Robert J. F. Laheij

The neutrophil-lymphocyte count ratio in patients with community-acquired pneumonia.

Study Objective The neutrophil-lymphocyte count ratio (NLCR) has been identified as a predictor of bacteremia in medical emergencies. The aim of this study was to investigate the value of the NLCR in patients with community-acquired pneumonia (CAP). Methods and Results Consecutive adult patients were prospectively studied. Pneumonia severity (CURB-65 score), clinical characteristics, complications and outcomes were related to the NLCR and compared with C-reactive protein (CRP), neutrophil count, white blood cell (WBC) count. The study cohort consisted of 395 patients diagnosed with CAP. The mean age of the patients was 63.4±16.0 years. 87.6% (346/395) of the patients required hospital admission, 7.8% (31/395) patients were admitted to the Intensive Care Unit (ICU) and 5.8% (23/395) patients of the study cohort died. The NLCR was increased in all patients, predicted adverse medical outcome and consistently increased as the CURB-65 score advanced. NLCR levels (mean ± SD) were significantly higher in non-survivors (23.3±16.8) than in survivors (13.0±11.4). The receiver-operating characteristic (ROC) curve for NLCR predicting mortality showed an area under the curve (AUC) of 0.701. This was better than the AUC for the neutrophil count, WBC count, lymphocyte count and CRP level (0.681, 0.672, 0.630 and 0.565, respectively). Conclusion Admission NLCR at the emergency department predicts severity and outcome of CAP with a higher prognostic accuracy as compared with traditional infection markers.

Statin use is associated with reduced all-cause mortality after endovascular abdominal aortic aneurysm repair.

It has been shown that preoperative statin therapy reduces all-cause and cardiovascular mortality in patients undergoing major noncardiac vascular surgery. In this report, we investigated the influence of statin use on early and late outcome following endovascular abdominal aortic aneurysm repair (EVAR). The study population, consisting of patients collated in the EUROSTAR registry, was stratified in two groups according to statin use. Baseline characteristics between the two groups were compared by chi-square and Wilcoxon rank sum tests for discrete and continuous variables. The effects of statin use on outcomes after EVAR were analyzed by multivariate regression models. Of the 5,892 patients enrolled in the EUROSTAR registry, 731 (12.4%) patients used statins for hyperlipidemia. Statin users were younger, were more obese, and had a higher prevalence of diabetes, cardiovascular disease, and hypertension. After 5 years of follow-up, the cumulative survival rate was 77% for nonusers of statin versus 81% for statin users (p = .005). After adjustment for age and other risk factors, statin use was still an independent predictor of improved survival (p = .03). Our results revealed that statin prescription was more frequent in younger patients. However, when adjusted for age and medical risk factors, the use of statin in patients who underwent EVAR was still independently associated with reduced overall mortality.

Outcome after endovascular abdominal aortic aneurysm repair: a meta-analysis.

Purpose: To determine the frequencies of complications and risk factors for complications following endovascular abdominal aortic aneurysm (AAA) repair (EVAR). Methods: Thirty-nine articles published between October 1995 and October 1999 in English, German, French, or Dutch were identified in electronic databases. All articles reported perioperative (30-day) complications on 2387 patients, while postoperative complications (>30 days) were reported on 1645 patients in 30 of 39 studies. Data were pooled and subjected to multivariable logistic regression analysis to identify risk factors for death, endoleak, rupture, conversion, and local and systemic complications. Effects of risk factors were expressed as odds ratios (OR) with 95% confidence interval (CI). Results: Mean follow-up was 13.9 months (range 4–29). The perioperative death rate (3.7%) was lower than postoperative mortality (5.0% per annum). The risks for both endoleak (13.1%) and conversion (5.0%) were higher in the perioperative period than postoperatively (5.4% and 1.4% per annum, respectively). Independent risk factors for perioperative complications were: general anesthesia (death: OR = 5.1, 95% CI 1.9–13.3); EVT graft (endoleak: OR = 3.0, 95% CI 1.3–7.0); female sex (rupture: OR = 2.8, 95% CI 1.4–5.8); hypertension (conversion: OR = 0.03, 95% CI 0.0–0.3); age >70 years (conversion: OR = 3.5, 95% CI 1.3–9.2); and team experience >30 patients (conversion: OR = 3.0, 95% CI 1.2–7.6). Independent risk factors for postoperative complications were: predischarge examination (death: OR = 0.2, 95% CI 0.0–0.7); follow-up 30 days after operation (death: OR = 0.3, 95% CI 0.1–1.0); and female sex (rupture: OR = 1.4, 95% CI 0.5–4.4; conversion: OR 6.8, 95% CI 2.0–23.4; and systemic complications: OR = 2.9, 95% CI 1.1–7.5). Conclusions: The risk of complications after EVAR is high, supporting the cautious use of EVAR. Both patient characteristics and procedural variables were independent risk factors for complications. To avoid the limitations of this study, the results of randomized clinical trials must determine if EVAR offers a safe and durable alternative to open AAA repair.

