CI For RR Research Articles

Geographic distribution of antibiotic resistance of Helicobacter pylori: A study in Bulgaria.

Prevalence of antibiotic resistant Helicobacter pylori was compared between 50 patients living outside the capital city and 50 matched pairs of capital city residents (CCRs). H. pylori isolates from 2018 to 2022 were included. Resistance rates in CCRs and those living elsewhere were 4.0 and 6.0% toamoxicillin, 48.0 and 42.0% to metronidazole, 30 and 30% to clarithromycin, and 4.0 and 4.0% to tetracycline, respectively. Levofloxacin resistance was higher (38.0%) in the capital city vs 20.0% (P=0.047) in the country. Odd ratio for levofloxacin resistance between pair-matched groups was 2.45 (95% CI, OR 1.0-6.02, P value = 0.05) and relative risk for fluoroquinolone resistance was 1.90 (95% CI for RR 0.98-3.67) for CCRs vs residents in other regions. Resistance rates to levofloxacin and clarithromycin were worryingly high in our study, most probably due to the high quinolone consumption (2.86 DDD/day in 2017) in Bulgaria and the increase in macrolide, lincosamide and streptogramin consumption, especially of azithromycin, by >42% with the start of COVID-19 pandemic. Briefly, antibiotic resistance of H. pylori has a dynamic change, and it can display different patterns in certain geographic regions. The results imply that antibiotic consumption should be carefully controlled and unjustified use of levofloxacin should be restricted, especially in some large cities. Antibiotic policy should be further strengthened and regular monitoring of resistance in various geographic regions is needed for treatment optimization.

Comparison of the efficacy and safety of the adalimumab biosimilar TQ-Z2301 and adalimumab for the treatment of Chinese patients with active ankylosing spondylitis: a multi-center, randomized, double-blind, phase III clinical trial

To assess the clinical equivalence of TQ-Z2301, a biosimilar of adalimumab, to the reference adalimumab in the treatment of Chinese patients with active ankylosing spondylitis. This multicenter, randomized, double-blind, positive-controlled phase III clinical trial was conducted in 19 centers across China. Chinese adults with active ankylosing spondylitis despite being treated with non-steroidal anti-inflammatory drugs for ≥ 4 weeks were randomized in a 1:1 ratio to subcutaneously receive 40 mg of TQ-Z2301 or adalimumab every other week for 24 weeks. The primary endpoint was the percentage of patients who achieved at least 20% improvement according to the Assessment of Spondyloarthritis International Society criteria (ASAS20) at week 24. The equivalence was established if the 90% CI for RR of ASAS20 between two groups at week 24 fell within (0.80, 1.25). Secondary endpoints included efficacy measures of disease activity, spinal mobility, physical function and quality of life, immunogenicity, and pharmacokinetic parameters. Safety analysis was done for all patients who received at least one study drug. A total of 380 patients were enrolled in the study between September 2018 and October 2019, including 188 in the TQ-Z2301 group and 192 in the adalimumab group. In the full analysis population, the ASAS20 response rate at week 24 was 86.70% in the TQ-Z2301 group, and 80.73% in the adalimumab group, the RR of ASAS20 for TQ-Z2301 versus adalimumab was 1.074, 90% CI (0.997, 1.157), fell within the predefined equivalence boundary (0.80, 1.25). Except for the SF-36 at week 12, there was no statistical difference between the two groups for all the secondary endpoints (P>0.05). The incidence of adverse events group was 82.45% in the TQ-Z2301, and 83.85% in the adalimumab group, the safety profile of the two groups was similar. The profiles of immunogenicity and pharmacokinetics were also similar between the two groups. TQ-Z2301 is equivalent to adalimumab for the treatment of Chinese patients with active ankylosing spondylitis. The safety, immunogenicity, and pharmacokinetic characteristics of both drugs are similar. The study (CTR20181863) was registered in the Chinese Clinical Trial Registry on 19 October 2018. Key Points • TQ-Z2301 showed the equivalence of efficacy compared with the reference adalimumab for the treatment of Chinese patients with active ankylosing spondylitis. • The safety, immunogenicity, and pharmacokinetics profiles of TQZ-2301 were similar to those of the reference adalimumab.

