Early Prediction Of Poor Outcome Research Articles

Clinical features and risk factors analysis for poor outcomes of severe community-acquired pneumonia in children: a nomogram prediction model.

Pneumonia remains the leading cause of death among children aged 1-59 months. The early prediction of poor outcomes (PO) is of critical concern. This study aimed to explore the risk factors relating to PO in severe community-acquired pneumonia (SCAP) and build a PO-predictive nomogram model for children with SCAP. We retrospectively identified 300 Chinese pediatric patients diagnosed with SCAP who were hospitalized in the Affiliated Hospital of Southwest Medical University from August 1, 2018, to October 31, 2021. Children were divided into the PO and the non-PO groups. The occurrence of PO was designated as the dependent variable. Univariate and multivariate logistic regression analyses were used to identify the risk factors of PO. A nomogram model was constructed from the multivariate logistic regression analysis and internally validated for model discrimination and calibration. The performance of the nomogram was estimated using the concordance index (C-index). According to the efficacy evaluation criteria, 56 of 300 children demonstrated PO. The multivariate logistic regression analysis resulted in the following independent risk factors for PO: co-morbidity (OR: 8.032, 95% CI: 3.556-18.140, P < 0.0001), requiring invasive mechanical ventilation (IMV) (OR: 7.081, 95% CI: 2.250-22.282, P = 0.001), and ALB < 35 g/L (OR: 3.203, 95% CI: 1.151-8.912, P = 0.026). Results of the internal validation confirmed that the model provided good discrimination (concordance index [C-index], 0.876 [95% CI: 0.828-0.925]). The calibration plots in the nomogram model were of high quality. The nomogram facilitated accurate prediction of PO in children diagnosed with SCAP and could be helpful for clinical decision-making.

Usefulness of complete blood count parameters to predict poor outcomes in cancer patients with febrile neutropenia presenting to the emergency department

Introduction Febrile neutropenia (FN) is one of the major complications with high mortality rates in cancer patients undergoing chemotherapy. The Multinational Association for Supportive Care in Cancer (MASCC) risk-index score has limited applicability for routine use in the emergency department (ED). This study aimed to develop simplified new nomograms that can predict 28-day mortality and the development of serious medical complications in patients with FN by using a combination of complete blood count (CBC) parameters with quick Sequential Organ Failure Assessment (qSOFA). Methods In this retrospective observational study, various models comprising qSOFA score and individual CBC parameters (red cell distribution width, delta neutrophil index, mean platelet volume (MPV)) were evaluated for association with outcomes by a multivariate logistic analysis. Subsequently, nomograms were developed for outcome prediction. The primary outcome was mortality at 28 days from ED presentation; the secondary outcome was the development of serious medical complications. Results A total of 378 patients were included. Among the CBC parameters, only MPV was significantly associated with 28-day mortality and serious medical complications in patients with FN. The nomogram developed to predict 28-day mortality and serious medical complications showed good discrimination with area under the receiver-operating characteristic curve (AUC) values of 0.729 and 0.862 (95% CI, 0.780–0.943), respectively, which were not different from those of the MASCC score (0.814, 95% CI, 0.705–0.922; p = .07 and 0.921, 95% CI, 0.863–0.979; p = .11, respectively) in the validation set. The calibration of both nomograms demonstrated good agreement in the validation set. Conclusion In this study, a novel prognostic nomogram using qSOFA score and MPV to identify cancer patients with FN with high risk of 28-day mortality and serious medical complications was verified and validated. Prompt management of fatal complications of FN can be possible through early prediction of poor outcomes with these new nomograms. KEY MESSAGES Among the evaluated CBC parameters, only mean platelet volume was associated with 28-day mortality and serious medical complications in cancer patients with febrile neutropenia. A novel and rapid prognostic nomogram was developed using quick Sequential Organ Failure Assessment score and mean platelet volume to identify cancer patients with febrile neutropenia having high risk of 28-day mortality and serious medical complications. The nomogram developed to predict 28-day mortality and serious medical complications in patients with febrile neutropenia showed good discrimination and provides rapid patient evaluation that is especially applicable in the emergency department.

