Hyperoxemia and long-term outcome after traumatic brain injury

Introduction

The relationship between hyperoxemia and outcome in patients with traumatic brain injury (TBI) is controversial. We sought to investigate the independent relationship between hyperoxemia and long-term mortality in patients with moderate-to-severe traumatic brain injury.

Methods

The Finnish Intensive Care Consortium database was screened for mechanically ventilated patients with a moderate-to-severe TBI. Patients were categorized, according to the highest measured alveolar-arterial O₂ gradient or the lowest measured PaO₂ value during the first 24 hours of ICU admission, to hypoxemia (<10.0 kPa), normoxemia (10.0 to 13.3 kPa) and hyperoxemia (>13.3 kPa). We adjusted for markers of illness severity to evaluate the independent relationship between hyperoxemia and 6-month mortality.

Results

A total of 1,116 patients were included in the study, of which 16% (n = 174) were hypoxemic, 51% (n = 567) normoxemic and 33% (n = 375) hyperoxemic. The total 6-month mortality was 39% (n = 435). A significant association between hyperoxemia and a decreased risk of mortality was found in univariate analysis (P = 0.012). However, after adjusting for markers of illness severity in a multivariate logistic regression model hyperoxemia showed no independent relationship with 6-month mortality (hyperoxemia vs. normoxemia OR 0.88, 95% CI 0. 63 to 1.22, P = 0.43; hyperoxemia vs. hypoxemia OR 0.97, 95% CI 0.63 to 1.50, P = 0.90).

Conclusion

Hyperoxemia in the first 24 hours of ICU admission after a moderate-to-severe TBI is not predictive of 6-month mortality.     

Risk Factors for Aspiration in Community-acquired Pneumonia: Analysis of a Hospitalized UK Cohort

Background

There is a move toward finding clinically useful “phenotypes” in community-acquired pneumonia: groups of patients displaying distinct clinical characteristics, microbiology, and prognosis. Aspiration pneumonia is an intuitive clinical phenotype; however, to date there are no recognized diagnostic criteria, and data regarding outcomes in suspected aspiration are limited.

Methods

An observational study of 1348 patients hospitalized with community-acquired pneumonia in the United Kingdom examined both short- and long-term outcomes for patients at risk of aspiration pneumonia. Patients were defined as “at risk” in the presence of chronic neurologic disorders, esophageal disorders and dysphagia, impaired conscious level, vomiting, or witnessed aspiration. The primary outcome was 30-day mortality. Secondary outcomes included 1-year mortality, readmissions, and recurrent pneumonia within 1 year.

Results

Some 13.8% of the cohort were classified as “at risk of aspiration.” These patients were older (median age, 74 years [interquartile range, 60-84] vs 66 years [interquartile range, 49-77]; P < .0001) and more likely to have comorbidities (chronic liver disease 11.3% vs 3.7%, P < .0001; congestive heart failure 28% vs 17.1%, P = .0004; and stroke 26.9% vs 9.5%, P < .0001). Patients at risk of aspiration pneumonia had a poorer short-term outcome (30-day mortality 17.2% vs 7.7%, P < .0001), but after adjusting for their greater severity of illness and comorbidities this difference was not significant (odds ratio 1.05; 95% confidence interval [CI], 0.63-1.76; P = .8). However, patients with aspiration risk factors were at greater risk of poor long-term outcomes with increased 1-year mortality (hazard ratio [HR], 1.73; 95% CI, 1.15-2.58), increased risk of rehospitalization (HR, 1.52; 95% CI, 1.21-1.91), and a strong association with recurrent admissions with pneumonia (HR, 3.13; 95% CI, 2.05-4.78) after multivariable adjustment.

Conclusions

Using risk factors to identify patients at risk of aspiration pneumonia identifies a distinct clinically useful phenotype of patients with greater severity of disease and poorer long-term outcomes.     

Percutaneous Endoscopic Gastrostomy (PEG) for Enteral Nutrition in Patients with Stroke

Background: The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. Methods: Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. Results: Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group ( n &#114 = &#114 115); 30-day mortality was similar but more patients recovered the ability to swallow. Conclusions: Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.     

