Clinical Deterioration In Patients Research Articles

Fatal subarachnoid hemorrhage following ischemia in vertebrobasilar dolichoectasia.

Vertebrobasilar dolichoectasia (VBD) is a chronic disorder with various cerebrovascular and compressive manifestations, involving subarachnoid hemorrhage (SAH). Occurrence of SAH shortly after worsening of clinical VBD symptoms has occasionally been reported. The goal of the study was to examine this association, in particular its pathophysiology, clinical precursor signs, time course, and outcome.To this end, in a retrospective multicenter study, we analyzed 20 patients with VBD and SAH in regard to preceding clinical symptoms, presence of vertebrobasilar thrombosis and ischemia, outcome and neuropathological correlates.Median age of the 7 female and 13 male patients was 70 years (interquartile range [IQR] 18.3 years). Fourteen patients (70%) presented with new or acutely worsening posterior fossa signs at a median of 3 days prior to SAH (IQR 2, range 0.5–14). A thrombus within the VBD was detected in 12 patients (60%). Thrombus formation was associated with clinical deterioration (χ2 = 4.38, P = 0.04) and ponto-cerebellar ischemia (χ2 = 8.09, P = 0.005). During follow-up after SAH, 13 patients (65%) died, after a median survival time of 24 hours (IQR 66.2, range 2–264 hours), with a significant association between proven ponto-cerebellar ischemia and case fatality (χ2 = 6.24, P = 0.01).The data establish an association between clinical deterioration in patients with VBD, vertebrobasilar ischemia, and subsequent SAH. Antithrombotic treatment after deterioration appears controversial and SAH outcome is frequently fatal. Our data also indicate a short window of 3 days that may allow for evaluating interventional treatment, preferably within randomized trials.

Biomarkers for Identifying Risk of Immune Reconstitution Inflammatory Syndrome

Biomarkers for Identifying Risk of Immune Reconstitution Inflammatory Syndrome

Living Donor Liver Transplantation in a Hepatitis B Patient with Acute on Chronic Liver Failure Accompanying Hepatocellular Carcinoma

Acute clinical deterioration in patients with chronic liver disease is called acute on chronic liver failure (ACLF). Principles of management of ACLF consist of early identifying etiology of liver disease, rapid intervention of precipitating event and discreet intensive cares. Despite medical intensive cares, if liver failure progresses, liver transplantation could be the other option. Also, liver transplantation is the only treatment that offers a chance of cure for hepatocellular carcinoma (HCC) and the underlying liver cirrhosis simultaneously. Emergent living donor liver transplantation (LDLT) can be performed for patients with acute liver failure and improves survival rate, especially in circumstances which liver graft is often not available because of deceased donors are not affordable. Here, we describe a chronic hepatitis B patient who developed ACLF accompanying early HCC. Because he did not improved with medical care, he received emergent LDLT. After LDLT, he showed great improvement without critical complications. (Ewha Med J 2016;39(3):76-80) Received July 29, 2015 Accepted May 18, 2016

Myocardial deformation parameters predict outcome in patients with repaired tetralogy of Fallot

BackgroundParameters of myocardial deformation have been suggested to be superior to conventional measures of ventricular function and to predict outcome in repaired tetralogy of Fallot (ToF). We aimed to test...

Association of neuropsychiatric syndromes with global clinical deterioration in Alzheimer's disease patients.

Data on the relationship between behavioral disturbances in Alzheimer's disease (AD) and global clinical deterioration is still controversial. The purpose of this study was to explore potential correlations of neuropsychiatric syndromes with global clinical deterioration in patients with AD, with particular consideration on severity levels of dementia. AD patients (n = 156) aged 76.7 years from Brazilian clinical centers were assessed to diagnose the five neuropsychiatric syndromes measured by the Neuropsychiatric Inventory-Clinician rating scale (NPI-C): psychosis, agitation, affective, apathy, and sleep. These syndromes were then analyzed for their correlation with the Global Deterioration Scale (GDS). To analyze the association of neuropsychiatric syndromes with the GDS, considering the total sample and patients grouped by dementia severity levels, we applied the coefficient of multiple correlation (Ryy), adjusted multiple linear regression, and the coefficient of determination (R2yx). We tested the significance of correlation coefficients using the Student t-test for simple correlations (a single independent variable) and analysis of variance (ANOVA) for multiple correlations. ANOVA was also used to compare means of demographic and some clinical variables at different levels of dementia. For the total sample, apathy and agitation syndromes were most strongly correlated (0.74; 0.72, respectively) with clinical deterioration according to the GDS, followed by psychosis (0.59), affective (0.45), and sleep syndromes (0.34). Agitation significantly correlated with mild and moderate dementia (CDR 1: 0.45; and CDR 2: 0.69, respectively). At CDR 2, agitation and affective syndromes were most strongly correlated (0.69; 0.59, respectively) with clinical deterioration while at CDR 3, the apathy syndrome was most strongly correlated with clinical deterioration (0.52). Agitation, apathy, and affective disorders were the syndromes most strongly correlated with global deterioration in AD patients, becoming more evident at severe stages of dementia.

