Showing papers on "Interquartile range published in 2010"
TL;DR: Severe hypoglycemia was strongly associated with increased risks of a range of adverse clinical outcomes, including respiratory, digestive, and skin conditions, and no relationship was found between repeated episodes of severe hypglycemia and vascular outcomes or death.
Abstract: Background Severe hypoglycemia may increase the risk of a poor outcome in patients with type 2 diabetes assigned to an intensive glucose-lowering intervention. We analyzed data from a large study of intensive glucose lowering to explore the relationship between severe hypoglycemia and adverse clinical outcomes. Methods We examined the associations between severe hypoglycemia and the risks of macrovascular or microvascular events and death among 11,140 patients with type 2 diabetes, using Cox proportional-hazards models with adjustment for covariates measured at baseline and after randomization. Results During a median follow-up period of 5 years, 231 patients (2.1%) had at least one severe hypoglycemic episode; 150 had been assigned to intensive glucose control (2.7% of the 5571 patients in that group), and 81 had been assigned to standard glucose control (1.5% of the 5569 patients in that group). The median times from the onset of severe hypoglycemia to the first major macrovascular event, the first major microvascular event, and death were 1.56 years (interquartile range, 0.84 to 2.41), 0.99 years (interquartile range, 0.40 to 2.17), and 1.05 years (interquartile range, 0.34 to 2.41), respectively. During follow-up, severe hypoglycemia was associated with a significant increase in the adjusted risks of major macrovascular events (hazard ratio, 2.88; 95% confidence interval [CI], 2.01 to 4.12), major microvascular events (hazard ratio, 1.81; 95% CI, 1.19 to 2.74), death from a cardiovascular cause (hazard ratio, 2.68; 95% CI, 1.72 to 4.19), and death from any cause (hazard ratio, 2.69; 95% CI, 1.97 to 3.67) (P<0.001 for all comparisons). Similar associations were apparent for a range of nonvascular outcomes, including respiratory, digestive, and skin conditions (P<0.01 for all comparisons). No relationship was found between repeated episodes of severe hypoglycemia and vascular outcomes or death. Conclusions Severe hypoglycemia was strongly associated with increased risks of a range of adverse clinical outcomes. It is possible that severe hypoglycemia contributes to adverse outcomes, but these analyses indicate that hypoglycemia is just as likely to be a marker of vulnerability to such events. (Funded by Servier and the National Health and Medical Research Council of Australia; ClinicalTrials.gov number, NCT00145925.)
1,441 citations
TL;DR: Among patients who are hospitalized for heart failure, substantial variation exists in hospital-level rates of early outpatient follow-up after discharge, and Patients who are discharged from hospitals that have higher early follow- up rates have a lower risk of 30-day readmission.
Abstract: Context Readmission after hospitalization for heart failure is common. Early outpatient follow-up after hospitalization has been proposed as a means of reducing readmission rates. However, there are limited data describing patterns of follow-up after heart failure hospitalization and its association with readmission rates. Objective To examine associations between outpatient follow-up within 7 days after discharge from a heart failure hospitalization and readmission within 30 days. Design, Setting, and Patients Observational analysis of patients 65 years or older with heart failure and discharged to home from hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure and the Get With the Guidelines-Heart Failure quality improvement program from January 1, 2003, through December 31, 2006. Main Outcome Measure All-cause readmission within 30 days after discharge. Results The study population included 30 136 patients from 225 hospitals. Median length of stay was 4 days (interquartile range, 2-6) and 21.3% of patients were readmitted within 30 days. At the hospital level, the median percentage of patients who had early follow-up after discharge from the index hospitalization was 38.3% (interquartile range, 32.4%-44.5%). Compared with patients whose index admission was in a hospital in the lowest quartile of early follow-up (30-day readmission rate, 23.3%), the rates of 30-day readmission were 20.5% among patients in the second quartile (risk-adjusted hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.93), 20.5% among patients in the third quartile (risk-adjusted HR, 0.87; 95% CI, 0.78-0.96), and 20.9% among patients in the fourth quartile (risk-adjusted HR, 0.91; 95% CI, 0.83-1.00). Conclusions Among patients who are hospitalized for heart failure, substantial variation exists in hospital-level rates of early outpatient follow-up after discharge. Patients who are discharged from hospitals that have higher early follow-up rates have a lower risk of 30-day readmission. Trial Registration clinicaltrials.gov Identifier: NCT00344513
1,053 citations
TL;DR: Despite being asymptomatic, patients with very severe aortic stenosis have a poor prognosis with a high event rate and a risk of rapid functional deterioration and early elective valve replacement surgery should be considered in these patients.
