute coronary syndrome in patients with a recent cannabis use: Results from ADDICT-ICCU trial

The prevalence and short-term cardiovascular consequences of recent cannabis use in patient admitted to the intensive cardiac care unit (ICCU) for acute coronary syndrome (ACS) is not well established. To assess the prevalence of recent cannabis use detected by a prospective systematic screening, and its prognostic value to predict the occurrence of in-hospital major adverse events (MAEs) in consecutive patients with ACS. In April 2021, all consecutive patients admitted to the ICCU in 39 centres throughout France were prospectively studied. Systematic illicit drug screening was performed on admission by urine assay in all patients. The primary outcome was the prevalence of recent cannabis use. The secondary outcome was in-hospital MAEs defined by death, resuscitated cardiac arrest and cardiogenic shock requiring medical or mechanical haemodynamic support. In the ADDICT-ICCU trial, 772 consecutive patients were hospitalized for ACS. After exclusion of patients with missing covariates, the final population for analysis was constituted of 743 patients (96.2%, (64 ± 13 years, 73% men) with 315 patients (42%) admitted for ST-elevation ACS and 428 (58%) patients for non-ST-elevation ACS. Among those, 83 patients (11.2%) had a positive urine test for cannabis (11.1% for STEMI and 11.1% for NSTEMI). Patients with an ACS and cannabis detected were more likely younger (53 years old for patients with cannabis detected vs. 65 in the other group, P < 0.001) and more frequently men (88% for patients with cannabis detected vs. 72%, P = 0.002). During hospitalisation, 33 (4.4%) in-hospital MAE occurred. The detection of cannabis was associated with a higher rate of in-hospital MAEs after adjustment for comorbidities (model 1: age, sex, smoking, cannabis drug test, diabetes, known coronary artery disease, creatinine, cannabis detected; adjusted odd [OR]: 3.29; 95% confidence interval [CI]: 1.21–8.41, P = 0.015), and after adjustment for known predictors of severity (model 2: age, sex, heart rate, systolic blood pressure, left ventricle ejection fraction, Killip classification, creatinine, cannabis detected; adjusted OR [OR]: 3.68; 95% CI: 1.33–9.57, P = 0.009) (Fig. 1). The prevalence of recent cannabis use in patients hospitalised in the ICCU for ACS was 11.2%. The detection of cannabis use was independently associated with a higher occurrence of in-hospital MAEs.

Prevalence of illicit drugs use and association with in-hospital major adverse events in patients hospitalised for acute cardiac events: the ADDICT-ICCU Trial

Abstract Background The prevalence and short-term cardiovascular consequences of illicit drug use in patients admitted to the intensive cardiac care unit (ICCU) for acute cardiovascular events are not well established. Purpose The Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study was designed to assess prospectively the prevalence of illicit drugs use, and their association with the occurrence of in-hospital major adverse events (MAEs) in consecutive patients admitted to ICCUs for acute cardiovascular events. Methods From 7 to 22 April 2021, screening for illicit drug was performed by systematic urinary testing in a prospective study including all consecutive patients admitted to ICCU in 39 centres throughout France. The primary outcome was the prevalence of the illicit drugs detected. The secondary clinical outcome was in-hospital Major Adverse cardiac Events (MAEs) defined by death, resuscitated cardiac arrest or cardiogenic shock. Results Among 1,499 consecutive patients screened (age 63.3±14.9 years, 69.6% male), 161 (10.7%) had a positive test for illicit drugs (cannabis: 9.1%, opioids: 2.1%, cocaine: 1.7%, amphetamines: 0.7%, 3,4-methylenedioxymethamphetamine: 0.6%). Patients who used illicit drugs were young (33.0% at age &amp;lt;40 vs. 5.9% at age ≥60 years), and more frequently male (11.9% vs. 8.1%, p&amp;lt;0.001). Self-reported current use was 56.5% in patients with a positive test. After a median duration of hospitalisation of five days, there were 61 in-hospital MAEs (4.1%). The detection of illicit drugs was associated with a higher rate of MAEs after adjustment for known predictors of severity (OR=8.84; 95% CI: 4.68–16.7, p&amp;lt;0.001) or after using a propensity score adjustment (OR=5.81; 95% CI: 4.14–8.14, p&amp;lt;0.001). After adjustment for age and sex, detection of cannabis or cocaine was significantly associated with MAEs (OR=3.53; 95% CI: 1.25–9.95, p&amp;lt;0.001; OR=5.12; 95% CI: 1.48–17.2, p=0.004 respectively). Multiple drug detection (28% of positive patients) was associated with a higher incidence of MAEs than single drug detection. Conclusions The prevalence of illicit drugs use in patients hospitalised in the ICCUs for acute cardiovascular events was 10.7% and was under-reported. Illicit drugs detection was independently associated with a higher occurrence of in-hospital MAEs. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Fondation Coeur et Recherche