Nosocomial sepsis and drug susceptibility pattern among patients admitted to adult intensive care unit of Ayder Comprehensive Specialized Hospital, Northern Ethiopia

ObjectiveDeveloping nosocomial sepsis within intensive care unit (ICU) is associated with increased mortality, morbidity, and length of hospital stay. But information is scarce regarding nosocomial sepsis in intensive care units of Northern Ethiopia. Hence, this study aims to determine the incidence of nosocomial sepsis, associated factors, bacteriological profile, drug susceptibility pattern, and outcome among patients admitted to the adult ICU of Ayder Comprehensive Specialized Hospital (ACSH), which is the largest tertiary hospital in Northern Ethiopia.MethodFacility-based longitudinal study was conducted by following 278 patients who were admitted for more than 48 h to adult ICU of ACSH, from October 2016 to October 2017. Data were collected from charts, electronic medical records, and microbiology registration book using a checklist. The collected data were subjected to descriptive statistics and multivariable logistic regression using SPSS version 25. Statistical significance was declared at p < 0.05.ResultOf all the patients, 60 (21.6%) of them acquired nosocomial sepsis. The risk of mortality was about two times higher among adult ICU patients who acquired nosocomial sepsis (RR = 2.2; 95% CI of RR = 1.3–3.5; p = 0.003). The odds of acquiring nosocomial sepsis among those who were on a mechanical ventilator (MV) and stayed more than a week were 5.7 and 9.3 times higher, respectively, than their corresponding counterparts. Among 48 isolates, Klebsiella was the most common pathogen. The isolates had a broad antibiotic resistance pattern for cephalosporins, penicillins, and methicillin.ConclusionThe incidence of nosocomial sepsis in the adult ICU patients of ACSH was higher when compared to the incidence reported from some African and Asian countries. Mortality was higher among patients who acquired nosocomial sepsis. Use of MV and longer length of ICU stay were the significant predictors of nosocomial sepsis. The isolates were resistant to several antibiotics. Therefore, strict application of infection prevention strategies and appropriate use of antibiotics is so crucial. As well, priority should be given to patients who develop nosocomial sepsis in ICU.

Development and External Validation of Thrombosis Lymphoma /Throly/ Score–Interim Analysis

Lymphoma patients are at increased risk of thromboembolic events (TE) but thromboprophylaxis in these patients is largely underused. Actual guidelines recommend Padua and Khorana score For thromboembolic risk estimation in cancer patients. Suggested models are of limited use in lymphoma patients as their development is not based on characteristics specific for this patient population. In this study, we sought to develop and validate a simple model, based on individual clinical and laboratory patient characteristics that would designate lymphoma patients at risk for thromboembolic event. The study population included consecutive patients with a confirmed diagnosis of non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), and chronic lymphocytic leukemia (CLL)/ small lymphocytic lymphoma (SLL). Data were collected for patients treated in two lymphoma centers in Serbia (derivation and internal validation cohorts) from 2006 to 2014, and for patients treated in four lymphoma centers from USA, France, Spain and Macedonia during 2015 to 2016 (external validation cohort). Data for newly diagnosed and relapsed patients who had completed a minimum of one chemotherapy cycle were collected for all venous and arterial TE events from time of diagnosis to 3 months after the last cycle of therapy. Specific demographic, clinical, and laboratory variables known to be associated with predictive scores were also extracted. Moreover, potential disease-related risk factors were gathered. The model was developed using data from a derivation cohort, which included 1236 patients. Once a final model was defined, patients were divided into low risk and at risk groups. The final model was then assessed in the internal (584 patients) and external validation cohort (n=822 patients). Sixty-five patients (5.3%) in the derivation cohort and 34 (5.8%) patients in the validation cohort developed thromboembolic events. The two cohorts were well balanced with respect to all assessed patient characteristics. The mean patient's age was 53.1 years (range, 15-87 years). Most patients (83%) were newly diagnosed and had advanced stage disease: Ann Arbor stage III, 14.7% and stage IV, 44%. A total of 778 patients (42.7%) had high-grade lymphoma; 351 (19.3%) had low-grade lymphoma; 266 (14.6%) had HL; 156 (8.6%) had other forms; and 269 (14.8%) had CLL/SLL. Of all the patients included in the study, 99 (5.4%) developed at least one TE during the follow-up period. There were 73 patients with venous TE (73.7%), and 25 with arterial TE (25.3%), while 1 patient had both. Patients with aggressive NHL had significantly higher odds of developing TE compared to patients with any other lymphoma type (RR=1.5; 95% CI for RR 1.1-2.4; p=0.027). The incidence of thromboembolism was 81 (5.3%) in the newly diagnosed patients and 18 (6.2%) in relapsed patients. Overall, 35.4% (35/99) of the patients with thromboembolism experienced the event before the start of chemotherapy. The majority of patients (64.6%) had TE events during chemotherapy or within 3 months after chemotherapy. The variables independently associated with risk for thromboembolism in derivation cohort were: previous venous and/or arterial events, mediastinal involvement, BMI>30 kg/m2, reduced mobility, extranodal localization, development of neutropenia and hemoglobin level < 100g/L. For patients classified at risk in derivation cohort, the model produced negative predictive value of 98.5%, positive predictive value of 25.1%, sensitivity of 75.4%, and specificity of 87.5%. The diagnostic performance measures retained similar values in the internal validation cohort. External validation cohort consisted of 248 (30.2%) indolent NHL, 291 (35.4%) agressive NHL, 149 (18%) CLL/SL and 125 (15.2%) HL patients, out of which 60 (7%) patients developed thromboembolic events. For patients classified at risk in external validation cohort, the model produced negative predictive value of 97%, positive predictive value of 15%, sensitivity of 71%, and specificity of 67%. Having in mind previosly mentioned data from interim analysis based we can conclude that developed prognostic Thrombosis Lymphoma - ThroLy score is more specific for lymphoma patients than any other available score targeting thrombosis in cancer patients. Model calibration will be needed based on data from large prospective cohort studies. DisclosuresCheson:Acerta, Pharmacyclics, Epizyme, Gilead, Roche, AbbVi: Other: Institution receives research support ; AbbVie, Roche-Genentech, Pharmacyclics, Acerta: Consultancy. Ianotto:Novartis: Other: Grant.

