A risk score to predict 30-day mortality in patients with intra-aortic balloon pump implantation

BACKGROUND: Several risk factors for early mortality after intra-aortic balloon pump (IABP) implantation have been described. METHODS: We performed a retrospective analysis in 120 patients receiving peri- or postoperative IABP support. Univariate and multivariate analyses were carried out to assess variables potentially influencing 30-day mortality in order to develop a risk score for the prognosis of survival and for the decision on optimal patient-specific treatment. RESULTS: The 4 parameters (mean arterial pressure, adrenaline dose, central venous pressure, and blood lactate concentrations) at 6 hours of IABP use were independently related to 30-day mortality. They were used to develop a risk score (0 - 4 points). With this score, patients who scored 3 or 4 points had no probability of surviving, whereas patients with a score of zero had a probability of 84.4 %. A prospectively screened cohort of 145 patients confirmed the reliability of our risk score. CONCLUSIONS: Our data demonstrate that a score can predict 30-day mortality in patients with IABP implantation. Such a score can be useful to find out whether or not ECMO/VAD implantation is necessary.     

Radial access: So much progress but a way to go

• Transradial access is the key bleeding avoidance strategy in percutaneous coronary intervention.
• This study showed a marked adoption of transradial access over a 10‐year period, however, women had a significantly lower rate compared to men and overall bleeding events did not decrease over time.
• Strategies to overcome barriers to radial access in women and to maintaining competency in femoral access in all patients are needed.

     

A new simplified model for predicting 30-day mortality in older medical emergency department patients: The rise up score

Background/ObjectivesCurrently, accurate clinical models that predict short-term mortality in older (≥ 65 years) emergency department (ED) patients are lacking. We aimed to develop and validate a prediction model for 30-day mortality in older ED patients that is easy to apply using variables that are readily available and reliably retrievable during the short phase of an ED stay.MethodsProspective multi-centre cohort study in older medical ED patients. The model was derived through logistic regression analyses, externally validated and compared with other well-known prediction models (Identification of Seniors at Risk (ISAR), ISAR-Hospitalised Patients, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Modified Early Warning Score (MEWS)).ResultsWithin 30 days after presentation, 66 (10.9%) of 603 patients in the derivation cohort and 105 (13.3%) of 792 patients in the validation cohort died. The newly developed model included 6 predictors: age, ≥2 abnormal vital signs, serum albumin, blood urea nitrogen, lactate dehydrogenase, and bilirubin. The discriminatory value of the model for mortality was very good with an AUC of 0.84 in the derivation and 0.83 in the validation cohort. The final model was excellently calibrated (Hosmer-Lemeshow p-value 0.89). The discriminatory value of the model was significantly higher than that of the four risk stratification scores (highest AUC of 0.69 for ISAR score, p-value 0.007).ConclusionWe developed and externally validated an accurate and simplified prediction model for 30-day mortality in older ED patients. This model may be useful to identify patients at risk of short-term mortality and to apply personalised medical care.     

Applicability of the PAINESD risk score for 30-day mortality prediction post ventricular tachycardia catheter ablation in Chagas disease

Background

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is standard of care. However, it is underutilized. In July 2012, our institution began providing cell phone adapters (CPAs) to patients free of charge following CIED implantation to improve remote transmission (RT) adherence.

Methods

Patients in our institution’s RM database from January 1, 2010, thru June 30, 2015, were retrospectively reviewed. There were 2157 eligible patients. Remote transmission proportion (RTP) and time to transmission (TT) were compared pre- and post-implementation of free CPA. Chi-squared analysis and Kruskal-Wallis tests were performed to compare RTP and TT.

Results

There was a significant increase in RTP (134 [18.4%] vs 99 [54.7%]; p?<?0.001) and decrease in median TT in days (189[110–279] vs 58 [10–149]; p?<?0.001) after CPAs were provided to patients. Caucasian patients were more likely than African Americans and Hispanics to use RM prior to CPAs (p?=?0.04). After the implementation of CPAs, there was a significant increase in RTP for all racial groups (<?0.001) with no difference in RTP among racial groups (p?=?0.18). The RTP for urban residents was significantly greater than non-urban residents with CPAs (p?=?0.008). Patients greater than 70 years of age were significantly less likely to participate in RT before and after CPAs were provided (p?=?0.03, p?=?0.01, respectively).

Conclusions

CPAs significantly improve RTP and reduce median TT for all patients regardless of race, geographic residence, and age (>?70 years old to lesser extent). Broad institution of CPAs following ICD implantation could potentially reduce disparity in RTP and deserves more study.

