Association Of Clinical Risk Factors Research Articles

Associations of Clinical Risk Factors and Novel Biomarkers With Age at Onset of Type 2 Diabetes.

Younger onset of type 2 diabetes (T2D) was associated with higher risks of vascular complications and mortality. To prospectively assess risk profiles for incident T2D stratified by age at onset. A total of 471 269 participants free of T2D at baseline were included from the UK Biobank. Approximately 70 clinical, lipid, lipoprotein, inflammatory, and metabolic markers, and genetic risk scores (GRSs) were analyzed. Stratified Cox proportional-hazards regression models were used to estimate hazard ratios (HRs) for T2D with age of diagnosis divided into 4 groups (≤50.0, 50.1-60.0, 60.1-70.0, and >70.0 years). During 11 years of follow-up, 15 805 incident T2D were identified. Among clinical risk factors, obesity had the highest HR at any age, ranging from 13.16 (95% CI, 9.67-17.91) for 50.0 years and younger to 4.13 (3.78-4.51) for older than 70.0 years. Other risks associated with T2D onset at age 50.0 years and younger included dyslipidemia (3.50, 2.91-4.20), hypertension (3.21, 2.71-3.80), cardiovascular disease (2.87, 2.13-3.87), parental history of diabetes (2.42, 2.04-2.86), education lower than college (1.89, 1.57-2.27), physical inactivity (1.73, 1.43-2.10), smoking (1.38, 1.13-1.68), several lipoprotein particles, inflammatory markers, liver enzymes, fatty acids, amino acids, as well as GRS. Associations of most risk factors and biomarkers were markedly attenuated with increasing age at onset (P interaction <.05), and some were not significant for onset at age older than 70.0 years, such as smoking, systolic blood pressure, and apolipoprotein B. Most risk factors or biomarkers had stronger relative risks for T2D at younger ages, which emphasizes the necessity of promoting primary prevention among younger individuals. Moreover, obesity should be prioritized.

Clinical Risk Factors For Kidney Tubule Biomarker Abnormalities Among Hypertensive Adults With Reduced eGFR in the SPRINT Trial.

Urine biomarkers of kidney tubule health may distinguish aspects of kidney damage that cannot be captured by current glomerular measures. Associations of clinical risk factors with specific kidney tubule biomarkers have not been evaluated in detail. We performed a cross-sectional study in the Systolic Blood Pressure Intervention Trial among 2,436 participants with a baseline estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Associations between demographic and clinical characteristics with urine biomarkers of kidney tubule health were evaluated using simultaneous multivariable linear regression of selected variables. Each standard deviation higher age (9 years) was associated with 13% higher levels of chitinase-3-like protein-1 (YKL-40), indicating higher levels of tubulointerstitial inflammation and repair. Men had 31% higher levels of alpha-1 microglobulin and 16% higher levels of beta-2 microglobulin, reflecting worse tubule resorptive function. Black race was associated with significantly higher levels of neutrophil gelatinase-associated lipocalin (12%) and lower kidney injury molecule-1 (26%) and uromodulin (22%). Each standard deviation (SD) higher systolic blood pressure (SBP) (16 mmHg) was associated with 10% higher beta-2 microglobulin and 10% higher alpha-1 microglobulin, reflecting lower tubule resorptive function. Clinical and demographic characteristics, such as race, sex, and elevated SBP, are associated with unique profiles of tubular damage, which could reflect under-recognized patterns of kidney tubule disease among persons with decreased eGFR.

Derivation and Validation of the Management and Supervision Tool (MaST) Risk of Crisis (RoC) Algorithm Using Electronic Health Record (EHR) Data

