Prognostic Tools for Early Mortality in Hemorrhagic Stroke: Systematic Review and Meta-Analysis

Background and Purpose

Several risk scores have been developed to predict mortality in intracerebral hemorrhage (ICH). We aimed to systematically determine the performance of published prognostic tools.

Methods

We searched MEDLINE and EMBASE for prognostic models (published between 2004 and April 2014) used in predicting early mortality (<6 months) after ICH. We evaluated the discrimination performance of the tools through a random-effects meta-analysis of the area under the receiver operating characteristic curve (AUC) or c-statistic. We evaluated the following components of the study validity: study design, collection of prognostic variables, treatment pathways, and missing data.

Results

We identified 11 articles (involving 41,555 patients) reporting on the accuracy of 12 different tools for predicting mortality in ICH. Most studies were either retrospective or post-hoc analyses of prospectively collected data; all but one produced validation data. The Hemphill-ICH score had the largest number of validation cohorts (9 studies involving 3,819 patients) within our systematic review and showed good performance in 4 countries, with a pooled AUC of 0.80 [95% confidence interval (CI)=0.77-0.85]. We identified several modified versions of the Hemphill-ICH score, with the ICH-Grading Scale (GS) score appearing to be the most promising variant, with a pooled AUC across four studies of 0.87 (95% CI=0.84-0.90). Subgroup testing found statistically significant differences between the AUCs obtained in studies involving Hemphill-ICH and ICH-GS scores (p=0.01).

Conclusions

Our meta-analysis evaluated the performance of 12 ICH prognostic tools and found greater supporting evidence for 2 models (Hemphill-ICH and ICH-GS), with generally good performance overall.     

Improved outcomes for paediatric renal transplant recipients

Pre-emptive living donor renal transplantation improves the morbidity and mortality of children with end stage kidney disease and is widely accepted as the gold standard for renal replacement therapy. As the accessibility to transplantation improves, its success is underpinned by the evolving importance of renal allograft matching and the principles of the immune mechanisms that lead the host response to engraftment. This coupled with the development of immunosuppressive protocols which have improved the renal allograft survival and simultaneous refinement of surgical expertise, allowing progressively younger children to undergo successful transplantation. Most importantly, advances have collectively improved the neurocognitive and psychosocial outcomes for children. However, despite great innovations, significant hurdles remain with improving outcomes for chronic allograft dysfunction and improving renal allograft survival. Unsurprisingly, best practice guidelines are debated with a growing shift from protocol based towards individualised therapy. In addition, immunosuppressive regimens are commonly associated with a significant increase in adverse effects, which correlates with a decline in adherence. Looking forwards, the global burden of transplantation outweighs the number of potential donors, therefore the legislative framework becomes more important to protect vulnerable individuals. This review explores transformative power of transplantation alongside the predicted challenges ahead.     

Synthesis of calcium carbonate microcapsules as self-healing containers

Contemporary studies of self-healing polymer composites are based on microcapsules synthesized using synthetic and toxic polymers, biopolymers, etc. via methods such as in situ polymerization, electrospraying, and air atomization. Herein, we synthesized a healing agent, epoxy (EPX) encapsulated calcium carbonate (CC) microcapsules, which was used to prepare self-healing EPX composites as a protective coating for metals. The CC microcapsules were synthesized using two facile methods, namely, the soft-template method (STM) and the in situ emulsion method (EM). Microcapsules prepared using the STM (ST-CC) were synthesized using sodium dodecyl sulphate (SDS) surfactant micelles as the soft-template, while the microcapsules prepared using the EM (EM-CC) were synthesized in an oil-in-water (O/W) in situ emulsion. These prepared CC microcapsules were characterized using light microscopy (LMC), field emission scanning electron microscopy (FE-SEM), fourier transform infrared spectroscopy (FTIR), nuclear magnetic resonance spectroscopy (NMR), and thermogravimetric analysis (TGA). The synthesized ST-CC microcapsules were spherical in shape, with an average diameter of 2.5 μm and an average shell wall thickness of 650 nm, while EM-CC microcapsules had a near-spherical shape with an average diameter of 3.4 μm and an average shell wall thickness of 880 nm. The ST-CC capsules exhibited flake-like rough surfaces while EM-CC capsules showed smooth bulgy surfaces. The loading capacity of ST-CC and EM-CC microcapsules were estimated using TGA and found to be 11% and 36%, respectively. The FTIR and NMR spectra confirmed the EPX encapsulation and the unreactive nature of the loaded EPX with the inner walls of CC microcapsules. The synthesized CC microcapsules were further incorporated into an EPX matrix to prepare composite coatings with 10 (w/w%), 20 (w/w%), and 50 (w/w%) capsule loadings. The prepared EPX composite coatings were scratched and observed using FE-SEM and LMC to evaluate the release of encapsulated EPX inside the CC capsules, which is analogous to the healing behaviour. Moreover, EPX composite coatings with 20 (w/w%) and 50 (w/w%) of ST-CC showed better healing performances. Thus, it was observed that ST-CC microcapsules outperformed EM-CC. Additionally, the EPX/CC coatings showed remarkable self-healing properties by closing the gaps of the scratch surfaces. Thus, these formaldehyde-free, biocompatible, biodegradable, and non-toxic CC based EPX composite coatings hold great potential to be used as a protective coating for metal substrates. Primary results detected significant corrosion retardancy due to the self-healing coatings under an accelerated corrosion process, which was performed with a salt spray test.

Healing agent, epoxy encapsulated calcium carbonate microcapsules were prepared using a facile method as a self-healing composite for protective metal coatings.     

Prognosis of multi-lobar pneumonia in community-acquired pneumonia: A systematic review and meta-analysis

BackgroundPneumonia is the leading cause of infection related mortality. Multilobar pneumonia (MLP) may have poorer outcomes and is a constituent of some prognostic indices. Our aim was to systematically-review and meta-analyse the impact of multi-lobar involvement in pneumonia.MethodsWe searched PubMed in June 2012 for studies reporting on the association between MLP and clinical outcomes. Potentially relevant studies were cross checked by two independent reviewers before final inclusion. Odds-ratios (OR) for the association between MLP and mortality, unfavourable outcomes, and poor treatment response were pooled using random effects meta-analysis.ResultsTwenty-two studies were included in this report. There were a total of 11,456 pneumonia patients including 2897 (25.3%) patients with MLP. As there was substantial clinical and statistical heterogeneity in the overall dataset, we limited the main meta-analysis to patients with community-acquired pneumonia (CAP). This showed that MLP was associated with increased mortality, OR 2.57 (95% CI: 1.83–3.61), with no statistical heterogeneity (I² = 0%). Evidence from other settings suggests that MLP may also be associated with higher likelihood of other poor outcomes such as worsening clinical/radiological status, delayed resolution, and need for mechanical ventilation.ConclusionMLP appears to be an independent risk factor for mortality in CAP. It may be possible to improve commonly used prognostic indices in CAP by addition of MLP as a criterion.