Electrically evoked multiplet discharges are associated with more marked clinical deterioration in motor neuron disease.

The aim of this study was to determine whether electrically evoked multiplet discharges (MDs) are related to severity of clinical deterioration in motor neuron disease (MND). Stimulated high-density surface electromyographic (HDsEMG) recordings were performed in thenar muscles. Data were collected from 31 MND patients. MDs from the HDsEMG recordings were determined at baseline. ALSFRS-R scores were obtained at baseline and at a maximum of 16 weeks follow-up. The presence of MDs was associated with progressive deterioration of ALSFRS-R score (P = 0.02) and fine motor function (FMF) (P < 0.001). Patients who had a higher number of motor units that generated MDs (r = 0.61, P < 0.001) and patients who had a higher number of MDs (as percentage of applied stimuli) (r = 0.59, P = 0.001) had a more severe decline in FMF. Electrically evoked MDs are associated with more marked clinical deterioration in patients with MND.

Concomitant ablation for atrial fibrillation during septal myectomy in patients with hypertrophic obstructive cardiomyopathy

Atrial fibrillation (AF) is the most common tachyarrhythmia in patients with hypertrophic obstructive cardiomyopathy (HOCM). AF emergence associated with significant clinical deterioration in patients with HOCM, that's why maintenance of sinus rhythm is desirable. The most papers are reported results about catheter AF ablation but only paper including date about concomitant AF ablation during septal myectomy.

Medication reconciliation of patients with hip fracture by clinical pharmacists

ObjectiveMedication reconciliation is a strategy for reducing medication discrepancies and improving patient safety. Transitions through different levels of care contribute to medication discrepancies caused by lack of communication. In October...

Acute-on-Chronic Liver Failure: Can We Agree on a Definition?

Acute-on-chronic liver failure (ACLF) has recently received more recognition. It is a condition characterized by acute clinical deterioration in patients with chronic liver disease and is often associated with a precipitant event. It is a form of decompensated cirrhosis characterized by the presence of extrahepatic organ failure and high short-term mortality. Several definitions have been recently proposed for ACLF; however, larger prospective studies are still needed to refine our understanding of this new entity. This article explores the most recently proposed definitions, classification, and prognostic models of ACLF.

Institution of sustained endovascular treatment prior to clinical deterioration in patients with severe angiographic vasospasm: A retrospective observational study of clinico-radiological outcomes

Severe angiographic vasospasm (aVSP) is a risk factor for infarction following subarachnoid haemorrhage and infarction is strongly associated with poor outcome. We present the clinico-radiological results of cohort with severe aVSP who underwent a program of angiographic surveillance and sustained endovascular treatment using multiple verapamil infusions and/or transluminal balloon angioplasty (TBA). This was a dual-centre retrospective observational study. Angiographic screening for vasospasm was undertaken at days 5-7 post-ictus. Treatment was instituted principally on the basis of radiographic findings. The rate of infarction was evaluated on follow-up CT. Clinical outcome was assessed using the modified Rankin Scale (mRS). Fifty-seven WFNS grades 1-5 patients were studied. The mean number of procedures/patient was 6, range 2-13. Mean verapamil dose administered to the ICA was 14 mg and VA was 12 mg. Thirty-one patients underwent TBA (52.6%). The rate of proximal vessel infarction was 3/45 (6.7%) for patients presenting <72 hours. Rates of favourable outcome (mRS 0-2) were 16/19 (84.2%) for WFNS grades 1-2, 12/19 (63.2%) for grades 3-4 and 5/19 (26.3%) for grade 5 patients. Delayed presentation >72 hours was the only factor on multivariate analysis to significantly predict aVSP-infarction [OR19.3 (3.2-116.6) P=0.0012]. Large aVSP-infarction [OR19.0 (1.7-216.4) 0.0179] and poor WFNS grade [OR 6.6 (1.3-33.9) P = 0.0233] were significant predictors of poor outcome on multivariate analysis. This approach may result in low rates of aVSP-infarction and encouraging rates of favourable outcome when compared to literature benchmarks. Delayed presentation, however, predicts infarction and large infarct and poor initial grade significantly influence functional outcome.