P-206 Association between primary tumor site of colorectal cancer and RAS/BRAF mutational status with venous thromboembolism: A retrospective-prospective cohort study from 3 Croatian oncology centers

Right-sided colorectal cancer (RCRC) is associated with several negative clinicopathological and molecular features and also with worse survival than left-sided colorectal cancer (LCRC). A recent study has shown an association between RCRC and increased incidence of venous thromboembolism (VTE). However, the role of RAS/BRAF mutations considering the risk of VTE in metastatic colorectal cancer (mCRC) remains unclear. The aim of our study was to examine impact of tumor sidedness and RAS/BRAF status regarding VTE occurrence in a cohort of patients with mCRC. We conducted a multicenter, combined retrospective-prospective, observational study, with 234 patients (n=234) and known KRAS/NRAS/BRAF status who were treated with first-line chemotherapy with or without biological therapy for mCRC in three Croatian oncologic centers (General Hospital of Šibenik-Knin County, General Hospital Zadar and General Hospital Dubrovnik) from June 2013 to March 2020. Considering prospective arm of the study 40 patients with informed consent were enrolled with minimum follow-up of 1 year. The primary endpoint was incidence of VTE and its association with location of the primary tumor and RAS/BRAF status. VTE was defined as deep venous thrombosis and/or pulmonary embolism occurred 6 months before or at any time after the diagnosis of mCRC. Numerical data were described by the median and the interquartile range (IQR). Categorical variables were tested by Chi-square test and by Fisher's exact test. The normality of the distribution was tested by the Shapiro-Wilk test. Differences between two independent groups were tested by Mann-Whitney's U test. Logistic regression analysis was used to analyze the independent factors associated with VTE. All P values were two-sided. The level of significance was set at Alpha of 0.05. The median follow-up time was 21 months (IQR13-33). Of 234 patients included in analysis 26% had RCRC and 74% had LCRC. KRAS, NRAS and BRAF mutations were detected in 50%, 3% and 5% of patients, respectively. KRAS/NRAS mutations were more common in RCRC than in LCRC (62% vs 50% p=0.001) and the same finding has been noticed with BRAF mutations (12% vs 2% p =0.001). A total of 56 (24%) patients experienced VTE. The incidence was 43% in RCRC patients and 17.3% in LCRC patients (p < 0.001). According to mutational status, incidence was 48.2% in KRAS/NRAS-mutated patients, 10.7% in BRAF-mutated patients and 41% in KRAS/NRAS/BRAF wilde type patients. The results of logistic regression adjustment for known predictors of VTE including Khorana score, use of bevacizumab or anti-EGFR therapy and chemotherapy confirmed that RCRC was significant predictor of VTE (OR=4.7; 95% CI 1.74 – 12.57). However KRAS/NRAS/BRAF mutations were not associated with VTE (OR =0.86; 95% CI 0.11-6.59). In our study, primary tumor sidedness has been associated with VTE in patients with mCRC. Our results have not confirmed an association between biomarker status (KRAS, NRAS and BRAF) and an increased risk of VTE in mCRC patients.

Clinical Significance of Global Wasted Work in Patients with Heart Failure Receiving Cardiac Resynchronization Therapy

