Vascular Comorbidities Research Articles

Abstract WP235: Risk of Arterial Ischemic Events After Non-Traumatic Subdural Hemorrhage

Introduction: To study the risk of arterial ischemic events after non-traumatic subdural hemorrhage (SDH). Methods: We performed a retrospective cohort study using inpatient and outpatient claims data from 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. The exposure was diagnosis of SDH. Our primary outcome was an arterial ischemic event defined as a composite of acute ischemic stroke and acute myocardial infarction (MI). Secondary outcomes were ischemic stroke alone and MI alone. We used validated ICD-9-CM diagnosis codes to identify our predictor and outcomes. We excluded patients who had an arterial ischemic event prior to SDH diagnosis. Using Cox regression and corresponding survival probabilities, adjusted for demographics and vascular comorbidities, we computed the hazard ratio (HR) in each 4-week interval after discharge for SDH. We performed secondary analyses stratified by strong indications for antithrombotic therapy (composite of atrial fibrillation, peripheral vascular disease, valvular heart disease and venous thromboembolism). Results: Among 1.7 million Medicare beneficiaries, 2,939 were diagnosed with SDH. Compared to patients without SDH, those with SDH were more often older, male, and had more vascular risk factors. In the 4 weeks after SDH, patients’ risk of an arterial ischemic event was substantially increased (HR, 4.2; 95% CI, 2.2-6.7). There was no association between SDH diagnosis and arterial ischemic event risk beyond 4 weeks. In secondary analysis, during the 4 weeks after SDH, patients’ risk of ischemic stroke was increased (HR, 5.6; 95% CI, 3.6-9.7) but not their risk of MI (HR, 0.8, 95% CI, 0.2-1.7). Patients with strong indications for antithrombotic therapy had similarly increased risks for arterial ischemic events as compared to patients in the primary analysis; patients without strong indications for antithrombotic did not demonstrate an increased risk for arterial ischemic events. Conclusions: Among Medicare beneficiaries, we found a heightened risk of arterial ischemic events, particularly ischemic stroke, in the four weeks after SDH. This increased risk may be driven by withholding of antithrombotic therapy after SDH diagnosis.

Strategies to prevent age-related cognitive decline

The increasing aging demographics never seen before is associated with the enormous challenge of dementia epidemics which urgently needs a paradigm shift in the approach to cognitive functions in health and disease. If on one hand the achievement or maintenance of a healthy lifestyle should be a medical priority, the early recognition of cognitive disturbances is mandatory. Cognitive impairment is not only associated with disability and lack of compliance and adherence, but also with dangerous geriatric syndromes such as instability, falls, and delirium. The evaluation of cognitive performance, particularly in older patients and especially in those hospitalized for other reasons, should be performed in all cases. While the National Institute of Aging and Alzheimer Association established new criteria for the diagnosis of Alzheimer's disease, the large majority of dementia cases are assigned to a multifactorial syndrome presenting as a long-lasting continuum from organ/function integrity to dementia. While the monoclonal antibody aducanumab is under careful evaluation for release on the market as the first curative drug, current anti-Alzheimer medication strategies remain symptomatic. In spite of the previous distinction between neurodegenerative and vascular forms of dementia, it is now accepted that control of vascular risk factors and comorbidities strongly affects the prevention of all types of cognitive impairment. The WHO has published in May 2019 an official guideline document for reducing dementia risk. The guidelines provide recommendations on the major modifiable lifestyle factors and chronic diseases. The best way to prevent cognitive impairment and its worsening include vascular risk control and a healthy diet including a balanced natural nutrition (without nutritional supplements for which scientific evidence is lacking), physical exercise (preferably aerobic), enough social participation, interaction and conviviality as well as cognitive exercise (focusing on general cognitive function, executive function and working memory) While the activation of all domains of lifestyle are critical for the achievement of the best preventive effects, these should be implemented 1) in a personalized, goal-oriented fashion (the so called tailored interventions) and 2) with the ultimate goal of maintaining the care of personal interests and functions along with quality of life and wellbeing.For an effective prevention of cognitive decline, resources from all domains of lifestyle (nutrition, exercise, rest, social participation, cognitive activity) should be used, however in a personalized way. The Comprehensive Geriatric Assessment (CGA), evaluating the physical, psychosocial and functional aspects of young-old, old-old and oldest-old persons, can be used to detect early cognitive impairment and factors associated with its course in order to modulate them.