Blockade of renin angiotensin system in heart failure post-myocardial infarction: what is the best therapy?

Heart Failure (HF) is a progressive and fatal disorder, which ranks among the major public health problems in Brazil and worldwide. However, survival for patients who developed the syndrome after myocardial infarction (MI) enhanced significantly, as a result of an improvement of pharmacological therapies. A medical breakthrough was the discovery that remodelling of the left ventricle (LV) may be limited by the blockade of the renin-angiotensin system (RAS), at the level of angiotensin converting enzyme (ACE) and binding of angiotensin (Ang) II to its AT1 receptor. This review shows that the therapeutic effects of both ACE inhibitors and the angiotensin receptor blockers (ARB) go beyond the interference in the biochemical pathway ACE-Ang II AT1-receptor. Such effects are also related to the potentiation of bradykinin and increased beneficial effects mediated by the AT2 receptor. Therefore, the results of five randomized trials were presented, which evaluated the use of losartan, valsartan or candesartan, considering their effects on survival and risk of clinical deterioration in patients with symptomatic HF after MI. These studies confirmed the advantage of ARBs over inhibitors in case of cough, rashes and angioneurotic edema, despite similar adverse effects, such as hyperkalemia, renal failure and hypotension. Thus, in this article we have discussed with patents that ACE inhibitors also appear as the first option as RAS inhibitors in search of relevant results for the patient, allowing the alternative use of ARBs to those patients with intolerance.

Multisite analysis of the timing and outcomes of unplanned transfers from subacute to acute care.

The aim of the present study was to examine the timing and outcomes of patients requiring an unplanned transfer from subacute to acute care. Subacute care in-patients requiring unplanned transfer to an acute care facility within four Victorian health services from 1 January to 31 December 2010 were included in the study. Data were collected using retrospective audit. The primary outcome was transfer within 24 h of subacute care admission. In all, 431 patients (median age 81 years) had unplanned transfers; of these, 37.8% had a limitation of medical treatment (LOMT) order. The median subacute care length of stay was 43 h: 29.0% of patients were transferred within 24 h and 83.5% were transferred within 72 h of subacute care admission. Predictors of transfer within 24 h were comorbidity weighting (odds ratio (OR) 1.1, P = 0.02) and LOMT order (OR 2.1, P < 0.01). Hospital admission occurred in 87.2% of patients and 15.4% died in hospital. Predictors of in-hospital mortality were comorbidity weighting (OR 1.2, P < 0.01) and the number of physiological abnormalities in the 24 h preceding transfer (OR 1.3, P < 0.01). There is a high rate of unplanned transfers to acute care within 24h of admission to subacute care. Unplanned transfers are associated with high hospital admission and in-hospital mortality rates.

Correlation between Changes of FDG-PET Findings and those of Mini- Mental Status Examination Scores in Patients with Moderate Alzheimer’s Disease: Usefulness of Stereotactic Extraction Estimation

Purpose: To investigate the association between changes on [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) and clinical deterioration in patients with moderate Alzheimer’s disease (AD), findings of FDG-PET in the first and follow-up stages were compared using stereotactic extraction estimation (SEE) and three-dimensional stereotactic surface projection (3D-SSP). Methods and patients: Thirty consecutive patients with AD examined twice by FDG-PET were divided into two groups with improved or stable mini-mental state examination (MMSE) (SI group, 14 patients) and deteriorated MMSE (D group, 16 patients). Statistical analysis using SEE in 3D-SSP was used to investigate the changes in Z-score in the frontal, parietal, temporal, and occipital lobes, precuneus, and posterior cingulate cortex (PCC). Results: Changes in Z-scores in the PCC (p=0.0006) and temporal lobe (p=0.021) were significantly higher in the D group than in the SI group. Z-score was significantly higher in the left PCC compared to the right PCC (p=0.0097). Conclusions: SEE in 3D-SSP is the helpful method to detect the regional differences. Metabolic reduction on FDG-PET in the left PCC detected by SEE and 3D-SSP is associated with clinical deterioration in patients with moderate AD. Keywords: Alzheimer's disease, FDG-PET, Stereotactic extraction estimation, 3D-SSP.

