Higher Risk Of Adverse Outcomes Research Articles

Post hospital admission blood lactate measurements are associated with mortality but not neurologic morbidity in children with cerebral malaria.

In children with cerebral malaria (CM) admission blood lactate has previously guided intravenous fluid therapy and been validated as a prognostic biomarker associated with death. The usefulness of post-admission measurements of blood lactate in children with CM is less clear. The strength of association between blood lactate and neurological sequelae in CM survivors, as well as the optimal duration of post-admission measurements of blood lactate to identify children at higher risk of adverse outcomes is unknown. A retrospective cohort study of 1674 Malawian children with CM hospitalized from 2000 to 2018 who had blood lactate measurements every 6h for the first 24h after admission was performed. The strength of association between admission lactate or values measured at any time point in the first 24h post-admission and outcomes (mortality and neurological morbidity in survivors) was estimated. The duration of time after admission that lactate remained a valid prognostic biomarker was assessed. When lactate is analysed as a continuous variable, children with CM who have higher values at admission have a 1.05-fold higher odds (95% CI 0.99-1.11) of death compared to those with lower lactate values. Children with higher blood lactate at 6h have 1.16-fold higher odds (95% CI 1.09-1.23) of death, compared to those with lower values. If lactate levels are dichotomized into hyperlactataemic (lactate > 5.0 mmol/L) or not, the strength of association between admission lactate and mortality increases (OR = 2.49, 95% CI 1.47-4.22). Blood lactate levels obtained after 18h post-admission are not associated with outcomes. Similarly, the change in lactate concentrations through time during the first 24h of hospital admission is not associated with outcomes. Blood lactate during hospitalization is not associated with adverse neurologic outcomes in CM survivors. In children with CM, blood lactate is associated with death but not neurologic morbidity in survivors. To comprehensively estimate prognosis, blood lactate in children with CM should be assessed at admission and for 18h afterwards.

Associations of metabolic variabilities and cardiovascular outcomes according to estimated glomerular filtration rate in chronic kidney disease: a nationwide observational cohort study.

The impact of baseline estimated glomerular filtration rate (eGFR) on the risk of adverse outcomes according to metabolic parameter variabilities in chronic kidney disease has rarely been investigated. We conducted a retrospective nationwide cohort study using the National Health Insurance System data in Korea from 2007 to 2013 to identify individuals with three or more health screenings. The metabolic components variability was defined as intraindividual variability between measurements using the variability independent of the mean. The metabolic variability score was defined as the total number of high-variability metabolic components. Multivariable-adjusted Cox regression analysis was conducted to evaluate the risks of all-cause mortality, myocardial infarction, and ischemic stroke. During a mean follow-up of 6.0 ± 0.7 years, 223,531 deaths, 107,140 myocardial infarctions, and 116,182 ischemic strokes were identified in 9,971,562 patients. Low eGFR categories and higher metabolic variability scores were associated with a higher risk of adverse outcomes. The degree of association between metabolic variability and adverse outcomes was significantly larger in those with low eGFR categories than in those with preserved eGFR (p for interaction < 0.001). Representatively, those with high metabolic variability in the eGFR of <15 mL/min/1.73 m2 group showed a prominently higher risk for all-cause mortality (adjusted hazard ratio [aHR], 5.28; 95% confidence interval [CI], 4.02-6.94) when the degree was compared to the findings in those with preserved (eGFR of ≥60 mL/min/1.73 m2) kidney function (aHR, 2.55; 95% CI, 2.41-2.69). The degree of adverse association between metabolic variability and poor prognosis is accentuated in patients with impaired kidney function.

Adherence to a handheld device-based atrial fibrillation screening protocol is associated with clinical outcomes

ObjectiveTo evaluate adherence and adherence consistency to the handheld ECG device-based screening protocol and their association with adverse cerebral and cardiovascular outcomes in two systematic atrial fibrillation (AF) screening programmes.MethodsIn...

The China Hypertrophic Cardiomyopathy Project (CHCMP): The Rationale and Design of a Multicenter, Prospective, Registry Cohort Study.