AimsThe Management and Supervision Tool (MaST) helps NHS mental health care professionals identify patients who are most likely to need psychiatric hospital admission or home treatment, due to severe mental illness, through a Risk of Crisis (RoC) algorithm driven by electronic health record (EHR) data analytics. We describe the derivation and validation of the MaST RoC algorithm, and its implementation to support preventative mental healthcare in the NHS.MethodsThe RoC algorithm was developed and evaluated with EHR data from six UK NHS trusts using Ordered Predictor List propensity scores informed by a priori weightings from pre-existing literature, as well as real-world evidence evaluating the associations of clinical risk factors with mental health crisis using NHS EHR data. Mental health crisis was defined as admission to a psychiatric hospital or acceptance to a community crisis service within a 28-day period. Predictor variables included age, gender, accommodation status, employment status, Mental Health Act (MHA) status (under section or Community Treatment Order), and previous mental health service contacts (including hospital admissions and crisis services). Data were analysed using Ordered Predictor List propensity scores. The algorithm was derived using structured EHR data from 2,620 patients in a single NHS trust and externally validated using data from 107,879 patients in five other NHS trusts. Qualitative and quantitative data on feasibility, acceptability and system efficiency impacts of MaST implementation were obtained through staff surveys and local audits.ResultsThe factors associated with greatest propensity for mental health crisis included recent previous crisis, multiple previous crises, higher number of mental health service contacts in recent weeks, MHA section, accommodation status and employment status. The RoC algorithm identified 64% and 80% crises in its top quintile. Sentiment analysis of staff surveys suggested that the use of MaST improved productivity by reducing time taken to access patient information to support caseload management that was previously difficult to obtain through manual review of EHRs. The systems efficiency audit revealed a reduction in duration of crisis and inpatient admissions following MaST implementation.ConclusionThe MaST RoC algorithm supports the identification of people more likely to use crisis services in NHS mental health trusts, is feasible to implement, and improves systems efficiency. EHR-derived algorithms can support real-world clinical practice to improve outcomes in people receiving NHS mental healthcare.

Risk Factors Associated with Prolonged Nasopharyngeal Carriage of SARS-CoV-2 and Length of Stay among Patients Admitted to a COVID-19 Referral Center in Manila, Philippines

Objective. Prolonged nasopharyngeal carriage of SARS-CoV-2 has been linked to prolonged hospital stay and delayed radiologic recovery. To determine if clinical risk factors are associated with prolonged nasopharyngeal carriage or longer hospital stay, we performed a descriptive analysis of 169 moderate to severe COVID-19 patients admitted at the Philippine General Hospital from March to June 2020. Methods. Length of nasopharyngeal RT-PCR positivity and clinical demographic data were extracted from existing patient records. Chi-square test, Mann-Whitney U test, and regression analysis were performed to describe the association of clinical risk factors with prolonged nasopharyngeal carriage and length of hospital stay. Results. The median duration of carriage was 19 days (IQR 12.0-30.0 days). No comorbidities or inflammatorymarkers had a statistically significant association with prolonged nasopharyngeal carriage defined as &gt;24 days of nasopharyngeal RT-PCR positivity. Characteristics associated with a statistically significant longer hospital stay included chronic kidney disease stages 3-5, severe disease, and use of empiric antibiotics on admission. Prolonged carriage &gt;24 days, hsCRP, and D-dimer at admission, also had a statistically significant but weak correlation with length of stay. Conclusion. Among patients with moderate disease, comorbidities and inflammatory markers were not associated with prolonged COVID-19 nasopharyngeal carriage. Prolonged nasopharyngeal carriage &gt;24 days was associated with longer hospital stay, while D-dimer and hsCRP levels at admission, also had statistically significant but small effects on increasing the hospital length of stay &nbsp; &nbsp; &nbsp

Aetiology and prognosis of the motoric cognitive risk syndrome: A population‐based comparison with mild cognitive impairment

