6-week Mortality Research Articles

Bedside risk-scoring model for predicting 6-week mortality in cirrhotic patients undergoing endoscopic band ligation for acute variceal bleeding.

Acute variceal bleeding (AVB) is a fatal adverse event of cirrhosis, and endoscopic band ligation (EBL) is the standard treatment for AVB. We developed a novel bedside risk-scoring model to predict the 6-week mortality in cirrhotic patients undergoing EBL for AVB. Cox regression analysis was used to assess the relationship of clinical, biological, and endoscopic variables with the 6-week mortality risk after EBL in a derivation cohort (n=1373). The primary outcome was the predictive accuracy of the new model for the 6-week mortality in the validation cohort. Moreover, we tested the adequacy of the mortality risk-based stratification and the discriminative performance of our new model in comparison with the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease scores in the validation cohort (n=200). On multivariate Cox regression analysis, five objective variables (use of beta-blockers, hepatocellular carcinoma, CTP class C, hypovolemic shock at initial presentation, and history of hepatic encephalopathy) were scored to generate a 12-point risk-prediction model. The model stratified the 6-week mortality risk in patients as low (3.5%), intermediate (21.1%), and high (53.4%) (P<0.001). Time-dependent area under the receiver operating characteristic curve for 6-week mortality showed that this model was a better prognostic indicator than the CTP class alone in the derivation (P<0.001) and validation (P<0.001) cohorts. A simplified scoring model with high potential for generalization refines the prediction of 6-week mortality in high-risk cirrhotic patients, thereby aiding the targeting and individualization of treatment strategies for decreasing the mortality rate.

Predictive factors of six-week mortality in critically ill patients with SARS-CoV-2: A multicenter prospective study.

ObjectiveThe objective of the study is to identify the risk factors associated with mortality at six weeks, especially by analyzing the role of antivirals and munomodulators.DesignProspective descriptive multicenter cohort study.Setting26 Intensive care units (ICU) from Andalusian region in Spain.Patients or participantsConsecutive critically ill patients with confirmed SARS-CoV-2 infection were included from March 8 to May 30.InterventionsNone.VariablesVariables analyzed were demographic, severity scores and clinical condition. Support therapy, drug and mortality were analyzed. An univariate followed by multivariate Cox regression with propensity score analysis was applied.Results495 patients were enrolled, but 73 of them were excluded for incomplete data. Thus, 422 patients were included in the final analysis. Median age was 63 years and 305 (72.3%) were men. ICU mortality: 144/422 34%; 14 days mortality: 81/422 (19.2%); 28 days mortality: 121/422 (28.7%); 6-week mortality 152/422 36.5%. By multivariable Cox proportional analysis, factors independently associated with 42-day mortality were age, APACHE II score, SOFA score at ICU admission >6, Lactate dehydrogenase at ICU admission >470 U/L, Use of vasopressors, extrarenal depuration, %lymphocytes 72 h post-ICU admission <6.5%, and thrombocytopenia whereas the use of lopinavir/ritonavir was a protective factor.ConclusionAge, APACHE II, SOFA > value of 6 points, along with vasopressor requirements or renal replacement therapy have been identified as predictor factors of mortality at six weeks.Administration of corticosteroids showed no benefits in mortality, as did treatment with tocilizumab.Lopinavir/ritonavir administration is identified as a protective factor.

Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child-Pugh B Cirrhosis and Acute Variceal Bleeding.

Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P<0.001] and 0.556 [P<0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

Mortality, Risk Factors and Disparities Associated with Esophageal Variceal Bleeding in Children's Hospitals in the US