Beyond a Broken Heart: Circulatory Dysfunction in the Failing Fontan

The role of ventricular dysfunction in late morbidity and mortality of univentricular hearts has been described previously. However, a significant proportion of adult Fontan patients who die or require heart transplantation do so with preserved ventricular function. The clinical deterioration in patients who have undergone Fontan palliation requires a broader view of circulatory dysfunction, one that takes into account the complex interaction of regulatory systems affecting hepatic, renal, and pulmonary blood flow, in addition to cardiac function. This review focuses primarily on the pathophysiology of multiple organ involvement in this circulatory dysfunction, with particular focus on the consequences of hepatic dysfunction and portal hypertension. The authors discuss hepatic perfusion, both in health and disease, and review the current understanding of liver histopathology and liver disease in adult Fontan patients and similar clinicopathologic states. They compare and contrast features of postsinusoidal portal hypertension with more typical adult cirrhotic disease. Finally, they delineate the related effects of portal hypertensive physiology on the systemic and pulmonary vasculature, the kidney, and the heart itself and discuss how these changes affect the care of the adult Fontan patient.

Myocardial deformation as provided by CMR based feature tracking is related to exercise capacity and outcome in patients with repaired tetralogy of Fallot

Background: Echo parameters of myocardial deformation have been suggested to be superior to conventional measures of ventricular function and to predict outcome in pts. with repaired tetralogy of Fallot (rToF). Little is known about CMR provided myocardial deformation parameters in this context. We assessed biventricular myocardial function using CMR cine-based feature tracking (FT) in a large cohort of rToF pts. to study its relation to clinical parameters and outcome. Methods and results: Pts. with rToF undergoing standardized CMR imaging were recruited as part of a nationwide, prospective study between 2005 and 2008. In addition to conventional parameters of ventricular volumes and function, myocardial deformation was assessed prospectively by CMR based FT (TomTec, Unterschleissheim, Germany). FT analysis was performed for the left (LV) and right ventricle (RV), providing longitudinal (LS), circumferential (CS) and radial global strain (RS). Cardiopulmonary exercise data at the time of CMR were available in 98% of pts. A composite endpoint of death, successful cardiopulmonary resuscitation, documented ventricular tachycardia (VT) or ICD implantation was employed. Overall, 372 patients (55% male, age 17.7±8.3 yrs., pulmonary regurgitant fraction 27±19%, RVEDVI 121±33 ml/m2, RV EF 50±9%, LV EF 57±9%) were included. Patients in NYHA-class 3 had significantly worse LV LS (median 10.1 vs. 15.0%, P=0.048), LV CS (median 15.4 vs. 21.7%, P=0.01) and more abnormal RV LS (median 10.4 vs. 34.8%, P=0.002) compared to patients in NYHA class 1 or 2. Furthermore, RV CS (OR 0.788, 95% CI 0.682-0.912, P=0.001) was associated with symptomatic deterioration of at least 1 NYHA class during follow-up on logistic regression analysis. During a median follow-up time of 4.9 (IQR 3.3-5.5) yrs., 10 adverse events occurred (including 3 deaths and 2 successful resuscitations). On bivariate Cox analysis LV CS emerged as the strongest predictor of outcome (HR 0.81, p=0.0007), independently of QRS-duration, LV and RV EF, RVEDVI, RVESVI, NYHA class and peak oxygen uptake. In addition, LV LS, LV RS and LV CS were related to the risk of death and nearly missed cardiac death (HR 0.76, 0.80 and 0.78; P=0.046, 0.006 and 0.04, respectively). Conclusions: Myocardial dysfunction on FT-CMR relates to symptoms and clinical deterioration in patients with rToF. LV circumferential global strain emerged as the strongest predictor of adverse outcome and should, thus, be considered as a useful adjunct to established risk makers, especially in younger rToF patients.

A trial of a real‐time Alert for clinical deterioration in Patients hospitalized on general medical wards

With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm. Randomized, controlled crossover study. Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. Intensive care unit transfer, hospital mortality, and hospital length of stay. Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.

