Metastatic epidural spinal cord compression among elderly patients with advanced prostate cancer

Background

A recent randomized trial demonstrated that for metastatic epidural spinal cord compression (MESCC), a complication of advanced prostate cancer, surgical decompression may be more effective than external beam radiation therapy (RT). We investigated predictors of MESCC, its treatment, and its impact on hospital length of stay for patients with advanced prostate cancer.

Methods

We used the SEER-Medicare database to identify patients >65 years with stage IV (n?=?14,800) prostate cancer. We used polytomous logistic regression to compare those with and without MESCC and those hospitalized for treatment with surgical decompression and/or RT.

Results

MESCC developed in 711 (5 %) of patients, among whom 359 (50 %) received RT and 107 (15 %) underwent surgery?±?RT. Median survival was 10 months. MESCC was more likely among patients who were black (OR 1.75, 95 %CI 1.39–2.19 vs. white) and had high-grade tumors (OR 3.01, 95 %CI 1.14–7.94), and less likely in those younger; with prior hormonal therapy (OR 0.73, 95 %CI 0.62–0.86); or with osteoporosis (OR 0.63, 95 %CI 0.47–0.83). Older patients were less likely to undergo either RT or surgery, as were those with ≥1 comorbidity. Patients with high-grade tumors were more likely to undergo RT (OR 1.92, 95 %CI 1.25–2.96). Those who underwent RT or surgery spent an additional 11 and 29 days, respectively, hospitalized.

Conclusions

We found that black men with metastatic prostate cancer are more likely to develop MESCC than whites. RT was more commonly utilized for treatment than surgery, but the elderly and those with comorbidities were unlikely to receive either treatment.     

Transcatheter aortic valve implantation in patients with and without concomitant coronary artery disease: comparison of characteristics and early outcome in the German multicenter TAVI registry

Objective

To examine the prevalence and impact of concomitant coronary artery disease (CAD) on short-term outcome after transcatheter aortic valve implantation (TAVI).

Background

The prevalence of CAD in patients undergoing surgical aortic valve replacement is estimated at 30–50?% and its presence increases procedural risk. The prevalence and impact of CAD on outcome after TAVI are not well defined.

Methods

We analyzed 1,382 patients enrolled in the German TAVI registry; the majority (81?%) received the Medtronic CoreValve. The presence of coronary lesions with ≥50?% stenosis on pre-TAVI angiography defined the existence of concomitant CAD.

Results

859 patients (62.2?%) had concomitant CAD, of which 534 (62.3?%) had multi-vessel and 83 (9.7?%) left main disease. Patients with CAD were younger (81.5?±?6.1 vs. 82.1?±?6.3?years, p?<?0.05), more commonly males (49.4 vs. 30.0?%, p?<?0.0001) and diabetics (36.9 vs. 31.2?%, p?<?0.05), and had a worse Canadian Cardiovascular Society angina class at baseline compared to patients with no CAD. During TAVI patients with CAD more often required additional coronary intervention and had longer procedures, but procedural success rates were similar (97.1 vs. 97.7?%). Crude in-hospital mortality was higher in patients with CAD (10.0 vs. 5.5?%, OR 1.90, 95?% CI 1.23–2.93), but this was not significant after adjustment for confounders (adjusted OR 1.41, 95?% CI 0.85–2.33). Both groups had significant improvement in 30-day symptoms and quality of life.

Conclusion

The prevalence of CAD in contemporary TAVI patients is high. Its presence characterizes a high-risk population and is associated with increased crude short-term mortality, largely explained by co-morbidities, but does not limit functional improvement after TAVI.     

Predictive value of bronchoscopy after infant cardiac surgery: a prospective study

Background and aims

Airway evaluation following infant cardiac surgery often reveals evidence of tracheobronchial narrowing. We studied the association between airway narrowing and extubation failure (EF) in this population.