Quantitative EEG provides early prediction of poor outcome in acute ischemic stroke after endovascular treatment: a preliminary study

ABSTRACT Background and Purpose: Quantitative electroencephalogram (QEEG) parameters have been previously utilized in prognosis following acute ischemic stroke (AIS). However, the use and interpretation of QEEG parameters remain scarce following endovascular treatment (EVT) of AIS. Methods: AIS patients were prospectively enrolled following EVT, and 24-hour EEG monitoring was conducted. Global delta/alpha ratio (DAR), (delta + theta)/(alpha + beta) ratio (DTABR), and relative band power were analyzed. Primary outcome was a poor outcome (modified Rankin Scale ≥4 at 90-day follow-up). Multivariate logistic regression and diagnostic analyses were performed. Results: Poor outcome was seen in 35.5% (11/31) of enrolled patients. Multivariable logistic regression identified that higher DAR (OR 1.10, 95% CI 1.02–1.18, p = 0.02) and higher DTABR (OR 1.13, 95% CI 1.01–1.27, p = 0.02) were associated with poor outcome. DAR ≥14.3 demonstrated high sensitivity (90.9%), specificity (90.0%) and accuracy (90.3%) for poor outcome. Conclusions: Early evidence of elevated DAR and DTABR on quantitative EEG was associated with poor outcome at 90 days following EVT for AIS.

Early Prediction of Poor Outcome Despite Successful Recanalization After Endovascular Treatment for Anterior Large Vessel Occlusion Stroke

Successful recanalization (SR) of the occluded artery does not always translate into a good outcome for patients with acute anterior circulation large-vessel occlusion stroke. This study aimed to develop a scale to predict poor outcome early despite SR after endovascular treatment (EVT) for candidates identified using current guidelines. The eligible patients with SR were retrospectively enrolled between 2014 and 2016. Poor outcome was defined as modified Rankin Scale of 3 to 6 at 90 days. Multivariable logistic regression was used to derive a PooR outcomE of enDovascular treatment wIth suCcessful recanalizaTion (PREDICT) scale. The discrimination and calibration of the scale were assessed. A total of 332 patients were enrolled. The PREDICT scale consisted of 5 items (prior intravenous thrombolysis, collateral status, blood glucose, blood neutrophil-to-lymphocyte ratio, and baseline National Institutes of Health Stroke Scale score). The scale had good discrimination and calibration. The risk of poor outcome was stratified into very low (PREDICT scale score ≤5), low (6-8), moderate (9-11), and high (≥12). Compared with patients with a score of ≤5, patients with a score of ≥12 had an 18.33-fold (95% confidence interval [CI], 6.36-52.89) increased risk of poor outcome. The PREDICT scale is a practical tool for early prediction of poor outcome despite SR after EVT in our patients and, if validated in other patient populations, may serve as a scale for identifying which patients are most, and least, likely to benefit from EVT.

Prognostic factors in the early phase of acute encephalopathy.

Neurological sequelae occur in 40% of patients with acute encephalopathy (AE). The early prediction of poor outcomes is critical to the initiation of appropriate treatment. The aim of the present study was therefore to elucidate prognostic factors that can be quickly and feasibly evaluated on hospital admission in patients with AE. We analyzed data from 51 AE patients admitted to Hirakata City Hospital between January 2005 and December 2014. Age at onset, sex, underlying disease, status epilepticus (SE), presence of benzodiazepine-resistant SE (BZD-resistant SE), and basic blood serum parameters on admission were evaluated in relation to each patient's outcome. On univariate analysis age at onset, BZD-resistant SE, and serum aspartate aminotransferase (AST), alanine aminotransferase, lactate dehydrogenase, and platelet count varied significantly according to outcome. On multivariate analysis age at onset (≤21months), presence of BZD-resistant SE, and AST (≥46IU/L) were identified as independent variables associated with poor outcome. Age at onset, presence of BZD-resistant SE, and AST are associated with a poor prognosis in AE.

Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis

BackgroundThe usefulness of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in providing bedside criteria for early prediction of poor outcomes in patients with suspected infection remains controversial. We investigated the prognostic performance of a positive qSOFA score outside the intensive care unit (ICU) compared with positive systemic inflammatory response syndrome (SIRS) criteria.MethodsA systematic literature search was performed using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Data were pooled on the basis of sensitivity, specificity, and diagnostic OR. Overall test performance was summarized using a hierarchical summary ROC and the AUC. Meta-regression analysis was used to identify potential sources of bias.ResultsWe identified 23 studies with a total of 146,551 patients. When predicting in-hospital mortality in our meta-analysis, we identified pooled sensitivities of 0.51 for a positive qSOFA score and 0.86 for positive SIRS criteria, as well as pooled specificities of 0.83 for a positive qSOFA score and 0.29 for positive SIRS criteria. Discrimination for in-hospital mortality had similar AUCs between the two tools (0.74 vs. 0.71; P = 0.816). Using meta-regression analysis, an overall mortality rate ≥ 10% and timing of qSOFA score measurement could be significant sources of heterogeneity. For predicting acute organ dysfunction, although the AUC for a positive qSOFA score was higher than that for positive SIRS criteria (0.87 vs. 0.76; P < 0.001), the pooled sensitivity of positive qSOFA score was very low (0.47). In addition, a positive qSOFA score tended to be inferior to positive SIRS criteria in predicting ICU admission (0.63 vs. 0.78; P = 0.121).ConclusionsA positive qSOFA score had high specificity outside the ICU in early detection of in-hospital mortality, acute organ dysfunction, and ICU admission, but low sensitivity may have limitations as a predictive tool for adverse outcomes. Because between-study heterogeneity was highly represented among the studies, our results should be interpreted with caution.

Patterns of C-reactive protein ratio predicts outcomes in healthcare-associated pneumonia in critically ill patients with cancer

PurposeDescribe the patterns of C-reactive protein relative changes in response to antibiotic therapy in critically ill cancer patients with healthcare-associated pneumonia (HCAP) and its ability to predict outcome. MethodsSecondary analysis of a prospective cohort of critically ill cancer patients with HCAP. CRP was sampled every other day from D0 to D6 of antibiotic therapy. Patients were classified according to an individual pattern of CRP-ratio response: fast – CRP at D4 of therapy was <0.4 of D0 CRP; slow – a continuous but slow decrease of CRP; non – CRP remained ≥0.8 of D0 CRP; biphasic – initial CRP decrease to levels <0.8 of the D0 CRP followed by a secondary rise ≥0.8. Results129 patients were included and septic shock was present in 74% and invasive mechanical ventilation was used in 73%. Intensive care unit (ICU) and hospital mortality rates were 47% and 64%, respectively. By D4, both CRP and CRP-ratio of survivors were significantly lower than in nonsurvivors (p<0.001 and p=0.004, respectively). Both time-dependent analysis of CRP-ratio of the four previously defined patterns (p<0.001) as ICU mortality were consistently different [fast 12.9%, slow 43.2%, biphasic 66.7% and non 71.8% (p<0.001)]. ConclusionCRP-ratio was useful in the early prediction of poor outcomes in cancer patients with HCAP.

Relevance of the ISGLS definition of posthepatectomy liver failure in early prediction of poor outcome after liver resection: study on 680 hepatectomies.