Triceps Skinfold as a Prognostic Predictor in Outpatient Heart Failure

Background

Most reports regarding the obesity paradox have focused on body mass index (BMI) to classify obesity and the prognostic values of other indirect measurements of body composition remain poorly examined in heart failure (HF).

Objective

To evaluate the association between BMI and other indirect, but easily accessible, body composition measurements associated with the risk of all-cause mortality in HF.

Methods

Anthropometric parameters of body composition were assessed in 344 outpatients with a left ventricular ejection fraction (LVEF) of ≤50% from a prospective HF cohort that was followed-up for 30 ± 8.2 months. Survival was evaluated using the Kaplan-Meier method and Cox proportional hazard regression analysis.

Results

HF patients were predominantly male, of non-ischemic etiology, and had moderate to severe LV systolic dysfunction (mean LVEF = 32 ± 9%). Triceps skinfold (TSF) was the only anthropometric index that was associated with HF prognosis and had significantly lower values in patients who died (p = 0.047). A TSF ≥ 20 mm was present in 9% of patients that died and 22% of those who survived (p = 0.027). Univariate analysis showed that serum creatinine level, LVEF, and NYHA class were associated with the risk of death, while Cox proportional hazard regression analysis showed that TSF ≥ 20 was a strong independent predictor of all-cause mortality (hazard ratio = 0.36; 95% CI = 0.13-0.97, p = 0.03).

Conclusion

Although BMI is the most widely used anthropometric parameter in clinical practice, our results suggested that TSF is a better predictive marker of mortality in HF outpatients.     

Circulating aldosterone and mortality in female nursing home residents

Objectives

To date studies evaluating the relation between circulating aldosterone levels and mortality in elderly female individuals are lacking. We therefore aimed to assess the relationship between circulating aldosterone levels and mortality in a population-based cohort study of female nursing home residents.

Methods

Individuals aged 70 years and older were recruited from 95 nursing homes in Austria. Participants were enrolled and followed up by mobile study teams. All participants underwent an extensive health examination and were followed until death or end of the study. Serum aldosterone concentration (SAC) was measured at baseline after exclusion of twenty seven patients taking mineralocorticoid-receptor (MR) blockers.

Results

Median SAC was 171.1 (IQR: 103.2–303.4) pg/mL (normal range: 30–400) in 471 female individuals (mean age: 83.7 ± 6.2 years). After a median follow-up of 27 ± 8 months, a total of 121 (25.7%) participants died. In multivariable Cox proportional hazard analysis, SAC levels stratified in quartiles were significantly associated with all-cause mortality. Compared with the reference (first) SAC quartile, the Cox proportional hazard ratio (confidence interval 95%) for the fourth SAC quartiles was 1.94, 95% CI = 1.08–3.46, p = 0.026. We found statistically significant interaction terms between SAC-related mortality and the presence of advanced heart failure (NYHA functional class III; p = 0.038), HbA1c (p = 0.043) and eGFR levels (p = 0.030).

Conclusions

Higher circulating aldosterone levels are related to an increased mortality risk in elderly female nursing home residents. Interventional studies are needed to assess the potential influence of MR blockade on “hard” clinical outcomes in individuals aged 70 years and older.     

Decreased prevalence of celiac disease among Brazilian elderly

AIM: To evaluate the prevalence of celiac disease in a group of Brazilian individuals over 60 years of age and compare it with the previously known prevalence in a pediatric group living in the same geographical area.METHODS: The research protocol was approved by the Ethics Committee of the University of Brasilia School of Medicine, Brasilia, Brazil. Blood samples from 946 individuals (295 male and 651 female) aged 60 years or older were collected between May 2010 and July 2011. The study subjects’ mean and median ages were 68.1 and 67 years, respectively, ranging from 60 to 92 years. That age distribution closely corresponded to the age distribution of the Brazilian population according to the Brazilian 2010 census. The participants were consecutive and unselected outpatients undergoing blood tests at the University of Brasilia Hospital’s Clinical Pathology Laboratory. All sera were tested for immunoglobulin A anti-transglutaminase antibodies (IgA-tTG) by enzymelinked immunosorbent assay, and those that were positive were further tested for immunoglobulin A antiendomysium antibodies (IgA-EMA). Human leukocyte antigen (HLA) genotyping was performed for all individuals who exhibited positive serologic results for IgA-tTG and/or IgA-EMA.RESULTS: Out of the 946 studied patients, only one previously diagnosed case of biopsy-proven celiac disease was detected. For the remaining subjects, nine serum samples tested positive for IgA-tTG antibodies; however, none of them tested positive for IgA-EMA antibodies. The HLA genotyping of those nine subjects revealed that one was carrying DQA1*0501 and two were carrying DQB1*0201 alleles. These data showed that, among those 946 elderly individuals, the prevalence of celiac disease (CD) was 0.1% (95%CI: 0.00-0.59). The prevalence of CD for the elderly group was compared with that observed for the group of 2034 children younger than 15 years (age range, 1-14 years; mean age, 8 years) who took part in our previous CD prevalence screening study. All the children came from the s     