Abstract: Background— We sought to assess the outcome of asymptomatic patients with very severe aortic stenosis. Methods and Results— We prospectively followed 116 consecutive asymptomatic patients (57 women; age, 67±16 years) with very severe isolated aortic stenosis defined by a peak aortic jet velocity (AV-Vel) ≥5.0 m/s (average AV-Vel, 5.37±0.35 m/s; valve area, 0.63±0.12 cm2). During a median follow-up of 41 months (interquartile range, 26 to 63 months), 96 events occurred (indication for aortic valve replacement, 90; cardiac deaths, 6). Event-free survival was 64%, 36%, 25%, 12%, and 3% at 1, 2, 3, 4, and 6 years, respectively. AV-Vel but not aortic valve area was shown to independently affect event-free survival. Patients with an AV-Vel ≥5.5 m/s had an event-free survival of 44%, 25%, 11%, and 4% at 1, 2, 3, and 4 years, respectively, compared with 76%, 43%, 33%, and 17% for patients with an AV-Vel between 5.0 and 5.5 m/s (P<0.0001). Six cardiac deaths occurred in previously asymptomatic patients (sudden dea...
507 citations
TL;DR: Prednisone reduced the need for hospitalization and therapeutic procedures and hastened improvements in symptoms, performance, and quality of life while investigating for drug-resistant tuberculosis and other causes for deterioration before administering glucocorticoids.
Abstract: Objective: Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of antiretroviral therapy in resourcelimited countries. We aimed to assess whether a 4-week course of prednisone would reduce morbidity in patients with paradoxical TB-IRIS without excess adverse events. Design: A randomized, double-blind, placebo-controlled trial of prednisone (1.5mg/ kg per day for 2 weeks then 0.75mg/kg per day for 2 weeks). Patients with immediately life-threatening TB-IRIS manifestations were excluded. Methods: The primary combined endpoint was days of hospitalization and outpatient therapeutic procedures, which were counted as one hospital day. Results: One hundred and ten participants were enrolled (55 to each arm). The primary combined endpoint was more frequent in the placebo than the prednisone arm {median hospital days 3 [interquartile range (IQR) 0‐9] and 0 (IQR 0‐3), respectively; P ¼0.04}. There were significantly greater improvements in symptoms, Karnofsky score, and qualityoflife(MOS-HIV)intheprednisonevs.theplaceboarmat2and4weeks,butnot at later time points. Chest radiographs improved significantly more in the prednisone arm at weeks 2 (P ¼0.002) and 4 (P ¼0.02). Infections on study medication occurred in more participants in prednisone than in placebo arm (27 vs. 17, respectively; P ¼0.05), but there was no difference in severe infections (2 vs. 4, respectively; P ¼0.40). Isolates from 10 participants were found to be resistant to rifampicin after enrolment. Conclusion: Prednisone reduced the need for hospitalization and therapeutic procedures and hastened improvements in symptoms, performance, and quality of life. It is importanttoinvestigatefordrug-resistanttuberculosisandothercausesfordeterioration before administering glucocorticoids. 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2010, 24:2381‐2390
387 citations
TL;DR: The procedure appears to offer an adequate and lasting resolution of aortic stenosis in selected patients and demonstrates good medium- to long-term durability and preserved hemodynamic function.
Abstract: Background-Although short- and medium-term outcomes after transcatheter aortic valve implantation are encouraging, long-term data on valve function and clinical outcomes are limited. Methods and Results-Consecutive high-risk patients who had been declined as surgical candidates because of comorbidities but who underwent successful transcatheter aortic valve implantation with a balloon-expandable valve between January 2005 and December 2006 and survived past 30 days were assessed. Clinical, echocardiographic, and computed tomographic follow-up examinations were performed. Seventy patients who underwent successful procedures and survived longer than 30 days were evaluated at a minimum follow-up of 3 years. At a median follow-up of 3.7 years (interquartile range 3.4 to 4.3 years), survival was 57%. Survival at 1, 2, and 3 years was 81%, 74%, and 61%, respectively. Freedom from reoperation was 98.5% (1 patient with endocarditis). During this early procedural experience, 11 patients died within 30 days, and 8 procedures were unsuccessful. When these patients were included, overall survival was 51 %. Transaortic pressure gradients increased from 10.0 mm Hg (interquartile range 8.0 to 12.0 mm Hg) immediately after the procedure to 12.1 mm Hg (interquartile range 8.6 to 16.0 mm Hg) after 3 years (P=0.03). Bioprosthetic valve area decreased from a mean of 1.7±0.4 cm 2 after the procedure to 1.4±0.3 cm 2 after 3 years (P<0.01). Aortic incompetence after implantation was trivial or mild in 84% of cases and remained unchanged or improved over time. There were no cases of structural valvular deterioration, stent fracture, deformation, or valve migration. Conclusions-Transcatheter aortic valve implantation demonstrates good medium- to long-term durability and preserved hemodynamic function, with no evidence of structural failure. The procedure appears to offer an adequate and lasting resolution of aortic stenosis in selected patients.
