De-novo immune-mediated thrombotic thrombocytopenic purpura following surgical and non-surgical procedures: A systematic review

When de-novo immune-mediated thrombotic thrombocytopenic purpura (TTP) is diagnosed following an invasive procedure, clinical presentation patterns and outcomes are poorly defined. Therefore, in a systematic literature review of patients diagnosed with TTP following an invasive surgical or non-surgical procedure, we identified 19 studies reporting data on 25 patients. These data suggest that 1) TTP pathogenesis likely begins prior to the invasive procedure, 2) patients experience significant diagnostic delays, and 3) there is a high incidence of renal replacement therapy. Although invasive procedures may trigger TTP, further studies are needed to clarify the mechanisms underlying this association.

The Frequency and Precipitating Factors for Breakthrough Seizures in Children with Epilepsy

Background and Purpose

To determine the common precipitating factors for breakthrough seizures in children with epilepsy.

Methods

This retrospective study reviewed the charts of children with epilepsy who were followed up in the pediatric neurology clinic of King Fahad Hospital in Al-Baha region, Saudi Arabia, between January 2015 and August 2022. Children between 1 to 14 years of age who had epilepsy, as per the International League Against Epilepsy definition and received anti-seizure medication with a seizure-free period of at least 2 months before breakthrough seizure episode, were included in the study.

Results

Of the 108 children included in the study, the mean age was 6.8±1.6 years, and among them (55.5%) were male. Most parents (69.5%) were unaware of the triggering factors of seizure. The majority of patients (88%) reported at least one precipitating factor for breakthrough seizures and the most common one was systemic infection associated with fever (52.8%), and then non-compliance to medications in (34.3%) of the patients. In terms of the electroencephalogram, around 84 patients (77.8%) had abnormal electroencephalogram. Finally, monotherapy was maintained in 63.9% of patients.

Conclusions

We conclude that the most common trigger for breakthrough seizure is a systemic infection associated with fever and non-compliance to anti-seizure medications. Increasing the level of awareness by different methods may help limit or even prevent seizures from occurring. Randomized controlled trials could shed light on the adjustment of anti-seizure medications temporarily by increasing the dosage or giving extra doses during the infection to avoid breakthrough seizures.

The predictive value of precipitating factors on clinical outcomes in hospitalized patients with decompensated heart failure: insights from the Egyptian cohort in the European Society of Cardiology Heart Failure long-term registry

BACKGROUND

Knowledge of the frequency of precipitating factors for acute heart failure (AHF) is important (either new-onset heart failure [NOHF] or worsening heart failure [WHF]), as this can guide strategies for prevention and treatment. Most data come only from Western Europe and North America; nevertheless, geographic differences do exist. We set out to study the prevalence of precipitating factors of AHF and their connection to patient characteristics and in-hospital and long-term mortality in patients from Egypt hospitalized for decompensated HF. Using the ESC-HF-LT Registry which is a prospective, multicenter, observational study of patients confessed to cardiology centers in the nations of Europe and the Mediterranean, patients presenting with AHF were recruited from 20 centers all over Egypt. Enrolling physicians were requested to report possible precipitants from among several predefined reasons.

RESULTS

We included 1515 patients (mean age 60 ± 12 years, 69% males). The mean LVEF was 38 ± 11%. Seventy-seven percent of the total population had HFrEF, 9.8% had HFmrEF, and 13.3% had HFpEF. The commonly reported precipitating factors for AHF hospitalization among study population were as follows (in decreasing order of frequency): infection in 30.3% of patients, acute coronary syndrome/myocardial ischemia (ACS/MI) in 26%, anemia in 24.3%, uncontrolled hypertension in 24.2%, atrial fibrillation (AF) in 18.3%, renal dysfunction in 14.6%, and non-compliance in 6.5% of patients. HFpEF patients had significantly higher rates of AF, uncontrolled hypertension, and anemia as precipitants for acute decompensation. ACS/MI were significantly more frequent in patients with HFmrEF. WHF patients had significantly higher rates of infection and non-compliance, whereas new-onset HF patients showed significantly higher rates of ACS/MI and uncontrolled hypertension. One-year follow-up revealed that patients with HFrEF had a significantly higher rate of mortality compared to patients with HFmrEF and HFpEF (28.3%, 19.5, and 19.4%, P = 0.004). Patients with WHF had a significantly higher rates of 1-year mortality when compared to those with NOHF (30.0% vs. 20.3%, P < 0.001). Renal dysfunction, anemia, and infection were independently connected to worse long-term survival.