Hypertrophic cardiomyopathy (HCM) is associated with adverse outcomes, such as heart failure, arrhythmia, and mortality. Sudden cardiac death (SCD) is a common cause of death in HCM patients, and identification of patients at a high risk of SCD is crucial in clinical practice.The China Hypertrophic Cardiomyopathy Project is a hospital-based, multicenter, prospective, registry cohort study of HCM patients, covering a total of 3000 participants and with a 5-year follow-up plan. A large number of demographic characteristics and clinical data will be fully collected to identify prognostic factors in Chinese HCM patients. Furthermore, the main purpose of this study is to integrate demographic and clinical characteristics to establish new 5-year SCD risk predictive equations for Chinese HCM patients by the use of machine learning technologies.The project has crucial clinical significance for risk stratification and determination of HCM patients with high risk of adverse outcomes. CLINICAL TRIALS REGISTRATION: ChiCTR2300070909.

Predictors of an unfavorable outcome in patients with severe pneumonia against the background of COVID-19 infection

Objective. To determine the predictors of an unfavorable outcome in patients with severe pneumonia against the background of COVID-19 infection.Materials and methods. A retrospective analysis of the case histories of deceased patients (control group, n = 40) for January 2021 (a continuous sample — 15.01.21–31.01.21) and surviving patients for the same period (n = 40) with a confirmed PCR diagnosis of coronavirus infection, who were on inpatient treatment at the state healthcare institution “Gomel City Clinical Hospital No. 3” (SHI “GCCH №3”) in Gomel. The Ethical Committee of SHI “GCCH №3” found no violations contradicting ethics and morality in conducting the study. Treatment of patients, assessment of the severity of the condition were carried out according to modern protocols for the diagnosis and treatment of COVID-19 infection, approved by the Ministry of Health of the Republic of Belarus (No. 1195 of 11.11.2020). The group of surviving patients was represented by 11 men and 29 women versus 24 men and 16 women in the control group (p &lt; 0.05).According to computed tomography of chest organs (CT CO), all 80 patients had signs of bilateral viral pneumonia characteristic of COVID-19. When processing and describing CT data, a semi-quantitative scale was used to estimate the volume of infiltration and consolidation zones of the lungs, recommended by temporary protocols. The total volume of lung damage in COVID-19 infection (“frosted glasses”, “cobblestone pavement”, “consolidation sites”) was &gt; 55% in both groups, p &gt; 0.05. CT CO was performed on Somatom Emotion 6 (Siemens) with a spiral type of scanning.Patients of both groups were comparable in age, concomitant comorbid pathology: coronary heart disease (CHD), arterial hypertension (AH), diabetes mellitus (DM), etc., however, they had differences in gender (the proportion of males prevailed in the group of deceased). A feature of the study was a solid sample among deceased patients. Taking into account the group differences by gender, in this study, an additional comparison of the results by gender was carried out. Results. The course of COVID-19 infection at the stationary stage is characterized by large-scale negative clinical dynamics, fever, “explosion” of acute phase indicators, thrombosis, distress syndrome with a drop in saturation and unfavorable outcomes. The indicators obtained using the NEWS-2, SHOCK-COVID scales (scales for predicting the severity of the clinical course of coronavirus infection) in severe patients, although they indicate a worsening of the patient’s clinical condition, but rather late, when the “cytokine storm”, powerful inflammation, thrombosis, significant damage to lung tissue already dominate among clinical syndromes, the decrease in saturation and the effectiveness of drug therapy is significantly limited.Conclusion. According to the results of the study, it is recommended to divide patients into groups of moderate and high risk of adverse outcome based on clinical, instrumental, laboratory data in dynamics. In patients with moderate risk, protocol therapy in most cases is sufficient to stabilize the general condition. In patients with an unfavorable outcome, this therapy does not restrain the growth of lung tissue damage with negative clinical, laboratory dynamics, which requires additional decisions, changes in the doses of drug therapy to prevent fatal outcomes.

The evolution of health system planning and implementation of maternal telehealth services during the COVID-19 Pandemic.

