Pulmonary embolism severity index, age-based markers and evaluation in the emergency department

OBJECTIVES

The purpose of this study was to assess the severity of pulmonary embolism in the emergency department using vital signs and age-based vital parameters and compare these parameters with pulmonary embolism severity index (PESI) score.

METHODS

Between January 2011 and October 2014, there were 284 patients diagnosed with pulmonary embolism in the Emergency Unit of Selcuk University Hospital. Patient records were reviewed retrospectively. The PESI scores were calculated, and patients were divided into high- and low-risk groups. Shock index (SI), age-based shock index (SIA), maximum heart rate (MHR), minpulse (MP) and pulse maximum index (PMI) were calculated. The association of these parameters with PESI was evaluated. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the association of risk and mortality with age-based markers.

RESULTS

There were 75 men (43%) in the 173 patients included in the study. The PESI classification showed 54 patients in the low-risk group and 119 patients in the high-risk group. Mortality was higher in the PESI high-risk group, and no deaths occurred in the low-risk group. Comparison of the age-based markers and PESI for patients who died or survived showed that AUC for PESI was 0.807, AUC for SI was 0.824 and AUC for SIA was 0.825.

CONCLUSIONS

The SIA risk classification was more efficient than SI in pulmonary embolism patients who presented to the emergency unit. The SIA was more accurate than SI or PESI in predicting mortality.

Neonatal admissions, quality of care and outcome: 4 years of inpatient audit data from The Gambia's teaching hospital

BACKGROUND

National facility-based neonatal mortality audits are an important source of data to identify areas for improvement of service delivery and outcome of care.

OBJECTIVES

To examine admissions to the neonatal unit, Edward Francis Small Teaching Hospital, Banjul, The Gambia and make recommendations for programme action to reduce mortality through improvements in the quality of care, particularly with respect to suspected neonatal infections.

METHODS

Case notes were reviewed for all neonates admitted to the neonatal unit during a 5-year period (1 January 2009 to 31 December 2013) to assess outcome and quality of care. Data for 2009 were subsequently excluded because of the low proportion of records retrieved.

RESULTS

Of the 4944 admissions between 1 January 2010 and 31 December 2013, 1734 infants (35%) died, with 57% of all deaths occurring within the first 48 hours of admission. There were 1267 early neonatal deaths (deaths occurring during the first 7 days of life), 67% of which occurred during the first 48 hours of life. Independent predictors of neonatal death in the multivariable analysis were; maternal lack of antenatal care, non-teaching hospital delivery, admission weight < 1500 g, abnormal blood glucose concentration ( < 2.6 mmol/L or >6.9 mmol/L) and hypothermia (axillary temperature < 36.5 ˚C). Forty-eight per cent of newborns had point-of-admission hypothermia. Possible severe bacterial infection (pSBI) accounted for 44% (2166/4944) of admissions, prematurity/low birthweight for 27% (1340/4944) and intrapartum-related conditions for 20%. Only 5% (104/2166) of pSBI cases had at least one supportive investigation; 41 had a chest radiograph, 26 had a blood culture and 43 had a lumbar puncture. Although 94% of the newborns received intravenous antibiotics, 55% of those who did lacked clinical evidence of pSBI and had no diagnostic work-up.

CONCLUSION

Priority areas for action include infection prevention and improved diagnosis and management. There is also scope to reduce hypothermia with feasible interventions particularly targeting preterm infants. Improved patient records and audit data with linked action and accountability are interventions which could prevent such deaths of newborns in The Gambia and other developing countries.

Long-term immunologic and virologic responses on raltegravir-containing regimens among ART-experienced participants in the HIV Outpatient Study

OBJECTIVES

Raltegravir (RAL)-containing antiretroviral therapy (ART) produced better immunologic and virologic responses than optimized background ART in clinical trials of heavily ART-experienced patients, but few data exist on long-term outcomes in routine HIV care.

METHODS

We studied ART-experienced HIV outpatient study (HOPS) participants seen at 10 US HIV-specialty clinics during 2007-2011.We identified patients who started (baseline date) either continuous ≥ 30 days of RAL-containing or RAL-sparing ART, and used propensity score (PS) matching methods to account for baseline clinical and demographic differences. We used Kaplan-Meier methods and log-rank tests for the matched subsets to evaluate probability of death, achieving HIV RNA < 50 copies/ml, and CD4 cell count (CD4) increase of ≥ 50 cells mm(- 3) during follow-up.

RESULTS

Among 784 RAL-exposed and 1062 RAL-unexposed patients, 472 from each group were matched by PS. At baseline, the 472 RAL-exposed patients (mean nadir CD4, 205 cells mm(- 3); mean baseline CD4, 460 cells mm(- 3); HIV RNA < 50 copies ml(- 1) in 61%; mean years on prescribed ART, 7.5) were similar to RAL unexposed. During a mean follow-up of over 3 years, mortality rates and immunologic and virologic trajectories did not differ between the two groups. Among patients with detectable baseline HIV RNA levels, 76% of RAL-exposed and 63% of RAL-unexposed achieved HIV RNA < 50 copies ml(- 1) (P = 0.51); 69 and 58%, respectively, achieved a CD4 increase ≥ 50 cells mm(- 3) (P = 0.70).