     

Treatment of hepatocellular carcinoma: Steps forward but still a long way to go

Hepatocellular carcinoma(HCC) is the fifth most common malignancy and the third cause of tumor associated deaths worldwide. HCC incidence rates are increasing in many parts of the world including developing and developed countries. Potentially curative treatments for HCC are resection and liver transplantation, but these are only suitable for patients with small tumors, meeting strict pre-defined criteria, or well-compensated liver disease. Early diagnosis of HCCcan be achieved by surveillance of at-risk populations. For patients with non-resectable disease treatments modalities include loco-ablative and systemic therapies. In this review we focus on treatment options in HCC and their allocation. Although significant research is in progress, to this date, the results are unsatisfactory with limited long-term survival. In the fight against this deadly disease, there is still a long way to go.     

The modified APACHE II score outperforms Curb65 pneumonia severity score as a predictor of 30-day mortality in patients with methicillin-resistant Staphylococcus aureus pneumonia

OBJECTIVE: To compare the predictive accuracy for 30-day mortality of the CURB65 score adopted by the British Thoracic Society and the simpler CRB65 score to APACHE (acute physiology and chronic health evaluation) II in patients with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. DESIGN: A retrospective, single-center, observational cohort study. SETTING: Barnes-Jewish Hospital, a 1,200-bed urban teaching hospital. PATIENTS: Adult patients requiring hospitalization identified to have MRSA pneumonia. INTERVENTIONS: Retrospective data collection from automated hospital, microbiology, and pharmacy databases. MEASUREMENTS AND MAIN RESULTS: Two hundred eighteen patients with MRSA pneumonia were identified over a 3-year period. Forty-four patients (20.2%) died during hospitalization. All three prediction rules had high negative predictive values but relatively low positive predictive values at most cut-off points examined. APACHE II had the greatest area under the receiver operating characteristic curve (0.805; 95% confidence interval [CI], 0.743 to 0.866) compared to CURB65 (0.634; 95% CI, 0.541 to 0.727) and CRB65 (0.643; 95% CI, 0.546 to 0.739) [p < 0.05 for both comparisons]. Similar results were obtained when the subgroups of community-acquired MRSA pneumonia and health-care-associated MRSA pneumonia were examined separately. CONCLUSIONS: APACHE II outperformed CURB65 and CRB65 for initial prognostic assessment in MRSA pneumonia.     

30-day mortality in UK patients with bacteraemic community-acquired pneumonia

Objectives

To determine 7 and 30-day mortality in consecutive patients with bacteraemic community-acquired pneumonia (CAP) and the association between predicted variables and likelihood of death.

Methods

From August 2007 to July 2011, demographic, clinical and microbiological data were prospectively collected on patients with bacteraemic CAP. Patients were followed until death, hospital discharge or recovery from infection. Univariate and multivariate analysis was performed to determine the association between predictor variables and 30-day mortality.

Results

7-day mortality was 61/252 [24.4 %, 95 % confidence interval (CI) 19.1–30.0 %] and by 30 days, this had risen to 77/252 (30.6 %, 95 % CI 24.9–36.6 %). In univariate analysis, factors associated with 30-day mortality were age, speciality within 48 h of admission, blood culture isolate and Charlson co-morbidity index (CCI). In multivariate analysis, age and CCI remained significantly associated. There was also a trend towards significance for meticillin-sensitive Staphylococcus aureus (MSSA) and Pseudomonas aeruginosa blood culture isolates compared to Streptococcus pneumoniae.

Conclusions

Overall, bacteraemic CAP was associated with high inpatient mortality. Because of their association with poor outcomes, patients with MSSA and P. aeruginosa bacteraemic CAP require further study.     

心力衰竭患者6 949例在院30 d病死率危险因素分析

目的:虽然心力衰竭（心衰）的治疗有了很大的进步，但心衰住院患者的在院病死率仍然很高。本项研究主要是调查影响心衰住院患者30 d在院病死率的独立危险因素。方法: 选择1993年1月1日～2007年12月31日15年间心衰住院患者6 949 (男4 344，女2 605)例，用Cox风险模型统计心衰住院患者在院病死率的独立危险因素。结果: 对心衰住院患者在院病死率有显著影响的因素是:老龄 ［HR 1.030，95%CI (1.021-1.039) P=0.000］；疾病包括冠心病、肺心病、心肌梗死、肺炎、脑血管病、消化道出血和肝硬化（P=0.000）,心肌病(P=0.006)、瓣膜性心脏病(P=0.025)、慢性阻塞型肺病(P=0.032)。Kaplan-Meier生成曲线显示共患疾病数目越多，死亡概率越大(HR 1.04, 95%CI 0.74-1.47 到HR 2.88， 95%CI 2.19-3.80,P<0.01)；本研究时段(1998-2002 vs. 1993-1997,HR 0.71 95%CI 0.55-0.93,P<0.05)；(2003-2007 vs. 1993-1997,HR 0.59 95%CI 0.46-0.76,P<0.01)。结论: 老龄、并发疾病、时段是影响心衰住院患者30 d在院病死率的独立危险因素。     

