Episodes Of Acute Decompensation Research Articles

Serum Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand and the Cardiovascular Disease Continuum: Insights from Hypertensive Urgencies and Acute Heart Failure Events

Background: Although TRAIL is a potent propapoptotic factor, its role in cardiovascular disease (CVD) remains unclear. This pilot exploratory study investigated serum TRAIL changes along the CVD continuum. We focused on two successive phases of this spectrum (systemic arterial hypertension and heart failure), with emphasis on acute cardiac events due to their immediate clinical significance. Methods: The study population included 90 age- and sex-matched patients hospitalized with hypertensive urgencies (HTUs) or acute decompensation episodes (ADHF). Key echocardiographic, endothelial, cardiometabolic, renal, and liver markers were assessed alongside TRAIL levels. Results: ADHF patients showed significantly elevated TRAIL concentrations, suggesting a progressive rise in TRAIL levels along the CVD continuum. They exhibited worse cardiac, hematologic, and renal profiles, with longer hospital stays and the cachexic phenotype. TRAIL correlated directly with asymmetric dimethylarginine, C-reactive protein, and admission potassium in ADHF patients. In hypertensive subjects, it correlated directly with asymmetric dimethylarginine and inversely with erythrocyte size variability. TRAIL may, thus, serve as a compensatory mechanism in HF, with potential as a biomarker for acute cardiovascular events. Conclusions: TRAIL dynamics provide valuable insights into CVD pathophysiology, particularly in acute settings, warranting further investigation to clarify its role in the broader context of apoptosis and cardiovascular health.

High ADMA Is Associated with Worse Health Profile in Heart Failure Patients Hospitalized for Episodes of Acute Decompensation

Background and Objectives: episodes of acute decompensation in chronic heart failure (ADHF), a common health problem for the growing elderly population, pose a significant socio-economic burden on the public health systems. Limited knowledge is available on both the endothelial function in and the cardio-metabolic health profile of old adults hospitalized due to ADHF. This study aimed to investigate the connection between asymmetric dimethylarginine (ADMA)—a potent inhibitor of nitric oxide—and key health biomarkers in this category of high-risk patients. Materials and Methods: this pilot study included 83 individuals with a known ADHF history who were admitted to the ICU due to acute cardiac decompensation. Selected cardiovascular, metabolic, haemogram, renal, and liver parameters were measured at admission to the ICU. Key renal function indicators (serum creatinine, sodium, and potassium) were determined again at discharge. These parameters were compared between patients stratified by median ADMA (114 ng/mL). Results: high ADMA patients showed a significantly higher incidence of ischemic cardiomyopathy and longer length of hospital stay compared to those with low ADMA subjects. These individuals exhibited significantly higher urea at admission and creatinine at discharge, indicating poorer renal function. Moreover, their lipid profile was less favorable, with significantly elevated levels of total cholesterol and HDL. However, no significant inter-group differences were observed for the other parameters measured. Conclusions: the present findings disclose multidimensional, adverse ADMA-related changes in the health risk profile of patients with chronic heart failure hospitalized due to recurrent decompensation episodes.

Adrenal insufficiency in liver diseases - pathophysiology and underlying mechanisms.

Relative adrenal insufficiency (RAI) is common in critically ill patients with cirrhosis, but it has been also documented in non-critically ill patients. Its pathophysiology is complex and not well understood yet. In this review, we aimed to present potential mechanisms and causal pathways implicated in the pathogenesis of RAI in cirrhosis. There is accumulating evidence supporting a suboptimal baseline adrenal function in cirrhosis mainly due to decreased cortisol synthesis and metabolism rates from the adrenal gland. Apart from this peripheral impairment, more recent studies suggest that there is a greater defect in the central stimulation of the hypothalamic-pituitary-adrenal (HPA) axis (hypothalamus/pituitary gland). Pro-inflammatory mediators, which are elevated in cirrhosis, have been also implicated through suppression of the HPA axis, decrease in cortisol synthesis and tissue glucocorticoid resistance. All abovementioned support the hepatoadrenal syndrome hypothesis that during episodes of acute decompensation there is suboptimal adrenocortical response that leads to worse outcomes. In conclusion, the complex pathophysiology of adrenal dysfunction in cirrhosis has not been fully elucidated yet and further research is needed in order to better understand this rather common entity in cirrhosis.