Methods

Prospective cohort study of infants (age ≤6?months) from March–September 2009. Flexible bronchoscopy (FB) evaluations were obtained using a standardised protocol after operative intervention. The primary endpoint was the development of extubation failure (EF; defined as the need for invasive mechanical ventilation ≤48?h after primary extubation) and several secondary endpoints.

Results

Fifty-three patients were evaluated at a median age of 81 [interquartile range (IQR) 13–164] days and weight of 4.2 (IQR 3.2–6.0) kg; 13 (25?%) of the patients had single ventricle palliations and two subsequently underwent heart transplantation. Significant airway narrowing was noted in 15 of 30 [50 %, 95 % confidence interval (CI) 31–69?%] patients who underwent FB; ten of the 53 patients (19 %, 95 %CI 10–32?%) subsequently developed EF. Narrowed airway calibre on bronchoscopy had a sensitivity and specificity of 50 % (95 %CI 28–71 %) and 50 % (95 %CI 28–71 %), respectively, for EF. The single greatest predictor of EF by univariate analysis was the need for preoperative ventilation [odds ratio (OR)?6.5, 95 %CI 1.3–33.2, p?=?0.03]. Patients with EF had a greater likelihood of intensive care readmission (OR?4.8, 95 %CI 1.1–21, p?<?0.04) during the same hospital admission.

Conclusions

Airway narrowing on FB is noted frequently after infant cardiac surgery. Overall assessment and presence of narrowing on bronchoscopy had poor sensitivity and specificity for EF in our cohort. Expert assessment of tracheobronchial narrowing on FB has poor to moderate inter-rater reliability.     

Medication induced diabetes during induction in pediatric acute lymphoblastic leukemia: prevalence, risk factors and characteristics

Introduction

Medication induced diabetes (MID) during induction therapy (MIDi) in patients with acute lymphoblastic leukemia (ALL) is not well characterized in children, with recent studies yielding conflicting results.

Purpose

The purpose of the study was to describe the prevalence of MIDi and risk factors for its development.

Methods

We retrospectively gathered demographic, disease course and treatment data on 363 patients aged 1 to 17.9?years diagnosed with ALL at a pediatric tertiary care hospital between 1998 and 2005. MIDi was defined as blood glucose ≥200?mg/dL (11.1?mmol/L) on at least 2 separate days during induction.

Results

Fifty-seven subjects (15.7%) developed MIDi during the study period. Patients ≥10?years were more likely to develop MIDi than those <10?years (odds ratio [OR] 9.6, 95% confidence interval [CI] 5.1–17.8). BMI percentile among those with MIDi (mean?±?SD 58.2?±?31.0) did not differ from those without MIDi (52.2?±?32.0, P?=?0.429). The presence of Trisomy 21 (OR 3.6, 95% CI 1.1–11.4, P?=?0.030) and CNS involvement at diagnosis (OR 3.8, 95% CI 1.4–10.1, P?=?0.009) were associated with an increased risk of MIDi. After adjustment for potential confounding variables, age ≥10?years and the presence of CNS disease at diagnosis remained significantly associated with MIDi.

Conclusions

Older age and CNS involvement at diagnosis increase the risk of MIDi. In contrast to previous studies, higher BMI was not associated with MIDi in our population.     

TEG® and RapidTEG® are unreliable for detecting warfarin-coagulopathy: a prospective cohort study

Background

Thromboelastography^® (TEG) utilizes kaolin, an intrinsic pathway activator, to assess clotting function. Recent published studies suggest that TEG results are commonly normal in patients receiving warfarin, despite an increased International Normalized Ratio (INR). Because RapidTEG? includes tissue factor, an extrinsic pathway activator, as well as kaolin, we hypothesized that RapidTEG would be more sensitive in detecting a warfarin-effect.

Methods

Included in this prospective study were 22 consecutive patients undergoing elective cardioversion and receiving warfarin. Prior to cardioversion, blood was collected to assess INR, Prothrombin Time, TEG, and RapidTEG.