Optic Disc Drusen Associated Anterior Ischemic Optic Neuropathy: Prevalence of Comorbidities and Vascular Risk Factors.

Nonarteritic anterior ischemic optic neuropathy (NA-AION) associated with optic disc drusen (ODD) is termed ODD-AION, where NA-AION with no evidence of ODD is simply termed NA-AION. Patients with ODD-AION have been found to be younger than those with NA-AION but with similar vascular risk factors. This study compares the known risk factors for NA-AION between a group with ODD-AION and a similarly aged group with NA-AION. A case-control study of 13 patients with ODD-AION and 14 patients with NA-AION diagnosed in the period 2008-2017. All patients underwent an interview designed to evaluate history of vascular risk factors and comorbidities and re-examination including enhanced depth imaging optical coherence tomography to confirm the presence or absence of ODD. No significant differences were found in demographic or clinical characteristics between the ODD-AION and the NA-AION group. Significantly more ODD-AION patients than NA-AION patients had no vascular risk factors (smoking, arterial hypertension, diabetes mellitus, and dyslipidemia) present (P = 0.047). Significantly fewer patients in the ODD-AION group were diagnosed with arterial hypertension or dyslipidemia than in the NA-AION group. In this cross-sectional study, the ODD-AION patients more often had no vascular risk factors as compared to NA-AION patients, which supports the hypothesis that ODD are an independent risk factor for AION.

Monocyte-derived extracellular vesicles upon treated by palmitate promote endothelial migration and monocytes attachment to endothelial cells

AimHigh circulating free fatty acid (FFA) concentration has a critical role in the development of obesity associated vascular comorbidities. Ample previous findings revealed that FFA, especially saturated, induce endothelial dysfunction throught multiple mechanisms (summarized as lipotoxicity). As a mediator that transfers information among cells, extracellular vesicles(EVs) participate in pathologic processes of many diseases, including angiocardiopathy, insulin resistance, autoimmunity disease. However, how lipotoxicity changed the proportion of EVs secreted from monocytes, furthermore, the effect of the EVs exerts on endothelial cells, haven’t been demonstrated. MethodIn our experience, differential ultracentrifugation was used to extract EVs from condition medium (CM) of THP-1 monocytes under given treatments. Then we co-incubated the EVs derived from palmitate-treated monocytes with HUVECs for 24 h, after which molecular and phenotypic assays were conducted. ResultPalmitate-treated monocytes EVs promote the production of adhesion associated proteins of endothelial cells, such as VCAM-1, ICAM-1. Meanwhile, palmitate-stimulation may play a promoter role in the pro-migration capacity of monocytes-EVs. In brief, EVs could be the new pathological junction between FFA and endothelial damage.

Sustained maternal smoking-associated changes in the physico-chemical properties of fetal RBC membranes might serve as early markers for vascular comorbidities

Maternal smoking-induced congenital heart and microvascular defects are closely associated with the impaired functioning of the in-utero feto-placental circulation system. Current groundbreaking facts revealed intimate crosstalk between circulating red blood cells (RBCs) and the vascular endothelium. Thus, RBCs have become the protagonists under varied pathological and adverse pro-oxidative cellular stress conditions. We isolated and screened fetal RBCs from the arterial cord blood of neonates, born to non-smoking (RBC-NS) and smoking mothers (RBC-S), assuming that parameters of fetal RBCs are blueprints of conditions experienced in-utero. Using atomic force microscopy and mass spectrometry-based shotgun lipidomics in the RBC-S population we revealed induced membrane stiffness, loss in intrinsic plastic activities and several abnormalities in their membrane-lipid composition, that could consequently result in perturbed hemodynamic flow movements. Altogether, these features are indicative of the outcome of neonatal microvascular complications and suggest unavailability for the potential rescue mechanism in cases of vascular endothelium impairment due to altered membrane integrity and rheological properties.

Relationship Between Cognitive Dysfunction and Systemic Metabolic Disorders in Elderly: Dementia Might be a Systematic Disease.