295 citations
TL;DR: One-fourth of children with functional constipation continued to experience symptoms at adult age and should be considered at an early stage for children who are unresponsive to first-line treatment.
Abstract: OBJECTIVES: This study examines long-term prognoses for children with constipation in adulthood and identifies prognostic factors associated with clinical outcomes. METHODS: In a Dutch tertiary hospital, children (5–18 years of age) who were diagnosed as having functional constipation were eligible for inclusion. After a 6-week treatment protocol, prospective follow-up evaluations were conducted at 6 and 12 months and annually thereafter. Good clinical outcomes were defined as ≥3 bowel movements per week for ≥4 weeks, with ≤2 fecal incontinence episodes per month, irrespective of laxative use. RESULTS: A total of 401 children (260 boys; median age: 8 years [interquartile range: 6–9 years]) were included, with a median follow-up period of 11 years (interquartile range: 9–13 years). The dropout rate during follow-up was 15%. Good clinical outcomes were achieved by 80% of patients at 16 years of age. Thereafter, this proportion remained constant at 75%. Poor clinical outcomes at adult age were associated with: older age at onset (odds ratio [OR]: 1.15 [95% confidence interval [CI]: 1.02–1.30]; P = .04), longer delay between onset and first visit to our outpatient clinic (OR: 1.24 [95% CI: 1.10–1.40]; P = .001), and lower defecation frequency at study entry (OR: 0.92 [95% CI: 0.84–1.00]; P = .03). CONCLUSIONS: One-fourth of children with functional constipation continued to experience symptoms at adult age. Certain risk factors for poor clinical outcomes in adulthood were identified. Referral to a specialized clinic should be considered at an early stage for children who are unresponsive to first-line treatment.
252 citations
TL;DR: Digital RH-PAT can predict patients with ischemic heart disease, especially NOCAD before angiography, and is potentially useful for identifying high-risk women for IHD.
231 citations
TL;DR: Eur J Clin Invest 2010; 40 (10): 887–892.
Abstract: Eur J Clin Invest 2010; 40 (10): 887–892
Abstract
Background The fibroblast growth factor 21 (FGF21) hormonal pathway is a metabolic signalling cascade and has been recently identified as the master hormonal regulator of glucose, lipids and overall energy balance. In this observational, case–control study, we assayed serum levels of FGF21 in patients with nonalcoholic fatty liver disease (NAFLD), a hepatic manifestation of the metabolic syndrome, and examined their association with clinical, biochemical and histological phenotypes.
Materials and methods Serum levels of FGF21 were assayed by ELISA in 82 patients with biopsy-proven NAFLD and 77 controls. We analysed associations between FGF21 and the characteristics of patients with NAFLD by multiple linear regression analysis.
Results Levels of FGF21 were significantly higher in patients with NAFLD (median 200 pg mL−1; interquartile range: 87–410 pg mL−1) than in healthy controls (median 93 pg mL−1; interquartile range: 70–180 pg mL−1, Mann–Whitney U-test, P < 0·001). There was a stepwise increase in serum FGF21 levels according to the liver steatosis score (median level in subjects with score 1: 170 pg mL−1; score 2: 220 pg mL−1; score 3: 280 pg mL−1, P for trend < 0·01). After stepwise linear regression analysis, serum FGF21 levels were the only independent predictor of hepatic steatosis scores in patients with NAFLD (β = 0·26; t = 2·659, P < 0·01).
Conclusions Serum FGF21 levels are increased in patients with NAFLD regardless of potential confounders and represent an independent predictor of liver steatosis. These findings support further investigation of this molecule in metabolic liver diseases.
199 citations
TL;DR: In this paper, the authors explored the temporal association between chronic cough and gastroesophageal reflux in patients in which non-GOR causes have been excluded using a novel simultaneous acoustic cough recording and impedance/pH monitoring technique.
171 citations
TL;DR: PCT concentrations were higher in more severe forms of severe sepsis, but a substantial concentration decrease was more important for survival than absolute values.