A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis

The prognostic impact of acute decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined non-acute decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis. A total of 617 outpatients with cirrhosis from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic. During follow-up, 154 patients (25.0% of total patients) developed complications, 69 patients (44.8%) developed NAD and 85 (55.2%) developed AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation than in patients with NAD or AD. On multivariable analysis, AD (hazard ratio [HR] 21.07, p <0.001), NAD (HR 7.13, p <0.001), the etiological cure of cirrhosis (HR 0.38, p <0.001) and model for end-stage liver disease score (HR 1.12, p= 0.003) were found to be independent predictors of mortality. The first decompensation is non-acute in almost 50% of outpatients, though such events are still associated with decreased survival compared to no decompensation. Patients who develop NAD must be treated with extreme care and monitored closely to prevent the development of AD. This multicenter study is the first to investigate the role of non-acute decompensation (NAD) in patients with cirrhosis. In fact, while the unfavorable impact of acute decompensation is well known, there is currently a dearth of evidence on NAD, despite it being a common occurrence in clinical practice. Our data show that almost half of decompensations in patients with cirrhosis can be considered NAD and that such events are associated with a higher risk of mortality than no decompensation. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality.

The Value of Neutrophil-to-Lymphocyte Ratio to Identify Bacterial Infection and Predict Short-Term Mortality in Patients with Acutely Decompensated Cirrhosis.

Liver cirrhosis patients are highly susceptible to infections, affecting survival, but current parameters for detecting infection are not reliable enough in this population. We investigated the ability of white blood cell (WBC), ∆WBC, neutrophil and ∆neutrophil counts, neutrophil-to-lymphocyte (NLR) and ∆NLR ratios and C-reactive protein (CRP) and procalcitonin (PCT) levels to identify infection and predict short-term mortality in liver cirrhosis patients. We recruited 233 patients with liver cirrhosis hospitalized with acute decompensation (AD) who had an outpatient visit within 1 month (baseline laboratory data) and followed them for 90 days. Difference between laboratory values at baseline and the AD episode was defined as delta (∆) values of the parameters. Delta values did not increase the diagnostic and predictive ability of investigated parameters. The CRP level was found to be the best diagnostic marker for infection in patients with cirrhosis. However, NLR seems to be superior for short-term mortality prediction, better than the WBC count. Distinguishing inflammations of different origin is a remaining clinical challenge in acutely decompensated cirrhosis. Based on our results, NLR might be more suitable for predicting short-term mortality in patients with AD than the WBC count currently included in the CLIF-C AD score.

Biochemical characterization of patients with dihydrolipoamide dehydrogenase deficiency.

Dihydrolipoamide dehydrogenase (DLD; E3) oxidizes lipoic acid. Restoring the oxidized state allows lipoic acid to act as a necessary electron sink for the four mitochondrial keto-acid dehydrogenases: pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, branched-chain α-keto-acid dehydrogenase, and 2-oxoadipate dehydrogenase. DLD deficiency (DLDD) is caused by biallelic pathogenic variants in DLD. Three major forms have been described: encephalopathic, hepatic, and myopathic, although DLDD patients exhibit overlapping phenotypes. Hyperlactatemia, hyperexcretion of tricarboxylic acid cycle (TCA) metabolites and branched-chain keto acids, increased plasma branched-chain amino acids and allo-isoleucine are intermittent metabolic abnormalities reported in patients with DLDD. However, the diagnostic performance of these metabolites has never been studied. Therefore, we sought to systematically evaluate the diagnostic utility of these biomarkers for DLDD. We retrospectively analyzed the results of biochemical testing of six unrelated DLDD patients, including values obtained during both well visits and acute decompensation episodes. Elevation of branched-chain amino acid concentrations was not consistently observed. We found that five of six patients in our cohort had a maximum lifetime value of allo-isoleucine of 6 μmol/L, showing that alloisoleucine elevations even during illness may be subtle. Urine organic acid analysis (UOA) during acute decompensation episodes was abnormal in all cases; however, the pattern of abnormalities had high intersubject variability. No single biomarker was universally present, even in patients experiencing metabolic decompensation. We also observed novel biochemical associations: three patients had hyperexcretion of TCA cycle metabolites during crisis; in two patients, 2-ketoadipic and 2-hydroxyadipic acids, by products of lysine degradation, were detected. We propose that these result from 2-oxoadipate dehydrogenase deficiency, an underappreciated biochemical abnormality in DLD. Given the diversity of biochemical profiles among the patients with DLDD, we conclude that accurate biochemical diagnosis relies on a high index of suspicion and multipronged biochemical analysis, including both plasma amino acid and urine organic acid quantitation during decompensation. Biochemical diagnosis during the well state is challenging. We emphasize the critical importance of multiple simultaneous biochemical tests for diagnosis and monitoring of DLDD. We also highlight the under-recognized role of DLD in the lysine degradation pathway. Larger cohorts of patients are needed to establish a correlation between the biochemical pattern and clinical outcomes, as well as a genotype-phenotype correlation.