CONCLUSIONS

Precipitating factors of AHF are frequent and substantially influence outcomes after hospitalization. They should be considered goals for avoiding AHF hospitalization and depicting those at highest risk for short-term mortality.

Adrenal crises in adolescents and young adults

PURPOSE

Review the literature concerning adrenal insufficiency (AI) and adrenal crisis (AC) in adolescents and young adults.

METHODS

Searches of PubMed identifying relevant reports up to March 2022.

RESULTS

AI is rare disorder that requires lifelong glucocorticoid replacement therapy and is associated with substantial morbidity and occasional mortality among adolescents and young adults. Aetiologies in this age group are more commonly congenital, with acquired causes, resulting from tumours in the hypothalamic-pituitary area and autoimmune adrenalitis among others, increasing with age. All patients with AI are at risk of AC, which have an estimated incidence of 6 to 8 ACs/100 patient years. Prevention of ACs includes use of educational interventions to achieve competency in dose escalation and parenteral glucocorticoid administration during times of physiological stress, such as an intercurrent infection. While the incidence of AI/AC in young children and adults has been documented, there are few studies focussed on the AC occurrence in adolescents and young adults with AI. This is despite the range of developmental, psychosocial, and structural changes that can interfere with chronic disease management during this important period of growth and development.

CONCLUSION

In this review, we examine the current state of knowledge of AC epidemiology in emerging adults; examine the causes of ACs in this age group; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in these patients.

Triggers in functional motor disorder: a clinical feature distinct from precipitating factors

Background and objective

People with functional motor disorder (FMD) report triggers—sensory or motor-induced stimuli that exacerbate or initiate paroxysmal occurrences of their movement disorder. These are a distinct phenomenon from precipitating factors occurring at the initial onset of the disorder. We aimed to assess triggers in FMD and understand their relevance to paroxysmal variability often seen in FMD.

Methods

We enrolled consecutive outpatients with a definite diagnosis of FMD. Each patient underwent a detailed clinical evaluation also including the presence of trigger factors and video-recordings both during neurological examination and physiotherapy treatment. Patients were classified as having “triggers” (T-FMD) or “not having triggers” (NoT-FMD) as well as “paroxysmal” compared to “persistent with paroxysmal variability”.

Results

The study sample was 100 patients (82% female) with FMD; the mean age at onset was 41 years. Triggers were observed in 88% of patients and in 65 of these the FMD was pure paroxysmal. The most common triggers were movement or physical exercise, followed by emotional, visual, touch, and auditory stimuli; 39 (44%) were isolated and 49 (56%) were combined triggers. Among the T-FMD patients, FMD were paroxysmal in 74% (n = 65) and persistent with paroxysmal variability in 26% (n = 23). The T-FMD patients were younger (p = 0.016) and had a gait disorder (p = 0.035) more frequently than the NoT-FMD patients.

Discussion

Triggers are frequent in FMD and may have diverse overlapping clinical presentations. In this sample, FMD was most often paroxysmal, suggesting the value of noting triggers as clinical clues in the diagnosis and rehabilitation of FMD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11102-1.

Delirium is associated with an increased morbidity and in-hospital mortality in cancer patients: Results from a prospective cohort study

OBJECTIVE

Delirium is a frequent complication in advanced cancer patients, among whom it is frequently underdiagnosed and inadequately treated. To date, evidence on risk factors and the prognostic impact of delirium on outcomes remains sparse in this patient population.

METHOD

In this prospective observational cohort study at a single tertiary-care center, 1,350 cancer patients were enrolled. Simple and multiple logistic regression models were utilized to identify associations between predisposing and precipitating factors and delirium. Cox proportional-hazards models were used to estimate the effect of delirium on death rate.

RESULTS

In our patient cohort, the prevalence of delirium was 34.3%. Delirium was associated inter alia with prolonged hospitalization, a doubling of care requirements, increased healthcare costs, increased need for institutionalization (OR 3.22), and increased mortality (OR 8.78). Predisposing factors for delirium were impaired activity (OR 10.82), frailty (OR 4.75); hearing (OR 2.23) and visual impairment (OR 1.89), chronic pneumonitis (OR 2.62), hypertension (OR 1.46), and renal insufficiency (OR 1.82). Precipitating factors were acute renal failure (OR 7.50), pressure sores (OR 3.78), pain (OR 2.86), and cystitis (OR 1.32). On multivariate Cox regression, delirium increased the mortality risk sixfold (HR 5.66). Age ≥ 65 years and comorbidities further doubled the mortality risk of delirious patients (HR 1.77; HR 2.05).