To assess the relevance of the International Study Group of Liver Surgery (ISGLS) definition of posthepatectomy liver failure compared with 2 well-established criteria, 50-50 and PeakBili>7, as early predictors of posthepatectomy outcome. There is limited data on the postoperative use of ISGLS definition of posthepatectomy liver failure as early predictor of outcome. Between 2007 and 2012, a total of 680 hepatectomies were analyzed from a prospective database. The value of each definition for prediction of 3-month major complications (Clavien III-V) and mortality was assessed either within 10 days of surgery or on postoperative day 5. Three-month major morbidity and mortality rates were 16.5% and 4.4%, respectively. Within 10 days, 79 patients fulfilled ISGLS definition compared with 24 for 50-50 and 44 for PeakBili>7 criteria. Sensitivities of ISGLS definition and 50-50 and PeakBili>7 criteria for prediction of major morbidity and mortality were 35.8, 17.4, 24.8% and 56.7, 36.7, 56.7%, respectively. Patients with no positive score had a risk of death or major complication below 5% and 15%, respectively. In patients with a positive score, the ISGLS definition was the least relevant to predict major complications and mortality (positive predictive values of 49.4% and 21.8% vs 79.2% and 47.8% for 50-50 and 61.4% and 40.5% for PeakBili>7 criteria). The relative risk of death was 6.9 (95% confidence interval, 3.1-15.4) if the ISGLS definition was evaluated on postoperative day 5 versus 21.1 (95% confidence interval, 7.7-57.7) for 50-50 and 21.7 (95% confidence interval, 7.4-63.3) for PeakBili>7 criteria. ISGLS definition was less discriminatory than 50-50 and PeakBili>7 criteria in identifying patients at risk of posthepatectomy major complications or death.

Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature

To assess the sensitivity and false positive rate (FPR) of neurological examination and somatosensory evoked potentials (SSEPs) to predict poor outcome in adult patients treated with therapeutic hypothermia after cardiopulmonary resuscitation (CPR). MEDLINE and EMBASE were searched for cohort studies describing the association of clinical neurological examination or SSEPs after return of spontaneous circulation with neurological outcome. Poor outcome was defined as severe disability, vegetative state and death. Sensitivity and FPR were determined. A total of 1,153 patients from ten studies were included. The FPR of a bilaterally absent cortical N20 response of the SSEP could be calculated from nine studies including 492 patients. The SSEP had an FPR of 0.007 (confidence interval, CI, 0.001-0.047) to predict poor outcome. The Glasgow coma score (GCS) motor response was assessed in 811 patients from nine studies. A GCS motor score of 1-2 at 72 h had a high FPR of 0.21 (CI 0.08-0.43). Corneal reflex and pupillary reactivity at 72 h after the arrest were available in 429 and 566 patients, respectively. Bilaterally absent corneal reflexes had an FPR of 0.02 (CI 0.002-0.13). Bilaterally absent pupillary reflexes had an FPR of 0.004 (CI 0.001-0.03). At 72 h after the arrest the motor response to painful stimuli and the corneal reflexes are not a reliable tool for the early prediction of poor outcome in patients treated with hypothermia. The reliability of the pupillary response to light and the SSEP is comparable to that in patients not treated with hypothermia.

Early prediction of poor outcome in severe hemispheric stroke by EEG patterns and gradings

Objectives: To find out the EEG abnormal patterns in massive cerebral hemispheric infarction (MCHI) and their correlation with poor outcome, and to construct an EEG grading for predicting the outcome of MCHI patients.Methods: Between 2000 and 2010, 162 patients with MCHI who met the selection criterions were selected for this study. All the patients underwent EEG examinations within 3 days after stroke onset and repeated on day 2 and 3. We classified the EEG recordings into 9 patterns and anglicized the correlation between EEG patterns and outcome. Then according to the results of the correlation between EEG patterns and outcome we constructed an EEG grading for predicting the outcome of MCHI patients.Results: We revealed that patterns of dominant alpha without reactivity, RAWOD, burst-suppression, α/θ-coma, epileptiform activity (without burst-suppression), and generalized suppression were correlated to poor outcome. We further modified the Young grading according to the correlation between EEG patterns and outcome. We found that the modified grading was superior to existing EEG gradings in predicting the outcome of MCHI patients, and it could predict the outcome of MCHI more accurately.Conclusions: MCHI is common in N-ICU (Neurology Intensive Care Unit). The EEG analysis would detect the degree of brain lesion during the ischemia within the acute stage after stroke onset. The EEG evaluation might assist the neurophysicians to predict outcome of patients and make decisions on the treatments.