HeartLogic™: real-world data-efficiency, resource consumption, and workflow optimization.

Heart failure (HF) is a major and still growing medical problem and is characterized by episodes of acute decompensation that are associated with a negative prognosis and a significant burden on the patients, doctors, and healthcare resources. Early detection of incipient HF may allow outpatient treatment before patients severely decompensate, thus reducing HF hospitalizations and related costs. The HeartLogic™ algorithm is an automatic, remotely managed system combining data directly related to HF pathophysiology into a single score, the HeartLogic™ index. This index proved to be effective in predicting the risk of incipient HF decompensation, allowing to redistribute resources from low-risk to high-risk patients in a timely and cost-saving manner. The alert-based remote management system seems more efficient than the one based on scheduled remote transmission in terms of caregivers' workload and alert detection timing. The widespread application of the HeartLogic™ algorithm requires the resolution of logistical and financial issues and the adoption of a pre-defined, functional workflow. In this paper, we reviewed general aspects of remote monitoring in HF patients, the functioning and pathophysiological basis of the HeartLogic index, its efficiency in the management of HF patients, and the economic effects and the organizational revolution associated with its use.

Plasma CoQ10 Status in Patients with Propionic Acidaemia and Possible Benefit of Treatment with Ubiquinol.

Propionic acidaemia (PA) is an innate error of metabolism involving a deficiency in the enzyme propionyl-CoA carboxylase. Better control of acute decompensation episodes together with better treatment and monitoring have improved the prognosis of patients with this problem. However, long-term complications can arise in those in whom good metabolic control is achieved, the result of mitochondrial dysfunction caused by deficient anaplerosis, increased oxidative stress, and reduced antioxidative capacity. Coenzyme Q10 (CoQ10) is a nutritional supplement that has a notable antioxidative effect and has been shown to improve mitochondrial function. The present prospective, interventional study examines the plasma concentration of CoQ10 in patients with PA, their tolerance of such supplementation with ubiquinol, and its benefits. Seven patients with PA (aged 2.5 to 20 years, 4 males) received supplements of CoQ10 in the form of ubiquinol (10 mg/kg/day for 6 months). A total of 6/7 patients showed reduced plasma CoQ10 concentrations that normalized after supplementation with ubiquinol (p-value < 0.001), which was well tolerated. Urinary citrate levels markedly increased during the study (p-value: 0.001), together with elevation of citrate/methlycitrate ratio (p-value: 0.03). No other significant changes were seen in plasma or urine biomarkers of PA. PA patients showed a deficiency of plasma CoQ10, which supplementation with ubiquinol corrected. The urinary excretion of Krebs cycle intermediate citrate and the citrate/methylcitrate ratio significantly increased compared to the baseline, suggesting improvement in anaplerosis. This treatment was well tolerated and should be further investigated as a means of preventing the chronic complications associated with likely multifactorial mitochondrial dysfunction in PA.

Use of short-acting vs. long-acting loop diuretics after heart failure hospitalization.

