Stamatis P. Efstathiou

Plasma adiponectin levels and five-year survival after first-ever ischemic stroke.

Background and Purpose— This study aimed to investigate the association between plasma adiponectin levels and 5-year survival after first-ever ischemic stroke. Methods— Plasma adiponectin measured within 24 hours after first-ever ischemic stroke was related to 5-year outcome. The Kaplan–Meier technique was applied in survival analysis, and the Cox proportional hazards model was used to evaluate the relationship between risk factors and prognosis. Results— The probabilities of death were 92.8%, 52.5%, and 10.5% (P<0.001) for patients stratified according to tertiles of adiponectin (<4 &mgr;g/mL, 4 to 7 &mgr;g/mL, and >7 &mgr;g/mL, respectively). The relative risk of death was 8.1 (95% CI, 3.1, 24.5; P<0.001) for individuals with adiponectin levels in the lowest tertile compared with the upper tertile. Adiponectin <4 &mgr;g/mL (hazard ratio [HR], 5.2; 95% CI, 2.1, 18.4; P<0.001), score >15 in the National Institutes of Health Stroke Scale (HR, 3.6; 95% CI, 1.7, 15.9; P<0.001), and coronary heart disease (HR, 2.9; 95% CI, 1.5, 12.3; P<0.001) were independently associated with mortality. Conclusions— Low plasma adiponectin is related to an increased risk of 5-year mortality after first-ever ischemic stroke, independently of other adverse predictors.

Comparison of antihypertensive effects of an angiotensin-converting enzyme inhibitor, a calcium antagonist and a diuretic in patients with hypertension not controlled by angiotensin receptor blocker monotherapy.

Objective To compare the additional antihypertensive effects of an angiotensin-converting enzyme inhibitor (ACEI), a dihydropyridine calcium antagonist and a diuretic in patients whose hypertension is not controlled by full-dose angiotensin receptor blocker (ARB) monotherapy. Design and methods Individuals with an ambulatory blood pressure (ABP) that was not controlled by valsartan 160 mg once daily were allocated randomly to two groups: those in group A (n = 35) were assigned randomly to treatment with benazepril 20 mg once daily or chlorthalidone 12.5 mg once daily, whereas patients in group B (n = 29) were assigned randomly to benazepril 20 mg once daily or amlodipine 5 mg once daily. All individuals continued to receive background valsartan 160 mg once daily. After 5 weeks, patients crossed over to the alternative valsartan-based combination treatment of each group for a second 5-week period. Twenty-four-hour ABP monitoring was performed before the random allocation to groups and at the end of each randomized combination pharmacotherapy period. Results Sixty-four individuals completed the study: 32 men and 32 women (mean ± SD age 48.2 ± 7.9 years, average 24-h ABP on valsartan monotherapy 143.4 ± 12.6/87.7 ± 7.8 mmHg). Significant additional antihypertensive effects on the average 24-h ABP were obtained with benazepril (8.6 ± 8.8/6.3 ± 6.7 mmHg), amlodipine (15.2 ± 12.9/9.9 ± 6.8 mmHg) and chlorthalidone (13.5 ± 11.6/9.5 ± 7.7 mmHg) (P < 0.001 for all additional antihypertensive effects). The additional effects of amlodipine and chlorthalidone added to valsartan were approximately 6/3.5 mmHg (P < 0.05) greater than that of benazepril. Conclusions In patients in whom hypertension was not controlled by full-dose ARB monotherapy, a diuretic, a calcium antagonist or an ACE inhibitor provided significant additional antihypertensive effect. The antihypertensive effects of the ARB–diuretic and the ARB–calcium antagonist combinations were superior to that of the ARB–ACE inhibitor combination.