Abstract: Introduction: This prospective study investigated the predictive value of procalcitonin (PCT) for survival in 242 adult patients with severe sepsis and septic shock treated in intensive care. Methods: PCT was analyzed from blood samples of all patients at baseline, and 155 patients 72 hours later. Results: The median PCT serum concentration on day 0 was 5.0 ng/ml (interquartile range (IQR) 1.0 and 20.1 ng/ml) and 1.3 ng/ml (IQR 0.5 and 5.8 ng/ml) 72 hours later. Hospital mortality was 25.6% (62/242). Median PCT concentrations in patients with community-acquired infections were higher than with nosocomial infections (P = 0.001). Blood cultures were positive in 28.5% of patients (n = 69), and severe sepsis with positive blood cultures was associated with higher PCT levels than with negative cultures (P = 50% (by 72 hours) compared to those with a < 50% decrease (12.2% vs. 29.8%, P = 0.007). Conclusions: PCT concentrations were higher in more severe forms of severe sepsis, but a substantial concentration decrease was more important for survival than absolute values.
169 citations
TL;DR: In this large cohort of ICU patients, females with severe sepsis/septic shock had a higher risk of dying in the hospital than did males, and this difference remained after multivariable adjustment.
TL;DR: Systematic toxicology investigation indicates that 3.1% of SDs are COC-related and are mainly due to cardio-cerebrovascular causes, which may account for myocardial ischaemia at risk of cardiac arrest in COC addicts.
Abstract: medical drugs. Autopsy was performed according to the European standardized protocol. Ten age- and sex- matched patients who died of violent causes with no antecedents of COC consumption and negative toxicology served as controls. During the study period, 2477 forensic autopsies were performed, including 1114 natural deaths. Among the latter, 668 fulfilled the criteria of SD and 21 (all males, mean age 34.6+ 7.3 years) resulted to be COC-related (3.1%). Cocaine was detected in 67.1% of the blood (median 0.17 mg/L, interquartile range 0.08-0.42) and in 83.0% of the urine samples (median 1.15 mg/L, interquartile range 0.37-17.34). A concomitant use of ethanol was found in 76.0% and cigarette smoking in 81.0%. Causes of SD were cardiovascular in 62.0%, cerebrovascular in 14.0%, excited delirium in 14.0%, respiratory and metabolic in 5.0% each. Left ventricular hyper- trophy was observed in 57.0%, small vessels disease in 42.9%, severe atherosclerotic coronary artery disease in 28.6%, and coronary thrombosis in 14.3%. Conclusion Systematic toxicology investigation indicates that 3.1% of SDs are COC-related and are mainly due to cardio- cerebrovascular causes. Left ventricular hypertrophy, small vessel disease, and premature coronary artery athero- sclerosis, with or without lumen thrombosis, are frequent findings that may account for myocardial ischaemia at risk of cardiac arrest in COC addicts. (EMCDDA), COC is a growing public health issue being the second most commonly used illicit substance among the general European population after cannabis. The estimated number of COC consumers is about 12 million Europeans with an overall prevalence of 3.7% of the total adult population (15-64 years). Ever in lifetime experience of COC is reported by more than 5% of the total adult European population in three countries: UK (7.7%), Spain (7.0%), and Italy (6.6%). The prevalence of use of COC is higher among young adults (15-34 years), with around
TL;DR: Infants with CDH and poor outcome have higher plasma ET1 levels and severity of PH than infants discharged on room air and increasing severity ofPH was associated with poor outcome at that time.
Abstract: Rationale: Endothelin-1 (ET1) is dysregulated in pulmonary hypertension (PH). It may be important in the pathobiology of congenital diaphragmatic hernia (CDH). Objectives: We hypothesized that ET1 levels in the first month would be higher in infants with CDH who subsequently expired or were discharged on oxygen (poor outcome). We further hypothesized that ET1 levels would be associated with concurrent severity of PH.Methods: We sampled plasma at 24 to 48 hours, and 1, 2, and 4 weeks of age in 40 prospectively enrolled newborns with CDH. We performed echocardiograms to estimate pulmonary artery pressure at less than 48 hours of age and weekly to 4 weeks. PH was classified in relationship to systemic blood pressure (SBP): less than 2/3 SBP, 2/3 SBP-systemic is related to pressure, or systemic-to-suprasystemic pressure.Measurements and Main Results: ET1 levels at 1 and 2 weeks were higher in infants with poor outcome compared with infants discharged on room air (median and interquartile range: 27.2 [22.6, 33...
TL;DR: Treatment with metformin is associated with a low risk of mortality in diabetic patients with heart failure compared with treatment with a sulfonylurea or insulin.