Furosemide, a short-acting loop diuretic (SD), is the dominant agent prescribed for heart failure (HF) in clinical practice. However, accumulating data suggests that long-acting loop diuretics (LD), such as torsemide or azosemide, might have more favourable pharmacological profiles. This study aimed to investigate the relationship between the type of loop diuretics and long-term outcomes among patients hospitalized for acute HF enrolled in a contemporary multicentre registry. Within the West Tokyo Heart Failure Registry from 2006 to 2017, a total of 2680 patients (60.1% men with a median age of 77years) were analysed. The patients were characterized by the type of diuretics used at the time of discharge; 2073 (77.4%) used SD, and 607 (22.6%) used LD. The primary endpoint was composite of all-cause death or HF re-admission after discharge, and the secondary endpoints were all-cause death and HF re-admission, respectively. During the median follow-up period of 2.1years, 639 patients died [n=519 (25.0%) in the SD group; n=120 (19.8%) in the LD group], and 868 patients were readmitted for HF [n=697 (33.6%) in the SD group; n=171 (28.2%) in the LD group]. After multivariable adjustment, the LD group had lower risk for the composite outcome [hazard ratio (HR), 0.80; 95% confidence interval (CI), 0.66-0.96; P=0.017], including all-cause death (HR; 0.73; 95% CI; 0.54-0.99; P=0.044) and HF re-admission (HR, 0.81; 95% CI, 0.66-0.99; P=0.038), than the SD group. Propensity score matching yielded estimates that were consistent with those of the multivariable analyses, with sub-group analyses demonstrating that use of LD was associated with favourable outcomes predominantly in younger patients with reduced ejection fraction. LD was associated with lower risk of long-term outcomes in patients with HF and a recent episode of acute decompensation.

Outcomes of Patients with Heart Failure followed in a Cardiological Setting to Parakou from 2016 to 2020

Introduction: Heart failure (HF) is a serious pathology whose evolution is made of episodes of acute decompensation, rhythmic and thromboembolic complications, causes of iterative hospitalizations and death. The objective of this study was to describe the outcomes of patients followed for heart failure in a cardiological setting in Parakou from 2016 to 2020. Methods: This was a longitudinal, descriptive and analytical retrospective study of heart failure patients followed in consultation and/or hospitalization over a period of 5 years (October 2016 to July 2020) in cardiology units of Parakou. The outcome of HF was assessed by the NYHA symptomatic stage, rehospitalization, complications and death. Epidata 3.1 fr and SPSS 21 software were used for data processing and analysis. Results: Of the 4902 cardiovascular admissions, 453 cases of HF (9.24%) were observed. At the onset of care, 51.50% of patients were at NYHA stage IV and 69.46% had left ventricular systolic dysfunction. During the follow-up period, there was a symptomatic improvement in the first 06 months but at one year of follow-up, 45.28% of the subjects were seen with a deteriorated stage. At one year of follow-up, the rehospitalization rate was 23.58%. The complications noted were arrhythmias in 8.32% of cases. The mortality rate was 30.37%. Advanced age > 60 years, Charlson score ≥ 3, hypokalemia and poor adherence to treatment were the factors associated with unfavorable outcomes. Conclusion: HF is associated with significant morbidity and mortality. This highlights the importance of its prevention, its better etiological research and patient’s therapeutic education.

Role of Lung Ultrasound and Inferior Vena Cava Diameter in Assessment of Patients with Heart Failure

Background: Congestive heart failure (CHF) is a multifaceted clinical condition marked by recurrent episodes of acute decompensation, needing repetitive hospital stays, and re-admissions. The CHF management is still a clinical challenge; choices are built on clinical evaluations of volume status, which are utilized for cardiac filling pressureestimation. Aims: This study aimed to investigate the role of lung US and Inferior Vena Cava Diameter (IVCD) in assessment of HF-cases. Patients and Methods: The current work has been performed on 50 HF (heart failure) cases diagnosed in the Chest Department of Al- Azhar University Hospitals from April 2019 to June 2021. Chest radiograph, as a reference for the presence of pulmonary congestion, echocardiography for both systolic and diastolic function assessment and lung U/S. US examinations of the anterolateral chest were done. Results: A highly significant association was found among inferior Vena Cava-Collapsibility Index (IVC-CI) and Dyspnea Class.A highly significant association was found among IVC-CI and echocardiography.A highly significant association was found among IVC-CI and B lines. Conclusion: Ultrasound can be utilized as an alternative technique for estimating the intra-vascular volume such as measuring the IVCD and so the caval index. The utilization of pulmonary ultrasound (PU) to evaluate dyspneic cases and those with HF in dissimilar clinical settings raises the sensitivity, specificity, and accuracy of pulmonary congestion diagnosing and prognosis in HF cases.