Vascular cognitive impairment (VCI) plays an important role in dementia in elderly people, and refers to the contribution of vascular pathology to the entire spectrum of cognitive disorders, ranging from mild cognitive impairment to severe dementia, as well as the pathological spectrum, from 'pure' Alzheimer disease through degrees of vascular comorbidity to 'pure' vascular dementia. In the present study, we investigated the relationship between cognitive dysfunction and systemic metabolic disorders, by employing deep learning (DL). We studied 202 patients (73.4±13.0years), 94.6% of whom were undergoing treatment for lifestyle diseases, and 68.8% of whom had a history of cerebrovascular disorder. We evaluated cognitive dysfunction by performing a Mini Mental State Examination (MMSE). We performed general blood examination, including Complete Blood Count and Basic Metabolic Panel, and measured cerebral blood oxygenation in the prefrontal cortex (PFC) using time-resolved near infrared spectroscopy (TNIRS). We then used deep neural networks to assess the MMSE scores of the subjects based on the TNIRS parameters and the blood examination data, independently. Next, we compared predicted MMSE scores based on the TNIRS and the blood examination. There was a significant positive correlation between the TNIRS parameters and the blood examination data (r=0.6, p<0.01). These observations suggest that cognitive dysfunction in patients with VCI may be caused by combinations of systemic metabolic disorders such as energy and oxygen metabolisms and cerebral circulatory disturbance due to arteriosclerosis resulting from lifestyle-related diseases.

Favorable preservation of erectile function after prostate brachytherapy for localized prostate cancer

PurposeWe analyzed the rate of preserved potency after prostate brachytherapy (PB) with radioactive seeds and the impact of patient comorbidities on post-PB erectile dysfunction (ED). MethodsWe included 627 patients who were assessed for pre- and postimplant potency between 2005 and 2017. Assessment was based on the Common Terminology Criteria for Adverse Events Scale (CTCAEs). Logistic regression models were used to assess clinical predictors of preserved potency after PB defined as having sufficient erections for sexual activity with or without the need of oral pharmacologic assistance. Covariates included age, diabetes (DM), hypertension (HTN), dyslipidemia (DLP), coronary artery disease (CAD), International Prostate Symptom Score (IPSS), prostate volume, and Cancer of the Prostate Risk Assessments (CAPRA) score. Patients on androgen deprivation therapy or using five alpha reductase inhibitors were excluded from analyses. ResultsPost-PB potency was assessed at an average of 6 months (n = 627), 1 year (n = 538), 2 years (=440), 4 years (n = 272), and 5 years (n = 124). At 2 and 5 years, post-PB potency was preserved in 87% and 84% of patients, respectively. When adjusting for all available covariates, advanced age, pre-PB potency, and the presence of vascular comorbidities (HTN, DM, and DLP) were all predictors of potency at 2 years after PB (all p < 0.01). When performing a sensitivity analysis for vascular comorbidities, the presence of DM had the strongest impact on ED than either HTN or DLP (p < 0.01). ConclusionMore than 84% of patients had preserved potency 5 years after PB. Advanced age, pre-PB potency, and vascular comorbidities had a statistically significant impact on potency after PB.

Negative predictors of shunt surgery outcome in normal pressure hydrocephalus.

The prevalence of idiopathic normal pressure hydrocephalus (iNPH) and vascular comorbidity increases with age. It has not been clarified if high age and vascular disease are negative predictors of shunt surgery outcome in patients with iNPH. The aim of this study was to investigate the impact of high age and vascular comorbidity on outcome after shunt surgery in patients with iNPH. All 332 patients with iNPH who were treated with shunts between 2011 and 2015 at a single centre were consecutively included. Hellström iNPH scale, without the neuropsychological tests, was calculated preoperatively and at follow-up 12months after shunt surgery. Outcome was defined as the difference between the post-operative and preoperative iNPH scale scores. A multivariable model was used to investigate the predictive effects of age and vascular comorbidity on shunt surgery outcome. In a multivariable analysis of covariance (ANCOVA) with post-operative outcome as the dependent variable, increasing age (years, B=-0.63, P<.001) and history of ischaemic stroke (B=-10.06, P=.0038) were negative predictors of shunt surgery outcome after controlling for waiting time for surgery, symptom severity at preoperative control, presence of diabetes mellitus, hypertension, hyperlipidaemia, history of myocardial infarction, duration of symptoms and shunt complications. High age and established cerebrovascular disease are associated with less favourable outcome after shunt surgery in patients with iNPH.

