Survival after inflammatory bowel disease-associated colorectal cancer in the Colon Cancer Family Registry

AIM: To investigate the survival of individuals with colorectal cancer (CRC) with inflammatory bowel disease (IBD-associated CRC) compared to that of individuals without IBD diagnosed with CRC. METHODS: Epidemiologic, clinical, and follow-up data were obtained from the Colon Cancer Family Registry (Colon CFR). IBD-associated cases were identified from self-report of physician diagnosis. For a subset of participants, medical records were examined to confirm self-report of IBD. Cox proportional hazards regression was applied to estimate adjusted hazard ratios (aHR) and 95%CI of mortality, comparing IBD-associated to non-IBD-associated CRC, adjusted for age at CRC diagnosis, sex, Colon CFR phase, and number of prior endoscopies. Following imputation to complete CRC stage information, adjustment for CRC stage was examined. RESULTS: A total of 7202 CRC cases, including 250 cases of IBD-associated CRC, were analyzed. Over a twelve year follow-up period following CRC diagnosis, 2013 and 74 deaths occurred among non-IBD associated CRC and IBD-associated CRC patients, respectively. The difference in survival between IBD-associated and non-IBD CRC cases was not statistically significant (aHR = 1.08; 95%CI: 0.85-1.36). However, the assumption of proportional hazards necessary for valid inference from Cox regression was not met over the entire follow-up period, and we therefore limited analyses to within five years after CRC diagnosis when the assumption of proportional hazards was met. Over this period, there was evidence of worse prognosis for IBD-associated CRC (aHR = 1.36; 95%CI: 1.05-1.76). Results were similar when adjusted for CRC stage, or restricted to IBD confirmed in medical records. CONCLUSION: These results support the hypothesis that IBD-associated CRC has a worse prognosis than non-IBD-associated CRC.

Reporting of Negative Randomized Trials in Three Major Medical Journals

Context: In recent years there has been increasing interest on publication bias and on initiatives to decrease bias, in- cluding trial registration. Objective: To test whether there has been an increase in reports of randomized control trials (RCT’s) with negative outcomes in major journals and to identify factors associated with these reports. Design: Retrospective review of reports of RCT’s published in the Journal of the American Medical Association, The Lancet and the New England Journal of Medicine before (2002-’03, pre-registration era) and after (2007-’08, registration era) the institution of mandatory trial registration. Main Outcome Measure: The primary outcome was the proportion of RCT reports with negative outcomes compared across the two eras. Secondary outcome includes other factors affecting pub-lication. Results: We identified 917 reports of RCT’s published in the two study eras. No publications in the pre-registration era reported trial registration compared with 94.4% in the registration era (p 0.001). There was a non-significant increase in negative trials from the pre-registration to the registration era (29.1% vs. 34.1%, p = 0.10, OR 1.26, 95% CI 0.96 - 1.67). Study characteristics associated with negative outcomes include trials of drugs (OR 1.62, 95% CI 1.08 - 2.43), procedures or devices (OR 2.08, 95% CI 1.29 - 3.35), explicit identification of a single primary endpoint (OR 1.70, 95% CI 1.40 - 2.47), and increasing sample size (OR 3.08, 95% CI 1.78 - 5.34). Non-inferiority study design was associated with a decreased likelihood of a negative outcome (OR 0.13, 95% CI 0.05 - 0.31). Conclusions: The proportion of published RCT reports with negative outcomes in three major medical journals has not significantly increased since the mandatory clinical trial registration policy. The observed prevalence of negative trials is associated with increases in sample size and greater specificity in trial endpoints.