Fever of unknown origin: Discrimination between infectious and non-infectious causes

OBJECTIVE The present study aimed to develop and evaluate a simple diagnostic model that could aid physicians to discriminate between infectious and non-infectious causes of fever of unknown origin (FUO). DESIGN/SETTING/SUBJECTS Patients with classical FUO were studied in two distinct, prospective, observational phases. In the derivation phase that lasted from 1992 to 2000, 33 variables regarding demographic characteristics, history, symptoms, signs, and laboratory profile were recorded and considered in a logistic regression analysis using the diagnosis of infection as a dependent variable. In the validation phase, the discriminatory capacity of a score based on the derived predictors of infection was calculated for FUO patients assessed from 2001 to 2007. RESULTS Data from 112 individuals (mean age 56.5+/-11.2 years) were analyzed in the derivation cohort. The final diagnoses included infections, malignancies, non-infectious inflammatory diseases, and miscellaneous conditions in 30.4%, 10.7%, 33% and 5.4% of subjects, whereas 20.5% of cases remained undiagnosed. C-reactive protein>60 mg/L (odds ratio 6.0 [95% confidence intervals 2.5, 9.8]), eosinophils<40/mm(3) (4.1 [2.0, 7.3]) and ferritin<500 microg/L (2.5 [1.3, 5.2]) were independently associated with diagnosis of infection. Among the 100 patients of the validation cohort, the presence of > or =2 of the above factors predicted infection with sensitivity, specificity, and positive and negative predictive values of 91.4%, 92.3%, 86.5%, and 95.2%, respectively. CONCLUSIONS The combination of C-reactive protein, ferritin and eosinophil count may be useful in discriminating infectious from non-infectious causes in patients hospitalised for classical FUO.

A mortality prediction model in diabetic ketoacidosis

aim To assess the value of clinical and laboratory parameters in predicting mortality in patients presenting with diabetic ketoacidosis (DKA).

Metabolic Syndrome in Adolescence: Can it be Predicted from Natal and Parental Profile? The Prediction of Metabolic Syndrome in Adolescence (PREMA) Study

Background— There are well-established predisposing factors for the development of metabolic syndrome (MetS) in childhood or adolescence, but no specific risk profile has been identified as yet. The Prediction of Metabolic Syndrome in Adolescence (PREMA) study was conducted (1) to construct a classification score that could detect children at high risk for MetS in adolescence and (2) to test its predictive accuracy. Methods and Results— In the derivation cohort (1270 children), data from natal and parental profile and from initial laboratory assessment at 6 to 8 years of age were used to detect independent predictors of MetS at 13 to 15 years of age according to the International Diabetes Federation definition. In the validation cohort (1091 adolescents), the discriminatory capacity of the derived prediction score was tested on an independent adolescent population. MetS was diagnosed in 105 adolescents in the derivation phase (8%), whereas birth weight <10th percentile (odds ratio, 6.02; 95% confidence interval, 2.53–10.12, P<0.001), birth head circumference <10th percentile (odds ratio, 4.15; 95% confidence interval, 2.04–7.14, P<0.001), and parental overweight or obesity (in at least 1 parent; odds ratio, 3.22; 95% confidence interval, 1.30–5.29, P<0.01) were independently associated with diagnosis of MetS in adolescence. Among adolescents in the validation cohort (86 [8%] with MetS), the presence of all these 3 predictors predicted MetS with a sensitivity of 91% and a specificity of 98%. Conclusions— The coexistence of low birth weight, small head circumference, and parental history of overweight or obesity may be useful for detection of children at risk of developing MetS in adolescence.Background— There are well-established predisposing factors for the development of metabolic syndrome (MetS) in childhood or adolescence, but no specific risk profile has been identified as yet. The Prediction of Metabolic Syndrome in Adolescence (PREMA) study was conducted (1) to construct a classification score that could detect children at high risk for MetS in adolescence and (2) to test its predictive accuracy. Methods and Results— In the derivation cohort (1270 children), data from natal and parental profile and from initial laboratory assessment at 6 to 8 years of age were used to detect independent predictors of MetS at 13 to 15 years of age according to the International Diabetes Federation definition. In the validation cohort (1091 adolescents), the discriminatory capacity of the derived prediction score was tested on an independent adolescent population. MetS was diagnosed in 105 adolescents in the derivation phase (8%), whereas birth weight <10th percentile (odds ratio, 6.02; 95% confidence interval, 2.53–10.12, P <0.001), birth head circumference <10th percentile (odds ratio, 4.15; 95% confidence interval, 2.04–7.14, P <0.001), and parental overweight or obesity (in at least 1 parent; odds ratio, 3.22; 95% confidence interval, 1.30–5.29, P <0.01) were independently associated with diagnosis of MetS in adolescence. Among adolescents in the validation cohort (86 [8%] with MetS), the presence of all these 3 predictors predicted MetS with a sensitivity of 91% and a specificity of 98%. Conclusions— The coexistence of low birth weight, small head circumference, and parental history of overweight or obesity may be useful for detection of children at risk of developing MetS in adolescence. # Clinical Perspective {#article-title-46}