Approach to decongestion therapy in patients with acute decompensated heart failure: the echocardiography guided strategy.

Goal The E / (Ea×Sa) index is an echocardiographic parameter to determine a patient's left ventricular filling pressure. This study aims to determine the safety and efficacy of the echocardiographic E / (Ea×Sa) index guided diuretic therapy compared to urine output (conventional) guided diuretic treatment.Material and Methods In this cross-sectional study, patients with heart failure with reduced ejection fraction (HFrEF) who were hospitalized due to acute decompensation episode were consecutively allocated in a 1:1 ratio to monitoring arms. The diuretic dose, which provided 20 % reduction in the E / (Ea×Sa) index value compared to initial value, was determined as adequate dose in echocardiography guided monitoring group. The estimated glomerular filtration rate (eGFR), change in weight, NT pro-BNP level and dyspnea assessment on visual analogue scale (VAS) were analyzed at the end of the monitoring.Results Although the similar doses of diuretics were used in both groups, the patients with E / (Ea×Sa) index guided strategy had the substantial lower NT pro-BNP level within 72 hours after diuretic administration (2172 vs.2514 pg / mL, p= 0.036). VAS score on dyspnea assessment was significantly better in the patients with E / (Ea×Sa) index guided strategy (52 vs. 65; p= 0.04). And, in term of body weight loss (4.93 vs.5.21 kg, p=0.87) and e-GFR (54.58±8.6 vs. 52.65±9.1 mL / min / 1.73 m2p=0.74) in both groups are associated with similar outcomes. In both groups, there was no worsening renal function and electrolyte imbalance that required stopping or decreasing loop diuretic dosing.Conclusions The E / (Ea×Sa) index guidance might be a safe strategy for more effective diuretic response that deserves consideration for selected a subgroup of acute decomposed HFrEF patients.

A novel, smartphone-based scleral image capture technique accurately determines serum bilirubin level and can be used for home-based monitoring of patients discharged from hospital, after an episode of acute decompensation

A novel, smartphone-based scleral image capture technique accurately determines serum bilirubin level and can be used for home-based monitoring of patients discharged from hospital, after an episode of acute decompensation

Genetic characteristics and follow-up of patients with fatty acid β-oxidation disorders through expanded newborn screening in a Northern Chinese population.

Background Fatty acid β-oxidation disorders (FAODs) include more than 15 distinct disorders and have a wide variety of symptoms, usually not evident between episodes of acute decompensation. After the introduction of newborn screening (NBS) using tandem mass spectrometry (MS/MS), early identification of FAODs has become feasible. We analyzed the MS/MS results in Tianjin, China during a six-year period to evaluate the incidence, disease spectrum, and genetic characteristics of FAODs. Methods We analyzed the MS/MS results for screening FAODs from May 2013 to December 2018 in Tianjin, China. Infants with positive screening results were confirmed through next-generation sequencing and validated by Sanger sequencing. Results A total of 220,443 infants were screened and 25 FAODs patients were identified (1:8,817). Primary carnitine deficiency (PCD) with an incidence rate up to 1:20,040 was the most common disorder among all FAODs. Recurrent mutations of relatively common diseases, like PCD and short-chain acyl-CoA dehydrogenase deficiency (SCADD), were identified. During the follow-up, two patients suffered from sudden death due to carnitine palmitoyl transferase-Ⅱ deficiency (CPT Ⅱ) and very-long-chain acyl-CoA dehydrogenase deficiency (VLCAD). Conclusion Our data indicated that FAODs are relatively common in Tianjin and may even cause infant death in certain cases. The elucidated disease spectrum and genetic backgrounds elucidated in this study may contribute to the treatment and prenatal genetic counseling of FAODs.

Use of Nonselective β-Blockers in Patients With End-Stage Liver Disease and Select Complications.

