Nonalcoholic fatty liver disease (NAFLD) is prevalent and may affect cognitive function. We studied associations of NAFLD with risk of cognitive impairment. Secondarily we evaluated liver biomarkers ...(alanine aminotransferase (ALT), aspartate aminotransferase (AST), their ratio, and gamma-glutamyl transpeptidase).
In a prospective cohort study, the REasons for Geographic and Racial Differences in Stroke, among 30,239 black and white adults aged ≥45,495 cases of incident cognitive impairment were identified over 3.4 years follow up. Cognitive impairment was identified as new impairment in two of three cognitive tests administered every two years during follow up; word list learning and recall, and verbal fluency. 587 controls were selected from an age, race, sex-stratified sample of the cohort. The fatty liver index was used to define baseline NAFLD. Liver biomarkers were measured using baseline blood samples.
NAFLD at baseline was associated with a 2.01-fold increased risk of incident cognitive impairment in a minimally adjusted model (95% CI 1.42, 2.85). The association was largest in those aged 45-65 (p interaction by age = 0.03), with the risk 2.95-fold increased (95% CI 1.05, 8.34) adjusting for cardiovascular, stroke and metabolic risk factors. Liver biomarkers were not associated with cognitive impairment, except AST/ALT >2, with an adjusted OR 1.86 (95% CI 0.81, 4.25) that did not differ by age.
A laboratory-based estimate of NAFLD was associated with development of cognitive impairment, particularly in mid-life, with a tripling in risk. Given its high prevalence, NAFLD may be a major reversible determinant of cognitive health.
Liver disease, particularly non-alcoholic fatty liver disease (NAFLD), is a risk factor for cardiovascular disease, but little is known about its relationship with ischemic stroke.
In the Reasons for ...Geographic and Racial Differences in Stroke (REGARDS) cohort of 30,239 American black and white adults, we assessed baseline NAFLD as fatty liver index (FLI) >60, and assessed liver biomarkers aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (GGT), and the AST/ALT ratio and risk of incident ischemic stroke over 5.8 years using a case-cohort study design.
Considering 572 strokes and a 1,017-person cohort sample, NAFLD was inversely associated with stroke risk in men (HR: 0.50; 95% CI: 0.26, 0.96), as was being in the highest ALT quintile versus the lowest (HR: 0.39; 95% CI: 0.19, 0.78) and the highest versus lowest GGT quintile (HR: 0.45, 95% CI: 0.24, 0.85), but not in women. Conversely, FLI score above the 90th percentile was associated with increased stroke risk among women (HR: 2.26; 95% CI: 1.14-4.47), but not men. AST was not associated with stroke risk in either sex. AST/ALT ratio >2 was strongly associated with increased stroke risk in whites, but not blacks (HRs: 3.64; 95% CI: 1.42-9.35 and 0.97; 95% CI: 0.45-1.99, respectively; p for interaction = 0.03).
The relationships between NAFLD, liver biomarkers, and ischemic stroke are complex, and sex and race differences we observed require further study and confirmation.
We studied circulating interleukin (IL)-6, IL-8, and IL-10 concentrations and incident ischemic stroke risk in a biracial cohort, and determined if these cytokines mediated the racial disparity in ...stroke incidence affecting the black population.
The Reasons for Geographic and Racial Differences in Stroke study enrolled 30,237 black and white men and women age ≥45 in 2003-2007. We measured baseline IL-6, IL-8, and IL-10 in a case-cohort study of 557 participants with incident stroke over 5.4 years and 951 participants in a cohort sample.
IL-6, but not IL-8 or IL-10, was higher in cases compared to the cohort sample (mean 4.5 vs 3.7 ng/mL;
< 0.001). Only IL-6 was associated with stroke risk factors. Adjusting for age, sex, and race, the hazard ratio (HR; 95% confidence interval) for incident stroke for the highest vs lowest quartile of IL-6 was 2.4 (1.6-3.4). HRs for the highest vs lowest quartiles of IL-8 and IL-10 were 1.5 (1.0-2.1) and 1.4 (1.0-1.9), respectively. After additional adjustment for stroke risk factors, only higher IL-6 remained associated with stroke risk (HR 2.0; 1.2-3.1). Associations did not differ by race. Mediation analyses showed that IL-6 mediated the black-white disparity in stroke risk, but mediation was via IL-6 associations with stroke risk factors.
In this biracial population-based sample, IL-6 was strongly associated with risk of incident stroke and mediated the racial disparity in stroke via inflammatory effects of risk factors. Further study on the clinical utility of IL-6 measurement in stroke risk assessment would be helpful.