O94 GASTRIC CONDUIT NECROSIS AFTER ESOPHAGECTOMY: RISK PREDICTION, MANAGEMENT AND OUTCOMES

Abstract Background Acute gastric conduit necrosis (AGCN) is a serious early complication of esophagectomy that can result in loss of the gastric conduit. The reported incidence is relatively low: 0.5-3.2%. Literature is thus scarce. However, vascular comorbidity has been shown to be a risk factor. This study aimed to assess the arterial calcification scores, clinical presentation, management, and outcome of patients who suffered from AGCN following esophagectomy in a high volume centre for esophageal cancer surgery. Methods Patients who underwent esophagectomy for esophageal cancer were selected (Jan-2011 till Feb-2019) from a prospectively maintained single-centre database that contains the patient characteristics, treatment details, and postoperative outcomes of all patients undergoing esophagogastric surgery. For the AGCN cases, additional information regarding their clinical course was retrieved from the electronic patient files. Arterial calcification scores were established by measuring calcifications at 4 arterial locations on preoperative computed tomography (CT) scans. Results From a total of 466 esophagectomies performed in the inclusion period, AGCN occurred in 8 cases (1.7%). Resection of the gastric conduit was required in 5 of these patients, of whom 3 patients had a fatal outcome. The other patients were successfully treated by conservative treatment involving a nil by mouth regimen (n=2) or a self-expanding metal stent (n=1). There was a high prevalence of supra-aortic (75%) and thoracic (87.5%) calcifications in the patients suffering from AGCN. Conclusion AGCN is a rare but serious complication following esophagectomy, with a high mortality. Patients with generalized vascular disease may be at particular risk of developing this complication.

Impact of cognitive impairment and systemic vascular comorbidities on risk of all-cause and cardiovascular mortality: National Health and Nutrition Examination Survey 1999 to 2002

ObjectivesTo evaluate impacts of cognitive impairment and systemic vascular comorbidities on hazards of all-cause and cardiovascular mortality in a representative United States population. MethodsSubjects aged ≥60 years from two waves of National Health and Nutrition Examination Survey were analyzed. Cognitive function was evaluated by Digit Symbol Substitution Test. Systemic vascular comorbidities included diabetes mellitus (DM), chronic kidney disease (CKD), high blood pressure (HBP) and hypotension. Hazards of all-cause and cardiovascular mortality were estimated with Cox proportional hazard regression models. ResultsAfter a median follow-up of 9.83 years, 937 (35.6%) and 247 (8.6%) deaths caused by all causes and cardiovascular diseases, respectively. After adjusting for confounders, cognitive impairment predicted a higher risk of all-cause mortality (Hazard Ratios (HR), 2.00; 95% confidence interval (CI), 1.62–2.46) and cardiovascular mortality (HR, 1.79; 95% CI, 1.27–2.53). Risk of all-cause mortality was further increased among those with cognitive impairment concomitant with DM (HR, 2.24; 95% CI, 1.61–3.13), CKD (HR, 2.56; 95% CI, 1.77–3.67), HBP (HR, 2.57; 95% CI, 1.73–3.84) or hypotension (HR, 2.38; 95% CI, 1.78–3.18). Co-presence of cognitive impairment with DM (HR, 2.30; 95% CI, 1.25–4.26), CKD (HR, 2.56; 95% CI, 1.35–4.88), HBP (HR, 4.65; 95% CI, 2.28–9.46) or hypotension (HR, 2.69; 95% CI, 1.67–4.31) also posed a significant higher risk of cardiovascular mortality than participants with neither condition. InterpretationCognitive impairment concomitant with other systemic vascular comorbidities predicted further increased risks of mortality. More extensive assessments and management of cognitive function and systemic vascular comorbidities are warranted.

Quality Improvement Initiative: Improving Time to First Dose in a Sickle Cell Infusion Center