Results

INR Results: 2.8?±?0.5 (1.6 to 4.2). Prothrombin Time Results: 19.1?±?2.2 (13.9. to 24.3). TEG Results (Reference Range): R-Time: 8.3?±?2.7 (2–8); K-Time: 2.1?±?1.4 (1–3); Angle: 62.5?±?10.3 (55–78); MA: 63.2?±?10.3 (51–69); G: 9.4?±?3.5 (4.6-10.9); R-Time within normal range: 10 (45.5%) with INR 2.9?±?0.3; Correlation coefficients for INR and each of the 5 TEG variables were insignificant (P?>?0.05). RapidTEG Results (Reference Range): ACT: 132?±?58 (86–118); K-Time: 1.2?±?0.5 (1–2); Angle: 75.4?±?5.2 (64–80); MA: 63.4?±?5.1 (52–71); G: 8.9?±?2.0 (5.0-11.6); ACT within normal range: 9 (40.9%) with INR 2.7?±?0.5; Correlation coefficients for INR and each of the 5 RapidTEG variables were insignificant (P?>?0.05).

Conclusions

TEG, using kaolin activation, and RapidTEG, with kaolin and tissue factor activation, were normal in a substantial percent of warfarin patients, despite an increased INR. The false-negative rate for detecting warfarin coagulopathy with either test is unacceptable. The lack of correlation between INR and all TEG and RapidTEG components further indicates that these methodologies are insensitive to warfarin effects. Findings suggest that intrinsic pathway activation may mitigate detection of an extrinsic pathway coagulopathy.     

Mottling score predicts survival in septic shock

Background

Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock.

Methods

We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa?=?0.87, 95% CI (0.72?C0.97)].

Results

Sixty patients were included. The SOFA score was 11.5 (8.5?C14.5), SAPS II was 59 (45?C71) and the 14-day mortality rate 45% [95% CI (33?C58)]. Six?hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p?=?0.001], arterial lactate level [<1.5 OR 1; between 1.5 and 3 OR 3.8 (0.7?C29.5); >3 OR 9.6 (2.1?C70.6), p?=?0.01] and mottling score [score 0?C1 OR 1; score 2?C3 OR 16, 95% CI (4?C81); score 4?C5 OR 74, 95% CI (11?C1,568), p?<?0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred (p?<?0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p?=?0.0005).

Conclusion

The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.     

Prävalenz beeinträchtigender Bauchschmerzen und Menstruationsbeschwerden

Background

There are no data available on the prevalence of disabling abdominal pain and menstrual cramp in adults in Germany.

Methods

Abdominal pain and menstrual cramp, additional somatic symptoms and depressive symptoms were assessed by the Patient Health Questionnaires (PHQ) 15 and 9 in persons ≥?14 years from a sample representative of the general German population. The association of disabling abdominal and menstrual cramp with demographic and clinical variables was tested by logistic regression analyses.

Results

A total of 2524 out of 4064 (62.1?%) contacted persons participated in the study. Of the participants 11.9?% reported suffering from slight abdominal pain and 0.9?% reported suffering from severe abdominal pain within the last 4 weeks. Female gender with an odds ratio (OR) of 2.23 (95?% confidence interval CI 1.67–2.98, p?<?0.001), younger age (OR 0.97, 95?% CI 0.96–0.98, p?<?0.001), physical symptom burden PHQ 15 (OR 1.33, 95?% CI 1.26–1.40, p?<?0.0001) and depression PHQ 9 (OR 1.13, 95?% CI 1.08–1.77, p?<?0.0001) were predictive for abdominal pain. Of the women aged 14–55 years 19.8?% reported to be slightly troubled by menstrual cramp and 3.9?% reported suffering from severe menstrual cramp within the last 4 weeks. Menstrual cramps were predicted by younger age (OR 0.96, 95?% CI 0.94–0.97, p?<?0.001), somatic symptom burden PHQ 15 (OR 1.24, 1.12–1.36, p?<?0.0001) and depression PHQ 9 (OR 1.08, 95?% CI 1.01–1.15, p?<?0.0001).