Objective: To review the literature and recommendations for nonselective β-blockers (NSBBs) in the setting of variceal bleeding prophylaxis and decompensated liver disease. Data Sources: Literature search of MEDLINE was performed (1988 to October 2019) using the following search terms: cirrhosis, advanced cirrhosis, β-blocker, decompensation, prophylaxis. Abstracts, peer-reviewed publications, clinical practice guidelines, and product monographs were reviewed. Study Selection and Data Extraction: Relevant English language studies and those conducted in humans were considered for analysis and inclusion. Data Synthesis: Evidence that suggests that NSBBs are harmful in advanced cirrhosis is overshadowed by confounding variables and small patient populations. The majority of the available evidence suggests neutral or beneficial effects on mortality with continuation of NSBBs despite liver disease progression. Based on the available literature, guidelines, and expert consensuses, NSBBs can be considered within this patient population and may have a positive impact on the majority of these patients. Relevance to Patient Care and Clinical Practice: This review summarizes current place in therapy for NSBBs in the setting of cirrhosis and variceal bleeding prophylaxis. It also includes a discussion of the literature for use of NSBBs within the setting of different acute decompensations in which the data and recommendations for use are less clear. Conclusions: Recent evidence shows neutral or positive results for NSBB use in particular decompensation subgroups, which suggests that NSBBs can be used cautiously with close monitoring in patients with advanced cirrhosis. Questions still remain regarding optimal agent and dose and whether agents can be safely restarted after an acute decompensation episode.

1270 Unexpected Microorganism in an Unexpected Place

INTRODUCTION: Candida Parapsilosis (CP) has been implicated in several intra- and extra- vascular infections and rarely been the cause of intraabdominal infections. We describe a case of CP infection complicating acute severe necrotizing pancreatitis. CASE DESCRIPTION/METHODS: A 68-year-old man presented with acute onset epigastric pain associated with nausea and vomiting. Physical examination revealed epigastric tenderness. Lipase was elevated at 7352 mg/dl and initial abdominal CT scan revealed changes consistent with acute edematous pancreatitis with possible early necrosis. His clinical course was complicated by acute respiratory failure, septic shock, and AKI requiring hemodialysis. He was in and out of the intensive care unit despite medical management including nutrition support and broad spectrum antibiotics. A repeat CT scan 4 weeks later showed acute necrotizing pancreatitis with walled-off necrosis (WON). After an episode of acute decompensation, a percutaneous drain was placed prior to necrosectomy. The aspirated fluid grew Candida Parapsilosis and patient was started initially on Micafungin, and then transitioned to oral fluconazole. Soon after starting antifungals the patient stabilized, clinically improved and was able to be discharged home. He subsequently underwent a video assisted retroperitoneal dissection, which revealed a small amount of necrosis and a pancreatic duct leak into the WON. He underwent ERCP with pancreas duct stent bypassing the leak. Upon most recent visit, patient showed considerable improvement. DISCUSSION: The incidence of CP infections has been greatly increased over the last decade. Primarily, CP is implicated in cases of fungemia accounting for 3–27% of all cases of in large studies and to lesser extent in extravascular infections like osteomyelitis. Intraabdominal infections are unusual and mostly associated with peritonitis complicating surgery and peritoneal dialysis. Despite the organism normally colonizes the GI tract, pancreatic infections by CP are rare, and are usually complicating acute pancreatitis. They could be explained by portal extension and be predisposed by use of broad spectrum antibiotics, surgery, and instrumentation. In conclusion, it is important to consider fungal infections in cases of complicated infected pancreatitis especially those not responding to broad spectrum antibiotics as they share similar clinical features with bacterial causes and prompt diagnosis and treatment are key to a better outcome.

THU-035-A shorter period of a subsequent episode of acute decompensation of cirrhosis predicts worse outcome: A single center experience

THU-035-A shorter period of a subsequent episode of acute decompensation of cirrhosis predicts worse outcome: A single center experience

Esquizofrenia: O Que o Médico Não Psiquiatra Precisa de Saber

Schizophrenia is a disabling and severe mental illness that affects all social classes and racial and ethnic groups, spreading across every part of the world. It's more frequent in males and it usually manifests itself in late adolescence or early adulthood and its early detection by all clinicians is important so that there is a proper referral to specialized psychiatric care. This article intends to update the knowledge regarding the diagnosis, treatment and prognosis of schizophrenia, with an emphasis on the warning signs for a timely referral to psychiatric evaluation. We conducted a literature search across through articles available in databases of scientific articles but also in scientific and technical books specialized in the field of schizophrenia. The clinical presentation of this illness is heterogeneous and complex, with a typical evolution based on several episodes of acute decompensation requiring hospitalization. The diagnosis of schizophrenia relies on some key symptoms, and the various international diagnostic criteria vary in relation to the temporal window with productive symptomatology required to establish a diagnosis. The prognosis is variable, not always deteriorating and is all the better when the treatment is started as early as possible. Treatment requires a multidisciplinary approach and is based primarily on antipsychotic drugs. This medication although very effective for the typical symptoms of this illness, entails some adverse effects with medical consequences that are important in the clinical practice of all doctors of other specialties.