Health-Related Quality of Life Outcomes Following Elective Open or Endovascular AAA Repair: A Randomized Controlled Trial

Purpose: To assess health-related quality of life outcomes after endovascular versus open abdominal aortic aneurysm repair. Methods: Participants were randomly assigned to receive either endovascular or open abdominal aortic aneurysm (AAA) surgery according to a rate of 3 endovascular patients to 1 with open repair. Data on patient characteristics, operative aspects, and procedural and device-related complications were compiled at a single center. Health-related quality of life was assessed before treatment and 1 and 3 months following operation using the Medical Outcomes Study Short-Form 36-item Health Survey (SF-36) and the EuroQol questionnaire. Results: Between 1996 and 1999, 57 patients (54 men; mean age 69 years, range 52–82) underwent endovascular and 19 patients (16 men; mean age 68 years, range 52–81) underwent open AAA repairs. Preoperatively, comparable scores were recorded in both treatment groups. One month after operation, patients of both groups scored significantly lower on the SF-36 domains of Role Limitations due to physical problems and Pain compared to preoperative scores. Three months after operation, both groups had scores in all domains comparable to preoperative levels of functioning. There was a significant benefit for the endovascular group 1 month after operation in the SF-36 domains of Physical Functioning, Role Limitations due to physical problems, Vitality, and Pain; their score on the EuroQol Usual Activities item was also significantly better. After 3 months, there were no longer differences between groups. Conclusions: Short-term health-related quality of life benefits were found after endovascular repair compared with standard open surgery.

Frequency, Predictive Factors, and Consequences of Stent-Graft Kink following Endovascular AAA Repair

Purpose: To determine from the EUROSTAR registry the incidence of stent-graft kink, predictive factors for kinking, and the consequences of this complication on graft patency and aneurysm exclusion. Methods: From January 1994 to June 2002, 4613 patients who underwent endovascular aneurysm repair were registered in the EUROSTAR registry. Presence of kink was determined according to the information available on the follow-up Case Record Form. The population was divided into those with and without stent-graft kink. Patient characteristics, morphological aneurysm features, team experience, type of device, period of implantation, and outcome were compared between the groups by univariate analysis. Significant factors were subsequently submitted to a multivariate Cox proportional hazard analysis. Results: One hundred seventy (3.7%) patients were reported as having a kink of the stent-graft during a mean follow-up of 21 months (range 1–72). Gender, neck angulation, team experience, period of implantation, ASA classification, and device type were independent predictors of kink. The presence of a kink was significantly associated with type I endoleaks (proximal and distal), type III endoleaks (midgraft), graft stenosis, graft limb thrombosis, graft migration, and conversion to open repair. No relationship was found between a decrease in the aneurysm diameter and the occurrence of stent-graft kink. Conclusions: Kinks of stent-grafts were infrequent events in the intermediate term. Patients most at risk were women with angulated aortic necks treated by a minimally experienced team. Kinks are potentially damaging events because they may lead to delayed device-related endoleaks, graft stenosis, thrombosis, and conversion to open repair. They appear more closely associated to graft migration than to aneurysm diameter reduction.