The relationship between myocardial work assessment using pressure-strain loops by echocardiography before cardiac resynchronization therapy (CRT) and response to CRT has been recently revealed. Among myocardial work parameters, the impact of left ventricular myocardial global wasted work (GWW) on response to CRT and outcome following CRT has been seldom studied. Hence, the authors evaluated the relationship between preprocedural GWW and outcome in a large prospective cohort of patients with heart failure (HF) and reduced ejection fraction receiving CRT. The study included 249 patients with HF. Myocardial work indices including GWW were calculated using speckle-tracking strain two-dimensional echocardiography using pressure-strain loops. End points of the study were (1) response to CRT, defined as left ventricular reverse remodeling and/or absence of hospitalization for HF, and (2) all-cause death during follow-up. Median follow-up duration was 48months (interquartile range, 43-54months). Median preoperative GWW was 281mm Hg% (interquartile range, 184-388mm Hg%). Preoperative GWW was associated with CRT response (area under the curve, 0.74; P<.0001), and a 200mm Hg% threshold discriminated CRT nonresponders from responders with 85% specificity and 50% sensitivity, even after adjustment for known predictors of CRT response (adjusted odds ratio, 4.03; 95% CI, 1.91-8.68; P<.001). After adjustment for established predictors of outcome in patients with HF with reduced ejection fraction receiving CRT, GWW < 200mm Hg% remained associated with a relative increased risk for all-cause death compared with GWW ≥ 200mm Hg% (adjusted hazard ratio, 2.0; 95% CI, 1.1-3.9; P=.0245). Adding GWW to a baseline model including known predictors of outcome in CRT resulted in an improvement of this model (χ2 to improve 4.85, P=.028). The relationship between GWW and CRT response and outcome was stronger in terms of size effect and statistical significance than for other myocardial work indices. Low preoperative GWW (<200mm Hg%) is associated with absence of CRT response in CRT candidates and with a relative increased risk for all-cause death. GWW appears to be a promising parameter to improve selection for CRT of patients with HF with reduced ejection fraction.

Incident cardiovascular events and risk of subsequent cancer diagnosis

Abstract Background Cardiovascular disease (CVD) and cancer share common risk factors. This study investigated the association of CVD diagnosis and the risk of future cancer. Methods We evaluated asymptomatic self-referred adults aged 40–79 years who participated in a screening program. All subjects were free of CVD and cancer at baseline. CVD was defined as the composite of acute coronary syndrome, percutaneous coronary intervention or stroke. Cancer and mortality data were available for all subjects from national registries. Primary end-point was development of cancer during follow up. Cox regression models were applied with CVD as a time-dependent covariate and death as a competing risk event. Results Final study population included 15,486 subjects. Median age was 50 years (Interquartile range [IQR] 44–55) and 72% were men. During median follow up time of 11 years (IQR 6–15) 1,028 (7%) subjects developed CVD, 1,281 (8%) developed cancer and 499 (3%) died. Most common cancer types were prostate among men (N=277, 1.8%) and breast among women (N=187, 1.2%). Time dependent survival analysis showed that subjects who developed CVD during follow up were 60% more likely to develop cancer (95% Confidence Interval [CI] 1.3–1.95, p&amp;lt;0.001). However, after adjustment for known predictors of cancer, the association of incident CVD with cancer diagnosis was no longer significant (p=0.21). Interaction analysis demonstrated that the association of incident CVD with the risk of future cancer diagnosis was age dependent such that in younger subjects (&amp;lt;50 years; N=7,649) incident CVD was associated with a significant 2 fold increased risk of subsequent cancer diagnosis (95% CI 1.2–3.6, p=0.014) while in older subjects incident CVD was not associated with increased risk of cancer in the multivariable model (p for interaction =0.035; Figure 1). Conclusions Incident CVD is independently associated with 2-fold increased risk of subsequent cancer diagnosis among young adults. Our analysis underscores the importance of cancer surveillance among young patients following a CVD event. Figure 1 Funding Acknowledgement Type of funding source: None

Elastic Bandage vs Hypertonic Albumin for Diuretic-Resistant Volume-Overloaded Patients in Intensive Care Unit: A Propensity-Match Study