Impact of colorectal cancer screening participation in remote northern Canada: A retrospective cohort study.

BACKGROUNDScreening provides earlier colorectal cancer (CRC) detection and improves outcomes. It remains poorly understood if these benefits are realized with screening guidelines in remote northern populations of Canada where CRC rates are nearly twice the national average and access to colonoscopy is limited.AIMTo evaluate the participation and impact of CRC screening guidelines in a remote northern population.METHODSThis retrospective cohort study included residents of the Northwest Territories, a northern region of Canada, age 50-74 who underwent CRC screening by a fecal immunohistochemical test (FIT) between January 1, 2014 to March 30, 2019. To assess impact, individuals with a screen-detected CRC were compared to clinically-detected CRC cases for stage and location of CRC between 2014-2016. To assess participation, we conducted subgroup analyses of FIT positive individuals exploring the relationships between signs and symptoms of CRC at the time of screening, wait-times for colonoscopy, and screening outcomes. Two sample Welch t-test was used for normally distributed continuous variables, Mann-Whitney-Wilcoxon Tests for data without normal distribution, and Chi-square goodness of fit test for categorical variables. A P value of < 0.05 was considered to be statistically significant.RESULTS6817 fecal tests were completed, meaning an annual average screening rate of 25.04%, 843 (12.37%) were positive, 629 individuals underwent a follow-up colonoscopy, of which, 24.48% had advanced neoplasia (AN), 5.41% had CRC. There were no significant differences in stage, pathology, or location between screen-detected cancers and clinically-detected cancers. In assessing participation and screening outcomes, we observed 49.51% of individuals referred for colonoscopy after FIT were ineligible for CRC screening, most often due to signs and symptoms of CRC. Individuals were more likely to have AN if they had signs and symptoms of cancer at the time of screening, waited over 180 d for colonoscopy, or were indigenous [respectively, estimated RR 1.18 95%CI of RR (0.89-1.59)]; RR 1.523 (CI: 1.035, 2.240); RR 1.722 (CI: 1.165, 2.547)].CONCLUSIONScreening did not facilitate early cancer detection but facilitated higher than anticipated AN detection. Signs and symptoms of CRC at screening, and long colonoscopy wait-times appear contributory.

Intraoperative vasopressors in head and neck free flap reconstruction.

Historically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis. Post hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review. Forty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively. Intraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.

Comparison Between Venetoclax-based and Bruton Tyrosine Kinase Inhibitor-based Therapy as Upfront Treatment of Chronic Lymphocytic Leukemia (CLL): A Systematic Review and Network Meta-analysis