Background Kidney disease has been associated with venous thromboembolism (VTE) risk, but results conflict and there is little information regarding blacks. Study Design Prospective cohort study. ...Setting & Participants 30,239 black and white adults 45 years or older enrolled in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study 2003 to 2007. Predictors Estimated glomerular filtration rate (eGFR) using the combined creatinine–cystatin C (eGFRcr-cys ) equation and urinary albumin-creatinine ratio (ACR). Outcomes The primary outcome was adjudicated VTE, and secondary outcomes were provoked and unprovoked VTE, separately. Mortality was a competing-risk event. Results During 4.6 years of follow-up, 239 incident VTE events occurred over 124,624 person-years. Cause-specific HRs of VTE were calculated using proportional hazards regression adjusted for age, sex, race, region of residence, and body mass index. Adjusted VTE HRs for eGFRcr-cys of 60 to <90, 45 to <60, and <45 versus ≥90 mL/min/1.73 m2 were 1.28 (95% CI, 0.94-1.76), 1.30 (95% CI, 0.77-2.18), and 2.13 (95% CI, 1.21-3.76). Adjusted VTE HRs for ACR of 10 to <30, 30 to <300, and ≥300 versus <10 mg/g were 1.14 (95% CI, 0.84-1.56), 1.15 (95% CI, 0.79-1.69), and 0.64 (95% CI, 0.25-1.62). Associations were similar for provoked and unprovoked VTE. Limitations Single measurement of eGFR and ACR may have led to misclassification. Smaller numbers of events may have limited power. Conclusions There was an independent association of low eGFR (<45 vs ≥90 mL/min/1.73 m2 ) with VTE risk, but no association of ACR and VTE.
Electronic cigarette use can produce rapid and high levels of nicotine and thus could produce or maintain a physical dependence on nicotine. No experimental and limited observational studies have ...tested whether cessation of e-cigarettes is associated with withdrawal symptoms. To examine withdrawal from electronic cigarettes and compare it to that from tobacco cigarettes, we searched the US Population Assessment of Tobacco and Health Survey to locate successful and unsuccessful attempts to stop electronic or tobacco cigarettes. We examined electronic cigarette-only users, tobacco cigarette-only users and dual users. A minority of e-cigarette users who stopped/reduced e-cigarettes reported withdrawal symptoms but reported fewer symptoms than tobacco cigarette users who stopped/reduced tobacco cigarettes. E-cigarette withdrawal was not significantly greater in those who tried but were unable to stop e-cigarettes. In dual users, continued tobacco use appeared to reduce e-cigarette withdrawal but the opposite was not true. Given our small sample size and use of retrospective recall, an experimental test of e-cigarette abstinence is needed to better describe the severity of electronic cigarette withdrawal.
•Some 25% of e-cigarette users had withdrawal symptoms when they stopped e-cigarettes.•Stopping e-cigarette users produced less withdrawal than stopping tobacco cigarettes.•Some e-cigarette users continue to be physically-dependent on nicotine.
Background
During the COVID‐19 pandemic, many healthcare services moved to telehealth delivery for continuation of care. The Mini Mental Status Examination (MMSE) has been used for follow‐up ...assessment of disease progression and care planning after dementia diagnosis. Carotentuto et al. (2018) found no difference in MMSE scores when repeating a telehealth MMSE two weeks after a face‐to‐face visit. The purpose of this study was to determine if telehealth cognitive testing (MMSE) is a reliable alternative to traditional face‐to‐face testing when nurse practitioners are providing follow‐up care (every 6 months) for person with dementia and their families.
Methods
To evaluate MMSE testing administered via telehealth, a retrospective chart review of patients (N = 90) seen between April 2020 and December 2021 was conducted. Those fitting the inclusion criteria of at least two previous face‐to‐face MMSE assessments, and two MMSE telehealth assessments were analyzed (n = 45). Linear regression calculated the slope for each patient’s MMSE score per year to compare the face‐to‐face and telehealth rates of cognitive decline for each individual. A paired t‐test was used to compare MMSE slope for face‐to‐face and telehealth assessments.
Results
Although there was a larger decrease per year in MMSE score across telehealth assessments (during the pandemic) when compared to in‐person (‐2.7 vs ‐1.2, respectively), the difference in individual decline was not statistically significant (p = 0.10). There was also no significant difference between MMSE slope of decline in each of the two nurse practitioner providers for in‐person testing mean (p = 0.32), telehealth mean (p = 0.34) and difference in slopes (p = 0.27).