Abstract: The safety of metformin in heart failure has been questioned because of a perceived risk of life-threatening lactic acidosis, though recent studies have not supported this concern. We investigated the risk of all-cause mortality associated with individual glucose-lowering treatment regimens used in current clinical practice in Denmark. All patients aged ≥30 years hospitalised for the first time for heart failure in 1997–2006 were identified and followed until the end of 2006. Patients who received treatment with metformin, a sulfonylurea and/or insulin were included and assigned to mono-, bi- or triple therapy groups. Multivariable Cox proportional hazard regression models were used to assess the risk of all-cause mortality. A total of 10,920 patients were included. The median observational time was 844 days (interquartile range 365–1,395 days). In total, 6,187 (57%) patients died. With sulfonylurea monotherapy used as the reference, adjusted hazard ratios for all-cause mortality associated with the different treatment groups were as follows: metformin 0.85 (95% CI 0.75–0.98, p = 0.02), metformin + sulfonylurea 0.89 (95% CI 0.82–0.96, p = 0.003), metformin + insulin 0.96 (95% CI 0.82–1.13, p = 0.6), metformin + insulin + sulfonylurea 0.94 (95% CI 0.77–1.15, p = 0.5), sulfonylurea + insulin 0.97 (95% CI 0.86–1.08, p = 0.5) and insulin 1.14 (95% CI 1.06–1.20, p = 0.0001). Treatment with metformin is associated with a low risk of mortality in diabetic patients with heart failure compared with treatment with a sulfonylurea or insulin.
TL;DR: AF at the time of the blood draw, rather than a history of AF, was independently associated with inflammation, and differences in transcardiac gradients suggest that AF results in sequestration of inflammatory cytokines in the heart.
TL;DR: In this paper, the authors evaluated the capacity of uIL-18 measured within 24 hours of ICU admission to predict AKI, death, and receipt of acute dialysis in a large mixed-adult ICU population.
Abstract: Background and objectives: Urine IL-18 (uIL-18) has demonstrated moderate capacity to predict acute kidney injury (AKI) and adverse outcomes in defined settings. Its ability to predict AKI and provide prognostic information in broadly selected, critically ill adults remains unknown.
Design, setting, participants, & measurements: The study prospectively evaluated the capacity of uIL-18 measured within 24 hours of intensive care unit (ICU) admission to predict AKI, death, and receipt of acute dialysis in a large mixed-adult ICU population.
Results: Of 451 patients, 86 developed AKI within 48 hours of enrollment and had higher median uIL-18 levels [426 (interquartile range [IQR]: 152 to 1183) pg/mg creatinine] compared with those without AKI [248 (IQR: 120 to 559) pg/mg]. The area under the receiver operating characteristic curve for uIL-18 predicting subsequent AKI within 24 hours was 0.62 (95% CI: 0.54 to 0.69) and improved modestly to 0.67 (95% CI: 0.53 to 0.81) in patients whose enrollment eGFR was ≥75 ml/min per 1.73 m2. The highest median uIL-18 levels were observed in patients with sepsis at enrollment [508 (IQR: 230 to 1281) pg/mg], those receiving acute dialysis [571 (IQR: 161 to 1614) pg/mg] or dying [532 (IQR: 210 to 1614) pg/mg] within 28 days of ascertainment. After adjustment for a priori selected clinical predictors, uIL-18 remained independently predictive of composite outcome of death or acute dialysis within 28 days of ascertainment (odds ratio, 1.86 [95% CI: 1.31 to 2.64]).
Conclusions: uIL-18 did not reliably predict AKI development, but did predict poor clinical outcomes in a broadly selected, critically ill adult population.
TL;DR: Stage 5 CKD patients have clinically important physical and psychological symptom burdens in the last month of life, similar or greater than those in advanced cancer patients.
TL;DR: RS fat volume is associated with the number of prescribed antihypertensive medications and stage II hypertension, and these results indicate that further studies are warranted to determine whether fat accumulation in the RS promotes hypertension.
Abstract: Fat in the renal sinus (RS), a region of the kidney in which low pressure venous and lymphatic vessels are present, may indirectly influence blood pressure. The purpose of this study was to assess the association between RS fat and control of blood pressure on receipt of antihypertensive medications. A total of 205 participants aged 55 to 85 years at risk for cardiovascular events underwent MRI assessments of abdominal and RS fat, measurement of blood pressure, and determination of the number of prescribed antihypertensive medications. Multivariable linear regression was used to determine associations among RS fat, blood pressure, and the number of prescribed antihypertensive medications. Abdominal fat averaged 416±160 cm 3 (median and interquartile range of 396 cm 3 and 308 to 518 cm 3 ); intraperitoneal fat averaged 141±73 cm 3 (median and interquartile range of 129 cm 3 and 86 to 194 cm 3 ); and RS fat averaged 4.6±3.2 cm 3 (median and interquartile range of 4.2 cm 3 and 2.2 to 6.6 cm 3 ). After accounting for age, sex, height, body mass index, and intraperitoneal fat, RS fat correlated with the number of prescribed antihypertensive medications ( P =0.010), stage II hypertension ( P =0.02), and renal size ( P ≤0.001). In conclusion, after accounting for other body fat depots and risk factors for hypertension, RS fat volume is associated with the number of prescribed antihypertensive medications and stage II hypertension. These results indicate that further studies are warranted to determine whether fat accumulation in the RS promotes hypertension.