Differential access to healthcare is associated with disparities in maternal outcomes. Telehealth is one approach for improving access to maternal services. However, little is known regarding how health systems leverage telehealth to close the access gap. This study examines how health systems have approached decisions about using telehealth for maternal services before and during the COVID-19 public health emergency and what factors were considered. We conducted semi-structured interviews with 15 health system leaders between July and October 2021 and June and August 2022. We used a rapid analysis followed by a content analysis approach. Five health systems did not provide maternal telehealth services before the PHE due to a lack of reimbursement. Two health systems provided limited services as research endeavors, and one had integrated telehealth into routine maternity care. During the PHE, all transitioned to telehealth, with the primary consideration being patient and staff safety. At the time of the interview, key considerations shifted to patient access, patient preferences, patient complexity, return on investment, and staff burnout. However, several barriers impacted telehealth use, including coverage of portable devices and connectivity. These issues were reported to be common among underinsured, low-income, and rural patients. Health systems with particularly advanced capabilities worked on approaches to fill access gaps for these patients. Some health systems prioritized telehealth to improve access to high-quality maternal services for patients at the highest risk of adverse outcomes. However, policy and patient-level barriers to equitable implementation of these services persist.

Hemoglobin Levels and Diabetic Foot Ulcer in Patients With Type 2 Diabetes: A Cross-Sectional Study

Background. Anemia is prevalent among patients with T2DM with DFU. However, there is limited research on the relationship between Hb level and DFU. Objective. To investigate the characteristics and relationship between Hb level and prognosis in patients with DFU. Materials and Methods. A total of 212 patients with T2DM were included and grouped according to the presence (n = 105) or absence (n = 107) of DFU. The independent t test and multiple logistic regression analysis were used to analyze the effect of different factors on the occurrence of anemia in patients with DFU and whether Hb level could be used to predict prognosis. Results. There were significant differences in clinical indicators that directly or indirectly contributed to anemia in patients with DFU (P &lt; .05). Hb level was independently associated with DFU (OR, 0.899; P &lt; .05). Hb levels were significantly decreased in patients aged 65 years or older (P &lt; .05). Mild anemia was prevalent among most patients with DFU (59.62%). Hb level decreased with the severity of foot ulcer (P &lt; .05) and was correlated with the duration of diabetes (R2 = 0.653; P &lt; .05). The AUC value was 0.82, with a cutoff value of 122.5 g/L to identify patients with DFU at high risk of adverse outcomes. Conclusion. Anemia is common in patients with DFU. Anemia is a marker of DFU severity, and Hb level can predict poor prognosis in patients with DFU.

Vertebral osteomyelitis in patients with an underlying malignancy or chronic kidney disease – Who is at higher risk for adverse outcome?

Vertebral osteomyelitis in patients with an underlying malignancy or chronic kidney disease – Who is at higher risk for adverse outcome?

МОРФОЛОГИЧЕСКИЕ ИЗМЕНЕНИЯ МИОМЕТРИЯ ВО ВРЕМЯ БЕРЕМЕННОСТИ И В ОТДАЛЕННОМ ПОСЛЕРОДОВОМ ПЕРИОДЕ В УСЛОВИЯХ ОСТРОГО ТОКСИЧЕСКОГО ГЕПАТОЗА И КОРРЕКЦИИ ИММОБИЛИЗИРОВАННОЙ ГИАЛУРОНИДАЗОЙ У МЫШЕЙ