Early post‐operative prediction of morbidity and mortality after a major liver resection for colorectal metastases

BackgroundAn early prediction of poor outcomes is essential in the management of patients after a liver resection. The aim of this study was to evaluate the role of selected biochemical parameters on post‐operative day 1 (POD 1) in the prediction of morbidity and mortality after a liver resection for colorectal metastases. MethodThis retrospective study was based on 236 major liver resections for colorectal metastases performed between 2006 and 2011. Results of biochemical tests of blood samples obtained on POD 1 were assessed as predictors of primary outcome measures (hepatic and overall morbidity, 90‐day mortality) using multiple regression and receiver‐operating characteristics (ROC). ResultsHepatic morbidity, overall morbidity and 90‐day mortality rates were 18.6%, 28.0% and 4.7%, respectively. On the basis of multiple regression analysis and comparisons of the prediction models, serum bilirubin was selected for the prediction of hepatic (>2.05 mg/dl, sensitivity 69.2%, specificity 71.2%) and overall (>2.05 mg/dl, sensitivity 61.1% and specificity 71.2%) morbidity, and aspartate aminotransferase (AST) was selected for the prediction of 90‐day mortality (>798 U/l, sensitivity 62.5% and specificity 90.4%). DiscussionBiochemical analyses of blood on POD1 enables stratification of patients into low‐ and high‐risk groups for negative outcomes, with serum bilirubin associated with overall and hepatic morbidity and AST associated with mortality.

The BCR-ABL Transcript Levels At 3 and 6 Months Predict the Long-Term Outcome of Chronic Myeloid Leukemia Patients Treated Frontline with Imatinib Mesylate: A Gimema CML WP Analysis