ObjectiveTo compare elastic bandage (EB) vs hypertonic albumin solution administration to increase fluid removal by enhancing loop diuretic efficiency (DE) in patients with volume overload and diuretic resistance. Patients and MethodsIn this historic cohort study with propensity matching, we included diuretic-resistant adult (≥18 years) patients with volume overload after fluid resuscitation admitted in the intensive care unit from January 1, 2006, through June 30, 2017. Regression models and propensity matching were used to assess the associations of these interventions with changes in DE and other clinical outcomes. ResultsOf 1147 patients (median age, 66; interquartile range [IQR], 56-76 years; 51% [n=590] men), 384 (33%) received EB and 763 (67%) received hypertonic albumin solution. In adjusted models, EB was significantly associated with higher DE compared with hypertonic albumin solution (odds ratio, 1.37; 95% CI, 1.04 to 1.81; P=.004). After propensity matching of 345 pairs, DE remained significantly different between the 2 groups (median, 2111; IQR, 1092 to 4665 mL for EB vs median, 1829; IQR, 1032 to 3436 mL for hypertonic albumin solution; P=.02). EB, male sex, lower baseline serum urea nitrogen level, lower Charlson Comorbidity Index score, and higher baseline left ventricular ejection fraction were DE determinants. The lowest DE quartile (<1073 mL/40-mg furosemide equivalent) following adjustment for known predictors of mortality remained independently associated with higher 90-day death rate (odds ratio, 1.64; 95% CI, 1.13 to 2.36; P=.009). ConclusionEB use is associated with greater DE than hypertonic albumin solution during the deescalation phase of sepsis resuscitation. Prospective clinical trials would validate the findings of this hypothesis-generating study.

Editors' note: Low hemoglobin and hematoma expansion after intracerebral hemorrhage

To corroborate previous reports that lower hemoglobin levels may be associated with hematoma expansion (HE) and poor functional outcomes after intracerebral hemorrhage (ICH), Drs. Roh et al. queried their single-center prospective ICH registry of 256 patients. After adjustment for known predictors of HE, each 1 g/dL fall in hemoglobin levels was associated with a 20% higher odds of HE and 24% higher odds of severe disability (modified Rankin Scale score 4–6) at 3 months. Mediation analysis demonstrated that HE contributed to the poor long-term outcomes seen in patients with lower admission hemoglobin levels. Yu et al. address important unmeasured confounders—notably, coagulopathy—which could have also contributed to adverse radiographic and clinical outcomes. However, as Dr. Roh responds, patients in this study were excluded if there was evidence of coagulopathy secondary to systemic disease. Furthermore, the investigators adjusted for the use of therapeutic anticoagulation, irrespective of coagulation studies. Ultimately, both groups agree that these results warrant replication in further studies. To corroborate previous reports that lower hemoglobin levels may be associated with hematoma expansion (HE) and poor functional outcomes after intracerebral hemorrhage (ICH), Drs. Roh et al. queried their single-center prospective ICH registry of 256 patients. After adjustment for known predictors of HE, each 1 g/dL fall in hemoglobin levels was associated with a 20% higher odds of HE and 24% higher odds of severe disability (modified Rankin Scale score 4–6) at 3 months. Mediation analysis demonstrated that HE contributed to the poor long-term outcomes seen in patients with lower admission hemoglobin levels. Yu et al. address important unmeasured confounders—notably, coagulopathy—which could have also contributed to adverse radiographic and clinical outcomes. However, as Dr. Roh responds, patients in this study were excluded if there was evidence of coagulopathy secondary to systemic disease. Furthermore, the investigators adjusted for the use of therapeutic anticoagulation, irrespective of coagulation studies. Ultimately, both groups agree that these results warrant replication in further studies.

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

To determine the prevalence and severity of traumatic intracranial hemorrhage (tICH) in a large cohort of older adults presenting with low-energy falls and the association with anticoagulation or antiplatelet medication. Bicentric retrospective cohort analysis. Two level 1 trauma centers in Switzerland and Germany. Consecutive sample of older adults (aged ≥65 y) presenting to the emergency department (ED) over a 1-year period with low-energy falls who received cranial computed tomography (cCT) within 48 hours of ED presentation. The prevalence and severity of tICHs was assessed and the outcomes (in-hospital mortality, admission to intensive care unit [ICU], or neurosurgical intervention) were specified. We used multivariate regression models to measure the association between anticoagulation/antiplatelet therapy and the risk for tICH after adjustment for known predictors. The overall prevalence for tICH detected by cCT was 176 of 2567 (6.9%). Neurosurgical intervention was performed in 15 of 176 (8.5%) patients with tICH, 28 of 176 (15.9%) patients were admitted to the ICU, and 14 of 176 (8.0%) died in the hospital. CT-detected skull fracture and signs of injury above the clavicles were the strongest predictors for the presence of tICH (odds ratio [OR] = 4.28; 95% confidence interval [CI] = 2.79-6.51; OR = 1.88; 95% CI = 1.3-2.73, respectively). Among 2567 included patients, 1424 (55%) were on anticoagulation/antiplatelet therapy. Multivariate regression models showed no differences for the risk of tICH (OR = 1.05; 95% CI = .76-1.47; P = .76) or association with the head-specific Injury Severity Scale (incident rate ratio = 1.08; 95% CI = .97-1.19; P = .15) with or without anticoagulation/antiplatelet therapy. Medication with anticoagulants or antiplatelet agents was not associated with higher prevalence and severity of tICH in older patients with low-energy falls undergoing cCT examination. In addition to cCT-detected skull fractures, visible injuries above the clavicles were the strongest clinical predictors for tICH. Our findings merit prospective validation. J Am Geriatr Soc 68:977-982, 2020.