Functional dyspepsia: not all roads seem to lead to rome.

Background The Rome criteria have been introduced to create order in the heterogeneity of functional dyspepsia. The applicability of these symptom-based classification systems remains controversial. Goal To evaluate the successive Rome criteria for functional dyspepsia in a large pool of patients with endoscopically verified functional dyspepsia. Study Patients referred to a secondary care district hospital were asked to fill out a questionnaire on gastrointestinal symptoms 2 weeks before upper gastrointestinal endoscopy. Patients were classified according to the Rome I, II, and III criteria for functional dyspepsia. Results Nine hundred and twelve (70%) patients had no organic disorder explaining their symptoms. According to the Rome I, II, and III criteria, 371 (41%), 735 (81%), and 551 (60%) of these patients had functional dyspepsia, respectively. Twenty-five percent of patients had functional dyspepsia according to all 3 Rome criteria, whereas 15% was not classifiable at all. Forty-four percent and 42% of the patients, respectively, had epigastric pain syndrome and postprandial distress syndrome according to the Rome III criteria; however, 26% of all patients met both criteria and 40% was not classified at all. Conclusions The symptom-based Rome classification of functional dyspepsia does not lead to an easily applicable and consistent system that is useful in clinical practice or scientific research.

Diagnostic performance of biopsy-based methods for determination of Helicobacter pylori infection without a reference standard

Endoscopic biopsy-based tests are considered to be the reference method for diagnosing Helicobacter pylori infection and monitoring antibiotic treatment, but unbiased data on their diagnostic performance is lacking. In this study we evaluated the diagnostic performance of culture, histology and rapid urease testing of antral biopsies separately and in combination. Antral biopsies were taken from consecutive patients undergoing upper gastrointestinal endoscopies at a single center between January 1995 and May 1997. The biopsies were examined for culture, histology, and CLOtest. The diagnostic performance, i.e., the sensitivity and specificity of the tests was estimated with 7 non-linear equations in 7 unknowns. To determine sources of heterogeneity that may have biased the results, data were stratified for age, gender, and whether they were taken before or after anti-Helicobacter antibiotic treatment. During the study period 631 patients underwent 869 upper gastrointestinal endoscopies. In 122 (14%) of the antral specimens the test results of culture, histology and CLOtest differed. Based on the nonlinear regression techniques we estimated that in 347 tests (40%) H. pylori infection was present. Overall sensitivity, specificity, positive and negative predictive value for each test were as follows: culture 91.4%, 96.3%, 94.2%, 94.4%, respectively; histology 90.3%, 97.8%, 96.4%, 93.8%, respectively; CLOtest 94.9%, 96.7%, 95.0%, 96.6%, respectively. In combination, the three tests provided the definitive diagnosis, either non-infected or infected, in 862 out of the 869 tests. Sensitivity of gastric antral histology was 64.9% (95% CI: 38-86) in females who did and 84.5% (95% CI: 77-90) in females who did not have had recent antibiotic therapy to cure the infection. Approximately 5-10% of H. pylori infected patients, were mis-diagnosed with a single biopsy-based test taken from the gastric antrum. Only a combination of bacterial culture, histological examination and the CLOtest represents an appropriate reference standard for research purposes to identify infected patients.

Influence of diabetes mellitus on the endovascular treatment of abdominal aortic aneurysms.