BackgroundAvailable targeted agents (TAs) for the upfront therapy of chronic lymphocytic leukemia (ie, ibrutinib, acalabrutinib, venetoclax) have rarely been compared in head-to-head clinical trials. In search of data for evidence-based treatment decisions, a systematic literature review and network meta-analysis was performed. Materials and MethodsThe screening process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA). ResultsOnly 3 trials were suitable for the base-case network analysis (ILLUMINATE, ELEVATE-TN, and CLL14). Regarding progression-free survival (PFS), fixed-effect analyses comparing ibrutinib-obinutuzumab (IO) with venetoclax-obinutuzumab (VO) (relative risk [RR], 1.52; 95% confidence interval [CI], 0.82-2.81), acalabrutinib (A) with IO (RR, 0.87; 95% CI, 0.47-1.61), and A with VO (RR, 0.57; 95% CI, 0.32-1.01) revealed that the upper limit of the 95% CI for RR did exceed the 1.0 value. This indicates a lack of significant difference in PFS for IO, VO, and A. In contrast, acalabrutinib plus obinutuzumab (AO) improved PFS in comparison with IO (RR, 0.43; 95% CI, 0.22-0.87) and VO (RR, 0.29; 95% CI, 0.15-0.56). No differences in the frequency of adverse events was observed across different TAs. Also, the analysis of PFS in relationship with high-risk genetic features (ie, TP53 aberrations, IGHV unmutated, 11q deletion) showed similar results for different TAs. However, patients with unmutated IGHV status fared better with AO than with VO in terms of PFS. ConclusionsThis systematic review and network meta-analysis indicated that upfront AO prolongs PFS in comparison with IO and VO, whereas no differences are observed between IO, VO, and single-agent A. Hopefully, ongoing studies will further delineate the position of different TAs in chronic lymphocytic leukemia therapy based on effectiveness, availability, safety, cost, and treatment objectives.

Association between prostate-specific antigen change over time and prostate cancer recurrence risk: A joint model.

Background:Prostate specific antigen (PSA) is an important biomarker to monitor patients after treated with radiation therapy (RT). The aim of this study is to evaluate the relationship between the PSA data and prostate cancer recurrence using the joint modeling.Methods:This historical cohort study was performed on 422 prostate cancer patients. Inclusion criteria included: patients with localized prostate cancer referring to Cancer Institute in Tehran (Iran) from 2007 to 2012, and under radiation therapy. Joint model has two components or sub-models. We showed the results by parameter estimating the longitudinal sub-model and survival sub-model. EM algorithm, Newton-Gauss and Gauss-Hermit law were used for final model parameters. R software version 3.2 was used for statistical analysis.Results:In this study, considering the inclusion and exclusion criteria, out of 422 patients, the data on 314 cases were selected for analysis and the main result of joint model was obtained. PSA directly and significantly was associated with recurrence risk, therefore increasing 2.6 ml/lit PSA (one unit in transformed PSA) increases 39% recurrence risk (95% CI for RR: 1.09-1.77). Also, slope of PSA trend has significant association with prostate cancer recurrence risk (95% CI for RR: 1.05-1.41).Conclusion:This study showed a significant relationship between PSA, and its slope with the recurrence risk by joint model, with regard to the pathological, demographic and clinical features in the Iranian population.

Timing of enterostomy closure for neonatal isolated intestinal perforation

PurposeNo consensus guidelines exist for timing of enterostomy closure in neonatal isolated intestinal perforation (IIP). This study evaluated neonates with IIP closed during the initial admission (A1) versus a separate admission (A2) comparing total length of stay and total hospital cost. MethodsUsing 2012 to 2017 Pediatric Health information System (PHIS) data, 359 neonates with IIP were identified who underwent enterostomy creation and enterostomy closure. Two hundred sixty-five neonates (A1) underwent enterostomy creation and enterostomy closure during the same admission. Ninety-four neonates (A2) underwent enterostomy creation at initial admission and enterostomy closure during subsequent admission. For the A2 neonates, total hospital length of stay was calculated as the sum of hospital days for both admissions. A1 neonates were matched to A2 neonates in a 1:1 ratio using propensity score matching. Multivariate models were used to compare the two matched pair groups for length of stay and cost comparisons. ResultsPrior to matching, the basic demographics of our study population included a median birthweight of 960 g, mean gestational age of 29.5 weeks, and average age at admission of 4 days. Eighty-seven pairs of neonates with IIP were identified during the matching process. Neonates in A2 had 91% shorter total hospital length of stay compared to A1 neonates (HR: 1.91; 95% CI for HR: 1.44–2.53; p < .0001). The median length of stay for A1 was 95 days (95% CI: 78–102 days) versus A2 length of stay of 67 days (95% CI: 56–76 days). Adjusting for the same covariates, A2 neonates had a 22% reduction in the average total cost compared A1 neonates (RR: 0.78; 95% CI for RR: 0.64–0.95; p-value = 0.014). The average total costs were $245,742.28 for A2 neonates vs. $315,052.21 for A1 neonates (p < 0.001). ConclusionNeonates with IIP have a 28 day shorter hospital length of stay, $75,000 or 24% lower total hospital costs, and a 22 day shorter post-operative course following enterostomy closure when enterostomy creation and closure is performed on separate admissions. Type of StudyPrognosis Study. Level of EvidenceLevel II.