Weight status and health-related quality of life during childhood and adolescence: effects of age and socioeconomic position.

Overweight and obesity in children is associated with poor health-related quality of life (HRQoL), but the nuances of this relationship across different age and socio-demographic groups are not well-established. The aim of this study is to examine how the association between weight status and HRQoL changes with age and socioeconomic position (SEP) throughout childhood and adolescence. We used data from the Longitudinal Study of Australian Children (LSAC), a cohort study in which children were interviewed biennially from ages 4 to 17 years over seven waves of data. Measurements of HRQoL (using PedsQLTM), body mass index (BMI), and socio-demographic characteristics were collected at each interview. Of the 4983 children recruited into the study, we included data from 4083 children (a total of 24,446 observations). We used generalised estimating equations to assess whether age and SEP modified the association between weight status and HRQoL, after controlling for sex, long-term medical condition, language spoken to child and maternal smoking status. Age was a significant modifier of the association between weight status and HRQoL, with adjustment for known predictors of HRQoL (P < 0.001). At age 4, children with obesity had, on average, a 0.99 (95% CI 0.02-1.96) point lower PedsQL total score than children at healthy weight. This difference became clinically important by age 9 at 4.50 (95% CI 3.86-5.13) points and increased to 6.69 (95% CI 5.74-7.64) points by age 17. There was no evidence that SEP modified the relationship between weight status and HRQoL (P > 0.05). Our results demonstrate that the relationship between overweight and obesity status and poor HRQoL is strengthened with increasing age through childhood and adolescence, but is not affected by SEP. Paediatricians, researchers and carers of children with obesity should acknowledge HRQoL outcomes, particularly for older children and adolescents.

Poor emotional well-being is associated with rapid progression in amyotrophic lateral sclerosis.

The study aimed to determine the impact of emotional well-being on disease aggressiveness and survival in amyotrophic lateral sclerosis (ALS). In 224 patients with ALS (without significant cognitive deficits) the revised ALS Functional Rating Scale (physical function), the ALS Assessment Questionnaire (ALSAQ-40) for health-related Quality of Life and survival data were collected. Data analysis comprised logistic regression, Kaplan-Meier curves analyses and Cox regression model. Most patients reported to be worried about how the disease will affect them in the future and 67% reported to feel depressed. Patients with good emotional well-being were characterized by better physical function (higher ALSFRS-R) and lower disease aggressiveness. The association between high emotional well-being and lower disease aggressiveness was confirmed in the univariate analysis and also after adjustment for known predictors of disease progression. In the Kaplan-Meier survival curve analysis the overall 1-year, 2-year and 3-year mortality did not significantly differ between patients with poor and good emotional well-being. Our study demonstrates an association between emotional well-being and disease progression. Knowing that subjective well-being is neither a necessary nor a sufficient cause of health, longitudinal studies are necessary to explore when well-being does and does not influence disease progress and survival in ALS.

Desmopressin administration and rebleeding in subarachnoid hemorrhage: analysis of an observational prospective database.