TL;DR: In hospitalized patients with a major diagnosis of cardiovascular disease, there is a modest independent association between increasing duration of storage of red cells and risk of in-hospital mortality that appears to be continuous and graded.
TL;DR: An extensive involvement of the gastrointestinal tract was significantly associated withCMV relapse, however, endoscopic evidence of resolution of gastrointestinal disease did not necessarily translate into a lower risk of CMV relapse.
TL;DR: This study suggests that an elevated NLR can identify a poor-risk subset of patients among those being treated for critical limb ischemia, and may, therefore, add to risk stratification of these high-risk patients.
TL;DR: Despite a high premature failure rate, ultrasonography-guided peripheral intravenous (IV) catheters appear to be an effective alternative to central line placement in ED patients with difficult access.
Abstract: Objectives We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access. Methods This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival >96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis. Results Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications. Conclusion Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.
TL;DR: It is suggested that patients with cardiogenic shock complicating acute myocardial infarction who undergo primary PCI assisted by IABP have a more favorable in-hospital outcome and lower in- hospital mortality than patients who receive IABp after PCI.
Abstract: Primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counterpulsation (IABP) are established treatment modalities in acute myocardial infarction complicated by cardiogenic shock. We hypothesized that the insertion of the IABP before primary PCI might result in better survival of patients with cardiogenic shock compared to postponing the insertion to after primary PCI. We, therefore, retrospectively studied 48 patients who had undergone primary PCI with IABP because of cardiogenic shock complicating acute myocardial infarction (26 patients received the IABP before and 22 patients after primary PCI). No significant differences were present in the baseline clinical characteristics between the 2 groups. The mean number of diseased vessels was greater in the group of patients treated with the IABP before primary PCI (2.8 ± 0.5 vs 2.3 ± 0.7, p = 0.012), but the difference in the number of treated vessels was not significant. The peak creatine kinase and creatine kinase -MB levels were lower in patients treated with the IABP before primary PCI (median 1,077, interquartile range 438 to 2067 vs median 3,299, interquartile range 695 to 6,834, p = 0.047, and median 95, interquartile range 34 to 196 vs median 192, interquartile range 82 to 467, p = 0.048, respectively). In-hospital mortality and the overall incidence of major adverse cardiac and cerebrovascular events were significantly lower in the group of patients receiving the IABP before primary PCI (19% vs 59% and 23% vs 77%, p = 0.007 and p = 0.0004, respectively). Multivariate analysis identified renal failure (odds ratio 15.2, 95% confidence interval 3.13 to 73.66) and insertion of the IABP after PCI (odds ratio 5.2, 95% confidence interval 1.09 to 24.76) as the only independent predictors of in-hospital mortality. In conclusion, the results of the present study suggest that patients with cardiogenic shock complicating acute myocardial infarction who undergo primary PCI assisted by IABP have a more favorable in-hospital outcome and lower in-hospital mortality than patients who receive IABP after PCI.
TL;DR: Prescription of an anticoagulant is independently associated with a decreased risk of death or stroke among patients with AF and a CHADS2 score =1.
Abstract: In patients with atrial fibrillation (AF) and an intermediate risk of stroke (CHADS2 score =1), available evidence from clinical trials is inconclusive and the present guidelines for the management of AF indicate that the choice between oral anticoagulant and aspirin in these patients is open. Our goal was to evaluate whether, in patients with AF and only one moderate risk factor for thromboembolism, treatment with an oral anticoagulant is appreciably more beneficial than treatment with an antiplatelet agent. Among 6,517 unselected patients with AF, 1,012 of them (15.5%) had a CHADS2 score of 1 and were liable to treatment with an antiplatelet agent or an anticoagulant. An oral anticoagulant was prescribed for 606 patients (59.9%) and an antiplatelet agent or no antithrombotic treatment for 406 (40.1%). During follow-up (median=793 days, interquartile range=1,332 days), 105 deaths (10.4%) and 19 strokes (1.9%) were recorded. The administration of an anticoagulant was associated with a lower rate of events (relative risk=0.42, 95% confidence interval 0.29–0.60, p<0.0001) than when no anticoagulant was prescribed. Results remained similar after adjustment for age and other confounding factors. In contrast, prescription of an antiplatelet agent was not associated with a lower risk of events. Factors independently associated with an increased risk of events were older age (p<0.0001), concomitant heart failure (p=0.0002), diabetes (p=0.0025), lack of prescription of an anticoagulant (p<0.0001) and permanent AF (p=0.04). Thus, prescription of an anticoagulant is independently associated with a decreased risk of death or stroke among patients with AF and a CHADS2 score =1.