SIGNIFICANCE OF RESULTS

Delirium is common in cancer patients and associated with increased morbidity and mortality. Systematically categorizing predisposing and precipitating factors might yield new strategies for preventing and managing delirium in cancer patients.

Factors Associated With Suicidal Ideation in Older Adults From Three Cities in Colombia, 2016

INTRODUCTION

Suicidal ideation refers to thoughts that range from a vague idea of committing suicide to a specific suicide plan.

OBJECTIVE

To explore factors such as demographic, social, family, abuse, risk of depression, habits and health conditions, which influence suicidal ideation in the elderly people in the cities of Medellín, Barranquilla, and Pasto (Colombia), with the intention to identify those associated factors that can be used in public health programs focused on this population.

METHODS

Cross-sectional analytical study was conducted using a secondary source, demographic, social, clinical variables, social support, discrimination, abuse, happiness, depression, functional capacity, and as a dependent variable were asked the question: "Have you ever thought about committing suicide?" A descriptive, bivariate and multivariate analysis was performed.

RESULTS

The median age was ≤ 69 [interquartile range, 11] years, and 58.2% were women. The prevalence of suicidal ideation was 6.4%, and of these, 28.7% had made plans to end their lives, and 66.7% had tried at least once. A statistical association was found with informal employment, cigarette consumption, alcohol and psychoactive substances, risk of depression, having a disability, dissatisfaction with their quality of life, with their health, with their economic situation, as well as feeling unhappy, bad treatment and bad relationships among family members, poor social support, sexual and economic abuse, and finally, discrimination.

CONCLUSIONS

Suicidal ideation in older adults in three cities of Colombia is explained by the sexual and economic abuse that this population is suffering, as well as bad personal relationships between the members of the family of the older adult. The risk of depression increases the probability of having thoughts against one's life.

Effect of intensive self-management education on seizure frequency and quality of life in epilepsy patients with prodromes or precipitating factors

PURPOSE

To explore the impact of an intensive self-management education strategy on seizure frequency and quality of life in patients with epileptic seizures with prodromes or precipitating factors. The intensive self-management education included monthly education sessions on prodromes and precipitating factors aiming to help patients to adopt self-management strategies.

METHODS

Adult patients with epilepsy (PWE) able to identify prodromes or precipitating factors of their seizures were randomly assigned to an intensive education group (IEG) (n = 45) or a regular education group(REG) (n = 47). All patients received a single face-to-face self-management education session at the time of enrollment. Both groups of patients received monthly telephone follow-up for 1 year. PWE in the IEG received intensive education during each follow-up call. Primary outcomes were seizure frequency, quality of life(Quality of life in epilepsy-31 inventory scores, QOLIE 31), and drug adherence(Morisky medication adherence scale,MMAS).

RESULTS

At the end of the 1-year follow-up period, seizure frequency in the IEG was significantly lower than at baseline (p < 0.001), but not in the REG(p = 0.085). Quality of life had improved significantly in the IEG (p < 0.001), but not in the REG (p = 0.073). Drug adherence was better in the IEG than in the REG (p = 0.003), and there were fewer accidental injuries in the IEG than the REG (p = 0.031).

CONCLUSIONS

In PWE aware of seizure prodromes or precipitating factors, intensive self-management education may reduce seizure frequency, improve quality of life, increase adherence with antiepileptic medication and reduce accidental injuries caused by seizures.

Precipitating Factors for Hospitalization with Heart Failure: Prevalence and Clinical Impact Observations from the Gulf CARE (Gulf aCute heArt failuRe rEgistry)

OBJECTIVE

Despite the expanding burden of heart failure (HF) worldwide, data on HF precipitating factors (PFs) in developing countries, particularly the Middle East, are very limited. We examined PFs in patients hospitalized with acute HF in a prospective multicenter HF registry from 7 countries in the Middle East.

METHOD

Data were derived from the Gulf CARE (Gulf aCute heArt failuRe rEgistry) for a prospective, multinational, multicenter study of consecutive patients hospitalized with HF in 47 hospitals in 7 Middle Eastern countries between February 2012 and November 2012. PFs were determined by the treating physician from a predefined list at the time of hospitalization.