Sickle cell Disease (SCD) is the most common inherited blood disorder in the US and is associated with significant morbidity and mortality. Vaso-occlusive crisis (VOC) is a frequent complication of SCD and the most common reason that patients seek medical care. The National Heart and Blood Lung Institute (NHBLI) guidelines recommend supportive care for acute VOC, which includes rapid assessment, hydration, and initiation of analgesic therapy within 60 minutes of registration. After moving to a new location, the Johns Hopkins Sickle Cell Infusion Center (SCIC) was found to have an increase in time to first dose (TTFD). We describe our experience with implementing a new intervention of audit and feedback to decrease our TTFD. As a second objective, we examine whether TTFD of parenteral medication within (≤) 60 minutes of arrival impacts important clinical outcomes of patient-reported pain, acute care utilization, and disposition after a SCIC visit. Methods: We implemented the audit and feedback intervention in October 2018 at the SCIC. We created a report with the help of the electronic medical record to calculate the TTFD, measured from time of registration to time of first parenteral dose of analgesic medication. TTFD was subdivided into time spent in waiting room, time spent with provider, and time from medication order to administration, allowing us to provide detailed feedback to medical staff involved in these specific processes. This report was generated weekly and results were shared with medical staff and feedback requested. Initial and final pain scores, acute care utilization (acute return visits within 7 days), and SCIC visit disposition were collected. Univariate analysis and logistic regression were performed for TTFD and clinical outcomes. Results: We analyzed data from 1454 unique weekday visits for patient with all SCD genotypes from January 2017 to June 2019, excluding emergency department (ED) transfers. The total number of acute visits for VOC were 647, 570, and 237 respectively for 2017, 2018, and 2019. Of the acute visits, 81.6% were discharged home, 14.1% were transferred to the ED, and 4.0% were admitted. After implementing the audit and feedback method in 2018, we found a significant decrease in the mean TTFD from 75 ± 38 minutes in 2018 to 58 ± 31 minutes in 2019 (Figure 1; p=0.0001). Furthermore, the percentage of acute visits achieving a TTFD ≤ 60 minutes increased annually (28.7%, 38.9%, and 68.7%, respectively). In assessing patient outcomes, for visits with TTFD ≤ 60 minutes the mean discharge pain score was lower (6.05 ± 2.00) than if TTFD was &amp;gt; 60 minutes (6.38 ± 1.93; p = 0.01), despite similar initial reported pain scores and controlling for the visit year. The number of acute return visits within 7 days was lower if TTFD was ≤ 60 minutes compared to &amp;gt; 60 minutes (0.30 ± 0.46 vs 0.37 ± 0.48; p = 0.006), however this difference did not remain statistically significant in multivariate analysis after controlling for year of visit. Surprisingly, the likelihood that a visit would end with patient being discharged home SCIC was higher for those with TTFD &amp;gt; 60 minutes( OR 1.4, CI 1.07-1.88). Limitations: Our TTFD model did not take into account potential confounders such as nurse to patient ratio, annual clinic policy changes, presence of central vascular access, patient comorbidities, and individual patient utilization behavior. Conclusion: Audit and feedback was an effective method to reduce the TTFD. Pain at discharge was lower for visits with TTFD ≤ 60 minutes. However, acute care utilization within 7 days of the visit was unchanged based on the TTFD. Further evaluation to better understand patient characteristics that might impact the likelihood of admission after a visit to the SCIC and evaluate the association between longer waits for medication and a decrease in risk of admission is planned. Disclosures Lanzkron: Pfizer: Research Funding; Global Blood Therapeutics: Research Funding; Ironwood: Research Funding; HRSA: Research Funding; NIH: Research Funding; PCORI: Research Funding.

Opportunities and Limitations of Vascular Risk Factor Models in Studying Plasticity-Promoting and Restorative Ischemic Stroke Therapies.

Major efforts are currently made promoting neuronal plasticity and brain remodeling in the postacute stroke phase. Experimental studies evaluating new stroke therapies are mostly performed in rodents, which compared to humans exhibit a short lifespan. These studies widely employ young, otherwise healthy, rodents that lack the vascular risk factors and comorbidities of stroke patients. These risk factors compromise postischemic neurological recovery and brain plasticity and in several contexts reduce the brain responsiveness to recovery-inducing plasticity-promoting treatments. By examining risk factor models, which have hitherto been used for studying experimentally induced ischemic stroke, this review outlines the possibilities and limitations of risk factor models in the evaluation of plasticity-promoting and restorative stroke treatments.

Neuroimaging Characteristic of Structural Disorders of the Brain and Cerebrospinal Fluid Spaces in Patients with Chronic Cerebral Ischemia