AbstractAbstract 1678 Background.Imatinib mesylate (IM) is the therapeutic standard for chronic myeloid leukemia (CML), but nilotinib and dasatinib, at least in selected patients, have the potential to replace it. The early prediction of poor outcome is important to optimize the treatment strategy. In IM-treated patients, BCR-ABL transcript levels according to the International Scale (IS) > 10% at 3 and > 1% at 6 months were able to identify high-risk groups (Marin et al, JClinOncol 2011; Hanfstein et al, Leukemia 2012). Similar analysis were performed within the IM arms of the ENESTnd trial (Hochhaus et al, EHA 2012) and the DASISION trial (Jabbour et al, EHA 2012). Methods.To investigate the prognostic impact of BCR-ABLIS levels at 3 and 6 months on the future response status and the long-term outcome of CML patients treated frontline with IM, we analyzed 559 patients enrolled within 3 trials of the GIMEMA CML WP (ClinTrialsGov NCT00514488/NCT00510926, observational trial CML023). Patients with evaluable QPCR sample at 3 and 6 months: 487/559 (87%) and 492/559 (88%), respectively. Definitions: major molecular response (MMR): BCR-ABLIS ratio <0.1%; molecular response with 4.0-log reduction (MR4.0): BCR-ABLIS <0.01%; failures: according to 2009 ELN recommendations. The rate of complete cytogenetic response (CCgR) and MMR at 1 year, the rate of MR4.0 at 2 years, the failure-free survival (FFS), the progression-free survival (PFS) and the overall survival (OS) according to the BCR-ABL transcript levels (≤10% vs >10 and ≤1% vs >1%) at 3 and 6 months were analyzed. Patients with events or censored within 3 or 6 months were excluded from the respective analysis. Receiver operating characteristic (ROC) curves were used for descriptive purposes. Results.Median age: 52 years (range 18–84). IM dose: 76% 400mg, 24% 800mg. Sokal score: 39% low, 39% intermediate, 22% high; EUTOS score: 93% low, 7% high. Median follow-up: 76 months (range: 7–99); 95% of patients had at least 5-year observation. BCR-ABLIS at 3 months: ≤1% in 336/487 (69%), >1% to ≤10% in 120/487 (25%) and >10% in 31/487 (6%). BCR-ABLIS at 6 months: ≤1% in 425/492 (86%), >1% to ≤10% in 54/492 (11%) and >10% in 13/492 (3%). Responses and outcomes according to transcript levels are presented in table 1. Patients with BCR-ABLIS >10% at 3 months achieved inferior CCgR and MMR rates at 1 year and inferior MR4.0 rate at 2 years, but the long-term outcome was comparable to patients with transcript levels < 10%. On the contrary, a BCR-ABLIS >1% at 3 months was associated, not only to lower subsequent response rates, but also to significantly inferior FFS, PFS and OS. The BCR-ABLIS levels able to predict for FFS, PFS and OS with maximal sensitivity and specificity (ROC curves) were 1.9%, 0.8% and 0.8%, respectively. Results were similar, with small differences, in the 6-month analysis. Conclusions.In a multicentric nationwide experience, the proportion of patients with BCR-ABLIS transcript levels >10% at 3 and 6 months was low. The risk distribution and the proportion of patients treated with high-dose IM may explain, at least in part, the differences with other published reports. At 3 and 6 months, a BCR-ABLIS cutoff of 1% was a reliable surrogate marker of response and outcome. A transcript level >10% identified a smaller cohort with inferior responses, but failed to predict the long-term outcome. A BCR-ABLIS level >1% at 3 and 6 months represents a warning, requiring a close monitoring. A switch to 2nd generation tyrosine kinase inhibitors should be considered. Acknowledgments.University of Bologna, BolognaAIL, COFIN, Fondazione Carisbo.BCR-ABL at 3 months (N = 487)< 10% (N = 456)> 10% (N = 31)p*< 1% (N = 336)> 1% (N = 151)p*CCgR at 1 year, %80.951.6<0.00187.560.3<0.001MMR at 1 year, %62.122.6<0.00170.535.1<0.001MR4.0 at 2 years, %20.03.20.01723.58.6<0.001FFS, %79.268.30.10483.766.8<0.001PFS, %85.290.00.77187.581.90.004OS, %86.587.10.62288.483.60.010BCR-ABL at 6 months (N = 492)< 10% (N = 479)> 10% (N = 13)p*< 1% (N = 425)> 1% (N = 67)p*CCgR at 1 year, %84.330.8<0.00188.746.3<0.001MMR at 1 year, %64.77.7<0.00171.113.4<0.001MR4.0 at 2 years, %19.600.14321.44.5<0.001FFS, %81.057.10.04583.657.4<0.001PFS, %86.474.10.11587.678.40.002OS, %87.376.90.07888.380.80.01*Responses at each timepoint were compared using χ2 test or Fisher exact test, as appropriate. FFS, PFS, OS were estimated using the Kaplan-Meier method and compared by log-rank test. Disclosures:Castagnetti:Bristol Myers Squibb: Consultancy, Honoraria, Speakers Bureau; Novartis Pharma: Consultancy, Honoraria, Speakers Bureau. Gugliotta:Novartis: Consultancy, Honoraria; Bristol-Myers-Squibb: Consultancy, Honoraria. Breccia:Bristol Myers Squibb: Consultancy; Novartis: Consultancy. Abruzzese:Bristol Myers-Squibb and Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees. Cavazzini:Novartis Pharma: Honoraria; Bristol Myers Squibb: Honoraria. Soverini:Novartis: Consultancy; Bristol-Myers Squibb: Consultancy; ARIAD: Consultancy. Saglio:Novartis: Consultancy, Speakers Bureau; BMS: Consultancy, Speakers Bureau; Pfizer: Consultancy. Martinelli:Bristol-Myers-Squibb: Consultancy, Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau. Baccarani:ARIAD, Novartis, Bristol Myers-Squibb, and Pfizer: Consultancy, Honoraria, Speakers Bureau. Rosti:Novartis Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Speakers Bureau; Pfizer: Speakers Bureau.