RESULTS

The study included 5,005 patients hospitalized with acute HF, 2,276 of whom (45.5%) were hospitalized with acute new-onset HF (NOHF) and 2,729 of whom (54.5%) had acute decompensated chronic HF (DCHF). PFs were identified in 4,319 patients (86.3%). The most common PF in the NOHF group was acute coronary syndromes (ACS) (39.2%). In the DCHF group, it was noncompliance with medications (27.8%). Overall, noncompliance with medications was associated with a lower inhospital mortality (OR 0.47; 95% CI 0.28-0.80; p = 0.005) but a higher 1-year mortality (OR 1.43; 95% CI 1.1-1.85; p = 0.007). ACS was associated with higher inhospital mortality (OR 1.84; 95% CI 1.26-2.68; p = 0.002) and higher 1-year mortality (OR 1.62; 95% CI 1.27-2.06; p = 0.001).

CONCLUSION

Preventive and therapeutic interventions specifically directed at noncompliance with medications and ACS are warranted in our region.

Weather, ambient air pollution, and risk of migraine headache onset among patients with migraine

OBJECTIVE

Migraine is a common recurrent headache disorder affecting 14% American adults. Although weather and air pollution are often reported by patients with migraine as precipitating factors, previous studies have had mixed results.

METHODS

We prospectively collected migraine headache onset data using electronic questionnaires from 98 adults with episodic migraine in the Greater Boston area (2016-2017). Each participant was followed for an average of 45 days for a total of 4406 days of observation. Temperature, relative humidity, and barometric pressure data were obtained from local weather station. Daily average fine particulate matter, daily maximum 1-hour sulfur dioxide, daily maximum 1-hour nitrogen dioxide, daily maximum 8-hour ozone, and daily maximum 8-hour carbon monoxide from local air pollution monitors. We conducted a repeated measures analysis using fixed effects logistic regression models. In the models we adjusted for day of week, a natural cubic spline term of day of the year with 4 degrees of freedom, and a participant identifier. We additionally adjusted for linear terms of temperature and relative humidity in the air pollution analyses. We also applied logistic regression models with generalized estimating equation (GEE) and autoregressive correlation structure in the sensitivity analysis.

RESULTS

The mean age was 35 years and 88% were women. Mean temperature was 56.9 °F, relative humidity 67.3%, and fine particulate matter 7.3 μg/m³. Higher relative humidity was associated with higher odds of migraine headache, but the association was only observed in warm season (April-September). Higher levels of daily maximum 8-hour ozone and daily maximum 8-hour carbon monoxide appeared to be associated with higher odds of migraine headache onset in cold season (October-March). Although the associations for ozone and relative humidity were attenuated and no longer statistically significant in the overall GEE analysis, the differing associations by season remained.

CONCLUSIONS

We found that higher relative humidity was associated with higher odds of migraine headache onset in warm season, and traffic-related gaseous pollutants may be associated with higher odds of migraine headache onset in cold season.

The predisposing and precipitating risk factors for delirium in neurosurgery: a prospective cohort study of 949 patients

BACKGROUND

Delirium is the most common neuropsychiatric presentation during hospitalization. In neurosurgery, studies on predisposing and precipitating risk factors for the development of delirium are rare but required for the individual risk estimation.

METHODS

Prospective cohort study in a tertiary university center. In total, 949 neurosurgical patients, 307 with and 642 without delirium, were included. Demographic factors, neurosurgery-related, neurological, and medical clusters were tested as predictors of delirium in multiple logistic regression analyses.

RESULTS

The incidence of delirium in this cohort of neurosurgical patients was 32.4%. Compared to patients without delirium, those with delirium were significantly older, more cognitively and neurologically impaired, transferred from hospitals and nursing homes, admitted as emergencies, longer hospitalized (16.2 vs. 9.5 days; p < 0.001), in greater need of intensive care management, and more frequently transferred to rehabilitation. Predisposing factors of delirium were stroke (OR 5.45, CI 2.12-14.0, p < 0.001), cardiac insufficiency (OR 4.59, CI 1.09-19.26, p = 0.038), cerebral neoplasm (OR 1.53, CI 0.92-2.54, p = 0.019), and age ≥ 65 years (OR 1.47, CI 1.03-2.09, p = 0.030). Precipitating factors of delirium were acute cerebral injury (OR 3.91, CI 2.24-6.83, p < 0.001), hydrocephalus (OR 3.10, CI 1.98-4.87, p < 0.001), and intracranial hemorrhage (OR 1.90, CI 1.23-2.94, p = 0.004).

CONCLUSIONS

Delirium in acute neurosurgical patients was associated with longer hospitalization. Whereas common etiologies of delirium like infections and dementia, did not predict delirium, pre-existing neurovascular and traumatic diseases, as well as surgery-related events seem important risk factors contributing to delirium in neurosurgery.