Validation and Recalibration of Seattle Heart Failure Model in Japanese Acute Heart Failure Patients

BackgroundPrecise risk stratification in heart failure (HF) patients enables clinicians to tailor the intensity of their management. The Seattle Heart Failure Model (SHFM), which uses conventional clinical variables for its prediction, is widely used. We aimed to externally validate SHFM in Japanese HF patients with a recent episode of acute decompensation requiring hospital admission. Methods and ResultsSHFM was applied to 2470 HF patients registered in the West Tokyo Heart Failure and National Cerebral And Cardiovascular Center Acute Decompensated Heart Failure databases from 2006 to 2016. Discrimination and calibration were assessed with the use of the c-statistic and calibration plots, respectively, in HF patients with reduced ejection fraction (HFrEF; <40%) and preserved ejection fraction (HFpEF; ≥40%). In a perfectly calibrated model, the slope and intercept would be 1.0 and 0.0, respectively. The method of intercept recalibration was used to update the model. The registered patients (mean age 74 ± 13 y) were predominantly men (62%). Overall, 572 patients (23.2%) died during a mean follow-up of 2.1 years. Among HFrEF patients, SHFM showed good discrimination (c-statistic = 0.75) but miscalibration, tending to overestimate 1-year survival (slope = 0.78; intercept = −0.22). Among HFpEF patients, SHFM showed modest discrimination (c-statistic = 0.69) and calibration, tending to underestimate 1-year survival (slope = 1.18; intercept = 0.16). Intercept recalibration (replacing the baseline survival function) successfully updated the model for HFrEF (slope = 1.03; intercept = −0.04) but not for HFpEF patients. ConclusionsIn Japanese acute HF patients, SHFM showed adequate performance after recalibration among HFrEF patients. Using prediction models to tailor the care for HF patients may improve the allocation of medical resources.

Red Blood Cell Distribution Width Improves Reclassification of Patients Admitted to the Emergency Department with Acute Decompensated Heart Failure.

SummaryBackgroundThe usual history of chronic heart failure (HF) is characterized by frequent episodes of acute decompensation (ADHF), needing urgent management in the emergency department (ED). Since the diagnostic accuracy of routine laboratory tests remains quite limited for predicting short-term mortality in ADHF, this retrospective study investigated the potential significance of combining red blood cell distribution width (RDW) with other conventional tests for prognosticating ADHF upon ED admission.MethodsWe conducted a retrospective study including visits for episodes of ADHF recorded in the ED of the Uni versity Hospital of Verona throughout a 4-year period. Demo - graphic and clinical features were recorded upon patient presentation. All patients were subjected to standard Chest X-ray, electrocardiogram (ECG) and laboratory testing in - cluding creatinine, blood urea nitrogen, B-type natriuretic peptide (BNP), complete blood cell count (CBC), sodium, chloride, potassium and RDW. The 30-day overall mortality after ED presentation was defined as primary endpoint.ResultsThe values of sodium, creatinine, BNP and RDW were higher in patients who died than in those who survived, whilst hypochloremia was more frequent in patients who died than in those who survived. The multivariate model, incorporating these parameters, displayed a modest efficiency for predicting 30-day mortality after ED admission (AUC, 0.701; 95% CI, 0.662-0.738; p=0.001). Notably, the inclusion of RDW in the model significantly enhanced prediction efficiency, with an AUC of 0.723 (95% CI, 0.693-0.763; p<0.001). These results were confirmed with net reclassification improvement (NRI) analysis, showing that combination of RDW with conventional laboratory tests resulted in a much better prediction performance (net reclassification index, 0.222; p=0.001).ConclusionsThe results of our study show that prognostic assessment of ADHF patients in the ED can be significantly improved by combining RDW with other conventional laboratory tests.