To use a large administrative database to determine the mortality, risk factors, and comorbidities of esophageal variceal bleeding in children. Retrospective cohort study using Pediatric Health Information System data from 50 tertiary children's hospitals in the US. International Classification of Diseases(ICD) codes (FY 2020 ICD-10 update and revision 10 of ICD-9) from 2004 through 2019 identified children 18years and younger with variceal bleeding and complications. Univariate analyses used the Student t -test for continuous variables (age) and the χ2 test for categorical variables (all others). A mixed-effects linear regression was performed for multiple variables. There were 1902 patients who had 3399 encounters for esophageal variceal bleeding. The mortality rate for variceal bleeding was 7.3%, increasing to 8.8% by 6weeks; any mortality during the study was 20.1%. Transfusion was required in 54.7% of encounters, and 42.6% were admitted to the intensive care unit. Variceal bleeding encounters were complicated by peptic ulcer disease (6.9%), bacteremia (11.4%), acute renal failure (5.1%), mechanical ventilation (18%), ascites (21.3%), and peritonitis (3.3%). Multivariable mixed-effects logistic regression showed that Black race (OR, 2.59; P<.001) or Hispanic ethnicity (OR, 2.31; P=.001), but not sex, household income, or insurance type, were associated with increased mortality. Bacteremia, peritonitis, mechanical ventilation, acute renal failure, and transfusion were associated with higher mortality (ORs of 2.29, 2.18, 1.93, 6.33, and 1.81, respectively; P<.001, .005, .011, <.001, and .005, respectively). The 6-week mortality rate for variceal bleeding in children is 8.8%. Black or Hispanic children are at higher risk of dying. Serious morbidities associated with variceal hemorrhage impact mortality. These data can inform consideration of prophylactic or therapeutic interventions for children at risk.

Predictive factors of failure to control bleeding and 6-week mortality after variceal hemorrhage in liver cirrhosis - a tertiary referral center experience.

IntroductionMortality from variceal bleeding remains high despite the therapeutic progress in severe cirrhosis. Understanding the predictive factors of failure to control bleeding (FTB) and mortality will lead to better future therapies. Comorbidities are thought to be important prognostic factors for variceal bleeding. The aim of the study was to assess the factors associated with FTB and with 42-day mortality and to evaluate the influence of comorbidities on these patients’ prognosis.Material and methodsWe prospectively included in the study all consecutive patients with cirrhosis and variceal bleeding presenting to the emergency room and we followed them up over 6 weeks. CirCom score and Charlson index were used for the assessment of comorbidities.ResultsOf the 138 patients included in the study, 27 (19.5%) were considered to have FTB. Child C class (74.07% vs. 32.43%, p < 0.001), Meld score (20.5 vs. 16.00, p = 0.004) and creatinine level (1.04 vs. 0.81, p = 0.01) were associated with FTB, but only Child class was independently associated with FTB in multivariate analysis (OR = 2.94, p = 0.006). Mortality at 42 days (21.7%) was influenced by the severity of the disease assessed through Child class (76.66% vs. 30.55% – Child C, p < 0.001) and MELD score (21.00 vs. 16.00, p < 0.001). Creatinine level (1.00 vs. 0.7, p = 0.02) and acute kidney injury (26.66% vs. 7.40%, p = 0.009) were also prognostic factors for the 6-week mortality. Comorbidities did not influence the mortality (CirCom > 1 (16.7% vs. 21.3%, p = 0.76) or Charlson index > 4 (36% vs. 47.2%, p = 0.41).ConclusionsThe severity of cirrhosis is an important prognostic factor for FTB and 42-day mortality. Identifying the factors associated with early mortality may help selecting patients needing more than conventional therapy.

Risk stratification in acute variceal bleeding: Far from an ideal score

OBJECTIVES:Acute variceal bleeding (AVB) results from rupture of esophageal or gastric varices. It is a life-threatening complication of portal hypertension. Nevertheless, it remains unclear how to predict adverse outcomes and identify high-risk patients. In variceal hemorrhage, high Child-Turcotte-Pugh (Child) and Model for End-stage Liver Disease (MELD) scores are associated with a worse prognosis. The Rockall system (Rockall), Glasgow-Blatchford (Blatchford), and AIMS65 scores have been validated for risk stratification for nonvariceal upper gastrointestinal bleeding; however, their use is controversial in AVB. The aim of this study was to compare the performance of Child, MELD, Rockall, Blatchford, and AIMS65 scores in risk stratification for rebleeding and/or mortality associated with AVB.METHODS:This retrospective study was conducted at a tertiary care hospital over 42 months. The outcomes were 6-week rebleeding and mortality. The AUROC was calculated for each score (1-0.9, 0.9-0.8, and 0.8-0.7, indicating excellent, good, and acceptable predictive power, respectively).RESULTS:In total, 222 patients were included. Six-week rebleeding and mortality rates were 14% and 18.5%, respectively. No score was useful for discriminating patients at a higher risk of rebleeding. The AUROCs were 0.59, 0.57, 0.61, 0.63, and 0.56 for Rockall, Blatchford, AIMS65, Child, and MELD scores, respectively. Prediction of 6-week mortality based on Rockall (AUROC 0.65), Blatchford (AUROC=0.60), and AIMS65 (AUROC=0.67) scores were also not considered acceptable. The AUROCs for predicting mortality were acceptable for Child and MELD scores (0.72 and 0.74, respectively).CONCLUSION:Rockall, Blatchford, and AIMS65 scores are not useful for predicting 6-week rebleeding or mortality in patients with AVB. Child and MELD scores can identify patients at higher risk for 6-week mortality but not for 6-week rebleeding.