Association of Pre-procedural High Sensitivity C-Reactive Protein with In-hospital Outcome of Patients Undergoing Percutaneous Coronary Intervention

Emerging evidence links an elevated baseline inflammatory status to adverse outcome among patients undergoing percutaneous coronary intervention (PCI). Baseline inflammation measured by high sensitivity C-reactive protein hsCRP may prove useful for identification of high risk patients requiring adjunctive therapies. This prospective study was carried out in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka, during October 2012 to September 2013.Two hundred consecutive patients with CSA and UA undergoing PCI were included in the study. Study patients were divided into two groups on the basis of hsCRP levels. In Group I hsCRP levels were elevated, that is ?3 mg/L and in Group II hsCRP levels were normal, that is &lt; 3 mg/L, with 100 patients in each group. Fol-lowing the procedure in-hospital outcome of study patients were observed. Increased inci-dence (44%) of adverse in-hospital outcome was found in Group I (44% Vs. 11%). Higher incidence of post procedural angina (17%), peri-procedural myocardial infarction (6%) and peri-procedural myocardial injury (10%) was observed in this group. Nonsignificant rate of acute myocardial infarction, significant arrhythmia, acute LVF, cardiogenic shock and death were found in elevated hsCRP Group. Overall Major Adverse Cardiac Events (6% Vs. 0%) were found in pre-procedural elevated hsCRP group. High sensitivity C-reactive protein remained independently predictive of adverse in-hospital outcome, with 95% CI of RR 1.4 – 4.4 and p&lt;001. The present study concludes that the hsCRP is an important and independent predictor of adverse in hospital outcome.

Gauging the response to cardiac resynchronization therapy: The important interplay between predictor variables and definition of a favorable outcome.

Selection of patients who are viable candidates for cardiac resynchronization therapy (CRT), prediction of the response to CRT as well as an optimal definition of a favorable response, all require further exploration. The purpose of this study was to evaluate the interplay between the prediction of the response to CRT and the definition of a favorable outcome. Seventy patients who received CRT were included. All patients met current guideline criteria for CRT. Forty-three echocardiographic parameters were evaluated before CRT and at 1, 3, 6, and 12months. M-mode, 2D echocardiography, and Doppler imaging were used to quantify left ventricular (LV) systolic and diastolic function, mitral regurgitation, right ventricular systolic function, pulmonary artery pressure, and myocardial mechanical dyssynchrony. The following definitions of a favorable CRT response were used: left ventricular ejection fraction (LVEF) improvement more >5% acutely following CRT, LVEF improvement >20% at 12-month follow-up, and a LV end-systolic volume (LVESV) decrease >15% at 12-month follow-up. For the LVEF improvement >5%, the best predictor was isovolumetric relaxation time (IVRT; P=.035). For improvement of LVEF >20%, the best predictors were left ventricular stroke index (LVSI; P=.044) and left ventricular fractional shortening (LVFS; P=.031). For the drop in left ventricular systolic volume (LVESV >15%), the best predictor was septal-to-lateral wall delay (ΔT) (P=.043, RR=1.023, 95% CI for RR=1.001-1.045). The definition of a favorable CRT response influenced the optimal predictor variable(s). Standardization of defining a favorable response to CRT is needed to guide clinical decision making processes.

Risk of trabeculectomy with an initial diagnosis of glaucoma versus ocular hypertension in Gloucestershire, UK

PurposeGloucestershire is a rural county in the UK, with a population of ~300,000 &gt; 40 years. Importantly, almost all glaucoma and OHT patients attend the Gloucestershire Eye Unit, under the care of one of two glaucoma specialists. Those treated privately will also be treated by the same clinicians: any audit of all the clinical activity of both might reasonably be extrapolated across the whole county. We use this approach to estimate risk of trabeculectomy in patients with an initial diagnosis of glaucoma versus OHT.MethodsAn audit of the case notes of all trabeculectomies performed between 2010 and 2012 was undertaken. The initial clinical diagnosis at presentation was recorded e.g. whether POAG, NTG, ACG, secondary glaucoma or OHT, as was the initial untreated IOP/severity of visual field loss (MD). Time elapsed between initial diagnosis and eventual surgery was calculated.ResultsConsidering only open‐angle glaucomas and OHT, there were 127 trabeculectomies in 119 patients over the two years of the audit. Secondary glaucomas (n = 14) were excluded. Annual risk of trabeculectomy in POAG was 2% per year based on an estimate of ~3000 glaucoma patients in the eye clinic. Median time from diagnosis to trabeculectomy: OHT (n = 4) 131 months, POAG (n = 93), 112 months, NTG (n = 14) 89 months, and PEX (n = 8) 55 months. Relative risk of trabeculectomy was 70 times higher in POAG compared with OHT, assuming prevalence of 2% POAG, 5% OHT in people &gt;40 years (95% CI of RR 20‐290).ConclusionsWhen compared with POAG, people with an initial diagnosis of OHT are 70 times less likely to need surgery. Patients with PXF had surgery much sooner than those with OHT. This audit provides prognostic predictions for glaucoma and OHT patients, and further, might suggest more resources be directed to patients with glaucoma, perhaps at the expense of patients with OHT.