Introduction. The prevalence of acute and chronic liver diseases in pregnant women increases every year, which is associated with a high risk of adverse outcome for the mother and fetus. At the same time, the mechanisms that ensure an increase in uterine mass, structural changes in the myometrium before childbirth and the process of postpartum involution of the uterus to the initial mass, the participation of molecular cellular mechanisms in pregnant women with liver pathology, and ways to correct it remain poorly understood. Aim. The aim of the study was to investigate morphological changes in the myometrium, during pregnancy and the late postpartum period in the myometrium of mice with acute CCl4-induced hepatosis and under conditions of its correction with immobilized hyaluronidase. Materials and methods. The experiment was performed on 200 female pregnant mice of the C57B1/6 line at two months of age. Acute toxic hepatosis was modeled by a single injection of tetrachlormethane. Correction of acute hepatosis was performed on the next day after administration of tetrachloromethane and subsequent days of pregnancy with a single injection of immobilized hyaluronidase. The animals were divided into 4 groups: a group with physiological pregnancy, animals with the immobilized hyaluronidase drug injection; animals with acute hepatosis; animals with acute hepatosis treated with immobilized hyaluronidase. Uterine samples were collected on the 18th, 21st days of pregnancy and on the 1st, 5th, 10th, 15th days after delivery. Results. The volume density (Vv) of myocytes in the state of apoptosis, interstitial cytoplasmic conglomerates, which are products of clasmacytosis, and necrotized myocytes were calculated, as well as the numerical density (Nai) of myocytes with positive expression of the p53 protein. Under conditions of acute hepatosis, structural transformations of the myometrium in the form of an increase in clasmacytosis, necrotized myocytes occur already during pregnancy. The main structural mechanism of the process of postpartum involution of the myometrium of mice in conditions of acute hepatosis in the long-term period of postpartum involution was clasmacyto sis and, to a lesser extent, necrosis of myocytes. The processes of myometrial involution in mice under conditions of acute hepatosis slow down and do not complete by the 15th day of the postpartum period. When correcting acute hepatosis with immobilized hyaluronidase, the volume density of cytoplasmic conglomerates, apoptotically altered myocytes and necrotized myocytes decreases from the 1st to the 15th day of the postpartum period, which indicates the completeness of postpartum uterine involution. Conclusion. Liver damage is accompanied by a change in the metabolism of sex hormones, which leads to an abnormality of the mechanisms of postpartum involution of the uterus, as well as its structural changes before childbirth.

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality.

Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease. In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package. A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001). This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

National Early Warning Score in Predicting Adverse Outcomes for Patients Admitted to Emergency Department; a Prognostic Accuracy Study.

Overcrowding in emergency departments (ED) is a global concern, emphasizing the need for effective resource allocation. Triage plays a crucial role in prioritizing patients based on medical needs. This study aimed to evaluate the accuracy of National Early Warning Score (NEWS) in predicting the ED patients' outcomes. A cross-sectional study was conducted in two tertiary hospitals in Tehran, Iran, from June to July 2023. Adult patients presenting to ED were included. Data for calculating the NEWs and emergency severity index (ESI), as well as outcomes were recorded by trained nurses, and then the accuracy of each score in predicting the outcomes was evaluated. A total of 2,085 patients were analyzed. The majority were male (57%) with a mean age of 54.4 years. The primary outcome, cardiopulmonary resuscitation (CPR) within 24 hours of admission, occurred in 1.9% of patients, while the need for intensive care unit (ICU) care and/or mechanical ventilation happened in 3.4%, and CPR or need for ICU care and/or mechanical ventilation was observed in 4.3% of studied cases. Each one-point increase in NEWS was associated with a 52% higher likelihood of CPR (95% confidence interval (CI): 1.41 to 1.65, p<0.001). Receiver operating characteristic curve analyses for the NEWS yielded the optimum cut-off value to be 6 for all three outcomes, with an overall area under the curve (AUC) of 0.856 (95% CI: 0.840 to 0.871), 0.834 (95% CI: 0.817 to 0.850), and 0.854 (95% CI: 0.838 to 0.869) for the primary, secondary, and tertiary outcomes, respectively. NEWS ≥ 6 was associated with a higher incidence of adverse outcomes, including ICU admission and need for CPR. The good predictive validity of NEWS highlights its value in identifying patients at higher risk of adverse outcomes.

Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System

Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.