AbstractBackgroundThe motoric cognitive risk syndrome (MCRS) has been proposed as a dementia prodrome that improves clinical risk stratification, by integrating slow gait and cognitive complaints. It remains undetermined to what extent pathophysiological substrates in terms of clinical risk factors, neuroimaging correlates and associations of MCRS with dementia are independent of the widely used concept of mild cognitive impairment (MCI).MethodsBetween 2009 and 2015, subjective cognitive complaints, objective cognitive impairment and gait speed were assessed in 3,025 dementia‐free participants of the population‐based Rotterdam Study (mean age 70.4 years, 54.7% women). In line with prior studies, MCI and MCRS were defined as subjective complaints along with a score of &gt;1.5 and &gt;1 standard deviations below the population mean of the neuropsychological test battery and gait speed, respectively. We used multinomial logistic regression models to determine cross‐sectional associations of clinical risk factors and neuroimaging markers with MCI and MCRS, and subsequently assessed risk of dementia or death, with follow‐up until 2016, in a competing risk framework.ResultsOf 3,025 individuals, 231 had MCRS (7.6%), 132 had MCI (4.4%), and 62 (2.0%) fulfilled criteria for both. Smoking, hypertension, diabetes and APOE‐ε4 carriership were shared risk factors between MCRS and MCI, but higher BMI predisposed predominantly to MCRS, whereas male sex and hypercholesterolemia were associated with MCI only. Lower total brain volume was more strongly related to MCI than to MCRS, driven by a difference in white matter volume. During a mean follow‐up of 3.9 years, 71 individuals developed dementia and 200 died. Compared to unaffected individuals, risk of dementia was higher with MCI and to a lesser extent with MRCS (subdistribution hazard ratio [95% confidence interval]: 6.95 [3.78‐12.75] and 3.55 [1.91‐6.60], respectively). Accounting for a higher mortality risk, 5‐year risk of dementia was 7.0% [2.5‐11.5%] for individuals with MCRS, versus 13.3% [5.8‐20.8%] with MCI and 2.3% [1.5‐3.1%] in unaffected individuals.ConclusionIn people with subjective cognitive complaints, both cognitive and motor function impairment are associated with dementia risk, with in part different pathophysiological substrates. While MCI has greater utility for dementia prediction, incorporation of motor function in clinical assessments may increase prognostic accuracy.

Circulating Dickkof-1 as a potential biomarker associated with the prognosis of patients with rheumatoid arthritis-associated interstitial lung disease.

Circulating Dickkof-1 as a potential biomarker associated with the prognosis of patients with rheumatoid arthritis-associated interstitial lung disease.

Incidence and Risk Factors Associated with Retinopathy of Prematurity in Peru.

PurposeThe purpose of this research is to determine retinopathy of prematurity (ROP) prevalence and possible risk factors associated with ROP development in newborns admitted to a neonatal unit of a Peruvian National Reference Hospital.Patients and MethodsThis retrospective study included 216 preterm infants. The data were collected between January 2016 and December 2018. All infants were examined according to Peruvian guidelines for screening and treatment of ROP. The association of clinical risk factors and the development of ROP was analyzed and predictive factors were determined.ResultsThe study subjects were 216 preterm infants of which 72 had some stage of ROP (32 stage 1; 23 stage 2 and 17 stage 3) and 144 preterm infants without ROP. The incidence of ROP in preterm infants less than 32 weeks was 60.9%, while for those weighing less than 1500 g it was 71.6%. The factors associated with ROP were gestational age below 32 weeks, birth weight below 1500 grams, neonatal sepsis, oxygen therapy, mechanical ventilation, hyaline membrane disease, bronchopulmonary dysplasia, persistence of ductus arteriosus and intraventricular hemorrhage. Exclusive breastfeeding was found to play a protective role against ROP. Binary logistic regression analysis found that only gestational age below 32 weeks (OR, 2.637; 95% CI, 1.04–6.69), weight below 1500 grams (OR, 4.377; 95% CI, 1.75–10.92), neonatal sepsis (OR, 6.517; 95% CI, 2.81–15.14), vaginal delivery (OR, 3.748; 95% CI: 1.54–9.14), and the presence of hyaline membrane disease (OR, 3.58; 95% CI, 1.47–8.74) are predictors of ROP.ConclusionThe incidence of ROP among very low birth weight infants was 71.6%. Infants with weight below 1500 grams, neonatal sepsis, presence of hyaline membrane disease whose mother had vaginal delivery are at risk for the development of ROP. Thus, preventing premature births and encouraging exclusive breastfeeding are two main ways to prevent ROP.

Association of peripartum management and high maternal blood loss at cesarean delivery for placenta accreta spectrum (PAS): A multinational database study.