Analysis of 30-day mortality for clostridium difficile-associated disease in the ICU setting

OBJECTIVE: To examine the 30-day mortality rate among patients with Clostridium difficile-associated disease (CDAD) requiring intensive care. DESIGN: A retrospective, single-center, observational, cohort study. SETTING: Barnes-Jewish Hospital, a 1,200-bed, urban, teaching facility. PATIENTS: Adult patients admitted to the ICU identified to have CDAD by enzyme immunoassay. INTERVENTIONS: Retrospective data collection from automated hospital, microbiology, and pharmacy databases. Measurements and main results: Two hundred seventy-eight patients with CDAD admitted to an ICU were identified over a 2-year period. Two hundred six patients (74.1%) received prior antibiotic therapy. The overall 30-day mortality rate was 36.7% (n = 102). Logistic regression analysis identified septic shock (adjusted odds ratio, 1.96; 95% confidence interval [CI], 1.47 to 2.61; p = 0.018), ward-to-ICU transfer (adjusted odds ratio, 2.12; 95% CI, 1.62 to 2.79; p = 0.006), and increasing APACHE (acute physiology and chronic health evaluation) II scores (1-point increments) [adjusted odds ratio, 1.09; 95% CI, 1.07 to 1.12; p < 0.001] as independent predictors for 30-day mortality. The attributable mortality associated with CDAD was estimated to be 6.1% (95% CI, - 1.7 to 13.9%; p = 0.127). CDAD was associated with an excess ICU length of stay (2.2 days) and hospital length of stay (4.5 days). CONCLUSIONS: We found a high 30-day crude mortality among patients with CDAD in the ICU setting. Although the attributable mortality from CDAD was relatively low, excess length of stay in the ICU and hospital was observed with CDAD. ICUs should routinely employ infection control efforts aimed at minimizing the occurrence of CDAD because of the excess morbidity associated with this nosocomial infection.     

Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis

OBJECTIVE: Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is increasingly used to treat complications of portal hypertension, but proven tools for risk assessment of early mortality are lacking. DESIGN: The prospective evaluation of a new 60-day mortality score. PATIENTS AND METHODS: In a tertiary medical centre, 30 consecutive TIPSS patients were analysed for early mortality predictors, such as Child-Pugh score, TIPSS urgency (elective: > or = 36 h or emergency: < 36 h after variceal bleeding), comorbidity (Acute Physiology and Chronic Health Evaluation [APACHE]-II) and clinical data. Main predictors (P< 0.01) in this group (group-1: Child-Pugh score 10A, 10B, 10C) were graded (1, 2 or 3 points representing low, medium and high risk, respectively) and summarized as a Bonn TIPSS early mortality (BOTEM) score. This score was then tested prospectively in the next 73 TIPSS patients (group-2: Child-Pugh score 14A, 42B, 17C). RESULTS : Group 1 early mortality (30%) depended primarily on bilirubin (P< 0.005), APACHE-II (P < 0.001) and TIPSS urgency (P< 0.001). Added risk points (1, 2, 3) for bilirubin (< 3 mg/dl, 3-6 mg/dl, > 6 mg/dl, respectively), APACHE-II (< 10, 10-20, > 20 points, respectively) and urgency (elective, emergency, active bleeding, respectively) represented individual BOTEM score points. BOTEM was the best mortality predictor (P< 0.001); < or = / > 6 score points was the optimal cut-off, with 56% sensitivity, 100% specificity, 100% positive predictive value, 84% negative predictive value and 87% accuracy. In group 2, early mortality (8.2%) was again best predicted by BOTEM (P < 0.01) with the same cut-off and 67% sensitivity, 99% specificity, 80% positive predictive value, 97% negative predictive value and 96% accuracy. CONCLUSION: BOTEM score based on bilirubin, comorbidity and TIPSS-urgency predicts rather reliably post-TIPSS 60-day mortality and might optimize TIPSS treatment.     

Risk factors for acute kidney injury and 30-day mortality after liver transplantation

Introduction. The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation.Material and methods. This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated.Results. A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8-14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients).Conclusions. Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.     

继往开来任重道远

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