The objective: to evaluate the neuroimaging markers of structural disorders of the brain and cerebrospinal fluid spaces in patients with chronic cerebral ischemia (CHEM) on the background of multifocal atherosclerosis.Materials and methods. The study enrolled 137 patients aged 40 to 84 years with chemotherapy with multifocal atherosclerosis. Patients were divided into three clinical groups depending on the localization of vascular pool lesions with stenosing atherosclerosis. Patients underwent qualitative and quantitative assessment of focal and diffuse changes in the substance of the brain and cerebrospinal fluid spaces.Results. According to the frequency of detection among structural changes in the brain in patients with different variants of the combination of vascular pools affected by atherosclerosis, mild leukoaraiosis (61.3% from 97.1%) and mixed cerebral atrophy (74.5%) prevailed. Lacunar focal changes in CHEM were found in half of the cases (51.8%), including in the clinical group I in 36.7% of cases, in the second group in 56.3%, in the III group in 55.0 % Single lacunar foci in the general group of patients prevailed over numerous 2.7 times (37.9% versus 13.9%; p&lt;0.001). More often, lacunar foci were territorially cortical (in 24.1% of cases) than subcortical (in 2.9% of cases; p &lt;0.001). Most patients with CHM have found a combination of several MR markers of structural brain damage.Conclusion. In patients of all age groups with chronic cerebral ischemia (CHEM), structural brain lesions were established based on the determination of various MR markers: white matter hypertension (leukoaraiosis – 97.1%), cerebral atrophy (74.4%), lacunar infarction (51, 8%), territorial postinfarction foci (56.2%). The multifocal nature of vascular lesion, comorbidity, and multifactoriality affect the heterogeneity and severity of structural brain disorders that determine the course of chemotherapy.

Is Benzodiazepine Use Associated With the Risk of Dementia and Cognitive Impairment-Not Dementia in Older Persons? The Canadian Study of Health and Aging.

Background: The use of benzodiazepines in relation to cognitive decline remains an area of controversy in aging populations. Objective: This study aims to evaluate the risk of cognitive impairment-not dementia (CIND), Alzheimer disease (AD), and all-cause dementia with benzodiazepine use. The effect modification by sex was also investigated. Methods: Data come from the Canadian Study of Health and Aging, a 10-year multicentric study involving 10 263 participants randomly selected, 65 years and older, living in the community and in institutions. Current exposure to benzodiazepines was assessed in a face-to-face interview or self-reported in a questionnaire. Cox proportional hazard regression models, using age as time scale, were conducted to estimate hazard ratios, with adjustment for sex, education, smoking, alcohol intake, depression, physical activity, nonsteroidal anti-inflammatory drug use, and vascular comorbidities. Results: Data sets included 5281 participants for dementia as the outcome, 5015 for AD, and 4187 for CIND. Compared with nonusers, current use of benzodiazepines was associated with an increased risk of CIND (hazard ratio = 1.36; 95% CI = 1.08-1.72) in the simplest model. Results remained similar in the fully adjusted model (hazard ratio = 1.32; 95% CI = 1.04-1.68). There was no association between benzodiazepine use and the risk of dementia or AD. All these effects were similar between men and women. Conclusion and Relevance: Benzodiazepine use in older people from the general population is related to subsequent occurrence of cognitive dysfunction but not implicated in the pathogenesis of dementia or AD. Caution should be exercised when prescribing benzodiazepines to preserve global cognitive function.

P3784Impact of progressively impaired renal function on major adverse outcomes in European patients with atrial fibrillation: a report from the ESC EORP-AF long-term general registry

Abstract Background Renal function is an important predictor of major adverse outcomes in the general population. In the setting of atrial fibrillation (AF), renal dysfunction may act both as a risk factor and a proxy of vascular risk factors and comorbidities. Methods We analyzed the association of renal function, as estimated glomerular filtration rate (eGFR) using the CKD-EPI formula, with 1-year outcomes in a “real-world” cohort of European AF patients from the EORP-AF Long-Term General Registry. Results 7725 were available for this analysis. Of these, 1294 (16.7%) had normal renal function (≥90 mL/min/1.73 m2), 3848 (49.8%) mildly reduced renal function (60–89 mL/min/1.73 m2), 2311 (29.9%) moderately reduced renal function (30–59 mL/min/1.73 m2) and 272 (3.5%) severely reduced renal function (&lt;30 mL/min/1.73 m2). CHA2DS2-VASc and HAS-BLED scores values increased across eGFR strata (p&lt;0.0001). Among patients qualifying for oral anticoagulant (OAC) therapy, those with severely impaired renal function were less often prescribed with any OAC (79.8%, p&lt;0.0001), more likely with vitamin K antagonist (62.9%) than non-vitamin K antagonist oral anticoagulants (16.9%) (p&lt;0.0001). At 1-year follow-up the rates of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death progressively increased with worsening renal function, up to 20.7% in patients with severe dysfunction (p&lt;0.0001). Rates of CV death and all-cause death were higher in severe renal dysfunction (16.9% and 21.3%; p&lt;0.0001). Cox regression analysis (adjusted for known predictors) showed that eGFR &lt;30 mL/min/1.73 m2, compared to normal renal function was associated with an increased risk of all the adverse outcomes (Table). eGFR decrease by 10 mL/min/1.73 m2 was associated with increased risks (Table). Any TE/ACS/CV Death CV Death All-Cause Death mL/min/1.73 m2 HR (95% CI) HR (95% CI) HR (95% CI) eGFR ≥90 (ref.) – – – eGFR 60–89 0.99 (0.67–1.46) 0.81 (0.44–1.51) 0.74 (0.47–1.19) eGFR 30–50 1.12 (0.74–1.69) 1.00 (0.53–1.89) 0.95 (0.59–1.54) eGFR &lt;30 2.47 (1.52–3.99) 2.73 (1.36–5.49) 2.16 (1.25–3.72) eGFR (by 10 mL/min/1.73 m2 decrease) 1.11 (1.05–1.17) 1.18 (1.10–1.27) 1.11 (1.03–1.18) ACS = Acute coronary syndrome; CI = Confidence interval; CV = Cardiovascular; eGFR = estimated Glomerular Filtration Rate; HR = Hazard ratio; TE = Thromboembolic event. Conclusions In AF patients, impaired renal function at baseline is associated with a progressive increase in the risk of major adverse outcomes during follow up. Severe renal dysfunction is an independent predictor of all the adverse outcomes.