Clinic, home and ambulatory pulse pressure: comparison and reproducibility

OBJECTIVE: Recent evidence suggests that pulse pressure (PP) is an independent predictor of cardiovascular risk. The objective of this study was to compare mean values and reproducibility of PP obtained in the clinic (CPP), at home (HPP) and with ambulatory monitoring (APP) and to evaluate potential implications for trials aiming to assess drug effects on PP. METHODS: A total of 393 hypertensive subjects [mean age 51.5 +/- 11.5 (SD) years, 59% men, 35% treated] measured CPP (two visits), HPP (6 days) and APP (24 h). The reproducibility of PP was assessed using the SD of differences (SDD) between measurements in 133 untreated subjects who had repeated CPP (five visits), HPP (6 days) and APP measurements (two occasions). RESULTS: There was no difference between mean CPP (51.0 +/- 13.3 mmHg) and HPP (50.2 +/- 11.0) whereas APP (48.8 +/- 8.4) was lower than both CPP [mean difference 2.3 +/- 10.3 mmHg; 95% confidence interval (CI), 1.2, 3.3; P < 0.01] and HPP (1.5 +/- 7.8; 95% CI, 0.7, 2.3; P < 0.01). The SDD between repeated measurements was about 10 mmHg for CPP (one visit), 5.2 mmHg for HPP (2 days) and 4 mmHg for APP (24-h). For a parallel comparative trial aiming to detect a difference of 3 mmHg PP in the effect of two drugs, 415 subjects would be required when using CPP, compared to 127 using HPP and 63 using APP. CONCLUSIONS: These data suggest that although differences among mean values of CPP, HPP and APP are small, differences in their reproducibility are important and should be taken into account in the design of trials assessing drug effects on PP.

Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis

BackgroundStaple line leaks represent a major concern in all laparoscopic operations but are particularly important in bariatric surgery, where leak complications carry significant morbidity and mortality. Therefore, several means of staple line reinforcement have been described, but none is totally accepted. In this study, we attempt to illuminate any clear benefit of staple line reinforcement through a systematic review and meta-analysis of reported articles.MethodsTwo major databases (PubMed and Cochrane) were searched and assessed by two reviewers. Inclusion criteria were: detailed description of operative technique, especially concerning staple line reinforcement, and possible existence of proven staple line leak. Selected studies were evaluated by systematic review and meta-analysis according to their eligibility. The study population was finally divided into two groups: reinforcement (of any type) and no reinforcement.ResultsIn the initial search, 126 studies were obtained. Then, 17 full papers, both randomised controlled trials (RCTs) and non-RCTs, were included in the systematic review. Seven studies, comprising 3,299 patients, were examined for evaluation of population odds of leak (7.69), which was considered clinically significant. Meta-analysis of three studies comprising 1,899 patients revealed no clear benefit of reinforcement group, though with marginal significance.ConclusionsAlthough several drawbacks exist, this study illustrates two important aspects: that current staplers may not be uniformly reliable, and that staple line reinforcement does not seem to have any clear benefit, at least concerning leak rate.