Conclusion
These preliminary findings indicate that administering the MMSE via telehealth does not result in scores that are markedly different from in‐person testing. Therefore, it is reasonable to use telehealth for follow‐up dementia care visits when an objective measure of cognitive decline is helpful to guide family caregiving. Telehealth may be a good alternative for patients and family who are unwilling or unable to travel to the clinic due to health concerns, poor weather, long travel time or agitation in a clinic setting, even when the pandemic has ended.
To analyze surgical site infections (SSIs) after infrainguinal bypass for standard dressings versus closed incision negative pressure wound therapy (ciNPWT) in the Society for Vascular Surgery's ...Vascular Quality Initiative (VQI).
We retrospectively analyzed SSI after infrainguinal bypass procedures in the VQI from December 2019 to December 2021 comparing ciNPWT and standard dressings. The primary outcome of any superficial or deep wound infection at 30 days was analyzed in a subset of procedures with 30-day follow-up data (cohort A, n = 1,575). Secondary outcomes including in-hospital SSI, return to the operating room (OR) for infection, and length of stay (LOS) were analyzed for all procedures (cohort B, n = 9,288). Outcomes were analyzed in propensity-matched cohorts.
Patients who received ciNPWT (n = 1,389) were more likely to be female (34% vs. 32%, P = 0.04) with a higher rate of smoking history (90% vs. 86%, P = 0.003), diabetes (54% vs. 50%, P = 0.007), obesity (34% vs. 26%, P < 0.001), prior peripheral vascular intervention (57% vs. 51%, P < 0.001), and to prosthetic conduit (55% vs. 48%, P < 0.001) compared to patients with standard dressings (n = 7,899). After propensity matching of cohort A (n = 1,256), the 30-day SSI rate was 4% (12/341) in the ciNPWT and 6% (54/896) in the standard dressing group (P = 0.07, 95% CI 0.03-1.06). In the propensity-matched in-hospital cohort B (n = 5,435), SSI was 3% (35/1,371) in the ciNPWT group and 2% (95/4,064) in the standard dressing group (P = 0.66). There was no difference in the rate of return to the OR for infection, 1% (36/4,064) vs. 1% (19/1,371) (P = 0.13) or LOS, 9.0 vs. 9.0 days (P = 0.86) for the standard versus ciNPWT groups.
In this analysis of the VQI registry, the use of ciNPWT after infrainguinal bypass did not result in a statistically significant decrease in 30-day SSI. We recommend that surgeons consider the use of ciNPWT as part of a bundled process of care for high risk rather than all patients, as it may reduce SSI after infrainguinal bypass.
Objective- Increased Lp(a) lipoprotein(a) is associated with coronary heart disease risk, but links with stroke are less consistent. Blacks have higher Lp(a) levels and stroke incidence than whites ...but have been underrepresented in studies. We hypothesized that Lp(a) is a risk factor for ischemic stroke and that risk differs by race. Approach and Results- REGARDS (Reasons for Geographic and Racial Differences in Stroke) recruited 30 239 black and white US adults aged ≥45 in 2003-2007 to study regional and racial differences in stroke mortality. We measured baseline Lp(a) by immunonephelometric assay in 572 cases of incident ischemic stroke and a 967-person cohort random sample. The hazard ratio of stroke by baseline Lp(a) was calculated using Cox proportional hazards models, stratified by race. Lp(a) was modeled in sex- and race-specific quartiles, given known differences in distributions by race and sex. Interactions were tested by including interaction terms in the proportional hazards models, with P<0.10 considered statistically significant. After adjustment for age, sex, and stroke risk factors, being in the fourth versus the first Lp(a) quartile was weakly associated with ischemic stroke overall, hazard ratio, 1.45 (95% CI, 0.96-2.19). In blacks, the hazard ratio was 1.96 (95% CI, 1.10-3.46), whereas in whites HR was 1.14 (95% CI, 0.64-2.04); P interaction=0.12. Lp(a) was lower in men than women, but associations with stroke in men and women were similar. Conclusions- We confirm that Lp(a) is a risk factor for ischemic stroke. Further research is needed to confirm the role of racial differences of the Lp(a) risk multiplier in ischemic stroke.
Background
Cholecystectomy is one of the most commonly performed general surgery procedures in the USA. It is most frequently performed for benign biliary disease such as biliary colic or ...cholecystitis; however, resected specimens are frequently sent for histopathological analysis due to the perceived risk of incidental gallbladder carcinoma (iGBC). The principle aim of this study is to review the pathology results from gallbladder specimens sent for routine pathology, determine the incidence of iGBC in our population, and determine whether surgeons need to send specimens for further analysis if no preoperative or intraoperative suspicion for malignancy is present.