Peripheral artery disease in patients with diabetes:Epidemiology,mechanisms,and outcomes

Peripheral artery disease(PAD) is the atherosclerosis of lower extremity arteries and is also associated with atherothrombosis of other vascular beds,including the cardiovascular and cerebrovascular systems.The presence of diabetes mellitus greatly increases therisk of PAD,as well as accelerates its course,making these patients more susceptible to ischemic events and impaired functional status compared to patients without diabetes.To minimize these cardiovascular risks it is critical to understand the pathophysiology of atherosclerosis in diabetic patients.This,in turn,can offer insights into the therapeutic avenues available for these patients.This article provides an overview of the epidemiology of PAD in diabetic patients,followed by an analysis of the mechanisms by which altered metabolism in diabetes promotes atherosclerosis and plaque instability.Outcomes of PAD in diabetic patients are also discussed,with a focus on diabetic ulcers and critical limb ischemia.

抑郁可预测心肌梗死伴心衰患者的死亡及住院

Background: To evaluate whether depressive symptoms are independently predictive of mortality and hospitalization among patients with acute myocardial infarction(AMI)complicated by heart failure. Methods: The EPHESUS trial enrolled patients with AMI complicated by heart failure. Patients from Canada, the UK, and the United States completed a Medical Outcomes Study-Depression questionnaire at baseline in addition to a comprehensive clinical examination. Cox proportional hazards regression was used to determine the relationship between depressive symptoms and outcomes, including 2-year all-cause mortality and cardiovascular death or hospitalization, adjusting for baseline clinical variables. Results: Overall, 143 of 634 patients(22.6% )had significant depressive symptoms at baseline(Medical Outcomes Study-Depression score ≥ 0.06). Depressed patients had higher 2-year mortality(29% vs 18% ; P=.004)and cardiovascular death or hospitalization(42% vs 33% ; P=.016). After risk adjustment, depressive symptoms remained significantly associated with mortality(hazard ratio 1.75, 95% CI 1.15- 2.68, P=.01)and cardiovascular death or hospitalization(hazard ratio 1.41, 95% CI 1.03- 1.93, P=.03). Results were consistent across demographic and clinical subgroups. Conclusions: Depression is an independent predictor of all-cause mortality and cardiovascular death or hospitalization after AMI complicated by heart failure. Although many factors may mediate outcomes in patients with AMI, studies are warranted to evaluate whether a depression intervention can improve survival and/or reduce hospitalizations.

老年患者行非心脏手术前红细胞压积水平与手术预后的关系

背景：接受非心脏手术的老年患者出现红细胞压积异常和心血管并发症的危险较高。尽管患者术前几乎都要进行红细胞压积筛查，但是有关术前贫血及红细胞增多症的不良影响的证据较为有限。 目的：于实施非心脏大手术的退伍老兵中评估术前贫血和红细胞增多症的发生率及其对术后30天预后的影响。 设计：利用全国退伍军人事务委员会（VA）于术质量改进计划数据库进行回顾性队列研究。根据术前红细胞压积水平将患者分为三类：贫血（红细胞压积〈39．0％）、正常（红细胞压积39．0％～53．9％）和红细胞增多症（红细胞压积≥54％）。对红细胞压积异常与术后30天心血管事件发生率及死亡率的关系进行评估。 地点及患者：纳入1997至2004年于全美132个退伍军人医疗中心接受非心脏大手术的310311例患者（年龄≥65岁）。 主要观测指标：主要观测指标为术后30天死亡率，次要观测指标包括术后30天死亡率或心脏事件（心脏骤停或Q波心肌梗死）发生率。 结果：与红细胞压积正常者相比，红细胞压积发生正向或负向偏离者术后30天死亡率和心脏事件发生率均有所增加。研究发现，红细胞压积水平较正常范围每增减1个百分点，术后30天死亡率就可增加1．6％（95％可信区间，1．1％-2．2％）。进一步分析显示，当红细胞压积降至39％以下或超过51％时，校正后30天死亡风险和心脏病患病风险就开始增加。 结论：接受非心脏大手术的老年患者（绝大多数为男性退伍军人）术前轻度贫血及红细胞增多症均可增加术后发生死亡和心脏事件的危险。今后的研究应明确上述发现可否见于其他人群，明确术前纠正贫血和红细胞增多症能否降低术后死亡风险。