Conclusion

Persons in the general German population frequently reported slightly disabling abdominal pain and menstrual cramp; however, severely disabling abdominal pain and menstrual cramp were rarely reported. Abdominal pain and menstrual cramps were associated with additional somatic complaints and depression.     

The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation

Purpose

While our understanding of the pathogenesis and management of acute respiratory distress syndrome (ARDS) has improved over the past decade, estimates of its incidence have been controversial. The goal of this study was to examine ARDS incidence and outcome under current lung protective ventilatory support practices before and after the diagnosis of ARDS.

Methods

This was a 1-year prospective, multicenter, observational study in 13 geographical areas of Spain (serving a population of 3.55 million at least 18?years of age) between November 2008 and October 2009. Subjects comprised all consecutive patients meeting American-European Consensus Criteria for ARDS. Data on ventilatory management, gas exchange, hemodynamics, and organ dysfunction were collected.

Results

A total of 255 mechanically ventilated patients fulfilled the ARDS definition, representing an incidence of 7.2/100,000?population/year. Pneumonia and sepsis were the most common causes of ARDS. At the time of meeting ARDS criteria, mean PaO₂/FiO₂ was 114?±?40?mmHg, mean tidal volume was 7.2?±?1.1?ml/kg predicted body weight, mean plateau pressure was 26?±?5?cmH₂O, and mean positive end-expiratory pressure (PEEP) was 9.3?±?2.4?cmH₂O. Overall ARDS intensive care unit (ICU) and hospital mortality was 42.7% (95%CI 37.7?C47.8) and 47.8% (95%CI 42.8?C53.0), respectively.

Conclusions

This is the first study to prospectively estimate the ARDS incidence during the routine application of lung protective ventilation. Our findings support previous estimates in Europe and are an order of magnitude lower than those reported in the USA and Australia. Despite use of lung protective ventilation, overall ICU and hospital mortality of ARDS patients is still higher than 40%.     

Treatment-related side effects and quality of life in cancer patients

Background

Cancer leads to a complicated pattern of change in quality of life (QoL).

Objective

The aims of this study were to assess the impact of treatment-related side effects on QoL in cancer patients and to explore which other factors, and to what extent, contribute to explain low QoL scores.

Methods

One hundred twenty-three cancer patients receiving chemotherapy completed the self-administered questionnaires (Medical Outcomes Short-Form-36 (SF-36) and 12-item General Health Questionnaire). Multiple regression analyses were conducted with the SF-36 physical component summary (PCS) and SF-36 mental component summary (MCS) scores as the dependent variables and demographic and clinical factors as independent variables.

Results

Seventy-two percent of patients experienced treatment-related side effects, and 32% resulted positive for psychiatric diseases. Two multivariate analyses showed that worse PCS scores, like worse MCS scores, were significantly and independently predicted by treatment-related side effects (odds ratio (OR)?=?5.00, 95%CI 1.29–19.45; OR?=?8.08, 95%CI 2.03–32.22, respectively) and changes in health over the last 12?months (OR =2.34, 95%CI 1.47–3.76; OR?=?3.21, 95%CI 1.90–5.41, respectively), after adjustment for age, gender, years of school, time from cancer diagnosis, and psychiatric disease.

Conclusions

Given the new emphasis on QoL, we suggest that physicians have a responsibility to openly discuss therapy efficacy, prognosis as well as the potential for adverse events with their patients. Changes in health, as perceived by patient, should also be monitored at follow-up.     

AV interval optimization using pressure volume loops in dual chamber pacemaker patients with maintained systolic left ventricular function

Background

Atrioventricular (AV) interval optimization is often deemed too time-consuming in dual-chamber pacemaker patients with maintained LV function. Thus the majority of patients are left at their default AV interval.

Objective

To quantify the magnitude of hemodynamic improvement following AV interval optimization in chronically paced dual chamber pacemaker patients.

Patients and methods

A pressure volume catheter was placed in the left ventricle of 19 patients with chronic dual chamber pacing and an ejection fraction >45?% undergoing elective coronary angiography. AV interval was varied in 10?ms steps from 80 to 300?ms, and pressure volume loops were recorded during breath hold.