Placenta accreta spectrum (PAS) carries a high burden of adverse maternal outcomes, especially significant blood loss, which can be life-threatening. Different management strategies have been proposed but the association of clinical risk factors and surgical management options during cesarean delivery with high blood loss is not clear. In this international multicenter study, 338 women with PAS undergoing cesarean delivery were included. Fourteen European and one non-European center (USA) provided cases treated retrospectively between 2008 and 2014 and prospectively from 2014 to 2019. Peripartum blood loss was estimated visually and/or by weighing and measuring of volume. Participants were grouped based on blood loss above or below the 75th percentile (>3500ml) and the 90th percentile (>5500ml). Placenta percreta was found in 58% of cases. Median blood loss was 2000ml (range: 150-20000ml). Unplanned hysterectomy was associated with an increased risk of blood loss >3500ml when compared with planned hysterectomy (adjusted OR [aOR] 3.7 [1.5-9.4], p=0.01). Focal resection was associated with blood loss comparable to that of planned hysterectomy (crude OR 0.7 [0.2-2.1], p=0.49). Blood loss >3500 ml was less common in patients undergoing successful conservative management (placenta left in situ, aOR 0.1 [0.0-0.6], p=0.02) but was more common in patients who required delayed hysterectomy (aOR 6.5 [1.7-24.4], p=0.001). Arterial occlusion methods (uterine or iliac artery ligation, embolization or intravascular balloons), application of uterotonic medication or tranexamic acid showed no significant effect on blood loss >3500 ml. Patients delivered by surgeons without experience in PAS were more likely to experience blood loss >3500 ml (aOR 3.0 [1.4-6.4], p=0.01). In pregnant women with PAS, the likelihood of blood loss >3500 ml was reduced in planned vs unplanned cesarean delivery, and when the surgery was performed by a specialist experienced in the management of PAS. This reinforces the necessity of delivery by an expert team. Conservative management was also associated with less blood loss, but only if successful. Therefore, careful patient selection is of great importance. Our study showed no consistent benefit of other adjunct measures such as arterial occlusion techniques, uterotonics or tranexamic acid.

Childhood Risk Factors and Adulthood Cardiovascular Disease: A Systematic Review

To conduct a comprehensive review of the literature on childhood risk factors and their associations with adulthood subclinical and clinical cardiovascular disease (CVD). A systematic search was performed using the MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases to identify English-language articles published through June 2018. Articles were included if they were longitudinal studies in community-based populations, the primary exposure occurred during childhood, and the primary outcome was either a measure of subclinical CVD or a clinical CVD event occurring in adulthood. Two independent reviewers screened determined whether eligibility criteria were met. There were 210 articles that met the predefined criteria. The greatest number of publications examined associations of clinical risk factors, including childhood adiposity, blood pressure, and cholesterol, with the development of adult CVD. Few studies examined childhood lifestyle factors including diet quality, physical activity, and tobacco exposure. Domains of risk beyond "traditional" cardiovascular risk factors, such as childhood psychosocial adversity, seemed to have strong published associations with the development of CVD. Although the evidence was fairly consistent in direction and magnitude for exposures such as childhood adiposity, hypertension, and hyperlipidemia, significant gaps remain in the understanding of how childhood health and behaviors translate to the risk of adulthood CVD, particularly in lesser studied exposures like glycemic indicators, physical activity, diet quality, very early life course exposure, and population subgroups.

Risk Factors and Wellness Measures Associated with Prediabetes and Newly Diagnosed Type 2 Diabetes Mellitus in Hispanic Adults.

Background: To characterize the associations of clinical risk factors, lifestyle factors, and wellness measures with prediabetes and new type 2 diabetes mellitus (T2DM) diagnosis in Hispanic adults and guide primary prevention. Methods:Sangre Por Salud Biobank enrolled 3733 Hispanic adults from Phoenix, AZ, United States, from 2013 to 2018. This analysis included participants with euglycemia, prediabetes, or new T2DM diagnosis (i.e., no prior T2DM diagnosis) at enrollment. Participants completed a baseline questionnaire on cardiometabolic risk factors and wellness measures and provided biometric measurements. The associations of factors and measures with odds (95% confidence interval) of prediabetes and new T2DM diagnosis were analyzed in logistic regression models. Results: Among 3299 participants with euglycemia (n = 1301), prediabetes (n = 1718), and new T2DM diagnosis (n = 280) at enrollment, 72% were women (n = 2376/3299). In adjusted models, most cardiometabolic risk factors were positively associated with prediabetes and new T2DM diagnosis, with stronger associations for new T2DM diagnosis. Obesity (body mass index ≥30 kg/m2 vs. lower) was associated with higher odds of new T2DM diagnosis (3.14 [2.30-4.28]; P < 0.01) than prediabetes versus euglycemia (1.96 [1.66-2.32]; P < 0.01) and Interaction (P = 0.01). Similarly, waist circumference, family history of diabetes, and average systolic and diastolic blood pressure were associated with higher odds of new T2DM diagnosis versus euglycemia than prediabetes versus euglycemia. Using stepwise logistic regression modeling, a parsimonious model of age, family history of diabetes, waist circumference, diastolic blood pressure, passive tobacco exposure, and self-rated general health were associated with new T2DM diagnosis versus euglycemia. Conclusions: In Hispanic adults, modifiable cardiometabolic and lifestyle factors were associated with prediabetes and new T2DM diagnosis. Personalized interventions targeting these factors and measures could guide T2DM primary prevention efforts among Hispanic adults.