New-Onset Asthma in Adults: What Does the Trigger History Tell Us?

BACKGROUND

Adult-onset asthma is an important asthma phenotype and, in contrast to childhood asthma, is often associated with specific triggers of onset. It is unknown whether these triggers correspond with specific phenotypic characteristics or predict a specific asthma outcome.

OBJECTIVE

To compare clinical, functional, and inflammatory characteristics between patients with different triggers of asthma onset, and relate these triggers to asthma outcome.

METHODS

Two hundred adults with recently diagnosed (<1 year) asthma were prospectively followed for 5 years. The trigger of asthma onset was patient reported and defined by the question: "What, in your opinion, elicited your asthma?" Asthma remission was defined as no asthma symptoms and no asthma medication use for ≥1 year. Kruskal-Wallis and Fisher's exact test were used to compare categories containing >10 patients.

RESULTS

Ten categories of triggers were identified, of which 5 contained >10 patients. Clinical and inflammatory characteristics and remission rates differed significantly between categories. "New allergic sensitization" (11%) was associated with mild atopic asthma and a relatively young age at onset; "pneumonia" (8%) with previous smoking, low IgE, and the highest remission rates (one third); "upper respiratory symptoms" (22%) with high exhaled NO and eosinophilia; "no trigger identified" (38%) did not show any specific characteristics; and "stressful life event" (7%) with high medication usage, low type 2 markers, and no disease remission.

CONCLUSIONS

Patients with adult-onset asthma can be characterized by the trigger that seemingly incited their asthma. These triggers might represent underlying mechanisms and may be important to phenotype patients and predict disease outcome.

Myxedema Coma

Myxedema may be the first presentation of patients with undiagnosed hypothyroidism. Definitive management is with thyroid hormone but supportive measures, identification and treatment of precipitating factors in an appropriately safe environment are vital. There is no consensus about preferred thyroid hormone regimen. Corticosteroid therapy is given until adrenal insufficiency has been excluded. We present here a case of seventy-four years old woman of myxodema coma.

Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality

AIMS

Hospitalizations for heart failure (HF) are common and are associated with significant morbidity, mortality and cost. However, precipitating factors leading to HF hospitalization and their importance with respect to subsequent outcomes are not well understood.

METHODS AND RESULTS

The symptoms and signs present at admission and investigator-identified factors thought to have contributed to the first adjudicated HF hospitalization in the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) programme were prospectively collected and stratified by ejection fraction (EF). Potential precipitants were collected using a specifically designed case report form and categorized according to the presence of cardiovascular (CV), non-CV and unknown factors. Associations between these factors and subsequent rehospitalization and mortality rates were examined. Of 1668 patients who experienced HF hospitalization, 1152 had reduced EF (≤40%, HFrEF) and 516 had preserved EF (HFpEF). Overall, 54% had CV, 32% had non-CV and 14% had unknown factors thought to have precipitated HF, with similar proportions in the HFrEF and HFpEF groups. The most common precipitants were arrhythmia (15%), other non-CV factors (11%) and respiratory infection (10%). Subsequent CV readmission rates were highest in those whose initial HF hospitalization was precipitated by CV factors. However, mortality rates were similar among patients with any of the three categories of precipitating factors. Results were similar in HFrEF and HFpEF.

CONCLUSIONS

Among chronic HF patients hospitalized for decompensation, the investigator-reported precipitating factor was not associated with the subsequent mortality rate, but was associated with type of readmission: readmissions for CV reasons were more likely when the index precipitant was CV.

Antecedents of Suicide among Youth Aged 11-15: A Multistate Mixed Methods Analysis