TL;DR: Few patients who experienced a CFS had ABM in the absence of other signs or symptoms, and none of the patients for whom an LP was not attempted subsequently returned to the hospital with a diagnosis of ABM.
Abstract: To assess the rate of acute bacterial meningitis (ABM) among children who present with their first complex febrile seizure (CFS). DESIGN AND METHODS: This study was a retrospective, cohort review of patients aged 6 to 60 months who were evaluated in a pediatric emergency department (ED) between 1995 and 2008 for their first CFS. Cases were identified by using a computerized text search followed by a manual chart review. Exclusion criteria included prior history of nonfebrile seizures, an immunocompromised state, an underlying ill- ness associated with seizures or altered mental status, or trauma. Data extracted included age, gender, seizure features, the number of previous simple febrile seizures, temperature, a family history of sei- zures, findings on physical examination, laboratory and imaging study results, and ED diagnosis and disposition. RESULTS: We identified 526 patients. The median age was 17 months (interquartile range: 13-24), and 44% were female. Ninety patients (17%) had a previous history of simple febrile seizures. Of the patients, 340 (64%) had a lumbar puncture (LP). The patients' median white blood cell count during a CFS was 1 cell per L (interquartile range: 1-2), and 14 patients had CSF pleocytosis (2.7% (95% confidence inter- val (CI): 1.5- 4.5)). Three patients had ABM (0.9% (95% CI: 0.2-2.8)). Two had Streptococcus pneumoniae in a culture of their cerebrospinal fluid. Among these 2 patients, 1 was nonresponsive during presenta- tion, and the other had a bulging fontanel and apnea. The third child appeared well; however, her blood culture grew S pneumoniae and failed the LP test. None of the patients for whom an LP was not at- tempted subsequently returned to the hospital with a diagnosis of ABM (0% (95% CI: 0, 0.9)). CONCLUSION: Few patients who experienced a CFS had ABM in the absence of other signs or symptoms. Pediatrics 2010;126:62-69
TL;DR: In this paper, the authors developed copy-years viremia as a measure of cumulative plasma HIV-1 viral load exposure among 297 HIV seroconverters from the Multicenter AIDS Cohort Study (1984-1996).
Abstract: Plasma human immunodeficiency virus type 1 (HIV-1) viral load is a valuable tool for HIV research and clinical care but is often used in a noncumulative manner. The authors developed copy-years viremia as a measure of cumulative plasma HIV-1 viral load exposure among 297 HIV seroconverters from the Multicenter AIDS Cohort Study (1984–1996). Men were followed from seroconversion to incident acquired immunodeficiency syndrome (AIDS), death, or the beginning of the combination antiretroviral therapy era (January 1, 1996); the median duration of follow-up was 4.6 years (interquartile range (IQR), 2.7–6.5). The median viral load and level of copy-years viremia over 2,281 semiannual follow-up assessments were 29,628 copies/mL (IQR, 8,547–80,210) and 63,659 copies × years/mL (IQR, 15,935–180,341). A total of 127 men developed AIDS or died, and 170 survived AIDS-free and were censored on January 1, 1996, or lost to follow-up. Rank correlations between copy-years viremia and other measures of viral load were 0.56–0.87. Each log10 increase in copy-years viremia was associated with a 1.70-fold increased hazard (95% confidence interval: 0.94, 3.07) of AIDS or death, independently of infection duration, age, race, CD4 cell count, set-point, peak viral load, or most recent viral load. Copy-years viremia, a novel measure of cumulative viral burden, may provide prognostic information beyond traditional single measures of viremia.
TL;DR: High rate of early clinical deterioration among 8,291 patients with TIA or minor stroke despite immediate admission to specialized stroke units was revealed, and predictors for neurologic deterioration apart from diabetes, hypertension, and the estimated ABCD2 score were stroke etiology, reinforcing the relevance of an immediate diagnostic workup, and coexistent acute infection and cardiac decompensation.