Intraoperative magnet in removal of intracerebral metallic foreign bodies

Advisability of magnets in neurotrauma is due to pattern of patients admitted to neurosurgical departments of military hospitals with wounds accompanied by intracranial fixation of foreign metallic ferromagnetic bodies. To study dimensions, mass and magnetic properties of fragments extracted from gunshot wounds inflicted by modern weapons; to assess the feasibility of devices and instruments for removing foreign bodies. We analyzed foreign bodies extracted after gunshot wounds. Shape, dimension, weight and magnetic properties were studied. We estimated 532 foreign bodies (497 surgeries) extracted at the Kirov Military Medical Academy and 83 foreign bodies (79 surgeries) extracted at the Burdenko Military Clinical Hospital. Distribution by anatomical regions was established for both groups. We intraoperatively used cylindrical neodymium magnets 3×20 and 5×20 mm to extract magnetic foreign bodies. These magnets were brought to the target using standard surgical tweezers or original devices. The median mass of removed fragments was 0.385 (Q1-Q3=0.12-1.435; min-max≤0.01-30.5) g at the Kirov Military Medical Academy and 0.4 (Q1-Q3≤0.001-1.6; min-max≤0.01-11.4) g at the Burdenko Military Clinical Hospital. Magnetic foreign bodies were found in 501 (94.2%) and 74 (94.8%) cases, respectively. In 8.8% of cases, foreign bodies were not removed due to difficult-to-reach location accompanied by higher risk of adverse outcomes after extraction. Extracted foreign bodies after combat injuries have magnetic properties in 94% of cases. Intraoperative magnet allows for safe extraction of fragments in 91% of cases. Devices with adjustable magnetic field strength seem perspective. Further analysis of indications for removal of wounding projectiles in primary and, especially, repeated surgical treatment of craniocerebral wounds is needed.

Frailty syndrome and end-stage kidney disease outcomes at a Latin American dialysis center.

Frailty syndrome generates a high risk of adverse outcomes and mortality, and its prevalence is elevated in patients with end-stage kidney disease. Few studies have reported the prevalence and outcomes of frailty in populations from less developed countries. To identify the clinical outcomes and factors associated with the frailty syndrome in patients with stage five chronic kidney disease who started renal replacement therapy - both hemodialysis and peritoneal dialysis- in a dialysis center in Bucaramanga, Colombia. This was a prospective study of patients with end-stage kidney disease who initiated dialysis at a center in Colombia and had a twelve-month follow-up. The overall frailty prevalence was 50.47% and two out of three patients older than 65 years had the syndrome. We found significantly higher followup mortality among patients with frailty: odds ratio of 2.95 (CI: 1.07- 8.13; p=0.036) in unadjusted analysis. Literature shows that compared to developed nations, Latin American adults are facing a higher prevalence of chronic diseases, and frailty syndrome is raising. In this study, according to the FRAIL scale, having a frailty syndrome predicts a higher mortality; hypoalbuminemia and low creatinine levels at the beginning of dialysis could act as predictors of its diagnosis.

THE INFLUENCE OF RURALITY AND FRAILTY ON HEALTH OUTCOMES IN OLDER ADULTS

Abstract Background Frailty is a syndrome representing a decline in physical function and an increased vulnerability to stressors. Older adults in rural areas may be at increased risk for frailty and adverse outcomes due to worse overall health. Our aim was to identify how rural/urban residence can influence frailty status. Methods We used National Health and Aging Trend Study (2011-2020) data, a cohort of Medicare beneficiaries. Participants were categorized as robust, pre-frail, and frail (Fried’s frailty phenotype). Rural residence included counties outside of a metropolitan statistical area (Office of Management and Budget). Participants were excluded if frailty components or geographical status were incomplete. We used logistic regression analyses for the relationship between adverse outcomes (death, nursing home placement over 2011-2020), rural/urban, and frailty status. Results Of 7,393 participants (57.2% female), median age range was 75-80 years and 19.4% were rural residents. Rates of robust, pre-frailty, and frailty were 41.4%, 48.4%, and 10.2%, respectively. There was no difference of frailty status by rural status nor was there a frailty x rural interaction. Older adults with pre-frailty (OR=1.18; 1.05-1.34) and frailty (OR=1.01; 0.82-1.24) had higher risk of residing in rural than urban areas. Rural residence (OR=1.75;1.33-2.24), pre-frailty (OR=1.87;1.54-2.28) and frailty (OR=3.62; 2.79-4.71) had higher risk of adverse outcomes. Conclusion Participants with pre-frailty had higher odds of living in a rural area. Similarly, participants in rural areas had higher odds of adverse outcomes. These findings may highlight health care disparities in rural areas and opportunities for system- and individual-level interventions to prevent frailty development.