Suicide is the second leading cause of death for youth aged 11 to 15, taking over 5,500 lives from 2003 to 2014. Suicide among this age group is linked to risk factors such as mental health problems, family history of suicidal behavior, biological factors, family problems, and peer victimization and bullying. However, few studies have examined the frequency with which such problems occur among youth suicide decedents or the context in which decedents experience these risk factors and the complex interplay of risk that results in a decedent's decision to take his/her own life. Data from a random sample of 482 youth (ages 11-15) suicide cases captured in the National Violent Death Reporting System from 2003 to 2014 were analyzed. The sample had fewer girls than boys (31 vs. 69 %) and comprised primarily White youth (79 %), but also African Americans (13 %), Asians (4 %), and youth of other races (4 %). Narrative data from coroner/medical examiner and law enforcement investigative reports were coded and analyzed to identify common behavioral patterns that preceded suicide. Emergent themes were quantified and examined using content and constant comparative analysis. Themes regarding antecedents across multiple levels of the social ecology emerged. Relationship problems, particularly with parents, were the most common suicide antecedent. Also, a pattern demonstrating a consistent progression toward suicidal behavior emerged from the data. Narratives indicated that youth were commonly exposed to one or more problems, often resulting in feelings of loneliness and burdensomeness, which progressed toward thoughts and sometimes plans for or attempts at suicide. Continued exposure to negative experiences and thoughts/plans about suicide, and/or self-injurious acts resulted in an acquired capacity to self-harm, eventually leading to suicide. These findings provide support for theories of suicidal behavior and highlight the importance of multi-level, comprehensive interventions that address individual cognitions and build social connectedness and support, as well as prevention strategies that increase awareness of the warning signs and symptoms of suicide, particularly among family members of at-risk youth.

[Precipitating factors in acute heart failure: a review]

Acute heart failure (AHF) has become a public health problem of the first magnitude: it is the main cause of emergencies and hospitalization in patients over the age of 65. Various guidelines for managing AHF have been drafted in recent years, yet we continue to see high readmission and mortality rates. The emergency department is where patients with AHF should be diagnosed and stabilized, and their clinical picture established. A next step would be to identify the factors that may have led to the acute event so that it can be managed optimally. Few studies have analyzed precipitating factors in AHF and their role in prognosis. This review analyzes the prevalence of precipitating factors and their relation to readmission and mortality.

The Study of Different Clinical Pattern of Diabetic Ketoacidosis and Common Precipitating Events and Independent Mortality Factors

INTRODUCTION

Diabetic Ketoacidosis (DKA) is an important cause of morbidity and mortality among diabetic patients in spite of major advances in the pathogenesis and more standardized diagnosis and treatment.

AIM

To find out the different patterns of clinical presentations, common precipitating factors and independent mortality factors in DKA.

MATERIALS AND METHODS

This study was conducted in a tertiary care hospital, Mysuru on 110 patients from November 2007 to October 2009. Clinical presentation and precipitating factors of DKA were monitored. Univariate analysis was done to identify statistically significant risk factors contributing to DKA mortality and was used for multiple logistic regressions to identify independent mortality predictors. A scoring methodology was used to identify the risk of having multiple risk factors in an individual.

RESULTS

In this study, the mean age was 42.33 years, with a male to female ratio of 1.2:1. The most common complaints were vomiting and generalized weakness seen in 55 (50%) and 49 (44.5%) cases respectively. The most common precipitating factors were infections and poor compliance to antidiabetic treatment seen in 57 (52%) and 23 (21%) cases respectively. The predictors of mortality included age equal to or more than 65 years, Depressed Mental State (DMS) in the first 24 hour, insulin requirement equal to or more than 50 units in the 12 hours to bring blood glucose to less than 300 mg%, fever in the first 24 hours, shock in the first 24 hours, RBS persistently equal to or more than 300 mg% even after 12 hours with standard treatment protocol, fluid requirement equal to or more than 6 L in the first 24 hours, pH less than 7.2 and bicarbonate less than 15 mmol/l at presentation were statistically significant predictors of mortality. Multivariate analysis failed to identify an independent mortality factor; but, adverse parameters of more than 5 was significantly associated with death.

CONCLUSION

Risk stratification of patients with DKA is possible from simple clinical and laboratory variables available during the first day of hospitalization and further channeling the patients to ICU at the correct time to prevent mortalities.

Status epilepticus in patients with juvenile myoclonic epilepsy: Frequency, precipitating factors and outcome

Status epilepticus (SE) is rarely described in patients with juvenile myoclonic epilepsy (JME), and little is known about its frequency, subtypes, and predictors and the prognosis of these patients. In this retrospective study, we aimed to analyze the incidence of SE in patients with JME and emphasize the risk factors and long-term outcome of SE in an epilepsy outpatient-based cohort. We included patients with JME with a history of predominant myoclonic seizures and at least one diagnostic EEG with normal background activity and bursts of typical ≥3-Hz generalized spike-polyspike and waves. We investigated the electroclinical features of patients with JME who had experienced SE and compared them with patients with JME without SE. Of the 133 patients with JME, only 5 patients were diagnosed with SE (3.8%) according to new criteria. The most common SE subtype was myoclonic SE (MSE, 4 patients), followed by generalized clonic-tonic-clonic SE (1 patient) and nonconvulsive SE (1 patient). One patient had both MSE and generalized clonic-tonic-clonic SE. In three out of five patients, recurrent episodes of SE were observed. Same seizure precipitants including sleep deprivation, inappropriate antiepileptic drug treatment, and noncompliance were identified in patients with JME with and without SE, not reaching a significant difference between the groups. Myoclonia limited to specific body parts (one arm, face, or head) were significantly more common in patients with JME with SE (p: 0.002). We did not find any significant correlation with drug-resistant course and SE. Status epilepticus is rarely observed in patients with JME, and MSE appears to be the most common subtype. Local myoclonia might predict SE in a subgroup of patients with JME. We may suggest that some patients with JME have a liability to SE, in addition to usual seizure precipitating factors of JME. It seems that SE per se does not affect the outcome of JME and the patients with SE did not have drug-resistant course in the final analysis.