Results

The average optimal AV interval was 152?±?39?ms compared to 155?±?8?ms for the average default AV interval (range 100–240?ms). The average improvement in stroke work following AV interval optimization was 935?±?760?mmHg/ml (range 0–2,908; p?p?=?0.01).

Conclusion

The overall hemodynamic effect of AV interval optimization in patients with maintained LV function is in the same range as for patients undergoing cardiac resynchronization therapy for several parameters. The positive effect of AV interval optimization also applies to patients who have been chronically paced for years.     

Outcomes in children with refractory pneumonia supported with extracorporeal membrane oxygenation

Purpose

To review the use of extracorporeal membrane oxygenation (ECMO) in severe paediatric pneumonia and evaluate factors that may affect efficacy of this treatment.

Methods

Retrospective study of the ECMO database of a tertiary paediatric intensive care unit and chart review of all patients who were managed with ECMO during their treatment for severe pneumonia over a 23-year period. The main outcome measures were survival to hospital discharge, and ICU and hospital length of stay. We compared the groups of culture-positive versus culture-negative pneumonia, venoarterial (VA) versus venovenous (VV) ECMO, community- versus hospital-acquired cases, and cases before and after 2005.

Results

Fifty patients had 52 cases of pneumonia managed with ECMO. Community-acquired cases were sicker with higher oxygenation index (41.5?±?20.5 versus 26.8?±?17.8; p?=?0.031) and higher inotrope score [20 (5–37.5) versus 7.5 (0–18.8); p?=?0.07]. Use of VA compared with VV ECMO was associated with higher inotrope scores [20 (10–50) versus 5 (0–20); p?=?0.012]. There was a trend towards improved survival in the VV ECMO group (82.4 versus 62.9?%; p?=?0.15). Since 2005, patients have been older [4.7 (1–8) versus 1.25 (0.15–2.8)?years; p?=?0.008] and survival has improved (88.2 versus 60.0?%; p?=?0.039).

Conclusions

Survival in children with pneumonia requiring ECMO has improved over time and is now 90?% in the modern era. Risk factors for death include performing a circuit change [odds ratio (OR) 5.0; 95?% confidence interval (CI) 1.02–24.41; p?=?0.047] and use of continuous renal replacement therapy (OR 4.2; 95?% CI 1.13–15.59; p?=?0.032).     

Long-term clinical outcomes following sirolimus-eluting stent implantation in patients with acute myocardial infarction. A meta-analysis of randomized trials

Objectives

The aim of this study was to perform a meta-analysis of randomized trials, evaluating the long-term outcomes of sirolimus-eluting stents (SES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI).

Background

Despite short-term outcomes of patients with STEMI undergoing primary percutaneous coronary intervention indicate a benefit of SES in terms of reintervention, several concerns remain on the long-term safety and efficacy of SES.

Methods

A systematic literature search of electronic resources, through October 2011, was performed using specific search terms. Included trials were randomized studies comparing SES to BMS in STEMI patients, with a follow-up ≥3?years.

Results

Seven trials were included, with a total of 2,364 patients. At a median follow-up of 3?years, SES significantly reduced the risk of target-vessel revascularization when compared with BMS [odds ratio (OR), 0.44; 95?% confidence interval (CI), 0.34–0.57; p?<?0.0001], without increasing the risk of mortality (OR 0.78; 95?% CI, 0.57–1.08; p?=?0.14), reinfarction (OR 0.91; 95?% CI, 0.61–1.35, p?=?0.64) and early to late stent thrombosis (OR 0.77; 95?% CI, 0.49–1.20; p?=?0.25). However after the first year, SES did not further reduce target-vessel revascularization (OR 1.06; 95?% CI, 0.64–1.74; p?=?0.83) and increased the risk of very late stent thrombosis (OR 2.81; 95?% CI, 1.33–5.92; p?=?0.007).