Methods
We performed a large single-center case-controlled retrospective study of all gallbladder specimens sent for routine histopathological analysis between 2009 and 2014. The results were tabulated, including both common and rare findings. We then analyzed patient outcomes and survival for the case group of iGBC patients and determined value in life years (LY) gained per dollar spent on pathological screening.
Results
A total of 2153 pathology reports were reviewed. After exclusion criteria, a total of 1984 were included in data analysis. The incidence of iGBC was 0.25 % (95 % CI 0.08, 0.59), and dysplasia was 0.70 % (0.39, 1.20). The most common pathological findings included chronic cholecystitis in 89 % (87.4, 90.3) and cholelithiasis in 81 % (79.1, 82.6) of specimens. Total charges for pathological screening were $65,404 per LY to date; however, two patients have ongoing disease-free survival and this figure is expected to decrease.
Conclusions
The incidence of significant pathology necessitating change in clinical management is extremely low in our population. Despite this, the cost per LY gained from routine pathological analysis appears to be of sufficient value to continue with current practice. Alternatively, selective screening based on risk factors, intraoperative findings, and on-table examination of specimen may be a more cost-effective approach.
Objective Our objective was to analyze periprocedural and 1-year outcomes of peripheral endovascular intervention (PVI) for critical limb ischemia (CLI). Methods We reviewed 1244 patients undergoing ...1414 PVIs for CLI (rest pain, 29%; tissue loss, 71%) within the Vascular Study Group of New England (VSGNE) from January 2010 to December 2011. Overall survival (OS), amputation-free survival (AFS), and freedom from major amputation at 1 year were analyzed using the Kaplan-Meier method. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Results The number of arteries treated during each procedure were 1 (49%), 2 (35%), 3 (12%), and ≥4 (5%). Target arterial segments and TransAtlantic Inter-Society Consensus classifications were aortoiliac, 27% (A, 48%; B, 28%; C, 12%; and D, 12%); femoral-popliteal, 48% (A, 29%; B, 34%; C, 20%; and D, 17%); and infrapopliteal, 25% (A, 17%; B, 14%; C, 25%; D, 44%). Technical success was 92%. Complications included access site hematoma (5.0%), occlusion (0.3%), and distal embolization (2.4%). Mortality and major amputation rates were 2.8% and 2.2% at 30 days, respectively. Overall percutaneous or open reintervention rate was 8.0% during the first year. At 1-year, OS, AFS, and freedom from major amputation were 87%, 87%, and 94% for patients with rest pain and 80%, 71%, and 81% for patients with tissue loss. Independent predictors of reduced 1-year OS (C index = .74) included dialysis (HR, 3.8; 95% CI, 2.8-5.1; P < .01), emergency procedure (HR, 2.5; 95% CI, 1.0-6.2; P = .05), age >80 years (HR, 2.2; 95% CI, 1.7-2.8; P < .01), not living at home preoperatively (HR, 2.0; 95% CI, 1.4-2.8; P < .01), creatinine >1.8 mg/dL (HR, 1.9; 95% CI, 1.3-2.8; P < .01), congestive heart failure (HR, 1.7; 95% CI, 1.3-2.2; P < .01), and chronic β-blocker use (HR, 1.4; 95% CI, 1.0-1.9; P = .03), whereas independent preoperative ambulation (HR, 0.7; 95% CI, 0.6-0.9; P = .014) was protective. Independent predictors of major amputation (C index = .69) at 1 year included dialysis (HR, 2.7; 95% CI, 1.6-4.5; P < .01), tissue loss (HR, 2.0; 95% CI, 1.1-3.7; P = .02), prior major contralateral amputation (HR, 2.0; 95% CI, 1.1-3.5; P = .02), non-Caucasian race (HR, 1.7; 95% CI, 1.0-2.9; P = .045), and male gender (HR, 1.6; 95% CI, 1.1-2.6; P = .03), whereas smoking (HR, .60; 95% CI, 0.4-1.0; P = .042) was protective. Conclusions Survival and major amputation after PVI for CLI are associated with different patient characteristics. Dialysis dependence is a common predictor that portends especially poor outcomes. These data may facilitate efforts to improve patient selection and, after further validation, enable risk-adjusted outcome reporting for CLI patients undergoing PVI.
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