Clinical Risk Factors Associated with Mortality Among Burn Patients Admitted to Jinnah Burn and Reconstructive Surgery Center, Lahore

Introduction: Burn injuries being highly devastating in nature, are associated with extensive morbidity and mortality. Although the incidence of burn injuries is less in developed countries but it is increasing in developing and low income countries. Aims &amp; Objectives: The aim of this study was to determine clinical risk factors associated with mortality among burn patients. Place and duration of study: Jinnah Burn and Reconstructive Surgery Center, Lahore from August 2018 till January 2019. Material &amp; Methods: Data was collected by researchers themselves by studying files of patients. Data analysis was done by using SPSS and Pearson Chi Square test was used to determine association of clinical risk factors with mortality among burn patients. Results: Out of 200 patients, 137 were males. The Mortality rate was 12.50 %. Cardiopulmonary arrest was the most common cause of death. Sepsis was the most common complication among burn patients. Higher mortality rates were observed among patients with arterial/venous and urinary catheterization done. Higher survival rates were seen in those patients who were treated with debridement, grafting surgeries, Colistin Use and aided by mechanical ventilation. Conclusion: Aid through mechanical ventilation, grafting surgeries, wound debridement, use of colistin are associated with improved survival outcomes among burn patients. Whereas inhalational injury, arterial/venous catheterization, urinary catheter and sepsis are seen as major predictors of mortality among burn patients

Risk Factors for Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation.

This study aimed to assess the association of clinical risk factors with severity of magnetic resonance imaging (MRI) brain injury in neonatal extracorporeal membrane oxygenation (ECMO) patients. This is a single-center retrospective study conducted at an outborn level IV neonatal intensive care unit in a free-standing academic children's hospital. Clinical and MRI data from neonates treated with ECMO between 2005 and 2015 were reviewed. MRI injury was graded by two radiologists according to a modified scoring system that assesses parenchymal injury, extra-axial hemorrhage, and cerebrospinal fluid spaces. MRI severity was classified as none (score = 0), mild/moderate (score = 1-13.5), and severe (score ≥ 14). The relationship between selected risk factors and MRI severity was assessed by Chi-square, analysis of variance, and Kruskal-Wallis tests where appropriate. Combinative predictive ability of significant risk factors was assessed by logistic regression analyses. MRI data were assessed in 81 neonates treated with ECMO. Veno-arterial (VA) patients had more severe injury compared with veno-venous patients. There was a trend toward less severe injury over time. After controlling for covariates, duration of ECMO remained significantly associated with brain injury, and the risk for severe injury was significantly increased in patients on ECMO beyond 210 hours. Risk for brain injury is increased with VA ECMO and with longer duration of ECMO. Improvements in care may be leading to decreasing incidence of brain injury in neonatal ECMO patients. · Veno-arterial ECMO is associated with more brain injury by MRI compared with veno-venous ECMO.. · Longer duration of ECMO is significantly associated with severe brain injury by MRI.. · Risk for neurologic injury may be decreasing over time with advances in neonatal ECMO..

Association between risk stratification for pulmonary embolism and deep vein thrombosis of lower extremities.