Conclusions

At long-term follow-up, SES compared to BMS use in STEMI patients reduces the risk of target-vessel revascularization, without increasing the risk of death and reinfarction. However, the strong SES efficacy is counterbalanced by a significant risk of very late stent thrombosis.     

Knee area tissue oxygen saturation is predictive of 14-day mortality in septic shock

Purpose

Thenar eminence tissue oxygen saturation (StO₂) was developed to assess organ perfusion. However, mottling, a strong predictor of mortality in septic shock, develops preferentially around the knee. We aimed to evaluate the prognostic value of StO₂ measured around the knee in septic shock patients and compare it to thenar StO₂.

Methods

This was a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included. Parameters were recorded when vasopressors were started (H0) and every 6?h during 24?h. Their predictive value was assessed on 14-day mortality.

Results

Fifty-two patients were included. SOFA score was 11 (9–15) and SAPS II was 56 (40–72). At 6?h after ICU admission (H6), mean arterial pressure, cardiac index, and central venous pressure were not different between non-survivors and survivors; but non-survivors had higher arterial lactate level (8.8?±?5.0 vs. 2.2?±?1.5?mmol/l, P?P?2 (62?±?20 vs. 72?±?9?%, P?=?0.03). At H6, StO₂ was lower in non-survivors; this difference was not significant for thenar StO₂ (70?±?15 vs. 77?±?12?%, P?=?0.10) but was very pronounced for knee StO₂ (39?±?23 vs. 71?±?12?%, P?2 was associated with a higher mottling score (P?P?R ²?=?0.2), and a lower urinary output (P?=?0.02, R ²?=?0.12).

Conclusion

After initial septic shock resuscitation, StO₂ measured around the knee is a strong predictive factor of 14-day mortality.     

Association between hyperkalemia at critical care initiation and mortality

Purpose

To investigate the association between potassium concentration at the initiation of critical care and all-cause mortality.

Methods

We performed a retrospective observational study on 39,705 patients, age?≥18?years, who received critical care between 1997 and 2007 in two tertiary care hospitals in Boston, Massachusetts. The exposure of interest was the highest potassium concentration on the day of critical care initiation and categorized a priori as 4.0–4.5, 4.5–5.0, 5.0–5.5, 5.5–6.0, 6.0–6.5, or?≥6.5?mEq/l. Logistic regression examined death by days 30, 90, and 365 post-critical care initiation, and in-hospital mortality. Adjusted odds ratios were estimated by multivariable logistic regression models.

Results

The potassium concentration was a strong predictor of all-cause mortality 30?days following critical care initiation with a significant risk gradient across potassium groups following multivariable adjustment: K?=?4.5–5.0?mEq/l OR 1.25 (95?% CI, 1.16–1.35; P?<?0.0001); K?=?5.0–5.5?mEq/l OR 1.42 (95?% CI, 1.29–1.56; P?<?0.0001); K?=?5.5–6.0?mEq/l OR 1.67 (95?% CI, 1.47–1.89; P?<?0.0001); K?=?6.0–6.5?mEq/l OR 1.63 (95?% CI, 1.36–1.95; P?<?0.0001); K?>?6.5?mEq/l OR 1.72 (95?% CI, 1.49–1.99; P?<?0.0001); all relative to patients with K?=?4.0–4.5?mEq/l. Similar significant associations post multivariable adjustments are seen with in-hospital mortality and death by days 90 and 365 post-critical care initiation. In patients whose hyperkalemia decreases?≥1?mEq/l in 48?h post-critical care initiation, the association between high potassium levels and mortality is no longer significant.

Conclusions

Our study demonstrates that a patient's potassium level at critical care initiation is robustly associated with the risk of death even at moderate increases above normal.     

Levosimendan infusion in newborns after corrective surgery for congenital heart disease: randomized controlled trial

Purpose

To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Methods

Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72?h continuous infusion of 0.1?μg/kg/min levosimendan or standard post-CPB inotrope infusion.