Abstract 367: Antibodies Against Oxidized LDL, ß2 Glycoprotein I and Chlamydia pneumoniae Heat Shock Protein 70 in Acute Coronary Atherothrombosis Development

Background and aims: Atherothrombosis is the major determinant of acute cardiovascular events, such as myocardial infarction. Inflammatory processes have been linked to all phases of atherogenesis. Data suggest that atherosclerosis also constitutes an autoimmune disease. We aimed to investigate the presence of anti oxidized LDL (ox-LDL) antibodies (IgG) and anti beta 2 glycoprotein I antibodies in acute coronary atherothrombosis development. Methods: The study included 206 participants of whom 106 were patients with acute coronary syndromes (ACS), (61.2 ± 3.21 years of age, 62% males) and 100 were age and sex matched controls with no known coronary artery disease. Patients with previous infection were excluded from the study. Blood was sampled, frozen and sent on dry ice to Immunosciences Lab. Inc (USA) for analyses. All traditional risk factors were noted. Anti ox-LDL antibodies (IgG), anti beta 2 glycoprotein I (IgG) antibodies were determined as well as anti Chlamydia pneumoniae heat shock protein (HSP) 70 (IgG) antibodies. Interleukin 6 and C- reactive protein were measured. Results: Our data showed significant prevalence of examined antibodies in patients with ACS: 30% of patients had anti Ox-LDL antibodies (IgG) detectable, 25% had anti beta glycoprotein I antibodies compared to 8% of controls. The total of 31% patients versus 13% of controls had anti Chlamydia pneumoniae HSP 70 (IgG) antibodies detectable, RR 2.36, (1.32-4.28 95% CI for RR, p=0.003) The levels of circulating antibodies were significantly higher in patients (p&lt;0.001). Markers of inflammation differed significantly between the groups. Our data indicated linear correlation between examined antibodies and markers of inflammation. In conclusion, the results of our study suggest that antibodies (IgG) against Ox- LDL, beta 2 glycoprotein I and Chlamydia pneumonia HSP 70 can be detected in patients with acute coronary atherothrombosis. The clinical relevance for circulating autoantibodies in cardiovascular outcomes is still debated. We believe that further research will help to assess if those autoantibodies could improve current cardiovascular risk stratification approaches and therapeutic algorithm, both in primary and secondary prevention.

Tu1447 A Long Term Retrospective Analysis of Large Polypectomies Using Standard Injection and Lift Techniques

characteristics, lesion location and histology. Statistical analyses were performed using SPSS 19 (SPSS Inc., Chicago, IL, USA). Results: EMR was performed in 1109 lesions 20mm (910 colon, 82%; 199 rectum, 18%). 37 patients did not have EMR and were excluded from analysis (22 cancer suspected; 15 technical difficulties). Significant differences exist in key patient and lesion characteristics, and procedural success rates (Table 1). Rectal lesions had a significantly higher risk of CRC than colonic lesions (11.5% v 6.0%, P 0.007). The odds of CRC in the rectum was 1.6 times greater than in the colon on multiple logistic regression analysis, however was not an independent predictor of CRC (95% CI 0.9-3.0, P 0.138). Independent predictors of CRC were Paris classification and morphology, presence of Kudo pit pattern 5 and lesion size (all P 0.05). The most common subgroup (0-IIa/b G lesions) had the same low risk for CRC in the colon and rectum (2.3% v 2.4%, P 1.000) (Table 2). A Is component in a G lesion magnified the risk of CRC in the colon, which was further increased in the rectum (5.9% v 9.6%, RR 1.63, P 0.196). The same applied to 0-IIa/b lesions with NG morphology in the colon compared to the rectum (7.7% v 22.2%, RR 2.87, P 0.171). NG lesions with a Is component in the rectum had the highest relative risk of CRC (7.1% v 30.8%, P 0.017, RR 4.31, 95% CI for RR 1.2-15.0). Conclusion: Specific subtypes of rectal AMNs have a greater relative risk of CRC compared to colonic AMNs, particularly NG lesions with a Is component. Endoscopic morphology determines the endoscopic therapeutic approach. Independent of site, granular flat lesions can be removed by multi-piece excision, as the risk of CRC is low. However, lesions with a Is component and NG morphology need to be assessed on a case by case basis to determine the correct strategy and should be considered for en bloc resection, particularly when found in the rectum.