Abstract: Objective: TIA is associated with a substantial short-term risk of stroke and is thus increasingly recognized as an unstable condition necessitating full medical attention. Our study sought to assess the rate of and predictors for early deterioration after TIA or minor stroke in a large nationwide survey among Austrian stroke units. Methods: Of the 29,287 patients prospectively enrolled in the Austrian Stroke Unit Registry (2003–2008), 8,291 presenting with a TIA or minor ischemic stroke, defined by an NIH Stroke Scale (NIHSS) score Results: A total of 374 patients (4.5%) experienced early clinical worsening during a mean stroke unit stay of 2.97 days (median 2 [interquartile range,1–4] days). In a multivariate stepwise regression analysis hypertension, diabetes, cardiac decompensation, acute infection, and stroke etiology emerged as independent risk predictors for early deterioration. The ABCD2 score could be estimated in a subgroup of 3,886 subjects and closely correlated with the risk of neurologic worsening. Conclusions: Our study revealed a high rate of early clinical deterioration (4.5%) among 8,291 patients with TIA or minor stroke despite immediate admission to specialized stroke units. Predictors for neurologic deterioration apart from diabetes, hypertension, and the estimated ABCD2 score were stroke etiology, reinforcing the relevance of an immediate diagnostic workup, and coexistent acute infection and cardiac decompensation, both conditions necessitating adequate attention in the emergency setting.
TL;DR: Analysis of the underlying medical conditions of fatal cases, based on the observed frequency of the conditions in the general population, confirms the risk for fatal outcome, which is most notably due to immunosuppression, diabetes and respiratory diseases.
Abstract: The mortality in Germany caused by the 2009 pandemic influenza A(H1N1) seems to have been one of the lowest in Europe. We provide a detailed analysis of all 252 fatal cases of confirmed infection with the pandemic virus notified between 29 April 2009 and 31 March 2010. The overall mortality was 3.1 (95% confidence interval (CI): 2.7 to 3.5) per one million inhabitants. We observed an increase in the case fatality rate of notified cases over time; notified cases aged 60 years or older had the highest case fatality rate (2.16%; 95% CI: 1.61 to 2.83; odds ratio: 5.4; p<0.001; reference group: 35-59 years). The median delay of four days (interquartile range (IQR): 2-7) between symptom onset and antiviral treatment was significantly longer in fatal cases than for non-fatal cases (median: two days (IQR: 1-3; p<0.001). Analysis of the underlying medical conditions of fatal cases, based on the observed frequency of the conditions in the general population, confirms the risk for fatal outcome, which is most notably due to immunosuppression, diabetes and respiratory diseases. Our results suggest that early treatment might have had an impact on overall mortality. Identification of risk groups for targeted intervention to prevent fatalities needs to take into account the distribution of underlying conditions in the population.
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TL;DR: A Web-based prognostic model was developed that directly allows clinicians to estimate the probability of developing disability in IgM MGUSP and decreases the risk of developing Rankin Scale score ≥3 in polyneuropathy associated with immunoglobulin M monoclonal gammopathy.
Abstract: Background: The disease course of polyneuropathy associated with immunoglobulin M monoclonal gammopathy (IgM MGUSP) can be highly variable. In order to identify factors that influence long-term disease outcome, a prospective cohort study was performed of 140 patients with IgM MGUSP over a period of 23 years. Methods: All patients with IgM MGUSP who were diagnosed in our tertiary referral center for polyneuropathy were eligible. All patients underwent nerve conduction studies and were tested for anti-MAG antibodies. The modified Rankin Scale, graded muscle strength, quantified sensory function, and laboratory testing were performed at 0, 1, 2, and 5 years and at last visit. The primary outcome measure was the risk of developing a modified Rankin Scale score of ≥3 points. Results: A total of 140 patients with IgM MGUSP fulfilled inclusion criteria (101 [72%] demyelinating, 39 [28%] axonal, 63 [44%] MAG positive). The median age at onset was 59 years (interquartile range 52–67), median disease duration at baseline was 3.2 years (interquartile range 1.9–6). Anti-MAG antibodies were associated with a lower risk of Rankin Scale score ≥3. Demyelination and a higher age at onset were associated with a higher risk for Rankin Scale score ≥3. Based on these 3 factors, a Web-based prognostic model was developed that directly allows clinicians to estimate the probability of developing disability (http://www.umcutrecht.nl/subsite/Prognosis-MGUS-Neuropathy). Conclusion: Higher age at onset and demyelination increase the risk, whereas anti-MAG antibodies decrease the risk, of developing Rankin Scale score ≥3 in polyneuropathy associated with immunoglobulin M monoclonal gammopathy (IgM MGUSP). Our Web-based prognostic model allows determination of prognosis in IgM MGUSP.
TL;DR: This study provides robust evidence of an association between plasma hsCRP and the APOE genotype, an association not explained by history of cardiovascular disease nor its risk factors.