Abstract 13: Asymmetry of Deep Medullary Veins in Susceptibility Weighted Imaging is associated with Poor Collaterals in Patients with Acute Ischemic Stroke

Background: Susceptibility Weighted Imaging (SWI) is a high spatial resolution of MR imaging technique showing magnetic inhomogeneity that could demonstrate increased oxygen extraction in ischemic hemisphere. The aim of this study was to investigate whether the asymmetry of deep medullary veins (DMVs) on SWI could indicate the poor collateral flow, which results in the hemodynamic derangement in acute ischemic stroke. Methods: Consecutive 132 patients with acute middle cerebral artery infarction within 6 hours from symptom onset were included. The DMVs of ipsilesional region of interests (ROIs) and contralateral ROIs were evaluated; score 0: no DMVs, score 1: moderately visibility of DMVs, and score 2: obviously visibility of DMVs. Asymmetry is defined as the difference in the scores of DMVs between both hemispheres. Collateral status on conventional angiography was graded 0 to 4 based on the ASTIN/SIR collateral flows grading system. Poor collateral flow is defined as grade 0-1. Early neurological deterioration was defined as an increase in the NIHSS score by ≥4 points during the first 48 hours after admission. Multivariable logistic regression analysis was used to examine the association between the presence of asymmetry of DMVs and poor collateral flow or clinical outcomes. Results: Of 132 patients, 74 (56.1%) had asymmetry of DMVs. Asymmetry of DMVs was independently associated with the poor collateral status (OR; 42.1, 95% confidential interval 1.99.-89.81, p=0.02) after adjusting confounders. Moreover, patients with asymmetry of DMVs were likely to have more profound infarction growth (OR; 6.01, 95% CI, 1.21-29.88, p=0.03) and results in the early neurological deterioration (OR; 5.49, 95% CI, 1.21-28.57, p=0.03). Conclusion: Asymmetry of DMVs is independently associated with poor collateral status which affects the clinical deterioration in patients with acute middle cerebral artery stroke.

Computed Tomography and Transcranial Doppler Findings in Acute and Subacute Phases of Intracerebral Hemorrhagic Stroke

The hematoma volume is an important determinant of outcome and a predictor of clinical deterioration in patients with intracerebral hemorrhage (ICH). Our goal was to evaluate alterations in the cerebral circulation, in respect to hemorrhage and edema volume changes, using transcranial Doppler (TCD). Twenty patients with acute supratentorial ICH were examined. Brain, hematoma, and edema volumes were calculated from CT scans performed at admission and 2 weeks later. Data were compared with those obtained from bilateral TCD recordings of the middle cerebral arteries. During TCD examination, blood flow velocities did not change, cerebral perfusion pressure (CPP) and resistance area product (RAP) decreased (P = .006, P = .002) while cerebral blood flow index (CBFI) remained constant on the affected side. Although hemorrhage volume did not correlate with RAP in the acute phase, correlation was found in the subacute phase (r = -.44, P = .04). TCD monitoring sensitively demonstrates the hemodynamic change caused by ICH but the severity of the changes does not correlate with the volume of the ICH in acute stage. The CPP, RAP, and CBFI values are more sensitive parameters than the absolute velocity values, therefore they contribute more to the understanding of hemodynamic changes developed after spontaneous ICH.

Stent Evaluation with Optical Coherence Tomography

Optical coherence tomography (OCT) has been recently applied to investigate coronary artery disease in interventional cardiology. Compared to intravascular ultrasound, OCT is able to visualize various vascular structures more clearly with higher resolution. Several validation studies have shown that OCT is more accurate in evaluating neointimal tissue after coronary stent implantation than intravascular ultrasound. Novel findings on OCT evaluation include the detection of strut coverage and the characterization of neointimal tissue in an in-vivo setting. In a previous study, neointimal healing of stent strut was pathologically the most important factor associated with stent thrombosis, a fatal complication, in patients treated with drug-eluting stent (DES). Recently, OCT-defined coverage of a stent strut was proposed to be related with clinical safety in DES-treated patients. Neoatherosclerosis is an atheromatous change of neointimal tissue within the stented segment. Clinical studies using OCT revealed neoatherosclerosis contributed to late-phase luminal narrowing after stent implantation. Like de novo native coronary lesions, the clinical presentation of OCT-derived neoatherosclerosis varied from stable angina to acute coronary syndrome including late stent thrombosis. Thus, early identification of neoatherosclerosis with OCT may predict clinical deterioration in patients treated with coronary stent. Additionally, intravascular OCT evaluation provides additive information about the performance of coronary stent. In the near future, new advances in OCT technology will help reduce complications with stent therapy and accelerating in the study of interventional cardiology.

180 The Incidence of Clinical Deterioration in Patients Diagnosed With Pulmonary Embolism: Results from the Safe Pulmonary Embolism Emergency Department Discharge Study

180 The Incidence of Clinical Deterioration in Patients Diagnosed With Pulmonary Embolism: Results from the Safe Pulmonary Embolism Emergency Department Discharge Study