Early combination therapy with hydroxychloroquine and azithromycin reduces mortality in 10,429 COVID-19 outpatients.

We evaluated the age-specific mortality of unselected adult outpatients infected with SARS-CoV-2 treated early in a dedicated COVID-19 day hospital and we assessed whether the use of hydroxychloroquine (HCQ) + azithromycin (AZ) was associated with improved survival in this cohort. A retrospective monocentric cohort study was conducted in the day hospital of our center from March to December 2020 in adults with PCR-proven infection who were treated as outpatients with a standardized protocol. The primary endpoint was 6-week mortality, and secondary endpoints were transfer to the intensive care unit and hospitalization rate. Among 10,429 patients (median age, 45 [IQR 32-57] years; 5597 [53.7%] women), 16 died (0.15%). The infection fatality rate was 0.06% among the 8315 patients treated with HCQ+AZ. No deaths occurred among the 8414 patients younger than 60 years. Older age and male sex were associated with a higher risk of death, ICU transfer, and hospitalization. Treatment with HCQ+AZ (0.17 [0.06-0.48]) was associated with a lower risk of death, independently of age, sex and epidemic period. Meta-analysis evidenced consistency with 4 previous outpatient studies (32,124 patients-Odds ratio 0.31 [0.20-0.47], I2 = 0%). Early ambulatory treatment of COVID-19 with HCQ+AZ as a standard of care is associated with very low mortality, and HCQ+AZ improve COVID-19 survival compared to other regimens.

A retrospective cohort study of intensive gastric variceal ligation versus endoscopic gastric variceal obturation in the management of gastric variceal bleeding.

Gastric variceal bleeding is often more serious and can be fatal. Currently, international consensus recommendations for the treatment of gastric variceal bleeding vary according to endoscopic classification. Few studies have investigated ligation versus gastric variceal obturation (GVO) for the treatment of gastric varices. The study included 79 patients with cirrhosis-induced bleeding from esophageal and fundal varices who were treated at the Second Hospital of Hebei Medical University between January 2016 and December 2020 and who met the inclusion criteria. Among them, 42 patients were included in the intensive gastric varices ligation (IGVL) group, and 37 were included in the GVO group. We conducted a retrospective cohort study to analyze the effectiveness and safety of these 2 treatments. The rebleeding rate after initial treatment was significantly lower in the IGVL group than in the GVO group (23.8% vs. 48.6%, P<0.05). No significant between-group difference was observed in overall mortality (14.3% vs. 32.4%), 6-week mortality (0.0% vs. 2.7%), or 1-year mortality (11.9% vs. 13.5%, all P>0.05). The >1-year mortality and bleeding-related mortality rates were significantly higher in the GVO group than in the IGVL group (23.3% vs. 2.7%, P<0.05; 27.0% vs. 9.5%, P<0.05). The incidence of adverse events was 57.1% in the IGVL group and 48.6% in the GVO group, with no significant difference (P>0.05). Independent predictors for rebleeding after initial treatment were the use of GVO as endoscopic treatment, total bilirubin >17.1 µmol/L, liver cancer, and diabetes. For mortality, the independent predictors were male sex, liver cancer, ascites, and rebleeding after initial treatment. Rebleeding after initial treatment was lower after IGVL than GVO. Independent predictors for rebleeding after initial treatment were endoscopic treatment method, total bilirubin >17.1 µmol/L, liver cancer, and diabetes. For mortality, the independent predictors were male sex, liver cancer, ascites, and rebleeding after initial treatment.