Comparison of the smoothness index, the trough: peak ratio and the morning

Objective To provide a direct comparison of the trough : peak ratio (TPR), the morning : evening home blood pressure ratio (MER) and the smoothness index (SI) in assessing the features of the antihypertensive drug effect. Patients and methods A total of 27 untreated hypertensives were randomized to receive lisinopril 20 mg o.d. or losartan 50 mg o.d. for 5 weeks and were subsequently crossed-over to the alternative treatment for a second 5-week period. Twenty-four hour ambulatory and 5-day home blood pressure were monitored before randomization and at the end of each treatment period. TPR, MER and SI were calculated for each drug for the total study population and for responders only. Results When all patients were considered, lisinopril provided higher values of TPR [0.63/0.66 for systolic/diastolic blood pressure (SBP/DBP)], MER (1.02/0.77) and SI (1.01/0.87) than losartan (0.35/0.51, 0.60/0.60 and 0.64/0.53, respectively). Analysis of responders only, again showed a clear advantage of lisinopril over losartan in TPR (0.77/0.67 versus 0.44/0.47, respectively) and MER (0.86/0.87 versus 0.48/0.61), whereas there was no difference in SI (1.25/1.13 for lisinopril versus 1.11/1.12 for losartan). Conclusions These data suggest that the assessment of the duration of the antihypertensive drug effect provided by the MER is consistent to that by the TPR and that two drugs with different levels of TPR and MER may have the same level of SI. It appears that the SI is not simply a more reliable index of the features of the antihypertensive drug effect, but offers a different type of information complementary to that provided by the TPR and the MER, in regard to the homogeneity and the magnitude but not the duration of the antihypertensive effect.

Blood pressure- and pulse pressure-lowering effects, trough:peak ratio and smoothness index of telmisartan compared with lisinopril.

Objective To compare lisinopril with telmisartan, in regard to: 1) their effect on blood pressure (BP) and pulse pressure (PP), and 2) the duration and the homogeneity of their antihypertensive effect. Patients and Methods A randomized, open-label, crossover, comparative study of telmisartan 80 mg versus lisinopril 20 mg was conducted in 32 untreated hypertensive patients using clinic and 24-hour ambulatory BP measurements. Trough: peak ratio (TPR) and smoothness index (SI) were calculated for each drug. Results Using both measurement techniques no difference was detected between the 2 drugs in their effects either on BP (mean difference in 24-hour systolic BP 1.2 ± 7.1 mm Hg, 95% confidence intervals –1.4, 3.8, and diastolic 0.7 ± 5.1, –1.2, 2.5) or on PP (0.5 ± 3.5, –0.7, 1.8). There was no difference between the TPR and the SI values of telmisartan (TPR 0.85/0.61 for systolic/diastolic BP and SI 1.46/1.2) and lisinopril (TPR 0.74/0.64 and SI 1.3/1.17). Conclusions These data suggest that telmisartan is as effective as lisinopril in reducing BP and PP. Both drugs seem to provide smooth and sustained effects throughout the full 24-hour period.

Pseudohyperkalemia in Patients with Increased Cellular Components of Blood

Objective:We performed a study to investigate the difference between serum and plasma potassium concentration in patients with increase in one or more of the cellular components of blood. Design and Methods:This study was performed in two phases. During the first phase, we performed a cross-sectional comparison of the difference between serum and plasma potassium concentration (Dk) in 341 patients with the various clinical conditions where pseudohyperkalemia has been described, as well as with secondary or spurious erythrocytosis and in 30 normal controls. A cut-off value of Dk discriminating polycythemia vera from other erythrocytoses was estimated. In the second phase we studied the significance of this cut-off value as predictor of polycythemia vera in 90 naive patients who were referred with an elevated hematocrit. Results:Dk was significantly increased in the groups with platelet, erythrocyte or with a mixed type disorder compared to the controls (P < 0.01). Among these groups, Dk was significantly increased in the groups with thrombocytosis and mixed type disorder, compared to the group with erythrocytosis (both P < 0.01). A cut-off value of Dk discriminating polycythemia vera from other erythrocytoses was estimated (0.70 mmol/L). Dk (≥ 0.70 mmol/L), platelet and white blood cell count were identified as significant independent predictors of polycythemia vera. Conclusions:The Dk is increased in patients with erythrocytoses, thrombocytoses or both. This phenomenon is more profound in patients with a mixed type disorder, such as polycythemia vera patients, compared to those with erythrocytoses alone.