EFFECTS OF CHILDCARE, WORK, AND CAREGIVING INTENSITY ON MALE AND FEMALE FAMILY CAREGIVERS

Abstract Objectives The Behavioral Risk Factor Surveillance System sampled 54,076 caregivers between 2015 and 2017 providing an opportunity to evaluate risk factors for poor mental and physical health among a representative sample of U.S. adult caregivers. This study aimed to evaluate the impact of childcare, work status, and intensity of caregiving among men and women caring for older adults (n = 17,271). Methods Controlling for sociodemographic factors, separate logistic regression analysis for women and men were carried out to assess the main and interaction effects of childcare, work status, and intensity of caregiving on number of poor mental and physical health days in the last month. Results Intensive caregiving demands had adverse effects on both women and men, but being in the workforce was beneficial to both men and women. Women with children at home reported adverse mental health effects but better physical health, while men with children at home reported adverse physical health effects. For women, the combination of not working, children in the household, and high-intensity caregiving were most detrimental to their mental health. Among men, those not working with children in the household, regardless of caregiving intensity, were at highest risk of adverse mental health effects. Discussion Our findings identify caregivers at high risk of adverse outcomes but also point to the need for more fine-grained analyses of how families negotiate the allocation of childcare, work, and caregiving responsibilities over time.

Afghan Immigrant and Refugee Women’s Satisfaction with Maternity Wards Services in Iran

Background: Pregnant refugee women are considered a vulnerable group. They are at too high risk of adverse outcomes for mother and newborns. This study aimed to determine Afghan immigrant and refugee women’s satisfaction with maternity wards services. Materials and methods: A retrospective study carried out on 317 mothers who had referred for postpartum, or abortion care to health care centers. A researcher-developed questionnaire with 32 questions in six different domains was used the level of satisfaction. Data were analyzed by SPSS software, and Spearman, Mann-Whitney, and Kruskal-Wallis tests. Results: Results showed that the mean age of the participants was 27.55±6.24 years. 50.7% had vaginal delivery. The mean score of verbal (15.73±0.53), physical (13.82±0.47), confidentiality (5.88±0.46), and payment process (4±0) domains of satisfaction was good. There was relationship between age of participants and verbal (r=0.15; p=0.02), physical (r=0.16; p=0.02), and consent on care domains of satisfaction (r=0.17; p=0.01). And the type of delivery was related to the negligence domain (p&lt;0.001). Conclusions: Participants received good respectful care except in negligence and consent on care domains. Specific interventions, or plans appear to be essential to improve all domains of care.

Head-to-head comparison of 19 prediction models for short-term outcome in medical patients in the emergency department: a retrospective study

IntroductionPrediction models for identifying emergency department (ED) patients at high risk of poor outcome are often not externally validated. We aimed to perform a head-to-head comparison of the discriminatory performance of several prediction models in a large cohort of ED patients.MethodsIn this retrospective study, we selected prediction models that aim to predict poor outcome and we included adult medical ED patients. Primary outcome was 31-day mortality, secondary outcomes were 1-day mortality, 7-day mortality, and a composite endpoint of 31-day mortality and admission to intensive care unit (ICU).The discriminatory performance of the prediction models was assessed using an area under the receiver operating characteristic curve (AUC). Finally, the prediction models with the highest performance to predict 31-day mortality were selected to further examine calibration and appropriate clinical cut-off points.ResultsWe included 19 prediction models and applied these to 2185 ED patients. Thirty-one-day mortality was 10.6% (231 patients), 1-day mortality was 1.4%, 7-day mortality was 4.4%, and 331 patients (15.1%) met the composite endpoint. The RISE UP and COPE score showed similar and very good discriminatory performance for 31-day mortality (AUC 0.86), 1-day mortality (AUC 0.87), 7-day mortality (AUC 0.86) and for the composite endpoint (AUC 0.81). Both scores were well calibrated. Almost no patients with RISE UP and COPE scores below 5% had an adverse outcome, while those with scores above 20% were at high risk of adverse outcome. Some of the other prediction models (i.e. APACHE II, NEWS, WPSS, MEWS, EWS and SOFA) showed significantly higher discriminatory performance for 1-day and 7-day mortality than for 31-day mortality.ConclusionsHead-to-head validation of 19 prediction models in medical ED patients showed that the RISE UP and COPE score outperformed other models regarding 31-day mortality.