Rebleeding remains a frequent and catastrophic event leading to poor outcome after subarachnoid hemorrhage (SAH). Reduced platelet function after the initial bleed is associated with higher risk of early rebleeding. Desmopressin (DDAVP) is a well-known hemostatic agent, and recent guidelines already suggest its use in individuals exposed to antiplatelet drugs. The authors hypothesized that DDAVP administration in patients with SAH at admission would be associated with lower risks of rebleeding. The authors performed an observational cohort study of patients enrolled in the Columbia University SAH Outcome Project between August 1996 and July 2015. The authors compared the rate of rebleeding between patients who were and those who were not treated with DDAVP. After adjustment for known predictors, logistic regression was used to measure the association between treatment with DDAVP and risks of rebleeding. Among 1639 patients with SAH, 12% were treated with DDAVP. The main indication for treatment was suspected exposure to an antiplatelet agent. The overall incidence of rebleeding was 9% (1% among patients treated with DDAVP compared with 8% among those not treated). After adjustment for antiplatelet use and known predictors, treatment with DDAVP was associated with a 45% reduction in the risks of rebleeding (adjusted OR 0.55, 95% CI 0.27-0.97). DDAVP was associated with a higher incidence of hyponatremia but not with thrombotic events or delayed cerebral ischemia. Treatment with DDAVP was associated with a lower risk of rebleeding among patients with SAH. These findings support further study of DDAVP as first-line therapy for medical hemostasis in patients with SAH.

Association between effort-reward imbalance and self-reported diabetes mellitus in older U.S. workers

ObjectiveStudies assessing the effects of work stress on health in older adults in the U.S. labor force are scarce. We examined the longitudinal association between work stress as measured by effort-reward imbalance (ERI) and incident diabetes over a 7-year period in U.S. working adults aged 50years and older. MethodsWe used longitudinal data from the 2006–2012 waves of the Health and Retirement Study (n=1932). Cox proportional hazard regression was used to examine whether ERI significantly predicted diabetes incidence in older adults who were diabetes-free at baseline. ResultsHigh stress level at work (ERI ratio>1.0) was found in participants who worked 55h or more a week (37.3%), had no insurance coverage (35.9%), and those working in blue collar jobs (34.4%). Participants with high ERI had a significantly higher risk of diabetes (HR=1.33, 95%CI=1.04–1.69) relative to those with low ERI, after adjustment for known predictors of adult-onset diabetes. ConclusionEffort-reward imbalance was associated with increased risk of diabetes incidence after controlling for other known predictive factors, which suggests an independent non-mediated effect of work stressors. More research is required to better understand the effects of work stress in aging populations and how psychosocial disequilibrium in the work environment may impact susceptibility to chronic conditions, and in particular how change in self-assessed reward might vary toward the end of a working lifetime.

Impact of home blood pressure monitoring on blood pressure control in older individuals: a French randomized study.

Home blood pressure (BP) monitoring is one of the tools recommended in hypertension management. However, its influence in older adults is seldom investigated. We aimed to assess whether regular home BP monitoring leads to a reduction of BP and an improvement in hypertension control in older adults. In a 24-month trial, individuals aged 73-97 years were randomized in a control (office and home BP measured at 0, 12, and 24 months) or an intervention (office measured at 0, 12, and 24 months; home BP measured every 3 months) group. The primary outcome was the difference in means office BP over 24 months in hypertensive patients. Secondary outcomes included differences in mean home BP over follow-up in hypertensive patients, and frequency of hypertension and of drug use at 24 months in the total sample. Intention-to-treat analyses comprised 1733 persons, among which 1043 were hypertensive. Hypertensive patients in the intervention group experienced a significantly greater fall in office systolic BP (SBP) [mean between-group difference -2.1 mmHg, 95% confidence interval (CI) -4.1; -0.2, P = 0.03], home SBP (mean between-group difference -3.4, 95% CI -4.8; -2.1, P < 0.0001), and home diastolic BP (mean between-group difference -1.1, 95% CI -1.8; -0.4, P = 0.002) than those in the control group, in the main model. No overall differences were observed for office diastolic BP (P = 0.74), frequency of hypertension (P = 0.92), or drug use (P = 0.51) over time. Similar results were observed after adjustment for known predictors of BP though attenuated for office SBP (P = 0.07). Regular home BP monitoring every 3 months without co-intervention results in small but greater reductions of BP over time. Further research in large trials focused on older adults is needed to confirm the effectiveness of this intervention in a variety of settings.

Zinc Deficiency Is associated With Depressive Symptoms-Results From the Berlin Aging Study II.