Prognosis and clinical characteristics of patients with early ventricular fibrillation in the 6-week guideline-offered time period: is it safe to wait 6 weeks with the assessment? (results from the VMAJOR-MI Registry)

The most common, potentially fatal complication following an acute myocardial infarction (AMI) is early ventricular fibrillation (EVF). According to the guidelines, the assessment of implanting an implantable cardioverter defibrillator (ICD) is sufficient 6 weeks after the event, in patients with reduced left ventricular ejection fraction (LVEF), regardless of VF. The present study aimed to evaluate the 6-week prognosis of patients surviving an EVF. We divided the patients in two group based on their general condition at the time they left the hospital. We investigated the clinical characteristics of patients discharged in good general health but still dying within 6 weeks. The present study comprised 12,270 patients with AMI following their primary revascularization in the first 12 h of symptom onset. Five hundred and forty-seven of them suffered EVF due to the AMI. Clinical and 6-week mortality data were examined. Poor general condition correlates with multiple comorbidities, higher troponin levels, more severe complications after the event. Patients leaving in good condition thought to be low risk, from dying. But low LVEF, high blood sugar, high cardiac biomarker level, poor renal function elevates the risk of dying within 6 weeks. However, there is no difference in clinical characteristics between EVF- cases and EVF+ cases in good condition who dies within 6 weeks. According to our study we can select patients who are safe in the critical 6-week period and those who need closer follow-up despite leaving in good general condition.

A novel treatment regimen of granulocyte colony-stimulating factor combined with ultra-low-dose decitabine and low-dose cytarabine in older patients with acute myeloid leukemia and myelodysplastic syndromes.

Background:Older patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) unfit for intensive chemotherapy are emergent for suitable treatment strategies. Hypomethylating agents and low-dose cytarabine have generated relevant benefits in the hematological malignancies over recent decades. We evaluated the efficacy and safety of the novel treatment regimen consisting of ultra-low-dose decitabine and low-dose cytarabine, with granulocyte colony-stimulating factor (G-CSF) in this population of patients.Methods and materials:Patients aged more than 60 years with newly diagnosed AML/MDS were enrolled to receive therapy combined of 300 µg subcutaneously per day for priming, decitabine 5.15–7.62 mg/m2/d intravenously and cytarabine 15 mg/m2/d twice a day subcutaneously and G-CSF for consecutive 10 days every 28 days. The study enrolled 28 patients unfit for standard intensive chemotherapy. The median age of patients was 68 years (range 60–83 years) and 20 (71.4%) patients harbored AML. The primary outcome was to evaluate overall response rate.Results:Overall, this novel ultra-low-dose treatment regimen was well tolerated, with 0% of both 4- and 8-week mortality occurrence. Objective response rate (CR + CRi + PR in AML and CR + mCR + PR in MDS) was 57.1% after the first treatment course. Responses of hematologic improvement (HI) aspect were achieved in 18 of 28 (64.3%) patients, 11 (39.3%), 12 (42.9%), and eight patients (28.6%) achieved HI-E, HI-P, HI-N, respectively.Conclusions:Untreated elderly with AML/MDS were well tolerated and benefited from this novel ultra-low-dose treatment regimen.

Xpert-Ultra to Detect and Quantify HIV-Associated &lt;i&gt;Mycobacterium tuberculosis&lt;/i&gt; Blood Stream Infection: A Cohort Study

Background: Mycobacterium tuberculosis bloodstream infection (MTBBSI) is a leading cause of death in people living with HIV. Tools to rapidly identify and quantify MTBBSI could facilitate both diagnosis and research for this critical condition. Methods: We developed a method to detect M. tuberculosis in blood using lysis-wash steps and the Xpert MTB/RIF Ultra platform, testing it on biobanked blood from participants hospitalized with HIV-associated TB. We assessed diagnostic yield (proportion of cases detected, with unavailable test results coded as negative) against a microbiological reference, both as a function of markers of critical-illness and compared with other rapid-diagnostics. Quantitative blood Xpert-Ultra results were evaluated as a disease biomarker by assessing association with disease phenotype defined by principal component analysis of 32 host-response markers, and prognostic value compared to other tuberculosis biomarkers models to predict 12-week mortality. Findings: Of 582 participants, 447 (77%) had tuberculosis; 165 out of 447 were blood Xpert-Ultra positive giving diagnostic yield 0·37 (95%CI 0·32 to 0·42). Diagnostic yield increased with lower CD4 cell count or haemoglobin, and outperformed urine lipoarabinomannan testing in participants with elevated venous lactate. Quantitative blood Xpert-Ultra results predicted mortality better than other tuberculosis biomarkers including blood culture, and urine lipoarabinomannan or urine-Xpert. Both blood Xpert-Ultra positivity and cycle threshold were strongly associated with a principal component of clinical phenotype capturing markers of inflammation, tissue damage and organ dysfunction. Interpretation: Xpert-Ultra testing of pre-processed blood could be used as a rapid diagnostic test in critically ill patients with suspected HIV-associated tuberculosis, while also giving additional prognostic information compared with other available markers. A dose-response relationship between quantitative blood Xpert-Ultra results, host-response phenotype, and mortality risk adds to evidence that suggests MTBBSI bacillary load is causally related to outcomes. Funding Information: Wellcome Trust, Fogarty International Center, South African MRC, NIHR(UK), National Research Foundation of South Africa. Declaration of Interests: All authors declare no conflict of interest. Ethics Approval Statement: This study was approved by the University of Cape Town Human Research Ethics Committee (HREC 057/2013).