Negative pressure wound therapy in the management of complex lower limb wounds: a case series highlighting outpatient care with small single-use devices

Background: Traditionally, the treatment of exposed tendon has required vascularised tissue coverage, usually with complex surgical intervention. The introduction of negative pressure wound therapy (NPWT) has challenged this traditional reconstructive concept. Unfortunately, standard NPWT units are usually bulky, noisy and curtail the mobility and lifestyle of patients. The introduction of small, modern, lightweight, portable, single-use NPWT units have therefore revitalised the use of NPWT and provided a solution to the many problems encountered with the larger devices. Case series: This study highlights three cases of patients with complex lower limb wounds with tendon exposure who were successfully treated with single-use NPWT in an outpatient setting. The median time for complete wound granulation was 5–10 weeks. Minor sharp debridement of wounds was required to encourage granulation tissue formation and this was well tolerated in the outpatient setting. Conclusion: Portable NPWT units provide an alternative to surgical reconstruction in patients with lower limb wounds with exposed tendon. These devices can be utilised in a purely outpatient setting, thus avoid long-term hospitalisation. Older patients with high anaesthesia risk or who lack alternative reconstructive options due to vascular co-morbidities are the most appropriate candidates for this treatment option.

Use of estimated glomerular filtration rate to predict incident chronic kidney disease in patients at risk of cardiovascular disease: a retrospective study

BackgroundPatients with cardiovascular disease are at an increased risk of chronic kidney disease (CKD). However, data on incident CKD in patients with multiple vascular comorbidities are insufficient. In this study, we identified the predictors of CKD stages 3–5 in patients at risk of cardiovascular disease and used their estimated glomerular filtration rate (eGFR) to construct a nomogram to predict the 5-year risk of incident CKD.MethodsAmbulatory data on 622 adults with preserved kidney function and one or more cardiovascular disease risk factors who attended outpatient clinics at a tertiary care hospital in Al-Ain, United Arab Emirates were obtained retrospectively. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation and assessed every 3 months from baseline to December 12, 2017. Fine and Gray competing risk regression model was used to identify the independent variables and construct a nomogram to predict incident CKD at 5 years, which is defined as eGFR < 60 mL/min/1.73 m2 for ≥3 months. Time-dependent area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the model. Calibration curves were applied to determine the calibration ability and adjusted for the competing risk of death. Internal validation of predictive accuracy was performed using K-fold cross-validation.ResultsOf the 622 patients, 71 had newly developed CKD stages 3–5 over a median follow-up of 96 months (interquartile range, 86–103 months). Baseline eGFR, hemoglobin A1c, total cholesterol, and history of diabetes mellitus were identified as significant predictors of CKD stages 3–5. The nomogram had good discrimination in predicting the disease stages, with a time-dependent AUC of 0.918 (95% confidence interval, 0.846–0.964) at 5 years, after internal validation by cross-validation.ConclusionsThis study demonstrated that incident CKD could be predicted with a simple and practical nomogram in patients at risk of cardiovascular disease and with preserved kidney function, which in turn could help clinicians make more informed decisions for CKD management in these patients.