Results

Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p?=?0.35), length of mechanical ventilation (5.9?±?5 vs. 6.9?±?8?days, p?=?0.54), and pediatric cardiac intensive care unit (PCICU) stay (11?±?8 vs. 14?±?14?days, p?=?0.26). Low cardiac output syndrome occurred in 37?% of levosimendan patients and in 61?% of controls (p?=?0.059, OR 0.38, 95?% CI 0.14–1.0). Postoperative heart rate, with a significant difference at 6 (p?=?0.008), 12 (p?=?0.037), and 24?h (p?=?0.046), and lactate levels, with a significant difference at PCICU admission (p?=?0.015) and after 6?h (p?=?0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6?h and after 12?h, (p?Conclusions Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3–4 neonates.     

Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

Purpose

The relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status.

Methods

We conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index?≥?30 kg/m²) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90.

Results

Three hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40–53) in the non-obese and 46% (95% CI, 36–56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9?±?4.2 cmH₂O) than in non-survivors (15.2?±?5.2 cmH₂O, p?<?0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7?±?4.5 cmH₂O) and non-survivors (13.2?±?5.1 cmH₂O, p?=?0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR?=?1.04 (95% CI 1.01–1.07) for each point of increase], Crs [HR?=?0.97 (95% CI 0.96–0.99) for each point of increase] and driving pressure [HR?=?1.07 (95% CI 1.04–1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients.

Conclusions

Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

     

Does femoral venous pressure measurement correlate well with intrabladder pressure measurement? A multicenter observational trial

Purpose

To investigate if femoral venous pressure (FVP) measurement can be used as a surrogate measure for intra-abdominal pressure (IAP) via the bladder.

Methods

This was a prospective, multicenter observational study. IAP and FVP were simultaneously measured in 149 patients. The effect of BMI on IAP was investigated.

Results

The incidences of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) were 58 and 7% respectively. The mean APACHE II score was 22?±?10, SAPS 2 score 42?±?20, and SOFA score 9?±?4. The mean IAP was 11.2?±?4.5?mmHg versus 12.7?±?4.7?mmHg for FVP. The bias and precision for all measurements were ?1.5 and 3.6?mmHg respectively with the lower and upper limits of agreement being ?8.6 and 5.7. When IAP was above 20?mmHg, the bias between IAP and FVP was 0.7 with a precision of 2.0?mmHg (lower and upper limits of agreement ?3 and 4.6 respectively). Excluding those with ACS, according to the receiver operating curve analysis FVP?=?11.5?mmHg predicted IAH with a sensitivity and specificity of 84.8 and 67.0% (AUC of 0.83 (95% CI 0.81?C0.86) with P?P?2 was 10.6?±?4.0?mmHg versus 13.8?±?3.8?mmHg in patients with a BMI????30?kg/m² (P?Conclusions FVP cannot be used as a surrogate measure of IAP unless IAP is above 20?mmHg.     

Clinical correlates of endothelial function in chronic heart failure

Objective

There is a close link between heart failure and endothelial dysfunction. Brachial flow-mediated dilation (FMD) is a validated non-invasive measure of endothelial function. The aim of this study was to investigate the clinical correlates of FMD in patients with chronic heart failure (CHF).

Design, setting, patients

We evaluated 60 CHF outpatients (age 62?±?14?years; 49 males, NYHA class 2.2?±?0.7, left ventricular ejection fraction, LVEF, 33?±?8%) taking conventional medical therapy (ACE-inhibitors and/or ARBs 93%, beta-blockers 95%) and in stable clinical conditions.

Main outcome measures

The maximum recovery value of FMD was calculated as the ratio of the change in diameter (maximum-baseline) over the baseline value.