Risk Factors for Chronic Pain Syndrome after Gynecological Surgery

Objective: to define risk factors for chronic postoperative pain syndrome (CPPS) in gynecological patients. Subjects and methods. The pre- and intraoperative examination data of 339 gynecological patients who had been operated on via only laparotomic approach and received postoperative traditional therapy (without adaptogens and antioxidants) were used to study the risk factors of CPPS. Postoperatively, subjective self-assessment tests were carried out using the visual analogue scale (VAS) and 4-point pain rating scale to measure pain intensity. Results. The material of 339 patients who had undergone gynecological surgery was used to investigate the importance of CPPS risk factors associated with their preoperative features and with the indicators characterizing the performed intervention. The reasons that were of statistically confirmed significance to the risk of CPPS were identified. The findings may be used to individualize a postoperative analgesic therapy regimen and they determine priority measures to prevent CPPS. Conclusion. The reasons associated with a significant increase in the relative risk of CPPS (RR, 1.3 to 2.6; p 0.05; 95% CI for RR and OR) are anemia with a preoperative hemoglobin concentration of 100 to 120 g/l, first-to-second-degree obesity, a less than 2-hour operation, an intraoperative blood loss of less than 500 ml, and preoperative parasympatotonia. Key words: gynecological surgery, chronic postoperative pain syndrome, risk factors.

Značaj standardne dvodimenzionalne i jednodimenzionalne ehokardiografije u proceni dobrog odgovora na resinhronizacionu terapiju miokarda kod bolesnika sa teškom dilatativnom kardiomiopatijom i srčanom insuficijencijom - jednogodišnje praćenje

Background: Cardiac resynchronization therapy (CRT) is considered to be a significant step forward in the treatment of patients with heart failure; it reduces morbidity and mortality due to proper selection of candidates for CRT. The aim of study was to assess the performance of echocardiographic parameters, including parameters of mechanical dyssynchrony, to predict CRT response. Methods: The 12-month trial was performed on 70 patients (53 men, 17 women) with standard inclusion criteria: New York Heart Association class III or IV heart failure, left ventricular ejection fraction (LVEF) ≤35 %, QRS ≥120 ms and optimal medical therapy. All echocardiographic parameters, using conventional and tissue Doppler-based methods, were evaluated. Indicator of positive CRT response was more than 20 % in improvement of LVEF. Results: LVEF increased >20 % in 60 % (42/70) pts. Out of twelve baseline echocardiographic parameters, six (left ventricular stroke volume, SV; left ventricular stroke index, SI; left ventricular fraction shortening, FS; right ventricular dimension, RVdim; peak velocity of mitral regurgitation, PVMR, proximal isovelocity surface area, PISA) had modest to good ability to predict LVEF response with sensitivity ranging from 62,2 % to 82,4 %, and specificity ranging from 56,5 % to 81,2 %. For those parameters, the area under the receiver operating characteristic curve for positive response to CRT was ≤0.76. Multivariate logistic regression analysis resulted in selection of left ventricular SI and FS as possible predictive independent echocardiographic parameters for a good CRT response The cutoff value for left ventricular stroke index was 38.7 ml/m2 (p=0.045, RR=0.896, 95 %CI for RR=0.805-0.998) and for left ventricular fraction shortening 13 % (p=0.032, RR=0.707, 95 % CI for RR= 0.515-0.970). Conclusions: The advantage of LVSI and LVFS, as independent predictors of good response to CRT, lies in simplicity of their assessing by conventional M-mode and 2D echocardiography. This could be an argument for adding them to the inclusion criteria for CRT.