Early prediction of poor outcome in extremely low birth weight infants by classification tree analysis

To predict death or neurodevelopmental impairment (NDI) in extremely low birth weight infants by classification trees with recursive partitioning and automatic selection of optimal cut points of variables. Data from the Trial of Indomethacin Prophylaxis in Preterms were randomly divided into development (n=784) and validation sets (n=262). Three models were developed for the combined outcome of death (8 days to 18 months) or NDI (cerebral palsy, cognitive delay, deafness, or blindness at 18 months corrected age): antenatal: antenatal data; early neonatal: antenatal+first 3 days data; and first week: antenatal, first 3 days, and 4th to 8th days data. Decision trees were tested on the validation set. Variables associated with death/NDI in each model were: Antenatal: Gestation<or=25.5 weeks and antenatal steroids<7 days. Early neonatal: Birth weight<or=787 g and fluid intake>01 mL/kg/d. First week: Birth weight<or=787 g: transfusion>3 mL/kg/d. Birth weight>787 g: cranial echodense intraparenchymal lesion and transfusion>1 mL/kg/d. Correct classification rates were 61% to 62% for all models. The ability to predict long-term morbidity/death in extremely low birth weight infants does not improve significantly over the first week of life. Effects of different variables depend on age.

Early prediction of poor outcome in patients with acute asthma in the emergency room.

Early identification of patients who need hospitalization or patients who should be discharged would be helpful for the management of acute asthma in the emergency room. The objective of the present study was to examine the clinical and pulmonary functional measures used during the first hour of assessment of acute asthma in the emergency room in order to predict the outcome. We evaluated 88 patients. The inclusion criteria were age between 12 and 55 years, forced expiratory volume in the first second below 50% of predicted value, and no history of chronic disease or pregnancy. After baseline evaluation, all patients were treated with 2.5 mg albuterol delivered by nebulization every 20 min in the first hour and 60 mg of intravenous methylprednisolone. Patients were reevaluated after 60 min of treatment. Sixty-five patients (73.9%) were successfully treated and discharged from the emergency room (good responders), and 23 (26.1%) were hospitalized or were treated and discharged with relapse within 10 days (poor responders). A predictive index was developed: peak expiratory flow rates after 1 h < or =0% of predicted values and accessory muscle use after 1 h. The index ranged from 0 to 2. An index of 1 or higher presented a sensitivity of 74.0, a specificity of 69.0, a positive predictive value of 46.0, and a negative predictive value of 88.0. It was possible to predict outcome in the first hour of management of acute asthma in the emergency room when the index score was 0 or 2.