Results

As compared with patients with a higher FMD, those with FMD below the median value (4.3%) were more frequently affected by ischemic cardiopathy (50 vs. 23%; p?=?0.032) and diabetes mellitus (20 vs. 3%; p?=?0.044), had a higher NYHA class (2.5?±?0.5 vs. 1.9?±?0.7; p?<?0.001) and NT-proBNP (2,690?±?3,690 vs. 822?±?1,060; p?=?0.001), lower glomerular filtration rate estimated by Cockcroft-Gault (GFRCG: 63?±?28 vs. 78?±?25; p?=?0.001) and LVEF (29?±?8 vs. 37?±?9; p?=?0.001), as well as more frequently showing a restrictive pattern (40 vs. 7%; p?=?0.002). In a multivariate regression model (R ²?=?0.48; p?<?0.001), FMD remained associated only with the NYHA class (p?=?0.039) and diabetes mellitus (p?=?0.024).

Conclusions

This study demonstrates that a better functional status and absence of diabetes mellitus are associated to higher FMD regardless of the etiology of the cardiac disease.     

A retrospective study to evaluate the time burden associated with outpatient red blood transfusions indicated for anemia due to concomitantly administered chemotherapy in cancer patients

Purpose

Anemia in cancer patients can be treated with red blood cell (RBC) transfusions. The patient burden associated with a treatment in terms of total time spent is an important factor to consider when measuring the benefits and challenges of a therapy. This study estimates the time-related patient burden associated with outpatient RBC transfusion.

Methods

A retrospective chart review of outpatient cancer patients receiving a RBC transfusion was conducted at 10 US centers. RBC transfusion time was measured as time elapsed from pre- to post-transfusion vital sign assessment and from transfusion start to stop time. Elapsed time from hemoglobin level testing and blood draw for cross-match to transfusion, estimated travel time and distance, and clinical and demographic data were also collected.

Results

Data from 110 patients (48.2 % male; mean age 64?±?12 years) showed that the mean elapsed time between pre- and post-vital sign assessment was 4.2 h (95 % confidence interval (CI), 3.64–4.81) including 3.6 h (95 % CI, 3.0–4.1) on average to receive the actual RBC transfusion treatment. Hemoglobin level testing (mean Hg level, 8.33 g/dL?±?0.67) and blood drawn for cross-match were completed in an average of 31.2 h (95 % CI, 17.0–45.5) and 18.2 h (95 % CI, 12.1–24.2) prior to transfusion, respectively. Patient one-way travel time averaged 30.0 min (95 % CI, 25.9–34.3).

Conclusions

In the US, CIA patients experience an important time burden when being treated with RBC transfusion in addition to the burden already added by chemotherapy.     

Prevalence and factors associated with polypharmacy in older people with cancer

Purpose

Polypharmacy has been associated with drug–drug interactions, adverse drug events, hospitalisation and increased mortality. The purpose of this study was to investigate the prevalence and factors associated with polypharmacy in older people with cancer.

Patients and methods

Patients aged ≥70 years (n?=?385) presenting to the medical oncology outpatient clinic at Royal Adelaide Hospital between January 2009 and July 2010 completed a structured data collection instrument. The instrument included domains related to medications, diagnoses, instrumental activities of daily living (IADLs), Karnofsky Performance Scale (KPS), physical function (SF-36), pain (ten-point visual analogue scale, VAS), weight loss (patient self-reported over previous 6 months), exhaustion (CES-D) and distress (ten-point VAS). Frailty was computed using Fried’s frailty phenotype. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association between polypharmacy (defined as five or more self-reported daily medications) and clinical parameters.

Results

Polypharmacy was present in 57 % (n?=?221) of patients. When adjusting for age, gender and Charlson Comorbidity Index (CCI), polypharmacy was associated with being pre-frail (OR?=?2.35, 95%CI?=?1.43–3.86) and frail (OR?=?4.48, 95%CI?=?1.90–10.54) compared to being robust. When adjusting for age, gender, exhaustion, KPS, IADLs, pain and distress, polypharmacy was associated with higher CCI scores (OR?=?1.58, 95%CI?=?1.29–1.94) and poorer physical function (OR?=?1.13, 95%CI?=?1.06–1.20).

Conclusions

Polypharmacy is highly prevalent in older people with cancer and associated with impaired physical function and being pre-frail and frail compared to being robust. Research is needed to identify strategies to minimize patients’ medication regimens.