Outbreak of hepatitis E with bimodal peak in rural area of Bhavnagar, India, 2010

Context : Rise in the number of jaundice cases were reported on 24 th of June 2010, in Dhola village, India. We investigated the outbreak to identify the source of infection and to facilitate control measures. Materials and Methods : We confirmed the outbreak by reviewing the rate of acute viral hepatitis in the year 2009-10. We defined a case of acute hepatitis as an acute illness with (a) discrete onset of symptoms and (b) jaundice or elevated serum aminotransferase levels, since March 2010 in Dhola village. We described the outbreak in terms of time, place, and person. We tested 20 blood samples of the case patient for hepatitis B surface antigen (HBs Ag), and immunoglobulin M (IgM) antibody for hepatitis A and E. We collected water samples for the bacteriological examination, and to test free chlorine in the water. Results : A total of 137 cases (attack rate 27.2/1000) were reported in this outbreak from March to August 2010. The attack rate was highest among the age group of 20-29 years. The attack rate was significantly higher in male (35/1000) than in female (18/1000). Out of 20 case-patients, 19 were found positive for hepatitis E virus (HEV) IgM antibodies. The water samples taken from households contained more than 10 coliforms in 100 ml sample. The relative risk of developing hepatitis E among people using pipeline water against those using ground water was 3.23 (95% CI of RR 1.59, 6.57). Conclusion : Outbreak that affected Dhola village was due to hepatitis E virus. Fecal contamination of water was the most likely source of this bimodal outbreak of hepatitis E.

Manejo activo de la tercera fase del parto más 400 μg de misoprostol sublingual y 200 μg de misoprostol rectal frente a manejo activo solo en la prevención de la hemorragia posparto. Ensayo clínico aleatorizado

ObjectivesTo evaluate the efficacy and safety of 400 μg sublingual misoprostol and 200 μg rectal misoprostol plus active management of the third stage of labour versus active management only to prevent postpartum haemorrhage. Subjects and methodsA total of 1400 women were randomly assigned to receive misoprostol plus active management (group I) or active management only (group II). The variables studied were incidence of postpartum haemorrhage, blood volume lost and need of additional uterotonics. ResultsIn group I there were 28/702 (4.0%) haemorrhages and in group II 50/698 (7.2%), P=.005; RR =.538; 95% CI for RR (0.335-0.866). In women having postpartum haemorrhage the lost blood volume was 981 ± 309 cc and 888 ± 326 cc. P=.225 in groups I and II, respectively.Additional uterotonics were needed in 33 women in group I (4.7%) vs. 54(7.7%) women in group II (P=.025). ConclusionsThe use of sublingual/rectal misoprostol plus active management appears to be useful for the prevention of postpartum haemorrhage.

Frequency of Electrocardiographic Recordings in Patients Presenting With Angina Pectoris (from the Investigation of National Coronary Disease Identification)

The appropriate progression of diagnostic testing for acute angina has been the topic of several recommendations by the American College of Cardiology and American Heart Association (ACC/AHA). We measured how frequently electrocardiography (ECG) is provided as the initial cardiac diagnostic test, as recommended for patients with new angina. Using an insurance database representing 2% of the U.S. adult population, we identified patients undergoing a new cardiac diagnostic process for angina. Rates of initial ECG were stratified by age, gender, co-morbid disease, and care setting. Of 4.4 million patients, 18,139 met the entry criteria by presenting with anginal symptoms for testing. A substantial portion (35%, 95% confidence interval [CI] 34% to 35%) did not receive the initial ECG recommended by expert guidelines. Patients treated in emergency departments received an initial ECG more frequently (91%, CI 90% to 92%) than patients tested in outpatient settings (61%, CI 60% to 62%; risk ratio [RR] 0.67, CI for RR 0.65 to 0.68) or in inpatient hospital settings (34%, CI 32% to 37%; RR 0.38, CI for RR 0.36 to 0.40). Slightly lower rates of initial ECG were observed in men (RR 0.93 vs women, CI for RR 0.91 to 0.95) and patients over 64 years (RR 0.93 vs younger patients, CI for RR 0.91 to 0.95). Total diagnostic costs averaged $954 when testing began with the recommended ECG versus $1,233 when testing did not. In conclusion, ECG is not universally obtained as the initial test for patients presenting with anginal symptoms despite evidence-based recommendations for such use. Clinicians should be aware that suboptimal use of ECG in certain settings may hinder investigations of heart disease.

Epidemiological investigation of a typhoid outbreak

Background: An outbreak of typhoid fever among school children of a school in military station in central India is reported here. It comprises of 98 students out of which 87 students were from one school. Methods: Detailed epidemiological case sheets were filled for cases and active case finding surveys were conducted among the school students during the period of study. It included 3313 students of the affected school. Result: Attack rate of the affected school was 2.62 percent (RR 13.38, 99 % CI of RR 10.8, 16.12). Blood samples were found to have Salmonella typhi in 5.43%. Eighty six blood samples (87.75%) were positive for Widal test. Sanitary survey revealed fecal contamination of water supply leading to the outbreak. Conclusion: We recommend having a sound vaccination programme for children, adequate chlorination of water supply and formation of local groups at school level to monitor water quality on a daily basis.