Efficacy of Endoscopic Variceal Ligation in the Control of Variceal Bleeding: A Real World Setting

Background: Combined pharmacological and endoscopic therapy, particularly endoscopic variceal ligation (EVL), is the first-line treatment for acute esophageal variceal bleeding (EVB). In patients with rebleeding, the rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS) is recommended. However, in a real world setting where the accessibility to TIPS is limited, repeated endoscopic therapy is inevitably performed. Objective: To study the outcomes of EVL on rebleeding and mortality in the resource-limited setting. Materials and Methods: Patients who underwent EVL during 2017 to 2018 are included. Patients were treated with vasoactive drugs and EVL until the eradication of varices. We focus on the outcome of a second attempt at EVL to control EVB. The rebleeding and mortality rate within 6 months after the combined treatment were collected. Logistic regression analysis was performed to identify risk factors of rebleeding. Results: There were 339 EVL performed during the 2-year period. Of these procedures, EVL was indicated to control acute EVB in 118 patients. EVB in 98 patients (83%) were successfully controlled in only one session of EVL, while those of 20 patients (17%) required at least 2 sessions to control the recurrent EVB. In the rebleeding group, no patient rebled within 5 days after the first EVL, while 15 patients (75%) rebled within 6 weeks. Once rebled, the second EVL was performed. There were 5 patients (25%) whom the second EVL failed to control the recurrent EVB. Those recurrent EVB were finally controlled by the other endoscopic therapy. The 6-week mortality after rebleeding was 15%. Hepatocellular carcinoma and creatinine are factors associated with recurrent EVB within 6 weeks with odds ratio (OR) 5.96 (95% CI 1.41 to 25.19, p = 0.02) and OR 1.47 (95% CI: 1.02 to 2.11, p = 0.04), respectively. Conclusion: The second attempt at endoscopic therapy can be considered to control recurrent EVB after the first EVL with a success rate of 75% in area where an accessibility to a treatment with TIPS is limited. Keywords: Endoscopic therapy, Outcomes, Real world, Recurrent, Variceal bleeding

High-density lipoprotein cholesterol is a predictor of survival in cirrhotic patients with acute gastrointestinal bleeding: a retrospective study

BackgroundLipid profiles are declined in patients with viral liver cirrhosis and correlated with severity of liver disease. Hepatitis B virus (HBV) is the leading cause of liver cirrhosis in China. Our primary aim was to investigate whether serum lipids and lipoproteins associate with survival in patients with HBV-related cirrhosis and acute gastrointestinal bleeding, and develop a 6-week mortality risk score that incorporates it.MethodsFrom January 2008 to December 2015, consecutive cirrhotic patients with acute gastrointestinal bleeding admitted to our hospital were evaluated and randomly divided into the derivation (n = 629) and validation (n = 314) cohorts. A logistic regression model was established to confirm the association between lipoprotein cholesterol and mortality. Accuracy to predict mortality were assessed by area under the receiver operating characteristic curves (AUROCs) and compared using the Hanley and McNeil test.ResultsAmong study subjects, the 6-week mortality rate was 10.6%. High-density lipoprotein cholesterol (HDL-C) level was found to correlate most strongly with prognostic scores. On ROC analysis, HDL-C showed excellent diagnostic accuracy for 6-week mortality. Logistic regression analysis provided a simple algorithm based on the combined use of 4 variables (total bilirubin (TBIL), HDL-C, International normalized ratio, and hemoglobin), allowing accurate discrimination of 3 distinct prognostic subgroups with 1.7% (low risk), 12.3% (intermediate risk), and 56.9% (high risk) mortality. Its accuracy was significantly better than that of Child–Pugh, model of end-stage liver disease, albumin-bilirubin score, D’Amico model, Augustin model, AIMS65 score and Glasgow-Blatchford score. Baseline HDL-C values ≤ 0.54 mmol/L were associated with markedly lower 6-week survival. Comparable results were found in the validation set.ConclusionHDL-C is a potential indicator for the prognosis of patients with cirrhosis and acute gastrointestinal bleeding. The new algorithm based on HDL-C allowed an accurate predictive assessment of 6-week mortality after bleeding attack.