DISCUSSION

In our large cohort of US ART-experienced patients with a wide spectrum of clinical history, similar outcomes were observed when prescribed RAL containing versus other contemporary ART.

Cerebral pathology post heart transplantation

Cerebral pathology is frequently encountered post heart transplantation with a cumulative incidence of about 80% after 15 years. A broad spectrum of disease entities is reported, from minor abnormalities to life-threatening diseases. Although cerebral infections and malignancies are rare in this patient population, they have a high mortality rate. Since 1991, 171 orthotopic heart transplantations were performed at the Ghent University Hospital with a 10-year survival rate of 75%. Severe cerebral complications occurred in 10 patients, with epilepsy in 2 patients, cerebrovascular accidents in 4 patients, cerebral infections in 3 patients and a cerebral malignancy in 1 patient, resulting in a fatal outcome in 7 patients. We present four of these cases.

Risk factors for carbapenem-resistant Klebsiella pneumoniae infection/colonization and predictors of mortality: a retrospective study

OBJECTIVE

To identify risk factors associated with carbapenem-resistant Klebsiella pneumoniae (CRKP) infection/colonization and death and to investigate the resistance and homology of CRKP.

METHODS

A retrospective 1:1 case-control study was conducted at Changhai Hospital, China, from January 2010 to December 2011.The study population included 30 patients with CRKP infection/colonization and 30 matched patients with carbapenem-susceptible K. pneumoniae (CSKP) infection/colonization at the same site. Homology analysis was conducted by multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE). Potential resistance genes were detected by PCR.

RESULTS

Independent risk factors for CRKP infection/colonization were admission to exposure to glycopeptides [Odds ratio (OR): 43.84, 95% confidence interval (CI): 1.73-1111.91, P = 0.020], cefoperazone plus sulbactam (OR: 49.56, 95% CI: 1.42-1726.72, P = 0.030) and tracheostomy (OR: 677.82, 95% CI: 2.76-1667, P = 0.020). Age (OR: 1.07, 95% CI: 1.00-1.14, P = 0.04), renal dysfunction (OR: 17.63, 95% CI: 2.34-132.87, P = 0.005) and exposure to cefoperazone plus sulbactam (OR: 8.87, 95% CI: 1.29-61.07, P = 0.026) were independent risk factors for the death of patients with K. pneumoniae infection/colonization. Older age (OR: 1.16, 95% CI: 1.01-1.39, P = 0.011) was an independent risk factor for the death of patients with CRKP infection/colonization. Thirty CRKP strains were all KPC-2-producing resistant strains with genotype of ST-11.

CONCLUSION

Exposure to glycopeptides, cefoperazone plus sulbactam and tracheostomy were independent risk factors for CRKP infection/colonization, and older age was an independent risk factor for CRKP infection/colonization caused death.

Module modified acute physiology and chronic health evaluation II: predicting the mortality of neuro-critical disease

OBJECTIVES

This study aimed to conduct and assess a module modified acute physiology and chronic health evaluation (MM-APACHE) II model, based on disease categories modified-acute physiology and chronic health evaluation (DCM-APACHE) II model, in predicting mortality more accurately in neuro-intensive care units (N-ICUs).

METHODS

In total, 1686 patients entered into this prospective study. Acute physiology and chronic health evaluation (APACHE) II scores of all patients on admission and worst 24-, 48-, 72-hour scores were obtained. Neurological diagnosis on admission was classified into five categories: cerebral infarction, intracranial hemorrhage, neurological infection, spinal neuromuscular (SNM) disease, and other neurological diseases. The APACHE II scores of cerebral infarction, intracranial hemorrhage, and neurological infection patients were used for building the MM-APACHE II model.

RESULTS

There were 1386 cases for cerebral infarction disease, intracranial hemorrhage disease, and neurological infection disease. The logistic linear regression showed that 72-hour APACHE II score (Wals  =  173.04, P < 0.001) and disease classification (Wals  =  12.51, P  =  0.02) were of importance in forecasting hospital mortality. Module modified acute physiology and chronic health evaluation II model, built on the variables of the 72-hour APACHE II score and disease category, had good discrimination (area under the receiver operating characteristic curve (AU-ROC  =  0.830)) and calibration (χ2  =  12.518, P  =  0.20), and was better than the Knaus APACHE II model (AU-ROC  =  0.778).

DISCUSSION

The APACHE II severity of disease classification system cannot provide accurate prognosis for all kinds of the diseases. A MM-APACHE II model can accurately predict hospital mortality for cerebral infarction, intracranial hemorrhage, and neurologic infection patients in N-ICU.