Purpose: To investigate the influence of diabetes mellitus on outcome after endovascular abdominal aortic aneurysm (AAA) repair. Methods: Of 6017 patients enrolled in the EUROSTAR registry after undergoing endovascular AAA repair between May 1994 and December 2003, 731 (12%) had diabetes mellitus (690 men; mean age 72 years, range 37–100). Patient demographics, risk factors, aneurysm morphology, operative and procedural details, complications, major events, and regular follow-up information were compared. The relationships of complications and events to diabetes mellitus, which were tested with multivariate logistic regression analysis and Cox proportional hazards modeling, are expressed as odds ratios (OR) and hazard rates (HR) with 95% confidence intervals (CI). Survival was compared with life-table analysis. Results: A significantly higher risk of device-related complications was observed in diabetic patients (8% versus 6%, p < 0.049; OR 1.35, 95% CI 1.00 to 1.82). The greatest difference in the groups was in mortality, which was significantly higher in the diabetic population (13%) compared to the nondiabetic patients (10%, p < 0.039; OR 1.27, 95% CI 1.01 to 1.59). Deaths, which occurred at a higher frequency within the 30-day perioperative period in diabetic patients, were primary due to cardiac complications. Insulin-controlled type 2 diabetic patients had significantly lower rates of early and late endoleaks and secondary interventions than diet-controlled type 2 diabetics (p=0.002, p=0.0001, and p=0.0008, respectively) and nondiabetic patients (p=0.002, p=0.0005, and p=0.0025, respectively). The cumulative survival after 48 months did not differ significantly: 74% in diabetics and 79% in the population without diabetes. Conclusions: Patients with diabetes mellitus had a significantly higher early mortality rate after EVAR, but their long-term survival was similar to nondiabetic patients.

Procedure-related mortality of endovascular abdominal aortic aneurysm repair using revised reporting standards

OBJECTIVE The aim of this study was to evaluate the definition of Procedure-related mortality after endovascular aneurysm repair (EVAR) as defined by the Committee for Standardized Reporting Practices in Vascular Surgery. METHODS Data on patients with an AAA were taken from the EUROSTAR database. The patients underwent EVAR between June 1996 and February 2004 and were analyzed retrospectively. Explicit probability of cause of death was recorded. The time interval from operation, hospital discharge or second interventions till death was recorded. RESULTS A total of 589 out of 5612 patients (10.5%) died after EVAR in total follow up and all causes of death were included. 141 (2.5%) patients died due to aneurysms reported after the EVAR procedure of which 28 (4.8%) were ruptures, 25 (4.2%) graft-infections and 88 (14.9%) patients who died within 30 days after the initial procedure (present definition, also known as short term clinical outcome). In addition 25 patients died after 30 days, but were then (at moment of death) still in the hospital, or were transferred to a nursing home for further re-evaluation, or needed second interventions. Taking into account the duration of hospitalization and mortality immediately after procedure-related second interventions, 49 delayed deaths might also be regarded as being EVAR procedure-related. CONCLUSION Delayed deaths are a considerable proportion of procedure-related deaths after EVAR within the revised time frame.

Hyperhomocysteinaemia and vitamin B12 deficiency: the long-term effects in cardiovascular disease.

Background: An elevated plasma homocysteine level is an established risk factor for cardiovascular disease. Vitamin B12 plays a key role in homocysteine metabolism and could be the main factor in causing cardiovascular disease as well. Objectives: The aim of this study was to assess whether vitamin B12 deficiency or hyperhomocysteinaemia is associated with recurrent cardiovascular events. Methods: Overall, 211 patients discharged alive from our Coronary Care Unit were recruited from February till May 1998. Serum vitamin B12 and plasma homocysteine levels were measured in fasting blood samples. Patient characteristics, medical information and cardiovascular risk factors were assessed from medical files. Patients were followed for 5 years and the prevalence of cardiovascular mortality and morbidity was collected. Results: In the follow-up period of 810 person-years, 48 (21%) of the patients experienced a nonfatal recurrent cardiovascular event and another 14 (7%) died of a cardiovascular cause. Among those with ischaemic heart disease at discharge, no difference in survival was found between the patients with a low (<250 pmol/l) or a high vitamin B12 level (p = 0.21). In patients with hyperhomocysteinaemia (>16 µmol/l), an increased risk of a recurrent cardio vascular event (p = 0.05) in comparison to those with normal plasma homocysteine levels was proven (adjusted hazard ratio of 2.22 (95% CI: 1.40–3.04). Conclusions: In conclusion, high plasma homocysteine concentration, but not a low serum vitamin B12 concentration, increases the risk of cardiovascular morbidity and mortality in patients with ischaemic heart disease.