Predictors of Early Mortality, Response, and Survival in Newly Diagnosed Acute Myeloid Leukemia (AML) Using a Contemporary Academic Cohort

Predictors of Early Mortality, Response, and Survival in Newly Diagnosed Acute Myeloid Leukemia (AML) Using a Contemporary Academic Cohort

Phase II Study of CPX-351 Plus Venetoclax in Patients with Acute Myeloid Leukemia (AML)

Phase II Study of CPX-351 Plus Venetoclax in Patients with Acute Myeloid Leukemia (AML)

Phase II Study of Venetoclax Added to Cladribine + Low Dose AraC (LDAC) Alternating with 5-Azacytidine Demonstrates High Rates of Minimal Residual Disease (MRD) Negative Complete Remissions (CR) and Excellent Tolerability in Older Patients with Newly Diagnosed Acute Myeloid Leukemia (AML)

Phase II Study of Venetoclax Added to Cladribine + Low Dose AraC (LDAC) Alternating with 5-Azacytidine Demonstrates High Rates of Minimal Residual Disease (MRD) Negative Complete Remissions (CR) and Excellent Tolerability in Older Patients with Newly Diagnosed Acute Myeloid Leukemia (AML)

SARS-CoV-2 detection in the lower respiratory tract of invasively ventilated ARDS patients

BackgroundData on SARS-CoV-2 load in lower respiratory tract (LRT) are scarce. Our objectives were to describe the viral shedding and the viral load in LRT and to determine their association with mortality in critically ill COVID-19 patients.MethodsWe conducted a binational study merging prospectively collected data from two COVID-19 reference centers in France and Switzerland. First, we described the viral shedding duration (i.e., time to negativity) in LRT samples. Second, we analyzed viral load in LRT samples. Third, we assessed the association between viral presence in LRT and mortality using mixed-effect logistic models for clustered data adjusting for the time between symptoms’ onset and date of sampling.ResultsFrom March to May 2020, 267 LRT samples were performed in 90 patients from both centers. The median time to negativity was 29 (IQR 23; 34) days. Prolonged viral shedding was not associated with age, gender, cardiac comorbidities, diabetes, immunosuppression, corticosteroids use, or antiviral therapy. The LRT viral load tended to be higher in non-survivors. This difference was statistically significant after adjusting for the time interval between onset of symptoms and date of sampling (OR 3.78, 95% CI 1.13–12.64, p = 0.03).ConclusionsThe viral shedding in LRT lasted almost 30 days in median in critically ill patients, and the viral load in the LRT was associated with the 6-week mortality.

S0634 Gastric Variceal Bleeding Carries Worse Prognosis Than Other Causes of Upper Gastrointestinal Bleeding in Cirrhosis