The stunting syndrome in developing countries

Linear growth failure is the most common form of undernutrition globally. With an estimated 165 million children below 5 years of age affected, stunting has been identified as a major public health priority, and there are ambitious targets to reduce the prevalence of stunting by 40% between 2010 and 2025. We view this condition as a 'stunting syndrome' in which multiple pathological changes marked by linear growth retardation in early life are associated with increased morbidity and mortality, reduced physical, neurodevelopmental and economic capacity and an elevated risk of metabolic disease into adulthood. Stunting is a cyclical process because women who were themselves stunted in childhood tend to have stunted offspring, creating an intergenerational cycle of poverty and reduced human capital that is difficult to break. In this review, the mechanisms underlying linear growth failure at different ages are described, the short-, medium- and long-term consequences of stunting are discussed, and the evidence for windows of opportunity during the life cycle to target interventions at the stunting syndrome are evaluated.

HbA1c is associated with increased all-cause mortality in the first year after acute ischemic stroke

OBJECTIVES

To assess the association between baseline HbA1c and the poor outcomes within 1 year after acute ischemic stroke.

METHODS

Acute ischemic stroke patients with HbA1c values at baseline (n  =  2186) were selected from the abnormal glucose regulation in patients with acute stroke across China study (ACROSS). Logistic regressions were performed to assess the association between HbA1c quartiles (<5.5% [37 mmol/mol], 5.5 to <6.1% [37 to <43 mmol/mol], 6.1 to <7.2% [43 to <55 mmol/mol], and ≥ 7.2% [≥ 55 mmol/mol]) and the poor outcomes within 1 year. Poor outcomes were defined as all-cause mortality (modified Rankin scale [mRS]  =  6) and poor functional outcome (mRS [2-6]).

RESULTS

The risk for all-cause mortality was significantly increased in HbA1c level >5.5% [>37 mmol/mol] when compared to HbA1c quartile <5.5% [<37 mmol/mol] and dramatically increased to two to three times higher in the highest HbA1c quartile ≥ 7.2% [>55 mmol/mol] (1-year all-cause mortality model, odds ratios [ORs] were 1.07, 1.01, and 2.45, P for trend 0.009). After the further analysis with previous diabetes mellitus (DM) and post-stroke insulin use stratified, the risk of mortality was increased across the HbA1c levels (P for trend 0.020) and dramatically augmented in HbA1c ≥ 7.2% [>55 mmol/mol] in patients without a history of DM and without post-stroke insulin use.

DISCUSSION

Elevated HbA1c (from 5.5% [37 mmol/mol]) presenting pre-stroke glycemia status has a significant trend in increasing the risk of 1-year all-cause mortality. HbA1c ≥ 7.2% (>55 mmol/mol) is an independent risk predictor for 1-year all-cause mortality after acute first-ever ischemic stroke. Such an association might be altered by glycometabolism status.

Asbestos in Belgium: an underestimated health risk. The evolution of mesothelioma mortality rates (1969-2009)

Background:

Although Belgium was once a major international manufacturer of asbestos products, asbestos-related diseases in the country have remained scarcely researched.

Objectives:

The aim of this study is to provide a descriptive analysis of Belgian mesothelioma mortality rates in order to improve the understanding of asbestos health hazards from an international perspective.

Methods:

Temporal and geographical analyses were performed on cause-specific mortality data (1969–2009) using quantitative demographic measures. Results were compared to recent findings on global mesothelioma deaths.

Results:

Belgium has one of the highest mesothelioma mortality rates in the world, following the UK, Australia, and Italy. With a progressive increase of male mesothelioma deaths in the mid-1980s, large differences in mortality rates between sexes are apparent. Mesothelioma deaths are primarily concentrated in geographic areas with proximity to former asbestos industries.

Conclusions:

Asbestos mortality in Belgium has been underestimated for decades. Our findings suggest that the location of asbestos industries is correlated with rates of mesothelioma, underlining the need to avert future asbestos exposure by thorough screening of potential contaminated sites and by pursuing a global ban on asbestos.

Mortality in patients presenting with fever of unknown origin

BACKGROUND

Few data exist on the contemporary prognosis of patients presenting with fever of unknown origin (FUO).

METHODS

The data of 436 adult immunocompetent patients presenting with FUO between 2000 and 2010 and followed for at least 6 months were analyzed, with a focus on FUO-related deaths. The following variables were assessed in survivors and non-survivors: age, underlying diagnosis, and, in a nested case-control design, fever periodicity, selected laboratory parameters (including peripheral blood counts, enzymes, and inflammatory markers) and organomegaly.

RESULTS

Thirty FUO-related deaths occurred (6·9%). Malignancy accounted for 11% of fevers but for 60% of deaths. Especially non-Hodgkin lymphoma carried a disproportionally high death toll. In the non-malignant categories, fatality rates were below 6%. All patients discharged without diagnosis in spite of ample investigations (n = 164) survived. Besides malignancy, age, continuous (as opposed to episodic) fever, anaemia, leucopenia, LDH levels, and hepatomegaly were associated with mortality.

CONCLUSIONS

Fatality rates of FUO have continuously declined over the past decades. Malignancy, including lymphoma, remains a cardinal cause of death. Patients with FUO discharged without diagnosis survive.