The association of clinical risk factors, in particular deep vein thrombosis (DVT), with risk stratification for pulmonary embolism (PE) remains to be identified. We therefore aimed to establish the relationship between risk stratification of PE patients and DVT of lower extremities. In this retrospective study, 93 out of 485 PE patients with uncompleted clinical data were excluded, resulting in 392 patients included for analysis. Based on the ESC criteria, 24, 171, and 197 patients were categorized into high (6.1%), intermediate (43.6%), and low risk (50.3%) subgroups, respectively. DVT was detected in 304 patients (77.6%). The incidence of DVT in patients with high and intermediate risk PE was much lower than in those patients with low risk PE (67.2% vs 87.8%, P < .0001). Further analyses of the 304 patients with DVT showed higher incidence of high and intermediate risk PE in patients with isolated distal DVT than proximal DVT (59.0% vs 39.1%, P = .005), with asymptomatic DVT than symptomatic DVT (63.0% vs 36.8%, P < .0001), and with bilateral DVT than unilateral DVT (54.5% vs 39.9%, P = .03). Stepwise logistic regression showed that symptomatic or asymptomatic DVT was an independent risk factor for risk stratification of PE patients with DVT (0.320, 95% confidence interval, 0.186-0.550). Patients with high and intermediate risk PE presented lower incidence of DVT compared with patients with low risk PE. In PE patients with comorbid DVT, asymptomatic DVT is an independent risk factor for high and intermediate risk of PE.

VITamin D and OmegA-3 TriaL (VITAL) bone health ancillary study: clinical factors associated with trabecular bone score in women and men.

We investigated whether TBS differs by sex, race, body mass index (BMI), and other clinical variables. The VITamin D and OmegA-3 TriaL (VITAL) is determining effects of vitamin D3 and/or omega-3 fatty acid (FA) supplements in reducing risks of cancer and cardiovascular disease. In the VITAL: Effects on Bone Structure/Architecture ancillary study, effects of these interventions on bone will be investigated. Here, we examine the associations of clinical risk factors with TBS assessments at baseline in the bone health sub-cohort, comprised of 672 participants (369 men and 303 women), mean (± SD) age 63.5 ± 6.0years; BMI ≤ 37kg/m2, no bisphosphonates within 2years or other bone active medications within 1year. TBS was greater in men than women (1.311 vs. 1.278, P < 0.001) and lower with elevated BMIs (P < 0.001), higher age (P = 0.004), diabetes (P = 0.008), SSRI use (P = 0.044), and high alcohol intake (P = 0.009). There was a trend for history of fragility fractures (P = 0.072), and lower TBS. TBS did not vary when analyzed by race, smoking, history of falls, and multivitamin or caffeine use. Lower TBS was associated with female sex, aging, BMI ≥ 25kg/m2, SSRI use, alcohol use, and presence of diabetes; there was a trend between lower TBS and history of fragility fractures. TBS may be useful clinically to assess structural changes that may be associated with fractures among patients who are overweight or obese, those on SSRIs, or with diabetes. Ongoing follow-up studies will clarify the effects of supplemental vitamin D3 and/or FA's on TBS and other bone health measures. NCT01747447.

Pulse oximetry values of neonates admitted for care and receiving routine oxygen therapy at a resource-limited hospital in Kenya.

AimThere are 2.7 million neonatal deaths annually, 75% of which occur in sub‐Saharan Africa and South Asia. Effective treatment of hypoxaemia through tailored oxygen therapy could reduce neonatal mortality and prevent oxygen toxicity.MethodsWe undertook a two‐part prospective study of neonates admitted to a neonatal unit in Nairobi, Kenya, between January and December 2015. We determined the prevalence of hypoxaemia and explored associations of clinical risk factors and signs of respiratory distress with hypoxaemia and mortality. After staff training on oxygen saturation (SpO2) target ranges, we enrolled a consecutive sample of neonates admitted for oxygen and measured SpO2 at 0, 6, 12, 18 and 24 h post‐admission. We estimated the proportion of neonates outside the target range (≥34 weeks: ≥92%; <34 weeks: 89–93%) with 95% confidence intervals (CIs).ResultsA total of 477 neonates were enrolled. Prevalence of hypoxaemia was 29.2%. Retractions (odds ratio (OR) 2.83, 95% CI 1.47–5.47), nasal flaring (OR 2.68, 95% CI 1.51–4.75), and grunting (OR 2.47, 95% CI 1.27–4.80) were significantly associated with hypoxaemia. Nasal flaring (OR 2.85, 95% CI 1.25–6.54), and hypoxaemia (OR 3.06, 95% CI 1.54–6.07) were significantly associated with mortality; 64% of neonates receiving oxygen were out of range at ≥2 time points and 43% at ≥3 time points.ConclusionThere is a high prevalence of hypoxaemia at admission and a strong association between hypoxaemia and mortality in this Kenyan neonatal unit. Many neonates had out of range SpO2 values while receiving oxygen. Further research is needed to test strategies aimed at improving the accuracy of oxygen provision in low‐resource settings.