Toxicity effect of Delonix elata (Yellow Gulmohr) and predatory efficiency of Copepod,Mesocyclops aspericornis for the control of dengue vector,Aedes aegypti

Objective

To evaluate the toxicity, predatory efficiency of Delonix elata (D. elata) and Mesocyclops aspericornis (M. aspericornis) against dengue vector, Aedes aegypti (Ae. aegypti).

Methods

A mosquitocidal bioassay was conducted at different concentration of plant extract followed by WHO standard method. The probit analysis of each tested concentration and control were observed by using software SPSS 11 version package. The each tested concentration variable was assessed by DMRT method. The predatory efficiency of copepod was followed by Deo et al., 1988. The predator, M. aspericornis was observed for mortality, abnormalities, survival and swimming activity after 24 h treatment of plant and also predation on the mosquito larvae were observed.

Results

D. elata were tested for biological activity against the larvae, and pupae of Ae. aegypti. Significant mortality effects were observed in each life stage. The percentage of mortality was 100% in first and second instars whereas 96%, 92% in third and fourth instars. Fitted probit-mortality curves for larvae indicated the median and 90% lethal concentrations of D. elata for instars 1-4 to be 4.91 (8.13), 5.16 (8.44), 5.95 (7.76) and 6.87 (11.23), respectively. The results indicate that leaf extract exhibits significant biological activity against life stages. The present study revealed that D. elata is potentially important in the control of Ae. aegypti. Similar studies were conducted for predatory efficiency of Copepod, M. aspericornis against mosquito vector Ae. Aegypti. This study reported that the predatory copepod fed on 39% and 25% in I and III instar larvae of mosquito and in combined treatment of D. elata and copepod maximum control of mosquito larval states and at 83%, 80%, 75% and 53% in I, II, III and IV instars, respectively.

Conclusions

The combined action of plant extract and predatory copepod to effectively control mosquito population and reduce the dengue transmitting diseases.     

Mortality after in-hospital cardiopulmonary resuscitation: Multicenter analysis in Korea

Purpose

The purpose of this study is to evaluate factors associated with the mortality of patients admitted to intensive care units (ICUs) after in-hospital cardiopulmonary resuscitation (CPR) and the impact of a hospital rapid response system (RRS) on patient mortality in Korea.

Materials and Methods

A prospective multicenter cohort study was done in 22 ICUs of 15 centers from July 1, 2010, to January 31, 2011. We only enrolled patients admitted to ICUs after in-hospital CPR and divided eligible patients into 2 groups—survivors and nonsurvivors.

Results

Among 4617 patients, 150 patients were admitted post-CPR, 76 died, and 74 survived. At 24 hours, the Sequential Organ Failure Assessment score, Simplified Acute Physiology Score II, and the best Glasgow Coma Scale were significantly lower in the nonsurvivors than in the survivors. In multivariate analysis, the Simplified Acute Physiology Score II and presence of lower respiratory infection were both independently associated with mortality. At the first hour after admission, lowest serum potassium and highest heart rate were associated with mortality. At 24 hours after admission, lowest mean arterial pressure, HCO₃ level, and venous oxygen saturation level; highest heart rate; and use of vasoactive drugs were associated with mortality. The mortality of patients in hospitals with an RRS was not significantly different from that of hospitals without an RRS.

Conclusion

Various physiologic and laboratory parameters were associated with the mortality of post-CPR ICU admitted patients, and the presence of an RRS did not reduce mortality of these patients in our study.