Stressful Events in the Onset of Chronic Fatigue Syndrome

BACKGROUND

Chronic Fatigue Syndrome (CFS) is a complex and multifactorial disease. Stressful situations experienced could be related to the presentation of the disease. Few studies have determined which factors could trigger CFS. The main objective of this study was to explore the stressful situations which can be associated with CFS presentation.

METHODS

Retrospective observational case-control study with CFS diagnosed patients according to the Fukuda's criteria. Controls were matched to cases by sex, age and educational level with a 1:1 ratio. Participants aged between 18 and 75 years from the province of Lleida. Information was obtained through personal questionnaires. The measure of association was the odds ratio.

RESULTS

In total, 77 cases and 77 controls were included. Association found between stressful life events and presentation of disease were pregnancy ORa=31.7 (CI95%:2.2-456.7), spousal abuse ORa= 10.2 (CI95%:1.2-88.4) and mobbing ORa=6.9 (CI95%:1.3-36.9), eating disorders=7.5 (CI95%:1.3-42.1), car accident ORa=5.5 (CI95%:1.7-17 9), economic problems ORa=5.1 (CI95%:2.1-12.6) and changes in sleep habits ORa=2.8 (CI95%:1.1-7.5).

CONCLUSIONS

Stressful life events as pregnancy, spousal abuse, mobbing, eating disorders, car accident, economic problems and changes in sleep habits felt by those affected must be taken into consideration when compiling background information related to the onset of Chronic Fatigue Syndrome. Adequate identification of these stressful life events in risk people could contribute to early diagnosis of Chronic Fatigue Syndrome.

Severe hypoglycaemia during treatment with sulphonylureas in patients with type 2 diabetes in the Capital Region of Denmark

AIMS

Sulphonylureas (SU) are currently recommended as a well-established second line treatment in guidelines for type 2 diabetes (T2DM). In the Capital Region of Denmark 16,865 patients were given SU as part of their treatment of T2DM in 2010-2011. To what extent SU are associated with hospitalizations due to severe hypoglycaemic episodes, defined as episodes with a need for external assistance, was investigated. The prevalence and characteristics of these patients and potential risk factors were studied.

METHODS

ICD-10 diagnosis codes were used to identify patients hospitalized due to hypoglycaemia and T2DM for a period of 2 years (2010-2011). Inclusion criteria were T2DM, hospitalization due to hypoglycaemia and treatment with SU as monotherapy or in combination with other glucose-lowering drugs except insulin treatment.

RESULTS

We identified 161 patients fulfilling the inclusion criteria. Their mean age was 76 (53-97) years and 54% were males. Sixty percent of the patients had diabetic complications, including 19% with diabetic nephropathy. The major reason for severe hypoglycaemia was an unchanged dose of SU despite of a significant decline in food intake (45%). In 22% of the patients more than one reason was listed, most commonly a concomitant infection associated with decreased food intake and unchanged dose of SU.

CONCLUSION

The incidence of hospital admission-requiring severe hypoglycaemia in patients treated with SU was 0.48 episodes per 100 patient-years of SU-treated patients. It was mainly older patients with diminished food intake, excessive alcohol use or other medications, concomitant infection, and with diabetic complications.

[PAPRICA-2 study: Role of precipitating factor of an acute heart failure episode on intermediate term prognosis]

OBJECTIVE

To evaluate the precipitating factors (PF) associated with acute heart failure and their association with medium-term prognosis.

PATIENTS AND METHODS

Multipurpose prospective study from the EAHFE Registry. We included as PF: infection, rapid atrial fibrillation (RAF), anaemia, hypertensive crisis, non-adherence to diet or drug therapy and non-ST-segment-elevation acute coronary syndrome (NSTEACS). Patients without PF were control group. Hazard ratios (HR) crudes and adjusted for reconsultations and mortality at 90 days were calculated.