Weight gain and supplemental O2 : Risk factors during the hematopoietic cell transplant admission in pediatric patients.

Respiratory failure in the pediatric hematopoietic cell transplant (HCT) recipient is the leading cause for admission to the intensive care unit and carries a high mortality rate. The objective of this study is to investigate the association of clinical risk factors with the development of respiratory failure in the pediatric allogeneic HCT recipient. This is a single-center, retrospective review of allogeneic pediatric HCT from 2008 to 2014. Multiple variables were examined. The primary outcome was respiratory failure. Percent weight gain was investigated at multiple time points. Bivariate and multivariate regression was used. Of the 87 allogeneic HCT recipients, 22 (25%) developed respiratory failure. Mortality for entire cohort was 13.8%. All who died were intubated prior to death. The group with respiratory failure had significantly higher percent weight gain increase at multiple time points: peak weight prior to discharge or intubation (P = 0.008), weight at discharge or intubation (P = .001), and weight at day 43 (median day for intubation) (P = 0.02). Odds ratio (OR) for respiratory failure increased with increasing percentage peak weight gain: 10% increase (3.1 [1.1, 9.0]), 15% increase (4.1 [1.5, 11.2]), and 20% (8.3 [2.4. 28.9]). Fifty percent of all patients required supplemental O2 . OR for respiratory failure in patients requiring more than 1 l supplemental O2 is 25.3 (6.5, 98.7). Percent weight gain and need for supplemental oxygen is highly associated with the development of respiratory failure in pediatric HCT recipients, representing predictors of acute respiratory failure in pediatric HCT. These data could be incorporated into an algorithm that should be developed, implemented, and validated in a prospective, multicenter fashion.

Increased Extravascular Lung Water and Plasma Biomarkers of Acute Lung Injury Precede Oxygenation Impairment in Primary Graft Dysfunction After Lung Transplantation.

After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.

Association of Clinical Risk Factors and Postoperative Complications With Unplanned Hospital Readmission After Head and Neck Cancer Surgery

Unplanned hospital readmission is costly and in recent years has become a focus of health care legislation intended to reduce health care expenditures. Greater understanding of which perioperative complications are associated with hospital readmission after surgery for head and neck cancer is needed to reduce unplanned readmissions. To determine which clinical risk factors and complications are associated with 30-day unplanned readmission after surgery for malignant neoplasms of the head and neck. This retrospective longitudinal claims analysis included data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from January 1, 2012, to December 31, 2014. Patients undergoing surgery for malignant tumors of the head and neck were included; those with a primary diagnosis of thyroid malignant disease and those undergoing free autologous tissue transfer were excluded. Clinical risk factors and complications were analyzed for association with unplanned hospital readmission using multivariable regression analysis. Statistical significance was determined using P < .05. A total of 7605 patients (5007 men [65.8%]; mean [SD] age, 64.2 [0.2] years) were identified and included for analysis. Overall, 1472 complications occurred in 912 cases. Three hundred eighty-eight patients (5.1%) had an unplanned readmission, which was lower than the previously published overall readmission rate for noncardiac surgical procedures in the NSQIP (6.8%). Clinical factors that were independently associated with unplanned readmission were age (adjusted odds ratio [AOR], 1.12; 95% CI, 1.03-1.22), diabetes (AOR, 1.60; 95% CI, 1.01-2.43), preoperative dyspnea at rest (AOR, 2.89; 95% CI, 1.40-5.55) and with moderate exertion (AOR, 1.48; 95% CI, 1.01-2.11), long-term use of corticosteroids (AOR, 2.45; 95% CI, 1.63-3.58), disseminated cancer (AOR, 1.57; 95% CI, 1.14-2.20), and a contaminated wound (AOR, 2.05; 95% CI, 1.05-3.7). When specific complications were examined, superficial incisional surgical site infection (SSI) (AOR, 2.02; 95% CI, 1.14-3.40), deep incisional SSI (AOR, 2.57; 95% CI, 1.26-5.03), organ or space SSI (AOR, 13.27; 95% CI, 6.57-26.61), wound disruption (AOR, 3.58; 95% CI, 1.95-6.31), pneumonia (AOR, 3.39; 95% CI, 1.88-5.96), deep vein thrombosis (AOR, 5.60; 95% CI, 1.90-15.25), pulmonary embolism (AOR, 20.72; 95% CI, 7.86-55.68), urinary tract infection (AOR, 2.66; 95% CI, 1.00-6.34), stroke (AOR, 12.42; 95% CI, 3.99-36.50), sepsis (AOR, 2.64; 95% CI, 1.27-5.30), and septic shock (AOR, 4.12; 95% CI, 1.10-15.81) were all associated with 30-day unplanned hospital readmission. This study evaluated clinical factors and postoperative complications to determine which ones were associated with 30-day unplanned hospital readmission among patients undergoing surgery for malignant tumors of the head and neck. Further understanding of which complications are associated with unplanned readmission after head and neck surgery will allow for improved risk stratification and development of postoperative care protocols to reduce unplanned hospital readmission.