Systematic review of early prediction of poor outcome in anoxicischaemic coma

Studies to assess the prognostic value of early neurological and neurophysiological findings in patients with anoxic-ischaemic coma have not led to precise, generally accepted, prognostic rules. We did a systematic review of the relevant literature to assess whether such rules could be derived from the combined results of these studies. From Medline and Embase databases we selected studies concerning patients older than 10 years with anoxic-ischaemic coma in which findings from early neurological examination, electroencephalogram (EEG), or somatosensory evoked potentials (SSEP) were related to poor outcome--defined as death or survival in a vegetative state. We selected variables with a specificity of 100% for poor outcome in all studies, and expressed the overall prognostic accuracy of these variables as pooled positive-likelihood ratios and as 95% CIs of the pooled false-positive test rates. In 33 studies, 14 prognostic variables were studied, three of which had a specificity of 100%: absence of pupillary light reflexes on day 3 (pooled positive-likelihood ratio 10.5 [95% CI 2.1-52.4]; 95% CI pooled false-positive test rate 0-11.9%); absent motor response to pain on day 3 (16.8 [3.4-84.1]; 0-6.7%); and bilateral absence of early cortical SSEP within the first week (12.0 [5.3-27.6]; 0-2.0%). EEG recordings with an isoelectric or burst-suppression pattern had a specificity of 100% in five of six relevant studies (pooled positive-likelihood ratio 9.0 [2.5-33.1]; 95%CI pooled false-positive test rate 0.2-5.9%). These characteristics were present in 19%, 31%, 33%, and 33% of pooled patient populations, respectively. For the 11 SSEP studies, results did not significantly differ between studies in which the treating physicians were or were not masked from the test result, prospective and retrospective studies, studies with short and long follow-up periods, and studies with high or low overall poor outcome. SSEP has the smallest CI of its pooled positive-likelihood ratio and its pooled false-positive test rate. Because evoked potentials are also the least susceptible to metabolic changes and drugs, recording of SSEP is the most useful method to predict poor outcome.

Pulmonary mechanics during respiratory distress syndrome in the prediction of outcome and differentiation of mild and severe bronchopulmonary dysplasia.

Pulmonary mechanics was prospectively and longitudinally studied in a cohort of 58 infants who suffered from respiratory distress syndrome. The aim was to determine if early compliance and resistance measurements had additional value to simple clinical variables in predicting poor outcome ie nonsurvival or severe bronchopulmonary dysplasia (BPD) at 28 days. Second, we wanted to determine whether and when the recently described type 1 (mild) BPD and type 2 (severe) BPD could be differentiated by means of lung function tests. In a logistic model, neither lung compliance nor pulmonary resistance at days 1 and 4 of life were selected as predictive variables. On the other hand, gestational age and the ventilatory index no. 1 (ventilator frequency x maximal inspiratory pressure) on day 3 were the best early predictors of poor outcome. Type 2 BPD was characterized by a lower lung compliance and a higher pulmonary resistance than type 1 BPD, although the differences were only significant at 28 days. In conclusion, pulmonary function tests were not helpful in the early prediction of poor outcome at 28 days. They might, however, be of value in the follow-up of BPD patients after 28 days.

Outcome From Central Nervous System Injury

In general, coma portends a very poor outcome in ICU patients except when a drug overdose is the cause. Interactions with concurrent diseases and the cause of the comatose state are important variables that modify mortality rates. Recent studies have made it possible to predict irreversibility with a high degree of specificity in many cases. Three approaches show promise for early prediction of poor outcome--multivariate analysis, neurologic findings, and technologic innovations. Multivariate analysis of combinations of clinical conditions common in ICUs appears to have defined some patients whose prognosis is nearly hopeless, empirically. It would seem reasonable to consider withholding or withdrawing life support from these patients so that mere prolongation of death is avoided. Additional studies are needed and are relatively easy to perform with computerized statistical analyses of a readily available database derived from large patient populations in multicenter studies. A second useful approach for predicting irreversibility has arisen from studies using neurologic findings at defined time points after brain injury. The studies of Levy and colleagues exemplify this approach; their data suggest that coma can be declared irreversible with a high degree of confidence in a large subset of patients, delineated by simple sequential neurologic observations. Finally, technologies are evolving that may lead to noninvasive measurements to provide quantitative evidence of irreversible brain damage. Additional clinical studies are needed to validate the predictive value of these approaches to identifying patients who are certain to have a poor ultimate outcome. It then may be possible to predict function and irreversibility of central nervous system injury in individual cases with a high degree of certainty early in the clinical course.