Early Microbiologic Markers of Pulmonary Tuberculosis Treatment Outcomes.

Rationale: Earlier biomarkers of pulmonary tuberculosis (PTB) treatment outcomes are critical to monitor shortened anti-TB treatment (ATT). Objectives: To identify early microbiologic markers of unfavorable TB treatment outcomes. Methods: We performed a subanalysis of 2 prospective TB cohort studies conducted from 2013 to 2019 in India. We included participants aged ⩾18 years who initiated 6-month ATT for clinically or microbiologically diagnosed drug-sensitive PTB and completed at least one follow-up visit. Sputum specimens were subjected to a baseline Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay, acid-fast bacilli (AFB) microscopy and liquid and solid cultures, and serial AFB microscopy and liquid and solid cultures at weeks 2, 4, and 8. Poisson regression was used to assess the impact of available microbiologic markers (test positivity, smear grade, time to detection, and time to conversion) on a composite outcome of failure, recurrence, or death by 18 months after the end of treatment. Models were adjusted for age, sex, nutritional status, diabetes, smoking, alcohol consumption, and regimen type. Results: Among 1,098 eligible cases, there were 251 (22%) adverse TB treatment outcomes: 127 (51%) treatment failures, 73 (29%) recurrences, and 51 (20%) deaths. The primary outcome was independently associated with the Xpert MTB/RIF assay (medium-positive adjusted incidence rate ratio [aIRR], 1.91; 95% confidence interval [CI], 1.07-3.40; high-positive aIRR, 2.51; 95% CI, 1.41-4.46), positive AFB smear (aIRR, 1.48; 95% CI, 1.06-2.06), and positive liquid culture (aIRR, 1.98; 95% CI, 1.21-3.23) at baseline; Week 2 positive liquid culture (aIRR, 1.47; 95% CI, 1.04-2.09); and Week 8 positive AFB smear (aIRR, 1.63; 95% CI, 1.06-2.50) and positive liquid culture (aIRR, 1.54; 95% CI, 1.07-2.22). There was no evidence of Mycobacterium tuberculosis growth in the Mycobacterium Growth Indicator Tube at Week 4 conferring a higher risk of adverse outcomes (aIRR, 1.25; 95% CI, 0.89-1.75). Conclusions: Our analysis identifies Week 2 respiratory mycobacterial culture as the earliest microbiologic marker of unfavorable PTB treatment outcomes.

Coronary no-reflow and adverse events in patients with acute myocardial infarction after percutaneous coronary intervention with current drug-eluting stents and third-generation P2Y12 inhibitors.

The frequency and prognostic value of coronary no-reflow (CNR) was investigated in studies that have used an outdated reperfusion therapy in terms of stent technology and antithrombotic drugs. We assessed the association of CNR with adverse outcomes in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and newer antithrombotic drugs, ticagrelor or prasugrel. This study included 3100 patients with AMI who underwent PCI with current DES and third-generation P2Y12 inhibitors. CNR was defined as Thrombolysis in Myocardial Infarction (TIMI) blood flow grade ≤ 2 at the end of PCI. The primary end point was 1-year incidence of net adverse clinical and cerebral events-a composite end point of death of any cause, myocardial infarction, stroke or major bleeding. CNR was diagnosed in 130 patients (4.2%). The primary end point occurred in 28 patients in the CNR group and 354 patients in the reflow group (cumulative incidence 23.2% and 12.8%; adjusted hazard ratio = 1.53, 95% confidence interval 1.01-2.33; P = 0.049). The 1-year incidences of death or myocardial infarction (14.6% vs. 7.6%; P = 0.003), myocardial infarction (8.8% vs. 3.9%; P = 0.007) and major bleeding (10.9% vs. 5.6%; P = 0.008) were significantly higher in patients with CNR than patients with reflow. The risk of adverse events in patients with CNR was highest within the first 30days after PCI. In patients with AMI undergoing PCI with current DES and third generation P2Y12 receptor inhibitors, CNR was associated with a higher risk of adverse outcomes at 1year.