RESULTS

3535 patients were included: 28% without and 72% with PF. Patients with RAF (HR 0.67; 95%CI 0.50-0.89) and hypertensive crisis (HR 0.45; 95%CI 0.28-0.72) had less mortality and patients with NSTEACS (HR 1.79; 95%CI 1.19-2.70) had more mortality. Reconsultation was fewer in patients with infection (HR 0.74; 95%CI 0.64-0.85), RAF (HR 0.69; 95%CI 0.58-0.83) and hypertensive crisis (HR 0.71; 95%CI 0.55-0.91). These differences were maintained in all the adjusted models except for hypertensive crisis.

CONCLUSIONS

One PF is identified in 3 out of 4 patients and it may influence medium-term prognosis. At 90 days, NSTEACS and RAF were associated with more and less mortality respectively, and RAF and infection with less probability of reconsultation.

[Acute heart failure: precipitating factors and prevention]

Acute heart failure episodes, whether onset or decompensation of a chronic form, are most often precipitated by a concurrent process or disease, described as precipitating factors of heart failure. In this article, we review these precipitating factors, their proportions and clinical relevance in general and in subgroups of patients, their relationship with prognosis, and their possible prevention.

Retrospective analysis of factors influencing the development and progression of hepatic encephalopathy in patients with hepatitis B virus-related cirrhosis

AIM: To investigate the factors influencing the development and progression of hepatic encephalopathy (HE) in patients with hepatitis B virus (HBV)-related cirrhosis (HBCE).

METHODS: The clinical data for 78 patients with HBCE and 52 patients with HBV-related cirrhosis without HE (HBCNE) treated at the First Affiliated Hospital of Dalian Medical University from March 2002 to May 2011 were retrospectively analyzed. Factors analyzed include gender, age, precipitating factors, ascites, esophageal-gastric varices (EGV), splenomegaly, grade of HE, Child-Pugh grade, blood ammonia (NH4), serum sodium (Na), serum cholinesterase (CHE), serum total bilirubin (TBil), serum albumin (ALB), blood urea nitrogen (BUN), serum creatinine (Cr), and prothrombin time (PT).

RESULTS: Infection was the most common precipitating factor to induce HE in patients with HBV-related cirrhosis (35.6%). Grade Ⅱ HE was most common (36.8%), followed by grade Ⅳ HE (25.3%). Child-Pugh grade, ascites, NH4, Na, CHE, TBil, ALB, BUN, and PT were significantly different between the HBCE and HBCNE groups (0:8:79 vs 0:21:31, 19:68 vs 36:16, 20.74 ± 70.44 vs 46.53 ± 10.67, 136.01 ± 6.65 vs 141.48 ± 3.34, 1927.34 ± 70.52 vs 3342.01 ± 38.03, 91.75 ± 84.56 vs 58.98 ± 14.46, 25.53 ± 3.84 vs 29.48 ± 2.58, 13.57 ± 14.76 vs 6.41 ± 1.57, 21.34 ± 7.12 vs 18.59 ± 1.66; all P < 0.05). The level of NH4 in patients with grade Ⅳ HE was significantly higher than those in patients with gradeⅠ, Ⅱ or Ⅲ HE (156.91 ± 62.94 vs 104.13 ± 73.07, 112.69 ± 60.87, 104.67 ± 82.00; all P < 0.05). Compared to patients with gradeⅠHE, the levels of Na in patients with grade Ⅱ, Ⅲ or Ⅳ HE significantly decreased (135.22 ± 6.05, 134.91 ± 7.79, 134.55 ± 6.25 vs 139.73 ± 5.15; all P < 0.05), and CHE declined in patients with grade Ⅳ HE (1605.19 ± 76.01 vs 2325.46 ± 71.31, P < 0.05). The level of BUN in patients with grade Ⅳ HE was higher than those in patients with gradeⅠor Ⅱ HE (21.65 ± 23.69 vs 6.53 ± 3.41, 10.62 ± 7.37; both P < 0.05).

CONCLUSION: Preventing and controlling infection could decrease the incidence of HE in patients with HBV-related cirrhosis. High levels of NH4, TBil and BUN, low levels of Na, CHE and ALB, Child-Pugh grade C, ascites, and prolonged PT could increase the incidence of HBCE. High levels of NH4 and BUN, and low levels of Na and CHE are associated with more severe HE.