INTRODUCTION: Gastric varices (GV) are present in approximately 20% of patients with cirrhosis and have been previously associated with poor outcomes. In part, this is because they are often not amenable to standard endoscopic band ligation. However endoscopic and endovascular interventions have been studied for GV management. Our single center study describes the characteristics and outcomes associated with GV bleeding (GVB) as well as the utilization of various therapies. METHODS: Adults admitted at an academic medical center between 2012 and 2018 with cirrhosis and upper gastrointestinal bleed (GIB) were included; those with lower GIB, malignancy as primary cause of liver disease, or previous liver transplant were excluded. The primary outcome was 6-week mortality from GVB. Secondary outcomes included endoscopic findings, endoscopic hemostasis rates, and 5-day survival. Logistic and linear regression analyzed outcomes. RESULTS: Of 208 included patients, 31 (14.9%) had GV and 75 (36.1%) had esophageal varices (EV) without GV. The identified source of bleeding was GV in 17 patients, 8 GV were actively bleeding on index endoscopy. Baseline characteristics between EV and GV bleeds were similar (Table 1). The primary type of GV identified was GOV1, and a variety of endoscopic therapies were utilized (Table 2). When controlling for age, gender, admission hemoglobin, INR, and Child Class, patients with active GVB had much lower rates of endoscopic hemostasis than those with EV bleed (25 vs 83.7%, OR 0.03, 95% CI 0.002-0.36, P < 0.01). While 13 (76.5%) GV bleed patients were eligible for transjugular intrahepatic portosystemic shunt (TIPS), only 3 received TIPS during hospitalization, 3 received TIPS post-discharge and 4 were transplanted. Six-week mortality for GV was 31.3% and 5-day mortality was 25%. In addition, overall clinical outcomes were much worse for those with GVB than other GIB causes (Table 3). When GV was identified as the source of bleed, mortality was numerically higher at 6 weeks (50 vs 12.5%, P = 0.10) as well as 5 days (37.5 vs 12.5%, P = 0.24) among patients who did not receive either endoscopic or endovascular therapies. CONCLUSION: Our single center case series correlates with previous findings that GVB is highly morbid, despite use of therapeutic options. GV patients had less hemostasis on endoscopy than EV and despite advanced therapies, mortality was higher than other upper GIB causes. Overall, advanced therapies trended towards improved outcomes but may have been underutilized.Table 1.: Patient Baseline CharacteristicsTable 2.: Types of gastric varices seen and clinical managementTable 3.: Outcomes of gastric variceal bleed

Prophylactic Antibiotics in Cirrhotic Patients With Upper Gastrointestinal Bleeding.

Cirrhotic patients often develop bleeding from gastric or esophageal varices that occur secondary to portal hypertension. Gastrointestinal (GI) bleeding is fatal in approximately 20% of these episodes and bacterial infections are an important contributor to this mortality. Patients with cirrhosis are also known to have impaired immune function and also at higher risk of translocation of bacteria from the gut into the bloodstream.1 Therefore, the administration of prophylactic antibiotics during the bleeding event might help prevent such infections.

AML-355: The Prognostic Validity of the Acute Myeloid Leukemia Composite Model in Predicting Risks of One-Year Mortality among Patients in Atlantic Canada: A Multi-Centre Experience

Background Intensive chemotherapy is the standard of care for remission induction for fit patients with newly diagnosed acute myeloid leukemia (AML). However, assessing the prognostic impact of comorbidities on outcomes when counselling patients remains a challenge. To this end, we sought to validate the prognostic validity of a newly proposed AML composite model (AML-CM) which incorporates both comorbidities and leukemia-specific features to predict overall mortality following administration of intensive induction chemotherapy. Methods We retrospectively collected data on patients with newly diagnosed AML who received their first induction chemotherapy in Halifax, NS and St. John's, NL, Canada. The AML-CM scores were calculated as per previously published guidelines (Sorror et al in 2017). Logistic regression models were performed to analyze 8-week and 1-year mortality and competing risk regression with Fine and Grey model to model overall survival after adjusting for known variables. Results 194 patients treated January 1, 2009 to December 31, 2017 were identified. Fifty-six percent were males. Median age at induction was 54 years with an age range from 18 to 75 years. Thirty-eight percent of patients were 60 years or older. Molecular/cytogenetic risk per ELN classification was as follows: 23% favourable risk, 37% intermediate risk, 34% high risk, and 6% unknown. The most frequently used regimen was the standard 3+7 regimen (daunorubicin and cytarabine). The AML-CM was predictive of 8-week, odds ratio 2.39 (95%CI 1.09-5.239) AML-CM 7-9 vs AML-CM 1-4, (p-value 0.0284) and 1-year mortality, odds ratio 11.76 (95% CI 2.45-56.51) AML-CM 10+ vs AML-CM 1-4 (p-value 0.0021). Overall survival was inversely proportional to increasing AML-CM scores (p Conclusions The AML-CM is a valid prognosticator for early and late mortality in our patient population. Our findings emphasize the significance of comorbidities assessment prior to induction therapy for AML and the potential use in tailoring targeted interventions to mitigate their risks alongside leukemia treatments. Additionally, the AML-CM could be utilized to adjust for the impact of comorbidities in clinical trials investigating newer intensive AML therapies.