Zinc plays an important role for behavioral and mental function, maintaining the correct functions of intracellular signal transduction, cellular and trans-membrane transport, protein synthesis, and antioxidant system. We investigated both dietary zinc intake and plasma zinc levels and the correlation with depressive symptoms in a large sample of community-dwelling old. One thousand five hundred fourteen older people (aged 60-84 years, 772 women) from the Berlin Aging Study II were included. Zinc intake was assessed by the EPIC Food Frequency Questionnaire. Plasma zinc levels were assessed with atomic-absorption spectrophotometry. Depressive symptoms were assessed with the "Center for Epidemiological Studies Depression Scale" and the "Geriatric Depression Scale." Zinc deficiency in blood plasma was found in 18.7% of participants, and depressive symptoms in 15.7%. Participants with depressive symptoms had lower energy-adjusted zinc intake (median 11.1 vs 11.6 µmol/L; p = .048) and lower plasma zinc levels (median 12.2 vs12.3 mg/dL; p = .037). Even after adjustment for known predictors of depression, plasma zinc deficiency remained significantly associated with depressive symptoms (odds ratio: 1.490, 95% confidence interval: 1.027-2.164; p = .036). In the multiple logistic regression model stratified by sex, we found that plasma zinc deficiency was strongly associated with a higher risk for depressive symptoms in women (odds ratio: 1.739, 95% confidence interval: 1.068-2.833; p = .026). Plasma zinc deficiency was common in our old study population. An increase in dietary zinc and higher plasma zinc levels may reduce the risk of depressive symptoms. A screening for reduced dietary zinc intake or plasma zinc deficiency might be beneficial in older people at risk of depressive symptoms.

Extremely elevated BNP in acute heart failure: Patient characteristics and outcomes

BackgroundWe explored the clinical characteristics and outcomes of patients with acute systolic heart failure (HF) and extremely elevated admission B-type natriuretic peptide (BNP). MethodsExtremely elevated BNP was defined if BNP level was >85th percentile of the study cohort (i.e. >1694pg/mL). Our objectives were to find characteristic features that identify patients with extremely elevated BNP, to compare the degree of congestion in both groups and to study post-discharge outcomes. Results347 patients (mean age 56years, 74% males) were divided into two groups based on whether BNP was extremely elevated (n=53) or not (n=294). Those with extremely elevated BNP were older (P=0.004), with a lower body mass index (P<0.0001), higher blood urea nitrogen (P=0.01), higher creatinine (P=0.005), lower cardiac output (P<0.0001) and lower cardiac index (P=0.001). With regards to signs of congestion, both groups had no significant difference in the frequency of rales (P=0.454), peripheral edema (P=0.397), jugular venous distension (P=0.396), positive hepatojugular reflux (P=0.083), S3 gallop (P=0.107), mean pulmonary capillary wedge pressure (P=0.351), and right atrial pressure (P=0.310). Both groups had similar frequency of rehospitalization for HF (P=0.939), nonetheless, patients with extremely elevated BNP had longer hospital stay during initial (P=0.014), or subsequent hospitalization (30days: P=0.01, 180days: P=0.008). 6-month all-cause-mortality was higher in patients with extremely elevated BNP (P=0.008), although death due to pump failure was not (P=0.921). Cox proportional hazard analysis revealed that extremely elevated admission BNP is an independent predictor of 6-month all-cause-mortality (hazard ratio 1.857, 95% CI=1.074–3.208, P=0.027) after adjustment for known predictors of post-discharge mortality in HF. ConclusionExtremely elevated admission BNP did not match the degree of congestion nor was a predictor of rehospitalization due to HF. It was associated with decreased COP, prolonged hospital stay, and increased 6-month all-cause-mortality.

Depression and Multiple Rehospitalizations in Patients With Heart Failure

There have been few studies of the effect of depression on rehospitalization in patients with heart failure (HF), and even fewer on its role in multiple rehospitalizations. Depression is an independent risk factor for multiple readmissions in patients with HF. A cohort of 662 patients with HF who were discharged alive after hospitalization were interviewed to evaluate symptoms of depression and were followed for 1 year. All-cause readmissions were documented by chart review. A marginal proportional rates model was used to model the effect of depression on the rate of rehospitalization with adjustment for known predictors of HF outcomes. Depression symptoms predicted multiple readmissions (adjusted hazard ratio [HR]: 1.08, 95% confidence interval [CI]: 1.03-1.13, P = 0.0008). Compared with patients without depression, those who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression at index were at the highest risk for multiple rehospitalizations (HR: 1.51, 95% CI: 1.15-1.97, P = 0.003). Depression is an independent risk factor for multiple all-cause readmissions in patients with HF.