Retinal vascular fractal dimension in bipolar disorder and schizophrenia

BackgroundBipolar disorder (BD) and schizophrenia (SCZ), are associated with greater vascular co-morbidities and adverse vascular events. Owing to shared developmental origins and morphology, retinal vasculature is a proxy assessment measure of the cerebral vasculature. Although retinal vascular fractal dimension (Df), a measure of vascular geometry and complexity of branching, has been shown to be directly associated with cerebrovascular pathology, it has not been examined in SCZ and BD. MethodsWe studied 277 participants (92 healthy volunteers, 98 SCZ, and 87 BD) from 18 to 50 years of age. Images were acquired by trained personnel using a non-mydriatic fundus camera and the retinal vascular Df was calculated by the box-counting method using an automated algorithm. The average Df across the left and right eyes were calculated. ResultsBoth SCZ and BD had significantly increased Df compared to HV despite controlling for possible confounding factors. However, there was no significant difference between SCZ and BD. These findings suggest abnormal retinal vascular Df in psychoses. LimitationsThe study design was cross-sectional, and patients were on medications. Confound of lifestyle factors such as diet and exercise, if any, was not controlled. Sub-group analysis between BD-I and BD-II was not performed in view of the small sample. ConclusionsConsidering the easy accessibility, affordability, and non-invasive nature of the examination, retinal vascular Df could serve as a surrogate marker for cerebral vascular abnormality and could potentially identify BD and SCZ patients at risk of developing adverse vascular events.

Vascular Mild Cognitive Impairment: Identifying Disease in Community-Dwelling Older Adults, Reducing Risk Factors, and Providing Support. The Osaki-Tajiri and Kurihara Projects.

Vascular mild cognitive impairment (MCI) is a critical disease. Its prognosis includes not only onset of vascular dementia, but also death by cardiovascular disease. The vascular risk factors for vascular MCI are treatable, and appropriate treatment can prevent or delay the progression to dementia. Therefore, this group is an excellent candidate for secondary prevention. However, community-dwelling older adults with vascular MCI are often undetected and are not clinically identified until they develop frank dementia. Furthermore, older adults with undetected vascular MCI often have decreased ability to follow their medication regimens and this poor medication adherence worsens their vascular comorbidities. This vicious cycle needs to be prevented through community-based interventions. There is evidence that treatment of hypertension or diabetes mellitus could lead to a reduced incidence of vascular MCI and dementia. In this review article, we first explain the background and etiology of vascular MCI. We then summarize phenotype of subcortical vascular dementia which is often unrecognized or “hidden” in the community. Then we introduce the Osaki-Tajiri and Kurihara Projects which have been conducted in Northern Japan, as an example of prevention projects aimed to identify early-stage vascular MCI in the community, reduce the risk factors and facilitate their treatment. Early identification of vascular MCI in the community could lead to a large reduction in the dementia burden worldwide. The outreach efforts presented here could be useful in developing secondary prevention strategies targeted to vascular MCI.

Listeria monocytogenes-associated endovascular infections: A study of 71 consecutive cases

Listeria monocytogenes-associated endovascular infections are not well characterized. Retrospective study of 71 culture-proven cases reported to the French National Reference Center for Listeria from 1993 to 2018. Seventy-one cases were identified: 42 with vascular aneurysms/prosthetic infections, 27 with endocarditis, 2 with both. Fifty-eight were men (82%); median age was 75 years [46-92]; 93% reported co-morbidities (66/71), including 50% with immunosuppressive conditions. Vascular infections consisted of infected aneurysms (68%) or prosthetic graft infections (32%); vascular rupture was reported in 25/42 (60%). Tissue samples grew L. monocytogenes in 98% (43/44) and blood cultures in 64% (27/42). Endocarditis cases involved prosthetic or native valves or intracardiac devices in respectively 62% (18/29), 28% (8/29) and 10% (3/29). Infected valves were aortic (62%, 16/26), mitral (31%, 8/26) or both (8%, 2/26); 38% patients required surgery; 45% displayed heart failure; 17% had concomitant neurolisteriosis. In-hospital mortality in vascular infections was 12% (5/42) and 41% (12/29) for Lm-associated endocarditis. Endovascular listeriosis is a rare but severe infection. It manifests as vascular infections and endocarditis, mostly in older patients with vascular or cardiac valve prosthetic devices and co-morbidities. Mortality in Lm-associated endocarditis is twice higher than with other pathogens, requiring prompt recognition and treatment.