Mortality of advanced Parkinson's disease patients treated with deep brain stimulation surgery

ObjectiveDespite the widespread use of deep brain stimulation (DBS) for patients with Parkinson's disease (PD), long-term outcomes remain unclear. We aimed to analyze the mortality of advanced PD patients who received DBS surgery. MethodsWe assessed the survival rate of 158 consecutive advanced PD patients who underwent DBS surgery between April 2002 and May 2014. Kaplan-Meier survival curves were constructed using death as the endpoint. Cox proportional hazards regression models were used to assess the association of clinical risk factors with survival. ResultsTwenty-seven (17.1%) PD patients (13 men and 14 women) died during the mean follow-up period of 5.3±3.1years. The survival rate was 97% at 3years and 85% at 5years after DBS surgery. Pneumonia (n=7) was the most common specific cause of death. Orthostatic hypotension was more frequent in deceased patients than in survivors (P=0.026). In a step-wise Cox regression analysis, male sex (hazard ratio (HR)=3.00; 95% confidence interval (CI)=1.35–6.65; P=0.007), visual hallucination (HR=3.95; 95% CI=1.60–9.78; P=0.003), and nursing home admission (HR=2.81; 95% CI=1.30–6.09; P=0.009) predicted poor survival. ConclusionThe poor survival of advanced PD patients who underwent DBS surgery was associated with male sex, orthostatic hypotension, visual hallucination, and nursing home admission.

Pediatric National Surgical Quality Improvement Program: Useful for Quality Improvement in Craniosynostosis Surgery?

The American College of Surgeons and the American Pediatric Surgical Association collaborate to provide pediatric hospitals with multispeciality surgical outcomes data through the Pediatric National Surgical Quality Improvement Program (NSQIP Peds). The authors used this national multicenter database to describe 30-day outcomes from craniosynostosis surgery and identify associations with perioperative events and blood transfusion.Data from NSQIP Peds were used to describe children undergoing craniosynostosis surgery. The authors examined statistical association of clinical risk factors with the defined end point outcomes of perioperative complications and blood transfusion.Five hundred seventy-two surgeries were included. By Common Procedural Terminology codes, 93 identified as single suture synostosis, the remainder as multiple or unknown suture involvement. Location of the affected suture is not captured. Mean surgical time was 196.84 minutes (SD 113.46). Mean length of stay was 4.22 days (SD 5.04). Sixty-seven percent of patients received blood transfusions. 3.15% were other perioperative occurrences, including infection, wound disruption, unplanned reintubation, stroke/hemorrhage, cardiac arrest, seizures, thromboembolism. 2.8% were readmitted; 2.45% underwent reoperation within 30 days. Duration of surgery and length of hospital stay significantly differed in the presence of blood transfusion versus none. On multivariate analysis, duration from anesthesia start to surgery start, duration from surgery end to anesthesia end, and duration of operation were risk factors for blood transfusion.Pediatric NSQIP gives a national overview of 30-day outcome metrics in craniosynostosis surgery. Perioperative adverse event rate was 3.15%. Duration of surgery and duration of anesthesia were significantly associated with blood transfusion. The authors identified opportunities for pediatric NSQIP database improvement.